Why are public health officials so bad at talking to us?
The fierce backlash to the CDC’s recent decision to shorten the recommended isolation period for people who test positive for Covid-19 was the latest in a series of communications blunders so severe that they have now become a meme.
Communication is an essential part of any public health response. But US health agencies have struggled with it since the very beginning of the pandemic, when government officials initially advised against wearing masks in early 2020 before reversing themselves to recommend nearly universal masking.
It appeared the initial guidance may have been issued in order to preserve enough masks for health care workers. Government officials were warning at the time that hospitals’ supplies could be depleted at a critical moment if there was a run on masks. It was the first of the pandemic’s “noble lies,” The Week’s Ryan Cooper wrote in a blistering essay on the paternalistic treatment of the US public that has undermined the country’s Covid-19 response.
America’s public health institutions have failed to communicate effectively with the US public throughout the pandemic for two reasons: either they have been left trying to defend poor policies, or the messaging has taken the place of creating any kind of coherent policy at all.
“I don’t think any federal or state agency has done a great job communicating policy during the pandemic,” Briana Mezuk, co-director of the Center for Social Epidemiology and Population Health at the University of Michigan School of Public Health, told me. “The CDC should have been setting the example, and I guess in a way it did: a less-than-great example.”
In those early days of the pandemic, a more explicit policy decision would have been to ration masks, telling the public that masks could be protective but that high-quality supplies would be reserved for health care workers. Instead, authorities sidestepped the issue and planted the seeds for the backlash.
“We cannot pretend that communication can get us out of policy answers,” Michael Mackert, director of the Center for Health Communication at the University of Texas Austin, told me.
The problem of unsound or indecisive policy creating bad messaging has been repeated over and over again throughout the pandemic, which has deepened skepticism about the agency’s recommendations and created a fertile environment for disinformation to flourish.
A year after the first masking flip-flop, the CDC stumbled on masks again. In April 2021, the agency urged vaccinated people to continue wearing masks in most indoor settings to reduce transmission before reversing itself and saying that vaccinated people could feel free not to wear masks indoors unless it was required by a local or state government.
Many public health experts believed the decision to relax the masking guidance for vaccinated people was premature and, just a few months later when the delta variant drove up cases, the CDC changed course again and recommended everyone, including vaccinated people, wear masks when indoors in public.
Contrast the whiplash in the US with the approach in Canada, which issued a much more limited change to its masking guidance around the same time and didn’t need to quickly revise it. Canadians were urged to keep masking, with the one exception of small indoor gatherings with other vaccinated people. Those recommendations remain more or less the same to this day.
Other crucial pivots in the US response were undermined in the following months. President Joe Biden announced in August that booster shots would soon be available for everyone. But some of the federal government’s scientific advisers balked at that idea in public meetings, sowing confusion about whether additional doses were really necessary for everyone.
Pubic health authorities faced serious obstacles to communicating effectively with the public. The American people are divided, consuming different information from different sources, motivated by different ideologies. Social media allows “alternative” sources of information to flourish. The world had never seen a virus quite like SARS-CoV-2 and scientists were learning more about the virus in real time. It was inevitable some of their early assumptions would be wrong and guidance would have to change.
But some of the confusion that has undermined the American response was avoidable. Prevailing attitudes inside the medical establishment prior to Covid-19 and specific mistakes made during the pandemic itself have contributed to the disconnect between public health authorities and the public they are trying to protect.
“Our institutions are failing us with the lack of coordination, the lack of clarity,” Scott Ratzan, editor-in-chief of the Journal of Health Communication: International Perspectives and a CUNY lecturer, told me. “This is a case clearly that shows our 21st-century institutions are not prepared.”
Why America’s public health institutions failed at pandemic messaging
The initial mistake in the messaging around masks — in effect, misleading the American people, seemingly to preserve the supply of masks — set the stage for what would follow: a pattern of public health authorities adopting a patronizing attitude toward the public they are supposed to serve.
Mezuk voiced her frustration with phrases like “follow the science” that were used to justify various policies. Individual people have to account for all kinds of other variables in their daily decisions — making money, educating their kids, caring for loved ones — as they make risk assessments regarding Covid-19, she said.
The government had more to consider than the public health ramifications of the Covid-19 response. There were economic and social consequences to weigh when it came to closing restaurants or mandating remote learning. An acknowledgment of that complexity might have engendered more trust when the pandemic persisted and some of those calculations began to change, rather than pretending the science had been settled.
