When trust is lost, how do we get it back?

Can you remember a time when you shared something that you later found out was not true or trustworthy?

“It’s all too easy to talk about the crisis of trust as something that happens to other people,” said Dean Megan L. Ranney, MD, MPH, who posed the question in her opening remarks at a conference about rebuilding trust in public health on February 10. She emphasized the need to recognize our own roles in the decline of trust in public health. “We are both agents of the problem, and also agents of the solution,” she said.

The conference, Rebuilding Trust in Public Health: Causes, Consequences, and Responses, had a variety of speakers discuss the broader crisis of trust and strategies for enhancing it, including community partnerships. The event was hosted by Yale School of Public Health (YSPH) at Kline Tower, and co-sponsored by the Institution for Social and Policy Studies (ISPS) at Yale University and the MacMillan Center for International & Area Studies at Yale. Dr. Jason L. Schwartz, PhD, associate professor of public health, led the conference.

Public health’s trust crisis began at a high point, the heady days when the COVID-19 vaccines arrived. “People loved public health. Everyone wanted to be an epidemiologist,” said Dr. Peter Lurie, MD, president and executive director of the Center for Science in the Public Interest.

But restrictive vaccine guidelines caused a large swath of the public to revolt and to seek sources online where they found a more sympathetic ear. Mandated social restrictions left people feeling ignored and condescended to as well as confused about the role of public health, said Dr. Brian C. Castrucci, DrPH, president and chief operating officer of The de Beaumont Foundation.

While most people understand a doctor's role in addressing their health issues, “no one talks about community and public health.”

As a child, his daughter explained the difference as “a physician helps one person at a time. Public health practitioners help everybody all the time,” he recalled. Castrucci urged attendees to talk about both roles.

Dr. David Bersoff, PhD, head of research at the Edelman Trust Institute, said people who are 18 to 54 believe doing research means “you can be as knowledgeable as a health care professional.”

AI, he said, will just worsen this effect. “So, the notion of expertise has been diluted,” he added. “Experts are considered elitists.”

His counter for being seen as elite is to humanize yourself to the public. “The public is often moved by personal experiences of people they know, often carrying more weight than peer-reviewed journals,” Bersoff said.

Just getting out of the lab to engage with the public can be effective, said Dr. Adam Seth Levine, PhD, SNF Agora Professor of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health. He discussed local health policy with county legislators in Upstate New York, which is mostly conservative and rural and “not a place Johns Hopkins professors usually go,” he said.

“Local policymakers rarely collaborate with local researchers to tackle policy challenges. But 60% of them wanted to,” Levine said. Collaborative relationships between diverse thinkers are essential to public health, but he noted that these are difficult to form.

Forming relationships may be the most important way to create trust, said Castrucci. “Who we live with and who we talk to is who we trust.”

He suggested that public health needs a friendly slogan, too, a memorable phrase that conveys its value to communities.

Perhaps “Helping you live longer” could reflect that in the last 100 years public health measures have increased life expectancy in the U.S. by an average of 25 years.

“What if you had a [life expectancy] serum and sold it at Nordstrom’s?” Castrucci asked. Public health has created this wonder elixir but “has put that serum in a vault” by failing to communicate its value.

“Maybe trust isn’t the thing we should be chasing,” said Dr. Jennifer Reich, PhD, a sociologist at the University of Colorado Denver. Reich studies how people make decisions. She offered a list of things she doesn't trust but uses anyway: restaurant kitchens, rideshare drivers, food expiration dates. She also acknowledged that she eats ice cream, even though she knows its nutritional properties. “It’s not a health literacy problem,” she assured the audience during a panel discussion on case studies in declining trust.

In her way, she is making decisions that defy the goals of public health. “Public health at times inhibits individual behavior so we can thrive as communities,” Reich said. “The belief is that with information, people will choose for themselves what the state chooses for them.”

But her research shows “people have substituted their expertise on their lives over that of experts,” she said, echoing Castrucci’s point. She pointed out that decision-making can be fluid. “Very few feel they are decided, and their strategies might change as their circumstances change.”

There are also significant differences in how ethnic and racial groups respond to outside information, said Dr. Vanessa Northington Gamble, MD, PhD, University Professor of Medical Humanities, professor of health policy and American studies, and professor of medicine at the George Washington University. She noted that Asian, white, Black, and Hispanic communities differ in how they view trust in health and health care.

Some of those differences come because of long experiences of inequity in health care, said Dr. Craig Spencer, MD, MPH, associate professor of the practice of health services, policy and practice at Brown University School of Public Health.

