The Word Is That We Haven’t Been Listening to People

One of the conclusions that many people have reached following last November’s election is that scientists, healthcare providers, and public health experts have not been listening to what people feel, think, believe, or want. We’ve been flooding the field with facts that have apparently not changed hearts or minds. We tell people that the earth is warming to dangerous levels because we are burning fossil fuels, but they seem not to want to take the necessary steps to shift to sustainable energy. We point out the data showing that immigrants to the United States are not responsible for increased crime, do not take away jobs from people already employed here, and generally benefit the economy, but many people still insist that undocumented immigrants are a threat to their jobs and their safety.. We detail how vaccines are safe and effective, that adding fluoride to drinking water decreases the burden of dental decay, and that drinking raw milk is hazardous, but many people harbor viewpoints that counter these facts.

All of this frustrates the scientific community while at the same time prompting calls that we must do better at understanding what is motivating people to adopt beliefs that are incompatible with evidence and often potentially harmful. We are told we must figure out how to listen better to what people want and try to craft public health messages that are sensitive to their wishes and desires.

This is a daunting assignment. Never have we faced the number of challenges to scientific wisdom that we do now. Sometimes we are left scratching our heads in disbelief. Don’t people realize that without vaccines millions will die of infectious diseases? Don’t they understand that milk is the perfect culture medium for multiple types of bacteria and without pasteurization we will see outbreaks of illnesses that will sometimes be fatal? Don’t they believe the CDC when it tells us that water fluoridation has proven to be a  triumph of public health intervention?

Three Reasons You Are Alive Today

In a bracing article in  Slate last November, Laura Helmuth declared, “There are three reasons you are alive today” and she proceeds to tell us what they are:

“One: clean water. Congratulations! You and/or your ancestors didn’t die of dysentery. You didn’t die of cholera. You didn’t die of typhoid fever.

Two: antibiotics. Congratulations! You didn’t die of scarlet fever. You didn’t die of a urinary tract infection. You didn’t die of a tooth abscess that turned into sepsis. You didn’t die of the bubonic freaking plague.

Three: vaccines. Congratulations! You didn’t die of measles. You didn’t die of tetanus. You didn’t die of pertussis. You didn’t die of polio. If you’ve been vaccinated against HPV, you almost certainly aren’t going to die of cervical or anal or throat cancer. You have survived COVID, the deadliest pandemic in a century.”

No doubt, Helmuth is perfectly correct. And yet, this is exactly the kind of messaging that seems to be going awry. We are about to have a new federal administration that many fear will try to limit vaccine access, stop water fluoridation, remove regulations on raw milk, and push forward a host of other policies that defy decades of public health achievement and recommendation. And that seems to be what many people want, or at least are okay with.

Right now, scientists, public health experts, and clinicians are trying to decide what to say about the incoming U.S. administration’s picks for leaders of public health and scientific agencies. Is it advisable to be critical of the choices that have been announced and the policies that proposed candidates for leadership positions have articulated? Are there pros and cons that should be highlighted about these positions or is it best to sit back, wait, and see how many of them are pursued once the new administration takes office this month?  Much of the debate centers on what to say about the opinions of Robert F. Kennedy Jr., who has been nominated to assume the post of Secretary of Health and Human Services (HHS). Do we continue to point out the facts about vaccines, how they are among the most extensively studied medications ever approved, with abundant evidence of safety and efficacy? Do we continue to fight the battle about face masks and other steps that evidence shows decrease the spread of the virus that causes Covid-19? How do we convince people to listen if it is really us who haven’t been listening?

What Does the Public Want?

Jack Healy, Isabelle Taft, and Kate Selig wrote an article in the  New York Times last November titled “Trump wants to shake up health care. Many Americans don’t mind.”  They interviewed nearly two dozen people who are supportive of President-elect Trump’s healthcare agenda and found that “they liked Mr. Kennedy because he shared their grievances about health care and shared their interest in alternative medicines and natural remedies.” Of course, there is no telling exactly what Trump and Kennedy would do if Kennedy were confirmed as HHS director. The New York Times authors note that Kennedy has articulated positions opposing the widespread availability of ultra processed foods and has been critical of corporate farmers and the pharmaceutical industry. On the other hand, “In his first term,” they point out, “Trump loosened nutrition rules for school lunches and approved scores of products containing pesticides.” There may then be differences of opinion among people in the new administration, making it unclear exactly what new policies will be pursued. Still, there is apparently significant support for Kennedy’s ideas and some of this seems to stem from general dissatisfaction with  the entire healthcare system.

