By Dean M. Harris, University of North Carolina at Chapel Hill, USA, Dean_Harris unc.edu

As I write this, the inauguration of a new U.S. president will be held in a few days. Many people outside the United States might experience the adverse consequences that the U.S. election is likely to have on global public health. At the European Public Health Conference in Vienna shortly after the election, one of the speakers, David Stuckler, described the new U.S. president as a “direct threat to public health.”[1]

In the long run, the political situation in the U.S. will change again. Eventually, the pendulum will swing back to place a higher priority on access to care and global health. But what is likely to happen in the meantime?

Within the United States, the election will adversely affect individual rights and access to care. President Obama’s Affordable Care Act (“ACA”) was passed in 2010 when his Democratic Party controlled both houses of Congress. As of January 2017, however, the Republican Party will control both houses of Congress and the White House, as well as executive agencies such as the Department of Health and Human Services. The Republicans will also have opportunities to change the composition of the U.S. Supreme Court, which could result in changes to existing precedents on reproductive rights and other public health issues.

On the domestic front, the new President and Congress are likely to make several types of changes. They are likely to shift the balance of power from the federal government in Washington to the 50 state governments. In addition, they will reduce individual rights to health insurance coverage and access to care, and they will try to reduce the individual right to choice in reproductive health services. They will probably reduce government regulation for public health and safety, which they blame for slow economic growth. For example, the President-elect’s campaign had proposed to get rid of regulations from “the FDA food police,” such as rules for the production and temperature of food.[2]

On the global level, the United States has worked for many years with other donor countries to promote health and development. These efforts have included the President’s Emergency Plan for AIDS Relief (PEPFAR), as well as financial support for programs to address malaria and Ebola.[3]

Is the role of the U.S. in global health likely to change as a result of the 2016 election and the resulting change of government? The short answer is yes. It is very likely that the change of government in the U.S. will: (1) reduce access to reproductive health services; (2) change the amounts and priorities of development aid from the U.S. government; (3) reduce progress in responding to global environmental problems; and (4) change U.S. immigration policies in ways that adversely affect other countries. Each of these likely effects is discussed in detail below.

1. Reduce access to reproductive health services

The new President might reinstate the U.S. government’s Mexico City policy. This policy is named for the city in which it was announced by former President Ronald Reagan. The policy prohibits foreign non-governmental organizations (NGOs) that receive U.S. funds from using their own funds for abortion-related services, referral, or advocacy.[4] Because it limits the ability to advocate for access to abortion outside of the U.S., critics refer to this policy as the “global gag rule.”

The Mexico City policy would not prohibit using U.S. funds for abortion in other countries because that is already prohibited by another U.S. law. Rather, this policy goes much further and prohibits foreign NGOs from using their own funds for activities related to abortion, if those NGOs receive any family planning funds from the U.S. Agency for International Development (USAID).[5]

This would not be like a parent saying, “I will give you this money, but you must use this money for your education, and you may not use this money to buy a car.” Rather, this would be like a parent saying, “I will give you this money for your education, but if you take this money from me, you may not use your own money—which you earned from your part-time job—to buy a car.” The paternalistic Mexico City policy would control what foreign NGOs can do with their own money in global public health.

In the United States, periodic cancellation and reinstatement of the Mexico City policy has become a ritual for newly elected presidents. Each time a Democrat is elected, the new president cancels the policy. In contrast, when Republican George W. Bush was elected, he reinstated the policy.[6] The new President has not clearly stated his intention with regard to this policy, but some experts think he is likely to reinstate it.[7] This is an issue that we will need to watch very carefully.

2. Change the amounts and priorities of development aid from the U.S. government

Progress in public health depends to a large extent on making continued improvements in nutrition, sanitation, housing, and education—especially the education of girls. Together with other donors, the U.S. government has contributed to global health and development for many years, and hopefully will continue to do so. There is a risk, however, that the health status of populations and individuals could be adversely affected by changes in government priorities and reductions in the amount of financial contributions.

In the past, global health programs such as PEPFAR have received support from both political parties.[8] PEPFAR was created in 2002 by Republican President George W. Bush. However, as Laurie Garrett pointed out, the new president has suggested that foreign assistance from the U.S. government should depend in part on whether a potential recipient country has been friendly to the United States.[9] Garrett also noted the new president’s distrust of government in general, as well as the risk that his attitude poses to public health which is primarily a function of government.[10]

3. Reduce progress on responding to global environmental problems

The new president is not only skeptical about government. He is also very skeptical about science, which is the foundation for making evidence-based decisions in public health. For example, he has argued that autism is caused by giving vaccines in the doses that are ordinarily used by doctors, even though medical science has clearly rejected a supposed relationship between autism and vaccines.[11] According to an anti-vaccine activist who recently met with the new president, the new president “says if you have enough anecdotal stories saying the exact same thing, that you can’t dismiss the validity.”[12] Apparently, the new president believes that something must be true if enough people repeat the same thing enough times. However, in science and public health, we know that “the plural of anecdote is not data.”[13]

The new president’s skepticism about science includes a refusal to accept the scientific consensus on global warming. He posted a message on Twitter that “[t]he concept of global warming was created by and for the Chinese in order to make U.S. manufacturing non-competitive.”[14]

Together with the Republican-controlled Congress, the new president and his officials are likely to reduce environmental regulation and enforcement within the United States. In addition, he will probably limit the U.S. government’s cooperation with other nations in responding to global problems of climate change. That could have the further effect of discouraging cooperation and progress by other nations. Climate change is a global problem, and failure to work together could have global consequences.

4. Change U.S. immigration policies in ways that adversely affect other countries

Although estimates differ, about 10 million undocumented persons reside in the United States. Many have lived and worked in the U.S. for years, but they are still undocumented. Children who were born in the U.S. are automatically U.S. citizens, regardless of the nationality or visa status of their parents. Many other children were brought to the U.S. at a young age, and they have little or no connection to the country of their birth. Under these circumstances, forced deportation of undocumented persons would cause tremendous hardship to individuals, break apart families, and disrupt local economies that depend on undocumented persons as workers, tenants, customers, and members of the community.

At various times, the new president has promised to immediately deport all undocumented persons, and, alternatively, to only deport some people immediately and decide later what to do about the rest. He has also promised to build a wall along the border between the U.S. and Mexico, and make Mexico pay for it. Of course, we do not know yet the specific immigration policies that will be adopted, but it is reasonable to assume that the new policies will be more restrictive in some respects about allowing non-citizens to enter and remain in the United States. These new immigration policies will not only affect people in the U.S., but also will have adverse effects in other countries.

Moving to the U.S. or another wealthy country can provide opportunities for migrants, and the remittances they send back to their countries of origin can significantly improve the health and welfare of their families. Migration can also reduce the level of unemployment in the home country. For refugees from war-torn countries, migration can mean the difference between life and death.

Conversely, deporting people from the U.S.—or restricting entry to the U.S.—would limit opportunities for migrants, deprive their families of the safety net provided by remittances, increase the level of unemployment in countries of origin, and deprive refugees of a safe haven from the danger and destruction of war. Moreover, if the new U.S. government refuses to accept its fair share of the world’s refugees, the burden on other destination countries would be increased or the refugees would remain in peril. Meanwhile, the U.S. is likely to continue its practice of importing foreign health care professionals, such as doctors and nurses, to meet the workforce needs of the U.S., despite the effect of that “brain drain” on the workforce needs of other countries.

In light of these likely effects on global health, what should we do? As expressed in an editorial by The Lancet shortly after the U.S. election, “the objective must be to organise, and to use evidence to promote a clear pro-health political agenda for the US, domestically and globally.”[15]