Pandemic and Crisis Preparedness and Response: Conceptualizing Cultural, Social and Political Drivers of Trustworthiness and Collective Action

Abstract

During the early phase of the COVID-19 pandemic, trust in governments and between individuals was associated with lower rates of infections and mortality. Thus, understanding the conditions under which public trust allows for the development of effective policymaking, regular revision, and voluntary mobilization for effective implementation in times of crisis, is important from both a public health and governance perspective. In this article, we explore how core structures of distinct empirical, social and moral phenomena are theoretically interconnected into a conceptual model of trustworthiness in governing authorities. We hypothesize that empirical trustworthiness built over time needs to be combined with specific conditions for trustworthy agencies in emergency situations. We present a theoretically consistent conceptual model in the form of a compass tool that identifies areas of trust-conducive conditions for trustworthy authorities to address. The compass can be operationalized and empirically tested in specific national contexts. It can be applied by various groups to guide debate, explore, and monitor progress in developing trust-conducive conditions in support of a nation’s holistic preparedness and response to crises. We have derived generalizable categories from specific issues occurring during the pandemic, but any team using this compass could dynamically align it for other types of crises.

Introduction

As of 23 October 2023, there were almost 7 million reported deaths and 771 million confirmed cases of COVID-19 reported to the World Health Organization (WHO).¹ The Lancet Commission on COVID-19 has concluded that: ‘Epidemic control was seriously hindered by substantial public opposition to routine public health and social measures, such as the wearing of properly fitting face masks and getting vaccinated. This opposition reflects a lack of social trust, low confidence in government advice, inconsistency of government advice, low health literacy, lack of sufficient behavioural-change interventions, and extensive misinformation and disinformation campaigns on social media’. (Sachs et al., 2022, 1225)

The role of trust during the pandemic has been broadly explored. Empirical literature underscores for example the role of trust in healthcare personnel during the pandemic (Cantarutti and Pothos, 2023), trust in governing authorities (Sætrevik et al., 2021), and confidence in the accuracy of health communication (Sætrevik et al., 2021) as important drivers for compliance with measures during the pandemic. Cross-national comparison in the CompCoRe² study suggests, as Sheila Jasanoff and Stephen Hildgartner write, that «on the whole that countries with relatively high levels of trust in their government’s ability to discern and serve the public interest have also generated fewer public controversies over scientific evidence….By contrast, scientific controversies have proliferated in countries where a sizeable fraction of citizens has lost faith in the state’s capacity to govern for the public good, such as Brazil and the United States.» (Jasanoff & Hildgartner, 2022). Trust in authorities has also been shown to vary across local and global agencies as well as governmental and private organizations (Robinson et al., 2021). Moreover, while the general imperative to protect ‘trust in medical science’ and ‘confidence in medical scientists’ is highlighted (Leonard et al., 2022) empirical data from the US indicates an increasing partisan divide with democrats occurring most prone to place such trust during the first part of the pandemic (Funk et al., 2020). Conspicuously, this empirical literature is not based on any consensual understanding of how trust relates to conditions for the trustworthiness of governing authorities and other agents who influence decision-making in the time of an emergency crisis.

