Trust and Public Health: A Dialogue
What role does trust play in public health contexts?
Trust is a core component of life. It informs every action we take (or don't take), and intersects with each and every aspect of our lives. But what is trust, really? What do we need it for, and how can we cultivate it? Can it be restored when our trust is broken? And how does trust work in different institutional contexts—like public health, the media, or informal learning settings such as museums or libraries?
To address these questions, cognitive psychologist John Voiklis (who heads up our behaviors research) is spending some time talking to staff from each of our four main research areas. In this piece, John engages Melina Sherman (our lead Wellbeing researcher) in a conversation about the role trust plays in public health. Some of the main takeaways from their discussion include:
- Trust is social – it's informed by our relationships, our beliefs and norms, and the way we see ourselves and others.
- Trust may be more important now than ever before – on account of the COVID-19 pandemic, the range of contexts in which questions about trust come up has expanded significantly, requiring us to trust others (along with being trustworthy toward others!) in ways never before considered.
- Trust is about transparency,responsibility, and reciprocity - when these things are lacking, we tend to lose trust in our institutions, our leaders, and each other.
- Trust can be restored – but doing this requires admitting to mistakes, along with demonstrations of benevolence.
For more insights into each of these points, listen to their conversation using the audio player. We've also included a transcript below.
What is the nature of trust as you see it? Where does that understanding come from? Is it even an important question?
Melina: I think trust is more than an attitude. Trust is also a social arrangement, one in which social references, social relations, and personal experiences are deeply embedded. I'm not sure where this understanding comes from, just that the literature insisting that trust is something purely psychological - an attitude - seems to be missing a couple other big elements in the larger picture. One is the importance of social relationships, which inform personal experiences and condition trust in an everyday kind of way. The second are social references, which is another way of saying relationships of shared identity/belonging. People tend to trust someone or something if it is familiar to them, if that person is an insider, or a community member. And that's not just psychological. It's fundamentally social.
There's also the possibility - increasingly, I think - that trust is ideological. After all, we choose who and what to trust. And that choice is rooted in our beliefs and values. I think that's part of why we see such drastic differences in trust in science, health, and expertise in general, between groups with distinct political ideologies. I think this is becoming more and more the case in an age where traditional sources of trust (the news, science, etc.) are plagued with mis- and dis-information. People no longer know whether they can trust something, whether it's real, so they choose whether or not to trust based on what they already believe and think they know.
John: Most psychologists (and definitely this psychologist) would likely say that trust is a set of social judgements and social behaviors. The behaviors (including cooperation, helping, making oneself vulnerable, etc.) provide evidence of the judgments (about an entity's competence, reliability, sincerity, commitment/integrity, benevolence)—at least when we are talking about relational trust (or, as I prefer, evidence-based or experiential trust). There is one aspect (likeability/favorability) of one kind of trust (identity-based trust) that is definitely an attitude. In part, if I like you, I am likely to risk approaching you (i.e., trust you). But that is only part of identity-based trust. The other part is, as you point out, some feeling of affinity or similarity.
Melina: Where does ideology fit into your understanding of trust?
John: I've had a lot of discussions about this topic with a lot of people. Those people tend to be ideologically savvy and actively promulgate a particular ideology. I am not so certain, though, that the vast majority of their fellow travelers are equally savvy. I think for many people ideological affinity groups are simply nominal groups—red team vs. blue team. They may occasionally perform ideology but without much feeling or commitment (perhaps, even, little understanding) beyond the need to establish their bona fides. In other words, I would argue that, in most cases, ideology can be folded into identity-based trust.
Identity-based trust allows people to make that first approach where they have no evidence (perhaps even counter evidence—e.g., ignoring a "bad" reputation). Otherwise, identity-based trust is impressionistic and ephemeral. It eventually has to give way to evidence-based trust because, eventually, one has directly experienced evidence in hand. In general, identity-based trust is more in the purview of marketers than psychologists. That said, there is one phenomenon related to identity-based trust that has piqued my interest. Identity-based trust appears to play an outsized role when one expert judges the credibility of another (and, maybe more generally, when members of a community of practice judge one another). I know that I am guilty of this when judging fellow psychologists, and, therefore, I prefer not to know the person if I admire their work. It is hard to admire the work of a jerk, to say the least!
