Contaminated Trust

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N O I T A GIA, M R FO GEOR AINE N I IS TS IN UKR D H PAC AND T L A E L IM TAN H C I IETA KHS L B PU S SOC KAZA IT AND

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THIS REPORT has been sponsored by the U.S. State Department.

The Critical Mass would like to thank the Department of State for funding this research, with special thanks to the report contributors, field partners, and research participants.

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EXECUTIVE SUMMARY

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campaigns emanating from Russia have been varied and far-reaching during

EALTH DISINFORMATION the COVID-19 pandemic. Research in this report provides front-line perspec-

tive on how Russian-originated medical disinformation impacts healthcare decision-making at the individual level in Georgia, Kazakhstan, and Ukraine. Recognizing the urgency of understanding and responding to this challenge, The Critical Mass with support from the U.S. Department of State Global Engagement Center, worked to identify and characterize real world impacts of Russian-origin health disinformation. Though proving a direct link between disinformation operations and health outcomes would require much additional research and investigation, this project sought to define, collect, and analyze expert experience, media consumption, and other data sets to provide funders, leaders, and stakeholders with insights to inform counterdisinformation efforts.

Many factors were found to correlate with health disinformation campaign efficacy, including audience profile, accessibility, language, and content. The most compelling destabilizing effect identified was how disinformation operations undermine confidence in traditionally trusted sources for information and expertise. The findings support pursuing lines of effort that engage institutions, medical professionals, and public health entities in creating fact-based, accessible information, while working to bolster the public’s confidence in their accuracy and objectivity, rather than expending effort and resources on thwarting Russian health disinformation campaigns at their source.

This environmental snapshot study is centered on interviews with select medical, media, and civil society leaders that were conducted in these countries as COVID-19 cases and fatalities peaked, medical supply chains became strained, and vaccine development and testing were underway. These in-depth interviews were analyzed in conjunction with self-reported media diaries from a separate sample of residents. Experts consulted during this research agreed that Russian health disinformation campaigns aim to weaken medical development, undermine public trust, and disrupt delivery capabilities in neighboring countries to increase reliance on Russian resources, including vaccines.

Analysis of over 50 expert interviews and nearly 80 media diaries from participants in this study revealed that political infighting and lack of access to trustworthy information drive citizens to seek out information from non-traditional media sources, social media, and other closed networking groups on platforms such as Facebook, YouTube, Instagram, Telegram, and WhatsApp. People in these countries who choose social media for health information are targets for “influencers” and interest groups whose information may be intentionally inaccurate in service of political or financial objectives. In-depth interviewees identified some of these disinformation disseminators associated with the Russian government and others as affiliated with anti-Western or anti-liberal political, economic, and commercial interests.

The interviews illustrated a consensus among experts that social factors and education are associated with susceptibility to misinformation and disinformation in the countries of study, and that language preference is an important determinate in what information consumers trust. Populations in the countries under study that do not speak multiple languages and lack access to quality education and healthcare were identified as vulnerable to misleading health information and its impacts. Moreover, the majority of populations of all three countries remain influenced by the vestiges of the Soviet education system, which discouraged critical analysis of official narratives and did not support media literacy.

While many interviewees cited disinformation narratives tracing back to Russia, several participants identified local actors spreading or “laundering” health disinformation: • Medical professionals—perceived as sources of misinformation and disinformation across all three countries, doctors and other medical professionals are presumed to lack expertise in applying evidence-based science to their practice.

This distrust was especially pronounced within older generations and rural populations.

• Religious officials—viewed as highly credible, their contribution to the spread of public health misinformation and disinformation during the COVID-19 pandemic is significant. In both Georgia and Ukraine, faith-based institutions wield considerable influence and have played a role in spreading misinformation and disinformation related to COVID-19.

By contrast, in Kazakhstan’s leading Muslim and Russian Orthodox Churches religious leaders were not perceived by in-country experts to endorse anti-vaccine rumors or engage in disinformation messaging.

• Russian state-affiliated or proxy local actors—considered to be exploiting domestic political strife and unrest during the global pandemic. These actors are presumed by the interviewed experts to be financially or ideologically motivated to delegitimize and undermine national authorities to increase Russian influence in the countries of study.

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RESEARCH CONTEXT, PURPOSE, AND METHODOLOGY

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SUMMARY

N OCTOBER 2020,

The Critical Mass (“TCM”) embarked on an eight-month research project to understand and counter Russian-origin health disinformation that has affected Eastern Europe and Central Asia (EE/CA).

The project’s goal was to research and disseminate findings exploring suspected Russian campaigns that weaponize health disinformation and learn about any real-world consequences it may have on the lives of people in three countries: Georgia, Kazakhstan, and Ukraine.

To develop this report, members from The Critical Mass research team, in-country research firms, and the Harriman Institute at Columbia University’s regional scholars designed a three-phase field study. The variety of methods and sources used for the study are detailed in the appendices. To understand public health impacts and their potential link to disinformation, research addressed the following questions:

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How and to what extent is Russian-origin health disinformation transferred to different countries in the region?

To what extent do local officials and public health institutions recognize Russian disinformation as damaging?

Is there an association between Russian-origin health disinformation campaigns and negative outcomes of those efforts? ( a) What awareness, prevention measures, and activities to combat Russian-origin health disinformation are in place in the public health sector? ( b) What additional activities can be conducted by the health community to raise public awareness and decrease the damage of disinformation messaging? Recommendations and observations from in-country experts and local stakeholders in the report contain policy and messaging ideas to alleviate the effects of disinformation. These ideas merit additional study and investigation. Opinions and suggested interventions presented balance findings from larger public health studies for designing and implementing counter-disinformation strategies.1

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WHY HEALTH-RELATED DISINFORMATION? Public health is ripe for malevolent disinformation campaigns because it is an emotional touchpoint between governments, institutions, and citizenry. Personal experience is used to evaluate national healthcare infrastructure and confidence in the system is reflected in acceptance or rejection of government healthcare policies. This connection means citizens viscerally feel the impact of changes in their healthcare system. The seeds for successful propagation of health disinformation in the former republics of the Soviet Union were planted long ago by the Soviet educational system. Over the years this legacy has created barriers to implementing evidence-based medicine. This merits further investigation, as this report will discuss.2

WHY HEALTH-RELATED DISINFORMATION OF RUSSIAN ORIGIN? Russia’s medical disinformation campaign concerning COVID-19 bears familiar hallmarks of past health disinformation operations. Russian history is replete with strategically deployed disinformation, targeting vaccines, health policies, and pharmaceuticals to enhance its influence. During the COVID-19 pandemic, Russia used health disinformation to exploit existing tensions in Georgia, Kazakhstan, Ukraine, and other areas. This report investigates how the erosion of trust in the media, state institutions, and public health sector in these three countries supports a cycle of disinformation.

WHY GEORGIA, KAZAKHSTAN, AND UKRAINE? Georgia, Kazakhstan, and Ukraine, former republics of the Soviet Union, once shared similar political and institutional emergency health response capabilities. Today, they are independent countries and differ in civil structure, levels of media freedom, and public infrastructure. Despite these differences, these countries share the challenge of overcoming Russian-origin medical disinformation campaigns meant to undermine public health sector development and years of cultivated skepticism national institutions and international research laboratories or partner-developed and/or sponsored technologies.3 Representing three regions (South Caucasus, Central Asia, and Eastern Europe), Georgia, Kazakhstan, and Ukraine grapple with citizen distrust of media, government, and institutions but differ in their levels of self-reported public health messaging capacity. (Supporting data and referenced indices for these characterizations are in the “Country Selection Process” appendix.) By investigating Russian-origin disinformation in these three environments, the research team was able to examine scenarios in which Russia’s health disinformation messaging creates rifts between citizens and national institutions.

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WHY THIS RESEARCH DESIGN? The Research Team used a mixed-methods research design consisting of a literature review, media diaries, in-depth interviews (IDIs), and online-media content analysis. The media diaries and content analysis were largely quantitative and the in-depth interviews were qualitative. The Research Team analyzed data systematically during and after the completion of fieldwork. The analysts employed data triangulation methods, including research designs, fieldwork, and evaluations. In-depth interview participants’ perspectives were summarized and thematically categorized, using the guidelines outlined in the IDI Summary Review rubric. Research Assistants followed a Media Diary Analysis Standard when assessing diary responses. These were analyzed to collect relevant data that ranked trust in media content and analyzed trends and themes. (Media Analysis involved data scraping used for extracting data from websites. The open-source media websites scraped for this research are included in the methodology section and the media landscape in the Appendix.)

The fieldwork was intended to be cumulative, with each phase of research informing the next. The literature review focused on a historical and comparative view of regional medical disinformation messages. This informed the keyword selection for the media content analysis, while IDI pilot interviews grounded the user media diaries. Together, the interviews and media diaries elucidate the effects of health disinformation.

The analysts used triangulation of the various data sources, by first synthesizing each research element and then comparing the findings of each phase of research. They used qualitative findings to contextualize and explain quantitative elements of the study.

This research and report were commissioned during a period of global focus on disinformation and its impact on the COVID-19 pandemic. This report provides an on-the-ground view of the realities of combatting a health crisis. The data collection team in each country provided findings based on their experiences conducting similar research in their countries. Further analysis was conducted through systematic review and coding of responses in original languages and English translations. Media diaries were collected from frequent news consumers who professed interest in news items on health and medical issues. For five days (seven in Georgia), participants documented news they consumed on health or medical issues. (For further details on recruitment strategy, data collection schedule, team structure, design, and methodology, please see Appendix 1. For a list of documents reviewed and all data collection protocols, see Appendices 4 and 8.)

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WHAT CAN BE DONE WITH THIS INFORMATION? TCM and their partners designed the study to investigate the impact of Russian-origin disinformation on trust and efficacy of National Public Health Institutions and initiatives. This research is intended to identify and design effective strategies to counter any negative effects of decreased public trust in COVID-19 control efforts.4 It will provide a succinct understanding of the implications of Russian-origin disinformation efforts in Georgia, Kazakhstan, and Ukraine and help decision-makers with programming to counter it.

Map of Georgia Map of Ukraine

Map of Kazakhstan

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GEORGIA, KAZAKHSTAN, AND UKRAINE BRIEF TIMELINE OF THE COVID-19 CRISIS IN

GEORGIA

Georgia’s first COVID-19 case was confirmed on February 26, 2020. Since that time, it has swung from a COVID-19 success story to a cautionary tale. As of September 2021, there were 614,673 confirmed cases and 8,976 deaths in Georgia’s population of 3.9 million.5 Through mid-2020, a strong government response matched with public buy-in was lauded for controlling transmission rates, but the economic strain of lockdown soon overtook public attention.6 The ruling Georgian Dream party, facing October parliamentary elections, chose to downplay Tbilisi, Georgia the importance of a lockdown. The Orthodox Church’s religious leaders also initially failed to advocate actively for vaccination campaigns.7 A second lockdown in late 2020 failed to bring the disease under control. Public protest of government lockdown measures grew,8 even as the country started to experience some of the worst rates of COVID-19 in the world by 2021. To combat this, Georgia pursued vaccines through the COVAX system and China. As of September 2021, around 910,000 Georgians had received at least one jab of Pfizer, AstraZeneca, or the Chinese vaccines, Sinopharm and SinoVac.9

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Kazakhstan’s first COVID-19 case was confirmed on March 13, 2020. Regional quarantines were quickly imposed but did not prevent transmission. The total number of reported cases and deaths as of September 2021 is 845,388 and 10,427, respectively.10 COVID-19 has taken a massive toll on Kazakhstan’s previously bright economic outlook, and it also strained public trust and confidence in governance.11 Legislation initially designed to address medical disinformation has instead primarily targeted oppositional figures and restricted criticism of public health policies.12

Nur-Sultan, Kazakhstan

Meanwhile, there has been alleged manipulation of statistics to “prevent panic,” 13 undercutting effective policy responses and leaving the country vulnerable to disinformation originating from Russia and China.14 Unlike Georgia and Ukraine, Kazakhstan has both purchased and produced the Russian Sputnik V vaccine. Notably, President Kassym-Jomart Tokayev’s government has also invested in the creation of a domestic vaccine option, QazVac, and purchased Chinese Sinopharm’s Hayat-Vax.15

