As the director of the US Centers for Disease Control and Prevention (CDC), Rochelle Walensky, recently acknowledged, poor public-health communication and messaging throughout the COVID-19 pandemic has damaged the public’s trust in health agencies and institutions. This, in turn, contributed to well-known problems such as vaccine hesitancy, noncompliance with mask recommendations and other protective measures, and general misinformation about the virus and how it is transmitted.
According to a 2021 poll from the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, only 52 percent of Americans now place a great deal of trust in the CDC, and only 37 percent have much confidence in the National Institutes of Health or the Food and Drug Administration. State health departments fare little better — they are trusted by just 41 percent of Americans, with local health departments trusted by 44 percent, and the same poll shows that positive ratings of the public health system declined from 43 percent to 34 percent between 2009 and 2021.
Clearly, public-health agencies need to win back the public’s trust, not just to combat crises like COVID-19 and monkeypox, but also to address a wider range of ongoing health issues. This process must start with a commitment to community engagement, partnerships across other sectors such as housing and education, effective communication at every level, and transparency and integrity in decision-making.
Public-health officials often must base their recommendations on incomplete data; as the data evolve, so will the recommendations. However, in a misguided effort to appear authoritative, public-health officials are rarely transparent about the nuances and fluid nature of what they are communicating.
A perfect example is the early advice on how SARS-CoV-2 is transmitted. The CDC was adamant that the coronavirus was spreading on surfaces and not through the air, rather than acknowledging that airborne transmission was still a strong possibility. This approach bred confusion and distrust, because the CDC eventually had to change its advice (as it should have foreseen). After acknowledging that SARS-CoV-2 was spreading through droplets, it finally also conceded that it was spreading through aerosol particles.
As this example shows, credibility often gets confused with infallibility, resulting in public-health officials who may be slow to admit mistakes — further undermining their credibility. Transparency is key, especially at a time when peddlers of online misinformation will seize every opportunity to discredit public-health officials. Successful public-health communication establishes credibility by being effective, not by being unchanging.
Another cornerstone of sound communication is clarity. Public-health officials must explain how data and recommendations relate to people’s everyday lives. Whether the information is correct or incorrect is a moot question if the public does not understand what is being communicated.
Here, US officials failed the messaging test again when they did not make clear that COVID-19 vaccines’ effectiveness was measured by hospitalizations, not infections. The public believed that vaccines would block transmission and infection; but when the Delta and Omicron variants emerged and caused breakthrough infections to surge, distrust and ‘booster-shot fatigue’ duly followed. As of August 3, only 32 percent of Americans had received their first booster shot.
In this case, public-health officials could have used the example of the Salk polio vaccine to assure the public that a vaccine does not need to prevent infection or transmission outright to eradicate a disease. Or, they could have emphasized how much the vaccines reduce the burden on our hospitals.
Unfortunately, other historical lessons seem not to have sunk in. Many public-health officials have been committing a grave error by stigmatizing monkeypox as a disease that only threatens gay, bisexual, and other men who have sex with men. Yet while it is true that this population has been disproportionately affected by the current outbreak, monkeypox can be transmitted in any situation where there is close skin-to-skin contact with lesions.
By depicting monkeypox as a sexually transmitted infection, public-health officials could give people the false impression that they are not at risk, preventing them from seeking a diagnosis or isolating if they do contract the virus. The situation is not dissimilar to the (incorrect) early messaging about HIV/AIDS spreading only among homosexual populations.
More broadly, public-health messages are best understood and most likely to be believed when they come from trusted individuals within the communities that need to be reached. The messenger is often as important as the message, especially in communities where structural racism and historical traumas have left people disinclined to trust medical authorities.
Rather than issuing authoritative statements and assuming that they will be heeded, local public-health officials should think of their messaging as being part of an inclusive conversation. They should seek out community voices and trusted advocates such as faith leaders, shelter managers, and food-bank directors to collaborate on messaging and reaching populations that may be vulnerable to health disparities.
Another good approach is the one pioneered by the Ryan White HIV/AIDS Health Services Planning Councils. These are community groups appointed by local officials whose members represent the general public, people living with HIV, funded service providers, and other health and social service organizations. Planning Council members work together to identify the care needs of people living with HIV. They then determine which services are the highest priority, and how much funding should be committed to each. This model of inclusive decision-making could be applied more broadly to public-health planning and resource allocation.
The current climate of ‘alternative facts’ and rampant disinformation presents many challenges to effective public-health communication. But by learning from past mistakes and developing messages that are clear, inclusive, and conveyed by the right sources, we can start the difficult but necessary process of rebuilding trust in public-health agencies before the next big crisis strikes.
QUOTE: The public believed that vaccines would block transmission and infection; but when the Delta and Omicron variants emerged and caused breakthrough infections to surge, distrust and ‘booster-shot fatigue’ duly followed.
William A. Haseltine
A scientist, biotech entrepreneur, and infectious disease expert, is Chair and President of the global health think tank ACCESS Health International.
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