Public trust is earned: Historical discrimination, carceral violence, and the COVID-19 pandemic

1 INTRODUCTION

The low early uptake of coronavirus vaccines among Black and Hispanic populations in the United States has been attributed to widespread medical mistrust rather than the misconduct of government and medical institutions.^1-4 Group-based knowledge of unequal treatment, neglect, and violence has led many to consider these institutions untrustworthy. Given the importance of laws and regulations in shaping health outcomes,^{5, 6} scholars have offered frameworks to expand analyses of institutional trust to distinguish between trust, distrust, mistrust, and trustworthiness and the important implications of each for public health and state actors.^7-15 Public perception of the trustworthiness (i.e., the perceived reliability of institutional actors to perform their duties or publicly stated commitments) of actors involved in the COVID-19 pandemic response predates the pandemic. The reputations of these actors may have improved or worsened as a result of actions taken to address the pandemic. Yet, less is known about whether knowledge of historical and contemporary abuses, crimes, and discrimination perpetrated by these actors influences their trustworthiness among Black and Hispanic populations.

Discrimination experienced within the health care system is a known contributor to institutional mistrust.¹⁶ For instance, despite mixed evidence, the US Public Health Service Study of Syphilis in Tuskegee has been repeatedly cited as a source of mistrust, particularly among Black Americans.^17-24 The United States has perpetrated or been complicit in health violence against Black, Hispanic, and Indigenous populations domestically and abroad (e.g., the sterilization of Native American women and girls through the Indian Health Service; the infection of prisoners, psychiatric patients, and sex workers to test the efficacy of penicillin in Guatemala), which led many to avoid health interventions proposed by actors perceived to act in partnership with those agencies and institutions.^25-29 Although knowledge of historical atrocities and common experiences of racial discrimination is known to have tangible health consequences,^{30, 31} this domain of knowledge has important behavioral consequences for public health actors that were underexplored during the COVID-19 pandemic.

Public health researchers and scholars across multiple disciplines have found police violence—disproportionately against Black Americans—has myriad health consequences in need of intervention.^32-38 Research shows that indirect police contact exacerbates health risks for people living in highly surveilled neighborhoods,^39-42, and the effects of this police contact have varied by gender.^{39, 43-45} Scholars have shown that routine exposure to police violence is linked to medical mistrust,⁴⁶ lower utilization of important health services,^{39, 47} and exacerbation of other known health disparities for youth and adults.^{40, 42, 43, 48, 49} Sociolegal scholars have also begun examining how legal standards are being enforced to deter police misconduct,^50-57 and others are beginning to ask questions about how to use available 21st-century technological innovations to regulate law enforcement behavior more expansively.^58-64 However, research examining the impact of police violence—or (dis)satisfaction with governmental responses to police violence—on the political behaviors of American citizens and residents remains scant, despite evidence demonstrating that knowledge of this violence also has important political consequences (particularly among racially minoritized populations).^65-67

In this paper, we use a novel survey fielded during the summer of 2021 to empirically examine whether knowledge of historical atrocities and (dis)satisfaction with governmental responses to police violence influence trust in key actors involved with the development and distribution of the coronavirus vaccines. We tested three hypotheses to evaluate whether (1) greater dissatisfaction with governmental responses to the death of George Floyd, (2) greater knowledge of the US Public Health Service Study of Syphilis in Tuskegee, and (3) greater knowledge of the unsanitary detainment of immigrant children and families by the US Immigration and Customs Enforcement (ICE) agency were associated with lower perceptions of the trustworthiness of the developers and distributors of the coronavirus vaccines among Black and Hispanic respondents. Based on our analysis, we offer observations about the importance of intentionally reconciling historical and contemporary harms committed against Black and Hispanic populations to promote a culture of health in the United States.

2 METHODS

3 RESULTS

Our sample (Table 1) included a greater proportion of participants who identified as women among Black (63.6% vs. 36.9%) and Hispanic (67.1% vs. 32.9%) respondents. Most participants were born in the United States. Nearly half of Black (43.3%) and nearly a third of Hispanic (31.9%) participants reported household incomes less than or equal to $25,000 per year. Over half of Black (53%) and nearly half of Hispanic (49.8%) participants strongly agreed/agreed with the statement that their destiny is tied to the destiny of other people of their racial and ethnic group in the US.

