What would Robert F. Kennedy junior mean for American health?

Public-health leaders have responded with horror and disbelief. “Robert F. Kennedy junior is not remotely qualified for the role,” said Dr Peter Lurie, president of the Centre for Science in Public Interest, a public-health watchdog, in a statement, adding that “nominating an anti-vaxxer like Kennedy to HHS is like putting a Flat Earther at the head of NASA.” Industry types are similarly worried. Shares in vaccine-makers, such as Moderna and Pfizer, and biotech firms fell in response to the news.

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The panic is understandable. Mr Kennedy has a long history of promoting debunked health theories and claims about vaccines, most damagingly about the risks of inoculating children. He has said that “there’s no vaccine that is safe and effective” and has advised parents not to follow guidance by the Centres for Disease Control and Prevention (CDC), one of the health agencies that could soon fall under his direction. He is a proponent of several unproven alternatives to mainstream medicine, ranging from the kooky but harmless to the actively dangerous. And he has promised to dismantle large parts of America’s core public-health agencies—including the CDC, the Food and Drug Administration and the National Institutes of Health (NIH)—and purge them of the “smothering cloud of corporate capture”.

If he does make it into the job (he will have to survive confirmation by the Senate), what might that mean in practice? His Make America Healthy Again (MAHA) movement, which the Trump campaign embraced in the final phase of the election, gives clues to some of his public-health priorities. But surprisingly little is known about his approach to other big issues, such as drug-price negotiations or government-funded health-care programmes. “I don’t think anybody really knows what it means for Medicare and Medicaid,” says James Capretta, from the American Enterprise Institute, a think-tank.

What is clear is that Mr Kennedy has radical ambitions and that Mr Trump, at least for now, has backed him fully. In his nomination statement, Mr Trump echoed Mr Kennedy’s favourite talking points, writing that “Americans have been crushed by the industrial food complex and drug companies who have engaged in deception, misinformation and disinformation when it comes to Public Health.” Mr Kennedy, he promised, would restore the government’s health agencies to “Gold Standard Scientific Research”, end the chronic-disease epidemic, and “Make America Great and Healthy Again”.

Many fear that the opposite could happen. They worry that core public health and research programmes will be shut down and replaced by pseudoscience. Those concerns are not unfounded. Mr Kennedy recently said that on the second day of the new administration, “600 people are going to walk into offices at NIH and 600 people are going to leave.” He has also suggested that half the NIH’s budget be devoted to researching “preventative, alternative and holistic” medicines.

Although the likely deprioritisation of tackling infectious diseases is worrying, Mr Kennedy’s mission to go after chronic disease in America is laudable. Nearly half the country is now pre-diabetic or diabetic and some of the methods he champions—such as eating healthy, pesticide-free food and exercising—are sensible. And Mr Kennedy’s candid criticisms of Big Food and Big Pharma are a salutary counterweight to powerful vested interests that few dare to stand up to. One need not be a conspiracy theorist to see that their relationships with regulators that they help fund are, at the very least, complex.

Yet precisely because of his bulldog attitude to industry, Mr Kennedy will probably run into trouble with Republicans in Congress, who have long relied on these sectors for support and may see his proposals as “nanny state” and anti-business. Although several Republican senators took to social media to pledge their support (Josh Hawley of Missouri said it was a “bad day for Big Pharma”), others reserved judgment. “I look forward to learning more about his other policy positions and how they will support a conservative, pro-American agenda,” wrote Bill Cassidy, from Louisiana.

If Mr Kennedy does become health secretary, the extent and duration of his power will depend on Mr Trump’s continued tolerance for letting him “go wild”. Unlike most of Mr Trump’s loyalist cabinet picks, Mr Kennedy is a former rival and a recent—and no doubt conditional—MAGA convert. For now, Mr Kennedy benefits from a boss who is not interested in health policy. This may change if Mr Trump is confronted with the type of public health disaster that can’t be ignored, as it happened with COVID-19 in his first term. Or perhaps he will pull the plug once he realises that Mr Kennedy is after his—and his voters’—cheeseburgers. Just as Mr Kennedy’s support for MAGA is conditional, so is Mr Trump’s commitment to “in sickness and in health”.

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