Getting the message across: risk communication and Ebola virus

I’ll say from the outset that I know very little about infectious diseases, so don’t read this expecting any great clarity on that side of things.

I do, however, know a bit about risk communication and perception (though I do not claim to be an expert). I know that people tend to over-estimate risks of rare but ‘dramatic’ events (e.g. being in a plane crash) while underestimating risks of more commonplace and less dramatic ones (e.g. being diagnosed with heart disease). I know that people tend to be more anxious about things that they perceive they cannot control (e.g. avoiding SARS) than things they perceive they can (e.g. avoiding diabetes), even if that perception of control does not translate into action. I know that gaps in reliable and clear information from domain experts can lead to non-experts (e.g. generalist media, people with products to sell) filling in those gaps in ways which may misinform.

That being the case, I have been reflecting on the risk communication I’ve seen around the West African Ebola outbreak, particularly with respect to the likelihood of the outbreak spreading to countries outside of that region.

The US vs UK media response

It is hard to know exactly whether there has been a substantial difference in media representation between the two countries, without conducting the level of investigation I don’t currently have time to do. I do offer two observations however. Firstly that a lot of US-based health professionals that I follow on Twitter seem to be expressing frustration that this latest outbreak has only received any serious coverage in the US following the infection of two US citizens (with the subtext being that the media only seem to care when it affects their own (white) citizens). Secondly, my primary news source (the BBC UK news website) has steadily been reporting the progression of the outbreak over the past few months, and we have no confirmed cases of UK citizens being infected. I make these two points to emphasise that here in the UK we are not having to rally against the same level of prejudicial/biased/suddenly-appearing-from-nowhere reporting that I perceive our US colleagues are facing. This shapes what I set out below.

The UK communications so far – official and professional sources

In brief, I would say that Public Health England are doing a good job of providing calm, factual updates to the situation here. This kind of communication reassures that incidents are being monitored, professional bodies are organised and up to date, and the situation is being handled in the optimal matter.

The advice on the NHS website is also clear and calm. This is pretty much the only place I’ve seen that clarifies the relationship between the period in which someone is infectious and the period in which they have symptoms. I think this is important (I’ll come back to this point).

The government response has, to my mind, been a bit ambiguous. A meeting of the emergency COBRA committee was called, which to political layman like myself usually indicates ‘BAD STUFF IS HAPPENING!’ It doesn’t necessary reassure to know that a topic has been deemed worthy of such a gathering. The main message that seemed to come out of it was that, in the event of it reaching UK shores, the NHS would be well placed to cope. I do not doubt this one bit, but it rather ignores the fact that infectious diseases can be public health and infrastructure problem, rather than simply a healthcare provision problem. Detail on that side of things was rather lacking. Perhaps that is deliberate, but lack of transparency can lead to loss of trust, which can in turn cause issues should a serious situation arise in the future.

Media response

Consider the following:

“A woman was tested for Ebola after being taken ill at the airport, having arrived from West Africa”

versus

“A woman in her 70s was tested for Ebola after being taken ill at the airport, having arrived from The Gambia.”

(N.B. The Gambia has no reported cases to date)

These two sentences are paraphrases of a story reported on the BBC website, firstly before full details were known and secondly after more information became available. To my mind, the first elicits substantially more concern as a reader than the latter, due to the extra contextual information in the second version. So why report the first version, which may cause unnecessary alarm? Why not wait until the additional details are available? It’s also worth noting that the woman in question sadly died (of a non-Ebola cause) and perhaps, having established that she had nothing to do with the outbreak, she and her family should be shown some respect and not be used for clickbait. (As an aside I think it was the correct decision to carry out tests, but reporting every test carried out is not in the public interest).

It’s also interesting to note variety in reporting of this particular case. The flight had originated in Sierra Leone (where there are cases) but the woman boarded at a stop in The Gambia (where there are none reported).

The Independent, Sky NewsBBC News and The Guardian correctly identified the passenger’s point of departure but The Telegraph and The Mirror (which the Telegraph bizarrely cites as its source) miscommunicated that she had come from Sierra Leone. The Daily Mail, meanwhile, took the ‘Scare first, clarify later’ approach of implying Sierra Leone as the origin in the headline and sub-headers, and stating the correct detail in the article.

I’ll leave you to draw your own conclusions as to which of the headlines count as ‘calm and factual’ and which are ‘alarmist and attention seeking’. (One even manages to imply, through bad wording, that she died on the flight)

Don’t Patronise or Mock

While much of the advice circulating on social media about the current low likelihood of spread to countries such as the UK is balanced and factual, some of it rather smacks of “Calm down dear, it’s only a haemorrhagic fever”. I’ve been a bit disappointed to see some people I follow on Twitter, whose opinions I respect, making exasperated comments that seem to trivialise people’s concerns. I acknowledge, however, they may have been prompted to do so by rather trying circumstances or melodramatic responses. Still, posting things like this:

ebola1just comes across as snarky, privileged and dismissive.

