• Professor Michael Parker, Professor of Bioethics, Director of the Ethox Centre, University of Oxford, Oxford, UK
• Professor Doris Schroeder, Co-ordinator of the TRUST project, Professor of Moral Philosophy, Director of the Centre for Professional Ethics, School of Sport and Health Sciences, University of Central Lancashire, United Kingdom
• Dr Lauren Paremoer, Department of Political Studies, University of Cape Town, Cape Town, South Africa.
• Mr Ethan Greenwood, Wellcome Global Monitor, Wellcome Trust, London, UK
Trust in government and other institutions is said to play a key role in the success of pandemic response. On the other hand, mistrust and distrust can impede the effectiveness of response measures. This leads some countries to fare worse than others despite similarities in epidemiological context and health system infrastructure. So, how exactly does this relationship between trust and successful pandemic response work? In this webinar, the panel discussed what key elements are needed strengthen trust? What can governments and public health authorities do during a crisis when operating with low levels of public trust? And, finally, what is the difference between promoting trustworthiness as opposed to promoting trust, and what is the relevance of this distinction for pandemic response efforts?
Professor Doris Schroeder began her presentation by discussing the Trust Project; a global interdisciplinary collaborative body seeking to introduce equity in research. Here as a Coordinator she's developed a research exploitation risk matrix which was subsequently mapped onto a moral framework consisting of the ethical values of fairness, respect, care and honesty. This framework can assist in the development of a global code of conduct, particularly in resource-poor settings. In regard to the concept of trust, and it’s relation to trustworthiness, Professor Schroeder argued that trust is given, while trustworthiness is earned. So in this instance, public health authorities, or governments must earn the right to be considered trustworthy, and members of the public can trust them on this basis. She noted that while there is substantial amount of research in trust, the concept of trustworthiness is often neglected. However, if we want to improve trust, particularly within a public health emergency such as the COVID-19 pandemic, it must come from the establishment of trustworthiness. Professor Schroeder argued the four ethical values of fairness, respect, care and honesty, can be instrumental in creating a standardised global code of conduct, precisely because they are also personal values. We can assess a person in relation to these values which manifest as characteristics. However, she concluded, that to live a moral life, or point out immorality in others, requires courage. This is difficult in today’s climate of fear and uncertainty.
Dr Lauren Paremoer discussed the idea of 'social citizenship', which she argued, refers to the fundamental obligation of the state to realise the welfare of its citizens. In this context, trust is the vehicle by which this can be achieved; not just in relation to political processes, but baseline material wealth as well. Dr Paremoer noted however, that states are positioned differently in regard to the global economy; and so their ability to fulfil this obligation is compromised to varying degrees. Developing states that can’t access public resources, have become ‘extraverted’ (Bayart, 2000), maintaining local economies that rely on extractivist modes of production to serve global markets. Dr Paremoer argued that neoliberal globalisation has intensified the legacy of colonialism, and also increased the extraverted qualities of states even within the Global North. In the context of the COVID-19 pandemic, citizens have experienced states prioritising the needs of the economy in respect of global capital at their expense. Furthermore within public health systems, the increasing privatisation and commercialisation of care, is a structural feature, which led to many citizens being unable to access it. As a result, there was a decline in trust toward governments and state institutions. Trust however is not just be seen in the context of the deficit which exists between citizens and governments but also citizens and broader global dynamics, which circumscribe and limits the promise of social citizenship.
Ethan Greenwood, prefaced his presentation by outlining his role as an analyst within the Wellcome Global Monitor. This is the largest global survey of attitudes to science and health. He began with a cautious note of optimism, highlighting that the key finding of the 2020 report, that despite the pandemic, trust in scientists across the world increased in every region except for sub-Saharan-Africa, Russia and Central Asia. Trust also increased in institutions, particularly institutions related to healthcare. Why did this happen? Mr Greenwood argued that one explanation is the ‘rally round the flag’ phenemona; that in other words, during the pandemic people were in an uncertain situation, and therefore had no choice but to trust institutions. Mr Greenwood also reported that in regard to trust in decision-makers, doctors and nurses received the highest support, followed by the World Health Organisation and governments. However, despite high trust in scientists, only a quarter of people felt their government valued scientific advice. More interestingly the countries which were more distrustful, aligned to the visible face of the pandemic; for example Italy which had a higher disease burden during the early-days of COVID-19. In regard to trust in vaccines, data was more limited and historical. However, a 2018 survey, indicated vaccine trust is linked very much to trust in scientists. It’s not completely black-and-white though; France for instance trusts scientists, but is distrustful of vaccines. Mr Greenwood argued that in order to strengthen trust, scientists must listen to, and understand the public, and be alert to the broader global context. Furthermore, the issue of trustworthiness, must then be seen in relation to trust-building efforts in affected settings. Mr Greenwood again reiterated that the onus is on scientists to build trust, and promote transparency and accountability, not the other way round.
