Trust issues

Lancet Infectious Diseases
Apr 2019  Volume 19Number 4p339-448, e109-e147

Trust issues
The Lancet Infectious Diseases
In November, 2017, we published an Editorial on measles vaccination, calling for strong interventions to curb preventable diseases. 18 months later, how have things changed? As reported in a news story in this issue, 229,000 cases of measles were reported in 2018, and 98 countries reported an increase in cases compared with 2017. Measles is a global health crisis and it is getting worse. Although the reasons vary by country, mistrust and misplaced reluctance to vaccinate, largely related to unfounded fears over safety, are important contributing factors from the Philippines to France, from Ukraine to the USA. WHO has named vaccine hesitancy as one of the top ten threats to global health in 2019.

Lack of trust is also central to another of the world’s major health emergencies: the Ebola virus disease outbreak in DR Congo. The epidemic is focused in the northeast of the country, where conflict, political tensions, and social grievances have instilled fear and suspicion in much of the local population. 40% of new cases so far this year have been in people who died in the community (ie, they hadn’t been to a treatment centre), and a large proportion of cases, particularly in Katwa and Butembo, cannot be linked to any other patients, suggesting that unknown chains of transmission exist. If patients are wary of seeking proper care, and if contact tracing cannot be done, the outbreak will not be stopped.

Mistrust has also manifested with more direct and violent consequences in DR Congo. Médecins Sans Frontières (MSF) has reported dozens of attacks on its workers in the region. In February, two treatment centres were attacked and burned down, forcing MSF to suspend its activities in Katwa and Butembo. Joanne Liu, the president of MSF, has been quoted as describing the atmosphere towards the response as “toxic”.

The importance of community engagement to build trust was well recognised in the aftermath of the west Africa Ebola epidemic, but the difficulties of the DR Congo outbreak have led to the use of coercion against patients and their contacts, and a reliance on police and UN peacekeepers for security has further alienated the local population. MSF has criticised the use of coercion in DR Congo, and in an interview with STAT, Liu has said that “using police to force people into complying with health measures is not only unethical, it’s totally counterproductive“. WHO is taking a different tack: on March 9, it announced that it had sought further support from UN and local police forces to protect treatment centres, despite recognising the importance of “maintaining the neutrality of the response”.

As for trust in measles vaccination, a Danish study of more than 650,000 children once again confirms that measles, mumps, and rubella (MMR) vaccination is not associated with autism. But while the findings are welcome, the paper will not change the beliefs of anti-vaccination advocates. The safety of MMR was already well established before this study—a shortage of reliable scientific evidence is not the problem. And in countries such as the USA, the dangers of not vaccinating have been shown repeatedly, most recently in an outbreak of measles among mainly unvaccinated children in Washington and Oregon, as reported in our March issue. Rather, it is the abundance of misinformation and distrust of authority that must be addressed. Social media companies such as YouTube and Facebook have made changes to begin to stem the tide of misleading claims, but the impact of these initiatives remains to be seen.

An anti-vaxxer in California, USA, for example, is vastly different from someone potentially exposed to Ebola in rural DR Congo. Yet there are similarities in their mistrust. A belief that vaccines cause autism or that Ebola is a government ploy likely has as much to do with wider grievances and distrust of authority as with the specifics of the scientific evidence and education. Part of the problem is that a lack of faith in government, the health-care system, and pharmaceutical companies is not always irrational. In DR Congo, the postponement of elections in the regions affected by Ebola has been considered to be motivated more by politics than by public health (the region is a stronghold for opposition to the ruling party). The poverty and conflict in the region have long been neglected. In the USA, the country is plagued by prescription opioid misuse fuelled by aggressive pharmaceutical marketing, the people of Flint, MI, have been without safe drinking water for 3 years, and the most basic drugs are often unaffordable because of profit-driven health care. Little wonder that some individuals question the authorities’ desire to prioritise their wellbeing. It is impossible to build trust while at the same time abusing it.