Public Health Must Rebuild Trust. Quickly.

Public health institutions and practitioners in the US must work to rebuild trust with Americans.

Key Points

• Research shows that trust in government, particularly health agencies, is key to disease control.

• Prior to the COVID-19 pandemic, trust in public health institutions was low.

• It has fallen further during the pandemic.

• Social engineers, embedded in public health, see the field as a tool for correcting many social policy failures.

• Health agencies and public health experts must rebuild trust by avoiding politically fraught issues, especially those outside the traditional ambit of public health.

In May, Nature’s Scientific Reports published a paper that examines the extent to which pre-Covid-19 country-level characteristics—for example, population density, technology, trust in national government—affected Covid-19 (“COVID”) morbidity and mortality across countries. Countries with high levels of trust in government, all things considered, had lower morbidity and mortality from COVID.¹ The authors didn’t examine trust in public health agencies within the countries, which would have been a better metric. That trust in public health institutions is key to disease mitigation is not lost on experts – risk communication is an essential part of public health.² During pandemics (or any disease outbreak for that matter), the public is invited to give up many of their rights to reduce the risk of contagion. This trust must be safeguarded.     

Mistrust of public health officials can be deadly. That is why it is astonishing that public health experts – a term I use to include public health agencies such as CDC, NIH, HHS, CMS, and FDA and their spokespersons, and scholars, and state and local health departments – in the US rapidly frittered away their trust by offering inconsistent advice and delving into politically divisive topics. For example, protesting the death of George Floyd during lockdowns was good but protesting mask mandates during lockdowns would lead to dire consequences. And for the record, at least one study shows that George Floyd protests increased COVID infection rates.³ Pushing a warped definition of equity—which does nothing to take care of individuals, an excessive focus on the population rather than the individual, focus on gun control—these are all cultural issues that divide Americans intensely. 

If public health wants to be taken seriously, it must return to its core mission – eradicating or controlling the spread of communicable and infectious diseases. But more importantly, the field must work to regain the trust of Americans. I agree with Mark Rothstein, writing in 2002 (yes, that far back), that “…clarity and consensus on the meaning of public health will lead to more efficient and effective interventions as well as increased public and political support for public health activities.”⁴

Crisis of Public Health

Public health has achieved remarkable successes, including the eradication of some of humanity’s greatest plagues, such as smallpox and poliomyelitis, and control of many other infectious diseases including measles. Unfortunately, in the US, public health experts have lost the trust of the public. In May 2021, the Harvard T.H. Chan School of Public Health in collaboration with the Robert Wood Johnson Foundation published the results of an extensive survey on how Americans rate the performance of public health agencies. More than two-thirds of Americans said they have a “great deal of trust” in healthcare workers they know, nurses and doctors in general. Just about half said the same of the CDC but only a third for the NIH, FDA, and HHS. In 2009, 43% of Americans had a positive rating of the public health system. That was already quite poor, until we see the rating fall to only 34% in 2021. What happened in the intervening decade to cause this collapse? 

Public health is over-extended by focusing on intractable social issues like racism, climate change, gun violence, homelessness, and others. And while it is true that a person’s health is determined by many factors, including social and economic circumstances, it doesn’t mean that public health is responsible for solving them. In fact, public health doesn’t seem to want to focus on individuals as much as the population, which has led the field into contentious societal issues, which tend to split along partisan and ideological lines. In a highly polarized environment, if the public health officials appear to favor one side over the other, trust falls. In the same Harvard report, when asked what they consider the main responsibilities of public health agencies (out of a list of 33 goals that public health practitioners believe to be their responsibilities!) reducing eviction and homelessness, racism, violence and deaths from guns, injuries and motor crashes, and climate change ranked in the bottom. Yet, these “divisive” issues tend to dominate all public health activities, at least from the perspective of the public. You wonder whether they do not have enough time on their hands with infectious diseases alone. Rothstein argues, most schools of public health would have to shutter or reduce in size if the field were to focus on controlling and eradicating dangerous infectious diseases. The truth is public health is simply not equipped to “solve” these issues. 

Why do public health experts feel the need to branch into all these areas? It’s a question of legitimacy. The skeptical population is less likely to resist actions in the name of health emergencies. To others, public health is a vehicle for social change, not disease control but the total wellbeing of the population. But public health isn’t equipped to tackle all of society’s problems.

How Lack of Trust Impedes the Effectiveness of Pandemic Response

In the most recent Ebola outbreak, Sierra Leone and Nigeria, two countries in West Africa, suffered starkly different outcomes even though they received similar mitigation strategies from their public health officials. What’s the difference? In Sierra Leone, trust in government is low after decades of war and poverty. Now consider what happens in the same country with varying levels of trust in the government. During the same outbreak in Liberia, individuals who expressed low trust in government were less likely to follow Ebola control interventions.⁵

Marginalized populations tend to have lower trust. In the US, I speak of two types of marginalization – the typical that affects poor people and the “otherization” type of marginalization. This second marginal group is important – it is not uncommon to see headlines about how “Trump” counties are dying more, most resistant to vaccination, “poorly educated” – all that sneering does not engender trust. This otherization isn’t coming directly from public health, and that is true, but remember people take information from various sources and the public health experts use the media to communicate.

One could argue that the level of trust in public health reflects the general level of trust in the government. In the US, trust in government and public institutions has been declining rapidly. And even worse, the decline in trust is ideological. Conservatives have low trust in government while people on the left have high trust. Ideology is an even bigger determinant of trust in government than race and ethnicity.     