Melina: I would agree that ideology can be folded into identity-based trust, but I'm not sure that means that people are somehow less ideological, especially because the changing times seem to indicate otherwise. They seem to indicate that more and more people stick to an ideology and commit to one side of the various issues that fall under it. So many sociologists have written that what we are seeing today is social polarization like no other time in human history. And if we agree that we are becoming more polarized, doesn't that also say that we are becoming more ideological? I'd love to see some actual research that shows how much of the U.S. population is apathetic or flaky about where they stand politically. But it seems to me like more and more of us are hell bent on one particular identity or ideology and that's the hill we're going to die on.
Is there anything special about the health context? How about the public health context?
Melina: I think there is something special about the health context, when it comes to trust, that has to do with the fact that, as I said earlier, trust is a social arrangement. It's also true that today, in our interconnected and highly contaminated world, there are few conditions that are really about individual health. Our health is deeply connected to the health of others, to the health of the environment, to the health of our institutions. And this makes the generation of trust more important than ever in the field of public health. The issue of vaccination speaks to this problem of individual vs. group health and trust most clearly. Today, public health experts have to convince people that vaccination is not just about making yourself immune. It's not just about individual protection. Rather, it's about protecting others, and making communities and societies immune. This is a much bigger ask, and it requires a trusting relationship not only with the person who gives you the shot, but also with immunology, epidemiology, and medical/scientific expertise as a whole. This is quite different from merely asking someone to act in their own self-interest and get vaccinated because it will protect them - and them alone.
John: I guess the argument for taking an individual approach is that if you convince enough individuals to comply with health advice, then you get the group effect for free. Do we know if it works the other way around? Maybe, because we know that free-riders in society benefit from the altruism and allo-centrism of other members in society. Have we observed the "greater good" motivation in practice? The ramp up to WWII is often presented as such a case, but have we seen it in a health context--perhaps in other, more collectivist cultures?
Melina: I think regardless of whether you understand the United States to be "individualist" or "collectivist," the issue of trust for individuals is inseparable from collective trust. Here's why: In a pandemic or "post-pandemic" world, we are now all asked to think about whether we trust others in so many new contexts. If you're at a restaurant, you must now decide to trust a host of people you wouldn't have been asked to confide in before. You must trust the patrons around you to be healthy and have their vaccine. You must trust the cooks and the servers and the hosts. And you must trust them not just to serve you uncontaminated food, but trust that they are taking care of themselves and their health in the way that you want them to. We're being asked to trust people today that are not the people in our small, social bubbles. And it's necessary if we're to have any semblance of a life outside of our homes. But it's tricky - especially in a political and social environment where so many have lost trust in their fellow citizens, in their institutions, and in their politicians. As Gil Eyal has pointed out in The Crisis of Expertise, we have been becoming less and less trusting of these entities. And I would add that now this is happening just at a time when we are told that our health - our very lives - are all connected, and that we must therefore trust and be trustworthy to everyone. It's a bitter contradiction, but it's the reality of trust in public health, and in the world today.
Do you have a vivid anecdote about trust either persisting or being betrayed in a health context?
Melina: My research on COVID-19 has led me to hear about a number of instances where trust was betrayed - on a population level. First, I think trust in U.S. public health institutions, government, and their expertise suffered a huge blow during the pandemic. Mainly due to two factors: First, an egregious lack of transparency about the evolving nature of certainty in science (i.e., the CDC and other public health mouthpieces giving citizens guidance without being clear about the fact that it could change, depending on the evolution of scientific data about the virus & its spread).
The second factor that led to broken trust was a series of recommendations that approached a social phenomenon (a global pandemic) with individual solutions (wear a mask, get vaccinated, social distance). This was essentially an abdication of responsibility on the part of the U.S. government, which chose to put the onus of responsibility on the shoulders of worn down individuals, rather than providing them with social support and attempting to alleviate the physical, emotional, and financial stress caused by the pandemic. This is all to say, that I think transparency and responsibility or accountability are two key factors that condition trust - especially in governments and social institutions.
