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Restoring Trust and Confidence in Public Health

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Robert Johnson:
This is Public Health Review. I'm Robert Johnson. On this episode, the impact of misinformation and conspiracy theories on the pandemic response and what it will take to restore confidence in public health.

Dr. David Sundwall:
It's a challenge. I think we're all going to have to work together to address the deficiencies that were exposed in this—the racial disparities, the other problems that have become so apparent. But I think we can recover. Of course, it's essential for all of us, and we just need to address some of these perceived problems and get back on track.

Dr. Ngozi Ezike:
It's such a horribly ironic situation that some of the groups that have been most hard-hit by the virus are those that have heard a lot of information that's not completely correct, that are most hesitant.

Johnson:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, the damage to America's confidence in the public health mission, how the pandemic response has been affected by rumors, lies, and unfounded fears.

Two experts join us to examine this topic. Dr. David Sundwall is a primary care physician in Salt Lake City. He was executive director of the Utah Department of Health and the state's commissioner of health from 2005 through 2010. His encouraging words for today's state and territorial health officials are later.

But first, we visit with Dr. Ngozi Ezike, director of the Illinois Department of Health, about the importance of two ideas—confidence and trust—as she and others lead teams across the nation, working to care for communities stricken by the COVID-19 virus.

Ezike:
No, I think you said it right, that they are big words. They carry a lot of weight and, without it, it is really hard to get people to do what you want to do.

Public health, essentially, is trying to get people to do what they think is the right thing to do. At its core, it's really like, "I know what's best," and nobody wants to hear that. People think, "I know what's best!"

And so, if you don't have a trusted message or a trusted messenger, giving this paternalistic kind of, "Please do what I say, I know what's best," then you're going nowhere. And people might, just in defiance, want to go the opposite direction.

Johnson:
How have you encountered those issues as you've worked to lead Illinois through this pandemic?

Ezike:
We have seen how confidence and trust can make or break this situation. The trust or confidence, and just the concept of masking, has been a huge deal. The lack of trust or confidence in the power of masking has resulted in untold numbers of additional infections and, unfortunately, deaths that followed. So, a huge issue—and it cannot be stated enough how important it is to have that trust and confidence.

Johnson:
The same goes for vaccines now, doesn't it?

Ezike:
Absolutely, absolutely. We're asking people to make a very personal medical decision that we are saying will benefit both that person and others around them, others in their community, others that they may not actually know. So, it's an important ask.

And, for many reasons, people would have some inclination to not want to comply with that ask. And so, again, that trust and confidence in both the message and the messenger makes a huge difference. And we know from vaccinology—from what we know about COVID—that vaccination is a key strategy in helping dampen the effects of this deadly virus.

Johnson:
How would you rate vaccine confidence and trust among communities of color in your state?

Ezike:
I think there's so many different reasons that people could have varying amounts of confidence and/or trust.

It's definitely not a one size fits all, and I don't want to use too broad of a brush, but being a person of color, being a Black woman, having worn this outfit—this shell—all of my life, you know, I know what it means. And, I know how my society, my government, even my healthcare systems have not always treated me fairly and justly.

So, when some of those same systems come to you with an ask, I understand the position of wanting to take a step back and really evaluate and re-evaluate and make sure, "Is this really what's the best for me?" Because there have been some situations where people have said stuff that wasn't the best for me.

Johnson:
History has a lot to do with it, I assume.

Ezike:
History has a lot to do with it. The history of this nation is ripe with examples, but you don't even have to go that far back. People have their lived history, they have the history of friends and family. So, when they think about not just, you know, what they've seen, what they've heard, what they've experienced and felt, all of that plays a significant role.

Johnson:
You held a town hall a few weeks ago to listen to people in your state about their concerns with vaccines. Who attended that event and what did you hear?

Ezike:
So, I think the event you're referring to was organized by church leaders in the area in concert with our public health coalition. We wanted to talk not just to the pastors, but also their membership, the people that they actually represent.

