What to do when trust in health workers collapses

BARCELONA — Sid, a 49-year-old driver living in the Haitian city of Port-au-Prince, had been suffering from a fever and coughing up blood for weeks before he visited Médecins Sans Frontières’ COVID-19 center. He had refused to go, worrying that he would be given a fatal vaccine, administered under the guise of treating COVID-19 but instead designed to increase the number of coronavirus deaths so that Haiti might receive more international aid.

“Recently, a man I used to play soccer with was hospitalized with a heart condition. He died two days later, and everyone thinks it was because he was injected with a vaccine,” Sid said, adding that despite having a fever, many in his neighborhood say they would rather die than go to the hospital.

Julie Rolinet, MSF health promotion manager in Port-au-Prince, said the rumor underlines widespread distrust in health facilities. “We [also] hear people say, ‘There is no COVID-19 in Haiti — it is made up by the government,’ or, ‘There is an epidemic of fever, but it is not COVID-19,’” she said.

Such distrust is not specific to Haiti. It is a global issue, and its roots are complex — arising from factors including corruption, high mortality rates, and cultural beliefs, said Amuda Baba Dieu-Merci, a former community health worker and director of the Pan African Institute of Community Health.

Where he is based in the Democratic Republic of the Congo, he said that when a woman or her baby dies during childbirth, families in rural areas often accuse health workers of killing them. In rural Africa, he said, people are more likely to trust traditional birth attendants and healers.

For David Sanchez, a nurse and founder of health care marketing agency Digitalis Medical, this is part of a broader trend in which society at large has become distrustful of many different organizations. “[If] people feel they can’t trust anybody, then it would be natural, as an extension of that, to not trust people making decisions about their physical health,” he said. “I’ve seen people hesitate because they weren’t sure who to trust, and it really does affect their health.”

That is because people either do not use the facilities, use them too late, or rely on self-medication, all of which puts their health at risk, Dieu-Merci said.

Out of 132 patients admitted to the MSF Port-au-Prince center between mid-May and mid-June, 12 died on arrival or within the first 24 hours, Rolinet said. “Some people avoid health facilities as much as possible — including ours — at the risk that their diseases worsen to the point of dying at home, at the gates of the hospital, or a few hours after their arrival. And among those who do come, we see more reluctance, even refusal, of treatment that requires an injection — such as for an IV, a malaria test, or a tetanus vaccine.”

Sid took traditional medicines made from oak leaves, lilacs, and aloe vera in an attempt to treat himself at home before his condition worsened.

How to build trust and tackle misinformation

The first thing is to understand the object of the distrust, but most often it relates to health workers, Dieu-Merci said. Having health workers integrate into the local community can go a long way in rectifying this and demonstrating respect. “We need to be social. We need to understand the cultural implications of the services because the use of the facilities depends on being accepted, and being accepted is much easier when people see that you comply with social [and] cultural behaviors,” he said.

Distrust can be heightened if a health worker is not from the same area. Recruiting locally is often best, but if staff members are coming in from elsewhere, it is essential that they take the time to understand the local context. “Even though [care] is facility-based, they look at the [individual] health workers. … If one [patient] felt that they were shocked by a health worker attitude, then they really decide not to use [a facility],” Dieu-Merci said. Hiring from within a community can help establish relationships, he added, alongside feedback mechanisms such as suggestion boxes within health centers.

When it comes to rumors or myths that perpetuate distrust, it is important to listen and take everything that a community says seriously while adopting an open mind, said Maciej Polkowski, head of the Health Care in Danger initiative at the International Committee of the Red Cross.

“The moment you close yourself off to what the community is saying and you conclude that these are conspiracy theories that are ridiculous, you corner yourself, in a way,” Polkowski said. “The moment you open up and seriously invest into the communities, gather live feedback, and engage in a dialogue, you may realize that things they are saying actually come from somewhere and there are reasons for the distrust.”

Once it is understood where a rumor has come from, Rolinet said you can then choose the best type of information to address it. For example, to combat the rumor about fatal COVID-19 injections, MSF health promoters have been showing that the official figures of coronavirus-related deaths have not been rising dramatically. If the authorities wanted to inflate the figures, they say, the numbers would be higher.

“We also ask where people heard these rumors and whether they personally know the people that these things happened to,” Rolinet said, adding that simply contradicting the rumor could be counterproductive. “If people feel taken aback, then the conversation is over. The process takes time, both to understand the rumor and to try to take it apart.”

While education and authority are among the biggest ways of building trust, so too is entertainment, Sanchez said. In the U.S., for example, it is commonplace for celebrities to speak out on a variety of issues — health or otherwise — to help generate trust. “Anybody who is famous [or] rich has a voice. If they say something, people automatically trust them, regardless of their actual knowledge or expertise in that area,” Sanchez said. The same approach can be used in other countries.

Community events can also be a way of reaching people and building relationships, although the current need for social distancing means these are mostly not possible. Instead, MSF Haiti is hosting training and awareness-raising in smaller groups in the hope that participants will share the information with those around them. They have also strengthened their door-to-door activities to provide accurate information and dispel myths preventing access to health care.

In most cases, distrust in health facilities reflects broader issues that health care workers cannot tackle alone. But as governments and organizations figure out strategies to tackle the issue, doctors and nurses still have to deal with it on the front line. For them, Sanchez suggested pointing patients in the direction of more information — such as a trusted website — to give them a foundation of knowledge that they can use to understand their ailments for themselves, avoiding jargon, and connecting with them on a personal level.

Sid, who is still recovering from COVID-19, said it is important that people feel confident to seek out treatment, especially if they have symptoms related to the virus. "They should not fear going to the hospital or [being] stigmatized by those around them,” he said.

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