American medicine has a trust problem

Over the last few weeks, I've found it difficult to ignore the headlines on the state of public health here in the US. Measles cases going up. Vaccination rates going down. Whooping cough is making a comeback. Thousands of government experts have been fired or resigned.

Amid these crises, the United States is undergoing a moment of intense distrust in public health – from multiple sides. There's the anti-vaccine community, who often distrust both America's health agencies and the big pharmaceutical companies. There are also the people who previously trusted health agencies, but are now sceptical of US President Donald Trump’s administration and are particularly wary of Secretary of Health and Human Services Robert F Kennedy Jr.

What does it mean for health outcomes when so many people don't believe in the doctors, drug companies and the public agencies who are there to treat us? What can be done to bring trust back?

For answers, I reached out to Leana Wen, a physician and writer who formerly served as commissioner of the Baltimore City Health Department. During the darkest days of the Covid-19 pandemic, I often interviewed her live on BBC News from a makeshift studio in my basement to get her insights on how to stay safe. 

Our conversation was a weighty one – but I found Wen's suggestions about how to approach concerned parents and vaccine sceptics to be particularly insightful at this moment. If you have a few minutes to spare, I really encourage you to watch or read a bit of our conversation below.

Below is an excerpt from our conversation, which has been edited for length and clarity.

Katty Kay: What are you worried about in terms of tangible health outcomes from this climate of mistrust? What worries you?

Leana Wen: What happens to vaccine-preventable diseases tops that list, because we're going to see those impacts really quickly. We are already seeing the single largest measles outbreak in the US in the last 30 years. Measles has been eliminated since 2000, but the US could lose its measles elimination status. We are seeing rising cases of things like whooping cough. If vaccination rates for other diseases fall, we could also see a return of rubella and chickenpox and even polio – things that would really have been unthinkable just several years ago.

But if you have such distrust over vaccines, that also means that there's a distrust of authority, of science, of the scientific method, of what counts as science and how one does research. And that could have negative impacts on many other aspects of health, too.

KK: Are there things that work for pulling people back into a position where they might have mistrusted medical authorities, but they can then say, 'OK, yes, I can trust authority. I can trust what science is telling me'?

LW: The core aspect of being a physician is the one-on-one conversation with our patients, and it's in those one-on-one conversations that we see a lot of change, because we never approach these conversations with the assumption that 'I'm right and you're wrong' or that you must have listened to all these conspiracy theories. We come to those conversations asking people what their thoughts are, what they have heard, why they believe one thing or another – and then we meet them where they are in those conversations.

Often, that means that we have to overlook their opposition to vaccines, because we don't want to push them away so much. Then, they're now not willing to get treatment for their high blood pressure and diabetes, and then may go out and have a stroke. So, I think part of building that trust actually is knowing when to make the case and when not to.

KK: If you were talking to parents of a young child who didn't want to get their child vaccinated against measles, [who are] afraid of measles vaccine and what it might do to their child, what would you say to them, doctor?

LW: I think I would start by asking them some more questions about what it is that they are afraid of. Are they afraid of all vaccines, or are they just afraid of this one? What exactly is the concern?

So, for example, if they're citing what they think is a possible link between the MMR [measles, mumps, rubella] vaccine and autism, I would point to the dozens of studies that have been done, including published in the New England Journal, that have debunked this association and the growing amount of evidence that whether you get autism was determined before birth. It is not determined after birth and in connection with vaccines. 

On the other hand, if what they're concerned about is all vaccines, because they don't believe that measles is that serious, then I would point to the reality about measles: that yes, it's true that most people who get measles will have a mild case of it, but 1 in 5 will have pneumonia. One in 20 will end up being hospitalised. One to 3 out of a thousand children with measles will die. 

So, I think it really depends on what those specific concerns are. But ultimately, the message is very straightforward: Vaccines are safe. They're effective. They're life-saving. 

KK: Do you think, in the environment we're living in, that it is sometimes impossible to persuade people because it's almost tribal? As somebody who is a scientist and a doctor, how personally frustrating is that?

