On Making America Healthy Again

On February 13, 2025, President Trump issued a Make America Healthy Again executive order (EO) creating a Commission tasked with reducing America’s burden of chronic disease and promoting health and well-being. The EO frames the problems for the Commission to address:

• Comparatively low life expectancy, high prevalence of chronic disease and mental illness;

• High prevalences of cancer, autism, asthma, IBD, psoriasis, MS, especially when compared to other high-income countries;

• 41% of American children with chronic condition: allergies, asthma, autoimmune;

• Autism 1/36 children (citing an increase from 1/2500 in 1980s);

• 18% fatty liver, 30% prediabetic, 40% overweight/obese;

• 3.4M American children on meds for ADD/ADHD; and

• 77% of American children not physically/mentally qualified for military service.

Having long been on the bandwagon of promoting health and well-being, I am encouraged by this EO…but also have some doubts.

First, the Commission will focus largely on children and adolescents, to keep chronic conditions from ever happening. Great idea, but adverse childhood experiences should be added to the problem list. 

In adults, lifestyle commonly gets blamed for America’s increase in chronic disease mortality and I’ve spent my whole career on using lifestyle to address cardiometabolic conditions. But the apparent rise in deaths from chronic disease is, in part, an artifact. 

Comparing causes of death in 1900 and in 2000, cardiovascular disease in 1900 was about 32% and is still 30%; stroke was 10% and is still 7%; accidents have held steady at about 4%. Alzheimer’s, likely an epiphenomenon of increased longevity, and emphysema due to the 20th century popularity of smoking, are the new entrants to the top 10 chronic disease causes of death. 

What’s gone down is infectious causes of death. Everyone dies of something, so the apparent rise in chronic disease mortality is partly a by-product of the invention of immunization and antibiotics for infectious diseases. This insight should cause pause when your Secretary of Health and Human Services – and prominent member of the Commission – has made a career of opposing vaccination. 

N.B.: In 1900, “Cardiovascular Disease” included mitral valve stenosis, which is a 20-40 year sequela of rheumatic fever, an immunological reaction to streptococcal infections. Because of penicillin treatment for strep throat, rheumatic heart disease has become uncommon in the United States. Also, in 1900, about 1 in 20 women died from child birth, primarily from hemorrhage and post-partum sepsis. Today, about 1 in 3000 American women die from child birth but it should be lower. CIA data show America’s maternal mortality ranks 122nd world-wide at 21 per 100,000 live births (the top-ranked countries are <5/100,000). 

Second, the EO calls for “fresh thinking on nutrition, physical activity, healthy lifestyles, over-reliance on meds and procedures, effects of new technology habits, environmental impacts, food and drug quality and safety” and to “promote health in addition to managing disease”. 

Hear, hear!! This call is better aimed at adults with chronic conditions. But – having long followed most of this literature – what America needs is implementation, at scale, of longstanding scientific findings. 

The main reasons our health care system doesn’t provide health promotion services are:

1. payment to physicians for such services barely meets (often doesn’t meet) the cost of providing them, and
2. federal and state governments insufficiently invest in public health and have effectively siloed health promotion away from mainstream medicine.

Americans who want health promotion and primary prevention have to pay cash, so those who can’t afford it don’t get it. Moreover, health promotion services are an unregulated market where the customer might get good advice…but might not. I’m thinking of you, neutriceutical vendors.

The bifurcation of medicine and public health can be traced to the late 19th and early 20th centuries. Physicians carved-out public health because technology-oriented disease care paid better than prevention. The result is that Medicare, Medicaid and private insurers don’t pay physicians well for preventive services today. With the exception of vaccinations, what American medicine calls “prevention” is actually an early detection form of disease care. For primary prevention, America leans on the public health system and “personal accountability”. 

The problem with relying on personal accountability paid for by cash is that poorer people don’t have discretionary income to spend on prevention and health and well-being promotion (which is, in part, why the burden of chronic diseases skews to lower socio-economic strata). The “fresh thinking” we need is an awareness that, whether we provide it through public health or private health insurance, America must spend enough on promoting health and well-being so as to create a viable business model for whole health providers. 

And if the Commission is truly going to support environmental and food safety, they likely will advise investing in clean air, clean water, reduction of chemical and antibiotic use in agriculture, less reliance on confined animal feedlot operations (CAFO’s) and no-till farming. It’s hard to fathom turning back towards Upton Sinclair’s, The Jungle. So why is the administration dismantling the EPA and USDA? 

Third, the EO calls for restoring scientific integrity and data transparency, protecting against industry and other bias. 

Hmmmm. As a clinical investigator with 48 peer-reviewed publications, the researchers who trained me and dozens more with whom I’ve collaborated are honest hard-working scholars. Bad apples get noticed in the news but are not the norm.  

The dark side of the system is peer review, an unsanctioned but de facto good-old-boy system. Reviewers wittingly or unwittingly favor their own biases and downgrade proposals that don’t align with their thinking, putting a premium on “grantsmanship”. Such catering to reviewers to improve one’s own chances of getting funded perpetuates the status quo and suppresses alternative views. 

As to transparency, NIH-funded research now has essentially open access to full data sets (albeit delayed so that the funded researchers can publish their findings first). NIH now even includes patient advocates in scientific meetings and in prioritizing research funding. 

Industry bias is indeed a problem. Industry sources of funding, particularly pharmaceutical producers, exert excessive authority over published manuscript(s) when they finance studies of their compounds. And Marian Nestle has pointed out that the USDA Dietary Guidelines have been heavily influenced by the food industry, though less so the views of scientific advisory panels. 

Given the Supreme Court’s decision on Citizens United that empowered corporations as citizens and gave corporate America a big megaphone, isn’t corporate influence over federal recommendations a case for more oversight? Doesn’t weakening the NIH, CDC and FDA provide industry even more power? 

The Make America Healthy Again EO has many good points and offers hope for advocates of whole health care. But the language in this EO and the actions of the President and his advisors gives me concern that they don’t share my view of the situation. I hope the Commission brings us in better alignment. 

References

Trump DJ. Establishing the President’s Make America Healthy Again Commission. The White House, Feb. 13, 2025. 

https://www.whitehouse.gov/presidential-actions/2025/02/establishing-the-presidents-make-america-healthy-again-commission/

Anderson RN. Deaths: leading causes for 2000. Nat Vital Stat Rep 50(16):1-85, 2002. 

https://www.cdc.gov/nchs/products/nvsr.htm

On maternal mortality: 

https://www.cia.gov/the-world-factbook/field/maternal-mortality-ratio/country-comparison/

Starr P. Chapter 5, The boundaries of public health, in The social transformation of American medicine. Basic Books, 1982, pp. 180-197.

https://www.hachettebookgroup.com/titles/paul-starr/the-social-transformation-of-american-medicine/9780465093038/?lens=basic-books

Nestle M. Food politics. University of California Press, Berkeley, CA, 2002.