Why trust is the bedrock of public health policy

I was at my gym last night (yes, it’s finally open).  Billy Joel’s ballad about trust was the metronome to my squats.  Though vaccinated, I was wearing my mask.  Knowing the latest evidence about vaccines, my mask was only for the optics of those mostly maskless around me.  I overheard the couple next to me say, “OMG. Fauci says we should double-mask. What a BSer!”

Trust is fundamental to the delivery of optimal health care.  Based on physicians’ extraordinary training and experience, a consensual knowledge base rooted in continuous and evolving peer-reviewed science, we have been endowed with coveted cultural authority, which is crucial for patients to comply with taking needed medications and recommendations for evidence-based intervention. That is why we bemoan the intrusion of insurance companies and lawyers into the patient-physician relationship, as it can be counter-therapeutic.  Once patients lose trust in their physician, compliance with even the simplest directives, like “you need to quit smoking and lose a few pounds,” is lessened, as any obese physician can tell you.   Cultural authority raises the likelihood that a particular definition of reality and judgment of meaning and value will prevail as valid and true.

Trust is foundational for public health policy, the overriding purpose of promoting societal health and well-being.  However, public health authorities have layers of purpose to prioritize using utilitarian principles, and those priorities change with fluid facts on the ground.  To maintain trust, transparency with current intent in the context of purpose is crucial.  Once trust erodes, it is difficult to rebuild.  When the authorities first stated masks were unnecessary, the science was ambiguous, and in retrospect, the misstatement was forgivable.  To subsequently state that truth was sacrificed for the higher purpose of preserving supply, eroded trust. It might have been prudent to admit the incomplete knowledge at the time of the statement and add that we chose to err on the side of supply management given the uncertainty.  It’s fair to admit erring in research. That is the underpinning of the scientific method.  Science learns, politicians … not so much.

More recently, the double messaging regarding the level of vaccination needed to get to herd immunity and the still necessary caution despite vaccination is another example of sowing distrust.  The authorities (including Dr. Fauci) initially stated that approximately 70% of the population needed vaccination to get to herd immunity (once the phrase became freed from politics and allowable).  No mention was made that those who had already been infected, with acquired antibodies effective for months (science now shows up to eight months), contribute to that 70% needed for populational immunity.  The authorities’ higher purpose of getting everyone vaccinated is perhaps understandable as an excuse for the omission.  But accepting that many are smart enough to understand both the need for vaccinating all possible while acknowledging that acquired immunity from infection contributes to population immunity is important when trust is critical.

Scott Fitzgerald wrote: ”The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time and still retain the ability to function.” The arrogance of some academicians and politicians dictates that the common mind is not first-rate, and therefore messaging must be black and white for the higher purpose. But when the concepts are simple to comprehend, such an attitude is a prescription for distrust, thus counter-productive.

Recently, recommending that now 90% vaccinated is needed for herd immunity, serves the agreed-upon higher purpose – maximizing vaccinations; yet, with 35% of all already infected, vaccines rolling out to 15%, and new infections plummeting,  that new 90% number vs. the old 70% risks credibility.   A simpler message is: Vaccinating all will maintain the gain, prevent future surges. Scaring people into wearing two masks, continued social distancing even if vaccinated, makes “simple” minds ask:  Why get vaccinated if that does not allow a return to normal?  Threats of new variant nightmare scenarios with only test tube evidence not only erode trust, but further, the panic driving an upsurge in the mental health crisis, delayed care for routine childhood vaccinations, growing domestic abuse, and accumulating harm to childrens’ development by irrationally keeping schools closed – not to mention delays in needed cancer screenings and seeking care for chronic and even urgent health conditions like heart attacks and strokes.

Infection control should not be the sole metric of public health, and trust is the bedrock of public health policy.  That crumbling bedrock needs solidification. That’s no BS.

Michael Brant-Zawadzki is a senior physician executive, and endowed chair, Pickup Family Neurosciences Institute, Hoag Hospital, Newport Beach, CA. The author’s opinions are his own and do not reflect those of his employer.

Image credit: Shutterstock.com

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