The announcements came Friday night, one after another, President-elect Donald Trump’s picks for the country’s premier health leadership roles: a New York family physician and Fox News medical contributor for surgeon general; a Florida physician and former congressman to lead the US Centers for Disease Control and Prevention; a surgeon and researcher at Johns Hopkins for the US Food and Drug Administration.
Several health experts said Makary and Nesheiwat were reasonable choices who may be tested under a federal health department with Robert F. Kennedy Jr., a prominent anti-vaccine conspiracy theorist, at the helm of the US Department of Health and Human Services. Several also raised concerns about Weldon, Trump’s pick to lead the CDC, who had previously introduced legislation that would have shifted vaccine safety oversight away from the CDC and has repeatedly raised questions about the safety of vaccines that had already been studied.
A key challenge for all of the Trump administration’s new public health leaders, the experts said, will be keeping politics out of science.
‘It’s very hard to defy your boss’
Dr. Ashish Jha, dean of Brown University’s School of Public Health and former White House Covid-19 response coordinator under President Joe Biden, said that one important question for senators to push each of the candidates on will be how they would handle a situation in which recommendations from scientists at the CDC or the FDA conflict with what the health secretary wants.
“It’s reasonable to disagree with people” on health policy, Jha said. “There are people out there who are smart, who are well-trained, who believe in modern medicine, who come out differently than I do because they read data differently than I do. That is a very normal part of scientific discourse.”
“It’s very hard to defy your boss,” Jha said. “There’s going to be an immense pressure on the CDC director, on the FDA commissioner, on all of these people. It’ll be very difficult for them to just make the decisions that are right for the health of the American people and not get swayed by someone who doesn’t understand evidence and data but has strongly held views.”
Weldon has his own partisan past with vaccines, and his nomination for CDC director has garnered far more hesitancy among experts.
“However, beyond his own lack of experience with large organizations (and the CDC is a behemoth), I have concerns about Dr. Weldon’s past statements on vaccines and believe he should be closely scrutinized on this issue during confirmation,” Adams wrote. “The CDC plays a critical role in global health, and it would be disastrous if its leader were to promote unfounded theories and exacerbate vaccine hesitancy.”
Vaccine views as a health policy bellwether
Vaccination is far from the only issue on which federal health leaders guide policy, but experts say that it is one of the most important right now — and it could be a bellwether of each leader’s approach.
The Covid-19 pandemic brought vaccines to the forefront of public health awareness and created opportunities for increased scrutiny but also dangerous skepticism and conspiracies that have had deadly consequences, said Dr. Peter Hotez, an infectious disease expert and director of vaccine development at Texas Children’s Hospital.
Hundreds of thousands of Americans died because they didn’t get vaccinated against Covid-19, he said, and big rises in preventable illnesses such as whooping cough and measles have become “imminent threats to the health of the American people.”
“It’s so dangerous for the country, and now it’s deadly,” Hotez said. “That’s going to continue to be one of our big challenges in uncoupling the anti-science from politics.”
The way a public health leader assesses scientific data on vaccines is an “important litmus test,” said Dr. Jennifer Nuzzo, a professor of epidemiology and director of the Pandemic Center at the Brown University School of Public Health.
“It shows how someone makes decisions about complex, high-stakes issues and what level of evidence and rigor someone insists upon when making those decisions,” she said. “When you see someone who says there is no safe and effective vaccine, and that statement is so at odds with all of the evidence we have, that really makes you question the judgment and character of the person who is making that statement. In my view, that is disqualifying for any serious governmental position.”
Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, said Weldon’s efforts in Congress worry him.
“I think it’s very concerning that [the] potential next chief of the CDC is someone who has been a purveyor of vaccine misinformation, particularly relating to the preservative [thimerosal],” Adalja wrote in an email, referring to the disproven belief that the preservative is linked to autism. “It requires a high degree of an evasion, especially in a physician, to accept fallacious ideas that lead people to diminish their acceptance of what is probably one of humankinds greatest technological developments.”
Weldon’s partisan past and hazy present
“Who?” Is the most common reaction Dr. Brian Castrucci said he’s heard in response to Weldon’s nomination to lead the CDC.
