Healthcare Musings For May 30, 2026

May 30, 2025

Dear Interested Readers,

 

Education, Research, Academic Freedom, and the Social Determinants of Health

 

Of all the things our president has done, which are very difficult to understand, nothing has seemed more counterproductive to me than his multi-pronged attack on our educational system, medical research community, and our public television and radio stations, which continue to educate and delight us throughout our lives. I am old enough to remember the relationship between our current public television (PBS) and National Educational Television (NET). I was the recipient of very generous grants and loans that made my education at Harvard Medical School possible. The salary I received as a cardiology fellow at the Peter Bent Brigham Hospital primarily came from National Institutes of Health grants, which also supported the salaries and research of my mentors. I doubt that any of us in the sixties or seventies would ever have imagined that our government would ever withdraw resources from education, research, and an educational and informative asset like public broadcasting. 

 

Some of my fellow students, several of my mentors, and eventually many of my colleagues had come from abroad to this country for the educational and research opportunities available here. They have remained critical contributors to the amazing progress that has been made in medical science over the last sixty years, and to be important participants in our healthcare delivery system. Dr. Eugene Braunwald, who became Physician-in-Chief at the Brigham in 1972 at the start of my junior residency, had escaped Nazi Germany as a child and rose to be one of the most influential contributors in American medicine. I shudder to think of all the talent we will lose in the future as our president makes it difficult for foreign students to access American universities. 

 

Even if I had never had these experiences, I don’t think I would have been able to anticipate or understand what is happening now. How can President Trump imagine “making America great again” by attacking assets that have contributed mightily to the greatness we have achieved? Even if Trump doesn’t understand the critical contributions ot our universities, they are envied around the world by some of the brightest and most capable potential contributors to the efforts to understand disease and create innovative treatment approaches. It is also a sad fact that without doctors who were trained abroad and came here to join our practices, our workforce shortages would be greater, and our access to care would be much more delayed than it is now. I see only loss and no gain in this effort by Trump and his co-conspirators to terrify foreign students with threats of expulsion as a part of the administration’s effort to undermine education, research, and the success of elite colleges and universities. Whatever the motivation, the stupidity and likely destructive outcomes nullify any plausible explanation and will certainly undermine our efforts to establish health equity and improve the social determinants of health.

 

In one of his recent daily “Substack” entries, Paul Krugman addressed some of the same questions in a piece entitled “The Economic Consequences of Destroying Harvard: Freedom is on the line. But so are jobs.” He begins with the personal revelation that he was rejected by Harvard when he applied as a high school senior. That rejection forced him to go to Yale as an undergraduate. He earned his doctorate at M.I.T. It must be difficult for college admission officers to look at high school applicants and identify future Nobel Prize winners. Krugman writes:

 

Harvard is easy to dislike. It’s rich. It’s elitist. It rejected my application back when I was a high school senior.

But the Trumpist effort to destroy Harvard and other elite universities — for that is clearly their intention — will do vast damage to our nation’s future.

 

What follows that confession of his rejection is his attempt to demonstrate just how valuable an asset Harvard is to even those it rejects and to the most loyal wearers of those red “MAGA” hats. I return to my habit of bolding the big thoughts.

 

The most important aspect of this campaign of intimidation and disruption is, of course, the attack on freedom of thought. I hope that nobody actually believes the MAGA line that universities are indoctrinating their students in wokeness, DEI, Marxism, whatever. The real complaint, obviously, is that these institutions aren’t indoctrinating their students — that they are exposing young people to a variety of ideas and encouraging them to think for themselves, when they should be preaching right-wing dogma and obedience to whatever The Leader says they should believe.

 

This week, Harvard’s president, Alan Garber, was interviewed on NPR by Steve Inskeep. In that interview, Garber responds to the allegations of the Trump administration. It would be naive to imagine that in a complex institution like Harvard, particularly after a year and a half of turmoil since the atrocities of October 7, 2023, there would not be moments when those expressing their feelings crossed a line of propriety. It seems to me quite a subjective call to say that the administrations of colleges like Harvard, Columbia, or the more than 130 other American colleges where there were protests against the war in Gaza, could have done much in the moment to tame the emotions of those who were upset. Implicit biases are a human reality that we all should struggle to control, but when big events occur the downside actions precipitated by those biases can converge with misinformation and spread like a virus and explode in the moment beyond the bounds of propriety or the ability in the moment for cooler heads with administrative responsibilities to quickly contain or control. I am aware of no evidence that any university or college could have done anything that would have prevented these exercises of First Amendment rights. Mr. Trump expects to be able to express any obnoxious idea that comes to his mind. In a democracy, we all have the right to let our words demonstrate our foolishness and bigotry. 

