Tracking the Trump administration’s rollback of climate and environmental policies can seem like being forced through a wormhole back in time. The administration tried to freeze funding that Joe Biden’s Inflation Reduction Act directed to clean energy, turning that particular clock back to 2022. The Environmental Protection Agency could scrap the finding that greenhouse-gas emissions pose threats to human health and the environment, which has underpinned federal climate efforts since 2009. The Trump administration has also barred scientists from working on the UN’s benchmark international climate report, a continuous collaboration since 1990. And it has demolished federal work on environmental justice, which dates back to the George H. W. Bush administration. As part of its purge of so-called DEI initiatives, the administration put 160 EPA employees who work on environmental justice on leave, rescinded Biden’s executive orders prioritizing this work, and pushed to terminate, “to the maximum extent allowed by law,” all environmental-justice offices and positions by March 21.

The concept of environmental justice is grounded in activists’ attempt in the early ’80s to block a dump for polychlorinated biphenyls, once widely used toxic chemicals, from being installed in Warren Country, North Carolina, a predominantly Black community. Evidence quickly mounted that Americans who were nonwhite or poor, and particularly those who were both, were more likely to live near hazardous-waste sites and other sources of pollution. Advocates for addressing these ills called unequal toxic exposures “environmental racism,” and the efforts to address them “environmental justice.” In the early ’90s, the first President Bush established the Office of Environmental Equity, eventually known as the EPA’s Office of Environmental Justice, and President Bill Clinton mandated that federal agencies incorporate environmental justice into their work.

Biden, though, was the first president to direct real money toward communities disproportionately affected by pollution—places where, say, multiple factories, refineries, truck yards, and garbage incinerators all operated in a condensed area. As with so many targets of Trump’s crusade against DEI, the damage will be felt by poor people across the country. This choice will certainly harm communities of color, but it will also touch everyone, including many of Trump’s supporters, living in a place burdened by multiple forms of environmental stress. Under Trump’s deregulatory policies, that category will only keep expanding.

“There are still these places where life expectancy is 10 to 15 years less than other parts of the country,” Adam Ortiz, the former administrator for EPA Region 3, which covers the mid-Atlantic, told me. Cancer rates are sky high in many of these areas too. Some of these communities are predominantly Black, such as Ivy City, in Washington, D.C., a historically redlined, segregated, working-class community where the air is fouled by a rail switchyard, a highway, and dozens of industrial sites located in a small area. But plenty of the small rural areas that have benefited from environmental-justice money look like Richwood, West Virginia, where catastrophic flooding—a growing climate hazard in the region—knocked out the local water-treatment plant. Residents there are poor, white, and generally politically conservative. In many cases, these communities had gotten little federal attention for generations, Ortiz said.

Untangling the knot of pollution in these places is slow work, in part because federal laws don’t adequately address overlapping environmental ills: The Clean Water Act and Clean Air Act regulate only one form and one source of pollution at a time. A population exposed to many pollution sources simultaneously, or to a cocktail of toxins, has little redress. Each business regulated by these laws may follow them and still end up creating places that, like Ivy City, have dangerously bad air quality. Cumulative impact is a gaping regulatory chasm into which millions of Americans fall each year. Federal environmental-justice efforts aimed to fill it.

The Trump administration has now halted projects such as the ones Ortiz worked on. People who had spent years gaining trust with local communities, and who had worked with local companies to help them alter things such as how they vented pollution, were dismissed or reassigned. By then, in Ivy City, the EPA had managed to address a “handful” of the 40 or 50 pollution sources plaguing the area, Ortiz said.

But some work did get done, and its benefit will likely persist despite the Trump administration’s attempt to make environmental justice disappear. Paul Mohai, a professor at the University of Michigan who served as a senior adviser to the EPA’s environmental-justice office, told me. In his view, one president can’t erase the progress made over the past decades, particularly outside the federal government.

Because he was there at the beginning, Mohai knows what these knotty pollution problems looked like when few in government were paying attention. When he co-wrote a review of the literature on environmental justice in the early 1990s, he struggled to find more than a dozen papers on the topic. Now, he said, more publications are coming out and more nonprofit groups have formed to tackle these issues than he can keep track of.

