The Collapse of Trust in Top-Down Public Health

Two years ago, 69 percent of Americans believed what the CDC had to say. Now, that number is 44 percent. After seven decades, CDC sat atop a pyramid of influence in public health. But today, top-down public health decrees meet with skepticism as often as with trust. We are living in an era when distrust is now the default, says Edelman in their latest Trust Barometer report.

Certainly, in obesity-related public health policy, decrees of this is what’s good for you have failed to bring change. Maybe, just maybe, it’s time for a bottom up orientation that respects the lived experiences of people with obesity and overweight.

Lessons from Colonial Public Health

Our friend Philippa Sandall recently pointed us to a history of efforts to control bubonic plague. In the colonial empire of Great Britain, top down strategies were not working too well at the turn of the twentieth century. So a medical service officer, Andrew Buchanan, learned from the success of a tiny village in western India that consistently avoided ravages of plague. It was due to their large population of cats.

Buchanan became an advocate of bottom up public health strategies that defied colonial norms and drew upon grass-roots wisdom. Cats became an animal technology for controlling the plague. Projit Bihari Mukharji describes the implications:

“Unlike Buchanan’s efforts to learn from colonised communities and their practices, public health views ‘from below’ usually remained distinct and separate from the vertically organised public health campaigns – especially in the colonies. What stands out most about Buchanan’s scheme is his own, explicit insistence that his scheme was a ‘People’s Remedy.’ In giving credit, finding data, and actively seeking to align the scheme with local cultural mores, Buchanan tried hard to live up to the moniker of a ‘People’s Remedy.’ This was rare in histories of public health in general and colonial public health in particular.”

Discounting the Affected People

Because of entrenched, implicit bias, the impulse is to dismiss the people who are living with obesity in public health strategies to address it. For example, in the new National Obesity Strategy for Australia, lived experiences of people with obesity are an afterthought. A quick look at their schema reveals a strong emphasis on educating and nudging people to “stay healthy.”

But VicHealth CEO Sandro Demaio correctly says that “relying on behaviour change is simply not going to move the needle.”

Nevertheless, that is the default thinking in most public health strategies for obesity. This is what’s good for you and you are going to have to change your ways.

More than a century ago, Buchanan found a better way. Get curious about the experiences of real people. Build your strategies from the bottom up. It’s an excellent way to foster trust and find an effective path forward.

Click here for Mukharji’s account of Buchanan’s efforts to learn from real people. For more about the Australian obesity strategy, click here.

Colonial Policy, painting by Pavel Filonov / WikiArt

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April 10, 2022