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WASHINGTON — Even without a presidential winner, one thing is already certain: The 2020 election results were a disaster for public health.

Results from Tuesday and early Wednesday underscore just how many Americans agree with a president who has called the nation’s top scientists “idiots,” openly mocked mask-wearing, and has insisted states must be “liberated” from lockdowns. No matter who wins the presidency, more than 67 million Americans already seem to have sided with Trump on public health. In preliminary exit polls, just 14% of Republican voters surveyed said the coronavirus pandemic was the deciding factor in who they voted for, despite the fact that the virus has killed more than 233,000 Americans and is spreading unabated across the nation.

That leaves public health officials to grapple with hard, existential questions: How can they forge new relationships with this huge swath of the country as the pandemic continues to unfold? Where does the public health field go from here?

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“Even if Trump does not win, much of the population will have voted for him, so that still seems like a big wake-up call!” said Heidi Tworek, an associate professor at the University of British Columbia, who has studied the successes of various countries in getting their populations to comply with Covid-19 mitigation measures.

“We’re going to have to do some serious soul searching,” said Georges Benjamin, the executive director of the American Public Health Association, who insisted that public health officials don’t deserve the blame for the political backlash to their message, but can “play a big role in making sure that we come up with ways to deal with this in the future.”

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Public health measures and guidance are not ideological in nature; nor is the response to them a monolith. But polling shows that Democrats, broadly, tend to favor a more robust public health response to the pandemic while Republicans have tended to oppose such measures.

Scientists, epidemiologists, and public health experts who spoke with STAT were divided about the future of public health. Most insisted there were straightforward, albeit challenging, ways to win over the people who have, until now, disavowed public health measures and who seemed to have voted against a more stringent public health response on Tuesday.

But at least one expert said the cause was hopeless.

“If there was a way to fix it, we would have done it,” said Holden Thorp, the editor-in-chief of Science and its family of other journals. “Science was on the ballot and this means that a significant portion of America doesn’t want science. … Science is now something for a subset of America.”

For Lindsey Leininger, a public health educator and clinical professor at Dartmouth College, winning more people over to the side of science is an existential imperative. Failing is “simply unacceptable.” For her, the first step is simple: acknowledging the problem.

“We have a huge gaping hole in our cultural intelligence and I think that that is really important for us to recognize and embrace,” she said. “We need to know that this is a blind spot, and we need to partner with people who believe in the science and have credibility in conservative circles.”

Others suggested that strikingly simple tactics — like listening to skeptics thoughtfully, like asking them to help brainstorm solutions — would also make major inroads.

“The approach often used is, ‘We just need to tell people who have those beliefs that they’re wrong.’ Maybe not that directly, but in other ways. Maybe what we need to do is invest in listening to their concerns, and understanding their perspectives, before we start giving them our messages,” said Glen Nowak, a longtime communicator at the Centers for Disease Control and Prevention who now heads the University of Georgia’s Center for Health and Risk Communication.

APHA’s Benjamin said similar. “Take it seriously. … Sit down and talk to folks and say: Hey, we want to stop the spread of this disease, what are your ideas?”

Krutika Kuppalli, a physician and professor at the Medical University of South Carolina, suggested doing in-person community outreach to make reluctant communities “feel empowered.”

Gregg Gonsalves, an assistant professor at Yale School of Public Health, added a caveat: target that engagement to those who seem willing to listen.

“You give people the benefit of the doubt as long as you can,” he said. “You see where you can engage … you don’t waste your time on the trolls or the ones who see public health as a punching bag for a larger political debate.”

There are reasons for hope for public health. Officials, for example, successfully helped quell the West Africa Ebola outbreak partially through door-to-door outreach. Taiwan, which publicly struggled to contain the 2003 SARS outbreak when its citizens resisted public health measures like quarantines, is now considered one of the best countries in terms of its response to the Covid-19 pandemic.

“Our fate really is in our hands … it is wholly possible to reform your system,” said the University of British Columbia’s Tworek, who studied the Taiwan example. “It’s an extraordinary difficult challenge, but that doesn’t mean that we should be nihilistic, give up, and do nothing.”

But knocking on doors and taking the time to make outreach to reluctant Americans could be harder if the public health workforce continues to dwindle — as several predicted it might after Tuesday’s election.

“We’ve been working on this pandemic for 10 months. … We are already exhausted, we are already overwhelmed, you are asking us to put our lives on the line,” said the Medical University of South Carolina’s Kuppalli, who noted she has colleagues who are already putting application packets together to work overseas.

“We could have what we call a brain drain in the United States,” she added.

As of August, at least 49 state and local public health officials around the country have left their post, according to an investigation by Kaiser Health News and the Associated Press. And that count does not include infectious disease doctors working in hospitals or academics working in universities.

Yale’s Gonsalves, insists, however that many people are not “cutting and running.”

“This is what we were made for. This is a pandemic, this is our challenge, this is our calling, this is our mission,” said Gonsalves. “We do what we do: Doctors don’t give up on patients and we don’t give up on the public health.”

