PLANETARY HEALTH WEEKLY

JAY’S BLOG #4

By: Jay D. Kravitz, BA, MD, MPH posted on January 11, 2021

This blog may be the most important reading of your day. Although I make this statement with a smile, this may not really be such an exaggeration if risk communication is part of your professional realm – or could be in the future. Ironically, overstatement is a risk communication technique. A touch of hyperbole to gain people’s attention! You can decide. 

Summarizing my Global Health course lectures, I’ll explain how integral communication is to the public health discipline. What’s the point of simply gathering data and drawing conclusions? You have to use that information to convey ideas and guide proper responses…and it’s complicated! 

In the field of public health, we unite science with people, who can be unpredictable and may not understand your message. The complex, interdisciplinary skills necessary to effectively deliver risk communication are intricately linked. In recent years “each situation has made us profoundly aware of how integral good communication is to disease control work.”¹  

And I predict in the future some of you will be overheard to say, “I never realized how important conveying risk information was until faced with that responsibility in a difficult situation!” 

Risk communication skills can’t be overemphasized, stated Dr. Baker, Director of the CDC Public Health Practice Program, in 2001 after the 9-11 terrorist attacks. “As we move into the 21^st century, communication may well become the central science of Public Health practice.”² Experts in the risk communication field, Covello³ and Sandman,⁴ provide insightful guidance that influenced this commentary. Sandman’s “3 golden rules:” Acknowledge and respect the public’s fear as natural, inevitable and appropriate; don’t understate risk to allay the public’s fears; and identify with and channel expected fear into action.

While serving as a public health official, I was frequently responsible for conveying risk information. That duty taught me the worrisome challenges associated with being an effective communicator when addressing the public or responding to mass media inquiries. When newly installed in my position (many years ago!), I was confronted by a television news reporter about a complaint with potential public health impact. I was unaware of this particular situation, so I declined to comment. The reporter’s aggressive response? “You have to talk to me, I’m television!” 

That experience captured the obvious. I had just encountered an unanticipated vocational obligation – the media interview process. My professional issue? Medical School and Master of Public Health graduate school did not provide risk communication mentorship beyond the interpersonal medical model with a patient or family. The bigger picture was apparently not considered curriculum worthy…Oversight? Puzzling? But, that was a different time. Risk communication and media interaction, therefore, became motivating topics for colleagues and students during my public health and academic careers.

I recommend attending educational media seminars, participating in simulations and reading the listed references. You might approach TV and radio interviews as a skills challenge. If you are in a situation where TV cameras are present, invite students and colleagues to stand behind the camera to observe and learn from the process.

Public health risk communication is intended to effectively convey clear and consistent information in high concern, sensitive or controversial situations. Proper messaging engages the public early with rational, measured communications. While different situations require different strategies, the intent is to help people bear the news and respond. Sometimes sharing decision dilemmas and involving the public is a reasonable approach to arrive at acceptable, coordinated solutions to a complex problem. 

The goal – or hope – is that the messages are actually understood and acted upon. Objectives seek to motivate individual action and stimulate an appropriate emergency response – neither too little nor too much. In a crisis it is very important to convince people to put ordinary concerns aside, take precautions and tolerate inconvenience, but not over-react. 

However, it can be vexingly difficult to find an appropriate balance. How many resources should be committed to an emergency? How often should messages be conveyed? How firm should a warning be? If people are non-compliant, should warnings include a penalty? Expectations of privacy, liberty and self-determination complicate this equation.

In some instances the question may be whether one should even release information. Sometimes messaging isn’t necessary. Reflectively, it isn’t always obvious what should be said. However, failure to inform, if expected, can be misconstrued. “There is only one reaction to a report that someone was unavailable for comment or did not return phone calls…They must be hiding something!”⁵ And the 2^nd of Sandman’s three golden rules⁴ is “don’t understate risk to allay the public’s fears.”

Seldom does one encounter an uncomplicated agenda, especially when societal matters, technology, economics, ethics, science and, especially, politics converge. Risk message conveyance and reception are naturally embedded in this macro “environment.” Frightening issues are harder for the public to contemplate, which can provoke irrational behaviours or lead to disregard of warnings. 

