Public Health, Trumpified
When prejudice dictates policy
On November 30th of 2016, the United States Department of Housing and Urban Development (or HUD) mandated that smoking be categorically prohibited in federally-subsidized housing units within eighteen months (HUD, 2016). Starting on July 30th of 2018, smoking anywhere inside a public housing unit, or within 25 feet of it, would constitute a lease violation (HUD, 2018). Chronically non-compliant tenants run the risk of being evicted.
At the time of the rule’s announcement, it was safe to assume that its main purpose was to slash the nation’s smoking rate, thereby reducing rates of lung cancer and emphysema. It was also reasonable to expect it to be enforced judiciously. And its negative externalities- most notably, eviction- would be minimized as much as possible. For as worthwhile a goal as reducing smoking rates is, the financial and personal consequences of eviction, especially for the working-class people who make up public housing units, are dire. In short, policy analysts could rest easy in the conviction that federal policymakers and politicians are working in good faith to advance the interests of this vulnerable population.
I don’t know about you, but Donald Trump doesn’t strike me as someone to whom this description readily applies. Knowing the typical political persuasion of undergraduates interested in public health, I don’t feel the need to convince you of the President’s callousness. Yet it’s still worth noting that, two years into his presidency, I’m hard-pressed to think of a single instance in which he showed concern for the well-being of average people (and here I mean sincere concern, not the throwaway paeans to “the forgotten man” that occasionally litter his speeches). What, then, informs Trump's political conscience, and in turn, his administration's policies?
In a word: racism. No other belief seems to animate him, to matter to him, as much as the notion that people of color are morally and intellectually inferior to white people. I won’t bore you with a laundry list of the many racist statements that President Trump has made, but I would like to focus for a moment on one particularly egregious example. During the very same meeting in which he referred to the countries whose citizens can apply for Temporary Protected Status as “shithole countries”, he also mused “Why do we need more Haitians? Take them out” (Vitali, Thorp, and Hunt V, 2018). The comment illustrates Trump’s conception of what government is: an instrument for inflicting harm upon people of color, whom he does not want in America.
Now, you might be wondering why all of this is relevant to the public housing smoking ban, a topic from which, admittedly, we have strayed. How exactly does this anti-Trump broadside, a depressingly popular genre of writing nowadays, apply to the field of public health policy? My answer is that I intend to discourage the public health profession from retaining the assumptions about policymaking that, until the dawn of the Trump era, we rarely had to question. Simply put, there is no good reason to conclude that the Trump Administration’s health policies are motivated by altruism, rather than by the president’s hateful views. However well-intentioned they might seem at first glance, they should always be treated with abundant wariness.
This is especially true of policies that, in the hands of a caring, competent President, could go a long way towards improving the health of the country’s most marginalized people. The public housing smoking ban, for instance, was a creation of the Obama Administration; I would trust him and his HUD to carry out the policy such that it lowered smoking rates while keeping evictions to a minimum. But Trump, to contrast, might use the public housing smoking ban as a vehicle for dispossessing low-income Americans of their housing. I recognize that that might sound far-fetched, so allow me to detail how such a perversion of public health policy might take place.
Trump, racist that he is, equates people of color with poverty and criminality. Accordingly, he might also believe that Section Eight housing is populated exclusively by people of color who “freeload” off the federal government. In his eyes, then, it is right and just for his HUD to carry out the smoking ban in such a way that it evicts as many tenants as possible. He might achieve this outcome by imposing harsher penalties upon first-time offenders than the original policy prescribes, or by ignoring any alleged abuses of the rule that arise in the wake of its implementation. Such a draconian approach would likely be met with approval among Trump’s electoral base, who tend to score significantly higher on measures of racial resentment than non-Trump voters (Hooghe and Dassonnville, 2018). Needless evictions would ensue, immiserating thousands, and nullifying the manifest health benefits of making more buildings smoke-free. To borrow Trump’s parlance, that would be a tremendous disgrace, believe me, a complete and total disaster; many people are saying- and you’re really hearing it more and more- that it would be one of the worst deals we’ve ever seen.
