Will Fauci have a job? Will the public regain trust in the FDA? 8 of the scientific institutions and traditions on the line on Tuesday

WASHINGTON — It’s impossible to overstate the impact of Tuesday’s presidential election on the health and science landscape.

It’s a contest between a candidate who says he’ll give federal scientists a major say in national policy and a president whose top aides have boasted that he wrested control of the U.S. “back from the doctors” in the early stages of the Covid-19 pandemic. One candidate has made the phrase “trust the scientists” a constant refrain. The other has focused far more on economic indicators than scientific ones — and considered it an insult to suggest that his opponent will “listen to the scientists” in determining pandemic policy.

The divergent positions of President Trump and former Vice President Joe Biden on these issues may be central to the outcome of the election and will likely impact every element of the American medical and scientific worlds. Based on the candidates’ own words, interviews with officials in both camps as well as public health experts, STAT outlines eight traditions, institutions, and norms that are on the line in the election.

Will the world’s most storied public health agency come out of the shadows?

One of the most surprising aspects of the Trump administration’s pandemic response has been its continued sidelining of the Centers for Disease Control and Prevention, the agency typically responsible for responding to infectious disease outbreaks, keeping the public informed, distributing vaccines (when they’re available), and tracking the latest data. This much seems clear: The role and the profile of the CDC would dramatically change if Biden is elected.

During Trump’s tenure, the agency has faded from the public eye. Trump has denigrated the CDC director, Robert Redfield, for providing basic information to the public: that masks are a more effective tool than vaccines at stopping coronavirus spread (vaccines, of course, don’t exist yet), and that most Americans might not be able to receive Covid-19 vaccinations until the middle of 2021.

Trump has also pushed CDC to the side within Operation Warp Speed, the government’s efforts to manufacture and distribute hundreds of millions of Covid-19 doses. Instead, the project relies heavily on military personnel — and experts say that’s not necessarily a bad thing.

Biden has pledged to institute daily pandemic press briefings with public health experts, which presumably would include the CDC. He’s made clear that his administration would place doctors at the center of the federal government’s Covid-19 messaging.

It’s an open question, however, whether a President Biden would stay the course or implement major changes to the Warp Speed vaccine distribution system.

“When you’ve got a question that impinges on science, you listen to the people who know what they’re talking about,” said Ezekiel Emanuel, a physician who was among the Affordable Care Act’s lead architects and a health care adviser to Biden’s campaign. “And I think that’s a characteristic of Joe Biden. He did the [cancer] moonshot. What was the moonshot? The moonshot was to empower and facilitate science. So I think that’s the kind of thing you’re likely to see from him.”

Informed health officials say that if Trump is reelected, expect an exodus of talent from the CDC, where many officials find the president’s treatment of the agency inexcusable.

Will scientists have the last word?

Often when leading federal scientists have opportunities to speak publicly about the Covid-19 pandemic, they’re undercut by Trump.

The president has directly contradicted Anthony Fauci, the government’s top infectious disease expert, on the effectiveness of hydroxychloroquine. He’s told reporters that Redfield was “confused” and had “made a mistake” about mask use and vaccine timelines, respectively. At a now-infamous press briefing, he suggested that injecting store-bought disinfectant or shining ultraviolet rays on skin might be worth examining as Covid-19 treatments. (He later insisted he was joking.)

Biden, meanwhile, has pledged his daily Covid-19 briefings will “put scientists and public health officials front and center.” Many Democrats have speculated that he would install Ron Klain as his chief of staff. Klain has no deep background in health and science, but he was respected as President Obama’s “Ebola czar’’ and has the trust of Biden, for whom he served in several senior roles over the years.

Trump allies argue that his combativeness is reflective of long-simmering resentment toward “establishment” scientists, and his pushback toward Fauci and Redfield attempts to incorporate the economic and social costs of extended economic slowdowns and social distancing.

“It’s above my pay grade, it’s above economists’ pay grade, to weigh the tradeoffs between those two positions,” said Katy Talento, an epidemiologist, Trump campaign surrogate, and former Trump health care adviser, who argued Trump hasn’t received appropriate credit for his efforts to balance economic growth and pandemic management. “If this were Barack Obama or Joe Biden weighing these tradeoffs, and taking the exact same position the president had taken in practice, you would not have any of the criticism you’re seeing today.”

