A meeting of the Ugandan COVID Task Force.
The COVID-19 pandemic moved into a new phase in 2022 with intensifying focus on technological responses. An increasing reference to “trust” in global-level policy discourse has been noticeable as we have engaged as social scientists and invited participants in global health agency meetings. For instance, in early 2022, a practitioner in an emergency health response agency asserted that trust had become the biggest challenge for efforts to maintain public health measures and to improve vaccine uptake globally. Low public trust was linked to low societal “compliance,” and a risk communication expert suggested that the involvement of local authority figures who command trust would lead to better community engagement. We observed how the focus on trust intensified alongside a pivot to “vaccine preparedness,” suggesting that trust looms larger on the radar of policymakers as vaccine technology becomes the way to shift the dial on pandemic control. These observations prompted us to reflect on the work that “trust” was doing in the explanatory frameworks of practitioners, and the disjuncture between such policy solutions and the complex realities that have emerged from ethnographic fieldwork.
Anthropologists have noted that a discourse of trust/mistrust can be deployed in a nebulous way to account for difficulties encountered in policy interventions. As such it, it can serve as proxy for a set of uncertain, complex, contextual and behavioral factors that hinder implementation. However, in the COVID-19 pandemic, the association of concerns about trust with vaccine hesitancy has added a particular inflection to this discursive work, one which we have explored in a research project on the meanings and practices of pandemic preparedness. An analysis of this association has proved illuminating of the limitations in approaches to pandemic preparedness, as well as limitations in dominant public health framings of vaccine hesitancy and in assumptions about the dynamics of trust. Below we draw on our research on COVID-19 vaccination in Sierra Leone and Uganda to argue for a re-orientation of the debate from the focus on “hesitancy” to the multiple factors generating positive and negative anxieties about vaccines, as means to a more nuanced conceptualization of trust.
From vaccine hesitancy to vaccine anxieties
In public health and policy, vaccine hesitancy has a long and established link to a deficit framing of the public understanding of science, which has conventionally conceptualized hesitancy as reflecting a lack of knowledge of medical matters and vaccine benefits, to be combatted with information. A shift in the COVID-19 pandemic has seen an expansion of this to include the recently coined notion of “infodemia”, which includes the idea that publics face an excess of information and are vulnerable to mis- and disinformation. The challenge then extends to replacing “wrong” with “right” information, part of “infodemic management.” The addition of trust as a variable in these framings adds a further assumed deficit, namely a lack of trust in the technology and medical science, and/or in those developing or delivering technologies. Proposed responses return to communication and engagement to strengthen and build trust.
Our work addresses the shortcomings of the vaccine hesitancy framing with respect to responses to COVID-19 vaccination in Uganda and Sierra Leone throughout 2021. Both countries have dealt with significant epidemics in recent years (including Ebola) but recorded relatively low mortality in the case of COVID-19. This research has also revealed the limitations in a conceptualization of trust as a concrete entity that can be augmented through biomedical facts and targeted strategies of persuasion. Ideas about vaccine trust/mistrust are subject to easy conflations of trust/mistrust in vaccines, in medicine, and in science. Furthermore, the tendency to focus on science and medicine misses a more complex reality, which needs to be unpacked across scales and across different kinds of institutions and relationships, from intimate kinship connections to state-citizen relations. This requires a deeper questioning of trust: In what? In whom? A further question would be trust as what? Is trust understood as quantifiable (more or less), binary (held or not held), relational, or a quality that can be possessed (trustworthiness)? How is trust shaped by and how does it manifest in relation to context–specific historical, social, political and economic conditions and different cultural logics and moral worlds?
In our fieldwork as part of our Pandemic Preparedness Project, we have traced how global debates about vaccines as a key element of pandemic response and future preparedness in the era of COVID-19 has focused on questions of supply, with attention to global injustice in vaccine distribution, particularly with respect to African countries. At the same time, vaccine demand and uptake are seen to be threatened by hesitancy, often attributed to an increasingly globalized anti-vaccine movement and associated misinformation , reaching African populations through social media.
Missing from these debates are the socio-political contexts through which vaccine technologies enter and are interpreted within African settings, and the crucial intersections between supply and demand. Our earlier ethnographic work in African and UK settings recast the dominant public health concept of vaccine hesitancy as “vaccine anxieties,” attending to both positive and negative anxieties—desires for access to vaccines and worries about vaccines—shaped by bodily, societal, and political understandings. We updated this anxieties framework in the context of COVID-19 debates, including more explicit attention to questions of vaccine supply and information. This provides an analytical lens to interpret ethnographic and narrative accounts in local and national settings in Uganda and Sierra Leone, and their (dis)connections with geopolitical debates. Four research officers on our team conducted participant observation and interviews while living for 1.5 years in rural village sites, two in Uganda and two in Sierra Leone. This ethnography was complemented by interviews with policymakers and health workers in district and national settings in both countries. Our team’s joint analysis considered the socially embedded reasons why people want or do not want COVID-19 vaccines, and how this intersects with the dynamics of vaccine supply, access, and distribution.
Anxieties in Uganda and Sierra Leone
Our team’s accounts from Uganda and Sierra Leone show how different layers of experience coalesce to generate anxieties, and what this implies about trust. Ideas about the body and vaccines are filtered also through national politics and interpretations of wider global debates. Public fears are affected by longstanding structural inequalities, which we have noted for COVID-19 responses more widely. Anxiety is generated by wider contextual factors which are multiple and shifting, and it involves concerns about supply and distribution as well as concerns about bodily effects. Similarly, the urgency to get a vaccine or not changes as circumstances change and with waves of infection and new variants.