 

Campus protests have a long history here. Do you not remember the campus protests against our war in Vietnam during the sixties and seventies? I do. I lived less than a half mile from Harvard Yard in 1969 when a force of 400 police officers was necessary to quell what was a huge protest and occupation of University Hall. I remember walking through Harvard Square the day after the police cleared Harvard Yard. I could have been in London the day after a Nazi blitz. Thankfully, there were no deaths at Harvard, but four students were shot and killed by the National Guard at Kent State in Ohio. It is my opinion that the proper reaction to what has happened on college campuses is not to undermine free speech, but to focus on what constitutes responsible and effective use of the First Amendment rights to free speech, a free press, and freedom of assembly. 

 

Trump’s actions against Harvard threaten all three of these fundamental freedoms, and in so doing will eventually have a direct impact on the quality, availability, and cost of healthcare. If he wants to attack or redefine fundamental constitutional rights, I would suggest that he turn his attention to the Second Amendment. Further limiting access to firearms would have a substantially positive impact on our collective life expectancy and be of tremendous benefit to the survival of women and children. Now that I have vented a little, back to Paul Krugman’s thoughtful post.

 

Given this terrifying reality of the Trumpian war on learning, indeed on scientific thought itself, it may seem crass to examine the economic consequences of the attacks on higher education. Yet it’s important to understand that these consequences will also be disastrous – both for the current economy and for the economy’s long-term future.

 

Klugman begins by explaining that from an economic perspective, foreign students are the equivalent of an American export. Foreign students usually pay the full tuition fee, and provide American institutions of higher learning billions of dollars of revenue every year, but that isn’t the whole story. Klugman explains:

 

Harvard is a major U.S. exporter. The foreign students that the Trump administration is trying to ban usually pay their own tuition — money that shows up as a credit in the US trade balance. But arguably the much larger issue is that Harvard is a crucial element within the Greater Boston economy. This regional economy is one of the crown jewels of the U.S. economy, one of the most important generators of high incomes, specialized knowledge and innovation.

 

Klugman provides a perspective that suggests there is more benefit from Harvard’s presence in Boston’s economy and the economy of the nation than Trump and his lackeys are considering as they vent their righteous anger at “elites” and the elite institutions like Harvard. One famous Republican, Ronald Reagan, tried to convince us that there was a trickle-down benefit from being gentle with taxes on the rich. There is a real trickle-down benefit from Harvard and our other institutions of higher learning. It may surprise you, but it is a great benefit to the entire community to be the hometown of an elite institution of higher learning. Why would you throw away this benefit if your goal was to “Make America Great Again”? Klugman explains:

 

Metropolitan economies are always more than the sum of their parts. Businesses clump together, forming a metropolitan economy, because their positive interactions create an industrial ecology of mutually reinforcing strengths, usually built around some kind of core competence. One famous example is the San Francisco Bay Area, a nexus of global leadership in digital technology. Another is Greater New York, the world’s leading financial center.

What is so special about Greater Boston? The economy of Greater Boston can seem confusing, because its world-beating sectors look quite different from each other on the surface. First, there are the schools: Colleges and universities employ 87,000 people in the Greater Boston area, accounting for a far higher share of employment than they do in America as a whole. Second, there’s a world-class medical complex, treating patients from around the world and also training many of the world’s top doctors. Third, Greater Boston is a leading player in both AI and “tough tech,” which emphasizes how information interacts with the physical world. Fourth, Greater Boston is the world’s leading biotech hub.

 

If Harvard is trashed or crippled as an example of Trump’s toughness and as a warning to other institutions that dare resist the will of the “dear leader,” the damage will spread like ripples from Cambridge. Klugman continues by explaining the connectivity between the university and the larger local, regional, and national economy.

 

What do all these activities have in common? The answer, surely, is that they’re all linked by intellectual curiosity, rigorous thinking, scientific discipline, and an openness to new ideas. All of these qualities engender an openness to the very best talent around the world – students, researchers and entrepreneurs. Moreover, all of the parts are mutually supporting: the intellectual ferment within the universities and medical complex is a prime source of business innovation, and business success brings financial support and acclaim for the schools.

