The visibility of public health—both as a science and a government responsibility—has increased dramatically with the COVID-19 pandemic. Public health science, surveillance, and emergency interventions are saving lives across the globe. Public health leaders are advising local, state, national, and international policymakers and have a consistent and strong voice in the media. We describe here the trust challenges facing public health in this moment of crisis, as well as the strategies necessary to maintain and increase that trust.
In the United States, public opinion data suggest that, while trust in science and government is relatively low and has been declining in recent years, trust in public health is high.1,2 In a survey released in April, 2020, the most trusted groups “to do the right thing” on COVID-19 were doctors, hospitals, scientists, researchers, and the Centers for Disease Control and Prevention (CDC).3 Trust in state government was the next highest. Some governors have been particularly strong in supporting public health messages. For example, Governor Gretchen Whitmer in Michigan has repeatedly stated that her decisions are based on science and public health4; Michiganders reported trust in state government at 79%, compared with trust in the White House at 54%.3 In Ohio, where Governor Mike DeWine has stood with his director of public health, Amy Acton, MD, MPH, in his pandemic response, trust in state government was 80%, compared with trust in the White House at 62%.3
Until there is an effective vaccine with high levels of uptake, COVID-19 prevention and control efforts are going to primarily rely on intrusive and challenging public health interventions such as school/business closures, stay-at-home orders, crowd limits, and travel restrictions. Maintaining trust in and support for both public health interventions and leaders requires intentional strategies that are sophisticated and deploy effective social marketing and risk communication strategies.
CHALLENGES TO MAINTAINING TRUST IN PUBLIC HEALTH
Early in the trajectory of COVID-19, Americans were almost uniform in their support for stay-at-home orders.5 Later, as the economic and social impact of self-quarantine, business, and school closures deepened, backlash began to increase.6 As recent protests against stay-at-home orders and other COVID-19-interventions reveal, many people do not understand the breadth of government’s duty to protect the public’s health and welfare. In fact, the US Constitution gives states a significant amount of power to protect the health, safety, and welfare of their populations, including “police powers” that generally fall into three categories: (a) protecting people who cannot protect themselves, (b) protecting people from others, and (c) protecting people from themselves.7,8 Current executive orders and other government actions designed to combat COVID-19 represent the use of police powers in all three of these areas.
It is exceedingly difficult for governments to design effective pandemic interventions—including executive orders and laws based on “police power”—that protect the public’s health without negatively affecting the economy, healthcare system, schools, and the financial and psychosocial welfare of citizens.
To compound this challenge, while local, state, and federal governments have the authority to act strongly and swiftly in a public crisis, American’s passionate political and philosophical attachments to freedom and self-determination and their skepticism about government interference cannot be dismissed. “Life, liberty, and the pursuit of happiness” is more than a line in the Declaration of Independence—it reflects a strong set of American values that make the case for action that is collectively based while honoring individual interests. Although Americans have a deep-seated belief in individual freedoms, public health relies on collective action for success. Public health leaders must understand this tension and effectively articulate why and when collective action is necessary while also articulating a path to move from a uniform, state-imposed emergency response to one that relies on responsible individual actions.
The federal government’s conflicting messages on science and the public health are also an enormous threat to public health. When the White House’s top trade adviser publicly criticizes the response of the CDC, the CDC guidance appears politicized, which erodes public trust.
Unfortunately, public health in the United States has generally struggled to make a clear and compelling case for prevention and nonmedical approaches to health and well-being. As the saying goes, “Public health is invisible when it is most effective.” Public health leaders are trained in epidemiology and other sciences, in community-based partnerships, and sometimes medicine. However, few public health leaders have been trained in advocacy communication.
STRATEGIES TO STRENGTHEN TRUST IN PUBLIC HEALTH
Government leaders and their partners can better balance the health, economic, and other needs of the population if they effectively communicate the rationale and need for population-based public health interventions in ways that are based on communication science and are politically savvy. A civics lesson from public health officials about constitutional law and the role of police power in combating COVID-19 is not likely to be effective. However, sophisticated messaging tailored to different audiences about the government’s role in protecting the health of everyone could be.
While much is still unknown regarding COVID-19, the evidence is clear that nonpharmaceutical interventions like self-quarantine and isolation, physical distancing, business and school closures, and other core public health strategies are effective in reducing community spread and can flatten the infectious-disease epidemiologic curve.9,10 Countries such as South Korea, New Zealand, Australia, and Germany—countries that have taken strong public-health approaches on social distancing and stay-at-home orders along with extensive testing and contact tracing—have demonstrated reduced rates of severe morbidity and mortality from COVID-19. Vietnam, a developing country of 96 million people that borders China, has reported zero deaths from COVID-19 to date because of both swift public health actions and strong communication strategies.11
Public health communication efforts regarding COVID-19 should be based on risk and crisis communication science and on best practices for social marketing that rallies people around shared values.12,13 For example, communications from Dr Acton have attempted to “inspire” rather than “order” people to physically isolate by appealing to widely shared core values.14 This includes acknowledging the hardships people are experiencing, emphasizing the important historic role that everyone is playing in their sacrifices, promoting determination rather than fear, and declaring that “not all heroes wear capes.” Best practices in communication also include segmenting audiences for the design and testing of different communication approaches.12
Public health leaders can also learn from the extensive research from other fields in how to build trust. Consumer product research emphasizes the importance of transparency in sharing known and unknown risks and admitting error when errors are made.15
Engagement of the public in policy decision-making is also essential in situations of uncertainty. Since much is unknown about COVID-19, policy guidance about mitigation and prevention strategies has changed in real time. Changing messages on the importance of face masks is an example of the trust challenge for public health. In the initial stages of the pandemic, the CDC discouraged the use of face masks. As more data became available, the CDC changed its guidance. Such changed guidance can undermine the entire public health message on protective factors. Acknowledging uncertainty and engaging the public in decision-making through a process of reflexive learning can build public trust in a time of uncertainty.16
COVID-19 has also reaffirmed and illuminated that the public health and healthcare delivery systems are intertwined. Failure to “flatten the curve” results in an overrun healthcare system, enormous costs, and significant mortality. However, public health efforts that successfully slow and limit community spread also produce significant financial losses for healthcare systems because the use of all types of nonemergent care greatly decreases. Public health and healthcare system leaders must partner in the strategic design and reinforcement of messages to build strong and lasting trust in the ongoing public health interventions and mandates that are going to be with us for the unforeseen future.
Finally, maintaining trust in the face of political attacks on our agencies of public health requires the healthcare community speak out in unity—endorsing science-based recommendations and supporting the CDC, the World Health Organization, and local public health.
Public health is at an unprecedented and crucial moment in this global pandemic, with growing societal understanding of the role that public health plays in our lives. Public health leaders have a unique opportunity to build on that understanding, strengthen trust, and increase funding and support for core public health services.
Balancing risks and benefits in the face of great uncertainty is never easy. With COVID-19, the horrific number of deaths and speed of community spread has led to a strong and essential public health emergency response throughout most of the country. Keeping the public committed to the important and ongoing measures necessary to ensure that prevention/control efforts are effective and that as few lives as possible are lost will require strengthening the widespread and deep trust in the science and practice of public health.
The authors have nothing to disclose.