UKRAINE

Ukraine was one of the earliest in the region to report and record a case of COVID-19 on March 3, 2020. As of September 2021, Ukrainian authorities reported more than 2.3 million total cases and 54,829 total deaths in a population of 44 million.16 An early quarantine was followed by a series of partial, short-term lockdowns, with former Health Minister Maksym Stepanov optimistically claiming in early May 2021, “The spring wave of the pandemic has ended.”17 Despite his claims, case numbers increased. Ukraine may now face its largest economic recession in decades, as the government simultaneously manages the pandemic, fighting in the eastern part of the country, and anti-corruption reforms.18 Like Georgia, domestic politics have disrupted planned public health policy initiatives. The pandemic hit Ukraine during a government overhaul of the inefficient and corrupt healthcare sector, which was initiated under former President Petro Poroshenko.19 Current President Volodymyr Zelensky also hired and fired a rotation of health ministers20 amidst medical equipment shortages and public dissatisfaction during 2020 and 2021.21 Lviv, Ukraine

Moreover, continued vaccine-hesitancy plagues the country. In early May 2021, a mere 428 people had been fully vaccinated.22 A March 2021 survey found 60 percent of Ukrainians were unwilling to be vaccinated.23 According to Ukrainian officials, this hesitancy toward vaccines, specifically AstraZeneca, is a consequence of Russian-originated disinformation.24 In fact, the Ukrainian government has prioritized vaccinating soldiers currently facing off against Russian-backed separatists, but even given their priority status, many soldiers refused vaccines. One UNICEF official in the country believes this hesitancy is due to disinformation.25 By September 14, 2021, only 12 percent of the population had been fully vaccinated against COVID-19.26 Like Georgia, Ukraine has eschewed Russian vaccines in favor of COVAX, Pfizer, AstraZeneca, and CoronaVac (also known as Sinovac).27

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RESEARCH FINDINGS AND DISCUSSION EROSIONS OF TRUST AND CONFIDENCE IN MEDIA, GOVERNMENT, AND MEDICINE The COVID-19 pandemic exacerbated an entrenched distrust of media, government, and medical institutions and shaken faith even in trusted authorities—a vulnerability exploited by disinformation actors. Social pillars with high credibility, such as religious organizations, have also been co-opted to disseminate false narratives. The findings section of this report examines how a lack of trustworthy information and political tensions drove citizens to seek alternative information in the form of social media and private messaging groups.

CONDUITS FOR DISINFORMATION: TRADITIONAL MEDIA, GOVERNMENT, AND ALTERNATIVE SOURCES OF INFORMATION DECREASED CONFIDENCE IN TRADITIONAL, STATE, AND INTERNATIONAL MEDIA EXACERBATES THE SPREAD OF FALSE NARRATIVES. Demand for alternative sources of information in the three countries is linked to a lack of access to trustworthy sources and programming. Experts and media diarists identified a confusing, biased, and unprofessional media landscape that prompts citizens to rely on the easily digestible information found on social media.

In Georgia, two-thirds of the experts interviewed agreed medical disinformation is more dangerous than non-medical disinformation because ill-informed health decisions can have fatal consequences.

As a Georgian civil society leader noted, “There are some ethical standards that one should be aware of media professionals need to possess basic education on a topic that they are covering in order to avoid broadcasting harmful information.” The interviewee added that upholding high ethical standards does not restrict freedom of speech but allows journalists to “broadcast [news] in a professional manner, maintaining high standards that are on par with the likes of the BBC and CNN.”

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According to one medical expert, media outlets in Georgia lack professional and ethical standards that exist in other developed countries. “We need to highlight the issue related to the qualification of our journalists—they ought to double-check and verify information before spreading it, but we have a very poor situation in this regard. No one takes professional responsibility and realizes how this information affects consciousness of the society; thus, everyone replicates various bits of information without adequate fact-checking, and this is becoming problematic.” In their opinion, media outlets with credentials, including blogs or other media platforms that disseminate material without prior fact-checking, operate due to this regulatory gap. A media expert in Georgia noted social media outlets present the most significant threat to fact-based narratives, as they are essentially “uncontrollable.” Respondents believed there would be fewer issues with disinformation if media content creators upheld appropriate standards.28

Kazakhstani media experts and civil society leaders agreed traditional media regularly covered news from official sources; however, the published information is frequently obtuse or highly technical. As a result, misinformation and disinformation messages in common, accessible vernacular are often more broadly consumed and shared. Also, in some cases, journalists who lack knowledge of health issues may inadvertently misrepresent information. A lack of editorial oversight and factchecking then results in the dissemination of erroneous information as truth.

Most experts in Kazakhstan do not believe inaccurate messaging is intentional, characterizing it as misinformation rather than disinformation. Experts cited multiple sources, including social media platforms and private networking groups, where personal connections had unwittingly posted inaccurate information. The interviewees stated instant messaging users share material rapidly without checking facts or verifying sources.

This was reported as especially pronounced when developments are believed to be “urgent.” Sharing unverified updates within these groups intensified during COVID-related quarantines and lockdowns. “It is not mass media [producing false information], but rather, it is mostly bloggers who are not professional journalists.

These are so-called new social media, all these TikToks, and so on,” noted one Kazakhstani expert.

all infor“ACTUALLY, mation today comes from one

main source. The internet is playing a very important role nowadays. It is really occupying a very vast segment in the information field because not many people listen to the radio, or read newspapers, or watch TV. Most people nowadays have smartphones, computers, and so on and receive information from these sources.”

KAZAKHSTANI

MEDICAL EXPERT

In Ukraine, most experts interviewed suggested the proliferation of media organizations in the wake of the collapse of the Soviet Union had left the population stymied by choice and unsure what sources to trust. This choice is further complicated when consumers consider the ownership of news outlets.

Ukrainian oligarchs and politicians own media companies and often direct them to influence policy-making and public opinion. They frequently prioritize political agendas and business interests over accuracy in reporting.

Further, geopolitical developments in Ukraine have shaped the media environment since 2014. Russia’s illegal annexation of Crimea in 2014 and the outbreak of military and hybrid conflict in Eastern Ukraine sparked far-reaching propaganda campaigns. In response, regional organizations initiated efforts to raise awareness and combat disinformation and misinformation.29 Prior to 2014, unreliable information and even conspiratorial myths permeated the health sector. After 2014, grassroots initiatives emerged, and several activists began to disseminate more reliable information about public health. “At least, we started talking about it [after 2014]. Now there are some active doctors, active scientists, active people […] who try to change the consciousness of our patients,” reported a highranking Ukrainian medical representative. However, misinformation and disinformation remain problematic for the country’s health sector. Many media diary participants in Ukraine sourced information from Viber groups, Telegram channels, and private Facebook groups.

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CONFIDENCE IN MEDIA SOURCES AND CONSUMPTION HABITS

GEORGIA

According to a Georgian media expert, distrust of the media is a frequent issue.

The media is politically polarized, so many assume reporting is biased. In analyzing media diaries, one percent of content shared by Georgian diarists was marked by the participants as “obvious mis or disinformation,” whereas 24 percent of the articles and video content were rated as “fact only.” The remaining 75 percent of news items were deemed as “in-between” misinformation/disinformation and factual, in terms of trustworthiness and accuracy. Georgian media diarists recorded their exposure to health-related news items as overwhelmingly from television and television-associated websites. Of traditional media outlets, the most viewed source was state-run Imedi TV (127 exposures), followed by the Georgian Public Broadcaster’s First Channel (88 exposures), and Rustavi2 (63 exposures).

Unlike Ukraine and Kazakhstan, social media did not rank among their top five sources for health-related individual who supports information. Facebook was reported as the source for 32 the government or the of over 800 exposures. ruling party, for example, Public programming in both the Georgian and Russian trusts Imedi TV and does languages topped other television viewings for COVIDnot trust Mtavari Arkhi 19-related content. Per the media analysis, the Kremand vice versa, those who lin-funded Sputnik Georgia, although not amongst the support United National top sources cited, was the non-TV news source with the Movement (UNM) trust highest audience numbers, most COVID-19 content, Mtavari Arkhi and does and most duplicated COVID-19-related content. The not trust narratives prosingle item with the most reprints/repeats was a Sputnik moted through the Imedi Georgia update that cited Georgian health ministry infecTV (state-run network) platform.” tion, treatment, and quarantine data. Interpressnews accounted for 19 media diarists’ recorded exposures and comprised a significant percentage of COVID-19 content

GEORGIAN MEDIA in traditional media. Mtavari Arkhi accounted for under EXPERT two percent of the COVID-19 content during the period but was much duplicated, indicating a high level of trust of its comparatively limited content.

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KAZAKHSTAN

Media diaries indicate half of the Kazakhstani participants relied on instinct and experience when making health decisions, eschewing state-controlled, independent, local, and foreign media. Media consumers ascribed trust to content based on factors that included clarity or reliability of sourcing, government affiliation, and foreign influence.

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Of over 700 news stories and articles consumed by 25 Kazakhstani media diarists, nearly 80 percent of the content was ranked between “High” and “Middle” trustworthiness, while the remaining were assigned “Low” trustworthiness. Local companies or institutions seemed to be given higher levels of trustworthiness, despite debatable claims in their articles. For example, one article rated by a media diary participant from a well-known news site, Liter.kz (ranked tenth among the most popular sources cited by diarists in Kazakhstan), covered the claims of a German scientist that COVID-19 had come from animal testing in a Chinese lab.30 While the author of the article noted there is no evidence of the claim, the clickbait title and structure of the article likely led the reader to this claim as newsworthy.

The media diary participant rated this article as “Very High” in terms of trustworthiness. Only two percent of the content shared by the Kazakhstani media diarists was marked by the participants as “obvious misinformation or disinformation.”

Overall, Kazakhstani media diarists recorded exposure to health-related news from over 100 sources.

Instagram and YouTube were the most identified sources, constituting 12 percent of health informa-

tion exposures. The most-viewed source among Kazakhstani media diarists were tengrinews.kz (49 exposures) and informburo.kz and nur.kz (both with 39 exposures each).

An analysis of key terms, results, and content from a cross-section of Kazakhstan’s traditional media outlets provided a “control” for comparison to the participants’ diaries. The media diarists’ source exposure agrees with traditional media audience analysis for the same period, specifically both datasets identify Tengrinews.kz as the traditional media COVID-19 coverage source with the widest audience.

Though Tengrinews.kz had the widest audience, inform.kz had the highest number of COVID-19 articles duplicated in other publications (at least 75 percent similar content), as well as the single most-duplicated article during the period. This piece covered a meeting between Kazakhstani and Kyrgyz leaders discussing COVID-19. Inform.kz’s frequent duplication may reflect higher industry trust for Inform.kz’s content.

UKRAINE

Of over 800 news stories and articles viewed by 25 Ukrainian media diarists who were surveyed over the course of five days, nearly 92 percent of the content was ranked between “High” and “Middling” trustworthiness, while the remaining 8 percent were assigned “Low” trustworthiness. Only 3.5 percent of the content shared by the Ukrainian media diarists was marked by the participants as “obvious mis or disinformation,” whereas 49.5 percent of the articles and video were rated as “fact only,” and the remaining 47 percent were deemed as “in-between” misinformation/disinformation and factual in terms of their trustworthiness and accuracy. Several of the clearest examples of misinformation assigned “Low” trustworthiness values by media diarists concerned alternative prevention or treatment for cancer rather than COVID-19.31

Ukrainian media diarists recorded exposure to health-related news items via social media, international, and domestic news sources. Facebook, YouTube, and Instagram were the most commonly identified sources. Combined, these constituted almost 15 percent of health information exposures. From traditional media outlets, the most-viewed source reported by media diarists was the online magazine Korrespondent (with 19 exposures), followed by Ukrayinska Pravda (18 exposures), and Ukrainian News Network’s (UNN) website (17 exposures).

