Ebola Risk Communication:

Talking about Ebola in Dallas,

West Africa, and the World

Three parts:

The First Email (October 3, 2014):

Tom Frieden’s SOCO and Other Aspects

of U.S. Ebola Risk Communication

by Peter M. Sandman and Jody Lanard

(email reponse to query from Sharon Begley of Reuters)

An Overarching Recommendation: Let Us Watch You Flail The following wasn’t explicit enough in the email to Sharon Begley of Reuters below. We wrote it and sent it to her afterwards. Managing a novel infectious disease outbreak – managing any new challenge, in fact – means there’s going to be some flailing. You learn as you go; you make some mistakes (even tragic ones, sometimes); you cope as best you can with ongoing uncertainty about what will happen and how best to handle it. Officials tend to think it’s important to hide the flailing. They’re especially likely to think so when the issue is potentially frightening to their audience. They’re not just protecting their reputations, they think; they’re protecting the public from panicking. What never quite sinks in is that it’s more reassuring to watch you flail than to watch you try to cover up your flailing. And it’s certainly more credibility-enhancing. Those are the only two options when the issue is big and the media are on it. Your false starts and mistakes – most of them, anyway – are bound to come out. Predict that there will be some. When they happen, tell us about them before someone else does. And keep reminding us of them: the hard lessons you have learned so far, and the high probability that there are more hard lessons to come. Yes, the reassuring truths are worth repeating too. It’s rare for anybody to catch Ebola without actual contact with the body fluids of someone who’s visibly sick. To break the back of any Ebola outbreak, whether it’s one case in Dallas or thousands in West Africa, the core job is to isolate visibly sick people so they can’t spread the virus to anyone else. We know how to do that, in principle. At least in Dallas, we’re confident that we can do it in practice; Dallas will never go the way of Monrovia. But tell us the alarming truths too. We’ve never done it before with big urban epidemics like the one in West Africa. And we’ve never done it before in a modern U.S. city. West Africa poses huge new challenges we don’t know for sure how to address, even if we can get enough resources in time, which is highly uncertain. Containing the West African epidemic so it’s less likely to catch hold elsewhere poses ethical as well as practical challenges. And even Dallas poses challenges we probably should have anticipated but didn’t: how to quickly get crucial travel history information from the nurse who knows it to the doctor who needs it;

how to get waste disposal professionals quickly licensed (and genuinely qualified) to remove Ebola-contaminated materials from a patient’s apartment and hospital room;

how to distinguish situations that pose a small-but-real Ebola risk from situations that pose no Ebola risk at all, when our forty years of real-world experience are almost entirely with situations that pose a large Ebola risk. Don’t try to reassure people by making it look easy, by prattling on about “tried and true” public health practices in an unprecedented situation. It rings false. We already know you’re flailing some. What erodes confidence isn’t that you’re flailing; it’s that you’re trying unsuccessfully to hide it. Let us watch you flail.

We appreciate the chance to give you our assessment of the risk communication performance of U.S. officials regarding the Thomas Eric Duncan case in Dallas – the first case of Ebola to be diagnosed outside of Africa. It’s a moving target, of course. Just as officials are learning unexpected lessons about how to manage Ebola in a modern U.S. city, they are presumably also learning better ways to talk about it. If there are additional cases, we can expect them to do a better job of both.

But here’s our take on the first two days, focusing on Tom Frieden, Director of the U.S. Centers for Disease Control and Prevention (CDC) and the dominant U.S. government spokesperson on Ebola.

Frieden’s SOCO

The CDC is a fervent believer that communicators should stick to their key messages as much as possible. The CDC’s unique jargon for this contention is SOCO: Single Overriding Communication Objective. Frieden is a determined practitioner of the SOCO strategy: Repeat your SOCO as often as you can. When you’re asked about something else, try to bridge back to your SOCO.

Frieden’s SOCO for the Duncan case seems to be something like this:

Unlike West Africa, the U.S. will stop Ebola cold by isolating patients quickly and locating and monitoring their contacts – tried and true public health strategies in which we excel. Because we have such a good public health system, you’re very safe here unless you’re one of the handful of people who were in close contact with Duncan after he became symptomatic. Job One is still in West Africa, not here.

SOCOs work fine on people who know next-to-nothing, but not so well on people who know disturbing things not mentioned in the SOCO. If you know things that seem to contradict the SOCO – for example, if you know some of the ways Dallas has mishandled this first domestic Ebola case – the SOCO tends to backfire. Instead of inculcating key messages as intended, it can inspire mistrust. People don’t listen to messengers who seem to be ignoring or denying important things they already know.

So SOCOs are great for talking to the general public on fairly minor issues. But SOCOs backfire even on minor issues when used on people who know more and care more. We call these people “attentives” as opposed to “browsers.” It follows that in every media interview or presser officials face a conflict between the SOCO strategy for the browsers (the general public) and the need to acknowledge problems and mistakes for the attentives. The conflict is even tougher at angry public meetings; most of the people in the room are attentives, but there are reporters in the room too, who will convey what you say to a much larger cohort of browsers.

Ideally, the way out of this dilemma is to aim for real candor with everyone. Then be ready to deal with lots of “Oh my God” reactions from surprised segments of the public. But senior political leaders often don’t let their officials do that. So the conflict remains real.

When an issue gets bigger, as Ebola got bigger in the U.S. on September 30, there are more and more attentives, so the SOCO does more and more collateral damage by alienating those attentives.

Today, there are probably still a fair number of Americans who know little about Ebola, for whom the SOCO is still working. But the more newsworthy Ebola gets and the better informed the public gets, the more off-target the SOCO approach will get.

But at least the CDC’s SOCO is factually accurate, and appropriately focused on the question of Ebola risk.

The SOCO of Texas Health Dallas Presbyterian Hospital has been bad from the start. Despite a major blunder, sending Duncan home on September 26, the hospital is slavishly sticking to its rah-rah SOCO: what a great hospital it is and what a good job it is doing. The hospital’s October 2 news release on that potentially tragic September 26 mistake includes nothing even remotely resembling an apology. Our proposed SOCO for Texas Health Dallas: “We are anguished and horrified by our blunders.”