What can be said about issues relating to trust in LMICs and HICs? How has the pandemic amplified this?
Mr Greenwood argued, with the exception of sub-Saharan African, almost all countries saw higher levels of trust during the COVID-19 pandemic; however the question of why needs further investigation. Dr Paremoer argued that the lack of trust is a driving factor in social discrepancies, which are related to both historical and contemporary factors. For example, historically, LMICs have been active in trialling new medicine, but this hasn’t necessarily translated into equitable access. This is one source of mistrust. Another more contemporary source is the failure of COVAX’s vaccine rollout which has been circumvented by high-income countries buying up vaccine stocks. Both examples, suggest that the multilateral system is a reflection of existing hierarchies, which are not effective. Professor Schroeder, argued vaccine trials have a potential to create a group feeling of exploitation, but context counts. For example, her own research, included a case study on the Ebola vaccine tested in West Africa, which was abandoned due to lack of participation, but in Canada people queued in order to be part of it. The difference, relates to whether the trial participant feels safe or not.
Giving the historical context, and geo-political structural issues, what as a global health community should we be focusing on in our efforts to build trustworthiness?
Dr Paremoer argued that a key issue effecting LMICs over the next few years is debt. Higher debt as the result of the pandemic; will create pressure for repayment, which in consequence will lead to austerity policies which in turn impact health budgets, and healthcare systems. Therefore, if we want to build trust, we need to protect health and healthcare systems, while also advocating against debt recovery policies which jeopardise them.
Is mistrust, then essentially a product of social, political and economic inequalities?
Dr Paremoer argued mistrust is one effect of these broader inequalities, but it is also a response to history. For example, the lack of support for TRIPS waivers, CTAP, and mRNA technology transfers, indicates short, medium and long term policy failures and inequalities which lay within broader historical patterns. Lack of trust is in fact indicative of a lack of global solidarity. Professor Schroeder agreed with this, stating the social determinants of health need to figure in answers. It’s possible to build pockets on trust in global relations, just as it is within research partnerships. However, until there is proper equity in these partnerships, trust can collapse easily.
Is there a connection between vulnerability and trust, and how should we understand that; not just on the basis of individuals, but also populations and groups?
Professor Schroeder argued that vulnerability can be seen in two ways: vulnerability to harm, and vulnerability to exploitation. If you’ve experienced either, you will have a higher level of mistrust, particularly in relation to groups who are harming or exploiting you. Furthermore, you are more likely to have experienced past injustices, and therefore more likely to be mistrustful. Dr Paremoer agreed with this, adding work with vulnerable populations should be mediated by trusted allies within those populations. In South Africa, this was one of the successful interventions during the COVID-19 pandemic, which has in fact increased vaccination uptake.
To What extent is lack of trust is a driving factor of low vaccine uptake.
Professor Schroeder said that fear perpetuated through social media is driving vaccine hesitancy. Challenging this, is the key to overcoming it. Dr Paremoer, argued hesitancy is not always related to doubt, but concern over an individual’s ability to access healthcare. When an individual is managing various comorbidities there’s a reasonable anxiety about adverse effects to vaccination and not being able to get help if required.
What can we do to reduce lack of trust in a climate of fear and uncertainty?
Dr Paremoer argued we need to leverage existing reservoirs of trust which exist outside of formal networks. Communities band together and sustain themselves through informal networks; such as churches, co-ops, and extended families. These networks can be a bridge to healthcare accessibility, however more often than not, such networks are stigmatised sometimes on account of the fact they transgress public health measures. For example COVID-19 containment measures stressed the importance of physical distancing and mask-wearing, however, when informal networks break such rules, it is because trust is already established, and so individuals accept a mutualisation of risk. If leveraged these informal networks can build bridges.
What are the responsibilities of individuals within academia? Do academics have a special role to play in this situation?
Professor Schroeder believes the answer to this question is yes; this can in fact be expressed through the work that academics take on. Dr Paremoer paraphrased a quote by Samora Machal, stating ‘Solidarity is not an act of charity, but mutual aid between forces fighting for the same objective.’ (Machal, 1973) A common goal gives a normative reference point and suggests that trust can be a mode of action. However, trust doesn’t imply a commitment to the same long term objective, social justice on the other hand does. Dr Paremoer made the point that we don’t have to all be the same; but through social justice, solidarity becomes a defining feature. In practical terms, Universities have a moral obligation to share scientific progress, and this can be done for instance through open IP.