The credibility crisis of public health messaging
I’ve become fascinated with the problems that we’ve had with public health communication during the pandemic.
I’m not talking about politics here - I’m talking about health professionals and scientists.
We have real messaging problems that have led to a bit of a credibility crisis - the cries of “I believe in science” have not served us as well as we’d like to believe that they would have:
“But for many crucial decisions of the last year, that unobjectionable version of trust the science didn’t get you very far. And when it had more sweeping implications, what the slogan implied was often much more dubious: a deference to the science bureaucracy during a crisis when bureaucratic norms needed to give way; an attempt by para-scientific enterprises to trade on (or trade away) science’s credibility for the sake of political agendas.”
The piece I linked to from the New York Times exemplifies the spirit of many critiques that I’ve been reading regarding our public health messaging: doctors, public health officials, and epidemiologists tend to conflate “the science” with our moral values and political ideals.
This conflation of what we know with our values can lead to mistrust of a message
There are things that we know with some degree of certainty.
For example, we know about the way the virus is spread, the disproportionate number of minorities affected, and the lack of benefit of hydroxychloroquine in COVID. Publicizing these pieces of information is straightforward, even if the solution is not.
There are other areas that we have significant knowledge gaps.
We don’t how many people want the vaccine or what numbers it will take to reach herd immunity.
So when Dr. Fauci says that he revises his herd immunity estimates based on how many people will take a vaccine, why should it be surprising that these remarks cause some to doubt his recommendations are based on the science instead of his values?
Similarly, we know that superspreader events account for the majority of COVID spread and that trying to minimize large gatherings is a key part of reducing pandemic hospitalizations and deaths.
But recommending that people avoid large gatherings can come across as being a value judgment rather than backed by science if physicians gather together to protest racial injustice.
There’s a difference between our description of (and outrage towards) the racial inequality in deaths or hospitalizations from COVID and suggesting that it’s only alright to gather in large groups when protesting racial injustice.
My point here is not to criticize these protests. Proponents of protests are right that racism and racial inequity in health outcomes are important public health issues. But conflating messages on two laudable goals - avoiding pandemic deaths and reducing racial disparities in health outcomes - sends contradictory signals to a public that isn’t paying close attention to the nuance of the discussion.
The pandemic has been radicalizing for many doctors
I understand - and have been guilty of - the way that values slowly creep into any discussion of the science.
This shouldn’t be surprising. Much of the medical profession exists at the intersection of many different worlds - public policy, behavioral economics, cultural values, personal decision making.
It’s really impossible for it not to be this way in normal times, but it’s heightened considerably in a pandemic. COVID isn’t just a medical catastrophe, it’s a supernova in human history. Of course it’s going to impact every aspect of human existence.
Seeing this up close has been radicalizing.
The visceral experience of the social inequities - deaths, prolonged hospitalizations, family separations and suffering - have never been as front and center as they are now for many of us.
It’s impossible to see that up close without it changing your perspective. When it’s so central to the physician experience of COVID, why wouldn’t you expect it to be part of our messaging?
And so I’m not surprised that Anthony Fauci - who is focused on a population based effort to end the pandemic - let his expectations about vaccine acceptance impact his public estimates of herd immunity numbers. The multiple realms that play into herd immunity aren’t neatly separated between the “science” ones and the “non-science” ones.
“Trust the science” is the wrong framework
When it’s about “trusting the science” that implies that dispassionate analysis of the numbers is all that you need to make the right decision.
But this is nonsense, and many of us know it.
Science allows for dissenting voices, disagreement, and debate. And when a decision has multifactorial inputs - thinking about who should get vaccinated first, for instance - of course values and even politics are going to play a role:
“If policy X leads to racially disparate death rates but policy Y requires overt racial discrimination, then the choice between the two is moral and political, not medical or scientific — as are other important questions like, “Who is actually an essential worker?” or “Should we focus more on slowing the spread or reducing the death rate?” (Or even, “Should we vaccinate men before women given that men are more likely to die of the disease?”)”
These are hard questions that science can’t answer.
It’s honestly no different than my recommendations to an individual patient about a non-COVID related condition. We can make estimates about risk of different outcomes, but ultimately each person’s decision making needs to be individualized.
When I’m considering a blood thinner with a patient who has coronary artery disease, I don’t just tell them to “trust the science” and take it. We discuss the risks and the benefits. The science informs the discussion, but ultimately doesn’t tell us what the right answer for the individual is, because it can’t.
The questions about what to do in a pandemic are multidisciplinary, they aren’t just scientific.
We should stop pretending that “trust the science” is enough.
Thank you for reading! If you’re enjoying my newsletter, please consider sharing with your friends and family and encouraging them to subscribe!
I always appreciate any feedback or thoughts you might have. You can reply directly to this email to reach me directly.