You Can Only Move at the Speed of Trust

When I wrote the introduction to this series, I said that rebuilding vaccine governance can only take place between two truths: the systems we had were imperfect, and abandoning them entirely is dangerous. Finding people who are genuinely doing that building, not just defending what was or completely tearing it down, is the whole purpose of these conversations.

Dr. Alister Martin was first in line.

In the face of federal changes over the past 18 months, states and local jurisdictions have had to fill the void as best they can. Martin is the Commissioner of the New York City Department of Health and Mental Hygiene. He oversees a city of 8.5 million people that functions, in many ways, as a national stress test for public health. He is also an emergency medicine physician, a former White House advisor, and the founder of national initiatives to connect patients to resources and civic power they already have.

I wanted to start this series with someone who is not theorizing about what rebuilding should look like from a distance, but is managing public health crises and the effects of a breakdown in federal vaccine governance in his community right now. When I told him I wanted to have this conversation, he said something that struck me: “This is only the beginning.” We already had something in common: building something better in the future doesn’t mean having the silver bullet, and anyone hoping to find an answer by the end of a single conversation, meeting, or conference is fooling themselves.

That’s the spirit I’m trying to bring to this series.

The full interview is below, but three ideas from our conversation have really stayed with me.

First, he emphasized that the urgency to rebuild is not hypothetical. The Hep B birth dose, which is administered in the hospital and is one of the first signals of a problem, is already declining in NYC. This is consistent with national trends in eroding vaccine confidence and declining vaccination rates.

Second, he proposes a governance model in which rigorous, independent science is at the top, connected to deep community engagement at the bottom. I’m genuinely torn on this framing: is this model still too top-down, with community engagement just a better delivery mechanism for expert consensus? Or is the risk the opposite, that we democratize vaccine governance in ways that undermine expertise? Many people working on this problem agree that vaccine governance shouldn’t be entirely top-down. But the devil is in the details of how horizontal it can really be, and that tension is one I expect to return to throughout this series.

Third, and most importantly for me: Martin argues that service has to be the message. Public health cannot ask for trust before it has earned it, and it earns it by solving the problems people actually have right now. His version of the question is simple: “Why are you going to take my recommendation about vaccines when I wasn’t there to help you with the things that you said were a major challenge in your life?” I find this one of his most compelling observations, and it is underrecognized in public health right now.

While trust and community are at the center of any answer, the harder question is: how do you earn trust at scale, across communities with genuinely different needs and worldviews, fast enough to matter? Is it even possible?

What follows is our conversation, lightly edited for length and clarity.

David Higgins: Alister Martin, thank you for taking the time for this conversation.

Alister Martin: Thank you. This is the first conversation of many.

You have an unusual career that spans emergency medicine, public health programs at a national scale, federal and state government, the White House, and now as NYC Health Commissioner. What brought you to this work?

It starts with my mom. Growing up, my mom was a nurse in a program called Nurse-Family Partnership, which is one of the most evidence-based and effective public health interventions that we know in terms of doing prenatal interventions and maternal education.

My early experience was that public health is deeply personal and happens in communities. It’s direct. It’s solving someone’s real problem. That’s what I saw growing up. But I also heard my mom’s stories of navigating systems that quite frankly seemed almost set up for the recipients to fail at accessing the resources they needed. Many of her patients were young immigrant moms, just like she was once. My mom was a Haitian immigrant who came to New York City when she was a teenager.

She taught me a lesson: when you are connected to someone’s problem, you have a responsibility to help them solve it. And I never forgot that, and I took that with me as an emergency room physician. You know just as well as I do, that we are often faced as doctors with challenging scenarios where the patient in front of us needs so much more than the walls and apparatus of healthcare can deliver. After a while, I had to make a decision: am I just going to complain about how bad healthcare is, or am I going to try and get in the ring and do something about it? And my life has been wrestling with that question: for patients who our healthcare system fails, there has to be a better way. And I think public health is a better way.

