HHS "reductions to absurdity," one week on.

We now have more details on last week's cuts. The analysis is not pretty.

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An AI-generated interpretation of what has been going on. Chat GPT 4o.

Last week, HHS moved to reduce the size of its workforce by around 10,000 people. This was done in the name of efficiency, but many of the moves appear counterproductive (at least so far), with thousands of employees being paid to do nothing for now, while our public health assets deteriorate, leaving us less safe. One week on, it’s time for some updates and analyses.

First, it bears repeating that most of the cuts have yet to be explained cogently by anyone in the administration. Indeed, why were some HHS employees and projects cut and others spared? Nobody really seems to know, or cares to say. That lack of transparency—despite promises of transparency—is at least part of the reason that many experts and others who care about US public health are incensed. (Albeit the major reasons experts are enraged are the implications of the cuts themselves and the cruelty and carelessness with which they have apparently been executed.)

Let’s look at what has happened in the week since the RIF emails went out….

Major public health experts are not happy.

In speaking to experts, I did not get a lot of, “Oh yeah, some of these cuts make sense.”(There was a little bit of that, but very little.) Rather, the changes overall were mostly met with concern and horror. Here’s an open letter written by over 100 major public health leaders, and posted by the American Public Health Association (of which I am a member) decrying the destructive policies. The major points in the letter are:

“Hold immediate oversight hearings on the restructuring of CDC and other HHS agencies.

Reinstate critical funding for public health programs, including funding for state, local and tribal public health departments.

Strengthen vaccination efforts and counter misinformation

Protect evidence-based public health programs, including those addressing chronic diseases, injury control, and environmental threats.”

Other pushback:

Last week, we in the Inside Medicine community heard from a RIF’d CDC/NIOSH worker, Dr. Micah Niemeier-Walsh. I don’t think I fully appreciated at the time that a large majority of NIOSH (National Institute for Occupational Safety and Health) workers were terminated in the RIFs. This is absolutely effing insane, I must say. Workplace safety is one of those hard-earned things—not something that just happened by accident in this country. An open letter written by “Friends of NIOSH”* was posted last week. Here’s an excerpt:

The health and safety of the American workforce is a shared goal of all our organizations. Many of our members are employed in high-risk occupations. Rather than accept that working requires individuals to place their health and well-being at risk, we believe strongly that all occupations can be made safer through the prevention of work-related injuries and illnesses. We urge you to do everything possible to reverse this misguided move immediately so that NIOSH’s vital mission continues, and its workforce can maintain efforts to keep Americans safe and well.

Fortunately, some Republicans, including Senator Shelley Capito of West Virginia seem concerned about this too. So, it’s possible that the mass NIOSH might get walked back. But, come on people, this should be an easy one!

The HHS reduction in force plan was sloppily executed.

Despite some claims that the reductions were carefully thought out, there’s evidence that the cuts were more of the Trump administration’s haphazard “break stuff and fix some of it later” approach. HHS Secretary Robert F. Kennedy Jr. admitted as much, when he said that up to 20% of the cuts announced last week are likely mistakes. For example, a scoop I had received (but never personally confirmed, so did not report) was that some NIH scientists in the Neuroscience Institute had been fired; well, according to Science, these terminations were “coding errors.” (Can you imagine the anguish, by the way? See above, under cruelty.)

All of this could have been avoided by simply taking some time to ask HHS leaders for ways to save taxpayer dollars. Instead, it’s increasingly clear that DOGE operatives with minimal public health experience were tasked with carrying out this massive endeavor. Meanwhile, things were so chaotic that some workers were fired, recalled, but not actually rehired. (I got whiplash writing that, let alone having to go through it.)

Cuts will alter HHS productivity and effectiveness—in a bad way.

There was lots of talk of reductions that were merely simplifying bureaucratic bloat. However, as the week unfolded, we learned about some of the HHS staff reductions and how they may compromise core mission activities. Dr. Robert Califf, the former FDA Commissioner under both President Obama and President Biden, wrote that the “FDA as we’ve known it is finished.” (I’ll be posting a conversation I had with Dr. Califf a few days ago for MedPage Today later this week.) Other experts have said the FDA’s review capacity has been diminished by the cuts. Some insiders that I spoke to pointed out that some of the cuts at FDA may not seem directly related to review activity, but they are. For example, the FDA’s library team was RIF’d. That especially matters because, recently, access to medical journals has been cut off too. How is a remaining scientist responsible for adjudicating some new drug or medical device supposed to do their job if they don’t have access to medical literature? The New York Times reported that food safety, drug review, and the evaluation of new and cheaper generic drugs could be compromised by the reductions.

Meanwhile, important projects such as bird flu testing programs were cut—a dangerous gamble, to say the least.

The “brain drain” is beginning.

Last week, we learned that 75% of US scientists who responded to a Nature survey said they might consider leaving the country. In a New York Times essay, Neel Patel wrote about what is happening on the ground, sharing the stories of several researchers. At the core of the piece is the destruction of young careers. “Early-career scientists cannot simply migrate to the private sector,” Patel wrote. “Many scientists who work at private labs got their start in academic ones, often supported by federal grants.”