There's one anecdote I can share that supports this idea. I interviewed dozens of nurses for a study about end-of-life care during the pandemic and found that nearly every nurse I spoke with felt betrayed by the institution or hospital for which they worked. Many - as a result - quit their jobs or left the field entirely. But they didn't just burn out. Rather, they lost faith. They stopped trusting their institutions. Part of this had to do with transparency - many of them told me stories about upper management instituting mandatory training and new protocols without spelling out the rationale behind them. Second, these same institutions provided little to no support to their nursing staff. They took no responsibility. A few nurses told me how hospital administrators would come to the nursing floor only to tell them what they needed to do now (stop letting visitors in, get vaccinated, etc.) rather than offering them help, like free mental health services, which many pandemic health care workers truly need. These nurses - most of them women - gave the hospital their all, risking their lives every shift, and for what? So there's the problem of transparency, of responsibility, but also of reciprocity. Trust is a two-way street. And nurses weren't getting back from their relationships with their institutions what they (rightly) thought they deserved. As a result, trust was broken.
John: That was quite vivid. I could see much of what you were describing both at the experiential and theoretical levels. So much of what you said touches on aspects of how I think about and measure trust in various settings: between people, between people and institutions, and between people within an institution.
How do we cultivate trust, and repair it where it is broken? Are these different, or must we always be repairing?
Melina: This is a good question, and it goes back to some of what I was saying earlier about the need for transparency in a trust relationship. Taking an example from public health, I think one of the biggest problems the CDC now has to deal with is broken trust after it was not transparent about what it did and didn't know, and about the scientific process and what it simply couldn't know. That's where it's guilty. Had it been transparent from the beginning, it would likely have more of the public's trust. But now that that trust is broken, is it enough to admit it was wrong to hide its uncertainty? Or would admitting uncertainty exists in health institutions break what semblance of trust there still is altogether? This is a question that scientific communication grapples with all the time. How to admit to being wrong without admitting to not having the answer. And I think some of the solution, in these cases, has to do with managing expectations. That's huge in a trust relationship. You cannot promise too much and set yourself up to fail and, as a result, doom your trusting relationship to break. You have to be forthright from the get-go about what it is that you cannot provide—whether that's absolute certainty about an evolving scientific phenomenon (like a virus) or something else. At the very least, to answer your question more directly, it seems like an admission of guilt is necessary so that it convinces people that you are willing to change and to become trustworthy once again.
John: Playing off these questions, my first question is whether evidence of benevolence—e.g., helping others to reach their goals or meet their needs—might do the (most) work in repairing trust? Almost every institution will claim to exist for the public good and, hence, is benevolent. This includes health institutions. However, one could make the case (drawing mostly from the literature on management and leadership) that those who care wholeheartedly about the good of the whole (an organization as a whole, or the public or society) may not care all that much about the good of the people constituting those wholes. Moreover, the flourishing of the whole does not necessarily help persons to flourish (and vice versa).
So that takes me back to the question: to what extent does providing evidence of benevolence (helping people to flourish) help to repair trust? Also, given that human flourishing requires knowledge of people's needs and goals, to what extent does simply seeking out that information (about needs and goals) perform the function of the mea culpa in truth and reconciliation? How clearly does it imply: "I'm sorry, I should have cared about you and not some amorphous public good?" I think it is an open question whether all situations require a mea culpa, but I am starting to lean in that direction. My question is, then, how much needs to be said about guilt to get the process of repair started.
Melina: John, I couldn't agree more, and I think your point about benevolence is particularly important in the health context. Health and public health institutions are charged with ensuring, protecting, and sustaining the wellbeing of individual people and the population as a whole. Which is a way of saying that their primary function is to be benevolent. Yet, like you said, sometimes taking care of the population can come into conflict with taking care of individuals. Part of that depends on who is being counted (and subsequently cared for) as part of that population. Unfortunately, even while public health is supposed to care for everyone (hence the "public"), it is often the case that decision-making benefits some individuals more than others. When equity is put on the back burner like this, it's almost inevitable that public health's perceived trustworthiness will suffer a heavy blow. To repair broken trust, especially with communities that have historically and persistently experienced health inequities, a mea culpa is necessary. Reparations must be made. I think that's where we're at right now in this moment of public health. In this context, trust is at an all time low - perhaps in part because COVID-19 made so salient the deadly consequences of health inequities, which undercut the perception that public health agencies are benevolent. To repair this broken trust, health institutions must not only talk the talk of benevolence, but also walk the walk. They must make amends and do things differently; only then will they become worthy of the public's trust.
Photo by Lauren Lulu Taylor on Unsplash