Why public trust counts in a pandemic — until it doesn’t

With the COVID-19 omicron variant loosening its grip, a “let’s leave it all behind us” sentiment is growing in the United States. But what feels like the right path, eyes forward, may be the deceptive restart of a circular pandemic policy.

As a medical anthropologist working in health security for decades, I can tell you it has a name, “panic and neglect.”  Decision-makers wake up during a catastrophic outbreak to the value of a strong public health sector only to return to slumber after the crisis, until another epidemic startles them anew.

A less well-known trend concerns me more, however, when responders discover late in an emergency that trust — not just biomedicine — is necessary to control contagion. After scrambling to act on this truth, they forget about it until the next full-blown health crisis. 

Successful public health interventions in an epidemic hinge on public trust, actionable information and a community-owned response. Witness the  2003 SARS outbreak, 2009 H1N1 influenza pandemic, Zika in the Americas from 2015 to2016, and now, the COVID-19 pandemic, among others.

In our lifetime, this lesson has failed to stick, even when ignoring it can be deadly. 

Early in the West Africa Ebola outbreak of 2014 to 2016, the response faltered as a result of poor communication and a decision-making process that was disconnected from the experiences on the ground. This initial approach fostered fear and mistrust in communities that had been served by a weak health system. People with suspected infections avoided testing, families hid their sick, and health workers encountered pushback, sometimes violence. But when the response involved the community as problem solvers and elicited their input, surveillance improved, safe burials increased and viral transmission slowed.

The “discover and disregard” cycle may be unraveling, some argue. UN agencies and health and humanitarian organizations have detailed valuable strategies on community engagement for epidemics. Social scientists have outlined to peers, funders and national governments how to integrate human factors into health security.

These global developments are unlikely to influence domestic health security, however. The U.S. fiercely guards its sovereignty and spurns international guidance. Technological innovation is deeply woven into our national identity, economic system and our health system. 

And so, we refuse to learn that outbreaks have a human side. Our pandemic vaccine strategy is a clear-cut case.

Public trust in vaccines was a key takeaway from the H1N1 flu pandemic. Many Americans rejected vaccines because of perceived safety concerns: the technology was “new,” “untested,” and/or “rushed” — all unfounded fears. Some people of color were wary of pandemic vaccine promotions due to past and present actions by health institutions that along with a lack of access, contributed to disparities in vaccination.

By the time the SARS-CoV-2 virus emerged, these insights were lost.

Operation Warp Speed — the initiative to develop and distribute COVID-19 pandemic vaccines to the U.S. population — was strictly a lab and logistics operation. The enterprise aimed for biological breakthroughs; it had no equivalent to ensure social success. The U.S. COVID-19 vaccination campaign has been playing catch-up even before the vaccines became available in December 2020.

Lack of access and lack of vaccine confidence predictably popped up again, especially for lower-income communities of color. Community advocates and public health have since doggedly worked to overcome these issues.

Hyperlocal outreach and workarounds — like empowering Black-owned barbershops and hair salons as community health hubs — are narrowing the COVID-19 vaccine coverage gap between white people and persons of color. Hair professionals talk vaccines with clients without judgment and host vaccination clinics in their shops. High-touch approaches may still benefit white community hold outs if we commit energy and resources to the outreach.   

Earlier this month, a widely reported research study in the Lancet raised hopes that the policy cycle concerning the sociality of outbreaks was breaking down. According to data from 177 countries, trust in government and trust between citizens predicted fewer COVID-19 infections. Pandemic preparedness and health system capacity — leading readiness/response measures — did not.

To apply these lessons and avoid yet another unhealthy cycle in U.S. health security, we have four steps to take.

1. Center public trust issues in any national COVID-19 commission. 

Factors that helped or hindered Americans in cooperating with public health interventions require investigation, including sick leave policies, institutional bias and logistical hurdles. A critical review of the response must take priority over the politics of the pathogen’s origins, and the bipartisan PREVENT Pandemics Act should empower a council on Public Trust and Help in Health Crises rather than the proposed advisory committee on communication and information. More than messaging drives behaviors like mask-wearing and vaccination.

2. Embed social science expertise at the highest policymaking levels.

Credentials for health security leadership should extend beyond medical and life sciences. Alondra Nelson, the first sociologist to lead the Office of Science and Technology Policy (OSTP), heralds a new trend. Because appointees turn over, the OSTP, the National Security Council, and the HHS Office of the Assistant Secretary for Preparedness and Response should carve out permanent positions in their organizations for the delivery of strategic social scientific advice on biological incidents.

3. Allocate a portion of medical countermeasure investments to social efficacy research and development. 

The Biden administration’s proposal to transform American pandemic preparedness capabilities includes an “extensive scientific workplan” to achieve production of flexible vaccines, therapeutics and diagnostics at not-yet-possible speeds. This $42 billion investment will more likely succeed if there is a well-funded strategy for investigating the socio-behavioral factors driving public access to and acceptance of cutting-edge technologies.

4. Engineer a trust infrastructure that bonds communities and public health. 

For the American people to consider the pandemic preparedness system as trustworthy, it must engage communities before, during and after an emergency. This requires an ample, skilled and sustainably financed workforce. Community health workers, as drafted in the PREVENT Pandemics Act, are critical, as is a full complement of health promoters, risk communicators, translators, social media strategists and social scientists in local health departments.

Health security must prioritize both trust and technology — only then can we prevent painful, protracted epidemics in the future.

Monica Schoch-Spana, Ph.D., a medical anthropologist, is a senior scholar with the Johns Hopkins Center for Health Security and a Senior Scientist in the Department of Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health. Since 1998, she has focused her public health career on generating and applying evidence to advise policymakers and practitioners on how to collaborate effectively with private citizens, businesses, and faith- and community-based groups in efforts to manage catastrophic health events.