Following the SARS outbreak of 2003, the WHO adopted revised versions of the International Health Regulations. Member states are committed to enhancing health system capacity for prevention, detection, and response to pathogens, as well as to report progress to WHO on a regular basis. The 2014 West African Ebola outbreak again brought the topic of global health security to focus. As a result, the Joint External Evaluation (JEE) provided a voluntary, externally validated collaborative assessment of 19 technical areas required to validate the country capacity to prevent, detect, and rapidly respond to public health threats (World Health Organization, 2017). In addition, the Nuclear Threat Initiative, the Johns Hopkins Center for Health Security, and the Economist Intelligence Unit developed the Global Health Security Index (GHSI) for ranking nations and stimulating competition and investment to improve capacities to prepare for epidemics and pandemics (Economist Impact, 2021). Analyses indicate that JEE and GHSI scores are highly correlated and roughly describe the same capacities, but neither score correlated with a country’s performance or response to the COVID-19 pandemic (Abbey et al., 2020; Haider et al., 2020). While these scores may map some necessary competencies, they do not capture the complex phenomena of trust that proved essential in supporting successful responses to the pandemic. For example, while the United States and the United Kingdom dominated global health security discourse and ranked highly in GHSI scores, both initially responded poorly to the COVID-19 pandemic (Abbey et al., 2020). Indexes with limited predictive value may drive complacency and promote poorly directed investments in health systems. Furthermore, they may drive a competitive and national framework for preparedness and response as opposed to promoting international collective action. A more effective approach to countering the threats of pandemics requires a holistic and multisectoral perspective as well as requirements for collective action (Malik et al., 2021; ten Have, 2022).

The social phenomenon of individuals placing trust in the government and in other persons has played a crucial role in compliance with burdensome or coercive measures meant to lower rates of infections (Bollyky et al., 2022). The GHSI index addresses the question of trust by asking what share of the population trusts medical and health advice from the government and from health professionals (Economist Impact, 2021). However, the Index by itself does not promote reflection of the authorities with vital actors regarding the measures to be adopted in the pandemic and the processes through which to determine them. Thus, there is a gap to fill regarding how to incorporate the complex phenomenon of trust into public discourse around efficacious response.

At the onset of a crisis, evidence is typically lacking or highly uncertain. This further accentuates the need for collective trust in governance. As evidence is lacking, trust that the authorities aim to serve the interests of the people can be the only motivational factor to act according to imposed policies. Accurate trust scores must therefore reflect the nature of collective trust in situations where hard evidence is lacking and policies may impose coercive and restrictive actions on the population and economy at large, such as stay-at-home orders. The GHSI index identifies criteria for preparedness that may indirectly relate to trust placed in authorities when knowledge is uncertain. However, these criteria need to be accompanied by a conceptual model that explains how they contribute to increasing levels of trust that promote collective compliance.

It is worth noting that indexes may not be as useful for building targeted preparedness when constructed from an array of disparate capabilities if they average out differences and obscure agendas for vital action. Also, if collective trust indicators are constrained by what can be measured, indexes may provide an incomplete estimation of strengths and weaknesses.

There is a gap in the literature regarding how to conceptualize the cultural, social and political drivers of trustworthiness and collective action consistently. Filling this gap requires cross-disciplinary efforts to understand how trust is built and destroyed (McKee et al., 2024). In addition, to avoid attention being constrained by what can be measured, there is a call for developing tools that can capture the holistic, integrated structures of trustworthy decision-making in times of crises.

In this article, we start the work of constructing a consistent conceptualization of what promotes, upholds, and reinforces trust in decision-makers in crises such as a pandemic. We develop theoretical claims about the structural connection between fundamental conditions of exercising power in the elected or assigned role of decision-makers and of creating accountability that generates trustworthiness in governing authorities, especially under conditions when significant policies are adopted and rapidly evolve based on uncertain evidence. Based on lessons learned and debated during the pandemic, we propose a list of substantive elements that may assist authorities in considering and promoting trustworthiness, although this list may not be exhaustive. We discuss how the trustworthiness of decision-makers in such circumstances is fundamentally and structurally dependent on the development of ‘long-term’ institutional accountability combined with specific ‘short-term’ actions for accountability in the face of a pandemic crisis. We argue that public authorities that aim for pandemic preparedness based on voluntarily complying, trusting citizens must recognize the complex nature of the social phenomenon of trustworthiness that drives collective trust. Furthermore, the authorities must take actions to explicitly target and strengthen both long- and short-term conditions of accountability.

