There are many reasons to worry about the incoming Trump administration’s health agenda, from its proposals to slash scientific agencies’ budgets to its policies that might hamper health insurance coverage. President-elect Donald Trump’s elevation of anti-vaccine activist Robert F. Kennedy Jr. to lead the department of Health and Human Services is especially alarming.

But there is one hopeful prospect: Marty Makary, Trump’s choice to lead the Food and Drug Administration, who might just serve as the bridge between the president-elect’s loyalists and public health advocates.

I first met Makary, a Johns Hopkins surgeon, more than 10 years ago, when we were both working to reduce hospital medical errors. Our paths crossed again during the covid-19 pandemic. He was an early and forceful opponent of many of the mitigation policies I championed, but our discussions were always civil. Despite our opposing views, we often found ourselves agreeing more than we disagreed. I respected him for being an independent thinker who was willing to change his stances when new evidence emerged.

Last month, before his and Kennedy’s selections were announced, I reached out to Makary for an interview. He agreed on the premise that he wouldn’t discuss his potential role in the administration or speak on behalf of Trump’s “Make America Healthy Again” platform. Instead, we discussed his views on critical reforms needed in health care.

The most striking part of the conversation was how Makary embodied core MAHA principles while also speaking the language of mainstream public health. His central argument is that the U.S. health-care system is broken. While we have world-class hospitals that provide state-of-the-art treatments, Americans are suffering from poor health because of preventable chronic diseases.

Obesity in young people has more than quadrupled over the last five decades. Today, 1 in 5 children and adolescents have the condition. Makary wants to examine what other countries are doing differently. For instance, why is Japan’s rate of childhood obesity five times lower?

“We are ignoring a giant blind spot, and that is we are not addressing the root cause of obesity,” Makary told me. He highlighted ultra-processed foods that are laden with chemicals such as preservatives, artificial dyes and thickeners, which comprise as much as 60 percent of the calories Americans consume.

Public health advocates have long argued for such an approach. The science is increasingly clear that ultra-processed foods are associated with myriad negative health outcomes — including diabetes, cancer, heart attacks and dementia. The Trump administration will have many policy levers to reduce the consumption of these products. It could, for instance, change dietary guidelines to call out these substances’ harms, stop SNAP benefits from being used on sodas and chips and remove unhealthy items from school meal programs.

Makary also explained how pesticides and microplastics might be implicated in the rise of chronic diseases such as attention-deficit/hyperactivity disorder, early-onset Alzheimer’s and autoimmune diseases. “Diseases that were rare a generation ago are now common,” he said. He wants the medical community to direct resources toward prevention rather than simply medicating people after they fall ill.

Here, again, it’s hard to disagree. Plenty of research links dietary pesticides to chronic diseases. And it’s frightening how much plastic is in our bodies. A 2024 study published in the New England Journal of Medicine found microplastics in some people’s neck arteries. Patients who had buildups of microplastic plaque had higher rates of heart attack, stroke and death compared with those who did not have microplastics detected.

An administration that reduces plastics pollution by capping production, banning single-use items and reducing leakage into waterways would be a win for health and the environment. Judging by Trump’s first administration, which weakened the Environmental Protection Agency and created a loophole that allowed companies to dodge requirements on chemical waste discharge, it is questionable such policies could gain footing over the next four years. But a bold FDA commissioner might just be a countervailing force to those trying to dismantle environmental protections.

It also remains to be seen how Makary’s FDA would handle infectious diseases. I don’t think he himself is anti-vaccine, but I don’t know how strongly he feels about protecting childhood immunizations. Will he toe the line and enforce his bosses’ policies, or will he stand up for science? If bird flu becomes the next pandemic, would he expedite vaccine and treatment authorization, or would he back down if the White House wishes to downplay the threat?

I hope Makary will serve as the fair and clearheaded arbiter I have known him to be. In the meantime, public health advocates would do well to look for areas of agreement with the MAHA movement and start developing alliances with thoughtful Trump acolytes such as Makary. Such alliances might lead to pragmatic solutions to America’s long-standing health crisis.