Anticipatory Guidance

One of Frieden’s (and the CDC’s) greatest strengths in communicating about Ebola was his acknowledgment early on that there would probably be U.S. cases sooner or later. On August 3, for example, here’s what he said on CBS’s “Face the Nation”:

We know that there are travelers from places where there is Ebola, we know it’s possible that someone will come in, if they go to a hospital and that hospital doesn’t recognize it’s Ebola there could be additional cases where their family members could have cases. That’s all possible. But I don’t think it’s in the cards that we would have widespread Ebola in this country.

Frieden trusted the public to bear the scary thought of Ebola arriving in the U.S. without a moon suit. But as is typical for a politician, President Obama had a more over-reassuring, less sustainable SOCO, pushing that it was unlikely to happen. Both of them rightly tried hard to redirect public concern to dealing with the globe-endangering catastrophe in West Africa. But Frieden set Americans up to be less shocked when the first Ebola case landed. Obama set them up to be mad at him for being wrong.

And on September 30, Day One of the Duncan story, Frieden gave this wonderful warning in a press statement issued by the CDC:

While it is not impossible that there could be additional cases associated with this patient in the coming weeks, I have no doubt that we will contain this.

We’d like this even better if he turned it around: “While I have no doubt that we will contain this, it is not impossible that there could be additional cases in the coming weeks.” Either way, it’s a candid warning about potential bad news to come married to firm determination about the ultimate outcome.

Though it never rose to SOCO status, Frieden publicly anticipated U.S. Ebola cases more than occasionally. Not all officials reiterated the point. And not everybody absorbed it. As you’d expect, those who already realized that sparks would inevitably be thrown off from West Africa’s conflagration were grateful to hear Frieden say so, leaving them less alone with their realistic fears. Others who had trouble accepting that Ebola could ever make it to America’s shores managed not to hear it.

Still, people were less shocked than they might otherwise have been by the news from Dallas. And at least a few commentators were able to report that, “As CDC and many experts predicted….”

In risk communication parlance, this is called anticipatory guidance : telling people what to expect.

The CDC’s much-publicized estimate of how many Ebola cases might be expected in West Africa by January if the epidemic continues unabated was a similar effort at anticipatory guidance. It wasn’t entirely successful. The media focused on the worst case number, 1.4 million, while Frieden tried to focus on his conviction that the actual number could be much, much smaller if President Obama’s intervention plans (and others around the world) worked as intended. Nobody really focused on the mathematics of exponential growth. Few reporters quite understood that if the epidemic continued to double every three weeks, then 1.4 million cases in mid-January meant 2.8 million cases by early February and 5.6 million by the end of February.

Most reporters treated “1.4 million” as the CDC’s estimate of the ultimate size of the epidemic. They missed that it was a worst case meant to describe what would happen if we don’t get our act together; and they missed that it was a way-station number, not an end-point number. Jody tried to help several reporters see both aspects of the 1.4 million figure, and found it heavy going. We guess the reporters did too. Still, the exercise did manage to convey the CDC’s main message – that day’s SOCO – that things could get really, really bad if the world didn’t take effective action in West Africa.

On some aspects of the Duncan case, the CDC managed its anticipatory guidance responsibility poorly. On Day One, Frieden and Texas officials talked about a “handful” of people or “12–18” people who would need to be monitored because they had had contact with Duncan after he got sick, without emphasizing strongly enough that the number could grow by a lot. Right after talking about a “handful,” Frieden mentioned casting a wide net, but the point got lost when a Texas official immediately followed the “wide net” comment by saying, “We think, again, it’s a small framework that we are looking at in terms of the number of people.”

The overall impression was that officials expected a small number of contacts, even though the patient had been symptomatic in the community for at least four days.

By Day Three, the media were reporting that the list of such contacts had grown to a hundred or so. Officials knew from the start that they would be including even casual contacts, and contacts of contacts, and that the number of contacts could therefore grow by a lot. They should have said so. Instead, they made it sound like they would cast a wide net, but the number of contacts caught in the net would be only a handful. So announcing a hundred-odd contacts made the problem sound like it had gotten bigger than expected.

And we haven’t seen any anticipatory guidance from the CDC suggesting that there may well be more contacts still uncounted that the family forgot or chose not to mention.

Uncertainties, Reversals, and Screw-ups

One characteristic of public health crises is that surprises happen. Pathogens behave in unexpected ways. So do people. Things go wrong. Policies have to be changed in real time.

So one of the most important kinds of anticipatory guidance is to warn people to expect uncertainties, reversals, and screw-ups. When he was at the World Health Organization, David Heymann did this elegantly during the 2002–2003 SARS epidemic. “We are building our boat and sailing it at the same time,” he said; in plainer English, we’re going to make some mistakes. Jeff Koplan was CDC Director during the 2001 anthrax attacks and even more poignantly said: “We will learn things in the coming weeks that we will then wish we had known when we started.”

And ABC News Medical Editor Richard Besser was Acting Director of the CDC when the 2009 swine flu pandemic struck (and before we knew it would turn out mild). On April 24, at the start of the CDC’s second swine flu news conference, he said:

I want to acknowledge the importance of uncertainty. At the early stages of an outbreak, there’s much uncertainty, and probably more than everyone would like. Our guidelines and advice our [are] likely to be interim and fluid, subject to change as we learn more….

If officials can’t bring themselves to forewarn the public that there will be uncertainties, reversals, and screw-ups, you’d think they could at least acknowledge the ones that have occurred. But it turns out that citing chapter and verse of what went wrong is actually harder for them than predicting in principle that things are bound to go wrong.

Probably the CDC’s worst Ebola risk communication blunder to date (as of October 3) was its decision, or conceivably the White House’s decision, to initially withhold the information that Duncan had gone to the Texas Dallas Health emergency room the night of September 25, told at least one screener that he had come from Liberia, and was nonetheless sent home with antibiotics a few hours later (early morning September 26). He remained a threat to those around him for two more days, until he returned to Texas Dallas Health in an ambulance on September 28.

In the same September 30 CDC press release with the great Frieden quote about how there might be additional cases connected to the first case, there was a much less admirable statement (this one not attributed to Frieden). It came across as an effort to gloss over the failure to hospitalize the patient the first time he came to Texas Health Dallas:

The person fell ill on Sept. 24 and sought medical care at Texas Health Presbyterian Hospital of Dallas on Sept. 26. After developing symptoms consistent with Ebola, he was admitted to hospital on Sept. 28.