According to web-based media audience analysis, the media diarists’ recorded sources for health information differed from the most popular traditional media sources for the same period. Although Ukrayinska Pravda had the largest audience according to the web media analysis, among our media diarists, it was less popular than Korrespondent, amongst our media diarists. Most broadly consumed web-based news sources (by audience) were only mentioned by a single respondent. The delta between COVID19 “coverage” and the health-related news exposures reported by media diarists may result from social media’s targeted content, as activities such as “reading the paper” for general world and domestic news are quickly falling out of favor. The specific political, technical, and government websites popular among the media diary participants were accorded high trust, as they have either come from the readers’ network or deliberate internet searches.

Although Ukrayinska Pravda had the widest audience of traditional media during the sampling period, Interfax-Ukraina had the highest number of COVID-19 articles duplicated or repeated (at least 75 percent similar content) in other publications. The latter publication also had the single most-duplicated article during the period—a piece about the commitment of the European Bank for Reconstruction and Development (“EBRD”) to various projects, including Kyiv’s metro renovations and COVID-19 relief. Interfax’s frequent duplication may reflect its breadth of coverage or industry confidence in its content. By contrast, although Ukrayinska Pravda had the largest potential reported viewership (or audience during the period), Ukrayinska Pravda’s COVID-19 content was sparse. Their COVID-19 article count during the end of February 2021 constituted well below 1 percent of available content (for comparison, Suspilne, the Public Broadcasting Company of Ukraine, accounted for 7.5 percent of COVID-19 articles during the same period).

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LOW TRUST IN GOVERNMENT INSTITUTIONS DRIVES SKEPTICISM TOWARD THEIR MESSAGING AND MANAGEMENT OF THE PANDEMIC Secondary factors leading interviewees to seek out alternative sources of information were political infighting among parties in Georgia and Ukraine and restriction of the media in Kazakhstan. For example, a media expert stated a survey was recently conducted under the auspices of a leading Georgian institution that specialized in international public affairs.32 The survey found that Russian-origin disinformation messaging related to COVID-19 was anticipated by both government officials and activists during recent parliamentary elections in Georgia. However, the study did not identify any direct threads between disinformation and the Russian government. Regarding the study, the expert stated, “The public was generally satisfied with the way that Georgia managed the COVID-19 pandemic. The entire state apparatus combined forces and worked together to combat the media trolls.” The expert further categoof the rized these “media trolls” as primarily “domestic” or “of oppodomestic origin.” sition party, United National In Kazakhstan, a one-party system and a strictly Movement, criticized the controlled media environment determine medical Georgian government’s messages, contradicting what people are witnessing management of the pandemic. in many cases. The Kazakhstani government’s selecThe disinformation the UNM tive distribution of misinformation is often intended to party spread was more about weaken political opposition groups.33 High-profile issues COVID-19 rather than poliwith Kazakhstan’s COVID-19 reporting statistics have tics and elections targeting the ruling party, Georgian Dream. damaged trust in government data.34 Our research with Thus, political parties, including media diarists found them seeking information from the political elite, used the unofficial and/or unverified sources, including private pandemic for their own Telegram and WhatsApp groups, increasing their vulnerpolitical agenda to increase ability to disinformation. When asked to assess the influence at the expense of the government’s management of the COVID-19 outbreak, opposing party in the context Kazakhstani media diary participants’ answers were of COVID-19 management.” split evenly, between “not particularly well” and “well.”

Some outliers claimed the government was doing “excellently” or very poorly.

GEORGIAN

“SUPPORTERS

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CSO LEADER Like Georgia, Ukraine is in political disharmony, which has affected pandemic response. One media diary participant in Ukraine stated the European Solidarity party is the only political organization supporting Ukrainians during the pandemic. This demonstrates how a media consumer’s party affiliation may align with perception of government response. Several Ukrainian experts highlighted how various voting demographics and their perceptions of the pandemic could be fed by messaging or utilized by political party leaders. Numerous interview participants stressed youth and/or education in being able to identify fake information. Several interviewees elaborated

that membership of parties which attract young and educated voters would be better at navigating misinformation. Nevertheless, this relationship could be reversed, with one expert saying, “If the party communicates absurdities, then its voters are more likely to believe medical mis or disinformation.”

The Ukrainian experts who participated in this study were skeptical of official government programs and messaging. Only two of the 18 Ukrainian experts had high trust in government statistics and reports. The remainder decried the government’s COVID-19 response as “unfocused,” with some attributing the pandemic’s spread to confusing and contradictory guidance.

One media diarist also gave a “Medium” trustworthiness rating to an article posted in a private Facebook group, claiming vaccination was not effective. The article held, “Ukrainian authorities are unable to cope with vaccination.” Six of the 25 media diarists expressed dissatisfaction with the Covishield vaccine the Ukrainian government procured, which they viewed as “less trustworthy.”

They criticized their failure to aggressively pursue alternatives.

Ukrainian media diarist’s screenshot from TASS:

“Ukraine registers Covishield without necessary In Georgia and Ukraine, domestic political strife approval certification.” has sown public distrust in political parties, the elected officials, and the media. In Kazakhstan, the media is viewed as an extension of the government.

Since lack of faith in government and media are linked, demand for alternative sources of information in the three countries can be attributed to diminished institutional trust.

In addition, language contributed to the consumption of online information in all three countries. Access and education affect language used by participants to consume media. Experts observed older and/ or less educated generations were constrained by a lack of media literacy and fluency in languages other than Russian, meaning fewer sources could be compared when they sought reliable information.

Notably, the language of consumption for media diarists was different across countries. (Georgians primarily used Georgian, Kazakhstanis primarily used Russian, and Ukrainians split evenly between Russian and Ukrainian.) In Ukraine, geographic location was strongly correlated with Russian or Ukrainian-language sources. Experts and media diarists pointed out that language and ease of access to information can often be more important than the political orientation of an information source.

They also perceived heightened disinformation in Russian-language sources.

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SOCIAL MEDIA: A POPULAR SOURCE OF HEALTH INFORMATION FOR MEDIA DIARY AND IDI PARTICIPANTS This research indicated the populations of Georgia, Kazakhstan, and Ukraine are turning to alternative sources of information because the pandemic has undermined their trust in traditional media and government messaging. (A list of social media channels mentioned by experts and media diary participants is available upon request.) The increase in medical disinformation in Georgia,35 Kazakhstan,36 and Ukraine can largely be attributed to the growing accessibility of social media.37 The prevailing sentiment from diarists was that disinformation is a persistent threat to institutions and individuals.

In Georgia, among the medical, media, and civil society experts interviewed, nearly all agreed social media was the most prevalent platform for spreading health disinformation.38 Increasingly, people choosing social media for health information are easy targets for “influencers” and interest groups.39 In-depth interviewees identified some interest groups are associated with Russia and, specifically, the Russian government, while others are affiliated with anti-Western or anti-liberal political groups.

Commercial enterprises with financial interests dependent upon misinformation and disinformation were also cited as disseminating inaccurate content. According to 18 out of 21 experts in Georgia, social media is the number one tool for spreading disinformation, with television ranked second (by 13 out of 21 experts).

In Ukraine, most experts and media consumers believe Facebook and Viber closed groups, Telegram, and YouTube are major sources of misinformation and disinformation. However, they still report frequent personal use of all four platforms. Many Telegram channels are anonymous yet branded to project authenticity. “Legitimny,” “Resident,” and “The Dark Knight” channels were highlighted in several media diaries. Several participants of this study highlighted Serhiy Hula as a popular example of a vlogger in Ukraine who spreads false information through his YouTube platform. Like the media diary participants, all in-depth Ukrainian interviewees shared the opinion that private social media channels, including Facebook, WhatsApp, or Viber groups, account for much of the spread of disinformation and misinformation (equally).

In all three countries, several experts mentioned social media “influencers” as a growing media segment and a source of misinformation and disinformation. Online media content sampling, analysis, and desk research found the reach of “influencers” growing during this project term (October 2020 to May 2021).40

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T N E T N O C A MEDI ALYSIS AN

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D A Y N R A T A E A ENC IARY D E PRIM ON I D A U I A D T T H M AT I A I ED E MED IS NO NFOR M INE D TH EDIA DISI L N D O SIS AN AM” M N AND E L P ALY TRE TIO M A S T AN AINS RMA E H T TEN “M INFO IES. C O N I C AT E D O F M I S O U N T R IND DUIT REE C CON THE TH IN

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example, the death of a 27- year-old nurse in the Georgian town of Akhaltsikhe, a recipient of the AstraZeneca vaccine, received wide coverage, but mainstream sources yielded only factual coverage.41

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Kazakhstan, in late February 2021, the International Federation of Red Cross and Red Crescent Societies (IFRC) launched a social media “chat bot” to combat conspiracy theories, misinformation, and disinformation driving vaccine hesitancy.

Sponsors cited studies attributing disinformation, including 5G and microchipping links, to COVID-19 vaccines.42 That week searches for “chipping,” “5G,” “Soros,” and other terms did not yield any false narratives presented as fact. The news item that achieved the largest audience for traditional media that week was Tengrinews.kz’s profile of a Karaganda-based pharmaceutical factory and the scheduled rollout of Kazakhstan’s locally produced Sputnik V vaccine.43.

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start of the Ukrainian vaccination drive on February 24, 2021, was met with a firestorm of critical social media response.

During the week of February 27 to March 6, 2021, social media was raging with conspiracy theories surrounding the side effects of the AstraZeneca (Covishield) vaccine.44 Conspiracy theorists were spreading unverified rumors of fatal reactions to the vaccine among members of the Ukrainian military, who were among the first to receive the vaccine.45 During this period, keyword searches of “military,” “soldier,” and “side effects” did not yield any relevant articles promoting this narrative. A single editorial in Novoye Vremya (NV.ua) condemned Ukrainian authorities for the fact that Covishield was the only available option (as opposed to the more popular Pfizer vaccine).46 However, the author of the article still encouraged readers to be vaccinated, noting, “They have nothing to lose.”

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THE SIGNIFICANT ROLE OF SOCIAL MEDIA “INFLUENCERS” IN PUBLIC HEALTH MISINFORMATION AND DISINFORMATION Several experts interviewed mentioned social media “influencers” as a growing media segment cited by patients, clients, and constituents espousing inaccurate information.

In Georgia, “influencer” culture is still in its nascent stages. As of January 2021, out of 3.9 million Georgian residents, 3.1 million are active on social media.47 As users, Georgians engage in publicly viewable discussions. This discourse may contribute to the spread of misinformation and disinformation about the pandemic. The array of “influencers” includes medical doctors and government experts in Georgia. Several noteworthy voices in the Georgian social media space include Nina Marji, who spreads anti-vaccine narratives, Nutsa Shanshiashvili, who denies the existence of COVID-19, and Koba Kuprashvili, an anti- COVID-19 activist. While some public health experts and medical doctors like Giorgi Ghoghoberidze, Bidzina Kulumbegov, and Giorgi Pkhakadze try to debunk myths about COVID-19 via their social media, other clinicians, such as Tina Topuria and Zaza Telia, contribute to sowing public distrust in the safety and efficacy of COVID-19 vaccines. Anti-vaccination narratives and COVID-19 denialism continue to challenge the state’s pandemic response.

Article shared by media diarist where Georgian medical expert tells Kviris Palitra outlet that talks about importing the Russian vaccine are “unacceptable.”

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Moreover, while Facebook dominates the social media space in Georgia and remains a primary platform for public health information, its ability to flag content as false has sent some “influencers” who spread disinformation to Telegram. These “influencers” mobilized their followers to migrate with them.

“Factually inaccurate content is mainly spread through closed groups on social media now,” noted a civil society leader. “Platforms like Telegram and WhatsApp that do not control the content are becoming increasingly popular,” they added.

YouTube is also a popular vlogger venue, though less so than Facebook due to a lack of Georgian-language content. According to a medical professional interviewed, using Georgian on social media platforms delayed the fact-checking process, so “disinformation can easily slip through factchecking cracks.”