Ethical issues are embedded when risk reduction mandates or recommendations are issued:

• The Common Good – Does a mandate remove or reduce the hazard threat, benefiting the whole community? 
• Access – Does everyone have similar preventive or treatment options?
• Autonomy – When does the greater social imperative take precedence over individuals who may express independence when making decisions about their own lives?
• Reciprocity – When individuals accept a burden for the community’s benefit should society provide something in return?
• Mandated Policy – Is the decision-making process transparent, accountable, fair, responsive and evidence-based?

Serious concerns often center on epidemics/pandemics. One dire example is the 2014 West African Ebola Virus crisis, which was made greater by weak regional health services. This epidemic “engendered acts of outstanding courage and solidarity,” but also caused “immense human suffering, fear and chaos.” Criticism was leveled at ineffective risk communication.⁶ 

Although Ebola was spreading tragically (and continues to sporadically surface), five months passed before an emergency declaration was issued by the WHO. “We need to strengthen core capacities in all countries to detect, report and respond rapidly to small outbreaks in order to prevent them from becoming large-scale emergencies.”⁷ 

Sound familiar? Events regarding COVID-19’s dangerously politicized and disregarded mitigation measures have required considerable, remedial attention to stem this widening pandemic. Sadly, key public health measures, including masks, social distancing and avoidance of crowds, have been deemed unimportant by a number of government and community leaders. Political interference, not only from the U.S. Department of Health and Human Services, but also the White House, hampered scientists’ efforts. “Every time that the science clashed with the messaging, messaging won.”⁸ 

Constructive public health recommendations that attend to socially mindful, reparative policies and equitable vaccine access are essential.⁹ The appropriate balance between paramount health safeguard priorities and competing business interests remains an ongoing challenge. Regardless, we must protect the public’s health by countering deliberate, misinformed messaging that has tragically ignored science. In essence, misinformation has done nothing but accelerate the pandemic.

An example of vexing reality occurred when the 2009 H1N1 swine influenza pandemic first appeared. Many people were in panic mode. Clinics and health departments were flooded with calls and walk-in patients, all with the same question: “When will a vaccine be available?” Yet, inexplicably, once a vaccine became available, many individuals, who routinely refuse seasonal flu vaccine, then refused the H1N1 vaccine. Patients became leery. “It’s not tested…Everyone knows there are problems with the vaccine…I’m not putting that in my body.” 

This dramatic behavioral shift couldn’t be related to logic or facts because new epidemiological data were not available, when demand began – and when demand diminished. When the “inoculum” of this dramatic new illness was introduced, the public psyche rapidly became infected. “It seemed to reflect some sort of psychological contagion of suspicion,” described as “emotional epidemiology” associated with a new and mysterious illness.¹⁰ 

Fear of the unknown provoked demand for an as-yet-unproduced vaccine. Yet, once this newly identified swine flu established itself, a certain degree of emotional tolerance developed, also typical. But, emotional epidemiology did not remain static. The public became impatient. The problem wasn’t solved. Not knowing whether to panic or express indifference, people instead can grow wary with only a loose connection to the actual epidemiology.

In terms of public relations, initially, information may not have been clearly delivered. Many issues were still unknown. This is reality. The scientific community may exhibit understandable, halting initial steps in uncharted waters. But, as more is learned, continued and consistent public health messaging is essential. Yet, that can sometimes seem like a constant barrage of serial over-reaction. Unfortunately, a frightened, skeptical or preoccupied constituency can have a contagion process of its own.

One of my colleagues observed: “One thing about the swine flu pandemic that surprised me was the fear – verging on terror – that the words, ‘swine flu’ elicited…Our local presentation ‘brand’ became “transmit the facts, not the flu.” People seemed to really respond to that approach.”¹¹

That strategy remains important because risk perceptions govern the public’s behaviour, influenced by factors that may have little to do with data! Risks are perceived to be more acceptable if expected responses are voluntary rather than imposed, natural rather than man-made and fairly distributed.

Headline-grabbing emerging diseases, like West Nile Fever, HIV, SARS, Nipah virus¹² and Ebola, can capture the public’s imagination and ignite fears in ways more familiar diseases do not. Gazing into the future, we must be aware of the sobering fact that novel zoonotic “spillover” can be expected.¹³ Exactly how this reality might provoke or guide protective responses remains unclear. Certainly, much must be studied and learned, arising from Covid-19.