This doesn’t quite claim that Duncan developed Ebola-like symptoms between his September 26 hospital visit (which started the night of September 25) and his September 28 return visit via ambulance. But it does seem designed to give the impression of a time series: “fell ill” [then] “sought medical care” [then] “develop[ed] symptoms consistent with Ebola” [then] “admitted to hospital.”

Frieden and his press advisors must have known the press corps would be all over that anomaly, and they were. So why not source the story correctly from the outset?

And once it was out, why not acknowledge its potentially tragic consequences more candidly, and with some justified sorrow and anguish? The emergency room mistake – the failure to isolate a patient with a West African travel history and a fever – was Texas Health Dallas’s mistake, not the CDC’s or the U.S. Government’s. We can understand why officials didn’t want to jump down the hospital management’s throat. But they could have pushed hospital officials to be more apologetic, instead of offering up the lame excuse that Duncan wasn’t yet exhibiting the more distinctive symptoms of later-stage Ebola. They could have been more emphatic themselves – emphatic if not censorious – about what a bad mistake it was. They could have dissociated themselves from the outrageous claim by Dallas County Judge Clay Jenkins that “the CDC is describing this as a ‘textbook response.’”

Most importantly, they could have stressed what that mistake means: that the U.S. isn’t as thoroughly prepared for Ebola as officials perhaps thought and certainly said.

It’s also possible that some fault may attach to the CDC about Duncan’s first emergency room visit.

The problem hinges on the phrase “symptoms consistent with Ebola.” Different CDC guidelines about how healthcare workers should evaluate potential Ebola patients are a little contradictory about whether you need fever “and” one or more other symptoms from a long list of potential symptoms, or just fever “or” one or more of the other symptoms. Also, some CDC guidance documents specify “fever of at least 101.5 degrees,” but more casual statements by CDC officials often just refer to “fever” as an important early Ebola symptom, without specifying how high the fever has to be to count.

What exact symptoms did Duncan have when he first went to the hospital, to go along with his travel history that fell through the cracks?

A day or so after the first announcement of the case, Texas officials said that on his initial presentation, the patient had a “low-grade fever and abdominal pain.” So “fever and.” But maybe not a high enough fever. For want of a few tenths of a degree? Is that possible? Or for want of a travel history? Or both? Somehow, the patient didn’t get hospitalized until two days later, when he was much sicker.

Needing to tighten up guidance documents and case definitions is a normal aspect of managing novel outbreaks. In 2003, for example, lots of changes got made in SARS case definitions. Back then, the CDC was very clear when it made changes in the case definitions. Canada or its provinces, by contrast, sometimes changed SARS case definitions without highlighting the changes, which caused problems for surveillance and data collection.

No one is talking openly about the possible ambiguity or confusion in the CDC guidance documents.

There may even be substantive changes the CDC will want to make as a result of the early management of this first U.S. Ebola case. If that happens, we look forward to seeing Dr. Frieden acknowledge it, in his usual forthright way, perhaps even with an anguished apology that the earlier guidance wasn’t clear enough or broad enough to catch this first patient in its net on his initial visit to the hospital.

We’re not questioning the truth of Frieden’s SOCO point that we will stop Ebola in its tracks in the U.S. The U.S. public health system is capable of extinguishing Ebola sparks. Dallas isn’t going to end up looking like Monrovia.

But there will continue to be uncertainties, reversals, and screw-ups. The CDC and other government agencies should start aggressively, publicly cataloguing the mistakes to date.

We think the most stunning mistake to date is the failure to immediately evacuate the family from the dangerously contaminated apartment Duncan had stayed in. It is almost incomprehensible that people are forcibly quarantined in Ebola-contaminated quarters. And obviously their 21 days cannot begin until they are out of there!

The most ghastly, inhuman communication so far about the U.S. Ebola case is the nonverbal message given by Dallas officials. They left Duncan’s endangered, terrified family exposed for days to the fetid, contaminated environment where the Ebola patient had vomited and defecated out huge viral loads of Ebola, sweating in soiled blankets and clothes. And when the family tried to leave, they put guards on the doors. The message was: You don’t matter.

This will be one of our lasting nightmare images of America’s first real-world Ebola case. It will always live in our memory next to the clean, sterile space capsule environment at Emory, where Dr. Kent Brantly was brought after he caught Ebola in Liberia. Texas state health officials or the CDC should have done something about this outrage on Day One.

And the CDC should start talking about it, and keep talking about it.

The case for that sort of candor isn’t just ethical. It is also practical. The closer attention journalists and the public are paying to a story, the more obviously advisable it is for the sources involved in that story to be up-front about uncertainties, reversals, and screw-ups. We think they should always be up-front about such matters – but when they’re under the microscope they have no sustainable alternative.

In the last couple of days, some portion of the U.S. media has turned almost hostile to the federal, state, and local officials who are managing Ebola in Dallas. This is a bit of a surprise. Investigative reporting in general is on the wane, and in the middle of public health crises reporters tend to see themselves as part of the home team, not the opposition. And Frieden is deservedly popular. His solemnly candid response to several CDC laboratory accidents (involving anthrax and bird flu) actually increased his popularity. A few days ago he looked likely to become Ebola’s White Knight – a less rumpled equivalent of the Nuclear Regulatory Commission’s Harold Denton, whom the public came to trust and admire during the 1979 Three Mile Island nuclear accident.

He may still. He brings real strengths to the job. He’s a long way from BP’s Tony Hayward (though we don’t doubt he wants his life back). But we think reporters and the public are less on his side than they were a few days ago. It’s not so much the things that have gone wrong in Dallas that are provoking a surprising dollop of media antagonism. It’s more the fact that they’re coming as a surprise, and that they’re coming as a result of journalistic digging.

Frieden and his colleagues aren’t hiding the truth of uncertainties, reversals, and screw-ups. At least we don’t see any evidence of that yet. But they’re not being aggressive enough about predicting embarrassing information, revealing embarrassing information, or discussing embarrassing information that has already been revealed. And not demanding that Dallas evacuate the family from the contaminated apartment was a horrible mistake.

CDC’s communication motto is “Be first, be right, be credible.” It needs to work harder to live up to that motto.

Overconfidence and Over-reassurance

Overconfidence and over-reassurance are the hallmarks of poor crisis communication. Both are so tempting, and succumbing to the temptation is so commonplace, that it’s almost unfair to call the result “poor.” It’s typical. But it undermines trust.

