Trump pressure on health agencies risks undermining public trust

The Trump administration’s moves pressuring science agencies to take controversial steps on the coronavirus are threatening to undermine public confidence in health experts at a moment when they have become uniquely visible.

On Sunday, the Food and Drug Administration (FDA) issued an emergency use authorization for convalescent plasma as a treatment for COVID-19. Scientific studies are inconclusive about taking that approach, and some said authorizing its use will hinder the ability to conduct more definitive research.

And on Monday, the Centers for Disease Control and Prevention (CDC) quietly changed its guidance on testing those who have come into contact with a COVID-19 patient. The agency no longer recommends those contacts be tested, despite what is known about the risk of asymptomatic and pre-symptomatic spread of the virus.

Both decisions appear tinged by politics: A new treatment, announced by President Trump on the eve of the Republican National Convention, has been presented as evidence that the nation is on the brink of a miraculous recovery. At the same time, guidance suggesting fewer people ought to be tested is likely to lead to lower case counts, even as the virus continues to spread widely.

And in both cases, the scientists who run the agencies later acknowledged the concerns raised by their actions. FDA Commissioner Stephen Hahn said criticism of his decision to authorize emergency use of convalescent plasma was “entirely justified,” while CDC Director Robert Redfield on Thursday clarified the new guidance against testing contacts.

But the initial decisions left some in the public health community worried that the damage has already been done.

“The recent episodes at FDA and CDC are prime examples of how you would go about undercutting or undermining trust in public health,” said Rich Besser, a former acting director of the CDC who now heads the Robert Wood Johnson Foundation. “When you see public health guidance that has been inordinately influenced by politics, that undercuts the trust that is so essential.”

Trump has disparaged the government’s public health experts and agencies, repeatedly casting doubt on guidance about protections meant to limit infections, from reopening the economy to the use of face coverings. That doubt has sewn rejection of basic adherence to public health guidance — and even skepticism that the virus is real — among Trump’s base and in conservative media.

“Government is supposed to be working together to protect the entire country, and instead we’re seeing these open disagreements that further sow public disagreement and undermine public trust,” said Howard Koh, an assistant secretary for health in the Obama administration who now teaches at Harvard’s Chan School of Public Health.

The risk in politicizing science and health, experts said, is that a distrustful public will become less willing to accept the next recommendation — or even a vaccine. Polling shows a significant percentage of Americans are unwilling to get a vaccine once an effective candidate emerges; that number would grow if the public has reason to question whether a vaccine is being rushed to market before the appropriate safety checks are completed.

“If there are concerns that the process by which FDA decides to approve a vaccine has been influenced by politics, that will reduce the confidence of the public in that vaccine,” Besser said. “It will likely lead to fewer people willing to receive that vaccine.”

Vaccines are most effective when administered to a broader share of the population, denying a pathogen the vectors it needs to spread and survive. The greater the share of a population that receives a vaccine, the lower the risk of spread — even among those who opt against being vaccinated themselves.

Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, warned this week against an emergency authorization for a vaccine before testing shows it is both safe and effective.

Koh said the U.S. is facing a make-or-break moment.

“This is a time to insist that the rigor and science of the decisionmaking process be held to the highest level. The future of global public health is dependent on that,” he said.

History is rife with examples of a distrustful public that does not adhere to health guidelines, to their own detriment. 

Polio vaccination campaigns in Afghanistan and Pakistan have been interrupted by rumors that vaccinators are secret intelligence agents. Ebola outbreaks in the Democratic Republic of the Congo and West Africa dragged on for years amid conspiracy theories that the virus was a plot hatched to eliminate one tribe or another.

“Trust is a two-way street between communities and individuals that have to take advice about things that they don’t have expertise in, and for reasons that may extend beyond their own self-interest,” said Prabhjot Singh, a global health expert at the Icahn School of Medicine and Mount Sinai Health System. “These are moments when people start to turn off their engagement, and that hurts low trust communities, it hurts the country and it hurts individuals. Putting that all back together takes a lot of deep work.”

Public health experts have watched with growing anxiety as the Trump administration has sidelined scientists, and especially the CDC. In previous health crises, CDC directors have served as the public face of the government response, in a way Redfield is not today.

“One of the most powerful tools that CDC has is the ability to communicate,” Besser said. “In this pandemic that’s been taken away from them.”