This article is written by Sabs Quereshi, senior public health managing associate at Hagerty Consulting and senior public health advisor for the State of California. Former USAID and UN advisor. Opinions are those solely of the author

As I ponder the changes 2021 could bring, two old adages come to mind.

The first is: “Everyone thinks of changing the world, but no-one thinks of changing himself.” The second is perhaps less clichéd: “Never doubt that a small group of thoughtful, committed citizens can change the world.”

Together, these statements encompass some of the biggest challenges the US currently (though not exclusively) faces in the battle to beat Covid-19.

There is currently a crisis of confidence in America around the credibility of public information. Citizens increasingly distrust what they read online, whether it be to do with last year’s presidential election, or this year’s vaccine roll-out.

While many American citizens can’t wait to receive their jabs, a growing number are suspicious of the efficacy of the vaccine, as well as the national programme to administer it.

One would think that breakthrough medicine, developed at a revolutionary pace to protect a whole population against a deadly virus, would be a cause for celebration. Having worked in the public health and humanitarian sector for almost 15 years, both in the US and abroad, I certainly do.

Yet, I’ve been shocked to learn that in my own country, vaccine acceptance rates are at an all-time low — 14% among African Americans, and 60% of white and high-income Americans. Emotional associations, rather than scientific data, are increasingly influencing the decisions of ordinary Americans. This leaves the US exposed to another spike in infections.

Over the past 12 months, physicians and US government officials have consistently failed to package public information about Covid-19 in a way that recognises people’s inherent distrust

Distrust of mass medical programmes among racial minorities in the US is not without precedent (see the Tuskegee Syphilis Experiment, conducted between 1932 and 1972). African Americans continue to receive below-average levels of healthcare, as well as regular under-diagnosis of serious health conditions. Where faith in basic healthcare suffers, trust in national schemes all but diminishes.

What makes it even more difficult for Americans to trust credible sources of public health information meanwhile is the social media business model, which matches content to the cognitive behavioural habits of consumers. This dramatically lessens the likelihood that the user ever sees information that goes against the grain of their convictions, let alone spots misinformation. In short, digital distribution is making people both less willing, and less capable, of changing themselves so as to change the world around them.

But this is not all there is to the story. Over the past 12 months, physicians and US government officials have consistently failed to package public information about Covid-19 in a way that recognises people’s inherent distrust. It shouldn’t surprise us therefore that the rift between government and the American people only appears to be widening.

Public servants should already know about these challenges, but what are they to do about them?

The playbook

Believe it or not, there is a playbook to turn to and adapt for the very situation we find ourselves in now. During the 2014 Ebola outbreak, all public health recommendations and immunisation efforts came with tailored, culturally-sensitive information strategies, using local languages and reflecting cultural norms and idiosyncrasies. This approach derives from what is known as the [Theory of Change](https://en.wikipedia.org/wiki/Theory_of_change#:~:text=Theory%20of%20Change%20(ToC%29%20is,backward%20to%20identify%20necessary%20preconditions.).

This effort required hundreds of trusted messengers, public health experts, and anthropologists to build targeted messaging geared towards impact, transparency and, ultimately, behavioral change.

As a public servant you may worry that, however necessary it is to rebuild public trust, be it in the US or elsewhere, it is already late in the game

Those teams gradually built trust, from communities in Sierra Leone, to the Democratic Republic of Congo (DRC). It is worth noting that the Ebola outbreak occurred in Sierra Leone barely a decade after a brutal civil war, which left in its wake a very fragile constitutional republic.

In 2016, I spent a lot of time extracting the crucial components of these initiatives, which did eventually stop the spread of Ebola. In DRC and South Sudan, my team and I collaborated with local community workers to get public safety information out to local populations.

We used mobile technology, local radio stations (one of the few sources of information trusted by the country's variety of tribes and populations), as well as hundreds of churches where ministers and religious leaders served as a bridge for a variety of congregations.

I believe these same approaches can be implemented now in the US. Here are three ways it can be done:

Messaging

By using community engagement, social mobilisation, and strategic behavioral change communication (SBCC) strategies to couple all public health with the necessary immunisation recommendations. SBCC work aims to engage children, families and communities to exercise their rights and unlock solutions that will create changes for a social cause.

Trust-building

Building back trust in the US requires channeling the message people need to hear through people with whom they are familiar and feel safe. In an HIV study conducted in the US between 2012 and 2016, similar interventions in local barbershops drove down the spread of HIV where initial strategies failed. More recent examples might include the funding by the Budweiser Superbowl, the use of black churches, and Latinx podcasts towards vaccine outreach and communication.

Technological progress

By analysing in detail data on the impact vaccine information is having, and whether people’s hesitancy or distrust can be reversed. This is important, as the US enters phases two and three of the Pfizer and Moderna vaccine roll-outs. Advancements in technology, such AI and machine learning, can help expedite these efforts. An example of this is Humanise AI, a chatbot that provides direct communication with large populations crossing language and culture divides.

As a public servant, you may worry that however necessary it is to rebuild public trust, be it in the US or elsewhere, it is already late in the game. That is a reasonable worry. Catching up will no doubt take time, and a great deal of effort. It will require buy-in from government leadership, as well as thousands of exhausted front line workers and advocates.

Now that I think again about those two adages mentioned at the start, perhaps their shared sentiment about creating sweeping change is less relevant to the year ahead of us than that of simply giving people a chance.

After all, that is where trust begins. It cannot happen without meeting individuals in the places in which they live, on their terms, and by building a network strong enough to withstand the next national crisis. – Sabs Quereshi

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