Vaccine Hesitancy Stems from Mistrust of the Healthcare System

Mounting reservations about the safety and effectiveness of FDA-approved vaccines are a case in point. Seasonal vaccines rates in the U.S. are  alarmingly low this year. As of the end of November 2024, only 37 percent of adults had received a flu shot, only 19% had received an updated Covid vaccination, and only 40 percent of adults 75 and older had been vaccinated against respiratory syncytial virus (RSV). These rates are worrisomely low. Some of the hesitancy toward vaccines,” writes Sabrina Malhi in the  Washington Post, “can be attributed to a swarm of misinformation on social media and the internet, which, in many instances, has overshadowed public health campaigns.”

If that is already the current state of vaccine acceptance, what will happen after January 20 when a new group of national health leaders takes office? Some of them have supported the debunked notion that the childhood MMR vaccine causes neurodevelopmental disorders and questioned the safety and efficacy of Covid vaccines. There has been talk of  ending the liability protection given by Congress in 1986 to vaccine manufacturers. Back in the 1980s there was  a rush of liability lawsuits against vaccine manufacturers over a non-existent adverse side effect to the pertussis (whooping cough) vaccine that led some manufacturers to pull out of the vaccine business. This led to a drop in vaccine supply. To maintain a continuous supply of vaccines while at the same time ensuring that people could be compensated if they experienced rare serious adverse side effects from vaccines, Congress passed the Vaccine Injury Compensation Program. This created the “vaccine court,” which allows people to make claims of vaccine injury and receive compensation from a fund set up by the federal government. Those who want to reverse this program forget what happened in the 1980s when there was a real threat to the U.S. vaccine supply.Of course, we don’t want to see a return of polio or outbreaks of meningococcemia on college campuses again. We have already seen the result of stopping measles vaccination with the tragedy that occurred in  Samoa in 2019 when anti-vaccine advocacy was followed by a measles outbreak that resulted in the death of 83 people, mostly children.

The facts, of course, are that vaccines are incredibly safe and effective and unquestionably essential. As Sarah Zhang put it in  The Atlantic, “For most of human history, half of all children died before reaching age 15; that number is down to just 4 percent worldwide, and far lower in developed countries, with vaccines one of the major drivers of improved life expectancy.”

So we know that vaccines don’t cause autism and that they save children’s lives. That message shouldn’t be so hard to get across. Zhang goes on to assert that the success of vaccines has led to a kind of “modern amnesia”: very few of us have ever seen a child with polio, measles, or diphtheria. It is easy, she insists, for anti-vaccine advocates “to make parents more afraid of the shots than the diseases their kids aren’t getting.” But if anti-vaccination sentiment were due solely to that kind of amnesia, why did it emerge so forcefully during the Covid-19 pandemic? The ravages of Covid-19 are obvious and the vaccines against it proven to be both very safe and very effective. Clearly, multiple factors are driving anti-science attitudes and political and social influences are very important. Critica’s Sara Gorman walks us through all of these factors in her new book The Anatomy of Deception: Conspiracy Theories, Distrust, and Public Health in America

There is no legitimate scientific, political, or ethical argument to restrict the availability of the currently approved vaccines. But that statement seems not to register with many people, no matter how much data we muster to support it. Instead, there seems to be some notion that mandatory vaccine programs threaten individual liberty, freedom of choice, and parental rights to make health decisions for their children. People have also concluded that because vaccines are manufactured by large, profit-driven corporations they must be unsafe. At the heart of this sentiment is the anger that many U.S. Americans understandably harbor toward the healthcare system. People struggle to access and to afford high-quality healthcare because of a system that is dominated by the health insurance business and large hospital corporations. Increasingly, people have limited contact with a trusted family physician who has the time to explain things to them. The breakdown in the American healthcare system creates widespread anger and mistrust, some of which is directed against vaccines and other clearly beneficial public health measures.

Instead, then, of endlessly reiterating the facts about clearly advantageous public health measures like vaccines, fluoride, and pasteurization, we need to listen to the anger people have and begin to help them find a path forward to negotiate our crippled healthcare system. What is crucially important is to understand the public’s anger and turn it into advocacy for reform. That means that rather than focusing on reversing years of public health achievements, we should be telling the federal government to do things like substantially increase funding for primary care physicians, curb health insurer abuses like prior authorization and algorithmic reimbursement denials, and strengthen both Medicaid and Obamacare so that all Americans have reliable health insurance.

People want to be healthy. They want to be able to have conversations with a trusted physician who knows them and their medical histories. They want to be able to afford healthcare.  A survey released in December showed that Americans’ view of the healthcare system is at its lowest since 2001. That is what we have not been listening to. And that anger is, we believe, at the heart of the willingness to support people who want to scrap the hard-won achievements science and public health have made since the beginning of the last century.