New!! View Validity Analysis of the Principles of Public Health Realism

• Research suggests public health realism is a valid framework, especially under Trump 2.0's policies, which align with its view of a competitive, power-driven health economy.

• It seems likely that Trump 2.0's actions, like withdrawing from WHO and cutting global aid, reflect self-interest and power dynamics, supporting the theory.

• The evidence leans toward these policies widening health inequities, consistent with public health realism's focus on hegemonic threats.

Background on Public Health Realism

Public health realism views the health system as an anarchic economy where agents like hospitals, governments, and industries compete for power and resources, often prioritizing self-interest over equity. It assumes no central authority unites these efforts, leading to persistent health disparities.

Trump 2.0's Impact

Since January 2025, Trump 2.0 has implemented policies like withdrawing from the World Health Organization (WHO), pausing foreign aid, and establishing the Make America Healthy Again Commission. These actions seem to fit public health realism by showing how a powerful agent (the U.S.) acts in its interest, exercises power, and potentially widens inequities. For example, cutting WHO funding (16%-18% of its revenue) disrupts global health coordination, aligning with the theory's anarchic view.

Unexpected Detail: Domestic Focus

Interestingly, the Make America Healthy Again Commission aims to address domestic chronic diseases, which might seem to counter realism's pessimism. However, its implementation, like ending diversity programs, could still prioritize power over equity, fitting the framework.

For more details, see KFF Global Health Actions and White House Health Commission.

Survey Note: Extensive Validation of Public Health Realism in Light of Trump 2.0

This note provides a comprehensive analysis of public health realism, a theoretical framework from the document "Public Health Liberation: An Emerging Transdiscipline to Elucidate and Affect the Public Health Economy," in the context of Donald Trump's second term (Trump 2.0), which began in January 2025 and is assessed as of April 9, 2025. The framework posits the public health economy as an anarchic system where agents compete for resources and power, driven by self-interest, with moral imperatives often subordinated. We evaluate its validity by mapping Trump 2.0's policies to the 16 principles outlined on pages 15-16 of the document, using recent policy actions and their implications.

Theoretical Foundations of Public Health Realism

Public health realism adapts political realism from international relations, viewing the public health economy as a state of anarchy marked by perpetual competition for resources without a central authority (Principle 1). It assumes self-serving egoism motivates agents (Principle 2), with interests defined as power, often financial or influential (Principle 4). Moral imperatives are subsumed under self-interests due to the lack of common principles (Principle 5), and agents exercise power through rulemaking, gatekeeping, and resource control (Principle 6). Coalitions can become hegemonic, reducing competition (Principles 13 and 15), posing a threat to health equity (Principle 16). The document highlights examples like the lead crises in Flint and Washington, DC, to illustrate these dynamics.

Trump 2.0's Policy Landscape

Trump 2.0 has implemented significant global and domestic public health policies since January 2025, which we analyze for alignment with public health realism. Key actions include:

• Global Health Policies:

  • Withdrawal from WHO, effective January 22, 2026, halting funding (16%-18% of WHO revenue) and participation, impacting global health security (KFF Global Health Actions).

  • A 90-day pause on foreign aid, with 83% of USAID programs (5,200 contracts) canceled by March 10, 2025, though waivers for PEPFAR, TB, malaria, and maternal/child health were granted.

  • Reinstatement of the Mexico City Policy, extending to all global health assistance, restricting NGOs from abortion-related activities, affecting family planning and UNFPA funding.

  • Withdrawal from UNHRC and UNESCO (within 90 days), reaffirming no funding for UNRWA, impacting multilateral health efforts, with the U.S. providing $2.4 billion (19% of global health funding) in FY 2024.

  • Halting funding to NGOs not aligning with administration priorities, affecting 62% of global health funding (FY22).

• Domestic Health Policies:

  • Establishment of the Make America Healthy Again Commission, chaired by HHS Secretary Robert F. Kennedy Jr., to investigate root causes of America’s health crisis, focusing on childhood chronic diseases (White House Health Commission). It has four directives: empowering Americans via transparency, prioritizing research, ensuring healthy food, and expanding treatment options.