Surely some of them will be affected by the president’s restrictions on grant making for scientific research. But the facts accrued through existing research cannot be erased: People of color in the U.S. are exposed to a 38 percent higher level of the respiratory irritant nitrogen dioxide, on average, than white people. Low-income communities are disproportionately targeted for hazardous-waste sites. Poor people and people of color suffer the most from climate impacts such as flooding and extreme heat. Several states have also put environmental-justice considerations into their laws; one in New Jersey restricts certain new industrial permits in places that are already overburdened, for instance. The decisions of a single administration can’t undo all that.

But millions of disadvantaged Americans live in states that are not interested in passing these kinds of laws. And layoffs at the EPA will dilute what protections federal clean-air and water legislation do afford, by making enforcement less possible. As the climate crisis deepens—growing the threats of extreme heat, sea-level rise, and catastrophic rainfall, each a hazard that can rob people of safety—more places could succumb to the gaps in these laws as well. Many climate dangers are akin to those of pollution because they create zones of harm where residents bear the costs of the country’s environmental compromises and have little to help them through it. Nothing in any federal law specifically compels the government to protect people from extreme heat, or from unprecedented flooding, though both are set to descend on Americans more often and disproportionately harm poor people and people of color.

As these stresses multiply, they’ll be layered onto a landscape already dotted with sites where heavy industry and major traffic create concentrations of emissions. Without laws to address the cumulative impact of these, more Americans will be left sicker and will die sooner. It’s taken decades for the country to start reckoning with that fact to begin to move toward a more useful vision of safety. For now, it seems, all progress is on pause.

Leading the FDA has long been one of the greatest professional achievements in American health. At the start of every administration, doctors jockey for the role, hoping to steer an agency that regulates 20 cents of every dollar spent in the United States. To be the FDA commissioner who presides over the approval of a cure for a previously intractable disease, or who launches an investigation into a product that is sickening Americans, is to etch your name into the annals of modern medicine. Perhaps you’ve never heard of David Kessler, the FDA commissioner for much of the 1990s, but he is largely the reason the federal government regulates cigarettes at all.   

Marty Makary, Donald Trump’s pick for FDA commissioner, is undoubtedly qualified for the job. A longtime Johns Hopkins surgeon and best-selling author, he has advised the World Health Organization and been elected to the National Academy of Medicine. (Makary, whose confirmation hearings kicked off in the Senate this morning, told Senator Rand Paul that he spent part of yesterday removing a patient’s gallbladder.) Makary is not universally embraced: As a Fox News contributor, he has repeatedly critiqued the medical establishment on air. But he’s still widely regarded as well-credentialed. “He has the ability to become one of the greatest commissioners we’ve seen,” Kavita Patel, a physician and former Obama administration official who considers Makary a personal friend, told me.

But Makary might end up with one of the worst jobs in the entire Trump administration. His scientific bona fides are at odds with the impulses of his boss, Robert F. Kennedy Jr. The newly confirmed secretary of Health and Human Services, who has a penchant for spreading conspiracy theories, has promised lawmakers that he will empower scientists and won’t “impose my preordained opinions on anybody.” But he has also promised to change the agency so radically that delivering on that vision would require Makary to throw much of his medical training out the window. What Makary decides to do will go a long way in determining the extent to which Kennedy is able to remake American health in his image.

That’s not to say that Makary, who did not respond to a request for comment, will be waging a war of resistance against everything RFK Jr. wants and believes. During his testimony this morning, Makary spoke about his desire to improve America’s diet and address chronic disease—both of which Kennedy has made his central focus as America’s health secretary. “We now have a generational opportunity in American health care,” Makary said. “President Trump and Secretary Kennedy’s focus on healthy foods has galvanized a grassroots movement in America.” Last fall, he took part in a roundtable with Kennedy where he lamented that “highly addictive chemicals” lace the U.S. food supply. Tackling that issue will be Makary’s surest bet for delivering on what Kennedy wants.

