Dear friends,

Health equity advocates are painfully aware of the consequences of H.R.1, the Republican budget bill that guts Medicaid and food assistance to fund tax cuts that primarily benefit the wealthy. Yet the bill has also given rise to more immediate, less visible obstacles: despair, at times complacency, and at other times myopia. The cuts’ cruelty has compounded the distress and other cuts of the past six months and stuck many of us in a state of grief. This is an eminently natural and understandable reaction. But to put the reality simply, we have to channel our grief into action, not get stuck in it.

Case in point: When I spoke with lobbyists for several healthcare institutions in April, bewildered by what I perceived as deafening silence, I hoped for reassurance that critical conversations were happening behind closed doors. Instead, I heard some version of, “You won’t hear institutions stand up until after reconciliation passes—they aren’t willing to lose on their provisions.” But that approach didn’t work. H.R.1 is now law and whatever meager concessions were obtained are eclipsed by the enormity of the law’s collective threat to healthcare access, food security, and affordability. As journalist David A. Graham recently wrote, “Institutions that are willing to sacrifice their values for the government’s favor are likely to end up with neither.”

The current administration in Washington is swiftly pursuing policies that erode democracy and concentrate power among a small elite—a shift which promises to bring more harm to vulnerable communities and society at large. A core strategy of authoritarians is to erode the institutions of democracy and civil society that protect public accountability, rights, and shared civic life, from elections to safety-net programs to due process. Some of these institutions preserve the rule of law and access to justice. Some preserve the right to health care, food, and other essential resources and opportunities. All are foundational to the public and private systems that preserve access to health care and social services—and all, as such, underpin health care’s quadruple aim.

In other words, assaults on institutional funding and integrity don’t just impact courts and universities, they also put hospitals, clinics, community-based nonprofits, and public health departments—and the communities that depend on them—in peril.

We can see clearly now that there will be more and more cuts and restrictions until these institutions no longer function or exist—and that these policies will place more vulnerable groups in harm’s way and threaten the work of public health and health care.

So how can health professionals and leaders respond to these common threats and defend the integrity and sustainability of vital institutions, including our own? And what do we do when we, as leaders, also lose faith and want to disengage?

Democracy’s shared power depends on institutional integrity, and institutional integrity depends on people seeing themselves in the system and engaging with it. So the erosion cycle works in reverse. When people lose faith in democratic institutions, they disengage or fall prey to disinformation and fear-based politics. This opens the door to self-serving leaders who erode our institutions further—which destabilizes core functions of society and undermines health leaders’ work to preserve the integrity of their own institutions.

This cycle is self-perpetuating—unless we act.

You may be a formal leader, contending with budget cuts and federal censorship at your organization. Or you may be an advocate called to lead by your own moral compass. Either way, the need to act is urgent. Institutions that act fairly, transparently, and serve the common good can rebuild trust and reinforce democratic norms. And it is up to us to insist on them.

Here are three ways you can begin.

1. Understand the role that you’re best suited to play in this moment. There is a role for each of us. It doesn’t matter which issue, from food security to maternal health to climate change, you focus on. The larger threat which endangers all health equity work is to democracy and the rule of law, which are the only conditions in which healthcare institutions can reliably uphold their mission and pursue the quadruple aim. Consider your unique advantages, as an individual or institution, and your particular spheres of influence. Then lean into them. For example, federal agencies will soon sort their priorities within the funds allocated by H.R.1. We can and must join forces to apply pressure for healthcare and social-needs coverage, especially through notice-and-comment rulemaking, a critical democratic process in which the public weighs in on new government rules before they’re finalized—and which the current administration is trying to shortcut. States, too, will be promulgating their own rules, and those leaders are still listening to their constituencies.

2. Find, connect, and collaborate with fellow leaders. The current censorship and bombardment of harmful policies isolates leaders and splits people into factions—and is part of the strategy to usurp democracy. Coalition building counteracts that isolation and enables the collaboration we need. It is not just necessary; it is an act of resistance. For example, HealthBegins’ Health Equity Policy Hub, supported in part by the Robert Wood Johnson Foundation, provides resources to help people make sense of current threats, identify channels for action, connect with partners, and find their unique power. Its organizers are not paid leaders but volunteers, exemplifying what leadership can look like. In previous times, institutions got away with saying that a particular issue was not in their lane. Push back on that fallacy. At this moment, all lanes are open.

3. Recognize that we are leading through a collective trauma, and we need to acknowledge and respond to the difficulty that brings. Part of our grief is the knowledge that this is structural violence; people will die from these policies. As a leader, you also know that others rely on you for answers or steadiness that you don’t always have. Tap valid approaches and tools, such as the Full Frame Initiative’s five domains of well-being, to meet this serious mental health challenge. And as my colleague Dr. Rishi Manchanda reminded us through a national protest fast he helped lead against H.R.1, let’s  remember the power of solidarity. When we work with other colleagues, leaders, and organizations in shared purpose, we make it possible for “our grief to give way to connection, and our outrage to make room for hope.”

The present threats to health equity feel overwhelming—and that’s on purpose. But we need not and cannot be overwhelmed. Democracy does not protect itself. Democracy and the promotion of equity that it enables survives only because we insist on it.Best,

Sadena Thevarajah, JD