Two complicated-but-important examples:

The categorical claim, endlessly repeated, that asymptomatic people cannot transmit Ebola. Nobody doubts that Ebola sufferers get more infectious as they get sicker. But the boundary between well and sick isn’t as rigid as this dichotomous claim suggests. And distributions have tails. Almost everything we know about Ebola we know from observing (with difficulty) what happens in African outbreaks. We know very little about what sorts of Ebola patterns might emerge in the developed world, including patterns that are atypical and unusual but not impossible. Sooner or later somebody will transmit Ebola to somebody else while credibly claiming to feel fine. Then the experts will say that s/he must have had mild symptoms of which s/he was unaware – a bit like a tree falling in the forest with nobody there to hear it. “Science says that if you are not exhibiting symptoms of this, there is zero chance that you can transmit this,” Dallas Mayor Mike Rawlings said on October 1. “Not minuscule – zero.” “Minuscule” would be more sustainable, we suspect. Despite what they say, Dallas and Texas officials are acting as if the risk posed by asymptomatic people were nontrivial. Duncan’s closest contacts have been forcibly quarantined, including the children, although they are asymptomatic. (This is at least in part because of concern that they might be lost to follow-up.) The schools the asymptomatic children attended have been specially scoured by janitors in hazmat suits (some with exposed skin and no hoods). We realize that these actions are motivated chiefly by the need to reassure anxious citizens. But they’re being justified as “an abundance of caution,” and little is being said by Dallas officials, Texas officials, or federal officials about the fact that they’re contrary to the CDC guidelines. We doubt this sounds like “zero” to the citizens of Dallas. It certainly doesn’t to us. During SARS, Singapore leaders took certain actions at schools that their health department said were not medically necessary. The Prime Minister announced the health department’s opinion, but respectfully said he was taking the measures anyway because so many parents and teachers felt strongly about them. He didn’t say “abundance of caution.” He said, “We are responding to your concerns [because] you are understandably afraid.” He gained enormous trust and credibility. Frieden fell more deeply into the symptomatic/asymptomatic trap at his October 2 news conference. As reported by Denise Grady of the New York Times : The disease is not contagious during the incubation period, and patients do not transmit it until they develop symptoms, [Frieden] said. And those with symptoms will probably feel sick enough to stay home. People are highly unlikely to catch the disease on the bus or subway, Dr. Frieden said.” Frieden’s claim that those with symptoms will probably feel sick enough to stay home is not true for a significant number of Ebola patients, early in their illnesses. Ebola-infected healthcare workers have even gone to work in the early phase of their illnesses. After treating an Ebola patient who recovered, the late Nigerian doctor Ikechukwu Enemuo developed symptoms on August 11. He continued to treat patients until August 13 – including two surgeries – when he got too sick. Then he stayed home with his wife and baby for another three days. He infected his wife, his sister, and a third person before he died. Some Ebola-infected healthcare workers have even continued to socialize during the early phase of their illnesses, during which time they infected others. Some Ebola Treatment Unit healthcare workers, feeling poorly but certain they didn’t have Ebola, have continued to come to work out of a strong humanitarian sense of dedication. Some of them infected others before they got too sick. It is really wrong to tell people that an asymptomatic person can’t transmit Ebola, and also tell them that a symptomatic person will be too sick to be out and about. The first half is almost certainly true almost all of the time – but there is not always a bright line between perfectly well and mildly symptomatic. The second half is far from true much of the time – there is often a fairly broad line, a couple of days wide, between mildly symptomatic and flat on your back. The oversimplified claim that Ebola transmits only via direct contact with bodily fluids. Here again, the point is probably almost entirely true but overstated. What gets across to most people is that to catch Ebola you must actually touch a sufferer’s feces, vomit, or blood. Not that most people think that’s the truth; they think that’s what officials are saying, and they decide for themselves that Ebola can probably sometimes transmit in subtler ways as well. The scenarios that officials tend to shy away from are the ones that don’t sound like “direct contact with bodily fluids,” but actually are. Shaking hands at a party with a sweaty new acquaintance from West Africa, and then rubbing your eyes. Riding in a taxi whose previous passenger left hard-to-interpret slightly damp stains on the seat. Making love to a man who has recently recovered from Ebola, whose sperm still carries the virus. Standing less than three feet from somebody who spits a bit when s/he talks (as we all do). The last one got Frieden into hot water in an October 1 CNN interview with Sanjay Gupta. Standing right next to Gupta, Frieden said: “Well actually, Sanjay and I, if one of us had Ebola, the other would not be a contact right now. Because we’re not in contact. Just talking to someone is not a way to get infected. It’s not like the flu, not like the common cold. It requires direct physical contact.” CNN host Michaela Pereira pointed out that sneezing would change the situation. And Gupta objected that “I am within three feet of you…. My understanding, reading your guidelines, sir, is that within three feet or direct contact – if I were to shake your hand, for example – would both qualify as being contact.” At that point Frieden should have said, simply, “You’re right. I misspoke. Ebola can sometimes transmit by droplets (for example, from a sneeze or saliva when people talk), or by fomites (for example, from a handshake). That’s pretty much the same pathways as flu, although Ebola is a lot less contagious than flu via the droplet route. Ebola spreads mostly via contact with bodily fluids.” What he actually said: “We look at each situation individually and we assess it based on how sick the individual is and what the nature of the contact is. And certainly if you’re within 3 feet, that’s a situation we’d want to be concerned about.” Not his best moment. The word “airborne” is also problematic. What airborne transmission means to a virologist is transmission via much smaller particles that can travel much further than large droplets. By that definition, Ebola isn’t airborne – although some experts are worried that the Ebola virus might mutate in a way that would permit airborne transmission. But what does “airborne” mean to ordinary people when they hear an official assure them that there’s no risk of airborne Ebola transmission? It means through the air. And by that definition, Ebola transmission is sometimes airborne, for example when people sneeze, cough, or emit droplets of saliva while talking. In this sense projectile vomiting is also airborne.

There are plenty of shorter, simpler examples as well. Dallas officials trumpeted the fact that the three EMTs who transported Duncan to the hospital had tested negative for Ebola. Ebola tests are usually negative until after symptoms appear, and the EMTs were asymptomatic. So the testing was purely for show. This sort of false reassurance works for a while, until people figure out – or just sense – that they’re being patronized and misled, treated more like children than like adults. Then they become much harder to reassure later if the news really is good news.

