Kim Shine:
Welcome to the Michigan Minds podcast, where we explore the wealth of knowledge from faculty experts at the University of Michigan. I’m Kim Shine, a senior public relations representative with Michigan News.

Today we’re talking to Scott L. Greer, whose work and research focuses on the intersection of public health and political science. Greer, Professor of Health Management and Policy and of Global Public Health at the School of Public Health, is here to discuss how personal health experiences and interactions with the healthcare system shape political engagement and trust in democratic institutions. We’ll also dive into the connections between far-right politics and global public health and examine the declining role of the United States as a global public health leader.
Thanks, Scott. You’ve been busy, and we really appreciate you joining us to share your research and your opinions on this very interesting intersection of politics and public health. So you’ve had multiple studies, commentaries, news articles, and podcasts on your work published recently, and one of the most recent was your review of decades of research that explains how health and healthcare systems shape political engagement and trust in democratic institutions. What were the top two or three takeaways of that research?

Scott Greer:
Thanks for having me here, and I love to start with this study because it was so interesting because the way results just jump off the page. Basically, what we found is a growing trend over about the last 30 years for ill health, for a decline in your self-reported health, to increasingly predict either dropping out of the political process or voting for the populist radical right, voting for Brexit, voting for the fascists in Europe. What’s going on?

There’s nothing intrinsic about being diagnosed with diabetes or lupus that is going to lead to your becoming increasingly conspiracist and anti-establishment and right-wing. Diabetes doesn’t do that. What happens is that when you’re diagnosed with a chronic disease or otherwise see a significant lasting decrease in your self-reported health, you get a lot of exposure to the healthcare system. You get a lot of exposure to your employer’s HR system. Maybe you get exposure to the government’s benefits system. Maybe you get exposure to the home healthcare system. And a little bit of exposure goes a long way with all of them because many of these systems are not designed to make you feel like an empowered patient, to feel like a respected adult human being. They’re disempowering, they aren’t necessarily trustworthy, and some of them are explicitly designed to create administrative burdens and make your life harder.

So what do you do when you’re spending a lot of your time dealing with people who are quite often legitimately not taking your interest seriously? You become less trusting. And when you become less trusting, there’s a political party on offer in most countries that’s willing to accept your vote and feed all of your worst instincts.

By and large, people in ill health voted for parties on the left. They voted for Democrats or Labour in Britain because they tended to be poorer, and those with the parties that were seen as reflecting the views of poorer people. That’s shifted, and that’s shifted because we have increasingly a lot of parties of the political right, not left populists, that are really going hard on distrust, distrust of science, of the establishment of medicine. And they’re activating the votes of people who are seeing a lot of healthcare systems that aren’t necessarily very patient-centric and aren’t very respectful of people, and they’re mad.

Kim Shine:
But how do you know one caused the other?

Scott Greer:
So I can’t speak for 170 studies covering everything from voting data in the rise of Mussolini in Italy through to following individuals in Britain in the last 20 years, but scientists are pretty good at distinguishing correlation from causation. And the studies that made me fall off my chair and say, “I need to pay more attention to this,” are ones that follow individual people. So you have somebody in 2014 who votes for Labour and supports Europe and England. In 2015, they get hit by some kind of a health shock, their self-reported health declines, and in 2016 you find them voting for Brexit.

Kim Shine:
And did your findings apply to US voters as well?

Scott Greer:
Yes.

Kim Shine:
Okay.