Contrasts with Norway 

I’m always wary of using Scandinavian countries to contrast policy outcomes in the US, given how dissimilar we are—they are almost homogeneous with little immigration compared to the incredible diversity of the US—but that is exactly why trust within those societies is worth examining. In a recent OECD report,⁶ Norway achieved one of the best outcomes because of the high levels of trust in government and in public health institutions. While trust in public institutions in the US has been declining over the years, it has risen consistently in Norway (figure 1.2 of the OECD report). In contrast with the US, trust in health authorities in Norway remained high throughout the pandemic (7 in 10 reported trusting them). I’m in no way suggesting the US becomes Scandinavia, but there are important lessons. The OECD report notes several factors that engender trust – arising from both competence (responsiveness, reliability) and values (openness, integrity, and fairness). Public health agencies and experts must exhibit these qualities to regain the public’s trust, especially in a highly polarized environment where even medicine has been politicized.     

How does public health regain trust?     

If we don’t build trust government in general but perhaps more importantly in public health institutions, we are doomed to flunk the next public health crisis. To restore public confidence, public health must:

• Return to basics. Public health should focus on eradicating or controlling infectious diseases where public health has been remarkably successful. As Jonathan Ellen from the Manhattan Institute and many others have mentioned, the key agencies tasked with disease control in the US must resist mission creep. 

• Public health communication should focus on risk communication,⁷ as argued by the scholar Thomas Abraham. Abraham argues that pandemic communication shouldn’t be about persuading people (advocacy) but “…about building a shared understanding with the public, about the nature of a risk and the measures needed to respond to it through dialogue.” The “dialogue” part was missing in the US response to COVID     .

• Trust Americans with the truth. Again, the focus should be risk mitigation, not advocacy. Lying to Americans that masks don’t help, to preserve limited supplies for health professionals, shattered the trust of many people. Personally, this was a turning point for me. And then, ironically, demanding that they all wear masks through mask mandates, followed by scolding and hypocrisy over anti-mask mandate rallies versus anti-racism protests. These are simple examples that show that public health officials distrust Americans with the truth. Trust is a two-way street.

• Be competent. Flunking test kits at the beginning of the pandemic didn’t bode well for the federal agencies, especially when other countries like South Korea and China had effective tests going for months. If you can’t prove to Americans that you can fulfill your core mission, perhaps you shouldn’t arrogate unto yourself extra responsibilities. For starters, go back to the basics and focus on health. There is no need to use public health to solve all problems that social policy has failed to solve. Public health won’t solve racism. It won’t solve gun violence. 

• Be truthful. It’s curious to me why we didn’t triage COVID mitigation strategies to focus more on the at-risk group: elderly and those with cardiovascular diseases, hypertension, and diabetes mellitus around the world and in the US.⁸ An honest public health policy would triage to protect this group. 

• Stop otherizing Americans. Ultimately, the public bears the brunt of risk mitigation measures. It is important to understand their skepticism and hesitation. The media have a role to play, in not looking to push narratives that otherize others – Trump vaccine, Trump voters are dying, etc. Studies that “confirm” one politically aligned group seems inferior to others shouldn’t be sensationalized.

This list is by no means exhaustive and represents what I choose to emphasize. COVID, and more recently the monkeypox virus have shown that the next pandemic is never far away. We need robust and reliable institutions to help us navigate health challenges as they arise.

1. Dianna Chang et al., “The Determinants of COVID-19 Morbidity and Mortality across Countries,” Scientific Reports 12, no. 1 (April 7, 2022): 19, https://doi.org/10.1038/s41598-022-09783-9.

2. Michael Siegrist and Alexandra Zingg, “The Role of Public Trust during Pandemics: Implications for Crisis Communication,” European Psychologist, Infectious Disease Outbreaks and Public Trust, 19, no. 1 (2014): 23–32, https://doi.org/10.1027/1016-9040/a000169.

3. Randall Valentine, Dawn Valentine, and Jimmie L. Valentine, “Relationship of George Floyd Protests to Increases in COVID-19 Cases Using Event Study Methodology,” Journal of Public Health (Oxford, England), accessed June 7, 2022, https://doi.org/10.1093/pubmed/fdaa127.

4. Mark A. Rothstein, “Rethinking the Meaning of Public Health,” The Journal of Law, Medicine & Ethics 30, no. 2 (June 1, 2002): 144–49, https://doi.org/10.1111/j.1748-720X.2002.tb00381.x.

5. Robert A. Blair, Benjamin S. Morse, and Lily L. Tsai, “Public Health and Public Trust: Survey Evidence from the Ebola Virus Disease Epidemic in Liberia,” Social Science & Medicine 172 (January 1, 2017): 89–97, https://doi.org/10.1016/j.socscimed.2016.11.016.

6. OECD, Drivers of Trust in Public Institutions in Norway (OECD, 2022), https://doi.org/10.1787/81b01318-en.

7. Thomas Abraham, “The Price of Poor Pandemic Communication,” BMJ: British Medical Journal 340, no. 7759 (2010): 1307–1307.

8. Stephanie L. Harrison et al., “Comorbidities Associated with Mortality in 31,461 Adults with COVID-19 in the United States: A Federated Electronic Medical Record Analysis,” PLoS Medicine 17, no. 9 (September 10, 2020): e1003321, https://doi.org/10.1371/journal.pmed.1003321.