Blog > nursing

Can Public Health Be Saved?

At the end of February, the Centers for Disease Control and Prevention issued a consequential turn in its mask guidance. The new recommendations meant that most of the country could stop requiring masks indoors — largely passing the decision on to local authorities, many of whom had already decided to roll back mask mandates. This was greeted with a mix of contempt and indifference. Depending on whom you ask, it was either too late (Masks? What masks? Fire Fauci.) or too soon and too cavalier. A unifying thread was that the C.D.C. is wrong, its rules are politically motivated and it needs to do … better.

As of this January, trust in the C.D.C. had plummeted. At the beginning of the pandemic, 69 percent of Americans believed what they heard from the agency, according to an NBC News poll. Now that has fallen to 44 percent. The numbers for Dr. Anthony Fauci have also substantially declined, despite his decades of government service under seven presidents and attempts to remove himself from political rhetoric.

Without this foundational trust, contempt for guidelines trickles down to anyone tasked with applying the rules. Retail workers, teachers and flight attendants asking people to wear masks end up serving as a proxy target for a deep-seated rage against the science.

To understand how the public health establishment has fallen, and what might be done to redeem it, one needn’t look far back. While the Trump administration may have created a new level of distrust by directly undermining experts, the issues are more deeply ingrained and something a changing of the guard alone couldn’t fix.

No moment in the pandemic underscores this better than July of 2021. You were there. It was great. The long-awaited — if regrettably nicknamed — “hot vax summer” was nearing a premature peak. It was a fleeting period of blissful ignorance. Many vaccinated people had stopped wearing masks after the C.D.C. told them they didn’t have to in most settings. Cases of Covid-19 had dropped, and the number of vaccinated Americans was growing. The long-promised return to normalcy was supposedly finally imminent.

Americans had been assured as much before. But this time, the United States had a new president who promised to follow science and surrounded himself with an esteemed team of doctors. Most notable was the chief of infectious diseases at Massachusetts General Hospital, Rochelle Walensky, whose appointment to lead the C.D.C. was greeted by resounding praise in the public health community. Under Donald Trump, the agency’s pandemic response had been defined by shortages and chaotic messaging. But that was finally over.

Then, the new hope crumbled. Leaked internal C.D.C. information suggested that vaccinated people who were infected with the new Delta variant might be able to spread the virus by way of breakthrough infections.

Americans squinting over their sunglasses weren’t sure what to make of the news. Immunologists had long mentioned the potential for post-vaccination infection, though it was unclear how often it would actually happen. Now the agency apparently had changed its recommendation on masks for the vaccinated based on data that the infections could be more common and consequential than originally thought. This had the potential to upend President Biden’s promise to end the pandemic. Yet the first word the public heard on the data was from a leaked presentation, devoid of context. This seemed the inverse of the candor and transparency Americans had been promised.

“I think there was a shortsighted hope that messaging that vaccines were perfect would ensure people get vaccinated,” said Julia Raifman, an assistant professor of health law, policy and management at Boston University.

By the height of the Delta surge, some 2,000 Americans were dying each day. Then during the Omicron wave in early 2022, the United States would see an even more severe wave of illness and death. Amid all of this, the public has received few news conferences from agency experts, instead parsing cryptic guidance on their own, amid news of testing shortages and reports of the C.D.C. withholding Covid data.

Many politicians and pundits actively work to highlight such failures as proof that nothing the agency says is to be trusted. Others are spreading outright falsehoods in bad faith. “It’s disgraceful, and it’s shameful, and it’s killing people,” said Dr. Francis Collins, former director of the National Institutes of Health. “Politicians and media and social media personalities who are distributing misinformation have blood on their hands.”

Some leaders brazenly do the opposite of what the C.D.C. recommends. In Florida, mask mandates have been banned, and the state is defying medical consensus by recommending that healthy children not be vaccinated against Covid. The overall effect can erode a common factual basis for reality, leaving many people believing that everything is simply a matter of opinion.