The argumentative structure of our approach is built up as follows: (i) we first clarify different versions of power that organize social interactions. (ii) We move on to discuss accountability resulting from fair and effective use of power. (iii) We then present the concepts of ‘empirical trust’ and the normative conditions for ‘trustworthiness’ connected with accountability. (iv) Finally, we argue that in crisis, institutional arrangements fostering trustworthiness will have to be supplemented with continued trust in decision-makers when time frames are short and evidence weak or uncertain and clarify how these conditions are related. We propose the use of two interrelated ‘compasses’ to facilitate structured efforts to evaluate and actively enhance support in governing authorities.

Power

Understanding how power works and is exercised by decision-makers is essential when discussing conditions for trustworthy decision-making. When power is exercised to benefit, those who are subjected to the decisions, people are given reason to believe that decision-makers are not aiming to harm them. An adequate understanding of power goes beyond the binary of those who dominate and those who are dominated. Different elements and stakes can be analytically distinguished as ‘power-over’, ‘power-to’, ‘power-with’ (Allen, 2018; Haugaard, 2020), and ‘power-within’ (VeneKlasen and Miller, 2002), and all can be at play at the same time. When policymakers exercise power and make decisions on behalf of their citizens, it can be carried out according to any of these dimensions.

Decision-making power involves ‘power-over’ in all hierarchically organized societies, but this does not have to result in a zero-sum understanding of power (Haugaard, 2020). In democratic societies, people subordinate themselves to the decision-making power of the governing authority while still exercising the ‘power-to’ choose different governing authorities in the next election cycle. The construction of hierarchically organized political decision-making structures does not necessarily mean that decisions will be oppressive or unresponsive to the interests of citizens³. In all societies, democratic or otherwise, there is some responsiveness of the governing to the governed. There are only special and short-lived circumstances when this responsibility can be curtailed, such as the legitimate dissolution of parliament or the use of coercive measures in response to emergencies or war.

By including citizens in deliberative processes, decision-makers are promoting citizens’ ‘power-to’ engage as well as their opportunity for gathering and exercising ‘power-with’ together with other individuals. This latter version of power is, for example, being played out when a group of citizens demonstrates against a proposed policy. ‘Power-over’ can also allow for individual awareness of one’s ‘power-within’. ‘Power-within’ refers to the force of having self-reflexive knowledge about oneself and one’s abilities and worth and is reflected in acknowledged respect of others (VeneKlasen and Miller, 2002). Preventing some people from exercising ‘power-to’ or ‘power-with’ can challenge perceptions of self-worth among those being excluded and respect provided by others. Governing authorities that do not accommodate people’s power to freely assess how they are being governed undermine the scope of opportunities for the governed to exercise these other power dimensions – and enhance a perception that governance is exercised without due concern for the benefit of all citizens.

When decision-makers exercise ‘power-over’ in ways that promote ‘power-to, -with and -within’, it indicates that they are not aiming to harm them. Arguably, it can even be interpreted as they are attempting to exercise power for the benefit of the citizens. Alternatively, ‘power-over’ can be used to suppress people´s abilities to ‘power-to, -with and -within’. Lukes’ account for how power-over can be exercised is useful to illustrate how power can play out constructively (Lukes, 2004; Grimen, 2009): 1) A decides over B with threat or use of force; 2) A controls the agenda for discussion; 3) A controls B’s worldview/thoughts (Lukes, 2004). Applying power in accordance with the interests of people involves letting stakeholders participate in the agenda-setting, raising issues, and co-establishing the values, rationales, and limitations involved in the processes – so that they can critically engage in deliberation with their own worldviews on what matters. Realizing these three dimensions of inclusion can create a better understanding of what a situation requires. Moreover, the stakeholders’ experiences of being taken seriously as agents and co-citizens may not only promote fairer outcomes (as more and different voices are having an impact on the decision) but also enhance compliance with the resulting policies.

