Americans trust their doctors. At least that was the idea, especially when it came to small-town physicians like Dr. Jennifer Bacani McKenney. She grew up in Fredonia, Kansas, population 2,151, and came back from medical school at the University of Kansas to practice there. People in town, all familiar faces, were over the moon, McKenney remembers. After all, health care is in short supply in rural Kansas, and Wichita, the closest large city, is 85 miles away.
But three years ago that trust and love suddenly crumbled when McKenney tried to shield her beloved little town from COVID-19.
“That was the first time in my career that I had people say, ‘No, we don’t believe you. We don’t think that a vaccine is the right thing. We don’t think we should wear masks,’” says McKenney. “And I was like, ‘Wait, remember that great relationship before, how you’d come to me for advice?’”
It wasn’t everyone. The walls of McKenney’s office are papered with letters of support and thanks that arrived during the pandemic. But Fredonia’s most vocal residents vilified their hometown doctor, cast her recommendations as part of a dark conspiracy to steal their rights, their guns — even their children. Some heaped abuse on McKenney online and in county commission meetings.
She was afraid for her own children’s safety, all while battling the pandemic in Fredonia’s small hospital.
She watched some patients refuse her advice, and die.
This same tragedy played out across the United States.
As many as half a million COVID deaths in the U.S. could have been prevented simply because Americans didn’t trust each other, says Tom Bollyky, director of the global health program at the Council on Foreign Relations.
Bollyky was lead author of a large study published in the Lancet this year, taking a fine-grain look at COVID death and infection rates across the United States and the many of the factors that contributed to the differences.
While the worst of the pandemic has passed (for now), the United States' deadly epidemic of mistrust is raging unchecked, Bollyky says.
“This pandemic has been less about the microbe spreading around, and more about the people to which it’s spreading,” says Bollyky. “It’s about us, and how we feel about each other, and how we hang together as a community.”
Trust in government to do the right thing, trust in neighbors has been sinking for years — ever since Watergate, Bollyky says.
“People don’t like to feel like they’re being taken advantage of,” he explains. “And to the extent they don’t believe others are doing the right things, they resist doing the right things themselves.”
New Hampshire is Norway, Mississippi is Bulgaria
COVID death rates varied wildly between states. The government tracked these rates as deaths per million people. In Kansas, the COVID death toll was 379 for every million people between Jan. 1, 2020, and July 31, 2022. New Hampshire lost 218 residents per million to COVID during the same period.
These days the Granite State has the highest rate of interpersonal trust in the U.S., as measured by long-running surveys testing trust between individuals. And Bollyky says that saved lives. COVID-19 was almost twice as deadly in Missouri as it was in New Hampshire. Almost a dozen other states fared even worse, partly due to distrust.
Trust wasn’t the only factor helping New Hampshire, but Bollyky says those variables can’t account for the enormous differences between it and other states.
“The U.S.’s best-performing states performed as well as Scandinavian countries,” he says. “The worst performing states would have been among the worst performing countries in the world.”
Meaning that in Mississippi, Arizona and West Virginia, people died at rates pretty close to those in Russia and Bulgaria.
And the problem didn't end when the pandemic eased.
“And then, to add insult to injury, we have lower rates for example of childhood immunization that directly come out of the pandemic and mistrust in vaccines generally,” says Brock Slabach, chief operations officer at the National Rural Health Association. “And so we’re going to see childhood diseases that we thought we’d eradicated returning.”
The lack of trust isn’t just a rural problem, but it tends to be worse in rural states, according to Bollyky. He said distrust runs highest among less educated, lower-income people with less access to healthcare — the very people who can least afford to take risks with their own health.
“We’re already behind the eight ball because we have higher poverty, lower rates of education, and less access to quality healthcare,” says Slabach. “And now, through the pandemic, we’ve added this issue of mistrust in the very professionals that for centuries we’ve valued as an important source of information for health and healthcare.”
More than 140 rural hospitals across the country have closed since 2010. Almost a third of those remaining, more than 600 hospitals, are at risk of closing this decade, according to the Center for Healthcare Quality and Payment Reform.
Part of the problem for rural hospitals is that Medicaid and private insurers reimburse their costs based on the cost of treatment in big urban medical centers, where economies of scale make treatment cheaper.
But rural hospitals also struggle to recruit doctors and nurses to move for work in small towns, where pay is lower and professional comradery is scarce. Now, some medical students say they’re worried that they won’t be safe in small rural towns, says McKenney, who in addition to her medical practice is associate dean of rural medical education at the University of Kansas Medical School.
So rural healthcare is scarce now and is likely to continue withering for the foreseeable future. The infrastructure for fighting disease in rural America is shrinking.
But that’s not what most scares people like Bollyky, Slabach and McKenney.
The next one could be worse
Bollyky, Slabach and McKenney are worried about the next epidemic — or other big crisis that demands widespread cooperation.
They all say the United States is in worse shape now than before the pandemic. Because trust is even weaker now than it was in January 2020.
“If we have another health crisis like a pandemic, this will come right back, because we’ve not addressed some of the underlying issues,” says Slabach.
“And so we’re still going to be facing higher rates of disease, higher spread of death,” he says, “because of this misinformation and because of the lack of trust that we have in those areas of our system that know what to do in response.”
Slabach says getting accurate information out faster might help. The best scientific data sometimes took months to reach the public during the pandemic, he notes, but by that time misinformation had already taken hold.
McKenney says she is trying to rebuild trust with her patients by being gentle when challenging their misperceptions.
She says more of her patients are reluctant to take her medical advice now, often because they saw something on YouTube or Facebook. She’s learned not to plead with them to, for instance, get a flu shot. She’s afraid of turning people away, of driving them into a smaller group of former patients, people who cut ties with her — and, as far as she knows, medicine in general during the pandemic.
“I can’t say it’s better,” McKenney says of practicing medicine in Fredonia now that the pandemic has mostly passed. “It’s just like, here’s everything that happened in that pandemic, and we’re like, ‘Well let’s just kind of pretend like that didn’t happen.’”
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