“Some amount of backtracking, revision, etc., of policies was inevitable. That should have been stated early, often, and repeatedly,” Mezuk told me.
Several experts told me public health officials should have better prepared their audience for inevitable policy changes, making it clear from the beginning that scientists were still learning more about the virus and policies would need to adjust.
“Instead, they went with ‘we are following the science,’ which was interpreted by the public as, ‘so if you disagree with our decision, you must not be following the science,’” she said. “That is just a false dichotomy, and people knew that. And so the CDC and other leaders lost a lot of credibility that I think the public would have freely given them had they not latched onto that simplistic narrative.”
In some ways, the battle to win hearts and minds during the pandemic was lost before Covid-19 ever arrived. Several experts pointed out that most people are not nearly as fluent in interpreting statistics or assessing risk as public health experts are trained to be, and public health officials have often failed to find simple but effective ways to convey complex ideas to the masses.
The debate over booster shots is perhaps the most important example of how the government can muddle the messaging around its own policies. Biden got out ahead of the government’s science advisers when he announced boosters for everybody in the late summer. The government’s scientific advisers and many public health commentators ended up being divided on the merits of boosters.
The CDC was left to try to craft recommendations in the middle of this chaotic debate. The agency initially attempted to split the difference, urging all people over 65 and people over 50 with underlying medical conditions to get boosters. It also said people under 50 who either have preexisting conditions or work in high-exposure settings could get an additional dose if they chose to.
Who the boosters were actually for (older people? essential workers? everyone?) got confused. By December, even after the CDC had revised that guidance to urge everyone over 18 to receive three doses of the vaccine, one in five vaccinated adults were unclear on what the agency had recommended, according to a Kaiser Family Foundation survey.
The US is now lagging behind the United Kingdom in administering third doses, particularly among the older people who benefit most from a booster. The UK had been more direct in its initial vaccine guidance: Certain people (adults over 50, front-line workers, immunocompromised people) should get the booster, full stop.
In the US, a messy policy process led to poor messaging. Several experts I spoke to contrasted the confusion over vaccines with the simple rubrics used to communicate the risk of an incoming hurricane. People don’t need to know the intricacies of meteorology to understand that a Category 5 hurricane is going to be bad. But we have failed to find the same effective shorthand to communicate basic facts about Covid-19.
“I don’t know the drop in barometric pressure. We don’t need to give people all the technical information that can be misconstrued and turned into misinformation,” Ratzan said. “The scientists might think they have to explain all the reasons. But, in the end, we need scientific consensus that is not only data-driven but also reflects a social science base of how people are going to respond.”
What it takes to effectively communicate in a public health emergency
There will be a lot of work to do to prevent a repeat of these mistakes in the future. In a December 2021 review published by the National Academy of Medicine, public health researchers advocated for a policy of “radical transparency” that attempts to meet people at all levels of health literacy.
Messages should be simple. The Japanese government’s “three Cs” — urging people to avoid closed spaces, crowded places, and close-contact settings — is seen as one of the more effective messages of the pandemic. This Vietnamese hand-washing PSA went viral in the spring of 2020, driven by a catchy song and a dance.
Suzanne Bakken, who has contributed to the National Academy’s work on Covid communications, told me that “flatten the curve” had been the most effective message deployed in the United States. It managed to communicate an important public health goal in an intelligible fashion and, for a time, gave people a shared goal to work around.
“That really spoke to people,” she said. “It was a pretty simple visualization.”
Academics such as Bakken are also thinking about how to empower local health authorities and nongovernmental groups, in which people might place more trust in the current polarized political environment. The National Academy of Medicine review contemplates some kind of national infrastructure that would disseminate information to local actors and allow them to decide how to tailor the message based on their particular community:
Communications should be adapted at the individual and community levels and take into account how centrally developed communications methods can be rooted in patriarchy, colonial oppression, and structural racism. Without this understanding, communications cannot be appropriately adapted to local contexts, and therefore may be rejected by many communities.
This is a lesson that other countries more accustomed to public health emergencies have already learned. In Vox’s Pandemic Playbook series, reporter Jen Kirby traveled to Senegal and spoke with community health workers who were integral to that country’s response, as the point of contact and primary communicator in their own villages and towns.
Given how diverse the US is, and how much trust in some of its national institutions has eroded, such a model would offer one way to begin repairing the relationship between the American public and its public health institutions.
“It’s not only getting the message right,” Ratzan said, “but having the right messenger, with the right dosage.”