“To the best of anyone’s knowledge, [Weldon has] not had much interactions or experience working in a health department. It doesn’t seem that he has much experience working in working in the field of public health,” said Castrucci, an epidemiologist who is president and CEO of the de Beaumont Foundation, a nonprofit focused on strengthening the US public health system.
“I think, unfortunately, given who may have been the nominee, there’s almost a sigh of relief, and somehow, not knowing who this person is is acceptable over some of the folks that it could have been. That’s not good enough for me,” Castrucci said.
Weldon served 14 years in Congress, representing a Florida district near Tampa from 1995 to 2009.
In 2007, Weldon introduced the Vaccine Safety and Public Confidence Assurance Act, which aimed to create an “Agency for Vaccine Safety Evaluation” within HHS, independent of the CDC. “The Centers for Disease Control and Prevention is responsible for promoting both high immunization rates and vaccine safety, duties perceived by some to constitute a conflict of interest,” the legislation noted.
Dr. Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, recalled a run-in with Weldon during his time on the CDC’s Advisory Committee for Immunization Practices, a board of independent experts who advise the agency on how to use vaccines to control diseases.
He said Weldon “believed strongly that [the measles, mumps and rubella vaccine] was the cause of autism. And he believed … that if you separate that vaccine into its three component parts, that you can avoid autism, which, of course, is absurd, because already studies had shown that you were at no greater risk of autism if you’d gotten that vaccine or you hadn’t.”
But Weldon’s position at the time on the House Appropriations Committee, on which the CDC depended for government funding, “essentially forced a vote” on whether to give the vaccine as three instead of one, Offit recalled. Studies had already showed that this had nothing to do with autism, Offit said, so “It was embarrassing.”
“And Weldon got what he wanted,” Offit said. “Because the way that story was carried was that we were discussing this like this was actually a real thing to consider, when it wasn’t.
“These are science-based agencies. They depend on good science to move forward. And when you have someone who has a series of fixed beliefs that they hold with the strength of religious convictions, that’s dangerous.”
If Kennedy and Weldon are confirmed, Offit said, “I think that there is every reason to believe that there will be a dismantling of the way that we perceive and administer vaccines in this country, and that that will cause a decrease in vaccine rates, and the first disease to come back is measles. And I think that we will make measles great again, and thousands of cases will result in some children dying from a disease that’s preventable.”
Hotez says that Weldon’s name hasn’t been on his radar for more than a decade and a half and that it will be important to hear at the confirmation hearing whether his stance has changed.
CDC directors were formerly appointed by the president, but the position will be subject to Senate confirmation beginning in January.
More unknowns
The US surgeon general typically serves as the voice of the administration’s public health policy while promoting their own agenda of issues that they feel are important to the health of American people.
Hotez says he was in regular conversation with Nesheiwat in the early days of the Covid-19 pandemic as leading public health voices in the media worked together to figure out how to process the onslaught of information and communicate effectively to the public. He said she was “open-minded and had an interest in really understanding and learning and being educated,” and that’s a good sign for how she would handle the surgeon general role.
Her regular appearances on Fox News have also “battle-tested” her ability to present solid health information without conforming to particular points of view, Hotez said. But he’s not sure what issues she might choose to promote in this high-profile role.
Other experts have called Makary a “contrarian” who has correctly made sharp critiques of FDA.
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But Offit said he would prefer that Makary take a stronger stance against Kennedy’s anti-vaccine ideas.
“It worries me when people like Makary is in that position that he doesn’t say, ‘Don’t worry about it. I’m very much pro-vaccine. Nothing anti-vaccine is going to ever be part of the FDA.’ Make people feel better, instead of just trying to whitewash what RFK Jr. constantly says,” he said.
Health agencies such as CDC and the FDA typically have a degree of separation and independence from HHS, experts say, but it’s hard to know how much unorthodox influence Kennedy could exert if he heads the health agency.
“One hopes that anyone who gets tapped for a role does the work for the American people, on behalf of the American people, fulfilling the obligations of the office, and not necessarily the person who accommodated them,” Nuzzo said.