It’s worth trying to understand where those melodramatic responses people are irritated by are coming from. Are there gaps in knowledge that professionals could be plugging? Certainly there are folks on the internet with whom one will never successfully engage in rational dialogue, but there are plenty who are inquisitive, anxious and seeking good information. Surely, better to engage and educate than judge and mock?

The more informative, official sources of information, do seek to reassure, but may leave other questions unanswered:

ebola2

A lot of advice seems to project the idea that only trained healthcare professionals come into proximity with the body fluids of others. The reality is that any city dweller or regular use of public transport encounters stranger secretions more often than desirable, whether it’s sweaty straphangers, snotty toddlers, or the pavement decoration one sees on a Sunday morning. Now, presumably the transmission risk is not simply a case of proximity but rather direct and substantial contact, but that’s a nuanced point which might not be getting across. As it stands, anyone stuck on the London Underground on a hot and sweaty day may well find themselves eyeing up fellow passengers carrying air-line labelled luggage with (probably unwarranted) suspicion. We could probably be doing more to make it clear just how close the contact needs to be for transmission to occur.

It’s also worth acknowledging that this is a rather different kind of disease and outbreak process to what most people are used to seeing. It generates a certain amount of cognitive dissonance to hear the general public told ‘You have little to worry about’ while observing that health care professionals are required to wear substantial protective equipment and may still get infected nonetheless. Without very clear information about the cross-infection process, this comes across as a double standard.

I think we do both ourselves, as (potential) risk communicators, and the general public a disservice when we casually dismiss fears the latter may have about something that is very new to them, where good sources of accessible information might only just be emerging.

Room for improvement

So far the risk communication in the UK has been reasonable, though this would need re-assessing in the event of a confirmed case here.

Here’s what I think could improve (though achieving that is another matter!):

  • Better communication about the latent-symptomatic-infectious cycle of Ebola. Otherwise people will start to think there are infectious carriers wandering around spreading disease without even realising it (given the reports that people can take up to 21 days to show symptoms). This seems to have been lacking in most of the risk comms I’ve seen so far. If it is the case that people only start to transmit the disease once they are so sick that they are almost invariably in hospital then make that clear.
  • Fewer comparisons of the “You’re more likely to die of [such and such] than Ebola” variety. Yes, it’s absolutely true, but that runs counter to many people’s risk perception instinct, and may not persuade. I think it’s also worth acknowledging that the unusually high death rate from this disease (compared, say, with seasonal influenza) is probably a factor weighing on people’s minds. While providing context and counter-examples can sometimes be an effective tool in risk communication, it also raises the possibility of sounding arrogantly dismissive of genuine anxiety. Perhaps focussing on clear communication of scenarios in which the disease can be transmitted, and how they are likely to be avoided or limited with our public health and hospital care system might be a better option.
  • More space given to the interesting, informed and engaging voices of those on the front line of this outbreak, or those with longstanding expertise.
  • Less media reporting of people being tested for Ebola and getting a negative result. It is non-news and puts the topic in the headlines more than necessary. If someone has been tested and is awaiting a result, does reporting of that actually help anyone? Could we not wait a few hours for the result before running the story? And if they are negative then the whole thing, with hindsight, was not news in the first place.
  • On that point, there is a big difference in testing someone as a ‘just in case’ measure (because they’re a bit ill and have travelled somewhere relevant) and testing someone who is exhibiting symptoms highly indicative that they might be a case. This distinction is not always made in communications (though I guess there may be confidentiality reasons for this).
  • Discouraging the media obsession with public-opinion gathering on every topic under the sun. There are some topics that it really is best to stick to the facts on. While ensuring that the public’s concerns are heard, it is not editorially wise to give the same amount of air time to Joe “I don’t believe anything these so-called-experts say” Bloggs on line one, as is given to Professor “I’ve been studying this disease for 15 years and have just spent 3 months on the front line” Doe. I’ve not seen/heard phone-ins yet on the media sources I follow, but it is inevitable.
  • Advertising standards regulations being used to clamp down on people who are trying to profit from fear by making false claims (e.g. that homeopathy can ‘cure’ Ebola). Aside from conning people into buying products that have no use, such sites are likely to spread false information about the disease.
  • Channelling people’s concern into something positive. It may well be that this outbreak is close to peaking, and may run its course without further global spread. But it’s likely to arise again in the future, at least in small localised clusters. I’m sure donations to Médecins Sans Frontières to support and equip front line medical workers, or to organisations working to treat neglected tropical diseases would be most welcome.

 

 

 

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