Trust and Localization: The Missing Tools in Pandemic Preparedness and Response

By guest contributors Dr. James White and Rachel Lobe-Costonis

What is humanity’s best defense against a pandemic or other major threat? You’d be partially right to think: high-tech equipment in gleaming new health facilities, a computer farm in the cloud to collect and share data, highly qualified clinical staff, vast sums for vaccine research and development, and expansive budgets funding expensive national public health systems.

If so, you’d be among those who continue to miss some vital, largely unheralded, and intertwined elements: trust and localization.  

A fearless and well-trained workforce, new technologies, and adequate financing to enable action are crucial but insufficient. How do we know this? Let’s look at the 2019 Global Health Security Index, which assessed 195 countries using 34 indicators in categories ranging from prevention and detection to finance. The health systems of the United States and United Kingdom ranked #1 and #2 on the GHSI scale in 2019. But despite their resources, they performed atrociously in their COVID-19 response. In March 2023, the U.K. ranked #176 in COVID-19 deaths per 100,000 out of 195, while the U.S. ranked #181.

What’s missing? The best predictor of pandemic response success was and remains societal interpersonal trust: confidence your neighbor will do the right thing for the common good. That was the conclusion of studies published last year in both The Lancet and Scientific Reports.

In the U.S. and around the globe, it was clear throughout the acute phase of the COVID-19 pandemic that distrust had swelled in government, science, medical institutions, and among neighbors with different political views. Dis-information, and worse mis-information, helped dissolve community cohesion and collective action, a culprit contributing to more than 1.1 million COVID-19 deaths in the U.S. as public health interventions struggled to take hold. Only 68 percent of the U.S. population has been fully vaccinated while the figure for the U.K. is about 75 percent. 

Contrast that with Vietnam’s experience. Sharing a border with China, Hanoi should have had enormous vulnerabilities from extensive trade and tourism connections with Beijing. Yet as of March, 2023, Vietnam recorded just 45 deaths attributed to COVID-19 per 100,000 citizens, compared with 342 per 100,000 in the better-funded and higher capacity healthcare system in the U.S. And nearly nine out of 10 Vietnamese are fully vaccinated.

A Brookings analysis noted that from the outset of the pandemic, Vietnam’s leaders focused on low-cost and well documented preventive social measures, such as contact tracing and targeted quarantine measures. Social media promoted health messages that refuted misinformation, and the government sent out a viral video and 6 billion cellphone messages stressing practical steps citizens could take for basic prevention. Vietnam used a no-frills preventive approach because it lacked the hospital beds, clinical staff, and supplies to mount an expensive medical system surge response. The strategy worked in part because trust was high. Not surprisingly, the Vietnamese government earned that trust by shepherding the country through the 1997 financial crisis and the severe acute respiratory syndrome outbreak two decades ago. The Lancet study also noted that trust in government in Liberia and trust in local community-liaison teams in Sierra Leone helped those countries contain the Ebola epidemic from 2014-2016.

Trust and localization go hand in hand. Doctors, nurses, and community health workers form the grassroots effort to keep people well. People you see every day–grocery store workers, public transit drivers, sanitation crews–ensure critical services are available when and where they’re needed to save people’s lives in a pandemic. These are the people neighbors should and can trust.

Investing in community communications channels that provide trusted information from these sources increases the likelihood people will take steps to protect themselves and others. It means relying not on just health workers but also on everyone from religious leaders to teachers, people who understand local culture and can develop messages that resonate with their communities’ values and unique needs.

Take the Abt-led, USAID-funded Local Health System Sustainability (LHSS) Project. LHSS embraces the concept of co-assessment of capacity strengthening needs. In the collaborative process, LHSS and local actors agree on the scope of an assessment and co-develop the assessment tool they will use. Representatives of the local organization are members of the assessment team alongside the LHSS country staff. Local actors thus are both leaders of and participants in the planning and conduct of the assessment and in subsequent capacity strengthening activities. The job of the LHSS country team is to guide and facilitate the discussions to ensure that they are both collaborative and efficient.

Consider the project’s work in Tajikistan. As recently as January 2023, only 56 percent of Tajikistan residents had received at least one dose of the COVID-19 vaccine. Misinformation and a lack of evidence-based information to counter it had eroded confidence in the vaccine.