Moreover, US dominance in the medical and scientific research space has been an ongoing project, relying on recruiting and keeping the best minds from other nations.

“This American brain trust has resulted in over 400 Nobel laureates, more than any other country in the world. As of 2023, an estimated 1.2 million people around the world held a Ph.D. in science, engineering or health earned at an American institution. The United States accounts for 27 percent of the world’s total research and development activity — the most of any nation — though China, at 22 percent, is closing in.” —Neel Patel, The New York Times.

Meanwhile, I saw posts online showing that graduate science programs in Canada were seeking to take advantage of our newfound stupidity, extending deadlines for admission to budding US scientists. China, too, has seen an opportunity to assume a position as a global leader, thanks to a void we are leaving behind with our destruction of USAID and retreat on the biomedical research front. Is this what we wanted? To make China great instead of us?

In other news…

At least Dr. Oz studied up…

Last week, the US Senate confirmed Dr. Mehmet Oz to run the Centers for Medicare and Medicaid Services (CMS), an agency that has as much power over our health as any. Dr. Oz has said a lot of boneheaded things over the years. But he’s also been something of an enigma. Before jumping the shark and becoming a televangelist for all manner of medical quackery, Dr. Oz was actually a highly skilled and respected cardiothoracic surgeon at Columbia University. He was so well-regarded before his television years that, according to my friend Dr. Craig Spencer (who overlapped with Dr. Oz on some cases in the ER at Columbia), some faculty used to invoke the phrase “Mehmet says,” during arguments—meaning that if Oz had said something, it was likely to have been both well-considered and true. Surprising, is it not?

Therefore, Dr. Oz’s radical departure from a life devoted to academic medicine and complicated clinical care—an Oprah-facilitated descent from wisdom to woo—has long been seen by his colleagues as a deep disappointment, if not an outright betrayal; Darth Vader-esque. In fact, Dr. Oz’s fall from grace to gratuitousness (ok, I’ll stop) was superbly documented over a dozen years ago in a fascinating piece published in The New Yorker. (The piece was also masterfully composed: “Oz is almost certainly the only cardiologist in American history with a full-time warmup comedian on his staff,” New Yorker staff writer Michael Specter wrote in the piece.)

Obviously when Dr. Oz was nominated by President Trump to the highly technocratic position of CMS administrator, I found it to be something of an odd choice. (Surgeon General seemed more up his alley.) But I also wondered which Dr. Oz would show up to the job. Would it be the earnest healer of his younger days or the cynical huckster of his later years? After all, Oz had once been a gifted student. Maybe he would buckle down and study for this role like it was a board exam, I thought. (And if he successfully did that, would that be good, or annoying? The answer is both.) Well, on the surface at least, it seems like that’s exactly what has happened over the last few months. While Oz has taken some regrettably pro-Trump stances, he seems to have come to his Senate hearings prepared. He was described by one former CMS administrator as “months ahead, preparation-wise, [of] where I was in 2001 when I took the job. And I had a lot of experience.” Oz even divested from professional activities that would amount to conflicts of interest, a rare nod to anti-government corruption norms of the past that have elsewhere been spurned by this administration.

Now, we’ll see what Oz does with his new position…

Legal updates.

Three quick updates from around the judicial system…

• Remember when the Trump administration suddenly cut $11 billion in public health funding to jurisdictions around the country that depend on that money to keep us safe? A judge blocked it last week. For now.

• Remember when the Trump administration tried to summarily cap all NIH indirect funding to institutions of higher education at 15%? A judge permanently blocked that too.

• Remember when the Trump administration suddenly cut a slew of NIH grants because the administration doesn’t like (or is afraid of) certain topics and research designed to understand and protect certain populations? The ACLU sued the administration last week over the moves. The lawsuit says that the administration has pursued a “reckless purge of federal grants, halting application processes midstream, and stripping funding opportunities from its website. Hundreds of research projects — many of which have been underway for years, representing thousands of hours of work and billions of dollars in investment — were abruptly canceled without a scientifically valid explanation.” Let’s hope the ACLU and the plaintiffs it represents win this one.

RFK Jr’s “MAHA” slogan revisited (already).

Not everyone gets their own Trumpy slogan. But RFK Jr. got one in “Make America Healthy Again.” There are many problems with all of this. One of them is that America was never all that healthy to begin with, Lila Shroff wrote in The Atlantic last week. On top of that, with vaccination rates down (and measles up), and now a push to stiff-arm the CDC into abandoning its pro-fluoride messaging, we might indeed be headed to the past. Unfortunately—and somebody please tell RFK Jr. this—that is a bad thing.

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That’s all for now. If you have information about any of the unfolding stories we are following, please email me or find me on Signal at InsideMedicine.88.

*I made an error in the earlier version of this. I mistakenly said Senator Lisa Murkowski was a co-author of the letter.

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