Accountability

Levels and Practices of Accountability

Exercising power that promotes ‘power-to, -with and -within’ is intimately linked with a specific understanding of accountability. In this context, it should not be understood in the quasi-legal retributive sense of making someone ‘pay for their actions’ but instead as the literal ‘giving of accounts’ that policy and decision-makers must carry out to enable citizens to understand the reasoning behind decisions. This understanding of accountability presumes openness and that decision-makers make their rationales accessible for scrutiny. It also implies that authorities are willing to correct course if decisions prove to be maladapted or conditions change. Accounting for decisions and their outcomes enables citizens to understand the reasons behind them and launch targeted, justifying appeals when relevant. This requires, in the words of Simone Chambers, ‘publicly articulating, explaining, and most importantly justifying public policy’ (Chambers, 2003, 308).

The democratic theory calls for the practice of accountability to be carried out at two levels:

1. Formal institutions: this is where public policy is designed and publicly defended. Public institutions should demonstrate competence, the consideration of evidence and different perspectives, and independence from political authority or commercial interests (Miller, 2003).

2. Informal public sphere: it is integral to consult and include citizens who will be affected by policy processes (Fishkin, 2009). Such efforts at inclusion can be fraught with problems arising from power asymmetries between participants (Árnason, 2013), regarding who is included, who sets the agenda, and who influences policymaking. Public institutions must demonstrate management of truly inclusive processes where citizens are provided with power-to and power-with to influence the processes, which requires rough background conditions of equality. Public inclusion can be difficult to practice during a pandemic but is crucial in the processes of preparing for and learning from crises.

Decision-makers exercise sustainable power in the interests of the public by establishing and maintaining accountability towards the population on both these levels. In contrast, when either of these accountability practices is neglected, citizens are left with insufficient opportunities to shape the policy agenda and hold decision-makers accountable for what they do. Whilst populations may still demonstrate de facto trust in autocratic authorities in times of crises, this trust will fundamentally depend on contingent historical factors rather than structural reasons for accountability (and is likely to be fragile).

Theoretical reflection or self-reflexive assessment on accountability involves an assessment of the practices occurring at the previously described two levels. This implies a critical investigation of ‘the quality, substance and rationality of the arguments and reasons brought to defend policy and law’ (Chambers, 2003, 309) at the first level. At the second level, it evaluates the venues and public spaces available for public deliberation and accountability as well as the conditions influencing the views and behavior of the participants. This reflection applies theoretical conditions for how (un)acceptable uses of power and accountability are applied to real-world practices, considering information asymmetries, the role of experts, and the population’s incentives, abilities, and conditions for legitimate, effective decision-making.

In the following section, we account for specific areas of accountability that are in citizens’ interest.

Accountability: Social Justice

Reflexive consideration about the areas over which decision-makers enjoy discretion reveals that discrimination between members or groups in society cannot be justified. Social justice calls for equal respect for all members. However, efficient governance requires the delegation of authority to the few. Not all decisions can be validated by all citizens. Hence, strategies of inclusion need to be developed that are publicly defensible, inclusive, and feasible.

Decision-makers who exercise power in the public interest have a duty to recognize the need to be held accountable by all those they govern and to reform pro-exclusion social structures and policies. In short, exercising beneficial power implies that the decision-maker actively takes responsibility for treating all members of society with equal respect and creates the possibility for decision-makers to be held to account.

Accountability: Fair Institutions

Decision-makers who are responsible for promoting social justice will establish and maintain institutions to realize this goal. This will result in institutions that consider not more than just the maximalization of benefits, but also their fair distribution. More specifically, the distribution of public health services and policies should take social inequality and inequity into account. Furthermore, these same decision-makers must build or continue to support decision-making processes that are organized in a fair way (i.e. being based on conditions perceived as reasonable by all stakeholders). Procedural approaches based on fair conditions, such as transparency, freedom of speech, and participation, are even more important in situations where there is likely to be disagreement over substantive principles of what counts as just distribution of social good (Daniels and Sabin, 2002).