Kazakhstan has also seen rapid growth in bloggers, vloggers, and “influencers.” They play a key role in marketing, discovering, and/or covering breaking news. However, the government of Kazakhstan has learned how to manipulate online bloggers to control digital discourse. They utilize an older, Soviet-style model where, according to a Kazakhstani civil society leader, “‘accredited journalists’ were ‘employed’ by the state to transmit the official messages and state ideology.” Further, even though bloggers and “influencers” are viewed as reputable sources in a country with low levels of trust in traditional public media, they are far from immune to state pressure. There is a strong incentive for

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we conducted research on vaccination and vaccination-related disinformation, it turned out that a lot of inaccurate information was being spread by the doctors and medical professionals. Most of them were elderly doctors who relied on outdated knowledge obtained back in the Soviet Union or repeated what they had heard on TV channels.”

“influencers” to avoid criticism of government because it could threaten the growth of their personal brand, so social media channels operate as if state monitored. The state’s selective application of its new anti-disinformation policy means malicious or inaccurate COVID-19 theories are being spread, while well-intentioned Kazakhstani bloggers are conforming to an unspoken standard of limited government criticism.

Access to social media has guided Ukrainian public discourse, too. Ukrainian “influencers” use platforms like Instagram, TikTok, YouTube, and Telegram to reach Ukrainian- and Russian-speaking audiences. Several “influencers” and bloggers are current or former politicians and regularly comment on politics. Many top political bloggers and “influencers” take a decisively pro-Kremlin stance. Several popular Telegram channels in the country, some anonymous, rehash Russian political narratives to hundreds of thousands of subscribers.

For example, three Telegram channels—“Legitimny” (Legitimate, 159,000 subscribers), “Rezident” (Resident,

UKRAINIAN 101,000 subscribers), and “Temniy Rytsar’” (Dark CSO LEADER Knight, 68,000 subscribers)—are anonymous channels that promote pro-Russian views.48 On the “Legitimny” channel, posts referred to the Western vaccine lobby as sorosyata, a play on financier George Soros’ name and the Ukrainian word for piglets (porosyata). “Rezident,” on its part, raised rumors about the possible forced resignation of Ukrainian Minister of Health Maksym Stepanov. All three of the aforementioned social media channels sowed doubt about Ukraine’s pandemic response. These specific Telegram channels have considerable influence over politicians in the Verkhovna Rada, the Supreme Council of Ukraine.49 Credible suspicions personnel is have been raised that these channels may have Russian highly ties—most Telegram accounts are hosted in Russia.50 uneducated, unfortunately.

The current system does not Anataloiy Shariy, with two million YouTube subscribers provide continuous education and his own political party, pushes pro-Russian of these individuals [in the messaging, including promoting Russia’s Sputnik V medical sector]. They were 51 vaccine. One leading Instagram “influencer,” Dmitriy educated 20 years ago, Stuzhuk, made headlines in 2020 for questioning the and even if you learned existence of COVID-19 before succumbing to the virus something 20 years ago, in October 2020.52 (His wife, Sofia Stuzhuk, remains one the country experienced of the country’s most popular lifestyle “influencers” with so many changes, but your over five million followers on Instagram).53 knowledge remains rooted in what you read all those years ago.”

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GEORGIAN MEDIA EXPERT

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LEGITIMIZING DISINFORMATION: THE ROLE OF THE MEDICAL AND PUBLIC HEALTH ESTABLISHMENT DOCTORS AND MEDICAL PROFESSIONALS ARE OFTEN PERCEIVED AS SOURCES OF MISINFORMATION AND DISINFORMATION, DUE TO A LACK OF CONFIDENCE AND ACCESS TO EVIDENCE-BASED SOURCES. EXPERTS EMPHASIZED MODERN EVIDENCE-BASED TRAINING PROGRAMS FOR MEDICAL PROFESSIONALS. The strain of COVID-19 has magnified systemic public health capacity restraints and inflamed resourcing issues that plague post-Soviet nations. Years of Soviet-model and Russian technology-focused training has led to outdated modes of practicing medicine, compounding misinformation and disinformation in the three countries studied.

Medical experts noted physicians are not equipped with contemporary, evidence-based methodology, and, in many cases, are not incentivized or provided with resources to update their medical education. This differs from other Western and European countries, where medical providers must continually renew and update their credentials. One high-ranking medical professional in Ukraine stated the lack of continuing education in the medical field is one of the primary sources of misinformation.

“Ignorance of scientific facts and lack of interest among medical personnel is a major problem.” The expert continued, stating those who do not strive for continuous medical development often serve as sources of misinformation and even disinformation in their profession. Health practitioners working with outdated information become unwitting participants in the spread of medical misinformation that goes unchallenged by patients.

News story shared by Kazakhstani diarist from Russia’s RBC about the ability to bypass the second dose of the vaccine for those who already had COVID.

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In Georgia, experts’ opinions differed on the medical sectors’ culpability in the spread of disinformation.

According to one medical expert, misleading information can be spread by doctors for a variety of reasons, including lack of sufficient training, financial incentives, or reticence to admit limitations to their expertise. Most frequently, “misinformation is spread by healthcare workers unintentionally and unknowingly,” said a Georgian medical professional.

According to one expert, medical personnel who lack training and work experience embellish their assertions and act as a “big trigger” to vulnerable groups who respond to emotional narratives. This expert said, in general, doctors with Ph.Ds. and those who specialize in alternative medicine are “pseudoscientists.” They serve as a significant source of disinformation, with their “scientific” claims affording them trust.

Five of the 21 expert interview participants in Georgia stated the main purpose of medical disinformation is to create fear in patients and distrust for public health establishments. In addition, low medical literacy has led to changes in public opinion regarding health interventions, including vaccines. Eight of the 21 Georgian experts referenced the measles vaccination rollout in 2008. That rollout was associated

with a deliberate spread of lies by the anti-vax movement, which subsequently led to low rates of vaccination.

By 2010, only 50 percent of nationwide immunization (targeting those six–27 years of age) was achieved, due to vaccine safety concerns.54 This was far lower than the goal of one million people. As a result, Georgia continues to battle outbreaks of measles and has suffered numerous fatalities.55 In Kazakhstan, perceived systemic corruption within the medical sector and alternative medicine market combine to drive distrust of public health policy. Kazakhstani experts identified corruption, not politically motivated disinformation, as the main cause of low trust in doctors, a problem that has worsened during the pandemic. Due to low trust in health institutions, experts reported misinformation has caused a rise in dangerous self-treatments.

Doctors who profit from drug sales were also mentioned as promoting disinformation. Kazakhstan and Russia share low evidentiary standards for pharmaceuticals, while other countries in the region have reformed the distribution of foreign medicines. Eight of the 18 Kazakhstani IDI participants noted pharmaceutical companies may spread disinformation for commercial purposes by distributing their products through doctors by distorting statistics or concealing facts. Two interviewees claimed Russian companies were responsible, while six spoke more generally or referenced domestic companies.

not even about “IT’S countries, it’s about corporations. There are

several pharmaceutical corporations that disseminate most of the disinformation. They distort statistics and facts about severity of diseases because their goal is to make profit on their products, and in an aim to achieve this goal, they invent non-existent diseases.

It happens very often, to my great regret, and doctors are also involved in this process.

While most doctors believe in this [disinformation], others do not, but nonetheless, they still get involved to make profit. In other words, it is a very-well funded [corruption] scheme.”

KAZAKHSTANI In Ukraine, in-depth interviews revealed a consensus that MEDIA EXPERT the medical sector does not place adequate emphasis on evidence-based medicine. Many doctors were educated using Soviet methods and have not trained in new methods or techniques. Ukrainian experts cited experiences where doctors did not advise patients to be vaccinated, provided inaccurate information about treatment, or even withheld diagnosis. This is not done intentionally but because doctors have their own beliefs from early in their careers. A lack of proper credentialing and continuing education opportunities from state-run institutions allows this to persist.

Experts named knowledge, scientific evidence, continuing professional education, access to modern literature, and the Internet as critical enablers for doctors to improve. The lack of access to these resources is a major problem, per interviewees. This was especially evident at the beginning of the pandemic when there was little to no information about COVID-19.

Before the pandemic, distrust of public health institutions, including the medical establishment, was pervasive in Georgia, Ukraine, and Kazakhstan. The deluge of information sources has only inflamed this problem.

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AMPLIFYING DISINFORMATION: THE ROLE OF RELIGIOUS AND COMMUNITY PILLARS RELIGIOUS OFFICIALS ARE VIEWED AS HIGHLY CREDIBLE, MAKING THEIR CONTRIBUTION TO THE SPREAD OF PUBLIC HEALTH MISINFORMATION AND DISINFORMATION SIGNIFICANT. Both in Georgia and Ukraine, faith-based institutions wield influence and have played a significant role in spreading misinformation and disinformation related to COVID-19.

In Georgia, where the church is tied to national identity, the Orthodox Church was cited as spreading misinformation and, to a lesser extent, disinformation, regarding public health, COVID-19, and vaccination.

In Ukraine, the church is also an important part of cultural identity, and some Ukrainian religious institutions downplayed the severity of COVID-19. Religious institutions have a stronger presence in Georgian and Ukrainian public life than in Kazakhstan, so, unsurprisingly, Kazakhstani interviewees did not identify churches as primary actors in the dissemination of health misinformation or disinformation.

Religious groups have promoted theories and narratives about the virus and vaccines, noted six of the 21 expert Georgian interviewees. According to media experts and CSO leaders, Georgia’s religious institutions posed a barrier to the effective management of the pandemic by spreading misinformation and disinformation. By appending religious issues to anti-vaccination narratives, conspiracy theorists coopted the status of the Church in Georgian life. According to a medical doctor interviewed, religion plays an active role in disinformation because some groups wrap messaging in “a pseudo-religious guise.”

This medical professional noted, since Georgia, Russia, and Greece hold Christian Orthodox beliefs, public statements and health messaging shares similarities. sermons made by Several Georgian experts cited church sermons as a the representatives of primary conduit for false information. At the outset of the Patriarchate and the the pandemic, they reported many Orthodox churches GOC more broadly play a denied the existence of the virus. They issued statements very important role. They describing COVID-19 as a “bluff” and told parishioners directly proclaim that the it was an attempt to control people.56 Spiritual narraCOVID-19 vaccine is dantives also emerged that focused on the vaccine’s side gerous, and a large part of effects causing physical harm and/or drastic population the population trusts these decline. The trust in Georgian faith leaders makes such scientifically unfounded proclamations. Such dismessaging particularly dangerous and undermines vacciinformation demonstrate nation campaigns. irresponsible behavior Experts and media diary participants referenced three on the part of the GOC myths attributable to the GOC: vaccine-related reproducofficials.” tive side effects, “microchipping” as a motive for vaccination, and efficacy of “folk” treatments for COVID-19 GEORGIAN instead of the vaccine. Conspiratorial theories mentioned

CSO LEADER by several experts included narratives about “satanic” COVID-19 vaccines developed to decrease birth rates.

One media diary participant cited a news story in which a Georgian Archpriest in the St. George Church in Vake (downtown Tbilisi) advised against the COVID-19 vaccine, as he believes it will “eradicate a large portion of the population.”57 A representative of the GOC’s Tianeti and Pshav-Khevsureti Eparchy claimed the only reliable vaccine against the coronavirus is “the flesh and blood of Jesus Christ the Savior and holy water.”58

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Experts reported seeing multiple messages from the GOC proclaiming Georgia is facing the threat of population-chipping via vaccine, stating security services are inserting

microchips in the nation’s citizens and utilizing data for government surveillance and control.59 A resolution adopted in 2019 against “mandatory chipping” that was made by a group of conservative activists affiliated with the Russian Orthodox Church (ROC) lent credence to the population-chipping rumor within devout circles.60

In February 2021, the governing body of the GOC, the Holy Synod, welcomed the government’s decision not to make vaccination “mandatory” and emphasized international experts continue to have “differing opinions” about vaccination.61 The GOC asserted discrimination against individuals who did not receive the COVID-19 vaccine is unacceptable. They reiterated the GOC would not participate in “vaccination propaganda” to encourage the population to receive the vaccine, which they consider “a responsibility of public health workers and not religious institutions.” The Synod also questioned the origins of the immunization shots imported into Georgia, and it urged health officials in the country to elaborate on their side effects and potential complications.