You know, I always ask to talk directly with the people. I don't want a filter. I want to talk directly to the people who may be struggling with the onslaught of information and be able to ask direct questions that also don't get filtered; that I hear the actual questions, can understand the thoughts and the feelings behind those questions, so we can really get down to business, and get to the truth, and get down to real talk.

Johnson:
Do those meetings help you lead and create strategies as you move forward through this effort?

Ezike: Yes, I absolutely think that they do. I might have things that I think are top of mind.

You know, I've learned very quickly as I try to communicate that you shouldn't spend a lot of time in introductory remarks. Just use every minute that you can scrape together to hear from people.

Because what I might think is a concern is not a concern to the person who's on the other end of the call or the line or the video. And so, really understanding that there are so many different perspectives represented, so many different concerns.

And I want to hear as many of them as possible so that I can think of the right messages and the issues, you know, to put out on our social media and other messages to share with other messengers so that they can all understand that this is a very complex issue on many levels.

Johnson:
There's a lot of misinformation on the street about these vaccines. What have you heard?

Ezike:
I have heard that the vaccine contains the COVID virus and will be used to infect people of color. I have heard that the vaccine causes infertility. I have heard that the vaccine contains a microchip. I have heard that the vaccine is a hoax because there's no virus that needs to be vaccinated against.

So, I've heard quite a bit, but I know every day there could be new information that is put out there that will further confuse the public that's trying to make sense of all of these inputs.

Johnson:
As deadly as this virus can be for some people who get infected, does it break your heart when you hear those rumors that essentially might be keeping someone from protecting themselves properly?

Ezike:
Absolutely. When I talked to different groups that are—you know, we are trying to focus on these high-risk groups that actually need it most.

And so, it's such a horribly ironic thing that some of the groups that have been most hard-hit by this virus are those that have heard a lot of information that's not completely correct, that are most hesitant.

And so, the need for them to have the right facts is so great, and so there's so much work to be done in those populations.

Johnson:
What are some of the strategies that you and your department are pursuing to try and clean up some of this misinformation, to get people the facts that they need in order to make a good decision about this vaccine?

Ezike:
I think it's always about communication, communication, communication, you know, as opposed to coercion.

I try to start upfront. I respect everybody's decision to do what they think is best for them and their family, but I just want to make sure that you have all the right information as you make this important choice. And so, it's communication, it's working with people who are those trusted messengers, and there are many trusted messengers out there.

So, whether you're working with church groups or other religious organizations—again, that's not a one-size-fits-all, not every person of color is part of a faith tradition or a religious organization. But, there's definitely, you know, opportunity there.

There are sororities and fraternities that are a big part of the Black community, but you have to be sensitive to the fact that that's a specific slice of the community, that's people who went to college, so we don't want to leave out people who didn't take that path.

You know, there are community-based organizations that are already entrenched and steeped in the community. Those are wonderful partners that can carry the message. You need fertile ground, and so people who have already been, you know, in the community already laying that seed. That's who you'd want to turn to.

So, those are just some of the ways that we can approach this with the right, again, messages and messengers.

Johnson:
Finding the right messenger seems to be key to all of this. You just went through some of the groups that you are working with across the state to get the information into the hands of the audiences that need it.

Is anything that you're doing working really well, anything worth highlighting, putting at the top of the list, as far as successes are concerned?

Ezike:
I think trying to take some of the concerns and try to pick it apart, you know—then people are left with the theory that doesn't maybe stand up as tall after the end of the interaction.

I know I hear a lot that, you know—whether it's in Black communities or Brown communities—that the vaccine was created to kill off certain segments of the community—the Black and Brown people. And so, I say, "You know, okay, let's think about this." I could maybe say, “You could hold on to that for a little bit.” If a vaccine came out and they said that, okay, every Black and Brown person, you go to the front of the line, you start. Everybody else, wait a little bit, but these Black and Brown communities all get the vaccine first. I said, "You know, you can say, wait a minute. What's going on here, since when do we get to be first at anything?"

