Before trust drifts downstream everywhere, a little humility about the lessons from the US

This morning, the Edelman Trust Institute’s newsletter went out under the subject line “Health trust begins in communities.” It promotes a special analysis that the firm produced with the Yale School of Public Health from a multi-country survey. The analysis ends its advice to health workers with one recommendation: grow a presence in the communities you serve.

In the United States, Yale’s “Why Should I Trust You?” project and a talk at CDC’s own epidemic intelligence conference on the “new geography of trust” make the same case. In Europe, colleagues from WHO Europe and EUPHA wrote in the European Journal of Public Health that “we must identify and elevate trusted messengers, such as civil society leaders, community organisations, and others with credibility and proximity to the public.” As vice president of EUPHA’s Global Health Section, I count that as our position too.

Much of this is right, and I have argued parts of it myself. With coauthors, I wrote that trust is a verb, something health workers and institutions do in every interaction. In the United States, where the Department of Health and Human Services has cut a large share of its staff and clawed back billions in state and local public health grants since early 2025, local health departments, clinics and community organizations are often where rebuilding has to start. The Yale team’s work in East Palestine, Ohio, where a researcher and a local activist went door to door and turned residents’ questions about their water into an NIH-funded study, is good public health.

But in how we talk about trust, we are repeating an old pattern. Popay, Whitehead and Hunter called it lifestyle drift, the tendency for policy to start off “recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors.” With trust, public health now asks less often whether health systems give people affordable, timely and respectful care, and more often whether individual health workers listen well enough. The first question needs budgets, rules and accountability. The second asks health workers and volunteers to do more with what they already have.

What respondents said about their health systems

People who had a lot of contact with the health system in recent years were more likely to hold three or more divisive health beliefs, such as that the risks of childhood vaccines outweigh the benefits, than people with little contact, 39 percent against 21 percent. The survey is cross-sectional, and part of this reflects who is sick and who uses care most. The analysis presents it as a sign that “the patient-provider relationship is under stress.”

Worry about being discriminated against in one’s own health care rises with the number of divisive beliefs people hold. When people explain why they listen to someone without medical credentials, one of their five leading reasons is that they do not have to pay or wait for an appointment. Most want health workers to take their resource constraints into account.

Independent surveys in 14 countries found that people who had unmet health care needs or had experienced discrimination or a medical mistake were less likely to be vaccinated against COVID-19. Whether people go without care, face discrimination or suffer a medical mistake depends on how a health system is financed and run, including what people pay at the point of care, how many staff a clinic has, and whether a complaint about discrimination leads anywhere.

What the analysis recommends

The analysis addresses all of its recommendations to individual health workers: listen first, welcome doubts, validate concerns, admit uncertainty, respect people’s values, and be present in their community. None is addressed to the payers, ministries or hospital boards that decide what care costs, how long people wait, and what happens when someone is treated badly.

The community recommendation also rests on one of the analysis’s weaker findings. Even among people who hold the most divisive beliefs, 46 percent say a provider’s presence in their community would be very or critically important to them, which is fewer than half of the group the recommendation is meant to reach.

Edelman is a communications and public relations firm, and it reads its data as a communications problem. Public health reads the data the same way when we answer cost, waiting and discrimination in care with better messengers.

The same words describe different health systems

For the past two years I have trained at a US school of public health and worked and learned side by side with US public health practitioners. I have seen how much of their daily work depends on community organizations, because many of the people they serve cannot get affordable or timely care. The contrast with the health systems I worked with at WHO, and grew up with in Slovenia, is stark.

US researchers locate medical mistrust “as a phenomenon created by and existing within a system” that sustains racism, classism and stigma. In the United States, “community” usually means the organizations and networks outside a fragmented health system that people rely on when that system fails them.

In Brazil and Ethiopia, the community health workers people meet are employed by the public primary care system, through Brazil’s Family Health Strategy and Ethiopia’s Health Extension Program. Across the former Soviet Union and parts of Central and Eastern Europe, people facing long waits, missing medicines and disrespectful treatment are more likely to make informal payments, and so are people with relatives to help them. In Kazakhstan, messages endorsed by the President, the Grand Mufti and the Chief Sanitary Doctor lowered parents’ intention to vaccinate their children. The parents’ doubts were about vaccine safety and efficacy, and the endorsements did not address them.

The Edelman and Yale analysis averages its findings across all its countries and reports none of them separately. Europe is represented by France, Germany and the United Kingdom. The one case study it offers practitioners comes from Ohio.

What European public health can do with its health systems

European public health, EUPHA and WHO Europe included, is taking up this approach while most European health systems are still universal and publicly accountable. Europe has little standing to lecture anyone on trust, with informal payments in parts of the region and waiting lists across it. The governments that run or regulate those systems can change what care costs, how long people wait and what happens after a complaint. Community engagement works best when it connects people to services that deliver. During the Ebola epidemic in Sierra Leone, communities working with trained mobilizers reported more safe burials and more cases referred for medical care within a day of symptoms. Engagement that stands in for those services asks community organizations to vouch for care that keeps people waiting, costs them money, or treats them badly.

Taking the survey seriously would mean treating cost, waiting and discrimination in care as causes of distrust that ministries and health boards can measure and reduce. European countries already collect much of the evidence. The EU tracks unmet need for medical care because of cost, distance and waiting lists, and the OECD’s PaRIS survey asks patients how primary care treats them. We could report those figures next to every trust survey, hold ministries and health boards responsible for them, and give trusted messengers services that have earned their trust.