Talking about West Africa

As communicators, public health professionals are happiest when they’re warning about risks that people are unwisely inclined to shrug off – risks like obesity, smoking, alcohol, and flu. “Watch out! This could kill you! Take the following precautions….” They’re typically a lot less comfortable offering reassurance, urging overly alarmed people to calm down.

It’s a rare public health professional who wouldn’t rather talk about the dangers of childhood diseases than the safety of the vaccines against those diseases.

So it’s not surprising that Frieden was at his best when Ebola was far away in West Africa and Americans were pretty apathetic about it. He could pull out all the stops in his efforts to convince the public and the politicians that fighting this epidemic should be a top priority. There were moments when he was truly masterful, almost Churchillian in his dogged-but-eloquent determination to beat the Ebola virus.

We thought there were other moments when he came across as over-optimistic, especially in his repeated insistence that “we know how to do this,” that all it takes is “meticulous” application of “tried-and-true” public health principles. Still, the good determination usually outshined the optimism. And optimism is less off-putting when you’re marshalling the troops to help fight a noble war than when you’re urging them to calm down and trust that you’ve got everything under control.

And he was pretty successful, too, at least with the politicians. (The paucity of U.S. citizen volunteers to go fight Ebola in West Africa is in stunning contrast to the superfluity of “disaster volunteers” for many other crises, such as the December 2004 tsunami.) We wonder whether President Obama and the U.S. Congress would have agreed to launch such an ambitious response in West Africa if not for Frieden’s personal credibility and unflagging advocacy. There’s reason to question whether that ambitious response will be big enough and soon enough to make a real difference. But there’s no question that if it does, a lot of the credit will deservedly go to Tom Frieden.

One imported case in Dallas should have been a teachable moment to raise Americans’ consciousness about the disaster in Africa and the threat that disaster poses to all of us. It’s not working out that way so far. Along with every virologist, epidemiologist, and public health expert in the country, Frieden rightly wants to hold the public’s newfound attention while turning the conversation back to Africa. We doubt he can as long as Dallas continues to yield embarrassment after embarrassment. And the focus on Dallas is understandable as long as we are all waiting to see how many additional cases end up launched by Patient Zero.

But if he can turn the conversation back to Africa, what should he say?

Frieden clearly understands that humanitarianism can’t be his Africa Ebola SOCO. To be sure, millions of Americans suffer for West Africa’s suffering, and it would be unwise as well as unempathic to abandon the message that we must help where we can. But hundreds of millions of Americans are more interested in a different question: How does Ebola there threaten us here, and what should we do to protect ourselves?

There seem to be four answers to that question:

We must develop and mass-manufacture an Ebola vaccine. We must insulate ourselves from the hot zones, refusing to allow people from there to come here unless they can prove themselves Ebola-free. We must break the back of the epidemic in West Africa, chiefly by isolating those who are sick, and then tracking their contacts. We must provide decent basic medical care for West Africans with Ebola, not just for humanitarian reasons but also because otherwise too many will flee, and some will take the virus with them.

These aren’t incompatible answers. It’s arguable that we must do all four.

But post-Dallas, the big fight will be over #2. Many people’s quite sensible intuitive response to Dallas is to want to shut the border to anyone who might be infected with Ebola. It won’t help to denigrate that response as nativist or naïve. Sometimes it is, of course. The track record of cordons sanitaires isn’t encouraging; they come at an awful human price, and still they leak.

Nonetheless, it is quite reasonable for people to ask how best to reduce the number of sparks flying out of Africa and threatening to ignite elsewhere. Extinguishing those sparks is burdensome and expensive in the developed world, and may prove impossible in the developing world. Nobody wants to see Ebola take root in Asia as well as Africa, wreaking havoc on everything from supply chains to political stability – while Europe and North America are kept busy coping with periodic Dallases. The only permanent solutions may be #1 or #3, immunizing the world or stopping the epidemic. Nobody knows if either is possible. While we find out, #2 – spark suppression – can buy desperately needed time.

Post-Dallas, in short, talking about West Africa is going to be chiefly talking about spark suppression. There will be nativist, naïve proposals on the table, proposals to close our border or, better yet, close theirs. The question is whether there will be more realistic, more empathic proposals on the table as well. Or will the issue be left to the far right?

We have no idea what Frieden may choose to say about spark suppression. For the most part, he has focused on treatment (#4) and isolation (#3) – stressing his view that the former is essential to achieving the latter. He surely favors an Ebola vaccine (#1), but he hasn’t pushed it hard.

With regard to spark suppression (#2), he has often pointed out that border closings don’t work, by which he appears to mean that they don’t work perfectly and have unacceptable humanitarian downsides. We hope he will have more to say in the coming months about how best to reduce the number of sparks emanating from West Africa and igniting here … or anywhere.

We hope someone will raise the possibility of a very difficult halfway measure between a doomed cordon sanitaire and today’s open borders – an “Ellis Island” approach, perhaps: 21 days of real quarantine for people coming from the hot zones. Start with returning volunteers who have been close to Ebola patients … and do it before the first not-really-quarantined returning volunteer gets sick and infects others.

