The disease of distrust.

An uncomfortable question has poked out from the chaos of the coronavirus disease 2019 (COVID-19) crisis—why does health inequity still persist in the United States? American people of color have been disproportionately affected by the pandemic. This, sadly, is no surprise because socioeconomic conditions, health care access challenges, and distrust in health care systems have historically prevented people of color from having healthier lives. As infections and deaths from COVID-19 continue to increase, effective treatments and vaccines are anxiously expected to become available soon. Unfortunately, less attention is being paid to questions about their equitable distribution and uptake. This only contributes to the suspicion felt by minority groups in the United States—particularly people of color—of the medical community. This barrier must come down. Every level of the health enterprise should pledge to reclaim the trust of all populations that is demanded by its professional oaths and missions. This legacy of mistrust by people of color in health institutions, health professionals, researchers, and health policy–makers in the United States has existed for decades. This painful reality has been amplified by the actions of the Trump administration and state-level officials, and by the behaviors of law enforcement, among others. It should be troubling to any health professional when thousands of African Americans pour into the streets to strenuously assert that their lives matter and that their humanity must be recognized. When people lose trust in the fundamental institutions of their society, decisions regarding the conduct of their lives become altered in both obvious and nuanced ways that affect their well-being. I was privileged to serve as the Commissioner of Public Health for Washington, DC, during the height of the HIV-AIDS epidemic. This agency's work was substantially compromised by the legacy of the 40-year Tuskegee Syphilis Study, which began in 1932, where African American men were misled into participating in research to find a cure for the disease. This mistrust has been compounded by other incidents, including the failure of the biomedical community to acknowledge an African American woman, Henrietta Lacks, as the source of an invaluable research cell line. A statue across from the New York Academy of Medicine honoring James Marion Sims, who achieved success through research on un-anesthetized enslaved American persons, was another visible insult. Misperceptions regarding the etiology of disease, the motives of policy formulators, the veracity of health institutions, and the trustworthiness of the research enterprise have become almost as difficult to overcome as diseases themselves. I am troubled by just how little the health profession has done to address the persistent misperceptions arising from the nation's history. Every aspect of the health enterprise must build the relationship between patients and health professionals. This includes facilitating inclusive input by disenfranchised communities into health policy formulation, reinforcing the actual and perceived protections and benefits of clinical research, and providing accessible scientific evidence to the public regarding therapeutics such as a COVID-19 vaccine. Let this be the moment when the health community speaks to society in a manner that reassures the disenfranchised of the strength of the bond with them. When the human dignity of people is assaulted, health outcomes are affected, thereby requiring health professionals to speak out on matters of social concern. When patients receive care that deviates from best evidence because of bias or socioeconomic hurdles associated with structural racism, advocacy is required to recognize and address the problem. Whether through individual action or the collective work of professional societies, disenfranchised people need to be assured that in matters pertaining to their health, there can be confidence in scientific-based guidance and advice. We must all recognize this disease of distrust as the scourge that it is and band together to reclaim this essential characteristic of the health profession: the preservation of the lives of all those who share our time and space. This should be the last time our society has to struggle against the legacy of the past as we fight persistent disparities in health outcomes and tackle this pandemic and the challenges to come.