Most Black participants in our sample rated pharmaceutical companies (80.6%), the FDA (81.5%), the Biden Administration (79.6%), their usual doctor or health care team (84.0%), and pharmacies and walk-in clinics where people can get vaccinated (84.1%) as trustworthy (i.e., completely/mostly/somewhat trustworthy) (Table 2). These same participants rated the elected officials in their state (66.2%) and the Trump Administration (33.2%) as not trustworthy (i.e., not much/not at all trustworthy). A similar pattern was observed among Hispanic participants. Most rated pharmaceutical companies (83.9%), the FDA (85.1%), the Biden Administration (76.3%), their doctor or health care team (84.7%), and vaccine clinics (85.6%) where they could obtain coronavirus vaccines as trustworthy. However, 55.4% of Hispanic participants rated the Trump Administration and 66.8% rated their state elected officials as not trustworthy.

Most Black (89.8%) and Hispanic (86.4%) participants had heard or read a lot about the death of George Floyd (Table 3). Most Black (63%) and nearly half of Hispanic (41.5%) respondents reported knowing a great deal/a lot/moderate amount about the Tuskegee Syphilis Study. Similarly, most Black (69.3%) and Hispanic (71.1%) participants reported knowing a great deal/a lot/a moderate amount about ICE's detainment of immigrant children and families. Overall, approximately half of Black respondents (50.6%) and 42.6% of Hispanic respondents reported not being satisfied with the outcome of the investigation into George Floyd's death.

Higher levels of knowledge of the US Public Health Service Study of Syphilis in Tuskegee were associated with rating doctors and health care teams as trustworthy (ME: 0.07; CI: 0.01, 0.13) among Black respondents (Table 4). Among Hispanic participants, higher levels of knowledge of ICE's detainment of children and families were associated with rating state elected officials as untrustworthy (ME: −0.09; CI: −0.16, 0.01), while higher levels of knowledge of the US Public Health Service Study of Syphilis in Tuskegee among these participants were associated with rating the Trump Administration as trustworthy (ME: 0.09; CI: 0.01, 0.16). We found no association between knowledge of the circumstances of George Floyd's death and ratings of trustworthiness among Black and Hispanic respondents.

Table 5 shifts the analytic focus from “knowledge” of the circumstances of George Floyd's death to “satisfaction” with the government's investigation of George Floyd's death. Among Black participants, on average, greater dissatisfaction in the Minnesota government's response to George Floyd's death by Derek Chauvin was associated with lower levels of trust in pharmaceutical companies (ME: −0.09; CI: −0.15, 0.02), the FDA (ME: −0.07; CI: −0.14, −0.00), the Trump Administration (ME: −0.09; CI: −0.16, −0.02), and elected officials in their state (ME: −0.10, CI: −0.18, −0.03). Similarly, lower levels of satisfaction in the investigation of George Floyd's death among Hispanic respondents were associated with lower trust in the Trump Administration (ME: −0.14, CI: −0.22, −0.06) and elected officials in their state (ME: −0.11; CI: −0.19, −0.02).

4 DISCUSSION

The US Public Health Service Study of Syphilis in Tuskegee is often cited as a signifier of historical medical racism and for the commonplace exploitation and mistreatment of Black Americans by medical institutions. Often, the study is invoked as an event that has undermined the trustworthiness of US medical institutions as well as countless other events that routinely occur during health care encounters.⁷⁵ Despite some studies that have reported that Black Americans tend to know very little about the study, most respondents in our study reported having heard or read a moderate to great deal about it. Our finding may be due to a resurgence of news coverage describing the study during the period the survey was administered and even before the pandemic.^{24, 76, 77} In addition, previous studies have been underpowered or limited to individual cities or research settings. Our study attempted to address some of these shortcomings by recruiting a large national sample of participants. Paradoxically, we found greater knowledge of the US Public Health Service Study of Syphilis in Tuskegee was associated with higher ratings of trustworthiness for usual care teams with similar directions of association for other actors (though not statistically significant). This may be because measures of high SES (e.g., education) were associated with increased trustworthiness of actors (Supplemental Appendix B); more educated patients may be more aware of the Tuskegee study and more trusting of their usual care teams and other actors. That is, the association between trustworthiness and knowledge of the Tuskegee study may be correlational and not causal.