When decision-making processes are organized in accordance with rules accepted as fair, it gives stakeholders reasons to judge and accept the outcome as fair, even if there were other outcomes they would perceive as more just or desirable. The conditions for fair processes are theoretically rooted in the idea that all individuals are moral equals and entitled to influence decisions that impact their lives. If conditions for being treated as moral equals are not in place, people are given reason to perceive the process as unfair. This, as we will discuss below, undermines both trust and the conditions for trustworthiness. We now turn to see how the perceived (un)fairness of the policymaking process is closely connected to judgments about (il)legitimate policies.

Accountability: Legitimate Processes

The conceptual definition of legitimacy is ambiguous. It is used in different contexts that relate to how governing authorities organize and set out power relationships, and refers to the relationship between regulation and implementation of laws. It is also used less rigorously to state the acceptability of political claims, arguments, and decisions.

‘Real world perceptions of legitimacy’ represent people’s attitudes to what is implemented and the actual outcomes and is not necessarily dependent on how legitimate a procedure is. As Weber pointed out, people’s reasons are not always rational; they can refer to unquestioned traditions or a leader’s charisma (Weber [1991] 1918). From the pragmatic point of view of instrumental rationality, this is all that is needed for the effective implementation of policies. As such it is fully compatible with technocratic governance, which is justified on the basis of evidence and technical expertise. From a moral (and democratic) point of view, however, the legitimacy of decisions must meet the normative standards of accountability, fair procedure, and accommodate the dimensions of power-to, -with, and -within the use of power that we have discussed above. If such conditions are not in place, the process can be perceived as illegitimate because citizens are not provided with reasons for accepting the policy.

Accountability: Expertise and Communication

Legitimate decision-making is not only assessed according to the fairness of the processes involved and the reasonableness of principles of distribution. The substantial outcome also matters. Successfully dealing with practical challenges crucially depends on the use of accurate and relevant knowledge; constructive use of expertise is a central part of legitimate policymaking. Legitimate decision-making depends on governance models that accommodate methods, knowledge, and perspectives from different fields, and for such consultations to be made public. Moreover, the authorities must demonstrate how they have considered expert advice and where and why they deviate from expert recommendations. In the event of a pandemic, expertise must be considered locally and from regional and global sources—as a means to expand relevant knowledge and to foster collective international action. Expertise, rationales, and values for policymaking must be translated into understandable and meaningful actions for the public. Thus, successful policies will also depend on the understandable, uncomplicated communication of integrated disciplinary knowledge providing the public with information they are able to act on (Norheim et al., 2021).

Accountability in Practice

Accountability put into practice permits the identification of aspects of laws, policies, and programs that are functioning well, so they can be strengthened and built on, as well as those aspects that require improvement or revision. Accountability also enables collective and individual grievances to be addressed, and laws and policies to be enforced ensuring non-repetition of abuses (OHCHR, 2013). Thus, ecosystems of accountability evolve and foster continuous learning and improvement in the health sector and beyond (UN Human Rights Council, 2012).

While we can establish the concept of accountability theoretically, practices may not play out accordingly (Horton, 2019). Limiting factors include lack of political will, weak institutions and legal frameworks, and lack of systematic practice of inclusion of the public. This calls for continuous self-reflexive consideration of practices at both levels of accountability discussed above.

Across very different contexts and legal systems, in low-, middle- and high-income countries, courts have required the executive and legislative branches of government to reform discriminatory laws, policies, and practices related to health (to provide access to health-related information, as well as both care and preconditions to health) and to provide public justification for the reasonableness of their policies and practices in relation to health (Flood and Gross, 2014). The impacts of such judgments can lead to actions from the executive and legislature, as well as mobilization from civil society, that produce transformative changes in the health sector, which transcend discrete remedial action and feedback into a continuous circle of learning and improvement (Yamin, 2011; Yamin and Lander, 2015).

