And Their Consequences for Public Health in the Trump Era
Here are three essential truths about trust and some thoughts on what they mean for public health.
- Communication is the most important component of trust.
- The erosion of trust hampers all communication.
- Trust is easily broken, but difficult to build or sustain.
1. Communication is the most important component of trust.
There are any number of formulations on what it takes to establish and maintain trust, but in general those components can be grouped and summarized as:
Does the person know what they’re talking about? Do they have training, education, or expertise in this subject?
Does the person change positions without reason? Is there congruence between what they say and what they do?
Is this person honest? Do they have a track record of telling the truth?
Are they able to express themselves clearly?
Conventional wisdom is that trust is secured when all four elements are present, but that may not actually be required. Take the case of Donald Trump and his statements on vaccinations, particularly those linking vaccines to autism. On this scale, Trump fails on the first three criteria and only scores on Communication.
He obviously has no medical or clinical background (no competence), frequently accuses others of precisely what he himself is doing (no reliability), notoriously lies on nearly a daily basis (no integrity), and yet, is able to persuade others to adopt his views (communication). In fact, one way of viewing his presidency is to see it as a sustained attack on these first three factors. He ignores and belittles expertise (from scientists, from the intelligence community, from the military, and even the National Weather Service) claiming both that he knows more than these experts and that his intuition is superior to their facts. But the canny pivot he’s made is from ‘I don’t trust them’ to ‘you shouldn’t trust them.’
On reliability, he’s been equally slippery, insisting that those who criticize him on any account are not be to believed. In other words, it’s not his inconsistency that’s up for discussion but others’ criticism of him.
His lies (integrity) are so frequent (over 16,000 in his first three years in office) that the media no longer reports many of them and the public is practically inured to them.
And yet, as least some of the blame for the drop in vaccination rates can be laid to his, admittedly effective, communications. [ 1 ]
But Trump was certainly not the first to promote specious theories about the cause of autism. Here are some other prominent players in this game:
While you may disagree with any of these particular scores, what’s undeniable is that what they all have in common is a mastery of communications and each (I would argue, consequently) has a large number of followers, people who believe their baseless claims about autism, despite their lack of some or all of the first three criteria for trust. [ 2 ]
Maybe a better way to look at this phenomenon is not that these people are somehow magically circumventing the requirements for establishing trust, but that the definition of trust itself –or rather how we trust– has changed. Somehow, it’s morphed into something more like faith, a condition that doesn’t require that the messenger have competence, reliability, integrity, or even an adherence to facts. In a way this makes sense, given the recent declines in critical thinking, extent of reading, and reading comprehension. [ 3 ] Couple that to the choice of many people who prefer to receive only siloed information and opinions, and it’s easy to see that faith is an easier way to make a connection than earned trust.
The result: communication has become the critical component of trust. And that should give us pause, especially as it applies to healthcare and public health.
So while Trump has been able to build trust in his views, he has done so only by seriously damaging trust in institutions like science and the media.
2. The erosion of trust hampers all communication.
The erosion of trust hampers all communication but it’s particularly corrosive and dangerous regarding matters of health. This observation is far from new (see, for example, Laurie Garrett’s Betrayal of Trust [ 4 ]), but bears repeating, especially for those of us approaching it from the communications, rather than the health, perspective. On the communications side I think we sometimes prioritize getting the message out over gauging how it will be received, and here is where trust becomes important. We assume that once the information is shared, trust will appear. But when we do so, we overlook what is often a long and troubling legacy of mis-information and fractured trust.
Where Garrett’s focus is primarily on the systemic collapse of public health and a more generalized abandonment of public health in favor or medical practice, there are sectors of the population that are deeply suspicious of any medical service or treatment. African Americans in particular have suffered mis-treatment, lack of treatment, and mis-information, all contributing to the building of formidable barriers to trust, the exchange of information, and free and open communication. The Tuskegee Study of Untreated Syphilis in the Negro Male and the unauthorized appropriation and exploitation of Henrietta Lacks’ cancer cells [ 5 ] are two of the more prominent examples.
A similar distrust can be found in the Democratic Republic of Congo, as citizens there not only fail to take needed precautions against the Ebola outbreak in that country, but have also set fire to at least two treatment facilities. A society so long traumatized by war and unable to count on its government to provide even minimal stability is fertile ground for mistrust of medical assistance, especially when it is predominantly provided by out-of-country NGOs.
And in yet another example, the rise (and in some cases resurfacing) of polio in Syria, Pakistan, Iraq, and possibly Afghanistan as well, may be attributable, at least in part, to the distrust of medical personnel following the CIA’s use of a local doctor to scope out the Bin Laden compound under the guise of vaccinating against HEP-B infections. [ 7 ]
These examples show the difficulty reestablishing trust once it has been broken. Which leads to the third truth:
3. Trust is one of those commodities that’s inherently fragile and easily broken while at the same time it’s difficult to build and sustain.
Some of the mechanisms of building and eroding trust are shown in this graphic.
