As the COVID-19 pandemic has abated, mortality from other causes in the United States has kept climbing, reflecting disturbing trends not seen in any other high-income country. Despite US health-care spending being about US$13,500 per person in 2022 — twice that of peer nations — its people are more likely to die younger, of preventable and treatable causes, by suicide and drug overdose or from complications of childbirth (see go.nature.com/4i41oqc). This is not owing to any law of nature, but system-wide failure.
Instead of investing in public care, US politics have prioritized market-based ideologies. This means subsidizing drug companies and private insurance while underfunding public health and social services, empowering businesses and charities to operate in their place — a process known as the privatization of public health. This generates large profits by exacerbating medical needs and costs but leaves millions without care.
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The Trump administration’s dismantling of public-health systems through proposed or enacted cuts to Medicaid, the US Indian Health Service, National Institutes of Health and US Centers for Disease Control and Prevention, as well as food-assistance and housing programmes, is likely to intensify these deadly dynamics. Trump has also put an anti-vaccine and anti-psychiatry activist, Robert F. Kennedy Jr, in control of the nation’s health systems.
In response, many health leaders have decried the politicization of public health, portraying it as a neutral domain under siege by political forces. But this misdiagnoses the problem and obscures the solution.
The real crisis is not that public health — which is fundamentally about policies dictating the distribution of resources required to protect human life — has been politicized. It is that it has not been politicized nearly enough.
Decades of bipartisan failure set the stage for this moment. As journalist Ed Yong described in The Atlantic in 2021 (see go.nature.com/4bun7hv), public health has “willingly silenced its own political voice”. US political leaders and health officials have abandoned the once-obvious truth that political reforms to counteract poverty, inequality and inadequate social services are crucial to preventing diseases. A medical field that’s focused on treating illness as a substitute for preventing it through public policies now laments the supposed intrusion of politics into health.
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But there can never be an apolitical approach to public health. Policy choices about caregiving infrastructure, taxes and economic inequality, environmental and consumer regulations, public housing and labour rights, for example, are inherently political. They determine who lives and who dies, whose lives matter and how much.
What has left US health so vulnerable to partisan capture is not an excess of politics but rather a depoliticizing distortion of public health that fixates on individualistic medical care and personal responsibility, rather than public responsibility to address root social and environmental causes of disease and care for those who are sick or disabled. This weakens communities, fuels resentment and social division, limits political imagination and undercuts political organizing among groups that could achieve change.
The US medical profession, which has long been conservative, bears considerable responsibility. We physicians have historically avoided engagement with politics, except for policies that might affect our compensation and power, often justifying our inaction by appealing to scientific neutrality and professionalism. But, as Trump has made clear, our refusal to engage politically has not protected public health or medical science — it has left both defenceless.