“If scientists shut up, there’s no countervailing weight to the crackpot theories and charlatanism,” he added.

  • I think one problem is that most public health experts don’t really understand *why* so many Americans are deeply distrustful of the whole thing.

    If you know enough about the field to understand the data and where it comes from, then what the data tells you is ‘obvious’. And all public health people are in this category.

    But if you don’t understand the process by which the data is generated, it’s a lot easier to believe that, say, all the official data is skewed to inflate the impact of COVID (say by marking down a lot of regular deaths as caused by COVID).

    In reality, that would be impossible, as far too many people are involved; but if all you hear is that this data is “from the CDC”, a faceless government institution, it’s not so hard to believe that there is just some bureaucrat somewhere writing down numbers.

    Combine that with the starting assumption that government is generally primarily interested in increasing its own size and power…

    • Hmm, but that’s all “why this can’t work” – I didn’t intend to sound quite this pessimistic.

      I think the key is that you need spokespeople — people who are seen as trusted or in some way authoritative, but not as “representatives of a vast government bureaucracy”. In some communities that might be pastors or ministers or other religious figures; in others it might be more local governmental officials.

      I’ve heard a saying that “Americans hate Congress but like their own representatives”, which I think gets to the core of this — it needs to be seen as not coming from ‘The Government’ as a faceless, vast, power-seeking bureaucracy whose internal workings are opaque to everyone else.

  • Which “science” was supposed to be followed: the initial “don’t wear masks” science or the later “masks are crucial” science? The initial “wash your hands” science or the later “it doesn’t really spread on surfaces” science? Or the “Trump rallies are unsafe, BLM protests are safe” “science”? Rather than admit that they don’t have the answers, that the science is unclear, and that public health exists in the real world, not in a lab, and involves tradeoffs like preventing infections while keeping the economy operating and educating children, the scientists were all too content to let the media order us all to follow the scientists’ ever-changing diktats or be deemed “science-denialists.” This is not a rejection of “science”; it’s a rejection of scientists who refuse to demonstrate humility by acknowledging the uncertainty and limitations of the science and denouncing the media’s efforts to advance political narratives by overstating the limited conclusions that the science supports.

  • I agree with you 100%. But talking about genetics as a factor is a taboo within the scientific community in the US. It quickly marks one as racist.

  • I am a scientist by training and I am appalled by the scientific community’s hubris in pretending to know more than what they know, politicizing a pandemic and talkjing AT people rather than talking to people and trying to frighten to feel important. To start with, the scientific community should have acknowledged that the limits of their understanding of a novel virus. Instead, they picked up their bull horns and started pontificating about millions of deaths which never materialized and advocating for shut downs (scientifically dubious and harmful). This time to say what you know and what you don’t, examine pros and cons, do NOT shut up anybody who disagrees as ignorant and for god’s sake leave the final decision to policy makers who know something about economy. Public health must be approached holistically. Our current public health leaders have betrayed the public health and instead promoted a one sided policy that s harmful to the psych of the vast majority of population.

  • Why are votes for Trump a repudiation of science? Perhaps they just believed that the economic harm from the restrictions was not worth the benefits in the lives saved. That is a values and political question, not a scientific one.

  • I am not a scientist but I began studying the virus 4 hours a day in order to make decisions for my family… at first and then I got sucked in. One result of my research outside of MSM was that I became critical of the tone set by the Democrats that Trump “caused death” or that somehow anyone’s behavior was to blame for the spread of the virus. The latter is a terrible message for young people as the normal impetus to socialize has become catastrophized. I began listening to scientists who considered the cost of lockdowns and who also taught me the concept (which I intuited) that a public health policy takes into consideration the whole population and makes decisions for the greater good. In my opinion Democratic politicians have not been doing this. Children’s needs have been nearly 100% discarded. Closing schools will have tremendous public health costs. There has been absolutely no policies addressing mental health by my Democrat governor who I have grown to frankly, despise as much as I have despised Trump.

    • EXACTLY SO. People would have listened far more to the scientists had they not played political games at first to scare the population, mislead about maskz and then taken overtly political stands that frankly neglected the educational and emotional well being of our children and the population at large. I suspect in the future entire monographs will be written on what the “experts” did wrong in this crisis

    • I agree schools should not have been closed, but this is not what many public health experts are advocating. Many, many have been sounding the alarm all summer that schools need to be open, that benefits of reduced transmission do not outweigh the myriad harms to children, and the like. The problem is that Democratic politicians are too beholden to teachers’ unions, and teachers got spooked when Trump publicly backed reopening with no plans and no safety measures to ensure their lives were being treated carefully. Also early on, there was some equipoise on whether lockdowns were worth it (for instance, the WHO was never fully on board with them!). But because Trump politicized them with clearly zero understanding of the pandemic, and because he knocked testing and tracing, he left public health experts with only one tool, one most didn’t like at all.