Three Miscellaneous Points

“The window is closing” We wish Frieden – and all Ebola commentators – would stop telling people that “the window [of opportunity] is closing” in West Africa. They never say when the window will be closed, and after a while everyone figures out that they will never say that the window is now closed. If they really mean what they say, they should tell us what they think should happen after the window closes. Tone The determined, Churchillian tone that we like when Frieden is trying to rouse people to take a risk seriously can come off as cocky or even smug when he’s telling people everything is under control and they should just calm down and let the people in charge get the job done. But we think the experience of the past three days may have solved that problem already. In crisis communication, the best combination is a confident tone and tentative content. You don’t know what’s going to happen next; you may have to change a bunch of policies after you see what works and what doesn’t; you’re building your boat and sailing it at the same time (David Heymann’s words); you know there will be screw-ups. But you’re used to that. Coping with chaos and uncertainty goes with the job, and it’s not freaking you out. The opposite combination – saying confident things in a tone that suggests you’re in over your head – is of course disastrous. So we’re not urging Frieden to change his tone, just his content. Alternative precautions This is particularly relevant for frontline healthcare workers and Personal Protective Equipment (PPE). When prescribing precautions, it’s always wise to give people a choice, and thus a sense of control. Ideally, we advise clients to try to offer an X, a Y, and a Z: At least do X. Even if you think we’re over-reacting, X is the minimum protection we think is necessary. We recommend Y. Y is more hassle and more costly than X, but it is also more protective than X. We think it’s worth it – but if you disagree and want to stop at X, okay. Z is still more bother and expense than Y, and again more protective. We don’t think it’s worth it; that’s why we recommend Y rather than Z. But if you think we’re not going far enough, if you feel more vulnerable than most people or more worried than most people, by all means go that extra mile and do Z, with our blessing. If there is a whole menu of X precautions, Y precautions, and Z precautions, that’s better yet. Two good things happen when you bracket your Y (your preferred recommendation) with an X and a Z. First, you get more Y. Because people feel more sense of control, they tend to be more willing to comply than when faced with a one-size-fits-all prescription. Second, you get less long-term rebellion. You have framed the choice of precautions so people who prefer X or Z to Y are still inside the system, not rebels. That makes them more receptive to your next precaution recommendation. In Dallas and around the country, a lot of people are looking for Ebola Z’s. Local officials want to quarantine asymptomatic contacts. Talk radio hosts want to close the border. Healthcare workers and cleanup workers want better PPE. If the CDC wants to avoid unacceptable Z’s, it will help to prescribe some acceptable ones. You can’t give every healthcare worker a moon suit like the ones we’ve all seen on television. But for many of them a surgical mask just doesn’t feel protective enough, even though you say it ought to be in many cases. So make N95 respirators your Z. Other people are in need of an X. Some contacts, for example, resist the prescribed quarantine protocol. This may be denial; they’re at risk and can’t let themselves believe it. Or they may rightly sense that you’re “casting a wide net,” as you say, and their risk is really negligible. So offer them a choice of protocols, including a less onerous X.

List of Ebola Risk Communication articles.

Copyright © 2014 by Peter M. Sandman and Jody Lanard





The Second Email (October 5, 2014):

What Needs to Change in Ebola Risk Communication:

Pivoting away from Dallas

by Peter M. Sandman and Jody Lanard

(email reponse to query from Kai Kupferschmidt of Science )

Like anyone who has been following events in West Africa, we knew that sparks from that conflagration would reach the rest of the world. We didn’t know the U.S. would go first, of course, but it wasn’t especially shocking. It wasn’t even the other shoe dropping – just one of many Ebola sparks that will probably land around the world over the next of couple of years.

One of our first thoughts was to wonder whether the U.S. media’s blanket coverage of Dallas would constitute a teachable moment for Americans to understand the global threat. Or would it be, instead, a sideshow distraction, or even a distortion. We’re still wondering.

So far it’s more a distraction and distortion. Of course the U.S. media need to respond to the interest and justified fearful attention of the U.S. public – and the response is useful for focusing hospital attention on preparedness. But with everyone paying attention, a huge effort should be made to vividly and dramatically tell people what might happen if the epidemic spreads throughout Africa and into other parts of the developing world, such as India. Telling people there could be up to 1.4 million cases by mid-January didn’t do it. The public at large, and most decision-makers, just don’t get it that this is a huge threat to the world, and not just (or primarily) because of sparks landing in Dallas or elsewhere in the developed world.

We think three things need to happen before American attention can focus where it belongs:

The Dallas “outbreak” needs to be stopped – stopped at one, ideally, but that die is cast. Either other people are already infected or they are not.

The screw-ups in Dallas need to stop. The two big ones so far: letting the patient go home from the hospital on September 26; and leaving the family in enforced quarantine inside a contaminated apartment for days.

The screw-ups in Dallas need to be acknowledged and apologized for – repeatedly. When a Texas official said they are “continuing to improve,” it sounded hollow and grossly insufficient, juxtaposed with news that the family had at last been removed from their apartment.

As long as U.S. media are justifiably fixated on “exposing” what went wrong and what keeps going wrong and what might go wrong in Dallas, the conversation here won’t turn to West Africa, where it belongs. The more officials continue to sound like cheerleaders, ignoring or minimizing what goes wrong, the more the media will focus on knocking them off their high horse.

If the Dallas outbreak remains at just one case, media and public attention will soon turn to other topics entirely, and the teachable moment will have been squandered. Officials need to clean up their act before Dallas stops being newsworthy – so they can pivot away from Dallas to West Africa and try to make the case for an incredibly huge effort to keep the Ebola epidemic from becoming a developing world pandemic.

On the other hand, the inevitable U.S. focus on various proposals to “close the border” is more on target than many public health professionals are willing to admit publicly.

Four Responses to the Epidemic

Excruciating stories about West African agony and appeals for humanitarian aid are not, in our judgment, the most important sorts of world media content about Ebola. It is true that millions of people around the world suffer for West Africa’s suffering, and it would be unwise as well as unempathic to abandon the message that we must help where we can. But hundreds of millions of people are more interested in a different question: How does Ebola in West Africa threaten us where we are, and what should we do to protect ourselves?

Different groups propose four different answers to that question:

We must try to develop and mass-manufacture an Ebola vaccine. We must insulate ourselves from the hot zones, refusing to allow people from there to come here unless they can prove themselves Ebola-free. (Among the proposals: 21-day quarantines before release into the U.S.) We must break the back of the epidemic in West Africa, chiefly by isolating those who are sick, and then tracking their contacts – the traditional public health response, which has never been tried in a hemorrhagic fever epidemic as enormous as this one. We must provide decent basic medical care for West Africans with Ebola, not just for humanitarian reasons but also because otherwise too many will flee, and some will take the virus with them.

These aren’t incompatible answers. It’s arguable that we must do all four.

But post-Dallas, the big fight will be over #2. Many people’s quite sensible intuitive response to Dallas is to want to shut the border to anyone who might be infected with Ebola. It won’t help to denigrate that response as nativist or naïve. Sometimes it is, of course. The track record of cordons sanitaires isn’t encouraging; they come at an awful human price, and still they leak.

Nonetheless, it is quite reasonable for people to ask how best to reduce the number of sparks flying out of Africa and threatening to ignite elsewhere. Extinguishing those sparks is burdensome and expensive in the developed world, and may prove impossible in the developing world. Nobody wants to see Ebola take root in Asia as well as Africa, wreaking havoc on everything from supply chains to political stability – while Europe and North America are kept busy coping with periodic Dallases. The only permanent solutions may be #1 or #3, immunizing the world or stopping the epidemic. Nobody knows if either is possible. While we find out, some version of #2 – spark suppression – can buy desperately needed time.