Scott Greer:
You see a lot of these studies on the county level, and I think both parties talk extensively about counties that get hit, for example, by poverty, unemployment, fentanyl, opioid epidemic in general. You see this county level correlation between decline in health status often decline in life expectancy and increased likelihood of voting for Trump. But the problem is American counties tend to be big square places with a lot of different people in them, so county level data is necessarily unsatisfying. You need to complement it with other things.
What’s really inspiring is this is actionable because if I go to you and I say, “We need a healthier population,” well great. A lot of the answers are things that we’ve known forever and we’ve chosen not to do it, right? More equal income distribution produces healthier populations, paid parental leave produces healthier populations. Have we done either of those in America?
But this is something where every little bit helps. If you run your medical practice in a way that alienates your patients, the patients might keep coming back because they’re stuck with you for insurance reasons or because the other guy in town doesn’t have any capacity, but you can make them less alienated and angry, and you can do that at the level of a partnership with a few doctors. You can do that at the level of a health system, a county health department, a state, an entire country. So the levers for affecting this are not just confined to the people writing the tax code, They’re also something that you can do by having a chat with your nurse about not calling older people sweetie.

Kim Shine:
How long have you been studying these connections between politics and health? And what put you on this path of scientific inquiry?

Scott Greer:
It was in the last century that I got interested in the topic when I was looking at basically how the United Kingdom’s four different health systems evolved and how they prioritized differently and thought differently about equity and public health and the needs of patients. And it’s just a fantastic topic because it’s endlessly interesting, endless supplies of smart people, and it matters to everybody, and there’s always a new bad argument. So even if you don’t score goals, you spend a lot of time as goalie.

Kim Shine:
And then let’s talk about going back, one of your earlier papers and an earlier decision in this administration to withdraw from the World Health Organization. You’ve weighed in on your concerns about that and how that affects the world, US citizens, but kind of wrap that up for me and kind of your top concerns with the United States withdrawing from WHO.

Scott Greer:
We’ve withdrawn from the World Health Organization, not the Pan American Health Organization, which is part of W-H-O. I’m unclear about why that happened. But we’ve also withdrawn from global health. So we left the W-H-O and took the 16% of the budget that we were providing to support everything from refugee health in Ukraine through to assistance in building management of wet markets and other sources of health emergencies predominantly in Asia.
Elon Musk boasted on Twitter that he put the USAID into a wood chipper. That’s 10,000 people fired on very short notice. We’ve left people with experimental medical implants that we have no intention of monitoring or removing.

We’ve effectively ended PEPFAR. There’s well-regarded modelers who put up a PEPFAR tracker that as we speak at the end of May there’s about 55,000 deaths so far that are attributable to Elon Musk and his wood chipper. So this is part of a bigger project.

How’s it going to hurt Americans? Well, first of all, we made a promise to millions of people. You can estimate up to 25 million deaths are likely if these cuts stick. And we’ve reneged on those promises, and we’ve reneged on the people on the ground who are working with us, and we’ve reneged on allies and civil society, and they’re going to learn a thing or two about the American people.

Secondly, even if we think we can plunge around in the world with no friends, there’s basic mechanical stuff. For example, how do you set the formula for the new flu vaccine? This usually has been a very technical and effective process in which CDC and a couple of other big agencies and WHO and the drug companies agree. And then we have the seasonal flu vaccine that means you don’t spend 10 days in bed and potentially infect somebody who’s vulnerable and could end up hospitalized or dead because of it. Flu’s a real disease. It’s not a head cold.

Well, we’ve left that. Occasionally somebody shows up. That’s bad enough, but it’s going to matter a lot more the next time we have an emerging mysterious infection like COVID-19 or if there’s a new variant of monkeypox or if highly pathogenic avian influenza takes off, which is quite likely. We are going to be cut off from those sources of international conversation.

And because of the scale of what we were contributing, we weren’t just paying for disease programs, we were paying for organizations that worked across a bunch of diseases and that could identify and squash an outbreak of Ebola or monkeypox or disease X that we have yet to think of, but which could be another COVID-19. Well, we’ve walked out on them. They’ll find other jobs probably. They’ll do other things, but they won’t be a healthcare infrastructure capable of squashing an outbreak when it’s just a few dozen people on the other side of the world. We’ll wait until it’s in Miami.

Kim Shine:
And you referenced 25 million deaths could occur. Where’s that come from and some examples of people and programs that are losing by leaving W-H-O?

