Dismissing criticism of vaccines in nationalist language doesn’t help in building trust

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Transparency and trust are two major —and interrelated — pillars of public policy decision-making. Transparency is the principle of allowing those affected by decisions to know about the outcome and the process that led to those decisions. Transparent governance means that government officials act in an open manner, with citizens being informed of the decisions they are making. Transparency has many components — availability of all relevant information in the public domain, a public discourse or debate based on this information and a final decision by the government, which acknowledges and addresses the issues raised during the debate.

Trust is the foundation upon which the legitimacy of public institutions is built and is crucial for the success of public policies that depend on behavioural responses from the public. Trust is earned by keeping the promises made and, perhaps, is not a “unitary” entity. A government could be trusted to do some things right and it cannot be relied on in some other respects. For example, trust in police services may be different than, say, in the judiciary, and within the judiciary, there could be a difference between the lower and higher judiciary. It is influenced by the integrity of the people and system, the perceived fairness and openness of these institutions. The robustness of institutional mechanisms depends on checks and balances. If the autonomy of institutions is compromised, trust is weakened.

The responsibility of maintaining transparency is with the government and given the fact that “trust’ has to be earned, the responsibility of government is again more important. Indians are brought up to trust higher authorities, including parents, and questioning them is considered rude. Thus, most Indian governments start off with an advantage; they must work hard to lose that trust. This has been repeatedly confirmed by the global trust surveys where India has always ranked high in trust of government. For example, in the 2018 Edelman Global Trust Survey, 70 per cent of the public had trust in the government — a high percentage, though a five-point decline from the previous year. However, in an apparent paradox, Indians do not really trust the capacity and fairness of public institutions in doing things the right way.

Let us review the decisions regarding the vaccine through these two prisms. The regulatory approval has been faulted on all the three counts of transparency, but primarily on the first criteria — the one related to the availability of data on safety and efficacy of the approved vaccines in public to enable a free and fair discussion among all stakeholders, and not just scientists and experts. The evidence regarding at least one of the vaccines had not yet been vetted by peers and there was no debate in the public. The Subject Expert Committee probably had a good discussion, but its details are not in the public domain. Finally, the decision was itself couched in terms which was not understood by large sections of people, including public health experts. Even though the government issued a clarification, the fact that it was compelled to do so says something — this situation was eminently avoidable.
We really do not have adequate platforms to have an open dialogue and debate on any public matter and that should be worrying. The media is, perhaps, the only such space available and it plays a critical role — by holding public institutions to account, it helps build trust in them. While in general, the media has asked the right questions on the vaccine issue, they have also contributed to erosion of trust by the tone and tenor of these questions — television is more culpable than the others. It has often failed to maintain the thin line separating responsible journalism of questioning the government on its decision and hounding or eulogising the government — both erode trust.

Public trust is critical for greater compliance with government guidelines during emergencies, be it COVID-appropriate behaviour or the acceptance of vaccination institutions. The offices of Indian Council of Medical Research (ICMR), National Centre for Disease Control (NCDC), Drugs Controller General of India (DCGI) and their capacity have come under scrutiny and there is a general feeling among scientists and public that these institutions have not performed their role appropriately. Only posterity will judge how well these institutions performed their role — or, at least, when we have travelled some distance from the pandemic. However, questions about their competence and autonomy are not good for generating public trust in the interim. It is difficult to say how much of the current vaccine hesitancy can be attributed to lack of transparency and trust, though undoubtedly, they have contributed to it.

The importance of transparency and trust in governance is to ensure that there is no “undue” influence in the government decision-making — political or commercial. In some ways, the decision on the vaccine has become less of a scientific one and more of a commercial and political one, especially with India wanting to lead the world in vaccine supply. Such opaqueness has also led to concerns about the cost of vaccination. The responses of some ministers that seem to be heavy on vaccine nationalist tones have not helped matters.

One could argue that in cases of emergencies like the COVID-19 pandemic, these values can be compromised. However, one could also argue that these situations call for more rigour in holding to these values.

It is in national interest that we promote transparency and trust in governance. This is not optional. We desperately need to cultivate public spaces for healthy dialogues, where all opinions are respected. Do we expect governments to pay only lip service to these values and not follow them in practice? An open and measurable accountability framework for governance in health is the need of the hour. We have enough theoretical frameworks for them but little operationalisation. It is time we bring it up as a priority public health agenda.

The writer is a professor at Centre for Community Medicine at the All India Institute of Medical Sciences, New Delhi. Views expressed are personal. 



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