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Public Health’s Share of the Blame: US COVID-19 Risk Communication Failures

The World Health Organization defines risk communications the exchange of real-time information, advice and opinions between experts and people facing threats to their health, economic or social well-being. The ultimate purpose of risk communication is to enable people at risk to take informed decisions to protect themselves and their loved ones. Risk communication uses many communications techniques ranging from media and social media communications, mass communications and community engagement. It requires a sound understanding of people’s perceptions, concerns and beliefs as well as their knowledge and practices. It also requires the early identification and management of rumors, misinformation and other challenges.

Editor’s Note: After 40+ years as a risk communication consultant, Dr. Peter Sandman came out of retirement in January 2020 to try to help with pandemic risk communication. Following is an abridged form of a commentary published on his website Aug 4, 2020, with new material added.

A reporter recently asked me what I consider “the single biggest communication failure” of public health experts and officials with regard to COVID-19. It took me a few weeks to think it through, but I now have a five-part answer to this question.

Let me state the obvious at the outset: Public health professionals are not single-handedly responsible for the dire COVID-19 situation in which the United States finds itself. If I had to specify a single culprit, I’d name the federal government, and especially President Trump. But I believe the public health profession bears a good deal more of the blame than it’s getting.

Several public health professionals who gave me comments on an earlier version of this article said a lot of the failings I attribute to public health professionals are actually down to the President and the federal public health agencies that report to him. There’s enough blame to go around. But I have spent the past 7 months reading and watching media, zeroing in especially on what experts and officials (especially those outside the federal government) were saying about COVID-19 in news stories, interviews, and op-eds. I don’t have a formal content analysis of their messaging and how it morphed over time. But my strong impression, bordering on conviction, is that their messaging often misled the public, and the political leadership as well. How that happened is the subject of this article.

I want to look at the big picture. I’ll ignore public health professionals’ smallish risk communication failures, such as their abrupt about-face without an apology on the advisability of wearing masks and their absolution of antiracism protesters for gathering in large crowds. The story I want to tell focuses on how the public health profession drastically underreacted to COVID-19 at first and left us unprepared, then overreacted and sent us into lockdown, and then justified the lockdown by switching from a “flatten the curve” narrative to a “prevent infections at all costs” narrative instead of teaching us to balance priorities and “dance” with the SARS-CoV-2 virus.

Part 1: Public health over-reassures the public

The most obvious communication failure of most public health professionals vis-à-vis COVID-19 was their huge failure to warn governments, companies, and the rest of us to prepare in January, February, and into March.

Almost from the outset, it was apparent to most experts that COVID-19 would probably keep spreading—that it was much likelier than not to “go pandemic.” But it wasn’t apparent at first how severe the COVID-19 pandemic would be. So the right messaging would have addressed logistical and emotional preparedness for the hard times that might (or might not) be coming.

Public health experts and officials chose instead to reassure the public. Alas, to everyone’s subsequent dismay, they succeeded. They were worried about public panic. So they validated the public’s complacency—and with it, the complacency of government officials and corporate leaders—and left us incredibly unprepared.

Not content merely to reassure, some leaders went out of their way to attack the very idea of anyone being frightened about what the world might be facing. Here is what World Health Organization Director-General Tedros Adhanom Ghebreyesus tweeted on February 28: Together, we are powerful. Our greatest enemy right now is not the [coronavirus] itself. It’s fear, rumours and stigma. And our greatest assets are facts, reason and solidarity.

Why did public health professionals downplay the danger of the SARS-CoV-2 virus? As the quotation from Tedros suggests, the root of the problem was what I have called “fear of fear”—especially experts’ and officials’ unjustified concern that vast numbers of people would freak out or even panic.

There was a more justified concern as well: experts’ and officials’ fear that they would be criticized for unduly frightening the public if COVID-19 fizzled or turned out to be mild. They had aggressively warned the world about a possibly disastrous bird flu pandemic in 2005 and it never happened; they had aggressively warned the world about a possibly disastrous swine flu pandemic in 2010 and it ended up less deadly than a typical flu season.

In the wake of these two false alarms, this time they elected not to shout from the rooftops.

Their warnings were sotto voce, easy to ignore. And their warnings stayed that way even after it was clear they were being ignored.

In those key early weeks, the main message from the public health establishment was that “the risk to people here in [wherever] is low.” This was technically true, since there weren’t yet a lot of COVID-19 cases in [wherever]. But public health professionals know that risk is often about the future. In any given October, before the start of the northern hemisphere’s flu season but well into flu vaccination season, they would never say that the risk of flu is low. Focusing on the known current risk instead of the likely near-term future risk allowed public health professionals to keep saying the risk was low for far too long, inducing massive complacency in citizens and leaders alike.

In February 2020, if you were looking for it, you could find some public health messaging to the effect that the COVID-19 risk might not stay low. Perhaps the most visible exception to the over-reassurance messaging came from Nancy Messonnier, MD, of the US Centers for Disease Control and Prevention (CDC). In a February 25 media briefing she said bluntly that “disruption to everyday life may be severe.” The stock market plummeted, the President was angered, and the CDC was rebuked.

Dr. Messonnier was back “on message” for her next briefing a few days later. This time she talked about the very few known US cases of local transmission. She repeatedly claimed that the risk of current, ongoing SARS-CoV-2 transmission was low in any community that had no positive test results (even though most communities had done no testing, and thus had no negative test results either). Jody Lanard and I wrote a website column critiquing this briefing. Our title says it all: “‘Absence of evidence’ portrayed as ‘evidence of absence.'”