No country in the world has had a perfect pandemic response. America is not alone in its struggles to develop and communicate effective policies. But one of the few constants of the pandemic is the fact that countries with high levels of social cohesion and trust in leadership fare better than those without it. The authority of the public health establishment lies in its trustworthiness among the public. Without that, it is ineffective. The Biden administration seemed to understand this and has made real attempts to restore the public trust that was lost under Mr. Trump. But America’s public health apparatus remains beleaguered.

How could it be that this happened, since it seemed all the best people were in place?

For all the blame placed on Mr. Trump for his failed pandemic response, many of the same issues of distrust and confusion have plagued the Biden administration, for nearly opposite reasons.

Under Mr. Trump, the silencing of health officials was overt. The administration blocked some C.D.C. officials from television interviews and reportedly reviewed C.D.C. reports and in some cases, requested word changes. Dr. Robert Redfield, the agency’s director at the time, and the coronavirus response coordinator, Dr. Deborah Birx, seemed to struggle to avoid contradicting Mr. Trump. The image of Dr. Fauci chuckling and cupping his head with his hand as the president spoke of the “Deep State Department” during a coronavirus briefing became indelible.

By contrast, Dr. Fauci has told me, President Biden is far more interested to hear from him and the other experts on the team. And the administration’s messaging is confident, concise and unified. There is very little daylight between what Dr. Fauci says and what Mr. Biden and Dr. Walensky say and what Jeff Zients (Dr. Birx’s successor) and Surgeon General Dr. Vivek Murthy say. This is, theoretically, ideal.

And yet the system is struggling. Public distrust, uncertainty and skepticism are at a low ebb. The generous read on the situation is: When leaders attempt to follow science earnestly — and wait for consensus among people who think in nuances — they risk being slow to respond and vague in advice and conclusions. The less generous read is that politics and science have melded so completely that the result has been neither scientifically nor politically effective.

“I think the administration has been thinking: ‘We want to speak with one voice. We don’t want to confuse people. We don’t want mixed messages,’” said Dr. Thomas Frieden, a former director of the C.D.C. who dealt with outbreaks such as Zika, H1N1 influenza and Ebola during his tenure. “‘So, all of the briefings will be from the White House.’ The problem is, then you don’t get the granular briefings you need.”

In the attempt to have a cohesive message, there appear to be delays and failures to say anything at all. Whatever the intent, the effect has left Americans feeling uncertain of whom to trust, at best. At worst, lied to. The issues go beyond messaging, to failures to update basic definitions or policies that could easily — instantly — be carried out.

For example, the definition of “fully vaccinated” has not yet been changed to include booster shots, even months after the C.D.C. recommended them for everyone. It can be argued there’s a political benefit to not doing so: If the definition were updated, the administration would no longer be able to tout the success of 65 percent of people being fully vaccinated. Suddenly that number would drop to around 44 percent. (The C.D.C. says people who have gotten their booster are considered “up to date.”)

Other decisions have been similarly vexing. During the Omicron surge, the administration maintained a travel ban against South Africa for weeks despite the fact that the virus was already in the United States. And for months there was persistent hesitation to acknowledge the usefulness of N95 masks and rapid tests, coinciding with a national shortage of both.

In isolation, any of these decisions might be dismissed as an earnest oversight. The agency is small, understaffed and underfunded. But taken together, there is a pattern of alignment between health information and political expediency. This approach may placate people in the short term, but it makes the crisis of trust only worse with time.

It is not too late for the Biden administration to make lasting changes expressly aimed at stopping the decline in trust. But it must act now. Because there is a real chance that America’s public health institutions will slide further into the realm of serving political agendas.

The situation could be far darker if another president came to office who proudly derided expertise and silenced agencies when their message became inconvenient. It’s not so hard to imagine that a second term for Donald Trump, for example, could see requirements of total fealty from scientists.

It doesn’t have to be this way. There are real steps that the government can take to rebuild public trust.