Post-Dallas, in short, talking about West Africa is going to be chiefly talking about spark suppression. There will be nativist, naïve proposals on the table, proposals to close our border or, better yet, close theirs. The question is whether there will be more realistic, more empathic proposals on the table as well. Or will the issue be left to the far right?

Too much of the messaging about Ebola in West Africa – by public health officials and humanitarian NGOs, and by reporters on the scene – has focused on treatment (#4), and to a lesser extent on isolation (#3). The public is hearing too little about what else can be done to speed the desperate search for an Ebola vaccine (#1). And it is hearing far too little about spark suppression (#2).

Improving Ebola Risk Communication

If we could change a few things about Ebola risk communication, here’s what we’d change:

Teach the world how exponential growth works. Explain that the CDC’s worst-case estimate of 1.4 million Ebola cases by mid-January is essentially the same estimate as 700,000 in late December and 2.8 million in early February. Reducing the doubling time of Ebola requires reducing the number of contacts sick people have a chance to infect. Isolation is – tragically – a much higher priority than treatment. This isn’t a humanitarian crisis. It is a global health crisis. And it is a global security crisis. Armies may be a more important part of the solution than healthcare workers. Teach the world what’s in store for us all if Ebola isn’t stopped. It’s about more than numbers. Paint vivid pictures of what life would be like if Ebola were to establish itself throughout the developing world the way it has established itself in three West African countries so far. Talk about the likely impact on supply chains, on the world economy, on political stability. Point out that developed countries can probably extinguish the sparks that come their way, at least if there aren’t too many – though with greater difficulty and greater pain than we’re imagining. And point out that developing countries probably can’t. Lagos and Port Harcourt somehow managed to extinguish the spark that ignited after Patrick Sawyer brought Ebola from Liberia to Nigeria, as few thought they could. Almost nobody thinks the developing world can extinguish spark after spark after spark. Teach the world why finding, testing, mass-producing, and actually distributing an Ebola vaccine is the only realistic way to end this global disaster-in-the-making. Investigate the vaccine development story in detail. Find the choke points that need to be smoothed. Figure out what else could be done to improve the probability of success and the speed with which it happens. Report in detail on what’s hopeful and what’s not so hopeful in the Ebola vaccine story so far. Assess – and keep assessing – whether a vaccine is a pie-in-the-sky deus-ex-machina or a reasonable hope. (This in particular is a job for Science !) Teach the world why “spark suppression” – reducing the number of Ebola sparks emanating from West Africa – is essential to buy time for the desperate attempt to find a vaccine. Don’t settle for the false dichotomy – the claim that since border closings never work perfectly, there’s no point in inhibiting travel. Foster a thoughtful debate about various proposals for reducing the number of sparks, and thus reducing not just the burden of extinguishing those sparks but also the chances of Ebola establishing itself in additional countries. Help assess which proposals will probably backfire, which will do little good at great humanitarian cost, and which will do comparatively more good at comparatively lower cost. Teach the world to endure uncertainty. The Ebola virus might mutate in ways that would make it even more dangerous than it is now – to enable airborne transmission, for example, or to enable an infected person to function longer in the world and thus spread the disease to more people. At the other extreme, Ebola might somehow burn itself out. Or it might become endemic in Africa without spreading widely elsewhere in the world. More important than any individual scenario is the reality that we know so little about which scenarios are likely and which are vanishingly unlikely or even impossible. Until now, our knowledge of Ebola comes almost entirely from small outbreaks in African villages; now we are learning from a big epidemic in West Africa. We still know next to nothing about how an Ebola outbreak might play out in a developed country in the northern hemisphere.

And then there are the basic crisis communication priorities, like these:

And so on….

List of Ebola Risk Communication articles.

Copyright © 2014 by Peter M. Sandman and Jody Lanard





The Third Email (October 6, 2014):

Three Ebola News Stories: Dallas, West Africa, and What-If

by Peter M. Sandman

(email reponse to query from Paul Farhi of the Washington Post )

There are three Ebola stories – the domestic Ebola story in Dallas, the epidemic Ebola story in West Africa, and the what-if Ebola story in the rest of the world. I’ll take them one at a time.

The Domestic Ebola Story in Dallas

Medically, the Dallas Ebola story is a much smaller story than the media coverage might suggest. There is one patient near death so far, Thomas Eric Duncan. There may or may not be a few more cases from among Duncan’s contacts. But the mantra of U.S. Government officials like the CDC’s Tom Frieden and the NIH’s Tony Fauci is almost certainly accurate: The U.S. will stop Ebola in its tracks by isolating patients and monitoring their contacts, tried-and-true public health techniques that will work. Dallas will never look like Monrovia. There is no imminent threat to the health of Americans.

Nonetheless, there are good reasons why Dallas is and should be a big story.

First, the public has always been interested in risks in proportion to how much fear or outrage they arouse, not in proportion to how much hazard they present. Since media coverage follows people’s interests, reporters inevitably cover scary diseases that aren’t very dangerous more than dangerous diseases that aren’t very scary. That may drive public health professionals crazy, but it’s a fact of life. Journalism is about news, not education. (Journalists do cover obesity, smoking, and other boring risk stories – occasionally.) And Ebola has all the hallmarks of a scary disease. It is novel, dramatic, horrifying, potentially catastrophic. It’s perfect for horror movies; why wouldn’t it be perfect for news stories?

Second, when people are newly aware of a risk, the natural response is a brief over-reaction, sometimes called an “adjustment reaction.” Adjustment reactions are both inevitable and useful; they’re emotional rehearsals that prepare people to cope later, if necessary. Right now the U.S. media and public are working their way through an adjustment reaction to domestic Ebola. The number of U.S. Google searches for “Ebola” peaked on October 2 and is already headed downward, though of course there may be other peaks if some of Duncan’s contacts get sick.

Third, Ebola in Dallas isn’t just an emotional rehearsal for the American public. It is also a logistical rehearsal for the American healthcare system. There is no reason not to expect other cases in other U.S. cities sooner or later. We are learning crucial lessons from Dallas – about the importance of travel histories, about the need to isolate suspected cases quickly before too many healthcare workers are exposed, about the problems of disposing of Ebola waste safely and legally, etc. More than anything else, it is the blanket media coverage that is teaching these lessons. When two doctors brought Middle East Respiratory Syndrome to the U.S. from Saudi Arabia last spring, both hospitals missed the travel histories at admission. Scores of healthcare workers were exposed. The delayed travel histories got hardly any media coverage, and a major teachable moment was lost.

