American Psychiatry in the Shadow of MAHA and MAGA

Reflections on medicine, politics, and public trust

Make America Healthy Again

Sociopolitical dysfunction and pseudoscientific populism in the US have come for psychiatry, as they have for much of academia and medicine. Just as sepsis affects all organs of a body, no social institution can function properly in a septic society. The predicament of American medicine is multi-layered, and failures of the healthcare system have played no small part in the etiogenesis.

There are at least three interrelated but somewhat distinct aspects of the current situation:

1. A slow deterioration of public trust in psychiatry and a failure of healthcare institutions to improve public mental health outcomes.

2. A rising populist, anti-establishment sentiment, currently exemplified by Make America Healthy Again (MAHA), that offers the veneer of a progressive movement but supports solutions that are oriented towards personal responsibility rather than public health (diet, exercise, and lifestyle change), skepticism toward public health mandates (e.g., regarding vaccinations), embrace of functional medicine and wellness grifters, and reliance on discredited scientific hypotheses (e.g., the link between vaccines and autism, the link between SSRIs and school shootings)

3. A proto-authoritarian government waging a war on scientific and academic institutions

Each aspect brings a distinct set of considerations and warrants a different kind of response. There is no simple or single action American medicine can take to undo any of this.

Take the issue of eroded public trust. It has many sources. It is related to a naively realistic and positivistic public view of how science operates, and when the public is exposed to the actual messiness of science (as happened during the COVID-19 pandemic), it reacts with suspicion and distrust. There are, of course, also issues with bad science and shoddy science journalism. The public has been fed headlines in the style of “Science says…” and “According to neuroscience…” and “Harvard scientists prove…” for decades, offering a steady barrage of mutually inconsistent research findings with confidence that would leave any sensible person skeptical. Replication crisis, p-hacking, publication bias, conflicts of interest, unreflective reliance on reductionistic language, and neglect of iatrogenic harm have all played into this.

And then there’s the issue of the disconnect between advances in medical technology and the poor state of public health. There is a strong Illichian temptation to think that more medicine is making us sicker, but this state of affairs is by and large the result of underresourced systems of care and a discrepancy between individual-centric and public health interventions.

It is unfortunate, but medical institutions are limited in what they can do about public health in the absence of political support—especially in a country like the US, where the right to health is not guaranteed and where a Scandinavian-style public welfare state is commonly dismissed as “communism.” Public money is subject to political agendas and political priorities, and it cannot be otherwise.

Think of gun violence, a heavily partisan issue, even though the scientific literature and clinical opinion are clear that easy accessibility of guns is a major culprit. And yet this has failed to persuade the public to a degree that any political action will follow. On social media, when physicians discuss gun violence, they are routinely told, “Stay in your lane.”

The importance of addressing social determinants of health is obvious by now. During her presidency of the American Psychiatric Association, Vivian Pender (2021-2022) made social determinants of mental health a priority; a dedicated APA Task Force produced, among other things, policy guidance for government agencies. This policy guidance didn’t really go anywhere. Congress couldn’t even save the expanded child credit that had cut child poverty in half. So what can physicians do in a situation like that? We simply do not possess the political authority to offer anything beyond policy guidance. And to the extent that we do anything beyond, it starts looking suspiciously partisan.

Folks like my friend Eric Reinhart look at this status quo with scathing judgment. In a recent Nature opinion piece, for example, Reinhart writes:

“What has left US health so vulnerable to partisan capture is not an excess of politics but rather a depoliticizing distortion of public health that fixates on individualistic medical care and personal responsibility, rather than public responsibility to address root social and environmental causes of disease and care for those who are sick or disabled. This weakens communities, fuels resentment and social division, limits political imagination and undercuts political organizing among groups that could achieve change.

The US medical profession, which has long been conservative, bears considerable responsibility. We physicians have historically avoided engagement with politics, except for policies that might affect our compensation and power, often justifying our inaction by appealing to scientific neutrality and professionalism. But, as Trump has made clear, our refusal to engage politically has not protected public health or medical science — it has left both defenceless.”

Here’s the problem with this. The moment we go beyond policy guidance based on scientific evidence to actual political engagement, we become subject to the ugly realities of partisan politics. And in a divided country where parties have so far alternated in power every 4-8 years, no scientific institution can survive being seen as partisan.

In fact, part of the reason academia is currently under attack from the Trump government is that despite being overtly depolitical in one sense, it is still seen as too partisan because academics by and large—and for good reasons—support a progressive political agenda.

Reinhart writes,

“US political leaders and health officials have abandoned the once-obvious truth that political reforms to counteract poverty, inequality and inadequate social services are crucial to preventing diseases. A medical field that’s focused on treating illness as a substitute for preventing it through public policies now laments the supposed intrusion of politics into health.”

This ignores the obvious: the medical field neither has the power nor the mandate to enact political reforms to counteract poverty, inequality, and inadequate social services.

I do agree that medicine and public health cannot be “apolitical.” This is because politics encompasses a variety of meanings. One of the best discussions that I’ve seen of the subject comes from John Z. Sadler in Values and Psychiatric Diagnosis (2004), in which he outlines four different senses of the word “politics”:

1. Broad social negotiation of interests: the way in which different individuals and groups with competing interests negotiate, advocate, and influence outcomes in society

2. Partisan, ideological conflict

3. Internal power dynamics within professions and institutions — including struggles for prestige, authority, control over knowledge, or resources

4. The dynamics of power, authority, and vulnerability within clinical encounters.

Medicine and public health cannot be “apolitical” in any absolute sense, but that doesn’t mean that medical institutions can or should become political actors in a highly partisan landscape.