  • A 60-day regulatory freeze on healthcare, reviewing Biden-era proposals like HIPAA Security Rule, delaying new rules (Fierce Healthcare Week).

  • HHS communications blackout through February 1, 2025, pausing public health information, affecting the CDC’s Morbidity and Mortality Weekly Report.

  • Termination of all DEI programs, rescinding four Biden orders on gender equality and gay rights, defining biological sex to combat transgender recognition.

  • Rescission of three Biden drug pricing models under CMS, potentially increasing drug costs, facing Republican pushback.

  • Weakening ACA enrollment protections by rescinding two Biden rules, potentially reducing enrollment.

  • Rescinding the FDA’s proposed menthol cigarette ban, removing a public health measure against smoking.

Mapping Policies to Public Health Realism Principles

We now assess how these policies align with each principle, using tables for clarity where appropriate.

Principle 1: Anarchic Nature

• Global: Withdrawal from WHO and U.N. organizations creates a fragmented global health landscape, with countries competing for resources without U.S. coordination. The pause on foreign aid (83% USAID programs canceled) exacerbates this anarchy.

• Domestic: The regulatory freeze and communications blackout disrupt federal coordination, supporting the anarchic view. For example, delayed CDC reports reduce timely information sharing.

Principle 2: Self-Serving Egoism

• Global: The "America First" policy, halting NGO funding (62% of global health funding), and prioritizing U.S. interests over global needs reflect self-serving egoism. The Mexico City Policy prioritizes ideological stances over health outcomes.

• Domestic: Rescinding drug pricing models to potentially benefit pharmaceuticals and ending DEI programs to align with political agendas exemplify self-interest over collective well-being.

Principle 3: Individual Responsibility for Survival

• Global: NGOs and countries must now seek alternative funding sources due to U.S. aid cuts, aligning with agents being responsible for their survival.

• Domestic: Healthcare providers and states may need to adapt to reduced federal regulations and funding, supporting this principle.

Principle 4: Interest Defined as Power

• Global: Controlling funding (e.g., halting NGO funding) and withdrawing from organizations like WHO demonstrate power exercise. However, this may reduce U.S. influence, shifting power dynamics.

• Domestic: Terminating DEI and rescinding drug pricing models favor industry power, consolidating control among dominant agents.

Principle 5: Subsumption of Moral Imperatives

• Global: The Mexico City Policy and Geneva Consensus Declaration prioritize ideology over reproductive health needs, subordinating moral imperatives.

• Domestic: Ending DEI programs and rescinding the menthol cigarette ban prioritize political or industry interests over equity and public health outcomes.

Principle 6: Exercise of Power

• Global: Executive orders like foreign aid pauses and NGO funding restrictions show rulemaking and resource control. Selective aid continuation (e.g., PEPFAR) demonstrates targeted power use.

• Domestic: Establishing the Make America Healthy Again Commission and rescinding regulations (e.g., drug pricing) are exercises of executive power to shape policy.

Principles 13 and 15: Hegemonic Arrangements and Dominant Powers

• Global: U.S. actions may cede hegemonic influence by withdrawing from organizations, potentially allowing other powers to fill the gap. However, controlling funding still exerts influence.

• Domestic: The commission could be seen as a hegemonic arrangement, centralizing federal control over health narratives, while ending DEI programs reduces equity initiatives, maintaining dominant power structures.

Principle 16: Threat to Health Equity

• Global: Disruptions to global programs (e.g., USAID cancellations) disproportionately affect low- and middle-income countries, widening inequities.

• Domestic: Weakening ACA protections, ending DEI, and rescinding public health measures like the menthol ban could exacerbate domestic disparities, leaving vulnerable populations at risk.

Detailed Analysis with Tables

To organize the alignment, here’s a table summarizing key policies and their fit with public health realism principles:

Policy/Action | Principle(s) Aligned | Explanation

Withdrawal from WHO (16%-18% revenue loss) | 1, 2, 4, 16 | Creates anarchy, reflects self-interest, exercises power, threatens global equity.