His personal example happened in 2014. Spencer had been treating Ebola patients in Guinea, West Africa only to contract the disease himself. He was admitted to Bellevue Hospital in New York City and treated by a specially trained team of experts and intensive care nurses. A hard-to-get treatment was offered to him, but he decided against using it.

A different doctor was not so lucky. Spencer wrote in The New England Journal of Medicine about Dr. Sheik Umar Khan, a preeminent Sierra Leonean physician who had also contracted Ebola. Khan was not offered the monoclonal antibody cocktail ZMapp, even though it was available at the hospital where he was treated. “He and I had the same disease. What we didn’t have was the same [health] system,” Spencer said. The difference wasn’t just in access, but in agency and autonomy, he added.

“Seeing science work but not seeing it work for you erodes trust,” he said, and he told the audience to look around. “We are sitting in this room wearing suits, putting up slides filled with beautiful data. And we are looking down from a literal ivory tower,” he said.

“Good communication is not going to dig us out of this hole. If we want to rebuild trust, one thing that will help us more than anything else — it’s really quite simple — is to talk to people. Outside of rooms like this.”

Kline Tower’s sweeping views don’t reveal that “Yale has a problem with trust in New Haven,” said Dr. Marco Ramos, MD, PhD, assistant professor at Yale School of Medicine. “How do we acknowledge and tell the truth about that harm, and how do we repair it?”

Following the example of a community organizer is one way. Fred Harris Jr. co-founded the Hill Parents Association to represent New Haven’s Hill neighborhood, which is largely composed of Black and Hispanic residents. At issue was how the Connecticut Mental Health Center (CMHC), a collaboration between the state of Connecticut and Yale School of Medicine, was not meeting the community’s needs. When it was founded in 1966, CMHC had no Spanish-speaking staff and few staff from the community — issues that are relevant today, Ramos said. He credited research by Sophie Edelstein, MPH ’24, for bringing renewed attention to Harris’ work.

“Medical practitioners need to understand harm so they don’t repeat it,” Ramos said. By acknowledging past wrongs, we can create a more trustworthy future, he added.

When Dr. Joan Monin, PhD, professor of public health at YSPH, began her caregiving and dementia research 16 years ago, she came up with study ideas in her office and then asked people in the community to participate. Her partnership with LiveWell, a brain health and dementia prevention alliance, changed her research, teaching her to listen to the needs of people living with dementia and their families — to trust their experiences — before starting the research.

Although structures and incentive systems are not historically set up for community-centered research, the panel highlighted exemplars of how this work can happen. “We want to partner with researchers to increase the relevance of their research,” said Ellen Sue Moses, an advisory board member at the Empowerment Partnerships Network at LiveWell Alliance who is living with dementia, emphasizing the need to work together to strengthen communities.

Trust cannot be declared, said Katelyn Jetelina, PhD, MPH, founder and CEO of Your Local Epidemiologist. “It’s demonstrated over and over again.” Jetelina, assistant professor adjunct of epidemiology at YSPH, considered the title of the panel she was moderating: “Reimagining trust: strategies to enhance public understanding of health and science.” The title “can quietly assume that the problem is a lack of knowledge, right?” she said.

The panel discussed how information moves through people and communities in different ways. Asuka Koda, a Yale College student and CNN journalist, said she hopes more health practitioners will engage with the media, as she believes experts have an important responsibility to help translate their knowledge for the public. Dr. Jessica McDonald, PhD ’13, science editor of FactCheck.org, suggested rethinking academic structures so that health scientists are incentivized to share their knowledge.

Journalism paywalls and social media algorithms also make it difficult to deliver public health news to a general audience. “The media environment lets us go find things that are perceived as being for us, things we want to hear but not necessarily the things we should trust,” said Dr. Emily Vraga, PhD, Don and Carole Larson Professor of Health Communication, Hubbard School of Journalism and Mass Communication at the University of Minnesota.

As the co-host of the podcast, “Why Should I Trust You?” Brinda Adhikari moderates conversations between people who are skeptical of the health system, like supporters of the Make America Healthy Again movement, and people from public health. If we can’t come together and talk, trust is not possible, Adhikari said.

“I love the idea of going into the community,” Adhikari said. “But rather than righting wrongs of the past, work with them on the problems of the now and the future.”

She exhorted people in public health to “lock into a fight,” she said. “Showing up in person is public health’s superpower. There are so many communities that need you to fight for them.”