  • ‘Science’ is hardly homogenous in its judgement of C19. There are many highly credible peer reviewed studies which point to glaring disagreement with public health officials. These studies are not attention grabbing and so they are not reported. Among them are strong indications that genetics plays a very strong role in determining severity of c19 infection for each of us. Genetic factors are generally not easy to modify although CRISPR is beginning to change that, so it is likely severity of C19 infection for each of us may be largely predetermined and therefore we should be modifying public policy responses. Undoubtedly there are myriad factors which make our current restrictions ineffective. In absence of facts supported by hard research at the beginning of the pandemic, our restrictions were generally reasonable public policy responses which did limit the spread of infection. That has not been the case for a few months. To call anyone who does not support ongoing and increased restrictions a Trump-supporting, non-science believing person which must be educated is ridiculous. It is much more likely the fear-motivated policy makers controlling our daily lives are on the wrong side of science. Can we not debate any of these issues without politicizing issues, insulting people’s intelligence and closing our minds to another point of view? Who here is open minded enough to read the science and debate the issues as an adult?

    • Yes, views are not totally homogeneous. SARS-CoV-2 is a novel virus. We’ve learned more as we’ve gone along. That’s a good thing, not bad. Are you still engaging in useful conversation with anti-vaxxers and climate-change deniers? Can we wait for CRISPR to do a full-bore pre-assessment of an individual’s risk profile so we can send the weak and vulnerable into solitary confinement?

    • I agree with you 100%. But talking about genetics as a factor is a taboo within the scientific community in the US. It quickly marks one as racist.

  • The noble lie that was told early in the pandemic that people should not wear masks as led to mistrust of public health. What little was gained, since N95 masks quickly became unavailable in any case, was that the public no longer trusts experts and “science”. Good luck on convincing the majority that vaccines are safe and effective.

    • Which science are you referring to? Are you aware of several comorbidities which are impossible to detect without genetic tracing, and which will likely be a death sentence if you get c19. Some of these genetic markers are rare in society, which means that the vast majority will not have any reaction at all to C19. This is only one example of ‘science’ which is being completely ignored by many people, which would dramatically change public policy response. Death by C19 is not random and will be completely predictable in time. In the meantime we should all take precautions, but individual freedom should not become a casualty. If you are fearful, stay inside. Otherwise live and let live.

    • Yes, let’s all just fall back on a lame excuse for not wearing masks. It sounds like pouting to me.

  • For months, COVID was something that was happening “elsewhere” in people’s minds — China, Italy, eastern cities. It was something of an abstract idea, and some people can only change their minds when a problem affects someone they know. Unfortunately, a lot of minds stand to be changed over the next 3 to 4 months.

  • First, many who voted for Trump (note I did not say supporters) did so because they do not want any form of socialism. Second, Thorpe’s comment about science only being for a ‘subset’ of America is the basis of the problem — assuming that if these people were ‘smarter’ than they would have voted for Biden and science. The answer is actually much easier — listen, ask their opinion and their perspective and don’t lecture them. While I disagree wholeheartedly with DT’s approach, he listened to them and his campaign responded to their concerns and fears.

    • Leave it to the swampy creatures at STAT to set up the false dichotomies they often do.

      Trump also listened to the public health “experts” at the beginning — Fauci and Birx were arguably the two most visible individuals in the first 120 days, and came out to the White House press room on almost a daily basis. They were key members of the team.

      He listened to them. He acted on their advice.

      And then, like the get-stuff-done business approach he has, Trump and his team went to work, almost EXCLUSIVELY on the advice and concerns of public health officials.

      “We need ventilators, lots and lots of ventilators.” The ventilators came.

      “We need hospital beds, lots and lots hospital beds.” The convention center hospital were built. The Hospital Ships were dispatched.

      But there are two problems here. The first is that public health officals, especially Fauci, were constantly changing their tune. Masks don’t work, now they are essential. 15 days to stop the spread–oh, we have to lock down for months. And instead of saying, you know, we’re trying to understand a difficult problem, and we’re making the best decisions under uncertainty, they say, “We’re SCIENTISTS!! We go where the data leads us.”

      That’s a flimsy excuse for being wrong.

      The second problem, and it is huge problem, is that public heath officials are only concerned with ONE side of public health. Fauci has tunnel vision. To him, public health is largely, if not exclusively about infectious diseases. Birx is an epidemiologist — she is largely, if not exclusively, concerned with epidemics. There is nothing wrong with focus, except when focus has you lose the forest for the trees.

      It’s time for public health officials, and epidemiologists, to show a lot more modesty and humility. Both are useful but in the end public health and epidemiology are very weak scientific disciplines. There is no falsifiable hypothesis testing. There are simply too many variables. There is no highly explanatory theoretical framework for the messy realities of biological activity and its effect BEYOND simply disease transmission.

      When Trump says the “cure can’t be worse than the disease” he has zeroed in on the key scientific uncertainty that characterizes the current state of public health “science.”

    • Listen people, we have to start believing our own eyes and ears and then actually remember correctly and accurately what what the president has said and done. At this point, trying to make excuses for the president’s abject failure to protect the lives of hundreds of thousands of Americans defies reality and comes off as willful ignorance.

      Also, the comment from KarlPK, since none of the points made are true, can only be regarded as sarcasm.

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