But, it's a vaccine that they gave first to all of the doctors, right? The surgeons, the ICU docs, the nurses and the registration person in the hospital—all of the hospital people got this vaccine first. Do we really think that we would kill off all of the healthcare workers just to get you to take it and then kill you off? Like, I don't think that follows, right?

So, you just try to take some of these myths and really strip it down to see if it can really hold up, you know, to some argument and to some chipping away at it, this idea that it's so dangerous.

You know, we have to remind people about vaccines and how people today don't even know what chicken pox is and, you know, reminding people about the benefits of vaccines. I think vaccines have hurt themselves by being so effective that people don't remember the diseases that they were brought on to deal with, because those diseases have to become a distant memory.

So, I think we need, going forward, we just really need to build up our vaccinology information. That we have to teach kindergartners about, "Once upon a time, little kids all got measles and they got these funny bumps with chicken pox, and they used to have to do double Dutch with these braces on their legs because they had polio."

I just think the fact that they're not seen means that the vaccines work so well, but it also means that people don't remember what vaccines have done.

Johnson:
Do you know if any of these efforts are having an impact as of yet?

Ezike:
I have watched very closely the numbers of individuals that get vaccinated, you know, the racial and ethnic breakdown, and we have seen, since the beginning of the vaccination effort to now, those numbers steadily climb for our Black and Brown communities.

So, I think we're moving in the right direction. We are continuing the efforts, we're not finished, we are not on par with where the numbers should be, but I think we're getting there.

And, I know that, with continued education, engagement, correct messages, correct messengers, I think we will get numbers that we can be proud of so that, with the vaccination, we don't perpetuate the disparities that we saw with the actual infection.

Johnson:
Is there anything in your view that could throw off this slow, but steady progress, anything that you're worried about that you're hoping won't happen, or that you are working hard to keep from happening?

Ezike:
I mean, trust and confidence, they are very tenuous things. And so, I think it's important, as part of that trust and confidence building, that people are very clear about what we do know and what we don't know.

Because, if we say too much and we've said stuff that we don't actually have evidence for, then if it turns out to be not the case, then all of that trust and confidence is significantly affected, if not completely erased.

And it will be a problem, not just for additional people to go on and get this vaccine, but it could destroy confidence in vaccines as a whole and put us in a much worse shape for, unfortunately, the next pandemic or even other vaccines that people will now reconsider.

Johnson:
Finally, changing public thinking is more than a full-time job. Would you say it's the toughest part of your job every day, the toughest part of the job for everyone in public health, given this pandemic and what we're up against—the race against the virus?

Ezike:
I always think that behavioral change is one of the hardest things that public health undertakes, and yet it is essential, right?

We had to have people understand that you want to strap up and put that seatbelt on. You have to have people change their behavior and understand the importance of condom use. You have to change peoples' ideas and change their behavior and say, you can't just sit on the couch all day, you actually have to move a lot more.

So, behavior changes at the crux of public health is one of the hardest things. We have done it before, it takes time. And so, we're at this point again, but we are making the change even faster.

We never wore masks in this country a year ago, and now we know that more people than not are wearing masks. So, we've made incredible strides and we will continue to do that.

Johnson:
Today, Dr. David Sundwall treats patients from an office in metro Salt Lake City. But, for about six years, he spent most of his time at the state capitol as executive director of the Utah Department of Health and the state's commissioner of health. He was ASTHO'S president in 2007 and 2008.

Here's what this former HERSA administrator and assistant surgeon general had to say about the pandemic and the public's reaction to the response.

Sundwall:
We have to stop and remember that a pandemic, as awful as it is, at least puts public health in the spotlight. And that's both good and bad.

As I mentioned in this recent opinion piece that I did in The Salt Lake Tribune, on a certain level I think most people appreciate that someone has their backs. There are some government programs that understand the dangers of various health risks and they're looking after the air we breathe, the food we eat, the water we drink, and vaccinations, so there is some fundamental appreciation.

