Abstract
It is almost 20 years since Laurie Garrett published her magnum opus, Betrayal of Trust, in which she described what she called the collapse of global public health. 1 By reference to a series of major public health failures including Yersinia Pestis in India and Ebola in Zaire, she accused the world’s governments of turning their backs on their primary duty of protecting the health of the most vulnerable. That book has been described as being on a par with Rachel Carson’s Silent Spring, published in 1962, which first alerted us to the harm we were doing to the global ecosystem which sustains us and life on earth. 2 In the intervening period, there is little to indicate that matters have improved and the issue of ‘Trust’ has been moving ever higher on the public health agenda.
The Cambridge dictionary definition of trust is being able to believe that ‘someone is good and honest and will not harm you, or that something is safe and reliable’. From Hillsborough to Grenfell Tower, from the Alder Hey Children’s Hospital Trust to the collapse of faith in immunisation and vaccination and the widespread use of disinformation on Ebola and other threats to public health, distrust is on the march. Yet you would be hard-pressed to find the theory and practice of trust-building and restoration on the medical or public health school curriculum; so what is going on and what needs to be done about it?
Former NHS chief executive in Cumbria, Sue Page, was fond of saying that ‘In God we trust, everybody else must bring data’. In the age of the Internet, of social media and the democratisation of access to knowledge, and ‘fake news’, the transformation of data into information and intelligence and a step change in levels of scientific and political literacy is a necessary starting point. Things are not helped by the persistence in the United Kingdom of C P Snow’s ‘Two Cultures’ in which the road divides at the age of 16 into those who study the sciences, those who study the humanities and those who embark on adult life without much of either.3 For those who aspire to positions of power and influence without a scientific grounding, the result is vulnerability to fad, fashion and charlatanry, while for those with only a narrow science world view, the outcome can be a form of ‘scientistic’ arrogance which discards the validity of citizen science and of lived experience. This has been well illustrated by each of the major failings alluded to. Andrew Wakefield’s disastrous anti-vaccine paper in the Lancet in 1998 had its impact in a context of widespread public ignorance about the safety of vaccines; 4 the Alder Hey organ retention scandal took place against a background of medical paternalism, arrogance and a sense of professional entitlement; and the refusal of Public Health England to instigate a programme of environmental toxicological sampling after the Grenfell Tower tragedy was a reflection of an incomplete and ‘scientistic’ framing of the issues which took no account of residents lived experiences and concerns and of a wider scientific framework that included combustion toxicology. Sometimes a little humility is called for.
In the search for the root causes of the blind spots that pervade these examples, it is also tempting to point the finger at the social as well as the educational background of those who frame the questions. A life of relative privilege is not necessarily a good base from which to incorporate empathy into a formulation and a dominant adherence to quantitative methods may downplay the importance of complex social and anthropological factors. Positivistic approaches coupled with the scientistic may lead to disastrous unsubstantiated ex-cathedra statements; will Public Health England’s support for electronic cigarettes being 95% safer than regular fags stand up in years to come and will Public Health England regret its exoneration of fracking as an environmental and public health hazard. History teaches us that in public health, in a state of incomplete knowledge, pragmatism and the precautionary principle go hand in glove. The form of words ‘in the present state of knowledge it would be prudent to …’ worked well for the Victorians and might well work well for us.