Both Ukrainian and Georgian experts reported instances of church leadership advocating for unproven and sometimes harmful “folk” treatments for COVID-19. These narratives have circulated in Georgia, reinforcing the challenges authorities face in managing the pandemic.62 By contrast, in Kazakhstan, Islam and the Russian Orthodox Church were not perceived by in-country experts to endorse anti-vaccine rumors. Religious officials in Kazakhstan were quick to issue statements favoring the vaccine.63 This is in line with research demonstrating Kazakhstani preference for division between Church and State.64 Based on data released by the Ministry of Healthcare of Kazakhstan before COVID-19, individuals who refused vaccines increased from around 12,000 in 2016 to nearly 17,000 in 2019.65 However, those who declined vaccines due to religious concerns decreased from around 50 percent to 30 percent of respondents.

In Ukraine, four of the 18 experts interviewed perceived religious organizations to be sources of disinformation. Before the Easter celebrations of April 2020, priests in the Orthodox Church of Ukraine (OCU) called on parishioners to attend church in defiance of public health protocols.66 A Ukrainian expert also told of seeing “vaccine-killers” booklets distributed in churches affiliated with the Ukrainian Orthodox Church of the Moscow Patriarchate (UOC-MP). These organizations were slow to renounce conspiratorial statements about COVID-19. A less “direct” contravention of social distancing was released by the UOC-MP. In it, Metropolitan Anthony Pakanich counseled followers “isolation” from the community was not as harmful as “isolation” from God, but he stopped short of advocating for the abandonment of quarantine or distancing measures.67 Religious rhetoric is in public discourse throughout the region, even in secular publications. One media diarist highlighted a story entitled “Does vaccination contradict God’s commandments?”

It was featured in Ukrayinska Pravda, a popular publication founded in 2000 as an independent news source, challenging corruption in Ukrainian elite.68 The author argues the church is not involved in setting the nation’s medical agenda. However, the headline led the media diary respondent to assume the piece furthered the antivaccination narrative. This demonstrates the chasm that can separate public messaging intention from its reception.

The church is in the top three most trusted institutions in Ukraine, according to a survey poll conducted by the Kharkiv Institute for Social Research in December 2020.69 Of those surveyed, 43.7 percent indicated the church is their most trusted source of information about the pandemic. There are regional differences, though. For instance, 73.7 percent of western Ukrainians have greater confidence in information shared by the church than any other institution, compared with 34.01 percent in northern Ukraine and 34.3 percent in central Ukraine. Neither the respondents nor the polling organization specified whether the survey participants were referring to the OCU or the UOC-MP, from which the OCU split in 2018.70 Expert interviewees posited the combination of religious conspiracy and distrust of vaccination in society has complicated Ukraine’s COVID-19 vaccine rollout.

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PERCEPTIONS OF RUSSIAN CULPABILITY IN SPREADING DISINFORMATION TO EXPLOIT UNREST, SOW DISTRUST, AND INCREASE INFLUENCE RUSSIAN STATE-AFFILIATED ACTORS ARE SEEN AS EXPLOITING DOMESTIC UNREST AND THE PANDEMIC TO PUSH DISINFORMATION AND INCREASE INFLUENCE IN THESE COUNTRIES.

my experience, most “IN of the disinformation comes from Russian

websites and TV channels, as well as YouTube or pro-Russian websites like strana.ua.”

Russia has historically promoted medical disinformation in these countries, a fact that remained fresh in experts’ minds, especially in Ukraine. Now, “western” vaccines and treatment protocols are the targets. In-depth interviews with experts and media diary entries demonstrate a connection between Russia and medical misinformation and disinformation (particularly related to vaccines).

Experts hypothesized Russia’s disinformation promulgators aim to weaken medical development and delivery capability in neighboring countries, increasing reliance on Russian resources (including vaccine solutions).

Twenty of the 21 Georgian experts perceived Russia as the main source of disinformation. One expert stated the Russian disinformation machine is one of the most effective of its kind and even advanced societies and states struggle to tackle it. They echoed a common belief in the complex “network” of systems, technologies, groups, and individuals working to share false information through a prescribed strategy of intermingling fact and fiction to lend credibility to disinformation narratives.

UKRAINIAN MEDIA EXPERT

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Some Georgian experts reported observing increased use of Georgian language by Russian media outlets. They cited examples of Russian-language disinformation translated to Georgian to overcome Georgian skepticism toward Russian-origin messaging. Georgian experts used the term “spoilers” to describe individuals and groups that engage in this information “laundering.” A CSO leader observed, “The Kremlin has realized that Russian-language content is less trusted [in Georgia], and now they are investing funds in pro-Russian Georgian platforms because content written in Georgian may look more credible to Georgian users than material presented in Russian.” The expert found these groups work locally but have Russian funders, including the Federal Secret Service. Per all Georgian civil society leaders interpublic viewed, the Kremlin has invested in pro-Russian Georgian opinion platforms to spread messaging in local languages more is the primary goal behind effectively.

Russia’s efforts in Georgia.”

In-depth interviews highlighted publications such as Marshall Press, Georgia and the World, and News Front GEORGIAN as openly pro-Russian. News Front, supported by the

MEDIA EXPERT Russian FSB, “did not have a wide reach in Georgia prior to the outbreak of the pandemic, but it has become active in creating chaos surrounding the coronavirus

“SHAPING

“RUSSIAN

sources are convenient and effective in Kazakhstan as they inhabit the same linguistic space. In Kazakhstan, language matters more than political orientation in disseminating misinformation and information in general. But traditional media, some argue, is too tightly controlled and policed to be able to spread wrongful information.”

pandemic,” stated a civil society member. Fact-checking institutions and state authorities are slower to validate information in Georgian than Russian or English. Several Georgian media experts mentioned Russian and English information is fact-checked quickly and, if necessary, taken down. However, information in Georgian stays on social media longer period, an advantage for those who spread disinformation.

In Kazakhstan, very few interviewees attributed disinformation, or even misinformation, campaigns to foreign governments. According to several experts in Kazakhstan, it is not Russia’s intention to spread disinformation in their country. However, they did acknowledge Kazakhstan is an ancillary recipient of other Russian-directed information campaigns because the country is part of the same linguistic and political space. Only two Kazakhstani experts named Russia or China as sponsors of disinformation campaigns.

Most Kazakhstani experts hypothesized it was financial gains motivating the spread of disinformation. One medical expert reflected favorably on evidence-based systems being implemented in the Georgian public health sector. They pointed out that Kazakhstan, like Russia, is facing a high level of corruption in the medical sector, which stems from the state government’s unwillingness to reform. “Medical misinformation is one of the main problems in our country, and it originates from state officials as its primary source [and is] fueled by the propensity for corruption of the entire healthcare system in Kazakhstan,” noted the expert. Another Kazakhstani medical professional emphasized financial gains in the medical sector, noting pharmaceutical manufacturers and medical clinicians are “a huge business.” The expert added this problem is directly “connected to corruption, on the one hand, and totalitarianism and dictatorship in our country [Kazakhstan], on the other hand.” The interviewee highlighted Kazakhstan’s “dependency on Russia” in the medical sector and concluded, “All of these problems and challenges are ultimately interconnected.”

KAZAKHSTANI MEDICAL PROFESSIONAL

On the other hand, 14 of the 18 Ukrainian experts interviewed believe anti-vaccination campaigns originated in Russia. Several mentioned a 2018 study in the American Journal of Public Health,71 which demonstrated the Russian Federation is responsible for spreading disinformation, and moreover, that Russian trolls are fueling the debate over vaccination, which led to a decline in vaccination coverage in Ukraine and Europe. Research by Broniatowski, et al., conducted in Ukraine in 2018 demonstrates the field of healthcare is politicized because it concerns the entire population—almost all citizens need healthcare at some point. Therefore, various political forces, including those with direct ties to the Russian Federation, exploit the universality of health issues. Ulana Suprun, the former acting Minister of Health in Ukraine, and the targeted disinformation spread about her policies provide one example. Disinformation clearly of Russian origin aimed to show Ulana Suprun “kills medicine,” a politically beneficial position for pro-Russian parties in Ukraine, according to one interviewee.

Fourteen of the 18 Ukrainian experts interviewed assumed COVID-19-related disinformation is a state strategy of the Russian Federation. The experts posited economic interest is directly tied to geopolitical agenda. Outbreaks of infectious diseases have severe consequences for Ukraine’s economy, which if strained will destabilize the state. In addition to political and economic interests, Russian pharmaceutical

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companies were mentioned as organizations with financial interest in Ukraine. They advertise pharmaceutical products in Ukraine that have not cleared proper approvals.

Piece on Gordon.ua website shared by Ukrainian media diarist that quotes Minister Stepanov about former Acting Minister Suprun’s policies.

Overall, expert interview results indicate an awareness that Russian state- and non-state affiliated actors exploited the ongoing health crisis to sow distrust in institutions and leadership of these three countries. Financial interests drive Russia’s spread of disinformation. The destabilization resulting from disinformation campaigns allows Russia to increase its control and expand its influence in the region. The politicization of COVID-19 and vaccinations add to Russia’s ability to use this information to further its own agenda.

THE IMPACT OF DISINFORMATION AND THE COUNTERMEASURES IN PLACE ACCORDING TO HEALTH, MEDIA, AND CIVIL SOCIETY EXPERTS, THE NEGATIVE EFFECTS OF DISINFORMATION ON PUBLIC HEALTH HAVE INCREASED WITH THE OUTBREAK OF THE PANDEMIC. One of the biggest threats of medical disinformation is its potential to thwart government-sponsored public health initiatives, stated 18 of the 21 Georgian experts (including all Georgian medical professionals interviewed), seven of the 18 Kazakhstani experts, and 10 of the 18 Ukrainian experts.

According to public health experts in all three countries, medical disinformation may hinder medical treatment on an individual level. Of the practitioners interviewed, 19 percent have encountered patients whose eroded trust in the medical field led them to value “crowdsourced” medical information over physician recommendations. Several experts mentioned individuals spread myths easily through “word of mouth.” For example, Georgians often compensate for structural shortcomings in national health infrastructure by consulting neighbors, relatives, and friends. Preventive medicine is not a widespread priority, with individuals focusing on ex post facto treatment and symptom management. Five of the 21 know what the basic Georgian experts opined the government’s agenda does motive is - creating not encourage preventive medicine, and there are few mistrust. Spreading conspiracy resources dedicated to its promotion. theories is shaking trust towards evidence-based On an individual level, experts are well aware of science and manipulating the negative effects of health-related disinformation. [vulnerable] people more Working in the health and public sectors, our particieasily.

The motive is clear: pants directly witnessed the consequences of individual to control you.” health decisions made with faulty information, and they provided compelling examples from their professional and personal lives. Experts stated they try to filter infor GEORGIAN

CSO LEADER mation, consume only trustworthy resources, and check the reliability of information. Most civic organizations, media journalists, and medical personnel operate in the constant presence of disinformation. The experts interviewed

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POS.tv article shared by Georgian media diarist— interview with Dr. Levan Ratiani where he claims that COVID will pass without a need for the vaccine.

view counteracting disinformation as routine.

According to one medical professional in Georgia, countering misinformation and disinformation has become “an integral part of the working process [of medics],” and the interviewee lamented, “Disinformation is wasting our time, energy, and resources when this time and energy could be used toward something more constructive for our country.” The expert concluded, “information warfare requires a lot of energy,” and the resources and efforts spent on combatting it “hinder the country’s development.”

In fact, of the experts interviewed in Georgia, six of the 21 mentioned medical disinformation is complicating doctors’ work, and that in addition to developing and resourcing treatment plans, they must campaign for their patients’ trust. They spent time refuting myths and advocating on behalf of evidence-based medicine.

In Kazakhstan, medical experts observed health disinformation’s most destructive impacts were during medical treatment. Medical professionals cited examples where disinformation complicated treatment processes, especially when patients self-diagnosed, followed pseudo-experts’ advice on YouTube, or refused to follow medical advice.

Disinformation can also result in self-diagnosed patient complaints, complicating the work of medical doctors, who spend time screening for phantom conditions. Seven of the 18 experts in Kazakhstan elaborated on the impact of disinformation and misinformation on their personal lives and loved ones. However, 10 of the 18 Kazakhstani experts blamed lack of professionalism and appropriate medical education for negative effects on public health, rather than misinformation or disinformation.