This pandemic has such an incredible effect on the globe, not just here, but public health also gets tainted with problems associated with dealing with such a universal problem. I think that public health has probably been attributed with some problems that weren't necessarily their fault, that there have been choices made to mitigate the spread of the virus that have been, in the minds of many people, draconian.

These lockdowns, shutting down businesses and schools and commerce and everything travel has been so disruptive. So, public health being the messenger of bad news with this awful virus and the morbidity and mortality associated with it, they're kind of considered the problem. And that's a shame.

We need to figure out how to help people appreciate that this is information which we need and some of the measures are necessary, but I think we've also learned that we need to be much more targeted in our efforts to mitigate spread of disease than we have done so far.

Johnson:
You led the Utah Department of Health during the H1N1 pandemic. How does everything that happened then compare to what you've witnessed now?

Sundwall:
You know, it's a good question because it was, in fact, a pandemic according to the World Health Organization. But in retrospect, it seems like it was a walk in the park.

I don't mean to trivialize what we did because Utah was one of the first states with clusters of cases. There was Texas, California, Utah, New York—actually, that came from students who were partying in Cancun and brought it back to Park City. I mean, whatever the entry here, we were a hotspot initially, but we pulled together and dealt with that in, I think, a responsible way.

We got about 70% of the state immunized, which was extraordinary given our traditional rate for seasonal flu. But anyhow, looking back on it, I think we did a good job. We mitigated spread and limited morbidity and mortality.

And now, to compare that with this pandemic, it’s just night and day because this has been so disruptive and challenging, and Utah also has had a fairly high incidence but a relatively low mortality. So, we had our challenges, but they are similar but way different in scale.

Johnson:
How serious do you think is the reputation damage to public health?

Sundwall:
I think it's serious, but it can be overcome.

It's funny—when we were talking about reputations, I was on an advisory council at the CDC one time, several years ago, and they had done some polling, I guess public relations work.

CDC enjoyed the highest reputation among the public of any government agency. That isn't true anymore. I mean that, it was nice. The branding, if you will, of the CDC was so high and other countries tried to replicate that and they have in China and other countries, they even call it the CDC.

But now, that has suffered. And I think that there are people who understand that we have been tainted by, like we have discussed, all of the negative consequences of the pandemic somehow being attributed to public health, if you will. It's a challenge.

I think we're all going to have to work together to address the deficiencies that were exposed in this—the racial disparities, the other problems that have become so apparent—but I think it can recover. Of course, it's essential for all of us, and we just need to address some of these perceived problems and get back on track.

Johnson:
Well, let's talk about that. What do you think the state and territorial health officials around the country need to do to begin that rebuilding process?

Sundwall:
Well, I think they need to stick to the facts and stick to science, as we've said. However, that doesn't wash with a lot of people, either. We just need to stay true to our mission and to our principles of being evidence-based, if you will, and our policies.

I'll tell you a little of a personal experience I had with a public response to this. I'm a participant in LinkedIn—that's a kind of a professional networking tool, computerized tool, and it allows people to communicate with fellow professionals across the country.

I was so pleased that Anthony Fauci was appointed by Biden to stay with him as the head on COVID because he'd had his challenges working with President Trump. But anyway, I just wrote a little statement and I said, "I'm so glad Dr. Fauci will stay. He's a man of absolute integrity, intelligence, and with an interest of the public first and foremost. I worked with him on the HIV/AIDS epidemic as that unfolded, and he was a champion of research and treatment."

Well, guess what? I had hundreds of negative responders to that message who said, "How dare you support this man? He's in a pocket of pharma, he's killed hundreds of thousands of people." I mean the most outlandish, silly, nasty kind of comments. And that was on what is perceived as a professional social network. So anyhow, in a very surprising way, informed me of the negative feelings harbored by many people about science, if you will, or public health efforts.