Trust and Trustworthiness

It is important to distinguish between trust and trustworthiness. It is an empirical matter of whether authorities and experts are in fact trusted (empirical trust), but whether they are worthy of trust is dependent on compliance with normative conditions. Trustworthiness is (theoretically considered) enhanced when power-over is exercised whilst also enhancing people’s power-to, -with- and -within. Trustworthy exercise of power is expected to motivate people to confer legitimacy. Trustworthy use of power is expected to generate empirical trust that is rewarded at re-election and continued mandate to govern based on fair and legitimate institutions and practice. It is a cumulative self-reinforcing process.

Epistemic and Recommendation Trust

In the interaction between citizens and policymakers, generating both epistemic and recommendation trust is important. These two kinds of trust each imply different requirements (Bennett, 2020). Requirements for epistemic trust pertain to the use of credible expertise and rest on the belief by citizens that the experts who provide information are sincere, knowledgeable, and competent. While epistemic trust is necessary for ensuring trust in decision-makers, it is not sufficient. For citizens to follow expert advice, they must also believe that the recommendations are crafted in their interests. Such recommendation trust is thus more demanding than epistemic trust and is dependent on other, more complicated factors. Both are needed to underpin the legitimacy of a policy (Magnússon, 2022).

Normative conditions for trustworthiness are different depending on how instilled a society’s democratic values are. Exercising power in a democracy in a trustworthy manner involves—from a theoretical point of view—both constructive use of expert authority and inclusion of citizens in the policymaking process. Such inclusion can lead to a greater understanding of the opportunities for effective or fair action, the basis of trade-offs, voluntary compliance with the resulting policies. It is worth noting, however, that involving citizens does not completely replace the ‘power-over’ structure of authorities’ governing control. Authorities make the final decisions and must be responsible for these decisions. Also, there is rarely full compliance, and this requires authorities to exercise coercive power-over those who do not follow the policies (Bennett, 2020).

Agents in the informal public sphere can play an important part in mediating between citizens and the authorities. By exercising ‘power-to’ and ‘power-with’ in addressing policymakers, civil society can push policymaking to be more inclusive, responsive, and accountable than it otherwise would have been. Accountable decision-making comprehensively carried out across both formal and informal levels can support trust in government. On the contrary, exercising oppressive power without accountability undermines trustworthiness. Strategic suppression of human rights, rampant corruption, incoherence and lack of proficiency, or lack of concern for accountability, makes it harder to justify either processes or outcomes as legitimate. People are not offered reasons to believe that policymakers and institutions aim to serve the interests of society.

Trust in Time of Crisis and Uncertainty

Enhanced compliance with health policies is not necessarily good independent of context and the aim of decision-makers. However, during a pandemic, protecting people from harm can require collective action in terms of compliance with health policies. Understanding what facilitates such compliance is therefore crucial when enhancing preparedness. Given the conceptual nexus of social interaction and institutionalizations we have described above, we hypothesize that any expected success of compliance with health policies in crises, when risks are high, timeframes narrow, and evidence and expertise uncertain, depends on whether citizens place recommendation trust in policymakers and their decisions. They might have historical reasons to do so.

Trustworthiness can depend on the extent to which accountability for decisions is already a feature within a system of institutions devoted to checks-and-balances. In general, people have no reason to stop placing trust, until the decision-makers clearly demonstrate they have willfully acted against the interests of those they serve and/or through gross incompetence. Therefore, existing accountability systems that have historically empowered stakeholders and proved to be fair and effective can provide structural support to political leadership during new conditions created by crisis. Trust in governing authorities and pandemic policies can be extended by nourishing already existing empirical trust promoted by well-functioning ecosystems of accountability. When otherwise trustworthy institutions of knowledge production can only deliver uncertain or preliminary results, decision-makers are still expected to act in the interests of the public—and can for example demonstrate this when willing to rapidly alter policies when proven inappropriate. In this way, a virtuous cycle of trust supports and engenders resilient policymaking, even in times of crises when time frames and uncertain knowledge force policymakers to cut the full cycle of trustworthy decision-making short.