No system of public health is perfect. But protecting science from politics as best as possible, without siloing it into obscurity, is a good goal and would go a long way to healing many of the divisions over public health that we’ve seen during this pandemic. In a hypothetical world, a president could assure Americans that everything is fine and churches could be packed by Easter. Then, a C.D.C. director could step to the podium to tell the public: “Well, I’m not sure they will be. Here are the numbers we have ….” And the public would be able to draw their own conclusions.

In any crisis, serious disagreement over values and priorities is inevitable. How many lives saved should justify, say, closing schools? Is preventable illness acceptable as long as our hospitals are not overcrowded? There is no single correct answer when choosing between losses that people value differently. Trust in a system does not mean always agreeing that the correct decision has been made but that decisions were made in good faith, transparently, taking all perspectives into account. We haven’t had enough of this in the pandemic.

This process cannot happen without a baseline of evidence and facts, from which people can agree or disagree about policy. A good example is weather. Meteorologists say that a hurricane is approaching the coast. Local leaders advise people to take precautions, maybe to shelter in place or evacuate. Some will decline to do so. But it’s not because they don’t believe in hurricanes or think the meteorologists are trying to fool them.

Similarly, people should be able to trust that a deadly virus is spreading and evolving, and agree on the numbers of cases and the potential consequences of various policy approaches, and then disagree about what approach to take. As it is, science and policy are packaged together. This causes situations in which people who disagree with a policy like school closures are accused of dismissing the seriousness of the virus altogether.

A healthy distance between the C.D.C. and other political leaders would allow the agency to quickly and transparently communicate information to the public, even when it’s politically inconvenient. When health agencies, scientists and politicians appear to be working as one, especially in a highly polarized political climate, people can dismiss the messages altogether. “For the people to whom the Biden White House is anathema, you basically get them to turn off to C.D.C.,” Dr. Frieden said.

One of the key steps to take, according to Dr. Frieden, would be freeing up the C.D.C. to do independent briefings. “If you look at H1N1, Ebola or Zika, we were giving nearly daily press conferences,” he said. “It hurts the public to not hear regularly from C.D.C.”

And not just the C.D.C. — Americans should hear from, and be heard by, all involved in a pandemic response and bear witness to a transparent process of decision-making. Even when it gets messy, the end result will feel less like a decree from an ivory tower and more like the imperfect product of continuing dialogue. The new mask guidelines in February may have felt too abrupt to some because the C.D.C. hadn’t yet explained the imperfection of relying on case numbers alone to define risk calculations; its new community-based guidance now includes the share of hospital beds being used and hospital admissions, in addition to case numbers.

Inevitably, pundits and political opportunists would attempt to paint disagreement as conflict, and changes in guidance as hypocritical contradictions. This could lead people to believe that no one knows what they’re doing, and so you may as well eat horse paste. This effect is not insurmountable. But it requires active work to earn trust and retain credibility.

To ensure that this kind of separation between politics and health can happen regardless of the presidential administration, new measures may need to be enacted. For example, Congress could move agencies like the C.D.C. and the Food and Drug Administration outside of the Department of Health and Human Services to allow for more independence. This has been called for many times over the years, and the case is only growing clearer. Within that arrangement, it may also be possible to limit the influence of any given president over public health, for example by requiring congressional approval of C.D.C. directors, possibly for a term that does not coincide with presidential terms.

And though communication lies at the heart of rebuilding public trust, the agencies must also have timely and credible — ideally impeccably vetted and contextualized — information to communicate. This means expanding them significantly, possibly via a mandatory funding stream that can allow for long-term planning and independence from political whims. In 2021, the C.D.C.’s discretionary funding was $7.1 billion, equal to roughly 1 percent of the funding for Department of Defense. Having just witnessed how costly a pandemic can be, we should take this moment to treat public health as a matter of national security and provide the agency the tools and personnel to live up to its own advice on crisis communication: “Be first, be right, be credible, express empathy, promote action and show respect.”

Absent this, Americans are witnessing what happens. Regular cycles of panic and confusion have worn everyone’s patience to the bone.

And this virus is not going away; there will be more surges. And there will be other pandemics. Our system has proved to be unprepared to deal with them. Investing in rebuilding sources of information is the only way forward.