This ‘trust stack,’ where each arrow can be read as “influences” or “colors,” suggests some ways that trust can be either reinforced (right) or degraded (left). One of the points this illustrates is that while trust can be broken by institutions, in contrast it more often must be built up personally or individually. So we start to destroy trust with propaganda but we build it beginning with our individual beliefs. This is why authoritarianism is relatively easy to establish (shattering trust in all institutions except the dictator himself) and maintaining a democracy is quite a bit more difficult because, essentially, each of us must individually and personally ‘sign up’ or give our assent for it to work.
And more to the point of the fragility of trust, think about the power of simple tweets by someone in authority (the propaganda, deception) to undermine trust in scientific, legal, legislative, and media institutions. Compare that to the more difficult endeavor of examining our own beliefs, holding them up to our daily experiences and those of others, and fully educating ourselves.
Of course, health communications take place within a larger context of societal trust. And that, unfortunately, at least in the US, now seems to be at a very low ebb. When lies proliferate and are actively promoted by those in authority, when institutions inherently designed to seek the truth like our courts and press are constantly disparaged, when science is viewed as opinion and not fact, conspiracy theories find fertile ground and practices like vaccinations are increasingly distrusted. Healing that environment and restoring general societal trust will probably take years of concerted effort.
What Can We Do?
The next president and Congress can make a host of legislative and regulatory changes in an attempt to restore the structural public health and healthcare landscape to at least the outlines of what it was in 2016, but even that will clearly not be enough to restore the actual level of care. Why? Because trust is the essential prerequisite for any such rebuilding. And that foundation of trust is clearly broken.
Restoring trust in health practices could be helped if we:
- Focus on outcomes, not just practices; e.g., not how many people have been vaccinated but how the rate of disease acquisition has dropped as a result of those activities. This kind of ‘outcomes communication’ may also be particularly helpful during the COVID-19 crisis.
- Create cognitive dissonance between falsehoods and common sense. For example, a visit to any graveyard will show the decline in childhood mortality over the last century, due in no small part to vaccinations.
- Make it personal. “Remember when you were a kid and you got polio and smallpox?” Of course not, and that’s the point. This kind of phrasing makes it personal.
- Focus on misconceptions, not on the people who hold them. It’s easier to let go of an idea than to get over personal attacks. So don’t attack Trump, or Kennedy, or Wakefield, Winfrey, or McCarthy, –or most importantly, those who believe them–, attack the ideas they hold. You’re far less likely to persuade a neighbor that he’s wrong by calling him stupid or uniformed than you are by saying there’s a flaw in what he’s been told.
The ongoing decline in trust throughout our society is truly worrisome given how essential it is to the functioning of our institutions and the fluidity of our daily lives. If this delicate tapestry of trust is torn and unreliable, we are in jeopardy. And if we can not trust the communications of our doctors, health officials, and our government, relying instead on uniformed and misguided opinions, we can too easily put ourselves and everyone around us in danger. So we really have no choice; We need to begin rebuilding that trust today.
Because an often-used symbol of trust is the handshake, I considered using a handshake graphic at the start of this post, but in light of the current COVID-19 outbreak, a single open hand, offered in trust and friendship, seemed more appropriate.
Please leave your comments below.
The Trump Twitter Archive is a fascinating, searchable, and sortable collection of thousands of Trump’s tweets. http://www.trumptwitterarchive.com See, specifically, this subset of his tweets about vaccines: http://www.trumptwitterarchive.com/highlights/vaccines .
[ 2 ]
See MIT professor Seth Mnookin’s book The Panic Virus, where he documents Kennedy’s distortions, Wakefield’s deceit, Oprah’s uncritical endorsements, and McCarthy’s many iterations on what she believes causes autism. http://sethmnookin.com/the-panic-virus/ and https://cmsw.mit.edu/profile/seth-mnookin/ .
[ 3 ]
Critical Thinking: The Emerging Crisis in Critical Thinking.
Reading: Leisure reading in the U.S. is at an all-time low.
Reading Comprehension: Reading Scores on National Exams Decline in Half of States. https://www.nytimes.com/2019/10/30/us/reading-scores-national-exam.html
[ 4 ]
There is probably no better discussion of this than Laurie Garrett’s Betrayal of Trust: The Collapse of Global Public Health. https://www.lauriegarrett.com/betrayal-of-trust
[ 5 ]
African American treatment generally: https://www.nytimes.com/2020/01/13/upshot/race-and-medicine-the-harm-that-comes-from-mistrust.html,
The Tuskegee study: https://www.cdc.gov/tuskegee/timeline.htm
[ 6 ]
Here’s why Ebola has been so hard to contain in Eastern Congo https://www.washingtonpost.com/politics/2019/06/25/heres-why-ebola-has-been-so-hard-contain-eastern-congo/
[ 7 ]
I say “in part” because there were other factors contributing to the distrust. From part 2 of the National Geographic series referenced below:
“Pakistan’s polio campaign had been dragging on fitfully since the mid-1990s, and even before the CIA’s tactics came to light, resentment against the campaign had been building.
“Among unschooled Pakistanis, many rumors abounded, including one that said the vaccine drops were part of a Western conspiracy to sterilize Muslims. (It hadn’t helped that early on, polio workers wore jackets left over from a family planning campaign.) Some clerics claimed falsely that the vaccine was made of pig products, which are taboo for Muslims. Even more bizarre was a story, widely circulated after the U.S. invasion of Afghanistan, that the vaccine contained urine from then President George W. Bush.”