As the Ebola epidemic raged in 2014, some West Africans resisted public health guidance. Some hid their symptoms or continued practicing burial rituals — like washing the bodies of their dead loved ones — despite the risk of infection. Others spread conspiracies claiming the virus was sent by Westerners or suggested it was all a hoax. In Conakry, Guinea’s capital city, an imam was arrested for violating his quarantine, and residents protested by not letting health officials check for fevers.
So the World Health Organization sent Cheikh Niang, a Senegalese medical anthropologist, and his team to figure out what was going on.
For six hours, Dr. Niang visited people in Conakry inside their homes. He wasn’t there to lecture. Residents asked him to write down their stories. When they finished, Dr. Niang finally spoke.
“I said, ‘I hear you,’” he told me recently over the phone from Senegal. “‘I want to and will help. But we still have an epidemic spreading and we need your help, too. We need to take your temperatures and we need to trace this virus.’ And they agreed. They trusted us.”
Turns out, the people Dr. Niang encountered weren’t selfish or anti-science. They were scared and felt stripped of dignity by officials who didn’t respect them or understand their traditions. What they needed was for someone to listen to them and to feel like they had some agency.
More than five years later, Dr. Niang is having flashbacks. Amid a new pandemic, he’s seeing public health officials dispense advice arrogantly, while frustrated populations rebel and endanger others. An epidemic is “a moment of truth between communities, health officials and the overall system of government,” Dr. Niang said. “When I see the U.S. on TV, I almost don’t believe it,” he added.
It’s a full-blown legitimacy crisis. Only this time it’s happening in the United States.
Taiwan is welcoming baseball fans back into stadiums. As of June, more than 20 other countries have begun the process of bringing children back to school. Thailand, a country of 70 million, hasn’t had an instance of local coronavirus transmission in seven weeks, as of last Thursday. And yet Americans are staring down nearly 150,000 virus deaths while governors and health officials pleading with citizens to wear masks are starting to sound like substitute teachers who’ve lost control of the classroom.
One indicator of how bad things are: Last week, Anthony Fauci, the United States’ leading infectious-disease doctor, felt compelled to reassure his audience during an online talk, “You can trust respected medical authorities.” He added, “I believe I’m one of them, so I think you can trust me.”
The Dimmer Switch
Polls suggest that most Americans do still have faith in scientific expertise. A June New York Times/Siena College survey showed that “84 percent of voters said they trusted medical scientists to provide reliable information about the virus.” That includes 90 percent of Democrats and 75 percent of Republicans.
But those figures are hard to square with the reality on the ground, where trust in science seems increasingly fragile.
That trust is endangered by what many public health experts I spoke with described as a messaging crisis. A big problem, according to Ranu Dhillon, a doctor at Harvard who advised the Guinean president during the Ebola crisis, is a lack of nuance.
“All advice ends up binary,” he told me recently. “It’s absolutely one way or absolutely the other way, when it should be shades of gray. It happened with the World Health Organization and denying asymptomatic transmission early on. It happened with masks. And it happened with states reopening.”
Given that this is a novel coronavirus, we’re learning on the fly — things that are true one day might need to be revised the next. Dr. Dhillon suggests that in their desire to be authoritative, public health experts have eroded trust by not accurately communicating uncertainty and by being stubborn about correcting the record when our understanding evolved. He described the strategy as a light switch that toggles on and off only when scientific consensus reaches a certain threshold. What’s needed, though, is something akin to a dimmer.
“When we do flip the switch, we rarely admit that we are pulling a 180,” he said. “We don’t apologize” (for instance, for the W.H.O.’s original assurances that masks were not needed). “Instead, we cast judgments and say, ‘OK, you’re not wearing a mask now and you are irresponsible and a bad person.’ That destroys credibility, creates confusion, and it alienates people.”
There have been similar unforced errors in messaging around outdoor transmission of the virus. Outdoor transmission is possible but much less likely, a nuance that wasn’t properly communicated early on.
“My perception is that public health officials were hesitant to be too vocal about the outdoors being safe,” Dr. Dhillon said. This was an example, he said, of experts hedging language to make sure the public didn’t over- or underreact. But it’s a gamble, trying to control how others receive your message. Dr. Dhillon argued that the same thing happened with masks, where officials and institutions were hesitant to suggest them early on because of supply chain issues. It’s possible that the reversal opened the door for the culture war we’re now experiencing around face coverings.
The Muddled Messages
Other experts suggest that government failures run much deeper than communication problems. “It’s not a lack of trust. It’s a legitimacy crisis,” Rhea Boyd, a pediatrician who teaches classes on structural inequality and health at Stanford, told me. “There’s been an active movement from the far right to render major scientific institutions and practices illegitimate. I’m worried less about messaging and more about a failed government response.”
Dr. Boyd cited the Trump administration’s attempts to cut the budget of the Centers for Disease Control and Prevention, its ouster of the National Security Council’s top pandemic response official, Mr. Trump’s downplaying of Covid-19 and his downright lies about it (most recently on display during a Sunday Fox News interview in which the president said that the United States had “one of the lowest mortality rates in the world” from the virus) and the White House’s muzzling of the C.D.C.
“We have the resources and the scientists and we didn’t support them — we undermined them,” Dr. Boyd said. “And so the cycle perpetuates itself. They’ve been gutted, so their response looks insufficient and ineffective. For those already prone to thinking public health was illegitimate, it’s confirmation bias.”
Indeed, almost every expert I spoke with cited the near-absence of the C.D.C. as a prime reason for the inept messaging.
“I’m sorry to say, but I think there’ll be long-term damage from the politicization and sidelining of the C.D.C.,” Tom Frieden, an infectious-disease expert and former director of the agency, told me in June.