In Ukraine, experts who practiced medicine agreed disinformation complicates medical treatment by sowing distrust between doctors and patients. Their experience was, after experiencing misinformation/disinformation, patients stop believing doctors yet simultaneously expect the doctor to cure them. A senior medical executive gave an example of non-communicable diseases, such as diabetes and hypertension, which are treated and prevented primarily through lifestyle modifications. Medical professionals observed that once patients continue to consume medical misinformation or disinformation, they approach the doctor wanting a “magic pill” for their condition, while not changing any behavioral patterns. This illustrates how the responsibility to combat false information is transferred to medical providers when disinformation distorts a patient’s understanding of medicine.

once treated patients with “Ifighting the drugs I am currently against due to their

lack of evidence… From the early professional years, the system taught me that these were effective and useful drugs, and they should be prescribed to patients. But when you go beyond the Ukrainian educational space, you encounter international evidence sources (such as the British NICE or the American CDC, among other professional associations), and realize that we are far from evidence-based medicine.”

UKRAINIAN MEDICAL PROFESSIONAL

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EXPERTS ACKNOWLEDGE THE DISINFORMATION THREAT BUT LACK CONFIDENCE IN CURRENT COUNTERMEASURES AWARENESS OF HEALTH-RELATED MISINFORMATION AND DISINFORMATION HAS INCREASED SINCE THE OUTBREAK OF COVID-19. HOWEVER, 16 OF THE 21 GEORGIAN EXPERTS, 12 OF THE 18 KAZAKHSTANI EXPERTS, AND EIGHT OF THE 18 UKRAINIAN EXPERTS EXPRESSED A LACK OF CONFIDENCE IN THEIR GOVERNMENTS, NONGOVERNMENTAL AGENCIES, OR CIVIL SOCIETY ORGANIZATIONS TO COUNTER IT. SOCIAL MEDIA’S POPULARITY AND ITS LAX OVERSIGHT WERE CITED AS VULNERABILITIES BY THOSE INTERVIEWED. According to interviewed experts in the three countries of study, neither the media nor the healthcare sectors take sufficient action to combat misinformation and disinformation. Media outlets suffer from the lack of resources to fact-check information. Reporting on the pandemic has also strained journalists, who are under pressure to produce real-time reports with little medical or scientific background. According to most experts interviewed, public health authorities are ineffective communicators with the public. There is insufficient coordination between health authorities and the media to ensure consistency of messaging around the pandemic and public health measures. Interviewees emphasized state authorities have a responsibility to ground communications and education in evidence-based medicine.

In Georgia, experts only cited international or partner-sponsored efforts, including the World Health Organization’s sponsored “infodemic management” training, and noted more media literacy training for journalists and consumers is needed. Some media sector representatives reported research or factchecking initiatives through their publishers or professional organizations. Several experts also emphasized the need to translate public campaigns, statements, and speeches into Russian, Armenian, Azeri, and other languages to guarantee accessibility to minorities.

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information “PUBLIC was very closed {after the outbreak of

COVID-19,]. Apart from the fact that the requested public information was not provided to us directly, its delivery was also delayed or entirely incomplete…

When the government and state agencies do not cooperate with the media during such a difficult time, it pours directly into the mill of disinformation.”

GEORGIAN

MEDIA EXPERT

Most Georgian experts had not been involved in awareness campaigns or training courses. Some struggled to remember whether such opportunities existed, but others readily cited NGOs working on these issues and awareness-raising activities. The Georgian government also engaged in this work on a limited level with public health projects. Eighteen of the 21 Georgian experts believed the government should play a significant role in combatting health misinformation and disinformation, while 11 of the experts said the government is not doing enough to fight medical disinformation. The experts were not aware of a standard protocol for evaluating or countering medical disinformation.

Georgian media experts pointed out the pandemic has exposed communication problems between the

government and media sectors. They stated critical messages are not shared efficiently, citing instances where information requests were not met promptly. Expert interviewees posited journalists and others working to inform the public should receive official statements quickly to minimize space for false information and conspiracy theories.

Twelve of the 18 Kazakhstani experts stated they had no awareness of events or activities aimed at combating health disinformation. “It takes too long to get a reaction from the Ministry of Health, and while they take their time to react, alternative sources of information emerge. If they do not react at all, rumors start to spread. Rumors also prevail in social networks. There is a rule, that if a rumor is confirmed by ten people, it becomes an axiom,” stated one expert. (However, some experts in Kazakhstan mentioned FactCheck.kz as a specific organization engaged in confronting misinformation and disinformation.) Several Kazakhstani experts recommended combatting disinformation by setting up a single platform with representatives of public health institutions, where an open dialogue could exist.

In Ukraine, experts underscored the need to include health officials and institutions in media literacy trainings and communications campaigns to improve government messaging on health-related issues.

Most Ukrainian experts agreed there is a need for more reliable information grounded in evidencebased medicine to combat disinformation and misinformation. State authorities have a special responsibility in this regard. Several Ukrainian experts interviewed posited every government agency should focus on different educational activities, information projects, and media activities. One expert cited the problematic example of Google searches. When using Google to search for a medical diagnosis in both English and Ukrainian, the English version yields government or medical sites with evidencebased medicine. However, the interviewee observed, “When I ‘Google’ a diagnosis in Ukrainian, it takes me to some obscure website, where I am told how to treat with some concoctions of nettles. This information is often translated into Russian. When I google the same diagnosis in English, however, I come across government sources, medical websites, specific data, etc.”

In Ukraine, over half of the experts were aware of activities, trainings, or working groups aimed at combating medical disinformation. Due to their senior standing, some served as event organizers or hosts. Experts reported participation in initiatives for varying target audiences, including UNICEF and USAID immunization programs, projects for responsible parenting, a WHO training for journalists, fact-checking training, and training to conduct medical investigations. Experts from all sectors in Ukraine emphasized the importance of professional medical development and enrichment. The adoption of evidence-based scientific investigation, education, and documentation has extended to policy and media circles, and experts hope this will continue in universities and hospitals.

Many of the experts, especially those in Ukraine and Georgia, suggested that educating health professionals in technical English would enable practitioners to access more evidence-based medicine sources.

31

MOVING FORWARD

T

MEETING CHALLENGES AND POTENTIAL NEXT STEPS ACCORDING TO EXPERTS

HIS REPORT

was compiled during the pandemic crisis from October 2020 to May 2021. Epidemic management strategies, vaccines, treatment technologies, novel messaging, and public information campaigns continue to evolve as this report is printed. End-users of the report are encouraged to form policy recommendations by considering the empirical data documented here and supplementing with other sources.

Governments must recognize medical disinformation as a significant challenge affecting their national security. Public health disinformation creates a fog of uncertainty and erodes trust in institutions and governments tasked with implementing critical interventions. In healthcare, timely intervention is critical, and delays due to disinformation and misinformation can be deadly. It has demonstrably prolonged the pandemic and caused unnecessary death and physical hardship in the countries of study.

Our findings showed in fraught healthcare decisions national and international organizations are often met with skepticism. Providing trusted institutions with messaging rooted in evidence-based research and accelerating the implementation of public health programs mitigates misinformation and disinformation’s negative effects. The recommendations below are informed by conversations with in-country experts.

• P RIORITIZE AND STREAMLINE COOPERATION BETWEEN GOVERNMENT AND PRIVATE SECTOR ACTORS IN THE FIGHT AGAINST COVID-19. Efforts to combat misinformation and disinformation often sideline NGOs, CSOs, or industry. Collaborating will increase the “marketability” of counter-disinformation efforts, while also separating these efforts from partisan agendas. This “whole-of-society” approach could consist of community-outreach NGOs or government and NGO experts working together on task forces.

Additionally, experts believe the politicization of information (whether intentional or unintentional) should be diminished because it provides material for adversarial states to use for their purposes.

In-country experts recommend government and private institutions hold each other accountable and fact-check the validity of information they disseminate to the public.

32

• ENSURE MEDICAL SECTOR PRACTITIONERS USE EVIDENCE-BASED BEST PRACTICES WHEN TREATING PATIENTS. A top-down, public commitment to unbiased, evidence-based practice will combat perceptions of incompetence in medical institutions, while also reducing fears of corrupt foreign influences in the sale of drugs or vaccine usage. Practitioners should be trained on how to discuss evidence-based treatment with patients. Medical institutions should put in place transparent mechanisms for the procurement of drugs and vaccines.

• COUNTER MISINFORMATION AND DISINFORMATION WITH HIGH-PROFILE, WELL-SUPPORTED, AND AUTHORITATIVE PROGRAMMING ON THE SAME PLATFORMS RESPONSIBLE FOR DISSEMINATING MISINFORMATION AND DISINFORMATION. Lack of access to trustworthy material drives citizens to seek information via social media on platforms such as Facebook, YouTube, Instagram, or WhatsApp. This demand for answers can be addressed through nonpartisan, straightforward programming with well-respected medical experts. Outcomes could include the development of an educational podcast and online video series answering audience questions about COVID-19. This could transition to covering public health issues after the pandemic. By enlisting government figures and celebrities in this messaging, counter-disinformation campaigns can leverage “elite” messaging on public opinion.72 •M EDICAL INSTITUTIONS CAN DEVELOP AND IMPROVE THEIR OUTREACH TO DIFFERENT AUDIENCES. Perceptions of corruption in the public health sector have created an environment for misinformation and disinformation.

The lack of training of hospital employees also causes hospital outreach services to be ineffective.

Each state hospital should establish a public outreach team.

• COORDINATE OUTREACH INITIATIVES WITH RELIGIOUS INSTITUTIONS. Most experts observed religious institutions deserve credit for the care they deliver to individuals suffering from COVID-19 and for their evolving understanding of the threat of COVID-19. Given the prominent position of religion in society, governments and the public health sector can work with religious institutions to identify the root causes behind vaccine hesitancy and create materials that address frequent concerns (such as the ingredients in treatments).

• CREATE MEDIA LITERACY AND CRITICAL THINKING SKILLS THROUGH EDUCATIONAL CURRICULA ON TOPICS SUCH AS PROTECTION FROM MISINFORMATION AND DISINFORMATION CAMPAIGNS. Most participants stressed complex media and informational spaces were confusing citizens rather than empowering them. The experts articulated a need for change from the Soviet legacy and the preparation of citizens for a fully digitized world. Media literacy and critical thinking training can be designed for secondary education and higher education training in journalism or medicine, which face challenges with misinformation and disinformation.

Recent studies have demonstrated the efficacy of even brief “inoculation against disinformation” training in increasing discernment and decreasing the spread of inaccurate information.73 Simple messaging that encourages news consumers to “slow down” before sharing content has effectively reduced the spread of certain narratives. By educating the population in countering disinformation, 74 media literacy implementers encourage responsible news consumption and dissemination.

• CONDUCT ANTI-MISINFORMATION AND ANTI-DISINFORMATION PROGRAMMING IN MULTIPLE LANGUAGES. Failure to create accessible programming for already at-risk minorities can lead to information bubbles or echo chambers. This also applies to translating medical texts, scientific journals, and the latest medical literature from English into other languages. As one Ukrainian medical expert noted, “Without [knowing] English, in the modern-day medical field, it is simply impossible [to practice current, evidence-based medicine] because all of the literature is in English. Whether you like it or not, this is the reality. And even if you work [as a health provider] in a village, access to the medical information is also related to Englishlanguage material.” In-country experts recommended medical centers start by creating review committees to evaluate and approve translated medical articles and materials.

Experts suggested the Ministries of Health and Education work in tandem to ensure under-served communities are provided with ethnically inclusive materials in multiple languages.

33

• COORDINATE COUNTER-DISINFORMATION AND COUNTER-MISINFORMATION EFFORTS BETWEEN TRUSTED LOCAL INSTITUTIONS AND INTERNATIONAL PUBLIC AND PRIVATE HEALTH SECTORS TO ACHIEVE A TIMELY “WHOLE-OF-SOCIETY” RESPONSE. High levels of regional medical misinformation and disinformation jeopardize the fight against COVID19. A global health crisis requires a global health response. Therefore, the fight to counter regional medical misinformation and disinformation would benefit from a joint international effort that leverages the international public and private health sectors with their regional counterparts. This effort would benefit from foreign expertise from embassies in Georgia, Kazakhstan, and Ukraine.

