Authors: Claire Hooker and Julie Leask, originally published on November 5 2014, cross-posted on January 5 2015: Listen up, health officials - here's how to reduce "Ebolanoia".
An epidemic disease such as Ebola brings suffering to more than those who get ill or die. Social and economic threats can actually outstrip the medical ones. The outbreaks of SARS [severe acute respiratory syndrome] in 2003, for example, cost the world economy some US$40 billion, partly as a result of highly disputed travel bans.
Epidemic diseases nearly always also lead to stigmatisation and ill treatment of groups associated with the disease. And because there are always people who are especially scared, epidemic diseases can cause social disruption by people who do such things as flee cities, swamp doctors and health services while well, and stockpile food or medicines.
We can't entirely eliminate these costs, but we can minimise "Ebolanoia" by addressing fears and directing people to positive actions. Here are some of the risk communication lessons our health officials and political leaders should be mindful of when they engage with the public about Ebola:
1. Don’t panic about panic
Governments and health officials think their job is to stop people panicking. They do this by telling people not to panic and by making emphatic pronouncements that the risk of community transmission is very low or that we are well prepared [PDF format]. But they over-reassure. We say "over-reassure" because this tactic does not eliminate fear and it disastrously erodes trust if it fails to address the complex reality that underlies simple statements, or worse, if it is later proven to be wrong.
Telling people not to panic can ironically strengthen the conceptual link between Ebola and panic – a bit like asking people to think of any colour but red.
Worse, it belittles genuine concerns. Australians who worry about Ebola do so because they see a brutal scenario unfolding in West Africa and they can imagine it happening here. The seemingly relentless physical disintegration that the virus causes in the human body inspires dread. The absence or failure of normal mechanisms of control such as vaccines, treatment drugs and in-patient infection control amplify that fear.
Risk communications experts such as Peter Sandman [ask] counsel officials to tolerate this kind of worry and over-reaction as part of the normal range of responses to a significant threat.
Sometimes, communicators may even need to take some responsibility for such reactions. Many infectious disease-control experts, for instance, are keen to see Australia step up its assistance to West Africa and some may emphasise the potential for outbreaks in Australia as a result of unchecked spread there.
It is reasonable for Australians to respond with an increased fear of an outbreak at home. What leaders can do is stay calm and communicate specifically about what is being done and why. It is better to tell people "There is a small chance Ebola could come to Australia, but we have prepared specialist spaces within hospitals to ensure it won’t spread beyond one case" than "We are well placed to deal with this threat."
2. Understand risk perception
Extensive studies have revealed how predictably people's perceptions of risk are influenced by certain factors, especially dread and control. "Bleeding from every orifice" or "having your brain turn to mush" create feelings of dread that drive up fear.
The severity of an outcome tends to make people over-emphasise their risk of getting it - this is called availability bias. It happens despite the relatively low infectivity of Ebola compared to diseases such as measles.
Also at stake is our sense of control - a disease with, as yet, no technological saviours (such as vaccines), and that is crossing national borders, strongly threatens this. Health officials need to restore people’s sense of control as much as possible, in part through establishing trust in their own competence and integrity and providing actions we can take.
3. Build trust
If we want people to follow directives about behaviour, to self-report illness, or voluntarily observe isolation, then they need to trust that health-care officials are acting in their best interest. Leaders should focus on the qualities that build trust [PDF format]: competence, objectivity, fairness, consistency and empathy. These qualities are communicated through what is said – and not said – but also through actions and timing.
Actions speak louder than words. The recent reported decision of the Australian government to cancel all temporary visas from Guinea, Sierra Leone and Liberia, including humanitarian visas, communicates neither fairness nor competency when it has no basis in evidence. Taking such action signals that Ebola is a real and frightening threat, a signal that will over-ride reassuring words to the contrary.
Transparency enhances trust. In an epidemic, this usually means communicating early and often. But it also includes being candid about what you don’t know and explicit about the rationale for policy decisions.
Officials may find this counter-intuitive and worry about public reaction to debate and uncertainty. But openness expresses trust in the public and if they know what’s going on, they also feel more in control.
If our leaders in the Ebola response can sustain public trust, they will have some leeway to make mistakes or shift or reverse earlier policy decisions without losing too much of this trust. Mistakes and changes are likely in an uncertain and developing situation. The best combination for crisis communication is a confident tone and tentative content, so that there’s flexibility to change tack.
4. Give people something to do
The fastest way to re-establish a sense of control is to be able to act. The public don’t have many actions at their disposal. They may hear stories about high-tech measures such as N95 masks, body suits and vaccines that they can’t access. But they can get into the habit of good infection control with hand-washing.
5. Work with medical reporters
Many people will blame the mass media for generating "Ebolanoia". It's true that a competitive media market drives sensationalist images and headlines. But overall the Australian media has done a reasonable job of sticking to the essential messages of concern for the situation overseas, the conditions under which it most poses a local threat, and the low risks within Australia.
We found in our research many knowledgeable and experienced journalists who act as gatekeepers and tone setters within the media. Scientists and health policymakers who want to ensure that the media contains accurate and complete information need to be constantly and immediately available to these journalists (especially to fact-check stories), sensitive to their deadlines, and able to offer them exclusive or advance access to important stories.
In the end, good risk communication requires the integrity to act according to the best evidence and in the collective interest and the courage to communicate openly about those choices.
This sort of communication can feel risky, leaving leaders vulnerable to making mistakes in public. But it’s the only way to earn the sort of trust that achieves compliance with quarantines and civil responses in a serious emergency. And it supports compassionate, reasonable and effective policy-making, which will continue to be of benefit once this particular disease threat has passed.
Image caption and credit: Telling people not to panic doesn't achieve its desired effect. EPA/Remko de Waal