Thus, in Uganda, people in our field site in Kasese district already suspected the politicization of COVID-19 prior to the arrival of vaccines. The first year of the pandemic saw little disease on the ground but quite brutal enforcement of restrictions by a government seeking to suppress opposition and gain re-election in early 2021. In 2020, people were calling it a political virus, as they experienced an increased military presence. The arrival of vaccines from China led to speculation about corruption and Ugandan government deals and open questioning of the quality of the vaccines, especially when they were allocated to teachers in a mandatory vaccination campaign. There was also suspicion about the different vaccines being supplied through the global collaboration for access to vaccines called COVAX and questions about their safety and the rapidity of their development. Astra Zeneca vaccines (AZ) were supplied through COVAX, and people questioned why EU regulators were suspicious of this product. The US also donated unused AZ to Africa after it was not deployed in the US, prompting social media commentary that inferior vaccines were being dumped in Africa. Similarly, the specific AZ supplied was developed by the Serum Institute in India, and some European countries did not consider those who had received it to be sufficiently vaccinated for travel purposes. This suspicion was amplified by nearly expired vaccines being sent to African countries. The Delta COVID-19 wave in June 2021 brought rising fear in Uganda and an increase in vaccine demand, in a context of limited supplies and challenges to distribution. Overall, however, the authoritarian political environment has continued to negatively influence trust in the intentions behind vaccine campaigns in Uganda.
In Sierra Leone, vaccination had long been accepted and generally valued as a way to protect and strengthen infants against childhood diseases such as measles. But people in our rural and urban field sites initially questioned COVID vaccines because they were for adults and for a disease that they–like our Ugandan informants—had hardly seen. In this context, wider political concerns gained traction, such as fears spread by diaspora and on social media that COVID vaccines were part of a western conspiracy to depopulate Africa. Concurrently, some people heard about the UK’s decision to withhold AZ vaccines from people under 25 due to risk of adverse events, highlighting that some types of vaccines were dangerous. Others speculated that Chinese vaccines (SINOVAC) might be safer, reflecting their relatively positive experiences with Chinese infrastructure investments, compared to perceived European neglect. These anxieties, linked as they were to local understandings of global power asymmetries, dovetailed with limitations in vaccine supplies. Until mid-2021, few people across our study sites in Sierra Leone got vaccinated.
From September 2021, Sierra Leone secured substantial supplies of the single dose Johnson & Johnson vaccine and rolled these out, even to remote rural areas. Some people did get the vaccine, less because of concerns about the dangers of COVID (which remained largely unseen or mild), and more for its perceived generalized protection against “small sicknesses”. Seeing relatives and neighbours having the vaccine with no ill effect encouraged others, and direct bodily experience began to override political anxieties. In cases where someone became ill shortly after having a COVID vaccine, this deterred neighbours and relatives from getting vaccinated. Positive anxieties for vaccines seemed to emerge more strongly where they were delivered by known local health personnel; in contrast, in a village where the community had a longstanding dispute with the health center, there was complete refusal. Such social and health service dimensions interplayed with peoples bodily and wider political reflections in shaping their COVID vaccine anxieties.
Conceptualizing trust from vaccine anxieties
These ethnographic findings point to the multi-layered nature of vaccine anxieties, in a situation that has also manifested as fluid, contingent, and shifting. Vaccine anxieties are clearly much more complex than supply side issues, lack of information, or misinformation. Also at stake are wider, historically-embedded, structural socio-political relations and inequalities, and associated framings. Whilst vaccine anxieties cannot be reduced to matters of trust, they do imbricate them, and an ethnographic focus through a vaccines lens offers some key pointers as to how trust should be considered. Trust and mistrust are not entities that are straightforward in presence or absence, or simply built through communication interventions.
Trust has multiple dimensions and layers, from the most intimate to the wider social and political. Whilst sometimes expressed as trust in a thing (a vaccine, a health service, a government), fundamentally trust concerns relations between people and groups. These are shaped by multiple experiences and are dynamic, shifting over time and as circumstances change. Trust relations are not a binary but a continuum; worry, ambivalence, hope, pragmatism, and accommodation can all co-exist, and as people navigate these, one cannot predict a direct link between trust and action. As we have seen, people may be skeptical about the value of a vaccine yet prepared to try it, especially if encouraged by trusting relationships with community nurses, or the experiences of their intimate relatives. Yet a bad experience can reignite wider antecedent political distrust and lead negative vaccine anxieties to win out. All this suggests a conceptualization of trust as praxis, to be understood not in universal terms but in socio-culturally and historically contextualized ones.
In this light, we need to question the work that dominant ideas of trust are doing in policy and practitioner spaces, around vaccines, pandemics, and more. Conceptions of trust as entity and deficit are not just misleadingly narrow. They also enable discourses that label and blame publics as distrustful, justifying their exclusion, re-education, or coercion. In place of such anti-politics, perhaps we should put the political dynamics of trust centre stage. Instead of blaming publics, we should ask instead about the trustworthiness of political authorities, and what they have done to foster inclusive, trusting relations with those they serve. And instead of top-down policy models to build trust, we can look to explore more deliberative dialogues about matters of concern, through which mutual trust relations might be strengthened along the way.
About the Authors
Hayley MacGregor is a clinically-trained medical anthropologist and a professor of medical anthropology and global health at the Institute of Development Studies at the University of Sussex in the United Kingdom.
Melissa Leach is a professor and social anthropologist specializing in global health and sustainability issues. She is Director of the Institute of Development Studies at the University of Sussex, UK.