• I NVESTIGATE AND UNDERSTAND THE COGNITIVE EVALUATIVE PROCESSES THAT INFLUENCE TARGET POPULATIONS. By applying cultural and linguistic context to advances in implementation and behavioral sciences, Georgia, Kazakhstan, Ukraine, and other regional neighbors can best adapt and adopt programs to counter health disinformation and its negative impacts. As disinformation has been a global challenge, many experts and international organizations have invested resources in understanding how and why certain messaging is effective. Some findings and trends are universal but applying study methodologies that have been used in other regions could yield specific insights into EE/CA- specific preferences or phenomena that will be useful in tailoring interventions from the international community, such as the WHO. (Please refer to endnote #1 for a selection of sources discussing public health studies and internationally vetted best practices, including research by WHO.)

RECOMMENDATIONS FROM EXPERTS IN GEORGIA • BOTH THE GEORGIAN GOVERNMENT AND POLITICAL OPPOSITION SHOULD PURSUE AN IMMEDIATE DEPOLITICIZATION OF COVID-19.

Political actors have used the pandemic as a prop. The public is aware of this, and it is deepening already inflamed internal divisions. Further policy decisions on COVID-19 measures should be presented to the public by multiparty teams of political figures and experts for a united front.

•M ANY EXPERTS RECOMMENDED COORDINATING OUTREACH INITIATIVES WITH FAITH LEADERS IN THE GEORGIAN ORTHODOX CHURCH, AN INSTITUTION WITH A HIGH LEVEL OF PUBLIC TRUST. Based on expert recommendations, GOC representatives and faith “influencers” could work with public figures to create and deliver COVID-19 programming, including the Church supporting vaccination efforts. Further research with local stakeholders could identify specific ways to engage with religious leaders.

• THE EXPERTS RECOMMEND THE GEORGIAN GOVERNMENT WORK WITH NGOS TO CREATE AND DISSEMINATE COUNTER-MISINFORMATION AND COUNTER-DISINFORMATION PROGRAMMING. State involvement in fighting COVID-19 has declined, along with public perception of the state’s efficacy in fighting the pandemic. Georgian experts were particularly interested in the state taking the lead to unite anti-misinformation and anti-disinformation efforts from government and nongovernment actors. The Georgian government should create a robust, expansive campaign that addresses public concerns on health and the economy across the ideological spectrum.

34

• IMPLEMENT

COUNTER-MISINFORMATION AND COUNTER-DISINFORMATION MESSAGING WITHIN A NATIONAL SECURITY FRAMEWORK. Oversight from the National Security Council would ensure the state funding and attention the pandemic and combatting misinformation and disinformation require. Disinformation is a national security threat. CSO leaders and media experts in Georgia recommended creating a counter-disinformation center within the National Security Council to ensure a coordinated approach to countering misinformation and disinformation.

• S EVERAL EXPERTS RECOMMENDED NATIONAL GOVERNMENT MORE VISIBLY SUPPORT HEALTH INSTITUTIONS, LOCAL COMMUNITY AUTHORITIES, AND ETHNIC MINORITIES. Coordinate with local government to form proactive and reactive medical information campaigns. Measure outcomes to define their effectiveness. Educational courses on COVID-19 must be offered to practicing providers. After the pandemic, continuing education for medical doctors and nurses should be mandatory. Provide practitioners with evidence-based information disseminated in conferences, webinars, group meetings, and newsletters. Include underserved ethnic minorities who have less access to medical information, as this study showed.

RECOMMENDATIONS FROM EXPERTS IN KAZAKHSTAN • ENCOURAGE OPPOSITION PARTY MEMBERS TO COORDINATE COVID-19 MESSAGING. The current authoritarian model persecutes political opponents and exposes medical practitioners to criticism, without addressing the lack of trustworthy information that has caused public confusion. Opposition members charged with COVID-19-related offenses (failure to comply with lockdown, curfew, and other pandemic regulations) could be offered amnesty. State ministries should design evidence-based, easy-to-understand public service campaigns about the pandemic.

• INCREASE COOPERATION BETWEEN STATE MINISTRIES IN FORMING AND IMPLEMENTING POLICY. The Ministries of Healthcare and Information can ensure public service materials are standardized before release, and a task force could be created to establish cross-ministry cooperation. CSO leaders and medical professionals recommended medical practitioners receive immediate standardized, specific guidance on COVID-19 concerns and media training.

• E XPAND TRAINING PROGRAMS FOR MEDICAL PRACTITIONERS AND PATIENTS TO COUNTER COVID- 19 MISINFORMATION AND DISINFORMATION. Doctors are not provided with tools to counter disinformation, and patients are often left to navigate their diagnoses in an informational vacuum. Kazakhstani experts recommended the Ministry of Healthcare establish standards for regional medical associations to adopt and/or coordinate with physicians through continuing medical education programs. Outpatient programming, as well as positive cooperation with journalists covering medical issues, have also been successful in the past with communicable disease issues. Patient education is crucial in reducing misinformation and increasing confidence in the medical sector.

• I MPROVE TRANSPARENCY AND REDUCE CORRUPTION IN DEMONSTRABLE WAYS WITHIN THE MEDICAL SECTOR. Public faith in this vital sector has fallen to new depths during the outbreak of COVID-19, with leadership perceived as apathetic, corrupt, or even in cooperation with foreign governments to the detriment of Kazakhstanis. Ensuring adequate compensation for healthcare providers could be a step toward retaining practitioners and reducing corruption/bribery in the medical field. Other transparency efforts could include documenting and publicizing the research and development process of various technologies, which would build faith in the scientific rigor behind treatments and vaccines.

35

RECOMMENDATIONS FROM EXPERTS IN UKRAINE • INCREASE CLARITY OF DESIRED PANDEMIC RESPONSE OUTCOMES AND COUNTER-MISINFORMATION AND COUNTER-DISINFORMATION EFFORTS. This is recommended by experts for the Ministry of Health (MoH) in both the public and regional health departments. Both sectors would benefit from more consistent access to centralized, standardized responses and resources for public health risks. Initial steps could include factfinding outreach and identifying public and health department concerns. Follow this with a clear and concise public action plan.

• PROVIDE UKRAINIAN HEALTH PRACTITIONERS WITH THE LATEST EVIDENCE-BASED MEDICAL TRAINING AND MATERIALS. Media professionals and CSO leaders also recommend the Ministry of Education (MoE) increase media literacy and critical thinking components of public educational institutions. The newly formed Center for Strategic Communications and Informational Security (under the Ministry of Culture and Information Policy) could work with the MoE and MoH to ensure continued improvements in the medical sector. Experts believe more competent, compassionate practitioners will increase trust and help patients recognize misinformation and disinformation. This is vital to Ukraine’s national security. Short-term outcomes should include updated definitions and protocols for how to discuss misinformation with patients and a national, medical digital presence that streamlines vaccination and/or COVID-19 information and appointments.

• ENACT 2017 HEALTHCARE REFORM LEGISLATION. Political pushback and COVID-19 have slowed national healthcare reform, but the implementation and maintenance of reform measures are vital to combating misinformation and disinformation. High-profile attacks on the legitimacy and efficacy of reform measures that do not offer solutions confuse the public. Meaningful critiques of reform measures, such as urban/rural divides in access, need to be addressed to increase public buy-in and trust. Any pause in movement will be interpreted by the long-suffering public as backsliding, so the second and third stages of the 2017 reform legislation need to be enacted.

• ESTABLISH A CENTRALIZED NATIONAL AUTHORITY FOR ADDRESSING MISINFORMATION AND DISINFORMATION. Ensure vulnerable populations are not harmed by public policy choices. Greater resources and strategic visions are needed to combat damaging narratives about COVID-19. The multiple sources of misinformation and disinformation also need to be addressed. Therefore, experts believe increased cooperation and information sharing is needed between the Center for Strategic Communications and Informational Security, the MoH, and other agencies responsible for Ukraine’s public health and informational security. The naming of misinformationproducing organizations may be necessary in some contexts, but it is recommended this collaboration prioritize identifying, quantifying, and addressing the variety of factors that allow for misinformation.

36

37

ENDNOTES: For a selection of sources discussing public health studies and internationally vetted best practices in designing and implementing counter-disinformation strategies, please see the following: Claire Felten and Arthur Nelson, “Countering Misinformation with Lessons from Public Health,” Countering Misinformation with Lessons from Public Health (Center for Strategic and International Studies, October 1, 2019), https://www.csis.org/countering-misinformation-lessons-public-health; Sarah Cunard Chaney, Peter Benjamin, and Patricia Mechael, “Finding the Signal Through the Noise,” Gavi, theVaccine Alliance (Health Enabled, June 2021), https://www.gavi.org/sites/default/files/2021-06/ Finding-the-Signal-Through-the-Noise.pdf; Tina D Purnat et al., “Infodemic Signal Detection during the Covid-19 Pandemic: Development of a Methodology for Identifying Potential Information Voids in Online Conversations,” JMIR Infodemiology (JMIR Publications Inc., July 28, 2021), https://infodemiology.jmir.org/2021/1/e30971; National Academies of Sciences, “Addressing Health Misinformation with Health Literacy Strategies,” National Center for Biotechnology Information (National Academies Press (US), December 17, 2020), https://www.ncbi.nlm.nih.gov/books/NBK565935/; Zara Abrams, “Controlling the Spread of Misinformation,” Monitor on Psychology (American Psychological Association, March 1, 2021), https://www.apa.org/monitor/2021/03/controlling-misinformation; Katherine J. Igoe, “Developing Public Health Communication Strategies-and Combating Misinformation-during Covid-19,” Executive and Continuing Professional Education (Harvard School of Public Health, April 3, 2020), https://www.hsph.harvard.edu/ecpe/public-health-communication-strategies-covid-19/; “NATO’s Approach to Countering Disinformation: a Focus on COVID-19,” North Atlantic Treaty Organization (NATO, July 17, 2020), https://www.nato.int/cps/en/natohq/177273.htm.

1

Bernd Rechel, Erica Richardson, and Martin McKee, Trends in Health Systems in the Former Soviet Countries (European Observatory on Health Systems and Policies, 2014), https://www.euro.who. int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Sovietcountries.pdf.

2

Paul Stronski, “Ex-Soviet Bioweapons Labs Are Fighting COVID-19. Moscow Doesn’t Like It,” Foreign Policy, June 25, 2020, https://foreignpolicy.com/2020/06/25/soviet-bioweapons-labs-georgia-armenia-kazakhstancoronavirus-russia-disinformation/.

3

This research builds on research conducted recently by the United States. Cognitive scientists have identified factors that may influence what news people “believe.” Recent studies indicate many of the factors that influence discernment and evaluation of media do not, by themselves, prevent people from separating fact from fiction. While this theory has primarily been supported by datasets and case studies from the United States, it provides a useful framework for understanding subtle underlying conditions that may be amplified to result in the perceptions and impacts of front-line sources. See more: Gordon Pennycook and David Rand, “The Psychology of Fake News,” Trends in Cognitive Sciences 25, no. 5 (May 2021): 388-402, https://archive.is/R3lxx.

4

38

5

“Stopcovid.ge,” accessed September 30, 2021, https://stopcov.gov.ge/.

Giorgi Lomsadze, “Georgia’s COVID Outbreak Grows from Molehill to ‘Everest,’” Eurasianet, December 7, 2020, https://archive.is/d7XUT.

6

Lomsadze, “Georgian COVID Immunization DRIVE Stumbles out of the Gate,” Eurasianet, March 24, 2021, https://eurasianet.org/georgian-covid-immunization-drive-stumbles-out-of-the-gate.

7

8

Lomsadze, “Georgia’s Covid Outbreak Grows from Molehill to ‘Everest.’”

Lomsadze, “Georgia: The DISCREET Inevitability of Chinese Vaccines,” Eurasianet, July 8, 2021, https://eurasianet.org/georgia-the-discreet-inevitability-of-chinese-vaccines.

9

“Kazakhstan,” Worldometer, accessed September 14, 2021, https://www.worldometers.info/coronavirus/country/kazakhstan/.