Other issues also loom. Uncertainty revolves around a United Nations prediction that the world’s urban population will double by 2050, mostly in low-income developing countries.¹⁴ Cities may become significant hubs for infectious disease transmission. The potential for consequential health risks could be associated with climate change and other local “on-the-ground environments.” 

The complexities of high-density societal dynamics, intra-urban public transit and conduct of business will facilitate disease contagion. Physicians and public health professionals must be aware of evolving disease epidemiological vulnerabilities associated with urbanization and counter those potential threats with risk intervention strategies. Prioritizing public trust by informing and involving communities in the protective process is obligatory.

“…Although we would like to believe that pandemics occur rarely, new infectious diseases, as well as other kinds of environmental threats, can emerge at any time…One challenge is to continue to invest in science — whether virology; surveillance; mitigation 

measures; vaccine development, manufacture and distribution; operations and logistics – so that when the next pandemic or other emerging infectious disease appears, we will have data to make informed decisions about how to confront it…”¹⁵

As I suggested in the introduction, sometimes it is necessary to overstate the extent of a problem to alert a complacent public, then relaxing the tone of subsequent statements once awakening is achieved. Perplexing questions include when and how to prioritize appropriate responses. Ultimately, success of persuasion is, perhaps, governed by the nuanced observation of risk communication expert, Covello: “…in high concern situations people will want to know that you care – before they care what you know.”¹⁶

To be continued next month in PART 2…

References

1. Mullin S. New York City’s communication trials by fire, from West Nile to SARS. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 1(4):2003:267-272. 
2. Guy D. Survey: Public Opinion in a Crisis. Healthcare Quarterly 2003;6(4):24. https://www.longwoods.com/content/16487//survey-public-opinion-in-a-crisis/
3. Peters R, Covello V, McCallum D. The Determinants of Trust and Credibility in Environmental Risk Communication. Risk Analysis 1997;17(1):43-54.
4. Sandman P, Lanard J. Fear is spreading faster than SARS – and so it should! April 2003:1-12. https://www.psandman.com/col/SARS-1.htm/
5. Molesworth J. Editor’s Report. Pacific Builder and Engineer. January 2007.
6. Kelland K. Global health experts accuse WHO of ‘egregious failure’ on Ebola. World News November 2015;3:46.https://www.reuters.com/article/uk-health-ebola-response-idAFKBN0TB10I20151122/
7. Piot P. 2011. https://www.humanosphere.org/global-health/2015/11/ebola-outbreak-health-experts-create-roadmap-prevent-next-global-health-crisis/
8. Weiland N. ‘Like a Hand Grasping’: Trump Appointees Describe the Crushing of the C.D.C. Quote: K. McGowan, Former Chief of Staff at the Centers for Disease Control and Prevention. New York Times Dec 16, 2020. https://www.nytimes.com/2020/12/16/us/politics/cdc-trump.html?action=click&module=Top%20Stories&pgtype=Homepage
9. Carlson C, Phelan A. A choice between two futures for pandemic recovery. Lancet Planetary Health December 2020;4:e545-546. https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30245-X/fulltext?dgcid=raven_jbs_etoc_email/
10. Ofri D. The Emotional Epidemiology of H1N1 Influenza Vaccination. New England Journal of Medicine 2009;361:2594-2595. https://www.nejm.org/doi/full/10.1056/NEJMp0911047/
11. Fautin C. 2009. Assistant Director of the Marion County Health Department. Personal communication.
12. Gibbs W. Trailing a virus. Scientific American August 1999;281(2):81-87.
13. Quammen D. Spillover: Animal Infections and the Next Human Pandemic. 2012.
14. Alirol E, Getaz L, Stoll B, Chappuis F, Loutan L. Urbanisation and infectious diseases in a globalised world. Lancet Infectious Diseases 2010;10:131-141.
15. Lurie N. Editorial. The need for science in the practice of public health. New England Journal of Medicine December 2009:1-2.
16. Covello V. Keys to Risk Communication: Anticipate, Prepare and Practice. July/August 2017. https://www.csg.org/pubs/capitolideas/enews/issue47_5.aspx/