Epidemiologists must persuade people to upend their lives even when there’s scant evidence that they’re directly at risk, notes an article by Charles Duhigg in The New Yorker. In the US, Seattle got it right. New York did not.
“Being approximately right most of the time is better than being precisely right occasionally,” the Scottish epidemiologist John Cowden wrote, in 2010. “You can only be sure when to act in retrospect.”
Epidemiologists also must learn how to maintain their persuasiveness even as their advice shifts. The recommendations that public-health professionals make at the beginning of an emergency – there’s no need to wear masks; children can’t become seriously ill – often change as hypotheses are disproved, new experiments occur, and a virus mutates.
Duhigg writes in the US, the initial coronavirus outbreaks on the East and West Coasts emerged at roughly the same time. But the danger was communicated very differently. In Seattle, leaders allowed scientists to take the lead. In New York they did not.
He says the US Centres for Disease Control and Prevention’s Field Epidemiology Manual, which devotes an entire chapter to communication during a health emergency, indicates that there should be a lead spokesperson whom the public gets to know – familiarity breeds trust. The spokesperson should have a “Single Overriding Health Communication Objective, or sohco (pronounced sock-O),” which should be repeated at the beginning and the end of any communication with the public. After the opening sohco, the spokesperson should “acknowledge concerns and express understanding of how those affected by the illnesses or injuries are probably feeling.”
Such a gesture of empathy establishes common ground with scared and dubious citizens – who , because of their mistrust, can be at the highest risk for transmission. The spokesperson should make special efforts to explain both what is known and what is unknown. Transparency is essential, the field manual says, and officials must “not over-reassure or overpromise.”
The lead spokesperson should be a scientist. Dr Richard Besser, a former acting CDC director and an EIS alumnus, explained, “If you have a politician on the stage, there’s a very real risk that half the nation is going to do the opposite of what they say.” During the H1N1 outbreak of 2009 – which caused some 12,000 US deaths, infections in every state, and seven hundred school closings – Besser and his successor at the CDC, Dr Tom Frieden, gave more than a hundred press briefings.
President Barack Obama spoke publicly about the outbreak only a few times, and generally limited himself to telling people to heed scientific experts and promising not to let politics distort the government’s response. “The Bush Administration did a good job of creating the infrastructure so that we can respond,” Obama said at the start of the pandemic, and then echoed the sohco by urging families, “Wash your hands when you shake hands. Cover your mouth when you cough. I know it sounds trivial, but it makes a huge difference.” At no time did Obama recommend particular medical treatments, nor did he forecast specifics about when the pandemic would end.
Whereas the CDC protocol encourages politicians to practice restraint, it invites the lead scientific spokesperson to demonstrate his or her advice ostentatiously, and to be a living example of the importance of, say, wearing a mask or getting a shot. When polio inoculations began, in the nineteen-fifties, many people worried that they were unsafe, so New York City’s commissioner of health – who happened to be married to the EIS’s founder—invited reporters to watch schoolchildren getting injections. She also enlisted Elvis to publicly get his shot. EIS personnel in the field have carried boxes of masks and gloves to distribute to pilots, flight attendants, journalists, and health workers – supplies that may not be needed by the recipients but emphasize how important universal compliance is.
When Besser gave briefings during the H1N1 pandemic, he sometimes started by describing how he had recently soaped up his fingers, or pointedly waited until everyone was away from the microphone before taking the stage. At the time, there was almost no chance that Besser and his colleagues were at immediate risk of contracting H1N1. “To maintain trust, you have to be as honest as possible, and make damn sure that everyone walks the walk,” Besser said. “If we order people to wear masks, then every CDC official must wear a mask in public. If we order hand washing, then we let the cameras see us washing our hands. We’re trying to do something nearly impossible, which is get people to take an outbreak seriously when, for most Americans, they don’t know anyone who’s sick and, if the plan works, they’ll never meet anyone who’s sick.”
Public-health officials say that the US culture poses special challenges. Our freedoms to assemble, to speak our minds, to ignore good advice, and to second-guess authority can facilitate the spread of a virus. “We’re not China – we can’t order people to stay inside,” Besser said. “Democracy is a great thing, but it means, for something like COVID-19, we have to persuade people to co-operate if we want to save their lives.”
But soon after the coronavirus landed on US shores the White House took over. EIS officers were dismayed to see the communication principles that the CDC had honed over the years being disregarded, and sometimes turned on their head. A Coronavirus Task Force, led by Vice-President Mike Pence, was formed, excluding everyone from the CDC except its director, Dr Robert Redfield. “The CDC was ordered into lockdown,” a former senior official at the agency told me. “They can’t speak to the media. These are people who have trained their entire lives for epidemics – the finest public-health army in history – and they’ve been told to shut up!”
