How US healthcare can win over—or win back—the American people

The American public’s trust in healthcare institutions, long a warmly extended expression of affection, fell off a cliff after the COVID-19 crisis. Tellingly, in national polling, local health officials took an even harder hit than the CDC. 

The latter may be catching up in the race to the bottom, thanks to the ongoing upheaval over vaccine recommendations under the HHS headship of Robert F. Kennedy Jr. 

Regardless, two and a half years after the end of the COVID-era public health emergency, healthcare consumers’ confidence in medical experts other than their own physicians still hasn’t climbed back up by much if at all.  

Two academic physicians have analyzed the situation and now propose a treatment pathway for the injured patient—that being our healthcare system’s reputation for reliability. 

“As physicians working inside public health and medicine, we believe we must do better,” write Daniel Morgan, MD, MS, of the University of Maryland and Deborah Korenstein, MD, of the Icahn School of Medicine at Mount Sinai. “While pandemic-era decisions eroded trust in public health, an open, nonpolitical discussion of what went wrong can inform solutions and present opportunities to build trust in public health.”

The opinion piece lays out four principles that, if widely adhered to, would help U.S. healthcare rebuild trust in its leading and guiding institutions in a post-pandemic landscape. 

1. First, do no harm. 

(Sound familiar?) Public health officials “must acknowledge potential harms from interventions and accept variation in how individuals and communities weigh the balance between benefits and harms,” Morgan and Korenstein state. For example, they note, schools and daycares were closed during the pandemic. The aim was to prevent the spread of COVID infection, but that good intention was applied with scant attention to local or age-based risk factors, which “led to the immediate harms of limiting access to education, social interaction, childcare and school meal programs.” More:

‘These closures were unjust in that they disproportionately affected children and marginalized groups. Yet some groups that advocated for open schools were demonized by the public health community without a robust discussion of the trade-offs and importance of different values.’
 

2. Public health officials must meet the public where they are—psychologically, physically and digitally. 

Because one needs to be in the field to best understand a situation, the CDC has traditionally sent epidemiologists to hot zones and outbreaks, the authors note. During the pandemic, many public health operations were carried out virtually. Experts rarely traveled to affected areas, leaving them out of touch. “Aside from enhancing understanding and lived experience in public health experts,” Morgan and Korenstein write, “in-person interactions can build trust, particularly in marginalized communities, and strengthen adherence to recommendations.” More: 

‘Public health experts must better communicate inclusive messages to all groups through a variety of mechanisms, including TV, radio and social media. Public health messaging should be honest and objective about the evidence supporting recommendations and the expected magnitude of impact.’ 
 

3. Public health leaders have to respect individual autonomy and a range of opinions. 

Although public health interventions are implicitly aimed at and measured in populations, populations contain diverse individuals, Morgan and Korenstein point out. “Respect for individuals requires valuing their autonomy, which is a core principle of medical and public health ethics but can be complex and deprioritized in some interventions,” they remark. “Only in the most extreme situations should the right to bodily autonomy be withheld. Because of this, we must reconsider a trusted tool of public health—mandates.” 

‘Mandates compel the public to follow guidance they may disagree with, alienating many. Increasingly, the energy generated by resistance to mandated vaccines is a major threat to public health. … Mandates often violate the least-coercive-means principle of public health ethics, so while it is important to recommend and promote beneficial interventions, [the effort] should almost never involve mandates.’ 
 

4. Public health measures need to be transparent and apolitical. 

During the pandemic, initial guidance against community masking was intended in part to prevent mask shortages in healthcare, the authors recall. However, the public was not informed of this rationale, they add. “A rapid switch to recommending masks eroded trust, as the public felt manipulated,” Morgan and Korenstein comment. “Transparency is key; although the concern for mask shortages in healthcare was real, it was an error to paternalistically not describe that reasoning.” More: 

‘Public health officials must trust the public before they can expect trust in return.’ 

Full honesty can help push against perceived liberal political bias in public health, Morgan and Korenstein maintain. 

“Messaging needs to be carefully evaluated for how it will be received by people across the political spectrum, and public health representatives need to avoid politically charged statements,” they add. “This went awry during the pandemic when public health entities recommended closing churches while supporting public rallies after the death of George Floyd. Public health and the public would have been better served by impartially describing the risks associated with social contact in different settings.”

JAMA Health Forum has posted the commentary in full for free.