What does vaccine governance—how guidance is developed, regulated, and implemented—look like from where you sit right now?

Well, let me just be honest: I’m tremendously concerned about where we are right now. What we’re seeing from the federal government is a systematic attempt to weaken trust in public health writ large, and specifically in vaccine guidance. These efforts have sown confusion and chaos, making it really challenging for individual New Yorkers to have the information they need to decide what they want to do about vaccines. And we’re seeing it already in our own data.

We’re already seeing a decrease in uptake of the Hep B birth dose. You can make an argument that maybe complete vaccine uptake isn’t happening because people are not following up because their lives are busy, or because parents are working multiple jobs. But the Hep B birth dose, that one should happen immediately after birth. I can’t draw a complete link between the rhetoric we’re hearing in DC and these numbers. But I have to tell you that it’s certainly not helping.

What can’t New York City live without from vaccine governance at the federal level? What do you need?

I think the future of what this looks like is the following. From the top-down, we need to have the science be rigorous, be independent, be clear enough that clinicians, insurers, schools, parents, and departments know what the standard is. That’s what we need at the top. But in the past, that’s all we relied on. What we also need is the bottom-up. Those recommendations from the top are only useful when the community trusts the messenger and can access them. So, you have to do both of these things at the same time.

In the past, we relied solely on the federal government for top-down messages. It’s possible that those days when we rely on the federal government are over. Because what we know from the last 10 years is that, even before this administration, trust in public health was declining. So this administration is making things more challenging, but the problems started before this administration. The piece we have to add is the bottom-up component.

What does that look like?

In every single community where we’re trying to get these messages out, we have to be methodical about several things: who are the best messengers to deliver these messages? — Are they community health workers? Are they navigators? Are they imams? Are they rabbis? And then, where do we meet people to deliver those messages? That is the work of public health now. It ends up looking a lot more like public engagement because, when you build a public engagement campaign, it really needs to reflect the specific context of the population. We’ve expected that one-size-fits-all messaging can get most of the work done. We have to shift away from that idea.

What do you do with the top-down if it’s not the federal government anymore?

Well, look at what you’re seeing from us. In New York City, we adopted the American Academy of Pediatrics guidelines. For adult vaccines, the gap left by the federal government is still open, though other professional bodies are working to fill it.

A share of Americans expressed some support for the current direction of federal vaccine policy. How do you engage with people who actually might find what is happening right now appealing — people who have a very different view than maybe you and I do sitting here?

It comes down to trust. You can only move at the speed of trust in public health. And I think what you’re seeing is a reflection of two things happening. That segment of the population no longer trusts the traditional approach to public health. They just don’t. And then there’s a group that agrees with them and says: hey, look, those public health folks have burned us once. And so, ‘here’s what we should do instead’.

It’s less about every person in that group doing hard-hitting research and trying to figure out if the evidence makes sense. It’s more about: are you speaking my language? And my language is: I’m hurt. I got let down by institutions. And now I’m looking for another way.

And let me be clear: everything I just said is what I’m seeing with the Make America Healthy Again (MAHA) movement. They are saying, ‘official public health and traditional institutions have not given you the full answer. They’ve let you down. Come this way instead.’ But I think there’s a third way between the traditional public health model and what MAHA’s doing. And the way I think about it is: to be trusted, you need to be trustworthy. You need to be worthy of someone’s trust. And how are you worthy of someone’s trust? You have to help them with their needs.

If I’ve never seen you on my block, and all of a sudden you drop into my neighborhood, and you say ‘you need to wear a mask’, and ‘you need to take this vaccine’, people will say ‘who are you? Where have you been? I’ve been hungry for the last two weeks. I don’t know if I’m gonna ever see a primary care doctor, because the waiting list is three years long. I don’t have a place to live. You haven’t been helping me solve these challenges, so why do you then get a seat to help me decide what I’m gonna do?’

So the direction we’re exploring here at the health department is: how can the service be the message? How can we serve people and address their material needs, solve their real problems, and let that be the message that builds trust?