LW: I think back to what the individual conversations with patients will look like, because it's not an option to get frustrated. And you could say, 'OK, we're not going to touch this subject for the time being, because we're not going to make headway'. And again, I don't want to drive you, the patient, away from all the other recommendations that are important for your health. If you don't see me as the doctor, maybe you'll go to somebody else who will take offense to what you're saying about vaccines and then you won't get any medical treatment. That's not a good outcome.

I think it is reasonable to put aside certain differences and maybe try to approach it later and focus on areas of common ground. But I think that most of all, it's really important to not approach the individual who you don't agree with with scorn or scepticism or anger, because that's only going to elicit a defensive reaction. 

KK: In April, after two small children died of measles, Health [and Human Services] Secretary Robert F Kennedy endorsed the MMR vaccine, which prevents measles. He then got attacked online from people who are in the anti-vax camp who were very disappointed that he had come out and endorsed the vaccine. A day later, he posted a photograph of himself with a couple of doctors who are opposed to vaccines, to the MMR vaccines. And he called them extraordinary healers. And he also promoted some unproven treatments.

So, I'm quite confused about where the health secretary stands on vaccines. And I imagine if my kids were still young and I was at the stage where I was having to look at getting them vaccinated, I, as a parent, might be quite confused, as well. Are you clear about where the health secretary stands, particularly on the measles vaccine, given the outbreak of measles in the country at the moment? 

LW: Yes, I am very clear on where RFK Jr stands, although I think that your interpretation of it is very fair and also very correct. You are confused because he intends for it to be confusing, because he is trying to speak to two very, very different constituencies who have completely opposing goals.

On the one hand, RFK Jr is a well-known vaccine conspiracy theorist who, for dozens of years, founded and ran an anti-vaccine organisation. He's seen as a champion by people who head up the anti-vaccine movements themselves. So, that is a core constituency that got him into this role and he has to placate them. So, he's said many things that are very harmful and untrue. Playing down, for example, the seriousness of the measles infection, talking about treatments that are not treatments.

To be clear, there is no specific antiviral that will cure measles. So, he talks about steroids and antibiotics and things that are not treatments for measles. In a way, that also plays down the seriousness of the disease – people mistakenly think that there is a treatment that there is not.

At the same time, he continues to spread doubt about the safety and effectiveness of the MMR vaccine. He has said in recent weeks that it causes just as much illness as measles itself. He has continued to promote the debunked allegation that the MMR vaccine is tied to autism. He's announced research to study this conspiracy. 

So, he's currently walking this line between trying to appease the anti-vaccine camp and trying to appease some people, including moderate Republicans, who are trying to get him to say things like, 'Well, the measles vaccine is a good thing'. 

So, he's trying to say both of these things and that's why it comes out sounding confused, because that's, in fact, how he intends it.

[In a statement to the BBC, Vianca N. Rodriguez Feliciano, press secretary at the US Department of Health and Human Services, said that the department is committed to building public trust in science and, specifically, "Secretary Kennedy is not anti-vaccine — he is pro-safety, pro-transparency, and pro-accountability".

Feliciano added that "claims that Secretary Kennedy is spreading misinformation or undermining vaccine confidence are flat-out false. These accusations ignore the facts and distract from the urgent public health work underway".] 

KK: Was there anything that's been done in the last three months that you think has been good on the health front in America, amid all of these changes? 

LW: Look, I think that a reexamination of how certain things have always been done is a good idea. So, for example, do we have the most efficient processes for approving new drugs? Can we be deploying artificial intelligence in a more thoughtful way? I think that it's fine and necessary even for us to be probing in this way.

In addition, I think that there are parts of Make America Healthy Again, Robert F Kennedy Jr's movement, that may be helpful. It's hard to disagree with him when he speaks about trying to cut chronic diseases. It's hard to disagree with him when he speaks about cutting out ultra-processed food or improving childhood nutrition.

These are all good things, necessary things for us to be aiming for. The only question, though, of course, is what else comes along with these goals? 

--

If you liked this story, sign up for The Essential List newsletter – a handpicked selection of features, videos and can't-miss news, delivered to your inbox twice a week.