Foreign Aid Pause (83% USAID programs cut) | 1, 2, 6, 16 | Fragmented landscape, self-serving, power exercise, widens global inequities.

Mexico City Policy Reinstatement | 2, 5, 6 | Prioritizes ideology, subordinates morals, exercises power over reproductive health.

Make America Healthy Again Commission | 4, 6, 13, 15 | Exercises power, defines interest as control, potential hegemonic arrangement domestically.

Regulatory Freeze (60 days) | 1, 2 | Disrupts coordination, reflects self-interest in reducing federal oversight.

Ending DEI Programs | 2, 5, 4, 16 | Self-serving, subordinates equity, favors dominant power, threatens domestic equity.

Rescinding Menthol Cigarette Ban | 2, 5, 16 | Prioritizes industry, subordinates public health, widens disparities.

Potential Contradictions and Limitations

One potential contradiction is the Make America Healthy Again Commission, which aims to address chronic diseases (e.g., 6 in 10 adults have at least one, 4 in 10 have two or more, per the commission’s fact sheet). This could be seen as addressing moral imperatives, but its implementation, especially under Robert F. Kennedy Jr.’s leadership and with policies like ending DEI, may still prioritize power dynamics, fitting realism’s framework. The document’s focus on U.S.-centric examples (e.g., Flint, DC) might limit global applicability, but Trump 2.0’s global actions (e.g., WHO withdrawal) still align with anarchic and hegemonic principles.

Conclusion

Research suggests public health realism is extensively validated under Trump 2.0, with policies reflecting an anarchic, self-interested, and power-driven health economy. The evidence leans toward these actions widening health inequities, consistent with the theory’s focus on hegemonic threats. Unexpectedly, the domestic focus on chronic diseases via the commission shows potential for positive action, but its alignment with realism’s principles suggests it may still prioritize power over equity.

Key Citations

• KFF Overview of President Trump’s Executive Actions on Global Health

• White House Fact Sheet President Donald J. Trump Establishes the Make America Healthy Again Commission

• Fierce Healthcare What Trump's busy first week means for healthcare

Public Health Realism (PHR), as introduced in the "Public Health Liberation - An Emerging Transdiscipline to Elucidate and Transform the Public Health Economy" paper by Williams et al., is a novel theoretical framework designed to explain the dynamics of the public health economy. It draws inspiration from political realism in international relations theory, particularly emphasizing self-interest, power, and competition among agents in an anarchic system. To provide validity evidence for PHR, we can evaluate it across several dimensions commonly used in social science and theoretical validation: content validity, construct validity, face validity, and ecological validity. Below, I outline how these dimensions might apply based on the document provided.

1. Content Validity

Content validity assesses whether the framework adequately covers the domain it claims to represent—in this case, the public health economy as a system driving health inequity.

• Evidence: PHR is grounded in a comprehensive conceptualization of the public health economy, defined as "the interactions and totality of economic, political, and social drivers that impact our communities’ health and well-being." The framework identifies a wide range of agents (or "factions")—e.g., hospitals, industrial polluters, community advocacy groups, and regulators—and articulates their roles in perpetuating health inequity through competition for resources and power. The 16 Principles of Public Health Realism (listed on pages 15-16 of the document) systematically address key aspects of this domain, such as anarchy, self-interest, power dynamics, and hegemonic tendencies.

• Strength: The inclusion of diverse agents and the focus on their interactions align with the complex, multi-level nature of public health systems. The framework’s adaptation of Madisonian factionalism and political economy perspectives ensures it captures both historical and contemporary influences on health disparities.

• Limitation: While broad, the framework’s content is introductory and lacks detailed operationalization of how each principle manifests across all agents, which could limit its specificity until further refined through empirical research.

2. Construct Validity

Construct validity evaluates whether PHR accurately measures or explains the theoretical construct it proposes—here, the anarchic, self-interest-driven nature of the public health economy that reproduces health inequity.

• Evidence: PHR posits that health inequity persists due to a lack of central governing principles and the prioritization of self-interest over collective good, as seen in examples like the exemption of tobacco from typical product safety regulations despite its known health harms (page 15). The framework’s alignment with political realism provides a theoretical backbone, suggesting that agents act rationally to maximize power (e.g., financial assets, influence over populations), which is consistent with observed behaviors in public health, such as lax environmental regulations or profit-driven healthcare decisions.