An LHSS case study found that doubts about the vaccine’s safety and efficacy kept many people from seeking additional doses. The study found that people saw health care workers as the most trusted source of information on health issues and vaccination. When a district’s vaccination awareness-raising campaign emphasized community engagement through health care workers, residents were more likely to get vaccinated.

The study also found that certain other influential community leaders, including religious leaders, were uninformed about the safety and efficacy of the vaccine. That prompted Dr. Ghafur Nazarov, a frontline health worker and director of the vaccination center in Tajikistan’s Dusti district, to enter a Ministry of Health contest to boost vaccination rates. He mobilized an army of trusted community leaders–clinical health workers, healthy lifestyle coaches, teachers, and religious leaders–to carry out the campaign to increase confidence in vaccinations. At in-person sessions, he provided accurate information about the vaccine and asked the leaders to share the information in their communities.

As a result, health care workers spoke with people at community education sessions, household visits, and office visits with patients. Teachers talked with schoolchildren about vaccines in general and COVID-19 specifically and how vaccines are saving lives around the world. Religious leaders who had themselves been skeptical about COVID-19 vaccination began promoting it in Friday prayer services. Cumulative COVID-19 vaccinations in the Dusti district climbed from 6,803 in August to 14,103 in September. “The contest provided an opportunity to remind health care workers about the importance and value of their work for the communities,” said Dr. Nazarov.

If the goal of localization is for donors and Global North contractors to work themselves out of jobs by partnering on a locally sustainable solution, that’s happening in Vietnam. A decade ago, when donor funding started to wane, the government took a three-pronged approach to cover the gap: mobilizing provincial budgets, covering HIV services with social health insurance (SHI), and promoting domestic contributions.

Those efforts are having an impact. With LHSS support, the Vietnam Administration of HIV/AIDS Control (VAAC) developed a resource estimation tool to enable provinces to develop sustainable financing plans. The share of provincial budgets allocated for HIV/AIDS services doubled between 2013 and 2022. About 95 percent of people living with HIV now hold SHI cards, twice the number of five years ago. And Vietnam now covers 52 percent of HIV services with domestic financial resources.

At the global level, health and donor agencies must reinforce and strengthen these local trust-building people, fora, and institutions to prepare for what’s next. Encouragingly, there has been progress on this front. Last year the World Bank Financial Intermediary Fund’s Governing Board approved an ambitious plan to spend as much as $10.5 billion a year to prepare for the next pandemic, and it included civil society representatives on the board to help determine program strategy. Other international donors such as the U.S Agency for International Development (USAID), the UK’s Foreign Commonwealth Development Office, and Australia’s Department of Foreign Assistance and Trade increasingly recognize the need for collective, localized, and coordinated approaches to build trust in an increasingly fractious world.

The trust and localization formula requires trust everywhere all at once. Relying on local influencers, decision makers, and trust building mechanisms is the key to resilience in the face of increasing threats to our lives, livelihoods, and environment. The people and community structures we interact with every day, perhaps more than any international effort or global organization, will determine our future. And possibly our very survival.

About the authors:

James White RN, CSGH, Ph.D. is a senior associate, clinical advisor and Global Health Security practice lead for the International Development Division of Rockville, Md.-based Abt Associates, a research, consulting and technology firm. His specialties include health service delivery in high-risk environments, pandemic preparedness and response, infectious disease control, brokering public-private partnerships, and strengthening the quality of clinical care in public and private health. He has worked on a broad range of global projects for international aid funders such as the U.S. Agency for International Development, Britain’s Foreign, Commonwealth & Development Office, and the Canadian International Development Association (now Global Affairs), all with the goal of protecting and improving health outcomes.

Rachel Lobe-Costonis, MPH serves as the Program Officer for Infectious Disease and Global Health Security at Abt Associates. In this role, she provides technical and program oversight on a variety of programs in Africa, Asia, and Latin America on topics related to global health security, outbreak response, and pandemic preparedness. She primarily focuses on the intersection of disaster response and health systems resilience, helping to better equip countries to prevent, detect, and respond to emerging infectious disease threats.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.