So anyhow, that was surprising to me, but it emphasized the fact that we in public health need to stay true to our principles and keep plugging away, no matter what happens across party lines. Believe me, no one has monopoly on negative things about this, whether you're Democrat or Republican, but we don't serve a party. We just serve the people. So, you need to kind of plug away.

And then, I was president of ASTHO one year and got to know my colleagues in public health very well across the country, and have great respect and admiration for them. A lot of us deal with conservative governors or legislators who may not have either information or appreciation for what we do, but it just makes it all the more important our efforts to stick to it. I call it patient persistence. You just have to be patient and pleasant and persistent to get these jobs done.

Johnson:
How much do you worry about efforts to weaken public health as a result of this pandemic?

Sundwall:
Well, I worry a lot about it, which prompted my opinion piece on the Tribune because here in Utah we heard rumors of dissembling the health department, that there would be a merging of units and that there would no longer be a Department of Health. They would take Medicaid out and they would parse some other aspects of other agencies. I think those ideas were floated by legislators that had a negative view of how they dealt with the pandemic here. So, people like me speaking up and others, they have reconsidered.

Now, they're going to merge agencies, then that's all right. I don't remember the number—ASTHO certainly has this information—but health departments are often part of a larger agency. They are not necessarily independent.

When I was commissioner of health here, we were independent and I was on the governor's cabinet. And that's nice because you have a high-level access and you can promote your policies and seek your budget a little more effectively, but it isn't essential that they be a free standing department. So, if there's reorganization, that's all right.

And, speaking with the governor and his staff, his efforts to reorganize were not based on pandemic problems or perceived deficiencies in the health department, it's simply to simplify and streamline government and he doesn't want such a big cabinet.

So, I think it's different in every state. When such efforts are anti-public health, that is a serious problem that needs to be addressed, but I think we need to also figure out how do we do what we're charged with doing within whatever organizational structure our legislature chooses to put us. Even if you are a unit within a bigger agency, you should ensure that you have access to the governor's office, can communicate directly with them, and make a case for your budget.

Johnson:
Do you think these negative feelings linger on once the pandemic is over?

Sundwall:
Do you know, I'll be surprised if they do on a large scale. I think that the negative things are part and parcel of a bigger malcontent or concern about everything else.

In other words, as the prevalence goes down, as mortality drops, I think there will be hopefully some rebalancing and people will again have that sense that, like I said, someone has your back, we're going to have your interest at heart. So, I don't think it's permanent. I think it'll wax and wane.

Like I mentioned in my article, we have be a little humble and take a step back and realize that there's nothing new about this resistance to public health. These episodes have caused previously all sorts of public outcry.

Johnson:
We've heard some people in public health say this experience will make public health better. What do you think about that idea?

Sundwall:
I think so. I think, first of all, if we pull together and do an honest reflection on what went right or wrong, we can indeed be better.

You know, the Navy has a term after a military engagement. They call it a hotwash, where they come together and review what went right or wrong with a battle and what caused them to succeed or fail.

And that's what we need to do in an honest way, and some of that has already happened and gone on. But I think we need to, for example, supply chain, clearly there were problems with getting protective equipment or respirators or antisepsis to people, masks, gloves, all of those things can be dealt with better. I also think our information systems could be improved where there's more real-time reporting. So, there are some real opportunities to do things better.

Johnson:
Before we go, we wanted to make sure to tell you about ASTHO'S first COVID-19 TechXpo, a virtual event coming up on March 31st from 2-7 p.m. Eastern Time. As a public health professional, it's your chance to learn more about the latest tools available to help you in your fight against the novel coronavirus.

Find out about technology to support case reporting and surveillance, laboratory testing and reporting, contact tracing and case investigation, and much more. If you work in government at any level, serve in the military, or are on staff at a nonprofit or educational organization, your registration is free.

Register for ASTHO's first COVID-19 TechXpo, a virtual event planned for March 31st, using the link in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us at pr@asto.org. That's PR @ ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials. For Public Health Review, I'm Robert Johnson. Be well.


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