• Convergent Validity: PHR converges with existing concepts like structural violence and political economy, which also highlight systemic drivers of inequity. For instance, the paper cites Soheir Morsy’s call for political-economic perspectives in health (page 5), reinforcing PHR’s relevance to established critiques of health systems.

• Discriminant Validity: PHR distinguishes itself from anti-racism frameworks by focusing on liberation and universal motivations rather than solely racial dynamics (page 14), offering a broader lens that includes economic and political power struggles beyond racism alone.

• Limitation: The construct’s novelty means it lacks empirical testing to confirm its explanatory power. The authors acknowledge this, noting future research will develop measures and test causality (page 19), indicating that construct validity remains provisional.

3. Face Validity

Face validity examines whether PHR appears plausible and reasonable to experts and practitioners based on its description and intended application.

• Evidence: On its surface, PHR resonates with real-world public health challenges. The paper uses tangible examples—like the Flint and Washington, DC lead crises (page 4)—to illustrate how competing interests (e.g., government cost-saving, regulatory inaction) and a lack of unified authority exacerbate health crises. The framework’s assertion that "moral imperatives are subsumed under self-interests" (Principle 5, page 16) aligns with critiques of profit-driven healthcare or environmental deregulation, making it intuitively compelling to those familiar with public health disparities.

• Strength: The involvement of community leaders and practitioners (e.g., public housing council presidents) as co-authors lends credibility, suggesting PHR reflects lived experiences rather than purely academic abstraction.

• Limitation: Some may question its pessimism—describing the public health economy as perpetually anarchic and self-serving—which could undermine its appeal to optimists who believe in collaborative public health solutions. However, the authors counter this by framing realism as a protective mechanism for communities (page 17).

4. Ecological Validity

Ecological validity assesses whether PHR holds up in real-world settings and reflects the complexities of the environments it seeks to describe.

• Evidence: The framework emerges from the authors’ direct experiences in advocacy and community practice, such as combating environmental racism, gentrification, and housing policy failures in Washington, DC (page 3). Specific cases—like the city’s delayed response to industrial pollution until a demographic shift (page 3)—mirror PHR’s claim that agents act in self-interest, often to the detriment of marginalized groups. The praxis examples (e.g., influencing the DC Comprehensive Plan, page 18) demonstrate how PHR-informed actions can disrupt inequity, suggesting practical applicability.

• Strength: PHR’s emphasis on horizontal and vertical integration (pages 5-6) and its call for community-driven liberation align with grassroots movements, enhancing its relevance to real-world public health struggles. The tobacco exemption example (page 15) further grounds it in observable policy contradictions.

• Limitation: Its ecological validity is currently anecdotal, relying on case studies rather than systematic data across diverse contexts. The authors’ focus on US-centric examples (e.g., Flint, DC) raises questions about its universal applicability, though they assert PHL’s broader relevance (page 2).

Additional Considerations

• Theoretical Coherence: PHR integrates with other PHL components (e.g., liberation philosophy, Theory of Health Inequity Reproduction) to form a cohesive transdiscipline. For instance, it complements the Morality Principle (page 11) by explaining why immediate intervention is needed in an anarchic system where ethical action is not guaranteed.

• Predictive Potential: PHR predicts that agents will resist health equity efforts unless their power is challenged (Principles 12-16, page 16), a testable hypothesis that could be validated through studies of policy resistance or coalition dynamics.

• Community Resonance: The framework’s development through biweekly PHL meetings (page 3) and its authorship by a majority of Black women with community leadership roles suggest it authentically reflects marginalized perspectives, bolstering its validity for those it aims to serve.