10

The World Bank, “The COVID-19 Shock to Kazakhstan’s Economy Largest in Two Decades: World Bank Report,” press release, July 22, 2020, https://archive.is/2NaAT; “Kazakhstan and Uzbekistan Experiment with Vaccines Amid Lack of Public Confidence,” Eurasianet, August 16, 2021, https://eurasianet.org/kazakhstan-and-uzbekistan-experiment-with-vaccines-amid-lack-of-public-confidence.

11

Almaz Kumenov, “Kazakhstan’s War on Coronavirus Fake News Underwhelms,” Eurasianet, August 28, 2020, https://archive.is/1TLi9.

12

Catherine Putz, “How Data Doomed Central Asia’s COVID-19 Responses,” Diplomat, July 23, 2020, https://archive.is/828E3.

13

David Stanway, “China’s Kazakhstan Embassy Warns Citizens of Pneumonia Deadlier than COVID-19,” Reuters, July 10, 2020, https://archive.is/NAsit.

14

“Kazakhstan to Launch Plant for Production of DOMESTIC COVID-19 Vaccine in September,” TASS, July 10, 2021, https://tass.com/economy/1312653.

15

“Ukraine,” Worldometer, accessed September 14, 2021, https://www.worldometers.info/coronavirus/country/ukraine/.

16

Anna Myroniuk, “Stepanov: Third Wave of COVID-19 Is over in Ukraine,” Kyiv Post, May 7, 2021, https://archive.is/6E5zj.

17

Gabriela Miranda et al., “THE COVID-19 CRISIS IN UKRAINE,” OECD Eurasia Division, December 11, 2020, https://archive.is/8KpAH. 18

Maryna Shevtsova, “COVID-19 PANDEMIC CASE STUDY: UKRAINE,” Heinrich-Böll-Stiftung, December 2020, 4, https://archive.is/Y3Jp6.

19

Mark Raczkiewycz, “Ukraine’s Health-Care System, Economy Struggle To Cope With COVID-19,” RFE/RL, January 4, 2021, https://archive.is/Y3Jp6.

20

Олексій Ляшенко, “Ставлення Українців До Вакцинації Проти COVID-19,” Research & Branding Group, March 25, 2021, https://archive.is/IOl6Z.

21

22

Raczkiewycz, “Ukraine’s Health-Care System.”

23

Ляшенко, “Ставлення Українців.”

Interfax, “Rumors about AstraZeneca Insecurity May Be Related to Information Attack from Russia Tkachenko,” Interfax-Ukraine, March 17, 2021, https://archive.is/dTHPU. 24

Furlong, Ray, “Troops and Medics in Ukraine’s War-Torn East Reject COVID-19 Vaccines,” RFE/RL, March 15, 2021, https://archive.is/5fGF0.

25

Gurman Bhatia, Prasanta Kumar Dutta, and Jon McClure, “Ukraine: The Latest CORONAVIRUS Counts, Charts and Maps,” Reuters, September 14, 2021), https://graphics.reuters.com/world-coronavirus-tracker-andmaps/countries-and-territories/ukraine/.

26

“Ministry of Health Reports How Many Ukrainians Received AstraZeneca, CoronaVac and Pfizer Vaccines,” 112 Ukraine, June 23, 2021, https://archive.is/GmicZ. 27

39

Misinformation being defined as false information that is spread regardless of the intent vs. disinformation which is defined as false information deliberately spread by a government or organization in the pursuit of a specific outcome. See: Dictionary.com, “‘Misinformation’ vs. ‘Disinformation’: Get Informed on the Difference,” accessed July 7, 2021, https://archive.is/SGAdb. 28

“Seven Years of Illegal Occupation of the Autonomous Republic of Crimea,” U.S. Embassy in Ukraine, March 10, 2021, https://archive.is/vGXPX. 29

Елбол Каримов, “Это Вас Сильно Удивит: Ученый Назвал ‘Вероятную На 99,9%” Версию Появления Коронавируса,” Liter.kz, February 20, 2021, https://archive.is/kASL3.

30

Natalya Movchan, 2021 “Другой больной, которого выписали из больницы помирать от рака желудка,”Facebook, February 19, 2021, https://archive.is/LgTfW. 31

In order to protect the identity of research participants, unless noted otherwise, their names, professional affiliation, and other identifying factors, have been preserved for confidentiality.

32

Max Bader, “Disinformation in Elections,” Security and Human Rights 29 1, no. 4 (2018): 24-35, https://archive.is/w6OUn. 33

Catherine Putz, “Kazakhstan’s COVID-19 Crisis Spinning On,” Diplomat, July 14, 2020, https:// thediplomat.com/2020/07/kazakhstans-covid-19-crisis-spinning-on/.

34

Tamar Kintsurashvili, “Infodemic in Georgia,” Media Development Foundation, accessed June 21, 2021, https://archive.is/fOMAz.

35

Bakhtiyar Nurumov et al., “Informing the Public about the Dangers of a Pandemic. Early COVID-19 Coverage by News Organizations in Kazakhstan,” Central Asia Program, December 11, 2020, https:// archive.is/k15D2.

36

UNICEF, “‘Infodemic’ of COVID-19 Disinformation Bad for Ukrainians Health, Study for UN Finds,” press release, March 3, 2021, https://archive.is/2Hojx.

37

For the purposes of this study, an “expert” is a person recognized as a leader in their respective field(s). This status as a leader could be due to their authoritative knowledge or skill, professional or social position, and/or any other relevant factors.

38

For the purposes of this study, an “influencer” is defined as a person of some fame who possesses a large following. Please see: Daniel Carter, “Hustle and Brand: The Sociotechnical Shaping of Influence,” Social Media + Society 2, no. 3 (September 2016): 1-12, https://journals.sagepub.com/ doi/10.1177/2056305116666305.

39

Katia Patin, “In Kazakhstan, Coronavirus Conspiracies Are the Latest Celebrity Craze,” Coda Story, November 5, 2020, https://archive.is/vsHKY. 40

40

“Georgia Investigating Death of Nurse After She Received AstraZeneca Vaccine,” RFE/RL, March 19, 2021, https://archive.is/5TwGu.

41

IFRC, “Kazakhstan: IFRC and Red Crescent launch bot to counter COVID misinformation,” IFRC press release, February 19, 2021, https://archive.is/gHckx.

42

“Боранбаев и “Спутник V”. Как делают вакцину в Казахстане,” Tengrinews.kz, February 16, 2021, https://archive.is/cdPdp.

43

The Oxford–AstraZeneca COVID-19 vaccine is also sold under the brand names Covishield (produced by the Indian Serum Institute) and Vaxzevria among others.

44

“Multiple Actors Attack Ukrainian COVID-19 Vaccination Efforts,” DFRLab, March 31, 2021, https://archive.is/HB34I. 45

46

This article has since been removed or is otherwise unavailable on the NV.ua website.

47

Simon Kemp, “Digital 2021: Georgia,” Datareportal, February 11, 2021, https://archive.is/s0NU0.

Yuri Smirnov, “Telegram. How the Anonymous Empire of Pavel Durov Works,” Projects.liga.net, March 2, 2020, https://archive.is/kccfB. 48

DFRLab, “How pro-Kremlin Telegram Channels Influence Ukrainian Parliamentary Decisions,” Medium, September 1, 2020, https://archive.is/tDGh2.

49

50

Ibid.

Анатолий Шарий, ”Медведчук о вакцине, бюджете, Нормандии,” Youtube video, uploaded on December 16, 2020, https://archive.is/7gOIo. 51

Will Stewart, “Ukrainian Fitness Instagram Influencer, 33, ‘Who Thought Covid Didn’t Exist’ Dies of Coronavirus,” Daily Mail Online, October 18, 2020, https://archive.is/P9GH7.

52

“Top 1000 Instagram Influencers in Ukraine in 2021,” StarNgage, accessed January 29, 2021, https://archive.is/8bEYg. 53

Natela Khetsuriani et al, “Impact of Unfounded Vaccine Safety Concerns on the Nationwide Measles-Rubella Immunization Campaign, GEORGIA, 2008,” U.S. National Library of Medicine (National Center for Biotechnology Information), September 7, 2010, https://pubmed.ncbi.nlm.nih. gov/20674880/.

54

Inge Snip, “Majority of Georgians May Reject Covid-19 Vaccine, New Survey Suggests,” OpenDemocracy, July 23, 2020, https://www.opendemocracy.net/en/odr/majority-georgians-may-reject-covid19-vaccine-new-survey-suggests/.

55

Nino Maisuradze and Nino Memanishvili, “Anti-Vaxxing, Homophobia, pro-Russian Sentiments – Is the Church an Obstacle on Georgia’s pro-Western Course?” English Jamnews, January 17, 2021, https://archive.is/luP5u.

56

“‘ვაქცინა უკვე არის, მაგრამ შეგნებულად ხდება ამ ყველაფრის მიჩქმალვა’ - მამა საბა ჭიკაიძე,” PalitraNews.ge, May 6, 2020, https://archive.is/cQOVA. 57

Nestan Ratiani, “Georgian Clerics as Guardians of Conspiracy Theories,” Myth Detector Lab, May 25, 2020, https://archive.is/W9AIC.

58

Maridona, “მამა ზოსიმე ბერიძეს ვთხოვე დამხმარებოდა და მან მითხრა რომ არიანო ადამიანებიო თქვენსავით დაჩიპული და გაწამებულებიო მაგრამ უშიშროება გვაჩუმებსო,’” Tvm.ge, April 9, 2020, https://tvm.ge/archives/27178.

59

Григорий Дубов and Евгения Баленко, “Общественники Подписали Резолюцию Против ‘Чипирования’ Россиян,” РБК, April 20, 2019, https://archive.is/u8ddw.

60

61

საქართველოს

საპატრიარქო,

“საქართველოს

სამოციქულო

ავტოკეფალური

41

მართლმადიდებელი ეკლესიის წმინდა სინოდის განჩინება,” Georgian Patriarchate press release, February 11, 2021, https://archive.is/RrpxI. ნასტასია არაბული, “ვაქცინაცია, კრიზისი, სანქციები და ნამახვანჰესი - აქცენტები პრეზიდენტის პარლამენტში გამოსვლიდან,” RFE/RL, April 9, 2021, https://archive.is/dQaTI.

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Svante Cornell, S. Frederick Starr, and Julian Tucker, “Religion and the Secular State in Kazakhstan” Institute for Security and Development Policy, April 24, 2020, https://archive.is/Mf0gB. 64

“Свыше 16 Тысяч Казахстанцев Отказались От Вакцинации Своих Детей в 2019 Году,” Kazinform, January 28, 2020, https://archive.is/nmiiD.

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Alya Shandra, “Defiant Moscow Patriarchate in Ukraine Calls Faithful to Church for Easter,” Euromaidan Press, April 23, 2020, https://archive.is/0L5Ff.

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“Управляющий делами УПЦ прокомментировал ситуацию с эвакуацией украинцев из Китая,” Православная Жизнь, February 20, 2020, https://archive.is/EdNQ6.

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Ольга Кириленко, “Чи Суперечить Вакцинація Божим Заповідям? Глави Церков України Розтлумачують Своє Ставлення До Щеплення Від COVID-19,” Українська правда, January 31, 2021, https://archive.is/1LrDn. 68

Denys Kobzin and Svitlana Shcherban, “PERCEPTION OF PANDEMIA COVID-19 and VACCINATION: Survey Results,” International Renaissance Foundation, accessed July 2, 2021, https://archive.is/D1ick.

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Tony Wesolowsky, “Prayers Answered? Ukrainian Orthodox Church Marks One Year of Independence from Moscow,” RFE/RL, January 24, 2020, https://archive.is/qVHns.

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David A. Broniatowski et al., “Weaponized Health Communication: Twitter Bots and Russian Trolls Amplify the Vaccine Debate,” American Journal of Public Health 108, no. 10 (September 2018): 1378-1384, https://archive.is/nhjoi.

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Gordan Pennycook and David Rand, “Fighting COVID-19 misinformation on social media: experimental evidence for a scalable accuracy nudge intervention” Psychological Science 31, no. 7 (July 2020): 770-780, https://archive.is/DXTzo. 73

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