Trust in Medicine

As the United States prepares to undertake one of the largest vaccination efforts in its history – the photo above shows an earlier such effort, the polio vaccination of the mid-to-late 1950s – approximately 60 percent of Americans report in a recent PEW survey that they are likely or very likely to take up a COVID vaccine.

In a survey of individuals from 19 countries on their willingness to be vaccinated, 71.5 percent of participants indicated they would be willing to be vaccinated – with much cross-country variation, ranging from 90 percent in China to less than 55 percent in Russia.

Thus, there is a large gap between those who are willing to be vaccinated and the target of 90 percent coverage for herd immunity recently suggested by Dr. Fauci. This large gap amidst a global pandemic highlights the importance of understanding the determinants of trust in medicine and willingness to be vaccinated. Recent work in economics has begun to explore how historical experiences shape trust in medicine and vaccination rates.

Sleeping Sickness Campaigns in Central Africa

In a paper with Eduardo Montero, we study the case of sleeping sickness campaigns undertaken by the French military in Cameroon and former French Equatorial Africa (present day Central African Republic, Chad, Republic of Congo, and Gabon). Between the 1920s and the 1950s, the French colonial governments organized extensive medical campaigns aimed at managing sleeping sickness, a lethal disease spread by the tsetse fly. Over the course of several decades, millions of individuals were forcibly injected with medications intended to either treat or prevent sleeping sickness. These medications were of dubious efficacy and has serious side effects, including blindness, gangrene infections, and death.

We digitize colonial records of campaign exposure for thirty years and match this data with present day information on vaccination rates for children and willingness to consent to a free and non-invasive blood test for HIV or anemia, which we interpret as a revealed preference measure of trust in medicine. Our results suggest that greater exposure to these historical medical campaigns characterized by lack of consent and use of harmful medications has led to lower trust in medicine. Those places with more exposure to the campaigns have lower vaccination rates for children and respondents are less likely to consent to the free blood test for HIV or anemia.

Nurse drawing blood in Cameroon.

The Tuskegee Study

Related work in the United States by Marcella Alsan and Marianne Wanamaker examines the legacy of the Tuskegee Study. Between the 1932 and 1972, hundreds of black men who were known to have syphilis were monitored by doctors to study the course of disease, despite the availability of effective treatment. In 1972, news of the study, its deception of participants, and the withholding of treatment for syphilis became public.

Alsan and Wanamaker examine how black men respond to the revelation of the study. They find that black men report greater mistrust in medicine and suffer from higher mortality. They are also less likely to interact with physicians. The authors estimate that the revelation of the Tuskegee study led to a decrease in life expectancy for black men of approximately 1.5 years – or 35 percent of the racial gap in life expectancy in 1980.

Blood is drawn from a Tuskegee study subject. (National Archives)

The CIA and Immunization in Pakistan

Monica Martinez-Bravo and Andreas Stegmann examine how a vaccine ruse organized by the CIA has affected immunization rates in Pakistan. In 2011, the CIA organized a vaccination campaign as a cover for their effort to find Osama Bin Laden. The goal of the vaccination campaign was to collect DNA samples from children living in what was suspected to be Bin Laden’s compound. Two months after the capture of Bin Laden, an article describing the vaccination ruse and the collaboration of a Pakistani doctor was published in the Guardian.

Martinez-Bravo and Stegmann find large decreases in vaccinations – particularly in those areas under the control of the Taliban where individuals where more likely to have been exposed to anti-vaccine propaganda campaigns.

A Pakistani health worker administers polio vaccine drops to a child in Quetta. (Getty)

Rebuilding Trust?

Together, these papers highlight the importance of historical experiences in shaping trust in medicine. They demonstrate how medical malpractice – either in the form of withholding treatment or forcibly treating individuals – and the use of vaccination campaigns for political purposes can lead to substantive and long-lasting negative effects in vaccination compliance and health outcomes. As the COVID pandemic has made particularly clear, rebuilding trust in medicine will be crucial to achieving effective vaccination coverage.

In an effort to understand how to improve health outcomes for black men, the group most affected by the Tuskegee study, Marcella Alsan, Owen Garrick, and Grant Graziani designed a study in which they randomly assign black men to have a black male doctor or a non-black male doctor. They examine how the identity of the doctor affects willingness to take up preventive health services, such as diabetes screening, cholesterol screening, and the flu shot. They find that black men are more likely to take up these preventative health services when they are paired with a black doctor. They find evidence that patients perceive that doctors of their own racial background were more likely to understand their health concerns.

These results suggest the importance of doctor identity in health care provision, as well as highlight one avenue for rebuilding trust in medicine among groups affected by historical medical malpractice.



  • Sara Lowes

    I am an Assistant Professor of Economics at the University of California, San Diego. I graduated from Harvard University in May 2017 with a Ph.D. from the Political Economy and Government program. I am a Faculty Research Fellow at the National Bureau of Economic Research (NBER), a CIFAR Azrieli Global Scholar with the Institutions, Organizations & Growth research program, and an Affiliate of the Centre for Economic Policy Research (CEPR). My research interests are at the intersection of development economics, political economy, and economic history. Many of my on-going projects are in the Democratic Republic of Congo.

Leave a Reply