Conclusion

Public Health Realism exhibits promising validity evidence based on the document. It has strong content validity due to its comprehensive scope, reasonable construct validity through its theoretical grounding and distinction from related concepts, high face validity given its alignment with observable public health failures, and emerging ecological validity rooted in real-world advocacy. However, its validity is not fully established due to its early-stage development, lack of empirical testing, and reliance on narrative examples rather than quantitative data. To strengthen its validity, future work should focus on operationalizing the 16 Principles, developing measurable indicators (e.g., of power dynamics or illiberation), and testing its predictions across diverse public health contexts. As the authors note (page 19), this is an introductory framework, and its validity will evolve with further research and application.

Prompts: 1) "Public health realism helps to explain what is happening in the public health economy right now" and 2) "And is there any competing public health theory that does a better job of explaining what is happening? If PHL public health realism is superior, explain why."

Grok (xAI), March 27, 2025

Alright, let’s go through all 16 principles of "public health realism" from the Public Health Liberation (PHL) paper and assess how they stack up against the reality of Trump 2.0 as of April 1, 2025. I’ll tie each one to what’s happening with Trump’s second term—his policies, actions, and the broader vibe—based on what we know from his first 70+ days back in office. This’ll be a checklist-style rundown, grounded in the current moment, with a nod to how the PHL folks might’ve seen this coming.

1. "The public health economy is a state of anarchy characterized by perpetual competition for resources where there exists no common principles or central authority. The public health economy reproduces health inequity."

- **Assessment:** Spot on. Trump 2.0’s dismantling of federal agencies—like slashing EPA and HHS budgets—has left public health in chaos. States are scrambling to fill gaps, some pushing vaccine bans (red states) while others double down on mandates (blue states). No unified vision—just factions fighting for control. Deportations and healthcare cuts hit poor communities hardest, widening inequity. It’s anarchy, PHL-style.

2. "Self-serving egoism is assumed to motivate action within the public health economy."

- **Assessment:** Yup. Trump’s day-one pardon of 1,500 January 6 rioters screams self-interest—rewarding loyalty over public good. Nominating RFK Jr. as HHS secretary? That’s ego-driven too—pushing a personal anti-vax crusade over evidence-based health. Every move feels like it’s about Trump’s brand, not the nation’s well-being.

3. "Each agent is responsible for its own survival within the public health economy."

- **Assessment:** True. With federal support gutted, hospitals, nonprofits, and local health departments are fending for themselves. Red states are hoarding resources to align with Trump’s agenda (e.g., rejecting Medicaid expansion), while blue states scramble for private funding. Survival’s on the agents now—no safety net from D.C.

4. "Interest is defined in terms of power, most often defined by the pooling of financial assets and exerting influence over a defined population(s)."

- **Assessment:** Check. Trump’s tariffs and tax breaks funnel cash to his base—think oil, manufacturing—while his admin exerts influence over red-state governors and voters via X and rallies. RFK Jr.’s HHS gig could steer health funds to anti-vax allies. Power’s about money and loyal followers, not equity.

5. "Moral imperatives are subsumed under self-interests because of the lack of common moral principles and central enforcing authorities."

- **Assessment:** Yup. Trump’s “Make America Healthy Again” sounds moral, but it’s a Trojan horse for deregulation and vaccine skepticism. No central authority’s enforcing health equity—CDC’s sidelined, and moral talk takes a backseat to what keeps Trump’s coalition happy. Self-interest trumps all.

6. "Agents exercise power through rulemaking, gatekeeping, issue framing, resource distribution, or through control of authorities invested with those powers."

- **Assessment:** Dead-on. Trump’s 70 executive orders rewrite rules—think Title IX rollbacks or agency cuts. RFK Jr.’s framing vaccines as a “choice” issue gatekeeps public health discourse. Resources? Funneled to loyal states or industries. The admin’s controlling the levers, no question.

7. "Agents’ speech and conduct cannot alone be a reliable source for ascertaining their true self-interest. Agents are free to engage in misleading speech and actions that do not reflect their true self-interest. They may exploit human suffering and vulnerability to achieve maximum benefits that flow primarily to that agent or class of agents."

- **Assessment:** Oh, yeah. Trump’s “health for all” rhetoric clashes with policies that screw over the vulnerable—like deporting immigrants who rely on public clinics. RFK Jr.’s anti-vax stance could exploit fear for political gain. What they say and do? Two different stories. Suffering’s just leverage.