 

Will Trump’s vendetta spread down Massachusetts Avenue to damage MIT, where Krugman earned his Ph.D.?  Perhaps it will cross the Charles and become a problem for Boston University or Boston College. It could spread to Boston’s suburbs and subdue intellectual activity at Tufts, Babson, Brandeis, or Bentley.  Surely those colleges and universities will be impacted by what happens to their ancient, famous neighbor and its affiliated hospitals. Klugman understands the relationships and wants us to realize that Trump’s ignorance is exposed by his desire to demonstrate that he is president and can do whatever might occur to him in the moment. I like Klugman’s analogy to a Jenga tower.

 

 

Harvard is by no means the dominant player in this intellectual and economic universe. It may not even be the most important player. At a guess M.I.T. has, in a direct sense, been a larger incubator of new businesses than its neighbor two miles up Massachusetts Ave. But M.I.T. wouldn’t be what it is without Harvard nearby, and vice versa. The same goes for the dozens of other fine universities in the area, and the hundreds — probably thousands — of businesses nearby. The hospitals and the medical research are part of the same ecosystem.

So destroying Harvard, even if the campaign against intellectualism stopped there — which it wouldn’t — would be like pulling a crucial piece out of a Jenga tower. The odds are that the whole structure of the Greater Boston education and innovation ecosystem would collapse. Consequently, America would lose all that Greater Boston does to advance and enrich our nation.

 

After a brief reflection on Harvard’s international benefit as an extension of America’s “soft power,” Krugman asks the question that I have asked too many times to count since January 21,

 

Do MAGA types understand how much damage their campaign against universities will do to American prosperity and power? Probably not. But I suspect that it wouldn’t matter if they did. From their point of view, making America poorer, weaker and sicker is an acceptable price for keeping the nation suitably ignorant.

 

Perhaps that last sentence does demonstrate that Klugman is an elitist. I doubt MAGA voters were asking how to make America “suitably ignorant.” They also probably never thought their Medicaid, fuel assistance, and SNAP benefits would be sacrificed as a partial funding of a tax reduction for those who already have more than they could ever use. Perhaps, they thought all of Trump’s campaign rhetoric was just theatrical hyperbole, or maybe it was part of some brilliant monologue by the author of The Art of the Deal. Just the possibility that Trump could have any success in his attack on Harvard should be a risk we are unwilling to take because it is a challenge to intellectual freedom and part of his larger attack on American education. If successful, these attacks will inevitably hurt all aspects of our society and hamper our attempts to improve the Social Determinants of Health. When there is no intellectual freedom, creativity suffers. When we introduce fear and political revenge into the mix, progress is in jeopardy. 

 

As the years go by, and my time in the clinic and hospitals fades into distant memory, I have shifted the emphasis of these notes toward the Social Determinants of Health. I believe that there is nothing more critical to the improvement of the Social Determinants of Health than how we educate our young. A worthwhile education is difficult to obtain when there is no academic freedom or effective DEI efforts that provide monetary support for previously excluded populations who will remain excluded by their persistent poverty.  When we fear the vigorous discussion of history and ideas, we are taking a step toward authoritarian government and cultural stagnation. As is often the case, one Trump initiative undermines another. It is hard to imagine “Making American Healthy Again” if we dampen intellecual freedom and cripple a system of funding for critical research and the support of diverse student bodies.  

 

As I was thinking about Trump’s attempts to hobble Harvard, I decided to ask ChatGPT for a review of how his executive orders over the first four months of his second term that are related to education might impact the Social Determinants of Health and the equity and quality of our healthcare. It took three tries for me to formulate my question in a way that the “bot” could understand and respond with an answer that was close to what I wanted and had been trying to convey in the first part of this letter to you. As I have facetiously said in the past, the trick to using AI is in formulating your question in a way that directs the bot to give you an answer that makes your points for you. Below is my very long question, and the bots attempt to be my servant. To my delight, the bot included many references. My question was:

 

 

How might the Social Determinants of Health (SDOH) and the delivery and quality of healthcare be eventually affected by the president’s executive orders banning DEI, attacks on academic freedom, and enrollment of foreign students and cancelation of research grants at elite universities like Harvard and Columbia plus attacks by DOGE on the Department of education?

 

The bot answered:

 

Trump administration’s recent executive actions—including the dismantling of diversity, equity, and inclusion (DEI) initiatives, restrictions on international student enrollment, cancellation of research grants at elite universities, and interventions by the Department of Government Efficiency (DOGE) in education policy—are poised to significantly impact the social determinants of health (SDOH), as well as the delivery and quality of healthcare in the United States.

