The Ebola crisis has highlighted the importance of risk communication. Are there any recurrent patterns or lessons learned that the Ebola crisis shares with past epidemics and may be relevant for risk communication? Can you think of some unique themes that have emerged compared to the ones described in your book, Epidemic City?
Public health officials have been attempting to deal with crisis outbreaks of infectious diseases for many decades, and a recurrent challenge is the difficulty of gaining trust and cooperation of the affected population. One of the most difficult things about the Ebola crisis is managing the use of quarantine, and there are many historical examples of the difficulty of doing this – of affected populations reacting very badly to quarantine, not cooperating with the recommendations of the public health officials because they lack trust or confidence in them, or do not believe that actions are being taken in their best interest, or even think that these actions might actually be harmful to them. In a notable episode in New York City in the mid-nineteenth century, a mob of people stormed a small pox quarantine hospital and burned it to the ground, because they believed that the small pox patients were posing a danger to the community. During an outbreak of plague in Honolulu around the turn of the century, the affected communities, who were of Asian origin, did not trust the public health officials, who were white. Similarly, in a small pox quarantine in San Francisco in 1905, the affected communities did not cooperate with the health officials. We have seen many such examples, through history, of the difficulty of communicating across barriers of culture, language, and class, and trying to gain the buy-in of affected communities. The challenge of effectively communicating with communities and gaining their voluntary cooperation is one of the themes in Epidemic City, and this applies not only to deadly infectious diseases, but across all public health issues.
What, in your opinion, is the historical role of public health in outbreak response and risk communication? How do you see public health playing this role in the Ebola crisis?
Risk communication is, obviously, a central task of public health officials, though this may not always be explicitly recognized. As a case in point, during the 2001 anthrax bioterrorism attacks, the key challenge of public health officials engaged in risk communication was what to tell people. On the one hand, if you were to tell the public that someone was sending an extremely deadly pathogen through the mail, would you trigger panic and dysfunctional responses? When the announcements were made about anthrax, we saw people flooding into emergency rooms, worried that they had been exposed, and clogging up the healthcare system. On the other hand, if you were to conceal information, would that sow mistrust among the public? This is a very difficult line to walk. The lesson that emerged for public health was to be as open and transparent as possible, communicate uncertainties, assure the public of best efforts, and enlist their help.
Earlier in the century, public health took a much more top–down approach, the prevalent idea being that health officials knew best, and the public needed to be obedient and abide by the health officials. In the last 50 years, however, there is a recognition on the part of the health officials that they have to work hard to secure people's buy-in and cooperation, and approach communities on a more equal footing. In more recent history, with the rise of the Internet and social media, health officials have realized that there are too many communication channels, and that they have to work with the public to get their message out.
What do you think are some of the major ethical considerations in outbreak or epidemic response? Are there specific considerations in the context of the Ebola outbreak?
Public health officials have to operate from an ethic of first do no harm. In the Ebola outbreak, where quarantine is being used and the movements of populations are being controlled, key ethical considerations are ensuring safe and habitable conditions, sufficient food and water, and medical care for the affected populations. Health officials also have an obligation to be transparent to the public they serve and in whose interests they are acting, to clearly communicate what they are doing, and explain the rationale and the purpose. This is especially difficult when there is longstanding mistrust and misunderstanding between the affected communities and health officials. Trust is not something you can win overnight, and is even more difficult to win in the context of a crisis, and an atmosphere of fear and panic.
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Dr James Colgrove, PhD, MPH, focuses on research that examines the relationship between individual rights and the collective well-being and the social, political, and legal processes through which public health policies have been mediated in American history. Dr Colgrove's most recent book is Epidemic City: The Politics of Public Health in New York (Russell Sage Foundation, 2011). He is also the author of State of Immunity: The Politics of Vaccination in Twentieth-Century America (University of California Press, 2006); co-author, with Amy Fairchild and Ronald Bayer, of Searching Eyes: Privacy, the State, and Disease Surveillance in America (University of California Press, 2007); and co-editor, with David Rosner and Gerald Markowitz, of The Contested Boundaries of American Public Health (Rutgers University Press, 2008). Articles by Dr Colgrove have been published in the New England Journal of Medicine, American Journal of Public Health, Science, Health Affairs, Bulletin of the History of Medicine, and the Journal of Law, Medicine and Ethics. His research has been supported by grants from the National Library of Medicine, the Greenwall Foundation, the Russell Sage Foundation, the Robert Wood Johnson Foundation, and the Milbank Memorial Fund.
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Interviewed by Radhika Ramesh, MA, editorial assistant, Journal of Communication in Healthcare (JCIH): Strategies, Media, and Engagement in Global Health on 19 September, 2014. The interview was solicited and organized by the journal's editor-in-chief, Dr Renata Schiavo, as part of a series of expert interviews JCIH publishes on topics of current interest, and their implications for health communication.