Now, I do not intend to demonize the HUD, or any other government agency which devises and enacts public health policies. There is no doubt in my mind that they are staffed with dedicated civil servants who would subvert President Trump’s agenda if they could. But they cannot: so long as Trump remains President, he and his acolytes control the priorities and appointments of the entire executive branch. Thus explains, for example, the Department of Health and Human Services being tasked last summer with housing thousands of migrant children whom the Department of Homeland Security separated from their parents (Ainsley, 2019). So while I would normally endorse nearly any anti-smoking initiative, I won’t support the ban until Trump and his ilk no longer control the branch of government which oversees public housing. It is too proximate to some of the country’s most marginalized people; its potential for enacting structural violence is too great.
Many of the Trump Administration’s ostensible health policy initiatives deserve the same skepticism. We should not believe the Administration’s Centers for Medicare and Medicaid Services (CMS) when it claims that it wants Medicaid recipients to enjoy “the dignity of work” (Council of Economic Advisers, 2018). Instead, we should recognize that Trump’s hostility towards poor people, particularly poor people of color, motivates CMS’ recently-announced waivers which allow states to impose work requirements upon Medicaid recipients (CMS, 2018). Similarly, we should recognize that his repeated attempts at repealing the Patient Protection and Affordable Care Act were nothing but attempts at erasing the first black President’s signature policy accomplishment. A recent study published in the journal Social Forces found that among white Americans, racial resentment is negatively correlated with support for various social welfare programs (Wetts and Willer, 2018). Its authors theorized that white Americans tend to support cuts to the welfare state because they perceive its programs as primarily benefiting people of color, thereby threatening white peoples’ position atop the American racial hierarchy.
Knowing Trump’s own views, is there any reason to doubt that his 2019 budget’s proposed cuts to Medicaid, Medicare, SNAP, TANF, and HUD’s Rental Assistance program (Office of Management and Budget, 2018) are motivated by that exact attitude?
As these examples demonstrate, what the Trump Administration refers to as its “health policies” often only meet the definition of that term inasmuch as they might worsen people’s health outcomes. They are better understood as thinly-veiled instruments of Trump’s overarching ideological project, which seeks to make the country more inhospitable towards people of color by any means possible. Whether the project succeeds depends upon our collective willingness to take him at his word. As such, the public health community must refrain from supporting the public housing smoking ban until a Democrat, or a Republican who repudiates Trump’s racism, occupies the White House. There is just no sense in supporting any of Trump’s health policies which he claims will improve the well-being of marginalized people. You and I both know that he wants the opposite to happen.
About the author: Matt Dargay is a senior at The University of Michigan, Ann Arbor, studying psychology. He is the managing editor of the UJPH blog, and wrote an article for the print edition of the UJPH in 2016. Questions about the piece can be directed to firstname.lastname@example.org.
Ainsley, J. (2019, January 17). Thousands more kids separated from parents under
Trump than reported. Retrieved January 19, 2019
C. (2018, July 12). CEA Report: Expanding Work Requirements in Non-Cash Welfare
Programs. Retrieved January 12, 2019
H. (2018, July 30). Getting Ready to Go Smoke-Free!(United States, Department of
Housing and Urban Development, Office of Public and Indian Housing).
Retrieved December 29, 2018.
Hooghe, M., & Dassonneville, R. (2018). Explaining the Trump Vote: The Effect of
Racist Resentment and Anti-Immigrant Sentiments. PS: Political Science & Politics,51(03), 528-534. doi:10.1017/s1049096518000367
Instituting Smoke-Free Public Housing, 24 Department of Housing and Urban
Development § CFR Parts 965 and 966 et seq. (2016).
Neale, B. (2018, January 11). Opportunities to Promote Work and Community
Engagement Among Medicaid Beneficiaries(United States, Department of
Health and Human Services, Centers for Medicare and Medicaid Services).
Retrieved January 13, 2019.
United States, Executive Office of the President of the United States, Office of
Management and Budget. (2018, February 12). Efficient, Effective, and Accountable: An American Budget. Retrieved December 30, 2018.
Vitali, A., Hunt, K., & Thorp, F., V. (2018, January 11). Trump referred to Haiti and
African nations as 'shithole' countries. Retrieved January 19, 2019
Wetts, R., & Willer, R. (2018). Privilege on the Precipice: Perceived Racial Status
Threats Lead White Americans to Oppose Welfare Programs. Social Forces,97(2), 793-822. doi:10.1093/sf/soy046