A Supply Chain of Trust

One strategy for improving public trust in science, the COVID-19 vaccine and possibly future COVID-19 vaccines or vaccines for emerging virus should be improving trustworthiness at all levels.

The way bioethics and public health approach public trust often leaves out the most crucial element: improving trustworthiness and maintaining trustworthy institutions. Doctors and other healthcare professionals need to perform in a trustworthy way. Hospitals, hospital systems, insurance companies, pharmaceutical companies, the FDA, CDC, and other government institutions do as well. They are the sources of data, approvals, and medicines. Outside influences alter trust. Lobbyists influencing elected officials who appoint leaders of government organizations undermine trust.

There is a supply chain of trust. At the bedside, the doctor is one end of that chain delivering care and information to the person in need of it. But the pharmaceutical companies, often with research institutions or academic medical centers, start the trust chain developing drugs and giving information to regulatory agencies in hopes of approval. Then again, pharmaceutical companies have a crucial link as manufacturers. Even the shippers of drugs have big responsibilities and must be held to high standards, especially when temperature must be maintained. Those advertising pharmaceuticals are also a link in the supply chain of trust.

Many disciplines view the crisis of public trust with the underlying hypothesis that the public perception is the issue to resolve, and they conclude that messaging or communications should be the path to resolution. That hypothesis leads to wide-ranging research about human nature and targeting messaging. The fields of political science, sociology, and psychology have extensive discourse about political polarization and rights, people drawn to conspiracy theories, the lack of science education, and people with paranoia or psychological traits that contribute to their lack of trust.

Other fields like public health take the tact that it is not only a lack of trust, but a lack of information, and they argue better communication of accurate science would improve compliance with scientific community recommendations, like masks and vaccines during the pandemic. Public health papers cite solutions like a trusted doctor delivering the scientific information and improving science education so that the public is more able to understand how vaccines are developed.

Better communication is a worthwhile endeavor, but a hard look at systems, people, and institutions reveals some fundamental issues. Public distrust is warranted considering relationships that taint the objectivity of the drug approval processes and financial conflicts of interest.  

Example

The FDA approval of OxyContin® for moderate pain exemplifies the justified distrust of the FDA. Language from Purdue Pharmaceutical’s fraudulent marketing materials that stated opioid use was safe were then used at the bedside. Purdue quite successfully added moderate pain to the litany of “intolerable” conditions on which some pharmaceutical companies thrive. The arguments surrounding pain made me, as a parent, feel like a villain for choosing quite effective IV forms of ibuprofen, acetaminophen, and a few other options, which, together decrease pain successfully. In my own experience, asking the “pain team” to dismantle a pain pump was always met with dismay. The pain scale of 1 to 10 became a commonplace source of angst – a preference to take ibuprofen and go from maybe a 7 or 8 to a 3 or 4 was met with consternation by doctors who felt they could relieve more pain with stronger medicines, like fentanyl and OxyContin. I argue Purdue Pharma through aggressive marketing furthered a societal intolerance of mild to moderate pain, in some cases making allowing pain seem commensurate with cruelty.

Each level of the Purdue fraud is important. The supply chain of trust had a lot of broken links. Yet while the company’s ethical violations are egregious, the FDA’s ethical violations were too. And the willingness of so many hospitals and doctor’s offices to meet with Purdue marketing people makes them complicit as well. While many were duped, others continued to prescribe despite cases of addiction of growing evidence of dishonesty. Hospitals and doctors should do more to resist marketing claims. OxyContin is alive and well, and the CDC just eliminated its recommended dosage cap in “a win” for doctors in the pain management arena, despite that two million people have a current opioid use disorder and deaths by overdose continue to climb, now topping 100,000 annually. When the approved, prescribed drug at the prescribed dose sparks the problem, trust is rightly questioned.

Societal Resilience in Public Health Crises

Shifting gears, the FDA came through with a speedy vaccine approval process. But the revolving door between government and industry, the corporate lobbying, and past fraudulent acts justify distrust, possibly decreasing public trust in the vaccine. Even if trustworthy behavior in drug approvals is the norm, the phenomena of fraud is not entirely uncommon in the US pharmaceutical industry, and conflicts of interest are common. No amount of messaging will outweigh the importance of added safeguards. I suspect that the more trustworthiness, the better likelihood of societal resilience in a public health crisis that requires respect for an FDA-approved remedy.