In February and well into March, COVID-19 warnings from US public health professionals were few and far between, a comparative whisper. The shouted message was that the (current) risk was low. And the implication of that message was that preparations and precautions were unnecessary, maybe foolish and alarmist, maybe even hysterical and panicky. So go about your business, go celebrate the Lunar New Year in large crowds, don’t worry about stockpiling medicines or food or toilet paper, don’t get unnecessarily fussed about this thing that might not even be a pandemic, and for God’s sake don’t wear a mask.

Part 2: Public health panics and overreacts

New York City became a disaster area because its government grotesquely underreacted to the emerging crisis as cases doubled and doubled again. Weeks too late, it finally banned mass gatherings, closed schools, announced social distancing policies, and more. Precisely because it was so slow to react before the virus had spread out of control, New York City’s government was wise to impose a near-total lockdown of the city, a radical solution to a disastrous situation. Governments in China and Italy were similarly wise to lock down Wuhan and later Milan. Wherever the SARS-CoV-2 virus was already widespread and expanding exponentially, local lockdowns made sense—to slow the spread, keep hospitals from being overwhelmed (or further overwhelmed), and buy time for urgent, belated preparations.

But does that mean lockdowns also made sense in places where the virus was not yet widespread? Most of the United States and much of Europe locked down at a time when more conventional, less extreme interventions might have sufficed.

Consider the measures that are now commonly utilized in places that are successfully managing the pandemic: social distancing, masks, cancelation of mass events and maybe of schools, handwashing, widespread testing, contact tracing and quarantine, expanded hospital capacity, expanded supplies of personal protective equipment (PPE), sequestration of especially vulnerable populations, special precautions for nursing homes and other congregate settings.

By the time New York City awoke to the COVID-19 danger, it was arguably too late for anything but lockdown. But wouldn’t these lesser (and economically less devastating) measures have worked elsewhere—instead of lockdown rather than after lockdown? Maybe even just some of these measures, if a few of the most difficult ones (like contact tracing) weren’t feasible?

Every pandemic plan I have worked on or looked at, starting in 2004, emphasized the importance of responding quickly with what the CDC has called “targeted and layered” local nonpharmaceutical interventions to slow the spread of the pathogen. The interventions the writers of these plans had in mind were the sorts of interventions I just listed. I never saw a plan that contemplated telling everyone to stay home, locking down entire states and countries.

Even now, I am at a loss to explain how the US public health profession suddenly came to the conclusion that a nearly national lockdown was the right response to SARS-CoV-2. China’s apparent success in suppressing the virus by locking down much of the country obviously played a key role. But I distinctly remember how shocked and disapproving most public health people seemed to be, at first, about China’s lockdown. Then came the disaster in northern Italy, with Milan following in the footsteps of Wuhan. New York City looked like it was following in the footsteps of Milan. And suddenly lockdown was deemed the appropriate response even in places that showed no signs of following in the footsteps of New York.

There were outliers within the public health profession—look here and here, for example—who said that such a widespread lockdown was an overreaction. What’s amazing is that they were outliers. (And as outliers so often do, they tended to go to the opposite extreme, opposing not just lockdown but less extreme interventions as well.) Virtually the whole profession suddenly seemed to support widespread and apparently indiscriminate use of a measure that to my knowledge had never even been contemplated for places with seemingly very low levels of infection.

I know now—because they have told me so—that there were more dissenters among public health professionals than were visible at the time. What was visible at the time was an apparent consensus for nearly nationwide lockdown.

People are now saying that a number of southern and western states came out of lockdown too soon. Almost universally ignored is the possibility that these states went into lockdown too soon. If places with relatively little community transmission had tried more moderate interventions in March, maybe they wouldn’t now face massive public lockdown fatigue as they decide whether to lock down again.

I’m just a risk communication expert, not an epidemiologist. I am not entitled to a professional opinion about whether widespread lockdowns rather than less extreme, targeted measures were called for. But it looked to me in real time—and still looks to me today—like public health experts and officials panicked. They saw what happened in Wuhan, then Milan, then New York. They realized how badly they had underreacted to COVID-19. And very suddenly, without a lot of public explanation (much less public debate), they overreacted and prescribed universal lockdown.

I am a longtime opponent of diagnosing panic when people get frightened about some risk and start taking precautions, even excessive precautions. As I have written again and again, panic is “doing something harmful to yourself or others that you would never do if you were thinking straight, but you can’t help yourself because of out-of-control emotions.” By that definition, panic is an extremely uncommon response to crisis.

But by that definition, I think it is fair to say that in places without a lot of SARS-CoV-2 circulating, politicians and their public health advisors who ordered massive lockdowns panicked.

Please note again: My opinion that it was a mistake to lock down places with very little viral spread is a nonprofessional opinion. Similarly, I have no professional opinion on whether or where lockdowns are needed now. What I can confidently say as a professional, though, is that the spring 2020 lockdowns got shockingly little public debate. There weren’t a lot of op-eds by public health experts pointing out that broad-based lockdowns were a deviation from all prior pandemic planning and wondering aloud if they were wise. There weren’t even a lot of op-eds explaining why an emerging consensus of public health professionals believed they were, in fact, wise.  Whether or not locking down most of the country was a public health mistake, certainly doing so with very little public discussion of the pros and cons—and with no sustainable rationale—was a risk communication mistake.

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