The Trust Gap

At the end of 2022, U.S. President Joe Biden signed into law a bipartisan package of reforms to make the United States and the world safer from future pandemics. The new law encourages faster development of vaccines and diagnostic tests, bigger stockpiles of protective equipment, and greater surveillance to more swiftly detect deadly viruses.

These and the other countermeasures are sensible, but they are not enough. A key lesson of the COVID-19 pandemic is that better vaccines and tests, more plentiful masks, and earlier warnings only work if people are willing to make use of them—and that willingness depends on a level of public trust that many Americans no longer have.

In the United States and other democracies, responding effectively to pandemics depends on persuading people to protect themselves and others. Measures such as contact tracing, gathering restrictions, and vaccination involve behaviors that free societies cannot easily compel or monitor. Trust, therefore, is vital at every stage of a pandemic response. And governments will need to find ways to fight pandemics, even when trust is low.

TRUST ISSUES

Early in the COVID-19 pandemic, people who reported higher levels of trust in others and in their governments tended to be more compliant with stay-at-home measures. Once vaccines became available, these more trusting individuals were more likely to heed public health advice regarding immunization (and countries with greater public trust tended to have higher vaccination rates.) After three years of COVID-19, the level of trust in both government and other people, as measured by leading surveys, has proven to be the best explanation for the differences among countries in COVID-19 outcomes.

Many assessments of how well countries responded to COVID-19 acknowledge the importance of public trust. But few governments have included concrete proposals for how to increase trust in their preparations for the next pandemic. That is because the process of building confidence between people and their governments is rightly perceived as slow, painstaking, and even generational.

But that doesn’t mean governments can afford to ignore the role of social solidarity in effective pandemic response. Low public trust is a risk factor that must be mitigated, which means it must be monitored at the local level. Public trust can vary widely within countries—domestic trust gaps sometimes exceed international ones. For that reason, democracies need pandemic strategies that can succeed in the divided communities they have, not just in the cohesive ones they hope to build.

 HOW TO REBUILD

Incorporating concerns about public trust into preparations for pandemics would mean planning for the effects of polarization, partisanship, and misinformation. Few studies have looked at how to foster cooperation in low-trust societies, but researchers have analyzed communities in southern Italy, Northern Ireland, and rural Romania, where people have historical reasons to mistrust their governments and neighbors but nonetheless cooperate with them every day. There are also lessons to be drawn from responses to health emergencies in post-conflict and post-communist nations.

These cases show that mandates, moral condemnation, and punishment can generate instability, pushback, and conflict in divided communities. Although such measures can spur cooperation in more harmonious societies by convincing potential holdouts that everyone else will comply, they may have the opposite effect in low-trust communities, according to researchers at the University of Konstanz in Germany. Another study published in the Journal of Cross-Cultural Psychology found no link between stringent rules and greater cooperation with handwashing or social distancing in low-trust communities during the pandemic.

What does spur cooperation in low-trust communities is shared material interest. As the Italian sociologist Diego Gambetta has shown, southern Italians have cooperated with the Mafia not primarily because they fear violent reprisals but because it is a source of trust and accountability in a regional economy with few alternatives. Similarly, cultural, religious, and kinship ties help low-trust communities set aside their suspicions. During the 2014 Ebola virus epidemic in Liberia, for instance, transmission rates started falling after governments and nongovernmental organizations recruited community youth leaders, pastors, and imams to check households for infected patients. Likewise, in Sierra Leone, community liaisons increased participation in Ebola vaccine trials. To enable cooperation in low-trust communities, democratic governments need to tap into these forces for solidarity as part of their preparation for future pandemics.

PARTNER UP

U.S. officials did too little to mitigate the health risks associated with low public trust during the pandemic. Only a quarter of U.S. states included community engagement strategies to encourage vaccination in racial and ethnic minority groups as part of their vaccine rollout plans, despite ample data showing that those communities have good reason to mistrust public health initiatives. One way officials could have improved vaccine uptake among marginalized groups would have been to invest in community-based organizations, such as local clinics or faith-based institutions, as the Commonwealth Fund has recommended. Doing so would have allowed state governments to improve public health provisions, collect data, solicit feedback, and communicate with constituents, but most did not conduct such outreach. And many states did not employ policies such as paid family and sick leave, which might have increased compliance with health measures among people who couldn’t afford to do so.    

Nor did the U.S. federal or state governments engage many high-profile emissaries, such as business leaders or talk show hosts, who might have appealed to those who doubt the current government on the safety and efficacy of vaccines, masking, and other pandemic prevention strategies. Government trust has long been partisan in the United States, with citizens reporting less faith in government when the president comes from a different party than their own. Stocking early COVID-19 advisory committees with medical experts and former government officials emphasized a reliance on a science-based approach, but it missed an opportunity to incorporate the representatives of communities where that science is contested.

Over the past three years, the crisis of public trust has only deepened. Pandemic fatigue has corroded people’s faith in government, even in countries that responded relatively effectively to the virus. In the United States, COVID-19 vaccines have become highly politicized, and only one out of three Americans reports trusting the national public health system. But trust in local physicians, community health centers, hospitals, and nurses remains consistently high and bipartisan. The U.S. government should build on these local networks, especially as misinformation and skepticism surrounding COVID-19 vaccines now threaten to undermine flu and childhood vaccinations and other U.S. public health priorities. Partnering with local cultural, ethnic, or faith-based institutions and leaders in divided communities can help identify trusted messengers and improve the response to the next public health crisis. Baltimore exemplified such an approach when it recruited locals to be vaccine ambassadors who went door-to-door in their communities sharing reliable information about the shots, boosting uptake rates.

Effective pandemic response requires the cooperation of billions of people. If today’s governments and public health institutions can’t inspire that kind of cooperation, they will need to be reformed or replaced with more effective and transparent institutions—ones that are better able to demonstrate their trustworthiness to the public.

COVID-19 has held a mirror up to societies, revealing that many communities are too divided and riven by mistrust to mobilize their citizens to protect themselves and others. Once this truth is acknowledged, the problem of public trust becomes clearer and easier to solve in the context of pandemic preparedness. Restoring faith in public institutions and one another is essential, but countries must also prepare for failure. To that end, governments should treat doubt in institutions as a health risk, monitoring and developing pandemic plans that can succeed even in the communities where distrust runs the deepest.