Finally, the various screw-ups in Dallas (sending Duncan home the first time he went to the emergency room, holding the family under armed guard in a contaminated apartment, etc.) have reminded reporters that they are not the natural allies of government (or hospital) officials. Journalists are supposed to be the adversaries of officials, holding their feet to the fire. And they are supposed to be independent seekers of truth, turning over rocks that officials may prefer to leave alone. The efforts of officials to hide or minimize their errors have backfired royally. So have their frequent appeals to the media as “partners.” At least for the moment, U.S. investigative Ebola reporting is flourishing, and that’s a blessing.

The Epidemic Ebola Story in West Africa

Needless to say, the Ebola epidemic is in West Africa, not in Dallas. Thousands of people are getting diagnosed with Ebola there; one so far has been diagnosed with it here. Public health experts and officials are understandably wringing their hands at the ways in which the U.S. story is overshadowing the West Africa story in U.S. coverage. They see Dallas as a sideshow, and in their Dallas messaging they keep trying to bridge to the main story in West Africa.

Ideally, the newsworthiness of Dallas would constitute a teachable moment for talking about West Africa. So far it’s turning out instead to be a distraction, or even a distortion. For that to change, the Dallas “outbreak” needs to be stopped, the screw-ups in Dallas need to end, and the screw-ups need to be more aggressively acknowledged and apologized for. As long as U.S. media are justifiably fixated on what went wrong and what keeps going wrong and what might go wrong in Dallas, the conversation won’t turn to West Africa. The more officials continue to sound like cheerleaders, ignoring or minimizing what goes wrong, the more the media will focus on knocking them off their high horse.

There are two West Africa stories, I think. One is the humanitarian story: the almost unimaginable suffering of West Africans with Ebola and their families, and the heroic but so far less-than-successful efforts to treat the sufferers. The other is the epidemiological story: the equally unsuccessful effort (so far) to break the back of the epidemic by isolating sufferers and monitoring their contacts.

The agonizing truth is that the humanitarian story is a lot less important than the epidemiological story. Treatment matters, but in the long run isolation matters more. As long as the number of Ebola cases keeps doubling every 20–30 days, even the most heroic treatment efforts are doomed. The job in West Africa may call for soldiers more than doctors and nurses. I think reporters on the ground and editors back home are beginning to realize this, as are many of their sources.

The two stories are not completely independent, of course. One good reason to try to treat sufferers is to give them a reason to accept isolation, rather than staying home and infecting their loved ones, or fleeing and taking the virus with them. Nonetheless, the West Africa story is slowly – too slowly, I think – morphing from a treatment focus to an isolation focus.

The What-If Ebola Story in the Rest of the World

Here’s what experts and officials are reluctant to say, and reporters reluctant to cover: As long as the conflagration in West Africa rages, it will keep throwing off sparks. Inevitably, some of those sparks will catch and start new conflagrations elsewhere in the world.

There may yet be a deus-ex-machina that prevents such a disaster, like the quick development and mass manufacture of an effective vaccine or treatment. But barring a magic bullet, we may very well be moving toward an Ebola pandemic that engulfs much of the developing world. The impacts of such a pandemic are likely to include serious supply chain disruptions, another global economic crisis, political unrest, massive movements of refugees, and massive efforts to close borders.

The sparks that land in the developed world will be extinguished, as the spark in Dallas is being extinguished. Doing so will sometimes be more difficult, costly, and painful than officials are implying, but they’re right that in countries with good healthcare systems “we know how” to prevent a widespread Ebola outbreak.

The sparks that land in the developing world are another story. Nigeria managed to extinguish such a spark, ignited when Liberian-American Patrick Sawyer flew from Monrovia to Lagos while sick with Ebola. Many experts were shocked at this success. Few are predicting that the developing world can manage to extinguish spark after spark after spark. Huge cities will be vulnerable, from Mumbai to Mexico City, from Cairo to Karachi, every time an Ebola-afflicted traveler manages to get there from West Africa.

This is the global what-if Ebola story. It is speculative – but not that speculative. It’s what many if not most experts privately think likeliest. But they are reluctant to say so. They don’t want to scare the public unduly; worse, they don’t want to be accused of trying to scare the public unduly. And in many cases they feel they have exhausted their credibility. SARS turned out manageable. Swine flu turned out mild. H5N1, H7N9, and MERS never amounted to much (so far, anyway). If you tried to sound the alarm about a couple of those in recent years, it’s understandable why you might hesitate to sound the alarm now about the possibility of a global Ebola pandemic – especially if you’re not sure there’s much the public can do about it anyhow.

Over the long haul, preventing a global Ebola pandemic requires either developing an effective treatment/vaccine or breaking the back of the epidemic in West Africa. Nobody knows if either is possible. Over the short haul, the crucial job is to buy time by reducing the number of sparks flying from West Africa to other parts of the world. In the wake of Lagos and now Dallas, spark suppression is going to be the most important Ebola story. I think it’s essential to get this story out, because it is a political and ethical story as much as a technical story.

Many Americans’ quite sensible intuitive response to Dallas is to want to shut the border to anyone who might be infected with Ebola. It won’t help to denigrate that response as nativist or naïve. Sometimes it is, of course. The track record of cordons sanitaires isn’t encouraging; they come at an awful human price, and still they leak. Nonetheless, it is quite reasonable for people to ask how best to reduce the number of sparks flying out of Africa and threatening to ignite elsewhere. There will be nativist, naïve proposals on the table, proposals to close our border or, better yet, close theirs. The question is whether there will be more realistic, more empathic proposals on the table as well. Or will the issue be left to the far right?

Too much of the messaging about Ebola in West Africa – by public health officials and humanitarian NGOs, and by reporters on the scene – has focused on treatment, and to a lesser extent on isolation. The public is hearing too little about what else can be done to speed the desperate search for an Ebola vaccine or treatment. And it is hearing far too little about spark suppression – and about the crucial role of spark suppression in reducing the risk of an Ebola pandemic in the developing world.

List of Ebola Risk Communication articles.

Copyright © 2014 by Peter M. Sandman