Caitlin Rivers at Force of infection, 4/9/25

Here's the latest newslettter from Dr Caitlin Rivers:

------------------------------------- 

What will the next public health response look like? Controlling epidemics requires both local control and federal support

"The second Trump administration is almost certain to face a major disease outbreak. If current trends hold, individuals and state and local governments will likely be expected to manage the response —but without strong federal support, that strategy is likely to falter.

"History is clear: every presidential administration has faced at least one outbreak that requires a robust federal response. President Bush faced the anthrax attacks and the 2003 SARS pandemic. President Obama managed the H1N1 influenza pandemic, Ebola in West Africa, and the emergence of Zika virus disease. In his first term, President Trump presided over the initial year of the COVID-19 pandemic, which President Biden inherited along with the H5N1 bird pandemic in 2021. Even now, a serious measles outbreak is underway.

"What clues do we have about how the second Trump administration will manage the next crisis? The administration has closed the Department of Education and is floating the idea of shuttering the Federal Emergency Management Agency. Federal officials have said that those functions are better handled by local governments, which better understand their community's needs and priorities.

"The same argument will likely be made for public health. The Department of Health and Human Services (HHS) may seek to minimize federal health agencies’ traditional roles in writing guidance, aggregating data, communicating information, and advising local experts. Instead, it will be up to state and local health departments to develop their own outbreak control strategies, muster the resources, and coordinate among themselves.

"HHS Secretary Robert F. Kennedy Jr. may take this even further. In response to the measles outbreak in West Texas, for example, he emphasized individual decision-making by advising people to consult their physician about whether to vaccinate their children. This is markedly different from communications strategies under prior administrations, which encouraged universal uptake of childhood vaccines. He also called for states to ban fluoride in drinking water, again citing individual choice.

"There is some merit to a states-first approach. Most public health authorities rest with state and local governments, not at the federal level1. The legal authority to issue enforceable quarantine orders, for example, is state and local except at international border crossings. Cases of new diseases are reported to state and local health authorities, and they conduct the contact tracing. And during the pandemic, it was individuals who were faced with decisions about whether and how to manage their personal risk.

"Still, for outbreak response to be successful, the federal government must be prepared to play a role.

"As I wrote in my book Crisis Averted, most Americans live in states that spend less than $100 per person each year on public health. A single outbreak can devastate the average health department’s budget. The solution is not to provide emergency funds, which often cannot be dispatched quickly enough to limit an outbreak’s spread. Returning control to state and local governments must involve equipping them with adequate baseline funding, so they can manage emerging issues effectively.

"Federal coordination around data sharing is essential, too. Local officials need to know what is happening beyond their borders. The Centers for Disease Control and Prevention is best equipped to carry out that role, as it has done for decades. To do so successfully, they must be allowed to maintain their gold-standard scientific integrity, without political interference.

"Lastly, no outbreak response can be successful without buy-in from the individuals affected. Whether they are being asked to get vaccinated, throw out contaminated food, or stay home while ill, voluntary cooperation is indispensable. For that, people need frequent, honest, and trustworthy information. The Trump administration should reverse the pause on public communication and allow experts to produce and distribute public health messages. They should also provide materials and expert support to state and local governments so they may do the same.

"A new public health emergency is likely. Local leadership won’t be enough without federal backup: funding, coordination, and clear, trusted messaging. But with the right support, a decentralized approach can work.

"Thanks for reading Force of Infection! This post is public so feel free to share it."

Photo by Yoav Aziz on Unsplash

1 Public health authority in the U.S. is divided between state and local governments, with about half of states operating under a decentralized system where counties hold primary power. The remaining states either have state control over public health functions or have a mixed approach. See KFF for more info.