There really is a deep state

Donald Trump’s re-election may seem like doomsday for America’s public health authorities. The newly elected president has promised to dismantle the federal bureaucracy. Robert F. Kennedy Jr., possibly his next health czar, wants to go even further. As part of his efforts to “Make America Healthy Again,” Kennedy recently vowed to tear up the FDA and its regulations, including those regarding vaccines and raw milk. But that effort will hit a major roadblock: the “deep state.”

The sentence deep state can conjure up images of tinfoil hats. After all, Trump has spent much of the past eight years falsely claiming that Democratic bureaucrats are unfairly prosecuting him. But operating within federal health agencies is a real deep state, albeit a much more benign and rational one than Trump has talked about. And maybe he can’t break it off easily.

Whether you know it or not, you’ve probably seen this deep state in action. It was the reason Trump’s treatment of choice for COVID during the early phases of the pandemic, hydroxychloroquine, did not flood pharmacies. And that was why the COVID vaccines were not rushed to market before the 2020 presidential election. Both attempts were nonetheless blocked by officials overt pressure by Trump and officials in his government.

Public health officials did not encourage Trump to sabotage him. They did this because both measurements were not scientifically sound. Vaccines were not authorized before the election because FDA officials knew they would have to wait at least two months after completing clinical trials to ensure the vaccines did not cause dangerous side effects. And the FDA blocked the use of hydroxychloroquine to treat COVID due to the drug’s unproven efficacy and poor safety results.

If they really wanted to, health officials could have given in to Trump’s requests. But in general, they do not easily give up their evidence-based views on science – no matter who is president. The FDA’s top vaccine regulator has promised that resign in 2020 as the agency caved to Trump’s pressure to approve vaccines early. Two other vaccine regulators resigned the first year of the Biden administration after the FDA announced the rollout of COVID boosters. After their resignation, the ex-officials publicly announced argued that “the data simply do not show that every healthy adult should receive a booster vaccination,” and that public health efforts should have been focused entirely on “vaccinating the unvaccinated wherever they live.”

Many scientists, lawyers, and physicians are involved in every decision federal health agencies make because the decisions must be based on evidence. Arbitrary decisions based on conspiracy theories or political whims can and will be challenged in court. “There could absolutely be a new administration that can set new policies,” said Lowell Schiller, who led the FDA’s policy office during part of Trump’s first term. But, he added, “there are a lot of laws they have to follow, and things have to go through the right procedures.”

Some changes that seem relatively minor require a lot of paperwork. When the FDA moved to revoke the standardized federal definition of frozen cherry pie (yes, it existed until earlier this year), it had to go through a formal process that forced the agency to defend its legal authority to take this step, as well as the costs and benefits of a more laissez-faire policy of cherry pie. The process took more than three years. Few things are more difficult than approving or withdrawing approval of a drug: In 2020, the FDA attempted to market an unproven drug intended to prevent premature birth. Despite much evidence that the drug was ineffective, the trial took almost three years. Now imagine what would happen if RFK Jr. would pressure the FDA to pull a vaccine from the market because it wrongly believes it causes autism.

A Trump administration could do some things more easily. For example, it could direct the FDA to stop enforcing the agency’s restrictions on some of the products Kennedy touts, such as raw milk and certain vitamins. The FDA often refuses to go after various products in the name of “enforcement discretion.” A decline in enforcement actions could anger some within the agency, but Trump could accomplish that with little red tape.

Kennedy has promised massive layoffs at the FDA, presumably to install loyalists who would carry out the agenda. That threat must be taken seriously. The president has enormous power to stop officials who ruin his agenda. Allegedly the Trump administration demoted one top federal official who opposed allowing hydroxychloroquine.

But there are also major checks on what a president can do to scare officials. Unlike many employees, federal employees can only be fired for cause or misconduct, and public employees have a right of appeal in either case. “It’s a complicated process that makes it difficult to get rid of people,” Donald Kettl, professor emeritus of public policy at the University of Maryland, told me. Trump was known for firing people during his first term, but the people who got the ax were political appointees who didn’t have the same protections as civil servants. In short, few federal employees can last just one Scaramucci.

However, there is still a major threat to federal workers. During his first term, Trump attempted to reclassify federal workers in a way that would deprive many of them of their protections, and he has said he will do so in his second term”immediately‘continue that action. Trump would have to go through an arduous process to make good on that threat, and it would likely be challenged in court. But if the policy is implemented, it could give Trump enormous leverage over firing workers.

Yet Trump takes these actions at the risk of his own agenda. The reality is that the same members of the so-called deep state that Trump and Kennedy are threatening to fire are also essential to making whatever the government wants to do happen. Pioneering parts of the Make America Healthy Again agenda should pass through this deep state. As Kennedy, a champion of psychedelicsFor the FDA to approve a new psilocybin-based treatment, the drug must be reviewed by the scientists and physicians who review other drugs for safety and efficacy. If he wants a national ban on fluoride in water, it would have to go through the EPA. There’s no way around this: Even if Trump were to appoint Kennedy as the unilateral king of every federal health agency, Kennedy can’t make these decisions alone.

A central tenet of the Make America Healthy Again agenda is removing potentially dangerous chemicals from food. Although the FDA has been slow to ban certain chemical additives, the agency appears to have recently seen the light. Earlier this year, it launched a new initiative to reassess the safety of these substances. But if Kennedy has the FDA nerve, there may be no one to make that assessment.

The Trump administration could hypothetically organize a massive job fair to get goons in all these roles — especially if the president-elect makes good on his promise to make hiring and firing bureaucrats easier — but few people can successfully perform these highly technical jobs . to mention that hiring in the federal government usually takes forever. (The average hiring time in 2023 was 101 days.)

Yet Trump’s second term will be one of the greatest challenges to our federal health care system. No president in modern history has been so determined to bend health agencies to his will, and he seems even more emboldened to do so now than in his first go-around. Trump will likely have some successes – some people may be fired and some key policies may be scrapped. America is about to find out how resilient the deep state really is.