And that was before the Trump administration this month ordered hospitals to bypass sending Covid-19 patient data to the C.D.C., as was standard procedure.
“Without a unified public health voice, it’s been left to individuals on places like Twitter to step up and fill the void,” Julia Marcus, an epidemiologist and assistant professor at Harvard Medical School, said. “You’re left with a highly fragmented set of muddled messages.”
We Messed Up. Now What?
Mark Navin, an expert in the ethics of public health at Oakland University, said we need to dismiss the notion that what we’re facing is new.
“There’s this idea that people always used to trust science and that there was total solidarity around public health advice,” he said. “But it strikes me as nostalgic and revisionist.”
I reached out to Dr. Navin because a quote of his has been echoing in my head since I read it in early May. “Every generation has to come and decide if they’re going to trust the government, and if they’re going to trust medicine,” Dr. Navin told BuzzFeed News. “And we’ve taken it for granted in the post-World War II era that people have this, but every generation has to come in and cultivate it.”
It reminded me of the process of renewing one’s wedding vows — a recommitment from both people in a relationship to continue to learn from each other and not take each other for granted. What would renewing America’s commitment to public health look like?
According to Dr. Marcus, it would involve a great deal of empathy (from institutions like the C.D.C. and W.H.O., and governors and mayors and the company executives deciding when to bring employees back to the office) and meeting people where they are. She cites lessons learned from the H.I.V. epidemic, suggesting that shaming and stigma backfire. “We have to do everything we can to attempt to understand,” she said, “and then acknowledge why people may not be adopting strategies.”
Dr. Marcus pointed to New York City’s messaging around sexual contact during the coronavirus pandemic as a successful example of this strategy. The guidance is clear: You’re taking a serious risk having sex with new partners. But it spells out what actions are safer and which are more likely to result in spreading the virus. “They really nailed it,” she said, “combining both harm reduction but while also acknowledging the basic human need of intimacy and providing guidance to bridge the gap.”
Dr. Marcus has seen this strategy bear fruit in her own work. In a recent Atlantic article about men who don’t wear masks, she acknowledged that masks don’t feel cool, can be obtrusive and block important body language signals, while still arguing emphatically for their importance. Dozens of non-mask wearers contacted her to thank her for the piece.
“These men were universally grateful to read something about anti-maskers that didn’t shame or demonize them,” she wrote. “It made them want to hear what else I had to say about why it might be worth wearing a mask.”
Aisha Langford, an assistant professor in N.Y.U.’s School of Medicine who specializes in public health communications, suggested tactics for rebuilding trust that echo Dr. Niang’s work in West Africa. She encourages local leaders and community physicians who’ve already built trust with their patients to take a leading role in creating tailored messaging.
For her own part, Dr. Langford told me, she is trying to reach out to people on places like Facebook. “I’ve tried to communicate what I know and what we don’t and that, hopefully, they can trust me because I’m right here with them,” she said.
But will this sort of thing be enough in communities where local leaders willfully flout public health guidelines? As the pandemic historian John M. Barry wrote in a Times Op-Ed last week, “when you mix science and politics, you get politics.” Nakedly political state responses from governors like Brian Kemp of Georgia, Doug Ducey of Arizona and Greg Abbott of Texas have undermined the scientific community’s already fragmented message. When your governor sues to prevent a mandatory mask requirement, as Governor Kemp did last week in Atlanta, how can individual public health officials hope to break through?
Normally, this is where the federal government would step in. But not now.
And do these solutions — tailored messaging and long listening sessions — scale? Or are they more like applying a Band-Aid to a gunshot wound?
“Trust alone is insufficient to save lives,” Dr. Boyd told me. She argues instead that we need large-scale public health solutions like universal health care, housing reform, universal worker protections and a substantial rise in the minimum wage that can begin to reverse longstanding racial health inequities. Without them, she argued, we’re just tinkering on the margins of a broken system. The more people that system leaves behind or fails completely, the less trust we’ll have in it.
What’s at Stake? Everything
In the past month, my conversations with public health officials, which were already quite grim, have taken on a darker tone.
“What worries me most right now is that the distrust we’re seeing today will happen with vaccines,” Dr. Frieden told me. “There’s already a huge amount of distrust in vaccines. We’ve got this scarily named Operation Warp Speed program for them. That kind of naming is just not the way to convince someone to put a needle in their arm. It runs the real risk going forward that whether or not the government cuts any corners on the construction of a vaccine, there will be a perception it has, unless we have very open and transparent communication about it.”
Many experts are preparing for such a misinformation nightmare scenario atop a nightmarish pandemic. Signs point to a growing anti-vaccine movement far savvier at bending the internet to its whims than its public health counterparts. That we’re even worrying about people refusing to get a coronavirus vaccine suggests something horrifying: that Americans’ trust in public health and the institutions of government will be worse off after the pandemic subsides than it was at the start.
“My gut tells me that there will be a lot of work to be done to recover from the effects of what’s happened,” Dr. Marcus said. “And that we’ll probably be in a worse place than when we started.”
“Stable, liberal democratic societies are not inevitable,” Dr. Navin told me. They need “care and maintenance from all of us.”
You cannot force public trust; you have to earn it by being humble and transparent, and by listening. And you can’t fake that care and maintenance — it’s the grueling and deeply human work of democracy, which is never finished.
“An epidemic is not only technical and medical — they are not cured only by science or vaccines,” Dr. Niang told me. His words have haunted me since. “Ebola was beaten back by many things, including building consensus inside communities and restoring dignity and trust. This is what we learned. Hopefully, it is not too late for you over there to learn it, too.”
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