Op-ed piece by Jelena Kalinić, 2022 HJN Ambassador

It is becoming increasingly clear to journalists that citizens across Western Balkans region do not trust their health systems. For starters, the region has low percentages of immunization against COVID-19 compared to other European countries. For example, official data say that in Bosnia, only 25.6% of population is fully vaccinated, in Serbia it is 47.9%, which is lower than the European’s average. This can be attributed to several factors, including low scientific and health literacy rates across the region, endemic corruption in health systems, lack of staff and equipment, and limited engagement of health workers in the promotion of vaccines. Some of health workers have even spread misinformation about the SARS-CoV-2 virus and vaccines.

Vaccination campaigns during the pandemic have shown that compliance with vaccinations is higher and resistance is lower when citizens have confidence in their public health institutions. Building trust, but also building mistrust, are processes. Institutions do not loose and gain trust all at once. So, what happened to trust in the Western Balkans region?

In Bosnia and Herzegovina, and in other countries created from the breakup of former Yugoslavia, health care institutions before the pandemic did not communicate with the public on a regular basis. They communicated  in echo chambers. Some officials from public health institutions even flirted with alternative treatment methods publicly and shared this information on official communication channels.

Our World in Data dashboard: COVID-19 data across the region

A rapid  examination of regional data on COVID-19 vaccines tells us that in Croatia 55 percent of the population is fully vaccinated, in Bosnia and Herzegovina (BH) only 35.8 percent are  fully vaccinated, in Serbia 47.5 percent, in Montenegro 47 percent, in Kosovo 46 percent, and in North Macedonia 40 percent. When we include those partially vaccinated, the percentages are only slightly higher.

People don’t follow up with the  third and fourth doses of the COVID-19 vaccines and there is no systemic way to convince them to follow through with all the recommended doses. In Bosnia and Herzegovina, it is possible that the percentages are slightly higher because they are based on the 2013 population census. The situation has changed considerably since then, with hundreds of thousands of citizens who have left the country. Yet, vaccine coverage percentages are lower than the world average, which is 63.2 percent of fully vaccinated persons.

Corruption in health systems

Most people seeking care during the pandemic, felt the corruption in healthcare firsthand. They were advised to take an envelope stashed with money to their health care providers. If not cash, alcohol, perfume or at the very least chocolate, were also accepted. If you wanted your pregnant wife or one of your ill relatives to be better taken care of while at the hospital, you tried these small bribes. Of course, there are honorable professionals who do not accept these, but the shadow of corruption taints everyone’s reputation.

Furthermore, in public health care facilities you can hardly get a referral for a preventive examination from a family doctor, let alone an electrocardiogram, a blood test, or an ultrasound. Only those who have enough money go to private doctors for preventive visits. When older people see their doctors, they are often prescribed the same therapy. There is no check up to determine if the therapy is even working. People rely on their personal blood pressure monitors or seek out private care. Those without money continue to suffer.

What I have described so far, make people not trust public health institutions, even when they are telling the truth. People turn to unproven methods of treating ailments, simply because they are more accessible. Predators target retirees whom they know are more likely to suffer from some kind of age-related ailment. They offer them unproven treatments that range from tinctures and teas, to dangerous snake oils and quantum medicine. The absence of preventive care, the slow referral system, the lack of communication –  or the use of  harsh language – push patients and their families into the trappings of gurus, shamans, and other sweet-talking motivational speakers who promote the latest pseudo-scientific remedy.

Ineffective crisis communication

Communication by public health institutions with the general public has been reduced to an occasional “awareness raising” campaign ran by an international organization fighting this or that health problem. Public health messaging is neither consistent, nor regular, nor visually impressive. Public health institutions in our region communicate trough prepackaged  interviews formatted as a PDF document that no one reads. These documents are filled with scripted and obscure medical terms  that highlight  the “untouchable” nature of the medical profession. The medical profession creates a “loop” of dry explanations.

Medical professionals in the Western Balkans region have known for years that a pandemic was likely to occur, yet they did not make an effort to communicate accurately with the public. Elementary mistakes were made in the crisis communication phase of the pandemic. What we needed was clear communication, supported by strong and data-driven visuals. In a public health emergency, there should be no room for unscientific interpretation or on-the-go stream of consciousness by experts. The messaging must be managed well from the start.

Unclear and ineffective communication fueled both panic and apathy among the public. Those with ill intentions leveraged public awareness of corruption in healthcare to introduce distrust in epidemiological measures and, later, in COVID-19 vaccines.

People want clear explanations, not superficial and dry instructions

In Bosnia the situation is even more complicated than in other states in the Western Balkans region. The health system is fragmented on multiple levels and there is little to no willingness to create a joint communication package to use in crisis situations. The few times they managed to offer coordinated answers to the public, they come across as superficial. The reality is that the public is no longer satisfied  with superficial answers and a few sentences. They are looking for evidence. They are looking for someone to unpack what is written in this or that scientific paper. It is not possible to repeat over and over again, “Vaccines are safe, effective and good.” People demand explanations. People want to know if Covid-19 have side effects, what they are, and how common they are. Medical professionals cannot patronize people when it comes to science and assume they are dumb or semi-literate. They need to step down from their pedestals and regain public trust.

People who feel helpless and marginalized often buy into conspiracy theories. How can you trust a system that has disenfranchised you? At the same time, groups that have a strong sense of belonging can also buy into in conspiracy theories to maintain their identity. Conspiracy theories amplify fears and panic. They gain popularity for many reasons, not out of the blue.

The fight against misinformation and dangerous conspiracy theories that fuel extremism must be rooted in social justice, trust, transparency and accountability of public health institutions. Unfortunately, poverty, inequality and injustice in many parts of the world, including the Balkans, have amplified mistrust and conspiracy theories to the point where it is very difficult to fight them. Fighting corruption at all levels, including in the health system, is away to regain public trust and to promote the right to health