Scott Greer:
By far, the biggest one is not actually WHO. It’s PEPFAR, the President’s Emergency Program for AIDS Relief, which is a big chunk of American foreign aid funding, or it was on January 20th. And PEPFAR gives highly active antiretroviral therapies to people with HIV in Sub-Saharan Africa. It has added, depending on your estimate, 12, 16 years to life expectancy in some countries. I grew up in the 1980s. The concept that we’d have AIDS basically under control was unfathomable to me until George W. Bush and the Republican Party went and did it and showed that the United States is capable of working with local partners and spending the money to not just add a dozen years to life expectancy in a country, but to manage transmission from parents to children to mean that you don’t have these countries carrying the burden of bereavement and caring and illness.

It’s good for the United States. And honestly, having not just friends, but having AIDS under control sounds great. And if you’d asked 1990s me entering grad school whether that was feasible, I would’ve laughed at you. And then George W. Bush teamed up with, essentially, Anthony Fauci, John Bolton, and evangelical Christians and set up the program that proved that is possible. That’s the bulk of the deaths that you will get from that wood chipper.

Kim Shine:
Interesting. I want to go back to flu vaccines, which you mentioned. You have another paper coming out about vaccine policies and politics.

Scott Greer:
Yeah. So “The Taster” is an article coming out in the British Medical Journal blog section with Anna Kirkland, also of Michigan, about vaccines and what it’s going to mean for the world. And we also have a book with the University of Michigan Press that’s going to be coming out later this year, which is a comparative study of vaccination politics in COVID-19 in 26 countries around the world.

There’s one simple takeaway, the entire American vaccine system, supportive scientific research, testing of safety, clinical trials, recommendations by the CDC, recommendations that filter through to whether insurance companies carry a vaccine, the whole system was built on the assumption of good faith. The whole system was built on the assumption that it would be staffed and the advisory committees would be staffed by professionals who understood that vaccines are one of the coolest and most powerful tools humanity has got from science. But since you give them to the whole population, you need to be really careful about side effects because you can’t go giving healthy people a shot that could do something bad to them.

So the system was built on the assumption of very, very rigorous oversight by people who believed in vaccines but wanted to be careful. That’s being turned inside out right now. We have an HHS being explicitly run by people who are somewhere between anti-vaccination advocates and extremely loud, just asking-questions types who have funded and worked with people who are pretty explicitly anti- vaccination activists.

So what they’re doing right now is they’re going through every little bit of the system and every decision that’s coming up, probing for a way to introduce questions about vaccines to reduce the number of people recommended for vaccines, for example removing the argument that pregnant women and children should receive COVID-19 vaccines, for which I see no clinical evidence, and which was done completely circumventing the normal system, or interfering with Novavax’s application for a permanent authorization for its COVID-19 vaccine on the basis that a couple of people in the administration don’t like single antigen virus vaccines, and you’re seeing the effects.

So Moderna was doing something so amazing. They were going to have an mRNA-based combined flu and COVID annual vaccine. And because they’ve been told loudly and clearly by the administration that the United States is no longer in favor of mRNA vaccines, they’ve withdrawn their application to bring it onto the U.S. market. Just to make it worse, this is going to affect the rest of the world.

An enormous sum of money has been given to a guy who was convicted of practicing medicine without a license for his adventures in autism quote unquote treatment in Maryland to identify the cause of quote unquote autism. I think we know what it might be according to him. That’s going to be such fuel for anti-vaccination movements around the world.

They have the United States federal government as an ally now, so I don’t think the rest of the world knows quite what’s going to hit them when the resources of the U.S. federal government are given to vaccine denialism. And I don’t think the rest of the world has internalized what’s going to happen as big drug makers decide whether or not to make vaccines when they can’t trust the United States market to give them a fair hearing.

Kim Shine:
And we talked, before we started recording today, about your concerns of the new approach to testing the safety of the COVID-19 vaccine. Tell me about your concerns with the placebo plans and all.

