ON Wednesday 9th November, America woke up to the shocking news that, after a long, bitter election cycle, Donald J. Trump, the reality television star and controversial businessman, had bested former Senator and Secretary of State Hillary Clinton to become the next President of the United States. The news was a startling surprise to those who had trusted the statisticians and prognosticators who had predicted a sweeping victory for the Democratic nominee, and a terrifying shock to those who have been disgusted by Trump’s oftentimes violently racist and misogynist rhetoric throughout the campaign.
In Atlanta, home to a number of distinguished public and global health institutions, we woke up to something else as well—smoke in the air. In the immediate aftermath of an emotional, acerbic election, it was hard not to let gallows humor creep in—has the country already begun burning to the ground? It was later determined that the smoke had blown down from forest fires in Northern Georgia and Tennessee, but questions persisted—What does this mean for the country? What does this mean for science in the United States? What does this mean for global health?
Powers of the Presidency
Before diving into the details of what a Trump administration will mean for global health, it’s worth revisiting the role and powers of the President. The Federal Government is divided between three branches—the Legislative Branch, consisting of a bicameral legislature that creates laws; the Judicial Branch, a system of courts that serve to interpret the law; and the Executive Branch, which sees that the laws are enforced. The President leads the Executive Branch, including the military, and has broad power over the government’s many agencies and regulatory bodies, including the Environmental Protection Agency (EPA), the Centers for Disease Control and Prevention (CDC), and USAID.
Powers of the federal government are subject to a system of checks and balances so that no one branch becomes dominant over the others. For example, many of the President’s choices to fill high-ranking government jobs and to lead federal agencies must be confirmed by Congress. Perhaps most importantly to this discussion, while candidates generally run on a platform of ideas that they would like to see enacted, once elected they must negotiate with Congress to have those ideas passed into law (and then hope that the Judicial Branch does not strike down those laws as unconstitutional).
Climate change is undoubtedly one of the most important issues facing humanity in this 21st century, and oftentimes a particularly difficult one for world leaders who must balance short-term economic growth with the long-term health and viability of the environment. In November 2012, well before he announced his candidacy, Trump planted his flag soundly on the side of climate skeptics with an infamous Tweet claiming that Climate Change is a hoax perpetrated by the Chinese in hopes of gaining an advantage in manufacturing.
Although Trump would later rephrase his anti-Climate Change views with slightly less incendiary language—he told the Washington Post editorial board that “I am not a believer. Perhaps there’s a minor effect, but I’m not a big believer in man-made climate change”—his pro-fossil fuel rhetoric proved a critical asset in rural coal mining communities that helped him to win Pennsylvania, one of the biggest upsets of the election.
Since the election, Trump appears to be following through on his campaign promises by nominating a climate skeptic to lead the EPA, which has broad powers over environmental regulations in the United States, and exploring ways to exit the recently signed Paris Agreement. With a Republican-led Congress it seems likely that Trump’s EPA nominee will be confirmed. The Paris Agreement was signed by President Obama without the Congressional approval normally required of a treaty (Obama justified this by classifying it as an “executive agreement”), which likely means that a future President could reverse that decision by a similar executive order. The Agreement’s language, however, includes a waiting period that restricts withdrawal by any country before 2019. While it’s possible the Trump administration could find a workaround to exit sooner, what seems more likely is that the Paris Agreement is left in place but poorly enforced under a weakened EPA.
Research, Aid and Development
The US government’s formal mechanisms for research, aid and development are distributed throughout a variety of institutions and centers. These include USAID, an agency that disperses foreign aid through technical and financial support; the National Institutes of Health, which conducts and funds medical research; and the Centers for Disease Control and Prevention, a wide-ranging public health institute that studies and responds to health challenges domestically and abroad. Along with other smaller governmental organizations, these institutions position the United States government as an important player in global health. So, how will a new administration affect the work currently being done by thousands of dedicated public and global health professionals under the auspices (and/or with funding from) US Government?
The Mexico City Policy will likely be reimplemented. Originally instituted by Republican President Ronald Reagan in 1984, the Mexico City Policy strengthens limitations on NGOs that receive USAID funds so that government money cannot be used to provide any kind of advice, counseling or other services that advocate for abortion as a method of family planning. This policy has reliably been repealed or reinstated depending on the President’s political affiliation (Bush I kept it, Clinton repealed it, Bush II reinstated it and most recently Obama repealed it). It’s worth noting that more permanent restrictions on the use of federal funds to provide abortions have been in effect since 1973.
Current research grants are unlikely to be affected, but the scope and nature of future grant funding will likely reflect the priorities of the new administration. Of course, this is true for all new administrations and the 2016 presidential campaign provided little insight into the priorities of the incoming President Elect. When asked about PEPFAR before the election, Trump appeared unfamiliar with the program but seemed to (in the most general terms) show some support for funding programs to address AIDS (and Alzheimer’s).