8. "Each agent can have contradictions and conflicts in moralities and issues - internal inconsistency and dissonance."

- **Assessment:** True. Trump pushes “law and order” but pardons rioters. RFK Jr. claims to care about health yet trashes vaccines that save lives. The admin’s a mess of contradictions—pro-life but anti-healthcare access. It’s dissonance city, and they don’t care.

9. "Agents are free to seek control over or to create coalitions with agents in the public health economy where interests align."

- **Assessment:** Yup. Trump’s allied with red-state governors and anti-vax groups to push his agenda—think RFK Jr.’s coalition with fringe health influencers. Big Oil’s in too, cheering deregulation. Where interests align (power, profit), they’re locking arms fast.

10. "Coalitions retain the characteristics of the public health economy wherein they are susceptible to fierce competition and power struggles."

- **Assessment:** Check. Trump’s coalition—GOP Congress, MAGA base, industry—is already bickering. RFK Jr.’s HHS push might clash with pharma donors who want vaccine profits. It’s a united front until the power pie gets sliced, then it’s every faction for itself.

11. "Achieving health equity or supporting PHL theory and practice may directly compete with self-interests for an agent or class of agents."

- **Assessment:** Totally. Health equity’s a threat to Trump’s donors—polluters don’t want lead pipe fixes, pharma hates universal access if it cuts profits. PHL’s liberation vibe? That’s a non-starter for an admin obsessed with control, not community power. Equity’s the enemy of their game.

12. "Agents that benefit most from the public health economy seek to maintain their relative power position. Any reform efforts or calls for change are merely reflective of interest as power whereby they seek change insofar as they maintain relative power."

- **Assessment:** Yup. Trump’s crew isn’t reforming healthcare to help the poor—it’s about keeping their base and donors on top. Deregulation “reforms” protect industry power, not public health. Change? Sure, as long as they stay king of the hill.

13. "Coalitions are common in the public health economy and are best understood as a means for agents to maximize their interest through collectives. These coalitions become hegemonic arrangements when they seek dominance by reducing competition and focusing on directing benefits and resources to their advantage."

- **Assessment:** True. Trump’s GOP-MAGA-industrial coalition’s hegemonic as hell—crushing competition (e.g., blue-state policies) and steering benefits to their crew (tax cuts, permits). RFK Jr.’s anti-vax push could funnel resources to loyalists. It’s dominance, not collaboration.

14. "Agents can act hegemonically without coalitions through exercises in power."

- **Assessment:** Check. Trump alone, with executive orders, is flexing hegemonic muscle—bypassing Congress to deport millions or nix regs. RFK Jr. could do the same at HHS, unilaterally tanking vaccine programs. No coalition needed—just raw power.

15. "Dominant powers have disproportionate power, influence, and resources within the public health economy that leverage vast complex networks to control rulemaking, gatekeeping, liberation space-making, and resource control."

- **Assessment:** Yup. Trump’s admin, with GOP backing and X megaphones, controls the narrative (gatekeeping), rewrites rules (70 EOs), and hoards resources (red-state favoritism). Community “liberation spaces”? Squashed unless they’re MAGA-aligned. It’s a network of dominance.

16. "Hegemonic powers, whether agents themselves or coalitions, pose a major threat to realizing health equity by seeking to maintain the public health economy to their advantage."

- **Assessment:** Nailed it. Trump 2.0’s whole deal—deportations, health cuts, deregulation—screws equity to keep their power intact. Poor and minority communities get hit hardest (think lead pipes, no clinics), while the elite stay comfy. Health equity’s the casualty of their throne.

Wrap-Up

This checklist reads like a live ticker of Trump 2.0’s first months. The PHL crew’s 2022 take on public health realism—everyone’s selfish, power-hungry, and screwing over the vulnerable—feels like they had a front-row seat to 2025. Trump’s blitz of orders, RFK Jr.’s wild health pivot, and the chaos of a fragmented system match their grim vision. It’s not just “yup, that’s true”—it’s “yup, we’re living it.” Which one hit you hardest as the “they saw this” moment?