To rebuild trust in public health: Better communication, fewer mandates, and small wins

It’s no surprise in today’s corrosive political environment that trust in government is near an all-time low. That’s a big problem. Communities with more trust during the Covid-19 pandemic had fewer deaths and less economic devastation.

In many countries — notably the United States — the pandemic dissolved trust between parts of the community and the public health system. How can that trust be restored? In a word: gradually. Trust is built in drops and lost in buckets.

I believe that three actions must be at the forefront of efforts to regain trust:

• improving communication
• making guidance and mandates limited, appropriate, and transparent
• demonstrating steady progress on health issues that matter to people

The decline in trust in science, and specifically in the Centers for Disease Control and Prevention, is substantial, dangerous, and largely partisan. Although overall trust in scientific expertise among Americans did not change substantially between 2016 and 2020, the proportion of people with both low and high trust increased while the proportion with moderate trust declined substantially. There was a slightly larger shift to increased trust than distrust, but trust and distrust became deeper and more entrenched at both ends of the spectrum.

Between January 2019 and October 2023, the percentage of adults with little or no trust in scientists more than doubled among Republicans, from 18% to 38%. Among Democrats, only 9% — half the Republican baseline — had little or no trust in scientists and that rose only slightly, to 13%. From December 2020 to April 2022, Republicans’ trust in the CDC’s information on Covid vaccines fell from 57% to 41%, while Democrats’ started high (88%) and remained high (89%). Covid didn’t so much create this partisan divide as deepen it.

Excess deaths during the pandemic were 43% higher among Republicans, primarily because of lower vaccination rates. From health warnings to recommendations on everything from contaminated food to extreme weather to the next pandemic, if many people don’t trust public health advice, there will be illness, death, and economic loss that could have been avoided.

A failure to communicate

During the Covid-19 pandemic, inconsistent and ineffective messaging increased politicization of public health and mistrust of government agencies. This wasn’t entirely the CDC’s fault. Nancy Meissonier, the agency’s lead scientist for respiratory viruses, spoke frankly, clearly, and appropriately in February and early March of 2020, as the coronavirus swept across the United States. Then the White House silenced her, and the CDC was silenced for the remainder of 2020. If an agency isn’t permitted to communicate, it certainly can’t communicate well.

Communication needs to be timely, accurate, and useful, with the right messengers and messages — “be first, be right, be credible,” the CDC’s mantra for crisis communication. Public health messengers must be upfront with what they know when they know it, and with what is fact and what is opinion. Overstating claims undermines trust.

The Biden administration exacerbated the problem by tying the CDC to White House messaging. This virtually ensured that a large proportion of the public would distrust CDC’s health warnings.

The CDC also made mistakes. Communications were sometimes unnecessarily complex and insufficiently transparent.

Good communication is two-way: listening — understanding, empathizing, and addressing concerns — as well as speaking. During the pandemic, many people with legitimate concerns felt they were being ignored.

It’s essential that public health communication be — and be seen as — free from political interference. The thousands of CDC doctors and scientists who have spent decades becoming world experts in their fields aren’t political appointees. They’re people who devote their lives to public health and whose information can help people protect themselves and their families.

But communication alone, no matter how effective, won’t restore trust.

Guidance and mandates

The CDC communicates data, such as case definitions, case counts, risk factors, epidemiologic findings, and more. These are technical, scientific findings, and the agency should be free from political interference to speak frankly and openly about the facts.

The CDC also provides guidance to clinicians. An excellent model is the CDC’s Advisory Committee on Immunization Practices (ACIP). All of ACIP’s presentations, deliberations, and conclusions are open to the public, recorded, and available online. Decisions are based on meticulous documentation of scientific findings and incorporate diverse stakeholder views. This committee is independent, and CDC then decides upon (although rarely diverges from) these recommendations.

But guidance on public behavior, for example mask-wearing and closing businesses and schools, represents a very different process. Broad policy guidance should be based on science, but policy decisions should be made transparently by political leaders who are informed by public health professionals. Mandates must be rare, appropriate, nuanced to time and place, and led by local decision-makers. Faced with identical epidemiologic data, two communities may decide differently about whether and when to close schools, businesses, and public gatherings and activities. That’s appropriate, and empowering communities to make these decisions is essential to increasing public acceptance.

The CDC must ensure feedback from clinicians, patients, families, affected organizations, and others is heard and documented in a publicly accessible record. The agency also needs to consider economic and societal realities, as the ACIP routinely does. And it needs to explain its methodology, rationale, scientific basis, and recommendations clearly and simply.

Progress toward trust

Nothing succeeds like success. Public health needs to protect and improve health — and demonstrate it is doing so — in ways people recognize and value: better prevention and treatment of opiate addiction; safe and clean food, water, and air; reduced risk of cancer, heart disease, and stroke; actionable information about health that is relevant to local communities.

Government, business, and health care all play important roles communicating effectively with the wide range of the public that will need to protect themselves, their families, and their communities. Trust in the private sector is high and has increased substantially in recent years. Public-private partnerships can work well, as exemplified by Operation Warp Speed delivering a safe and effective Covid-19 vaccine in record time. Improved primary health care is essential; healthier people are more resilient to epidemics. Doctors and nurses remain highly trusted sources of information, and front-line clinicians can sound the alarm about emerging health threats and deliver treatment and vaccines in a way that’s efficient and accepted.

The more trust that can be built, the faster and more effectively the country can respond to emergencies. Restoring trust won’t be quick or easy — especially in a divisive political season — but that doesn’t make it any less important. The word trust comes from the word strength. The more we earn each other’s trust, the stronger each of us, and our society, will be.

Tom Frieden, M.D., is the president and CEO of Resolve to Save Lives, a non-profit organization partnering with countries to make the world safer from epidemics and prevent deaths from heart attack and stroke. He was the director of the Centers for Disease Control and Prevention from 2009 to 2017, where he oversaw responses to the H1N1 influenza, Ebola, and Zika epidemics.