It’s also worth noting that Trump’s Contract with the American Voter includes a call for a hiring freeze on all federal employees, but exempts public health employees from that policy, a tacit (or perhaps unintentional) acknowledgement of the importance of public health.
Foreign aid will reflect diplomatic and political priorities. That the United States’ humanitarian and development priorities would reflect political and diplomatic relationships has never been a well-kept secret. This relationship has played out in a sometimes uncomfortable relationship between the State Department and USAID for decades, but has become more overt as Trump’s campaign progressed. In an interview with the New York Times, the then-candidate was asked if he supported humanitarian intervention. His response:
Humanitarian? Yes, I would be. You know, to help I would be, depending on where and who and what. […] It depends on the country, the region, how friendly they’ve been toward us. You have countries that haven’t been friendly to us that we’re protecting. So it’s how good they’ve been toward us, et cetera, et cetera.
The response is shocking in both its directness and implications, especially given Trump’s oftentimes extreme isolationist diplomatic views.
Security and Refugees
When he is sworn into office, Donald Trump will be the first President in American history without ever having held a position in government or the military (and only the fourth without government experience). This critical lack of experience was evident early on in his campaign when his lack of knowledge on Middle East policy was exposed during an interview with the conservative radio host Hugh Hewitt. While a political candidate might be excused for not knowing the difference between Quds and Kurds (one is an Iranian special forces unit, the other an Ethnic group), Trump further exposed his lack of foreign policy experience with brash, cavalier pronouncements about committing war crimes against the families of terrorists and “carpet-bombing ISIS.”
Unlike some of the legislative and personnel moves that would affect traditional global health issues like development aid and research, the President has significant powers when it comes to military policy and action. Presidents also have significant leeway to determine how immigration laws are interpreted and how refugees are welcomed. Some of Trump’s most inflammatory and racist language has been directed at refugee communities, including a complete ban on Muslims entering the United States (a position he has since retreated from). While that ban might seem unprecedented, it’s worth remembering that the Supreme Court decision justifying the internment of Japanese immigrants by Executive Order during WWII still stands.
Mainly because of geography, the United States has not taken in as many refugees as its European allies (although it should be noted that President Obama has set a goal of taking in 10,000 Syrian refugees this year, significantly less than Canada). A Trump administration is more likely to do harm to refugees by expanding the crisis through misguided foreign policy in the Middle East than through an unlikely ban on Muslims entering the United States.
Final Thoughts: Room for Cautious Optimism?
Above all else, Donald Trump seems to be a man whose opinions change with the wind—who was for the Iraq War before he was against it, he was pro-choice before he was pro-life (and, for a few minutes, was pro-punishment for women seeking abortions). He has walked back his call for a complete ban on Muslims entering the United States and, since winning the election, softened his stance on the Affordable Care Act (Obamacare). Many Americans (rightfully) remain disgusted at the terrible things he has said about immigrants, women, the disabled and prisoners of war (to name just a few), but given his mercurial nature, I at least allow for the possibility that Trump might surprise the world. If George W. Bush could work with a hostile Congress to create PEPFAR, couldn’t Trump do the same?
President Obama’s two terms in office have shown the world many things, not the least of which is that being a productive executive, getting stuff done, as President is difficult. Obama was an accomplished constitutional scholar and Senator before running for President. He stocked his Cabinet full of some of the most brilliant, came into office with a huge public mandate and majorities in both houses of Congress. Even so, he struggled throughout his two terms to be productive. Obamacare passed in early 2010 but cost the President nearly all of his political capital, forcing him to work largely by executive action rather than collaborate with a hostile Congress during his remaining 6 years in office. While Trump has Republican majorities in both houses of Congress and a seasoned political veteran in Reince Priebus as Chief of Staff, his campaign was staffed mostly with government outsiders who have little experience with the mechanics of American Government. Combined with Trump’s lack of experience and understanding, it seems entirely possible that his presidency might be one of the least effective in modern times, at least for the first few years as his administration struggles with the sharpest of learning curves.
The common theme here is that we have very little evidence to predict what Donald Trump believes or how he will govern. He ran the most opaque campaign in modern history and has proven time again time and time again that he will say or do nearly anything to benefit himself. During the campaign, this resulted in some of the most vile and disgusting rhetoric in American history. Despite (or perhaps because of) this, I remain ever so cautiously optimistic that the next four years will see America continue to be a leader in global health.
Author’s note: This was a difficult piece to write in the immediate aftermath of a divisive election. Although I tried to be objective, my biases are likely clear and should be noted—I supported Hillary Clinton throughout the election cycle (including several small donations to her campaign) and remain disgusted by Donald Trump’s hateful and violent rhetoric. As always, these opinions are my own and do not necessarily represent my employer or any affiliated institutions.