WILMOT JAMES: Trust in government and leaders is earned the hard way and over time

Trust matters in organising the activities, business and health of people. In a pandemic, it matters more acutely.

The Covid-19 National Preparedness Collaborators group of authors scoured one of the largest databases of Covid-19 infection and death rates and expressed the conclusion in The Lancet that higher levels of both trust in government and among citizens may have led to lower infection rates. 

The observation came as no surprise. Low levels of confidence in government institutions were flagged as a major concern in the 2021 Global Health Security Index (GHS Index), an assessment of national level health security capacities, as was leaders’ commitment to improving national biosecurity, a key factor in building trust in national preparedness.

Building trust involves the historically conditioned process of consistent and cumulative promise-keeping between citizen and state, and between citizen and citizen. For Covid-19, trust is built on past positive experiences with governments’ provisioning of health services, including the delivery of the tools to combat local, regional and national outbreaks. Solidarity between citizen and citizen involves whether one could count on one’s neighbours to comply with necessary public health-related behaviour changes, such as mask wearing and isolating those who fall ill, for the protection of all.  

Who or which part of government people trust is contextually and culturally specific. Surveys conducted by Resolve to Save Lives with the Africa Centers for Disease Control and Prevention (Africa CDC) showed that in Tunisia the most trusted entity was the military; in Kenya, public health authorities; in Nigeria, individual states, not the federal government; and in SA, President Cyril Ramaphosa. This is vital strategic information for it identifies to whom and in which trusted source in government the public health authorities can turn for more effective trust-building risk communication.

Trust is earned the hard way, over a period. Like so much else in life, trust can easily crumble when leaders and governments misstep, miscommunicate and fail, as we have seen with some Covid-19 state responses. To keep and build on the hard-earned levels of citizen trust, governments must respond nimbly, sensibly and effectively in pandemic risk management. To do so requires a firm grip on the gaps, risks and hazards individual countries face, the data for which the GHS Index provided in 2019 and 2021. Without the data, countries must fly blind. With the data, countries know which deficiencies to address in preparation for when the next inevitable health emergency comes around.

The baseline measures of trust provided by the index indicate how heavy a lift many countries face. In assessing 195 countries and their health security capacities, only 8% scored in the highest tier for government effectiveness and only 17% had evidence of a high level of public confidence in government. The challenges with trust are further exacerbated when looking at income levels: 70% of low-income countries show low public confidence in government. Collectively, low-income countries have also been shown to have the lowest level of capacities for pandemic preparedness and response, particularly when looking at reporting data related to Covid-19 cases and deaths.

Catalysing trust involves collaborating with all communities to ensure participation in planning and response, and in making sure everyone has the resources they need to comply with recommended actions. Yet scores from the GHS Index for meeting the needs of vulnerable populations, which are historically underserved by governments, remain low. Further, more than three quarters of countries have no plans for ensuring risk communication messages will reach populations and sectors with different messages tailored to diversity of language, location and media reach, and 81% of countries do not provide economic support, medical care and tools to those – and their contacts – infected to self-isolate or quarantine as recommended. Both factors proved crucial in effective Covid-19 responses. 

The importance of identifying a trusted spokesperson – another measure of the GHS Index – to relay risk messages and adapting responses to cultural contexts, has been proven to work repeatedly. In some success stories polio eradicators in India engaged with religious leaders and prominent athletes while adapting other community-based tools to address Covid-19. Indigenous leaders in Canada developed unique responses that considered cultural calendars and living situations. The Catholic Church is the most trusted source of credible vaccine-related messages in vast swathes of the Democratic Republic of Congo. The UN International Children’s Emergency Fund, which has the special responsibility of delivering vaccines to the developed world, has a division where social science analytics are strategically used to identify who has influence in which communities, to counter misinformation and build trust in evidence-based communications.

A multisite project is underway in SA and Zimbabwe to objectively identify trusted local community leaders who could convey data-driven confidence-building messages to drive up vaccination rates in both countries. Called the Vaccine Information Network, Columbia University partnered with the University of the Witwatersrand and the Charles River Medical Group in Zimbabwe to collect real-time information from vaccinated populations about who influenced their decisions to come for vaccinations, and what barriers they had to overcome along the way.

Many African countries, including SA, Senegal, Morocco and Kenya, are adapting the biotechnologies, developing the tools and establishing the infrastructure to produce vaccines. Those efforts will be meaningless if people believe locally produced vaccines fail to meet rigorous safety standards. The GHS Index assesses whether countries have the regulatory sophistication to approve of medical countermeasures like vaccines and antiviral therapies. It ranks SA in the top tier in this respect, as it is very well served by the high safety standards set by the SA Health Products Regulatory Authority, which are monitored in turn by its ever-vigilant chair, the distinguished physician Prof Helen Rees.

The deplorable Russian invasion of Ukraine has raised grave issues of biological (and chemical, radiological and nuclear) security. The index assesses whether countries have guardrails in place to shield ordinary people from such hazards, and measures, particularly those capable of dealing with biological threats. In this respect a mere handful of countries do well. Russia received a score of 37.3% for biosecurity and Ukraine 36%. SA scores very poorly indeed – 4% – for biosecurity, raising a red flag for those who care to notice. 

As it evolves to sketch the clearest picture possible of country vulnerabilities to biological and epidemiological hazards, and as the importance – and failure – of leadership in building trust became glaringly obvious during the current pandemic, the index added new measures to its 2021 edition. Among those the index takes into consideration are whether leaders, including heads of state, spread misinformation or disinformation; whether public officials make public commitments to improve capacity to address epidemic threats; and whether countries designated a primary spokesperson to communicate public health messages.

The index is a leading tool for alerting national and global leaders to a wide variety of preparedness gaps and encourages actions to address them. While ensuring they have the tangible capacities for controlling the next threat, leaders must also encourage the creation of the social environments critical to a successful response by acting honestly, ethically and transparently to protect the health and livelihoods of all.

• Dr James, a former DA MP and federal chair, is senior research scholar and chair of the Pandemic Research Center at Columbia University.