And the last thing I’ll say on this: this isn’t anything new. This is how public health started. Public health emerged because people were getting sick from contaminated street wastewater, which was dangerous. Public health began by going out to clean up the mess. Literally. And so I think we need to get more involved in people’s lives in this way — through what we’re calling direct action public health.

You said better community engagement enhances trust, and part of that is listening. What does genuine listening look like, and how do you feed the listening back into the decisions you’re making?

The way I’ve been thinking about it is this: let’s make sure we take care of all the standard health interventions — the vegetables — but also make sure we’re addressing the person’s top-of-mind problem right now.

Here’s one example of what it looks like in practice: partnering with managed care organizations to deliver large amounts of free food directly to communities through neighborhood health action centers and clinics. We run a network of three action centers and 11 public health clinics that deliver healthcare services, and address the social determinants of health by helping people enroll in SNAP, Medicaid, and tax assistance programs.

But you can’t start the conversation there. You start with food. If people are hungry and facing food insecurity, that is what brings them in the door. Let’s address that immediate need first. Then, in the wake of that interaction, once trust has been built and that need has been met, we can start talking about the other things. Is your Medicaid coverage stable? Can we help you enroll in SNAP? Are your child’s vaccines up to date? How else can we help? The listening should come after we help solve the person’s current problem, because that’s how you build the trust to get them to share what’s actually going on.

The second thing: you need to incorporate their perspective in the creation of the new intervention. We’re currently building a whole series of interventions to keep people on their Medicaid coverage ahead of the January 1, 2027, HR1 start date. I might come up with some pretty good ideas, and my chief of staff might too. But none of them, when the rubber meets the road, are probably as good as someone who’s actually lived this challenge. They’re gonna have ideas far better than ours. You’ve got to incorporate folks into the decision-making, into the building of the intervention.

You have said affordability is obviously a public health priority, but it’s also a path to rebuilding trust. Walk me through that argument, specifically about vaccines.

I think this is a direct line, and I think we’ve been talking about it the whole time, but I’ll be even more explicit. Number one: You cannot have a conversation in this country around affordability without talking about health. Number two: when we look at what really makes people sick in this city and in this country, it’s poverty. My patients, your patients, many of them are making decisions every single day between putting more food in the fridge and paying their copay. Do they take a day off from work to see their primary care doctor, knowing that if they do, it might mean they lose their job?

We’re putting people in an impossibly challenging position, which is literally bankrupting many New Yorkers and Americans. And to date, public health has not really made itself part of the affordability conversation. It needs to be. It needs to be at the center of the conversation.

Some of the things we’re going after are these four. The first: Medicaid coverage, doing everything we can to help people cut through the bureaucratic red tape and keep their Medicaid status. The second is benefit enrollment. We’ve calculated that there are millions upon millions of dollars in this city alone that people leave on the table because they’re not enrolling in cash assistance benefits: SNAP, Lifeline, tax credits. We as a health department see hundreds of thousands of people a year, either in our clinics or action centers or vital records shops. Why aren’t we helping people enroll in these programs? The third is medical debt. Medical debt is the number one driver of personal bankruptcy. We’ve already erased about $135 million of medical debt, helping thousands of New Yorkers, and I think we could do a lot more. And then the fourth is eviction: helping people who are facing eviction connect to legal counsel and help them keep their homes.

Here’s how it all links back to vaccines. It’s all the same conversation. If we don’t help you with these types of things around affordability, the things that are the thorns in your side right now, why are you going to take my recommendation about vaccines when I wasn’t there to help you with the thing that you said was a major challenge in your life? It comes back, for me personally, to that story I told you at the beginning: once you’re connected to someone’s problems, you have a responsibility to help solve them. And I think public health has that same dynamic.

Dr. Alister Martin is the Commissioner of the New York City Department of Health and Mental Hygiene. This conversation has been lightly edited for length and clarity.

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