The medical profession should do its utmost to inform and educate the public. We have not done the best job of this, I agree. Some of what medicine has to say will have clear policy implications. Public health must be political in the sense of advocating for structural conditions conducive to human flourishing. But the role of medical institutions ends there… and our role as politically engaged individuals in a democracy begins. If we want political change, we have to undertake the difficult, messy work of politics. No amount of politicized medicine will do that for us.

We also need to be careful not to accept a structural determinism that underplays the multidimensionality of human suffering. Social inequality, privatization, and political neglect are major contributors to morbidity and mortality. But disease, disability, and death are not wholly preventable through even the most just social arrangements. It is also the case that beliefs about health, autonomy, and responsibility are embedded in cultural tendencies. Public mistrust of health institutions, vaccine skepticism, and resistance to public mandates are not simple byproducts of economic insecurity and inaccessible social services. How healthcare should be delivered, by whom, under what obligations, and with what respect for competing considerations like freedom, fairness, and pluralism are questions that admit no easy public consensus.

---

My qualified disagreements above aside, I have to say that Reinhart has so far offered the best diagnosis of MAHA’s internal contradiction in his public writings. Two articles in particular are notable. “RFK Jr.’s Mental Health Bait and Switch” [The New Republic, 27 February 2025] and “How MAHA is Helping Poison Americans While Claiming to Save Them” with Biella Coleman [Politico Magazine, 2 April 2025]

Reinhart’s argument is that although RFK Jr. and the administration purport to challenge the over-medicalization of mental health—an issue that resonates with long-standing critiques within social and critical psychiatry—their policies in practice decimate public health infrastructure and deepen social inequities. The result is not a liberation from psychiatric overreach but a worsening of health disparities. While MAHA presents itself as a populist challenge to corporate capture, environmental toxicity, and the medicalization of social distress, it reveals a profound incoherence at its core by also simultaneously supporting an aggressive deregulatory agenda that leaves everyone less protected. Movements like MAHA, while identifying and campaigning on real grievances, are aligned with political forces committed to dismantling the state apparatus needed to address those grievances. It is popular anger against elites co-opted into deregulatory projects.

My own reaction to MAHA aligns strongly with that of Dost Öngür, whose viewpoint article in JAMA Psychiatry (“Psychiatry and the Make America Healthy Again Commission,” April 17, 2025) offers an elegant and succinct analysis. As Öngür notes, the very language of the MAHA executive order betrays a suspicion that psychotropic medications are inherently detrimental. Öngür also recognizes that psychiatry’s problems are, at their core, systemic—reflecting deeper failures in healthcare, social services, and research culture.

Öngür calls for a reimagined psychiatry that embraces humility, fosters participatory and methodologically rigorous research, strengthens community-based care, resists ideological capture, and recognizes the indispensable role of social supports.

“Psychiatry can and should be more self-critical and public health–oriented, and it can benefit from a public commission that promulgates a reform agenda focused on improving access to care, reducing stigma, and conducting research on questions and outcomes that patients and families and the public care about. This work should be conducted with minimal intellectual bias and maximal transparency, and it should proceed along multiple dimensions to improve the lot of individuals with mental illnesses and their families.”

Öngür’s analysis and answer is one that I can wholeheartedly agree with.

---

With regard to rising authoritarianism and political attacks on science in the US, I am genuinely unsure how to proceed. The scope of the problem exceeds my abilities to such a degree that my inclination is to simply withdraw. Reinhart, on the other hand, would like the profession to go out with a bang.

In “The Rise of Medical Fascism” (The Nation, 21 April 2025), Reinhart calls on medical professionals to actively resist the rising authoritarianism in healthcare. He advocates for collective action, including forming networks of mutual aid and engaging in civil disobedience. He stresses that neutrality is not an option in the face of state violence and that the medical profession must prioritize ethical obligations over compliance with oppressive policies.

For my part, I don’t have any substantive answers. I do not have the temperament of an activist, and political protest doesn’t come naturally to me. The idea of medical institutions in the US engaging in civil disobedience seems so unrealistic and utopian to me that I cannot even entertain it. The medical profession would have to be structured entirely differently and would have to consist of entirely different personality types than the one we have at present—it would have to be a medicine that doesn’t depend on state support and that doesn’t have risk aversion drilled into trainees from day one.

I grew up in Pakistan, a post-colonial, Islamist, hybrid state with strong authoritarian tendencies. Open dissent was dangerous. Mobs routinely killed people for perceived insults to religion, and blasphemy charges led to life imprisonment. Critiques of military power would result in the disappearance, torture, and, at times, assassination of journalists. A sliver of progressive, freethinking civil society existed, but it was extremely fragile. It couldn’t afford to draw attention to itself or make itself a target simply for the sake of some symbolic show of resistance. The goal was to keep a spark of freethought alive in a society fanatical about ideological purity. It was about survival in a hostile environment and the wisdom of knowing which battles are winnable.

What is happening politically in the US is still in evolution. Perhaps a lot can be done through the democratic channels that still exist. Maybe if medical professionals do refuse to comply, authoritarianism will falter, as Reinhart hopes. Certainly “do not obey in advance,” “defend institutions,” “remember professional ethics,” and other Snyderian lessons remain essential. But if American fascism continues its march, private and quiet acts of intellectual resistance by medical professionals may eventually be as valuable as public acts of disobedience.

---

Psychiatry at the Margins is a reader-supported publication. Subscribe here.

See also:

Building a Shared Scientific Understanding of Psychopathology: Q&A with Dost Öngür

The Social World Is Something We Collectively Create

Rejection of Hijab as a Psychiatric Problem in Iran