After disastrous communications during the 2001 anthrax attacks — when white powder in envelopes sparked widespread panic — the Centers for Disease Control and Prevention created a 450-page manual outlining how U.S. leaders should talk to the public during crises.

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Protecting vulnerable people from a virus that, according to some projections, could infect millions and kill hundreds of thousands, depends on U.S. leaders issuing clear public health instructions and the public’s trust to follow directions that could save their lives.

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“Sometimes it seems like they have literally thrown out the book,” said Joshua Sharfstein, a former top FDA official and Johns Hopkins University professor who is using the CDC manual to teach a crisis communication class. “We’re studying what to do — and at times seeing what not to do — on the same day.”

Two weeks ago, Trump said the country would soon have zero cases. This week, there were more than 2,200 and 49 deaths. When asked at a news conference Friday why he disbanded the White House’s pandemic office, Trump denied doing so, saying, “I didn’t do it … I don’t know anything about it.” When asked if he bore any responsibility for disastrous delays in testing, Trump said no, blaming instead “circumstances” and “regulations” created by others. When asked if Americans should believe Trump or his top health official, Anthony S. Fauci — whom Trump has contradicted repeatedly — Trump sidestepped the question.

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“For those of us in this field, this is profoundly and deeply distressing,” said Matthew Seeger, a risk communication expert at Wayne State University who developed the CDC guidebook alongside many top doctors, public health researchers, scientists, consultants and behavioral psychologists.

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“It’s creating higher levels of anxiety, higher levels of uncertainty and higher levels of social disruption. … We spent decades training people and investing in developing this competency. We know how to do this.”

For three years, the Trump administration has often taken a hostile stance to science and its practitioners, but health crisis experts say it’s not too late and the fruits of their research — like the CDC’s 450-page manual — are waiting, untapped, to serve as a road map to help leaders navigate the growing pandemic.

Breaking every rule

The fundamental principles behind good public health communication are almost stunningly simple: Be consistent. Be accurate. Don’t withhold vital information, the CDC manual says. And above all, don’t let anyone onto the podium without the preparation, knowledge and discipline to deliver vital health messages.

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Experts say that means not having multiple messengers jockeying for attention with completely different information. It means not overly reassuring people in the face of a threat that is likely to sicken many and kill some. It also means expressing empathy while also delivering information that may be scary. Tell people what they can and should do at an individual level to help those who are at greatest risk.

“It’s in the nature of leaders sometimes to want to tell everybody we have everything under control,” said Michael Palenchar, a crisis communications expert at the University of Tennessee at Knoxville. “We know overwhelmingly that research suggests that’s detrimental to health and safety.”

Palenchar was one of more than 180 who contributed to the CDC manual, including experts from the CDC, American Red Cross, FBI and EPA as well as federal and state health departments.

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They compiled a list of pitfalls to avoid — a list that has begun to look a lot like the administration’s playbook.

Nearly every day since the coronavirus landed in America, the White House has issued “mixed and conflicting messages from multiple sources,” the first guideline in the manual’s list of potentially harmful practices. “Overly reassuring and unrealistic communication” has come from the highest levels of government. The “perception that certain groups are gaining preferential treatment” has become a problem with health care workers complaining they can’t get tested while two asymptomatic Trump allies in Congress, Celine Dion and the members of the Utah Jazz basketball team were able to access tests.

Crucial messaging also appears to be failing to reach or convince many in America. Nearly 50 million in the country are 65 or older — the most vulnerable age group for severe symptoms and death. But many are shrugging off pleas for them to practice social distancing. At The Villages, a sprawling Florida retirement community, many seniors said the crisis is being overblown and talked of continuing their normal lives.

The Right Spokesperson

The CDC manual devotes an entire chapter to “choosing the right spokesperson,” someone who gives the government and its message “a human form.” But the government’s leading health experts have had to repeatedly cede the microphone to politicians — with the nation’s top health officials repeatedly canceling news conferences to make room for Vice President Pence or Trump or to avoid upstaging other White House announcements.

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Last week, instead of holding CDC’s news conference focused on coronavirus, Trump toured the CDC in front of cameras, telling the public, “Anybody right now and yesterday, anybody that needs a test gets a test. And the tests are beautiful.” This Friday, CDC’s press call was canceled again so that Trump could hold his Rose Garden news conference.

In recent days, rather than having one voice, the spokesperson role has ping ponged among Pence, Health and Human Services Secretary Alex Azar, Fauci and Trump. Trump in particular checks off many of attributes the manual specifically warns against. The spokesperson must be “familiar with the subject matter” and have the “ability to talk about it clearly and with confidence.”

Since taking office, Trump has ousted scientists, muzzled researchers and suppressed basic information on climate change. Public health officials worry that his erosion of public trust of science, coupled with the ongoing conflicting messaging between experts and politicians, is making it unclear whom the public should listen to.

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“I’m fearful we’ve continued to undermine our belief that subject matter experts are people we should listen to,” said Seeger, the Wayne State professor. “We’ve done a good job over the last couple decades of undermining science and telling people scientists aren’t to be believed.”

Class in Session

All semester long, Johns Hopkins professor Sharfstein has been drilling the principles of the CDC manual into the class he teaches at Johns Hopkins. On Thursday, as the White house issued more contradictory statements, his students — a mix of undergrad and graduate students — debated the Trump administration’s response, which has served as a real-time master class for what not to do in a crisis.

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They compared it to historical blunders in health communications: the 2009 H1N1 swine flu pandemic, when officials gave overly optimistic timetables on vaccines, and bungled messaging by British leaders on mad cow disease in the 1990s, which led to millions in economic damage to the country’s beef industry.

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Similarly, several students noted, the messaging disasters in recent weeks have muddled and overshadowed lifesaving health advice to the public.

Many of his students were especially puzzled by the Trump administration’s reluctance to admit fault on its dire problems in testing for the coronavirus.

“They have so much less credibility because of that,” said one student, noting how questions of what went wrong keep dominating congressional hearings and news conferences — making it hard to get instructions to the public on how to prepare and suppress the spreading virus.

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Another empathized with Trump officials: “It’s a fine line between apologizing and putting yourself out there for attacks.”

Sharfstein — who served as Maryland’s health secretary and a top FDA official in the Obama administration — asked his students whether they thought the Trump administration would be willing to make a partial admission: “Obviously something has gone wrong. There will be time to assess what went wrong, but right now here’s what I’m focused on to fix the problem.”

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Students began workshopping what the White House could do to right the ship:

— Tell Americans, “We made mistakes. Here’s how we’re going to fix them.”

— Stop pretending testing is fine. Explain what solutions are underway

— One student simply cited the cover of the CDC manual: “Be first. Be right. Be credible.”