Biden isn’t immune to scientific exaggeration, even if it’s to a lesser degree. Even in the context of the cancer moonshot, he’s pledged that the country will “cure cancer” if he’s elected. (In fact, so has Trump.) Both claims have prompted rebukes from scientists who warn it’s an impossible pledge and stress that cancer, of course, isn’t just a single disease.

What does the future hold for Anthony Fauci?

That depends on who is president. Biden has made his respect for Fauci a campaign promise. The former vice president says that if he wins, he would immediately call Fauci, who turns 80 in December, and ask him to continue his government service.

By contrast, Trump’s patience with Fauci is wearing thin, as this past weekend made clear. In a Saturday interview with the Washington Post, Fauci seemed to voice a clear preference for Biden’s public health approach. The former vice president, he said, “is “is taking [the pandemic] seriously from a public health perspective, while Trump is “looking at it from a different perspective,” citing the president’s focus on the economy and lifting Covid-19 restrictions.

On Sunday, Trump suggested he would fire him after the election. As a crowd at a Pennsylvania rally chanted “Fire Fauci,” Trump paused and then responded: “Don’t tell anybody, but let me wait until after the election … he’s a nice man, but he’s been wrong on a lot.”

Trump has expressed discontent without Fauci all through 2020, but he’s also expressed reluctance to dismiss him (technically, he doesn’t have the authority to do so, though his administration could likely reassign Fauci if it wanted to).

“Every time he goes on television, there’s always a bomb,” Trump said on a recent call with campaign staff. “But there’s a bigger bomb if you fire him.”

One reading of Trump’s remarks: He recognizes that Fauci is a popular figure nationally, and dismissing him could be harmful politically. But if Trump is reelected, campaign concerns are no longer relevant, and Fauci’s standing in government would be more tenuous than ever before.

Can we trust the FDA?

For most of its 114-year history, the Food and Drug Administration has pronounced drugs safe or unsafe, and for the most part, the public hasn’t thought twice about following the agency’s advice. But the Covid-19 pandemic and highly politicized messaging regarding therapeutic and vaccine approvals has brought an end to that long-held trust. States including California, Washington, and New York, fearing a politicized vaccine process, have created independent commissions to review the data underpinning a potential emergency authorization.

A similar effort, from the National Medical Association, a professional association of Black doctors, has said it will independently review safety and efficacy data for drugs and vaccines that the FDA authorizes or approves. It’s partly an acknowledgment of the United States’ brutal history of abusing Black participants in medical research or failing to include the Black population in clinical trials altogether. It’s also a response to the Trump administration’s frequent pledges of an imminent vaccine approval and the controversial messaging that accompanied emergency authorizations for potential Covid-19 therapies like convalescent plasma. Whether or not the president has inappropriately leaned on FDA, the agency’s credibility has taken a major hit.

Perhaps more remarkably, state governments are forming their own working groups to evaluate vaccine safety in the event of an FDA authorization or approval. California, Washington, Oregon, and Nevada have teamed up on one such effort, and New York’s government also announced a similar task force.

If he wins, Biden has his work cut out for him if he wants to restore that trust. But his campaign has pledged that the FDA and the federal government’s vaccine efforts would be more broadly transparent with all relevant data and decision-making. And while it’s impossible to erase centuries of justified mistrust, Biden’s campaign has highlighted racial disparities in its health care platform.

“If Biden wins, he will need to reassure African Americans that the federal government will limit bias and assure this group that the government will treat medical racism as any other manageable risk factor in vaccine development, testing, and trials,” said Kristie Lipford, an urban studies professor and health disparities researcher at Rhodes College in Memphis, Tenn.

Will the U.S. rejoin the WHO?

Trump shook the global health world when he began the process of withdrawing the United States from World Health Organization membership. For months, he’s blamed the global health agency for failing to demand transparency from China in the pandemic’s early stages and complained that China shoulders a comparatively tiny amount of the WHO’s cost compared to the United States.

The WHO hasn’t been immune to criticism from the broader scientific community, but there’s near-consensus among global health experts that a U.S. withdrawal could have major consequences for international research partnerships, coordinated health communication, and even the country’s ability to develop effective flu vaccines.