Societies without traditions for holding policymakers and institutions accountable would be expected to be less prone to give trust on the premises described above. This does not mean, however, that people will not comply with policies. Indeed, they might do so because they are used to following top-down directives, they place epistemic trust in authorities, or they face sanctions if they refuse. From the theoretical, normative point of view and in line with the ethico-political ideal of protecting individual self-determination, we conceptualize the connection between trust and compliance as trustworthy leadership based on the beneficial use of power and accountability mechanisms promote voluntary compliance with decisions, also in emergencies when the timeframe is narrow and evidence often uncertain (Fig. 1).

In the next section, we divide normative conditions for trustworthiness into long- and short-term conditions for trustworthiness and explore how crisis-specific, short-term conditions support trustworthiness that accommodates citizens’ recommendation trust in governing authorities, or at least, prevent such established trust from collapsing.

Long- and Short-term Conditions for Trustworthiness and Modeled ‘Compasses’ for Evaluation

Virtuous Cycles of Trust: Long-term Conditions for Trustworthiness

Empirical circumstances impact the conceptualized interplay of power, accountability, and empirical trust in a variety of ways (see fig.1). The stability of virtuous cycles of trust in democratic societies is supported by the duration of historical opportunities to hold policymakers responsible and accountable for how they exercise ‘power-over’ civilians. In societies where virtuous cycles of trust have extended over generations, the population have reasons to be ‘trusting’. These virtuous cycles can be targeted and strengthened step-by-step and over time by building up fair and legitimate institutions and policymaking and responding rapidly to refine policies that prove inappropriate in implementation. This ecosystem leads to the development of independent centers of expertise and supports a robust and independent media that contributes to informed and open discussions. This, in turn, impacts the crafting of legitimate and successful policies. In societies where the ecosystem is short-lived, trust is likely to be more fragile. People will need proof of accountability; they have no reason to simply assume it is present.

The stability of virtuous cycles of trust is also supported by the range of established institutions that ensure checks and balances both within and across sectors. When these are numerous and established to comprehensively avoid disrespect, discrimination, and unfairness, authorities are providing people with reasons to believe they aim for the common good and are competent even in areas when there is weak or non-available scientific evidence to justify decisions or when the institutions deal with decisions that are difficult to understand from a lay perspective.

Importantly, different cycles of trust can exist side-by-side. When it comes to health, the trustworthiness of decisions can be seen as inherently structured around trustworthy research practices and within the competence of regulated professions. Trust in ‘scientific experts’ allows people to assume the legitimacy of policies based on complex knowledge that is hard to grasp.

In order to explicitly strengthen trustworthiness, public agencies can explicitly promote self-reflexive consideration of the degrees of accountability and trust that society holds for various public health authorities. We suggest that rather than quantifying these complex social phenomena and building them into an index to be maximized, policymakers should use a ‘compass’ model to open reflective processes and invite assessment by diverse groups within society. Different institutions might wish to engage staff or the broader public to systematically assess the degree to which they are perceived as forwarding social justice (and to do so competently through the use of independent expertise), public consultation through legitimate processes, transparent publishing of evidence, and open and understandable communication of policies and their rationales to the public (Norheim et al., 2021). This can be part of a long-term effort to consider, learn from, and build increasingly trusted and fair public institutions, including within the specific health area (see fig. 2).

Virtuous Cycles of Trust: Short-term Conditions for Trustworthiness

No matter the proficiency by which public health authorities have established and built trust over the longer term, the conditions of acute crisis will stress the system and relations within society. In the face of urgent need, huge deployment of resources, enforced draconian policies, and stark choices—all with the absence of good evidence—there will be doubt and questioning determined by different interests that can easily drive towards politicized agendas. In a situation of crisis, there is limited time for public engagement, but this can be (partly) compensated for by regular communication, good access to information, including limits to what is known, and clearly articulated policies based on addressed and procedurally deliberated public concerns, as opposed to top-down unexplained policies being imposed on the community (Childress et al., 2002).