Duhigg says since then, the primary spokesperson during the pandemic has been not a scientist but President Donald Trump – a politician notoriously hostile to science. Further complicating matters, Trump has highlighted a rotating cast of supporting characters, including Pence; Dr Anthony Fauci, from the National Institutes of Health; Dr Deborah Birx, from the State Department; and the President’s son-in-law, Jared Kushner.
“When there are so many different figures, it can cause real confusion about whom to listen to, or who’s in charge of what,” Dr Tom Inglesby, the director of the Centre for Health Security, at Johns Hopkins, said. “And, if the response becomes political, it’s a disaster, because people won’t know if you are making recommendations based on science or politics, and so there’s the risk they’ll start to tune out.”
Already, it’s clear that some confusion has taken hold. Though the CDC formally recommended, in mid-March, that Americans practice social distancing, governors in five states have refused to order residents to stay home. (One of those states, South Dakota, is now contending with a major outbreak.) Federal leaders have given shifting advice – initially, Americans were told that they did not need to wear masks in public, but on 3 April, at a White House press briefing, masks were recommended – and this has risked undermining public confidence. Trump announced the change by saying, “You don’t have to do it. I’m choosing not to do it.”
Had the CDC been in charge of communicating about masks, the agency surely would have used the change in guidance as a teaching opportunity, explaining that scientists had come to understand that people infected with the coronavirus can be contagious but asymptomatic for longer than originally thought – which means that we need to be more careful when we cough, even if we feel healthy or just have seasonal allergies.
Also, Duhigg says, Trump’s daily briefings are chaotic and contradictory. Within the span of a few days, Trump threatened to quarantine New York City, then reversed himself; soon after declaring that he intended to “reopen” the US economy within two weeks, he called for thirty additional days of social distancing. Such inconstancy from a leader is distracting in the best of times. It is dangerous in a pandemic. “Right now, everyone is so confused by all the conflicting messages that, each time the guidance evolves, fewer and fewer people might follow it,” Besser, the former CDC director, said. “We’re going backward in our sophistication.”
Morale at the CDC has plummeted. “For all the responses that I was involved in, there was always this feeling of camaraderie, that you were part of something bigger than yourself,” another former high-ranking CDC official told me. “Now everyone I talk to is so dispirited. They’re working sixteen-hour days, but they feel ignored. I’ve never seen so many people so frustrated and upset and sad. We could have saved so many more lives. We have the best public-health agency in the world, and we know how to persuade people to do what they need to do. Instead, we’re ignoring everything we’ve learned over the last century.”
Duhigg writes that the initial coronavirus outbreaks in New York City emerged at roughly the same time as those in Seattle. But the cities’ experiences with the disease have markedly differed. By the second week of April, Washington State had roughly one recorded fatality per fourteen thousand residents. New York’s rate of death was nearly six times higher.
There are many explanations for this divergence. New York is denser than Seattle and relies more heavily on public transportation, which forces commuters into close contact. In Seattle, efforts at social distancing may have been aided by local attitudes – newcomers are warned of the Seattle Freeze, which one local columnist compared to the popular girl in high school who “always smiles and says hello” but “doesn’t know your name and doesn’t care to.” New Yorkers are in your face, whether you like it or not. New York also has more poverty and inequality than Seattle, and more international travellers. Moreover, as Mike Famulare, a senior research scientist at the Institute for Disease Modelling, put it to me, “There’s always some element of good luck and bad luck in a pandemic.”
He writes that it is also true, however, that the cities’ leaders acted and communicated very differently in the early stages of the pandemic. Seattle’s leaders moved fast to persuade people to stay home and follow the scientists’ advice; New York’s leaders, despite having a highly esteemed public-health department, moved more slowly, offered more muddied messages, and let politicians’ voices dominate.
In New York City, the Health Department began collecting swabs, but the initiative met swift resistance. Under federal health laws, such swabs have to be anonymised for patients who haven’t consented to a coronavirus test. This meant that, even if city officials learned that many people were infected, officials wouldn’t be able to identify, let alone warn, any of them. The Mayor’s office refused to authorise testing the swabs. “They didn’t want to have to say, ‘There are hundreds, maybe thousands, of you who are positive for coronavirus, but we don’t know who,’ ” a Department of Health official is quoted in the report as saying. The effort was blocked over fears that it might create a panic, but such alarm might have proved useful.
As New York City schools, bars, and restaurants remained open, relations between the Department of Health and City Hall devolved. Health supervisors were “very, very angry,” one official told me. In particular, health officials were furious that de Blasio kept telling New Yorkers to go out and get a test if they suspected they were infected. On March 4th, he tweeted, “If you feel flu-like symptoms (fever, cough and shortness of breath), and recently travelled to an area affected by coronavirus… go to your doctor.” This was the opposite of what city health supervisors were advising: people needed to stay inside and call their doctor if they felt sick. Making trips to doctors’ offices or emergency rooms only increased the odds that the virus would spread, and the city’s limited supply of tests needed to be saved for people with life-threatening conditions.
