America’s Public Health System Was Too Easy to Break

Over the last two centuries, a series of severe health threats prompted the American government to build a layered sword-and-shield of agencies to protect the public from preventable harm and to advance its well-being.

These successive crises exposed serious vulnerabilities in the nation’s defenses, leading to incremental reforms that built federal health institutions in multi-pronged layers. in Each piece of today’s interconnected systems serves complementary roles in the public health machine; the National Institutes of Health (NIH) supports scientific research; the Food and Drug Administration (FDA) evaluates the safety and effectiveness of medical products; the Centers for Disease Control and Prevention (CDC) monitors and responds to threats in real time; and the Department of Health and Human Services (HHS) oversees and coordinates them. As these structures took shape, they brought waves of research, innovation, and lifesaving changes, from safer food, water, and drugs to increased disease surveillance, prevention, and treatment.

All of it was built around a foundational principle: health-related decisions should be informed by ongoing consideration of both risks and benefits to the population in light of the most recent evidence. This includes weighing the harms of action, such as the recommendation that all children receive an HPV vaccine to protect against the cancers the virus can cause, against the less apparent harms of inaction, such as the preventable cases of HPV-related cancers that would have occurred if they hadn’t made that recommendation. Ultimately, it has led to a drastic reduction in several of those cancers.

These layered protections have served well under leadership that internalizes this foundational standard, so much so that, paradoxically, people began to take for granted the vast improvements in population-level health. The horrific conditions of the past, with illness and mortality raging on a far more in-your-face level, faded from the collective memory.

Meanwhile, erosion of the value of science and truth has accelerated. Lack of trust in government agencies, medical bodies, and experts has long been documented. Much of this distrust is justified because those in charge of health have regularly acted in untrustworthy ways.

For pediatrician Paul Offit, the director of the Vaccine Education Center at Children’s Hospital Philadelphia and a former member of advisory committees at the FDA and CDC, the world built on the shared values underpinning modern public health efforts has been turned upside down.

The Covid pandemic revealed the extent of these vulnerabilities. Robert F. Kennedy Jr.’s leadership and his camp’s worldview, which gives outsized weight to risks in risk-benefit calculations, have highly distorted tried-and-true public health approaches, laying waste to the system.

But it’s also important to consider that there were weaknesses in these defenses from the start. Some of these were latent, but they nevertheless left swathes of the population unprotected and allowed preventable harm all along. Those with the privilege of good health often don’t see these gaps that have always allowed unnecessary illness and death.

Under Kennedy, these public health munitions and defenses have fallen into the hands of those who eschew the basic principles on which they were built. It worsens preventable harm and health disparities between the most and least privileged.

Witnessing this preventable harm, both before and after Donald Trump was first sworn into office, reminds Offit of W. H. Auden’s 1952 poem “The Shield of Achilles,” which contrasts the idealized, heroic world described in Homer’s Iliad with World War II and the era’s bleak realities.

When the standards of care fall into the hands of those who upend them, the victims, like those in the poem, are “small and could not hope for help.” What’s particularly disturbing to him is that children often bear the brunt of the fallout, especially under the current administration.

Restoring and reinforcing public health in America will require not only the colossal task of seizing it back from those who have more recently mishandled it and putting qualified officials back in place. It will also involve addressing the vulnerabilities that already existed, and working to repair the public’s long-broken trust.

Broken Firewalls

Patricia Zettler, a professor at the Ohio State University Moritz College of Law who researches how laws governing the FDA shape regulation of health-related products, said that strongly held bipartisan norms, rather than hard-and-fast rules, are part of what upholds the protective shields of federal health agencies.

A key to these layers of protection is the intentional coupling of safety and effectiveness considerations for drug approval.

Thalidomide reform set the standard for the combined consideration of safety and effectiveness. The drug was first used in large numbers worldwide, including in Europe, starting in the late 1950s, for its effects of reducing extreme morning sickness in pregnancy. The U.S. FDA director at the time, Dr. Frances Oldham Kelsey, MD, PhD, famously rejected it because, while evidence unequivocally showed benefits of successfully treating morning sickness, there wasn’t enough evidence that it would be safe during pregnancy. She didn’t foresee a specific bad outcome, but kept stressing that available safety evidence was anecdotal, not clinical, and that there were also remaining questions about how pregnant versus non-pregnant individuals metabolize the drug.

It was eventually evident that she made the right call to protect people in the U.S., as the drug became highly associated with congenital disabilities in countries that had approved it for this use. Thalidomide was pulled off the market for morning sickness in 1961, with the CDC establishing the first population-based congenital anomaly surveillance program in the United States shortly thereafter.

Independent research on the drug for other uses continued. Soon, evidence for anti-cancer properties emerged. With support from the National Institutes of Health, including the National Cancer Institute, researchers undertook renewed research on the drug. Clinical trial evidence showed it had a significant effect against certain cancerous tumors. After an extensive evaluation, the FDA approved it for this use in 2006.

Thalidomide’s remarkable trajectory, from its rise in use for morning sickness, its tragic fall from grace, and its renewed triumph against cancer, was rooted in the understanding that safety and effectiveness depend on the specific condition a drug is used to treat and the population for which it is intended. Thalidomide saved the lives of thousands of cancer patients and paved the way for ongoing research into related drugs.

All in all, it showed that a sort of permeable shield can have a transformative impact on public health. When wielded carefully, it weighs the foundational principles to balance health-related options for those who can benefit while also protecting those vulnerable to harm.

As the agencies ushered in a safer and healthier era, along with developing a collective amnesia of the horrific conditions of the not-so-distant past, the public came to have very high standards, as they should.