 

🏥 Impact on Healthcare Delivery and Quality

1. Elimination of DEI Programs

DEI initiatives have been instrumental in promoting culturally competent care, improving patient-provider communication, and addressing health disparities. The removal of these programs is likely to:

• Reduce the diversity of the healthcare workforce, potentially leading to a lack of representation and understanding of minority patient needs.KFF
• Erode patient trust and satisfaction, as culturally sensitive care becomes less prevalent.
• Widen existing health disparities, particularly among marginalized communities.

Studies have shown that DEI efforts contribute to better health outcomes by fostering environments where patients feel understood and respected. Penn LDI

2. Restrictions on International Students

International students, especially those in healthcare fields, play a crucial role in the U.S. medical system. Limiting their enrollment can:

• Exacerbate shortages in the healthcare workforce, particularly in underserved areas.
• Diminish the cultural competence of healthcare providers, affecting the quality of care for diverse populations.
• Hinder collaborative research efforts that rely on international perspectives and expertise. The Times of India

The proposed 15% cap on foreign students threatens to undermine the academic and financial health of institutions like Harvard, which rely on international enrollment for diversity and innovation . The Times of India+1San Francisco Chronicle+1

3. Cancellation of Research Grants

The termination of federal research funding, particularly from agencies like the NIH, disrupts ongoing studies critical to public health. Consequences include:

• Delays in the development of treatments and medical advancements.
• Loss of valuable data and momentum in addressing pressing health issues.
• Potential setbacks in training the next generation of healthcare professionals.

For instance, the cancellation of grants at Harvard has jeopardized research into diseases such as cancer and ALS.

🏫 Effects on Education and Health Equity

1. DOGE’s Interventions in Education

DOGE’s actions, including efforts to dismantle the Department of Education and reduce federal oversight, may lead to: Education Week

• Increased disparities in educational quality across states.
• Reduced access to higher education for low-income and minority students.
• Challenges in maintaining nationwide standards for educational equity.

Such changes could indirectly affect health outcomes, as education is a key determinant of health.

2. Impact on Social Determinants of Health

The combined effect of these policies may:

• Limit access to quality education and healthcare services.
• Increase socioeconomic disparities, leading to poorer health outcomes.
• Undermine community health initiatives aimed at addressing SDOH. Managed Healthcare Executive+1Walden University+1

By disrupting the systems that support health equity, these actions risk reversing progress made in addressing the root causes of health disparities.

In summary, the administration’s recent policies are likely to have far-reaching consequences on the healthcare system, educational equity, and the broader determinants of health, potentially exacerbating existing disparities and hindering efforts to promote health and well-being for all Americans.

 

Chaos, confusion, and calamity are characteristics of a disaster. They are not descriptors that one would like to apply to one’s government. Unfortunately, those are the words that seem appropriate, as with each new day, there is an unexpected event that reveals even more outrageous incompetence and simultaneously the vulnerability of our democracy. It is sad to realize the possibility of the reversal of the amazing progress that we have made in our quest to live up to the principles enunciated at our founding. One wonders what comes next and how it will end.

 

After a Soggy Graduation, a Few Days of Good Things and Good Weather Before More Rain

 

We had been looking forward to our granddaughter’s graduation from college for several months. The family rented an “Air B and B” so that we would have plenty of room to be together. As the day approached, it became obvious that it would be yet another wet Saturday in a long chain of weekend washouts. This coming weekend is looking like another watering of the greenery.

 

As it became clear that no reprieve was possible, we assumed that the powers that be at Bowdoin College would elect to move the graduation indoors, but that did not happen. We sat in a cold rain for three hours to see what you can see in the header of this letter. That young woman in the middle of the picture with a big smile on her face while flipping her tassel is my granddaughter. It was still a great day, and maybe it will endure in memory because it was a joy despite some pretty awful cold and wet weather. 

 

A couple of months ago, our graduate had asked if she could bring a few friends to the lake for an after-graduation celebration. Ten recent grads arrived late on Sunday afternoon. There were seven men and three women. Fortunately, the new grads brought great weather. They enjoyed three days of warm weather, wake surfing, kayaking, having conversations around a fire pit, and doing some pretty good cooking. My wife and I got a good taste of what it would be like to run a B and B. We tried to stay out of the way and just enjoy observing so much youthful exuberance and fellowship. 

 

After the party was over on Wednesday, I had my first cataract op yesterday. Immediately, things were clearer, and there was an amazing difference in color and clarity between the just-fixed eye and the one that will be done in two weeks. I hope to be able to read closed captions with ease on “Brit Box” after the second op two weeks from now.

 

I hope that your summer is off to a good start. A good gathering with exceptional young adults and a little sunshine can help you survive a week of disturbing news and events. 

Be well,

Gene