We also measured knowledge of the detainment of immigrant children and families in unsanitary conditions and overcrowded facilities operated by the U.S. Immigration and Customs Enforcement (ICE) agency. The ICE has maintained a detained population of 45,000 people across 131 of its listed facilities since 2003.^78-80 The detainments drew national attention in June 2019, when Customs and Border Patrol was holding more than 15,000 detainees in crowded holding cells above their capacity (4000).⁸¹ Therefore, it is plausible that the actions of ICE are associated with lower ratings of trustworthiness of actors involved in the development and distribution of the coronavirus vaccines among Hispanic respondents (Hypothesis 3). We indeed found, among Hispanic respondents, that greater knowledge of these detainments was associated with lower trustworthiness ratings of state and local elected officials. State and local governments are key partners in the coordination and enforcement of federal immigration policy, and Hispanic ethnic groups from Mexico, Guatemala, and Honduras are disproportionally detained and deported.^{82, 83}

George Floyd's death led to one of the largest social movements in US history and brought unprecedented international attention to police brutality (e.g., excessive force, false imprisonment, wrongful search and seizure). His death further challenged the trustworthiness of the people empowered by the state to ensure the safety of American citizens—the police—which may have increased suspicion of all agents of the state working to protect the health and safety of people living in the U.S. We tested whether greater dissatisfaction with the response to the death of George Floyd was associated with lower trustworthiness ratings. We found most Black and Hispanic respondents had heard moderate to a great deal about George Floyd's death, and nearly a third of respondents were not satisfied with how Minnesota state and local government officials handled the investigation into his death. Among Black respondents, greater dissatisfaction in the response to his death was associated with lower trustworthiness ratings for pharmaceutical companies, the Trump/Pence administration, and state elected officials. Among Hispanic respondents, greater dissatisfaction in the response to George Floyd's death was associated with lower trustworthiness ratings of the Trump Administration and state elected officials, exclusively. Previous work has found that individual and vicarious experiences with police officers may fuel general mistrust of law enforcement and governmental actors.⁸⁴ While George Floyd's death may represent a more salient contemporary event, many speculate that harmful historical events also shape perceptions of the contemporary trustworthiness of government institutions.⁷⁶

These events are only a few of many recent and historical circumstances and events that may influence public trust in government, public health, and medical institutions. While we found lowered levels of trust in government officials and administrations, we did not find evidence of the erosion of trust in direct sources of health care delivery, information, or regulation: usual sources of care, vaccine clinics, or the FDA. This may be due to a number of factors—the perceived nonpolitical nature of healthcare, the increased interpersonal interactions within healthcare, the duration of relationships within healthcare, or other factors. One meta-analysis of 39 studies found trust often increases with the duration of relationships and frequency of contact.⁸⁵

5 CONCLUSION

Trust in public and private institutions depends on their trustworthiness. Public health practitioners rely on a wellspring of trust in emergencies when the general population must act quickly (e.g., using masks and taking vaccines) to stop the spread of disease. But this trust must be earned by improving the trustworthiness of institutions. The erosion of trust through untrustworthy actions of one institution or system (e.g., the criminal legal system) may spill over to other distinct institutions and systems (e.g., health care).⁴⁷ Our findings suggest an association between perceptions of trustworthiness in the people and institutions involved in the development and distribution of coronavirus vaccines and events that erode trust in American institutions. Trustworthiness varied between actors in government and health care institutions with differential associations with historical and contemporary atrocities among Black and Hispanic respondents. Respondents generally rated their doctors and health care teams, pharmacies and walk-in clinics, and the FDA as trustworthy. They rated elected officials and the Biden and Trump administrations as less trustworthy. Future research should assess whether similar contemporary experiences within and beyond health systems have an impact on trust in doctors and health care teams. Improving the trustworthiness of American institutions for Black and Hispanic populations in the U.S. is not only essential to an improved response to future pandemics but also to creating cultures of health that produce equitable outcomes for all populations.