Trust and public health

How to be transparent so we are trusted without having to say “trust us.”

This piece was co-written by Dr Salma Abdalla and is also cross-posted here.

It is in relationships where trust is strongest that it is often most unspoken. We generally do not spend our days saying “trust me” to our spouse, to our children, to friends who have known us for a long time. Trust is implicit, understood, tested over years of relying, and being relied on. It is simply a fact of these relationships, something we take for granted. If we find ourselves having to say, “trust me,” it is likely something has gone wrong.

For a long time, public health enjoyed the kind of trust that does not have to say, “trust me,” in which the public understood it could trust what we say and do without having to be reassured of our honesty. Public health institutions had credibility because they were seen as broadly nonpartisan, guided by scientific rigor, towards the goal of keeping populations safe.

Just think back to movies, like 1995’s Outbreak or the 2011 film Contagion, in which public health officials are portrayed as competent, data-driven professionals, the heroes of the story. What is striking about these portrayals is how unmarkable they seem. There is a sense in these films that of course public health officials would be portrayed this way because of course this is how they conduct themselves—as sober professionals, trustworthy in pursuit of their mission.

But while fictional virus outbreaks can see public health’s reputation burnished, the recent real one opened a gap between what we say and the public’s willingness to trust us—a gap which has arguably widened in the years since the pandemic.

Survey data have shown significant declines in trust in public health since 2020. One study, for example, found “Between February and May 2020, the percentage of respondents reporting high confidence in the CDC decreased from 82% to 68%, before dropping to 56% in 2022.” This has happened in a context of declining trust in science generally, with the share of US adults with a “great deal” of confidence in scientists falling from 39% in 2020 to about 23% in 2023. But these declines in trust are only part of the story. Perhaps equally, if not more, significant is the sharp polarization of Americans’ trust in science, with just 52% of Republicans viewing research scientists as honest, compared with 80% of Democrats. More recently, however, that pattern has begun to invert and trust among Democrats has declined sharply after the change in federal administration and the accompanying shifts in health policy.

All this has meant that public health is, increasingly, in the position of having to say, “trust me,”. This is not sustainable. Trust is essential to the work of public health. Without it, we cannot do what we do. It is not enough for half the country to trust us while the other half doubts our honesty. Building a Purple Public Health means ensuring that this trust is shared across both red and blue America. The first step to rebuilding trust is to ask ourselves honestly why we may have lost it, owning up to our shortcomings. We recognize that trust in public health is also shaped by forces beyond our control like deliberate disinformation campaigns, changes in media ecosystems that reward polarization, and a broader erosion of trust in all kinds of institutions. These factors matter, and we do not mean to minimize them. But they are not the part of the picture we can change from within the field. Our focus here is on what we can change: the choices, habits, and practices that are ours to reckon with. With this in mind, we suggest the following three reasons why we have lost much of the public’s trust and why this loss has so strongly intersected with the country’s political divide. We do not think, in any way, that these are the only reasons, but rather they are three reasons that we think matter and that are important to discuss within the public health community, to think of ways in which we can address them, simply to do better.

Partisanship

Public health has long been perceived to lean to the progressive left. However, during the pandemic years, and as part of the broader polarization of the current era of US politics, this bias became more explicit in our words and actions. Such bias can be seen, for example, in the CDC shaping guidance about school reopening with significant input from teachers unions—arguably placing the priorities of a political interest group over what the data said about the complexities of reopening schools during COVID. It can also be seen in public health’s widespread comfort with the language, attitudes, and priorities of the political left, and its discomfort with the signs and symbols of the political right—or, at times, of even the moderate left.

None of this is necessarily bad. We are not saying public health should not have a political perspective. It should—and this will not make it unusual. Institutions and individuals have personal beliefs about issues and there is nothing wrong with that. We may know, for example, that a teacher or a newscaster feels a certain way about politics. We can still trust them, however, when we can feel secure that their personal beliefs do not unduly influence their work. A history teacher may feel like the New Deal was a failure, but she can still expose her class to a range of views about it, keeping her personal perspective to herself. A newscaster may feel the US should rarely, if ever, get involved militarily in other countries, while giving airtime to those feel differently. Personal belief only becomes problematic when it seems to be shaping what we do in the course of our work. It is when perspective becomes outright partisanship that we risk the integrity of our efforts and the public’s trust in what we do. To the extent that we have run this risk in recent years, we need to rethink our engagement with politics to ensure we can still lay claim to a level of neutrality in our work, even as we stay true to our values and their policy implications.