Scott Greer:
So this has been an anti-vaccination talking point for a long time. They’ve got a lexicon of things that sound very reasonable, right? Personal choice, do your own research, that kind of thing. And one of the most pernicious ones, these guys are clever, is saying correctly that a lot of vaccines haven’t had a placebo trial. Well, here’s why. If we have a vaccine that works well and we’re considering a vaccine that promises to work better, you don’t go back and try it against no vaccine at all. You’re evaluating whether the new vaccine is better than the one that works.
So if we were to come up with, say, a better vaccine against measles, the ethical thing to do is to compare it to the existing measles vaccines and see if it’s better, fewer side effects, better immunity, whatever. What they’re calling for when they say placebo trials, use the example of measles as a hypothetical, is we’d be saying that half of you are going to get a measles vaccine that might be really good, and half of you’re going to get sugar water. And if your immune system is destroyed by measles or you end up hospitalized or die, well, at least we’ve done a placebo trial. It’s unethical in at least two ways. One is we’d be deliberately exposing people to viruses that we can completely prevent. And the other is that you shouldn’t run human subjects research, taking the time and energy and health of real people, when the research is pointless. You don’t compare a new vaccine to sugar water. You compare a new vaccine to the previous vaccine that by definition, if it was on the market, worked well.

Kim Shine:
Where do you see us going next? What’s the future of public health and political science?

Scott Greer:
Well, it’s a crisis, and my favorite definition of a crisis is it’s a situation when you simply don’t know what the future is going to look like. And there are more possibilities now for America and health politics and global health politics and American politics, full stop, than there have been open at any time in at least my life. And health policy is downstream of the political crisis that we’re in.

But a couple of points that might be relevant. One is that the administration’s approach to health is not super well known but very unpopular. The Medicaid cuts, which we haven’t discussed, that are proposed in the budget peak out at about 14, one-four, percent public support. And Medicaid is something most Americans kind of know about, and a lot of them in red and blue states and young and old rely on it in one way or another, from newborn babies to mid-career adults whose parents depend on a nursing home through to people who are directly on it for one reason or another. The attacks on bioscience are really impressive. The budget that was proposed to the House of Representatives involved a 55% cut to NIH, just for one example, and the cuts already, tens of thousands of skilled staff, enormous numbers of people who were on grants to local public health agencies. These have not, by and large, broken through. And a lot of the problem is simply the drug companies are used to very refined insider lobbying campaigns. Scientists, by and large, like to do science more than they like to do advocacy, and they don’t necessarily have a cadre of experienced activists who know how to get out into the street.

It’s a huge sector of the American economy, it’s a huge force for the American economy to be thriving, and it’s not really politically mobilized. Will it mobilize? I don’t know. Does telling people what’s going on even within the sector where you think it’s just my university or it’s just my funding area? Well, it’s not. It’s everything. When they say 55% cut, they mean 55% cut. When they say 20,000 people, they mean 20,000 skilled people.

The other thing I would point out is there’s a dynamic well-known to political scientists, which is called thermostatic public opinion, where it’s like a thermostat. If the room heats up, the air conditioning goes on. And if the room cools off, the heating goes on. And it means that whenever a government does something, it tends to produce a reaction against it. On one hand, the government supporters make excuses for it, but equally they ease up. In a few months, football season will be coming and Trump supporters will think about something else. And the people who don’t like the policy get angrier and angrier, and tend to get better and better organized, and tend to get louder and louder and more salient, and answer pollsters’ phone calls and get out into the street.

So pretty much any president should expect a thermostatic public reaction against them, which is why presidents’ parties usually lose midterm elections. And that dynamic might be particularly interesting and maybe even strong in this case because, for example, you’d never had an administration that so explicitly decided that it was going to attack the scientific research and public health. Will that get people out in the street? I don’t know.

Kim Shine:
We will end on that and ponder. Thank you very much for being with us today, Scott. Interesting stuff.

Scott Greer:
It was a pleasure to be here.

Kim Shine:
Thank you for listening to this episode of Michigan Minds, produced by Michigan News, a division of the university’s Office of the Vice President for Communications.