Contrary to Kennedy’s long-standing anti-vaccine advocacy, Makary reiterated in his Senate testimony that he believes that “vaccines save lives.” But like Kennedy and several other prominent Trump health advisers, Makary has been a vocal critic of how the Biden administration handled COVID. In 2021, he called out the FDA’s decision to approve COVID boosters for young, healthy Americans, citing a lack of clear evidence for their benefits relative to the potential side effects. The government’s “policies are no longer driven by science,” he wrote at the time, and “data is being cherry-picked to support predetermined agendas.” (The FDA pushed forward with boosters for young adults without convening its own independent advisory committee, though the agency said its decision was supported by data.) Other statements Makary has made are more questionable. In an appearance on Fox News in July 2023, he said that “100 percent” of Kennedy’s book on Anthony Fauci was true. He didn’t acknowledge that the book falsely claims that “COVID vaccines were causing far more deaths than they were averting.” (“The Marty you might see on Fox News clips is obviously not the person I know,” Patel told me.)

Much of what Makary actually wants to do at the FDA remains unclear. He spent little time during his testimony on Thursday outlining his moves once confirmed. Still, most of the changes Kennedy wants to see at the agency are untenable for any FDA commissioner concerned about adhering to basic science. Kennedy has said that the FDA’s “war” on treatments such as stem cells and psychedelic drugs “is about to end.” Decisions on how to regulate these products typically don’t rest with the health secretary or the FDA commissioner, but with the agency’s scientists and doctors. In both cases, there is no scientific reason for the FDA to change course. The agency doesn’t allow stem-cell treatments for most conditions because they aren’t proven to work and can cause people serious harm; last year, the FDA rejected what would have been the first MDMA-based medical treatment, likely due to shoddy clinical-trial data.

On his own, Makary can do only so much. The FDA’s powers are actually given by law to the HHS secretary, who then has historically delegated powers to the FDA commissioner, according to Lewis Grossman, a law professor at American University. What is given can be taken away; if Kennedy wants to meddle in Makary’s work, he’s well within his rights to do so.

Still, should Makary stand up to Kennedy, he will not be the first FDA secretary to clash with more powerful officials in the administration. Kessler’s efforts to investigate the tobacco industry were so controversial in Washington that, as he wrote in his memoir, the White House worried he would resign if they didn’t allow him to continue his work. If Makary can conjure up a similar power—using whatever leverage and cache he would have as FDA commissioner to negotiate with Kennedy and the Trump White House—he may hold his own. Makary “has both a mandate and an authority to not feel like he needs to step in line with any secretary, much less RFK Jr.,” Patel said.

The first major test for how willing Makary is to stand up to his boss will likely center on mifepristone, an abortion pill. Kennedy told senators in January that he would order the FDA and NIH to review the safety of the drug to determine whether access to it should be restricted. (Access to mifepristone varies by state, though prescriptions via telehealth have complicated the picture.) But that review has already been done. The FDA recently rereviewed the drug’s safety information, and determined that previous restrictions around the drug, namely that patients needed to physically go to a clinic to get it, were unnecessary. The agency is unlikely to find any new evidence that the drug is especially dangerous. If Makary comes up with a reason to question its safety, and thus meddles with the agency’s previous findings, it will show that his loyalty rests more with Kennedy than FDA’s scientists. During his confirmation hearing, Makary was unwilling to preview how exactly he would come down on the issue, much to the frustration of some Democratic senators.

In any administration, overseeing the FDA’s sprawling, vital work is a colossal undertaking. Should he be confirmed, Makary will be tasked with safeguarding the infant formula Americans feed their newborns, the cosmetics we use on our skin, the painkillers we take when we have a headache, the chemotherapy we receive to fight cancer, the pacemakers that keep hearts ticking, the flu shots we get every fall, and even the hand sanitizer we reach for when our hands are dirty. Makary’s biggest challenge, however, could turn out to be his ability to manage up. His ideal version of the FDA presumably is different from Kennedy’s. They both can’t get their way.