Some people, however, came to expect perfection without realizing that perfection is practically impossible. There have always been tradeoffs to these decisions. There is no such thing as a zero-risk approach to vaccines or any health-related intervention because nothing is risk-free. The goal of public health isn’t to eliminate risk; it’s to understand it and act accordingly.

For instance, routine oral polio vaccines, which previously contained live, weakened virus, were once deemed worth the risks they posed to a small fraction of the population. Compared to shots, they were relatively easy to administer on a large scale, and were especially potent against the disease that caused so much devastating paralysis and death. These risks included temporary, minor ones like fever or rash, or, more rarely, serious effects like permanent paralysis. But on a population level, these small risks were deemed worthwhile given the dire consequences of polio circulating unchecked.

Overall, the universal polio vaccine campaign is considered one of the most successful public health interventions ever, reducing polio cases by over 99 percent globally. As the infection became far less common, the threshold for acceptable risk decreased. Though it’s not as strong a polio-eradicating powerhouse as the live attenuated oral vaccine, the inactivated shot, which is relatively less effective — but still effective enough to theoretically keep the infection at bay under new and improved circumstances — became the standard. It highlighted the importance of ongoing analysis and dynamic decision-making.

U.S. bureaucracy has never and can never be perfect, said Dorit Reiss, Professor of Law at UC Law San Francisco who specializes in vaccine-related law and policy. Weighing risks and benefits is a complicated, never-ending task; it’s not based on a formula that crunches out prescriptive answers. These decisions are inherently fraught and political.

One way that the government has handled the innate challenges of health-related decision-making is through federal expert advisory committees that provide guidance to the multi-tiered federal health agencies.

Consider the Advisory Committee on Immunization Practices, or ACIP, on which Offit formerly served. It began in the 1960s and met multiple times a year publicly.  Its task has been to develop age-group-based schedules and inform national policies for lifesaving vaccines.

Kennedy dismissed ACIP’s 17 sitting members, who had extensive relevant expertise and histories of operating on the basis of scientific consensus, in 2025. He replaced them with assorted members with far fewer relevant qualifications, with histories of disregarding or misconstruing what the data show about the risks and benefits of vaccines given on an evidence-based schedule. The alarm among established medical organizations was swift.

It was a huge blow, but Kennedy was largely within his legal right to do it. That’s because, historically, there weren’t structural rules that codified and ensured these principles guide decisions made by highly qualified experts; it was strongly held norms and shared belief in the importance of upholding science-based standards.

This lack of codification is a major part of what left public health vulnerable to political whims, said Reiss.

In similar ways, the Trump administration was able to dismantle dozens of these committees because they were not the letter of the law.

Wariness of health authorities is also fed by a complex landscape of misinformation that has been in force long before Trump first took office, as far back as the smallpox epidemics in the 18th century. The spread of false narratives is a multifaceted ongoing area of research. Overall, it has always relied on a web of pseudoscientific or misleading arguments, many of which have roots in racism, ableism, and other forms of oppression, that have circulated for ages and inflicted real damage.

With the Trump administration, these views, which formerly seemed to live more on the fringes, are front and center in the White House.

Building Back Better

Fixing and reinforcing public health agencies will require that the central values of evidence-based policy, expertise, and the weighing of risks and benefits are built into the legislative process to protect them against political will.

Replacing Kennedy with an HHS secretary who “actually cares about public health,” and reconstructing a roster of officials with high regard for the body of evidence, is a key priority, Offit explained. It will be a long, grueling road.

Offit is tenacious, but he also feels his fair share of despair. The current administration is determined to eliminate expertise, so he sees no reason why qualified, principled individuals would consider working in an expert capacity for federal health agencies. Under the current administration, you have to “check your sense of morality at the door,” he said.

Drawing qualified individuals back in will require extensive groundwork, and the removal of hurdles for academic involvement in government. Pathways to important expert roles have historically not been straightforward.

Universities have had myriad formal partnerships with federal public health agencies, along with state and local governments, in the last few decades. A framework known as Academic Health Departments emerged in the early 2000s to guide them. Researchers increasingly see these relationships as an approach to strengthen that roster through merit-based procedures. Expanding and formalizing these long-term partnerships can ultimately help incorporate high-quality research into practice and promote evidence-based decision-making.

Several remarkable public health achievements have happened partly thanks to these partnerships between academia and governments. So far, these have largely been established as informal agreements. Solidifying the institutional links can also help reestablish the kind of scientific integrity that would not only appeal to qualified individuals but also provide clear-cut, resilient paths for academics to undertake federal advisory service.

Returning lost funding to this network, including grant funding, is a crucial piece that has been widely recognized. So side-politicizing it and insulating against future partisan interference, Reiss explained.

Another major priority is structural and legal fixes. Legislative reinforcement of the CDC is, in some ways, more urgent than dealing with the FDA because the former was established by executive action and relies more on norms, whereas the latter was built on a strong statutory basis early on, said Reiss.

Restoring advisory committees is one important piece. But it’s just the first step. Reiss explained that hard-coding ACIP’s structure, member qualifications, and decision criteria will better future-proof it against political whims.

Evidence suggests that more transparency around the values of advisory boards and the processes behind decision-making in public health could bolster public trust.

“Science can’t answer all the questions regulators have to face,” but sound science, evidence, and transparency about the process should be a cornerstone, said Zettler.

Restoring the firewalls and fixing the agencies tasked with carrying out public health may take years, even decades, of collaborative efforts. Even many of the privileged won’t get through it unscathed.

But hope is not unjustified. History has shown that when they’re seen not only as tragic historical events but also as valuable lessons for reform, crises do not have to go to waste.