A pandemic by definition is an event that is not confined to national borders and cannot be entirely managed through effective action at the national level. Thus, authorities should be expected to demonstrate a willingness to expose their challenges and failures, learn from other nations, and engage in a degree of international cooperation. Learning and cooperation must be internationalized and balanced with efforts to protect the national interest (cf. ten Have, 2022).

In the short-term response, we suggest the use of a modified compass to deal with more tangible and immediate elements of trust and fairness. Such a compass will include elements of trustworthy communication and leadership, independent expertise, duty of care (as historically shaping the professional role of health workers), levels of decision-making (which are contextually different but require accountability practices) and international collaboration in terms of engagement in international research, policy, and pandemic management efforts (see fig.3).

The use of the two ‘compasses’ should be interrelated. While the focus of the former is on building long-term public trust in institutions and processes, the objective of the latter is maintaining this trust in the short-term under highly testing conditions and the need for rapid, flexible action. Further work is clearly needed to adapt these compasses to local contexts or situations. The different levels of letter scores require specifications of what basic institutions and arrangements are expected to be in place. The development of such specifications should be both theoretically and empirically informed by a variety of research disciplines and methods, including the collection of citizens’ experiences and perspectives. By regular use of these compasses for self-reflexive assessment, authorities can reduce the punitive nature of assessment and accountability. When the emergency arrives, the conditions for trustworthiness are familiar and will—when present—engender trust and collective action that allow rapid response to the pandemic.

Conclusions

Empirical, de facto trust in governing authorities is shaped by the complex interplay between personal experiences, social interaction, available information, and the design of social and cultural institutions. This makes it challenging to capture the general conditions of public trust from a data-driven approach. A purely theoretical conceptualization of trust, on the other hand, will be too decontextualized and general to have helpful practical relevance. In this article, we have suggested a middle-ground approach as we have explored how core structures of distinct empirical, social, and moral phenomena are meaningfully interconnected into a conceptual model of trustworthiness in governing authorities. We have further developed a conceptual model of the interrelations between governing authorities’ power to make policies, their accountability for their use of power to develop, maintain, and respect institutions that promote social equality and fairness, use of robust evidence, and communication, and their trustworthiness. We have discussed how trustworthiness in times of crises requires both long-term conditions and short-term action and have proposed a model of two integrated ‘compasses’ that can be further scrutinized, detailed, operationalized, and tested based on empirical evidence of people’s perspectives and experiences.

This compass model is not a series of indicators to be measured. Rather we envision it as a tool to guide inclusive deliberation. The compass draws decision makers’ attention explicitly to the issue of trust and decomposes this broad and complex issue into a series of collectively agreed components that allow tangible intervention. Each component can be purposefully debated and scored. The relative scorings indicate where the group understands lie strengths and weaknesses in public trust and government trustworthiness, and hence an action agenda for improvement. Furthermore, the compass can be used to direct discussion and scoring among disparate groups to compare and contrast rankings of trust between different constituencies. Lastly, the compass can be used to score trust dimensions over time, map out dynamic changes in trust dimensions, monitor the success of action to enhance trust, and reveal changing needs to shore up trust in different groups on different issues as a pandemic evolves.

Acknowledgements

Thank you to the reviewers of the journal for very helpful comments. Thank you to Bergen Centre for Ethics and Priority Setting in health (BCEPS) and Iceland Research Fund for funding of this research.

Funding

KB, AEY, and APD were funded by Bergen Centre for Ethics and Prioirty Setting in health (BCEPS). VÁ was funded by University of Iceland Research Fund.

References

Footnotes