Inconsistency

Consistency is a companion of truth, and trust. We trust people in the moment because they have demonstrated trustworthiness over the long term. Rare is the person we meet and immediately feel like we can trust with what is most precious to us—and that, we should remember, is what we are asking the public to do, to trust us with what is most precious to them, their health. Earning this kind of trust means behaving consistently, over time, in a trustworthy way. It means that whenever we make recommendations based on incomplete information, we are up-front about what we know and what we do not know. It means always following the data, even when the data lead us to places that challenge our ideological priors. It means, when we fall short of the highest standards of trust, when we do something partisan, or shortsighted, or just plain wrong, we are quick to own our mistake, to explain why we made it, to commit to doing better, and then to actually do better—consistently, over time. Have we always conducted ourselves this way? An honest reckoning with recent years suggests we have not. Perhaps the central example of this during the pandemic was our attitude towards public gatherings. In the early days of COVID, public health was very critical of groups of people who congregated in defiance of advice about the dangers of doing so. Particular criticism was directed at those who attended the Sturgis Motorcycle Rally in South Dakota. However, after George Floyd’s murder in May of 2020, public health was broadly supportive of mass rallies across the country. It is hard to overstate how much this inconsistency eroded the public’s trust in us by contributing to the view that we place activism above science and that our activism skews one way—to the left. Many in public health argued that the imperative of addressing systemic racism, and the fact that the protests were outdoors, made gathering in protest worth it, despite the risks. Nevertheless, this seeming inconsistency that has had consequences for how half the country hears us, and we must reckon with this if we are to earn back the trust we have lost.

Lack of transparency

A hallmark of trustworthy action is transparency. Research has shown, for example, that managers who are maximally transparent are more trusted by their employees. We build trust when we are willing to share data, share the reasons why we do what we do, and act in ways that subject us to the accountability that comes with working out in the open. However, we have not always embraced transparency. Rather than share our data and reasoning, we have been quick to claim that we speak for “the science” and that this should be enough of a justification for what we wish to do. Rather than work in the open, where the public can fairly judge what we do, we have embraced a bureaucratic vision of power, pursuing our interests through institutions and funding structures whose workings have not always been easily viewable or understandable by the public. An example of this has been the public conversation, which has widely occurred outside the public health “bubble,” about the origins of COVID-19 and whether US public health agencies may have leveraged the opacity of the funding process to support research that was not being conducted safely and which may have led to the inadvertent leak of the virus from a Chinese lab. This may be an uncomfortable topic to raise within institutional public health, but, outside our spaces, it is very much a live issue, with genuine political force, fueling the view that public health is not transparent and that this lack of transparency can, and did, place the public at risk. We cannot pretend that this conversation is not happening if we are to build back the trust we have lost. Rather, we should engage with it (even as we acknowledge its potential to be weaponized by bad faith actors), embrace accountability, and learn the lessons of the last seven years, to ensure the COVID moment represents the nadir of the public’s trust in us, rather than the edge of a cliff off of which we continue to freefall.

Trust is built slowly, but it can be lost quickly. Rebuilding trust is a painstaking process. It will not be easy to reclaim the credibility we have lost. But the path is there for us if we wish to walk it. It entails taking an honest look at ourselves and then being honest with the public about what we see. It means having uncomfortable conversations which some in our field—in our organizations, our offices, even our friend circles—may not want to have. And it means, having identified where we have fallen short of full honesty, taking pains to not fall short again. If we can do this, we can rebuild the public’s trust in us and remain worthy of it in the years ahead. That will have been worthwhile work indeed.

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The Purple Public Health Project

This piece is part of the Purple Public Health Project. The Purple Public Health project is a multiyear, multimedia effort to re-establish public health’s legitimacy, broaden its reach, and shore up its foundations in this moment and beyond. The project engages with topics that are core to shaping a more heterodox public health. Previous essays and other material related to the project are available on the Healthier Futures Lab webpage.

One of our Purple Public Health products is an ongoing podcast. This month, Salma’s guest is Erin O’Malley, executive director of the Coalition for Trust in Health and Science, a coalition of more than ninety organizations working to enhance public trust in health and science. Erin brings nearly two decades of experience in health policy, advocacy, and cross-sector partnership, and she leads an organization that is grappling daily with the question at the heart of this month’s work: how do institutions that have lost public confidence go about becoming trustworthy again? The conversation explores what the coalition does, what Erin has learned about the mechanics of trust-building, and what she thinks the path forward looks like, including the practical question of how any of us can navigate an increasingly complex information environment.

Listen to this episode on Apple Podcasts, Spotify, Amazon Music, Podbean or wherever you get your podcast. You can also watch the episode on YouTube.

Each month, we will also highlight perspectives that inform or complicate the month’s theme. These are meant as starting points for deeper engagement with the ideas the project is exploring. This month’s perspective is from Dr Matthew Motta, Associate Professor at Boston University’s School of Public Health, about communication across values and trust in public health.

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Also this week

Delighted to announce the launch of Ideas Matter, a new podcast I am hosting at WashU. The podcast features conversations with experts about the ideas and forces shaping this moment. The first episode is a conversation with Alexander Kustov, an expert in public opinion and democratic governance and a professor of global affairs at the University of Notre Dame, about immigration in a changing world.

Also, in JAMA Health Forum: The Year We Lost Medicaid

Spoke with Bryant Furlow in The Lancet Child & Adolescent Health about social media use and youth mental health.

What gives you hope? Over the past year, I have had the privilege of speaking with colleagues about the work they are doing at the WashU School of Public Health. I always end these conversations by asking what gives them hope in this moment. Here are their replies