De Blasio’s staff, however, had started micromanaging the department’s communications, including on Twitter. Finally, on 15 March, the Department of Health was allowed to post a thread: “If you are sick, stay home. If you do not feel better in 3 to 4 days, consult with your health care provider”; “Testing should only be used for people who need to be hospitalized”; “Everyone in NYC should act as if they have been exposed to coronavirus… New Yorkers who are not sick should also stay home as much as possible.” One City Council member said that health officials “had been trying to say that publicly for weeks, but this mayor refuses to trust the experts – it’s mind-boggling.”
As the city’s scientists offered plans for more aggressive action and provided data showing that time was running out, the Mayor’s staff responded that the health officials were politically naïve. At one point, Dr Marcelle Layton, the city’s assistant commissioner of communicable diseases, and an EIS alum who is revered by health officials across the nation for her inventiveness and dedication, was ordered to City Hall, in case she was needed to help the Mayor answer questions from the press. She sat on a bench in a hallway for three hours, away from her team, while politicians spoke to the media. (Layton declined interview requests.) At press conferences, Layton and other physicians played minimal roles while de Blasio and Cuomo, long-time rivals, each attempted to take centre stage. The two men even began publicly feuding – arguing in the press, and through aides, about who had authority over schools and workplace closures.
De Blasio and Cuomo kept bickering. On 17 March, de Blasio told residents to “be prepared right now for the possibility of a shelter-in-place order.” The same day, Cuomo told a reporter, “There’s not going to be any ‘you must stay in your house’ rule.” Cuomo’s staff quietly told reporters that de Blasio was acting “psychotic.”
Three days later, though, Cuomo announced an executive order putting the state on “pause” – which was essentially indistinguishable from stay-at-home orders issued by cities in Washington State, California, and elsewhere. (A spokesperson for de Blasio said that City Hall’s “messaging changed as the situation and the science changed” and that there was “no dithering.” A spokesperson for Cuomo said that “the governor communicated clearly the seriousness of this pandemic” and that “the governor has been laser focused on communicating his actions in a way that doesn’t scare people.”)
Duhigg writes that to a certain extent, de Blasio’s and Cuomo’s tortured delays make sense. Good politicians should worry about poor children missing school just as much as they worry about the threat of an emerging disease. “That’s why EIS training is so important,” Sonja Rasmussen, a former CDC official, said in the report. In a pandemic, “the old ways of thinking get flipped around.” She added, “You have to make the kinds of choices that, if you aren’t trained for them, are really hard to make. And there’s no time to learn from your mistakes.”
Today, New York City has the same social-distancing policies and business-closure rules as Seattle. But, he points out, because New York’s recommendations came later than Seattle’s – and because communication was less consistent – it took longer to influence how people behaved. According to data collected by Google from cell phones, nearly a quarter of Seattleites were avoiding their workplaces by 6 March. In New York City, another week passed until an equivalent percentage did the same.
Tom Frieden, the former CDC director, has estimated that, if New York had started implementing stay-at-home orders ten days earlier than it did, it might have reduced COVID-19 deaths by 50% to 80%. Another former New York City health commissioner told me that “de Blasio was just horrible,” adding, “Maybe it was unintentional, maybe it was his arrogance. But, if you tell people to stay home and then you go to the gym, you can’t really be surprised when people keep going outside.”
More than fifteen thousand people in New York are believed to have died from COVID-19. Last week in Washington State, the estimate was fewer than seven hundred people. New Yorkers now hear constant ambulance sirens, which remind them of the invisible viral threat; residents are currently staying home at even higher rates than in Seattle. And de Blasio and Cuomo – even as they continue to squabble over, say, who gets to reopen schools – have become more forceful in their warnings.
Rasmussen said, “It seems silly, but all these rules and sohcos and telling people again and again to wash their hands – they make a huge difference. That’s why we study it and teach it.” She continued, “It’s really easy, with the best of intentions, to say the wrong thing or send the wrong message. And then more people die.”
[link url="https://www.newyorker.com/magazine/2020/05/04/seattles-leaders-let-scientists-take-the-lead-new-yorks-did-not?utm_source=nl&utm_brand=tny&utm_mailing=TNY_Daily_042620&utm_campaign=aud-dev&utm_medium=email&bxid=5c5fec846c28c708816e9840&cndid=56376852&hasha=0161bd27b328a4029d4b216e13d0ca28&hashb=6de162ddc8d1f884caeed975b57e96cf9209d065&hashc=d62de4c7db6a010a10bcf401ac35ad7215ab28812398590a7f6b3b2c74c51fbf&esrc=bounceX&utm_term=TNY_Daily"]Full report in The New Yorker[/link]