Biden has said he would reverse the decision to withdraw on his first day in office. By law, Trump had to give one year’s notice, so if Biden is elected, he’d have ample time to prevent the move from going forward.

“There was a lot of criticism for the WHO after Ebola, and there’s always going to be criticism because they’re a body of consensus,” said Nahid Bhadelia, an infectious diseases physician and assistant professor at Boston University School of Medicine. “They’ve had issues, but they are the only body that creates a platform for this type of international collaboration in the middle of a pandemic. Rather than investing in and making the WHO better, we’ve actually shot ourselves in the foot, because we’re farther away from this global collaboration.”

Will the White House actually actually empower its science adviser?

In the Obama administration, White House science adviser and Office of Science and Technology Policy director John Holdren played a central role in many policy decisions, from climate change to artificial intelligence.

The office hasn’t received much attention during the Trump administration. The president left the office without a director for nearly two years following his inauguration. Major scientific organizations generally voiced approval for the president’s eventual pick, meteorologist Kelvin Droegemeier, but have since soured on his two-year tenure, arguing there is little evidence he has attempted to mitigate Trump’s anti-science tendencies.

Perhaps the biggest headlines OSTP has received under Trump were last week, after the office issued a press release trumpeting the administration’s scientific accomplishments that included “Ending the Covid-19 Pandemic.” The obvious mischaracterization was a sign of how far the office has fallen, said Holdren, who added he was confident Biden would quickly install new scientific leadership.

“The idea that the administration claimed to have defeated [Covid-19] is emblematic of the kind of preposterous misstatements that continue to issue from this White House,” he said. “The key to ensuring that public policy is informed by up-to-date and authoritative scientific evidence, the key to that is science-savvy leadership at the top.”

Will Brad Pitt and his ilk be front and center in public health messaging?

Trump has assigned himself the marquee role of being the frontman on public health. The role of federal officials has been muted. Yes, there’s an ongoing partnership between the Ad Council, the nonprofit that often works with the government on PSA campaigns, and the CDC. But its spots don’t usually appear in prime time, and there hasn’t been much engagement on the part of big-name celebrities.

The Trump administration’s recent attempt at a $250 million public outreach campaign to educate the public on Covid-19 — and sell the public on the president’s accomplishments — has failed to recruit celebrities, who feared their participation would be seen as political and pro-Trump.

The Biden campaign has hinted that it would revive such a campaign. Given Biden’s long list of celebrity endorsements — last week he aired a prime-time ad voiced by Brad Pitt — that world would be more likely to climb on board, whether or not their participation is viewed as partisan. It’s likely that if Biden wins, his public outreach work could begin even before he takes office, especially if he moves quickly to select heads of health care agencies.

“Once you have these appointees, before they take their positions they can publicly start speaking about this,” said Bhadelia. “They’d have a certain amount of credibility.”

Remember the White House science fair?

While Trump once said he has “a natural instinct for science,’’ it has been obvious for years that he is not a science enthusiast.

One of his recent business flops was a nutritional supplement company that attempted to sell customers scientifically dubious urine test kits. He also made it a priority to withdraw the U.S. from the Paris Climate Accords, over the near-consensus objections of American researchers.

But perhaps the most telling example is that Trump discontinued the custom of hosting U.S. Nobel laureates at the White House.

The tradition doesn’t exactly date back centuries — it was only a fixture during the administrations of George W. Bush and Barack Obama. But the scientific community viewed the Trump administration’s decision to forgo the event, and the Nobel laureates’ refusal to participate even if they’d been invited, as an early sign that their community and the Trump administration were not copacetic. The same goes for the Trump administration’s failure to follow through on an initial pledge that they’d continue the Obama-era tradition of a White House science fair.

Biden hasn’t made it explicit that he’d invite the Nobel laureates back, or that he’d restart the White House Science Fair. But Holdren, Obama’s science adviser, said Biden would be a “science-savvy” leader, and recalled that he, as vice president, frequently lingered after meetings with a White House scientific council.

“Almost invariably Vice President Biden would want to stay and continue to interact with this group of eminent scientists and technologists, to pick their brains,” he said.