Public Health messaging: how not to communicate with a population

Donald Trump wants packed churches by Easter. Boris Johnson wants us to stay at home except for when we go out for our one mandated walk or travel via packed tube train to the workplace that our employer insists can’t be done at home. Or when we go to work on a building site that Sadiq Khan thinks we shouldn’t. You can go to the allotment but not golfing on your own. You can go out for essentials. The pubs are now forcibly closed, yet off-licenses are reclassified as allowed to open – does running out of beer mean an ‘essential shopping trip’?. You can visit Halfords bike repair shop. You can go to work to sell cosmetics and clothes from Asos. If it’s essential. Only if it’s all essential. 

More than a quarter of the world’s population is under some kind of lockdown. Yet those messages have sparked a wave of queries. Whilst the messaging has moved a long way away from simply ‘wash your hands’, is it too nuanced for a nation obsessed with finding loopholes? 

Wow. That escalated quickly, didn’t it? This time last week we were all being told brand new information about self-isolation for families with one symptomatic case. Previously, if one member of a household had shown symptoms, the rest of the family were recommended to go about their day as usual.

Suddenly, it was all change.

Suddenly the schools were being ordered to close, too.

We’d all have to home school while simultaneously working from home.

Disney Plus rubbed their hands with glee at their (some conspiracy theorists would argue, knowing) fortune at setting a release date for Tuesday 24th March.

Life seemed surreal and it would only get worse.

The Prime Minister released his statement which was the first measure intended to “flatten the curve”

“So stay at home for seven days if you think you have the symptoms.” Johnson explained.  “Remember the two key symptoms are high temperature, a continuous new cough. The whole household [is] to stay at home for 14 days if one member in that household thinks he/she has the symptoms. Avoid all unnecessary gatherings – pubs, clubs, bars, restaurants, theatres and so on and work from home if you can. Wash your hands.”

Flattening the curve

The notion of “flattening the curve” was the first time I’d even heard a politician employ the idea of a graph to a nation in terms of public health messaging. It was introduced without much explanation, with the words “So looking at the curve of the disease and looking at where we are now – we think now that we must apply downward pressure, further downward pressure on that upward curve by closing the schools.”

“Flattening the curve”, along with “stay at home, save lives” were adopted as new mantras, even as the measures and the phrases employed seemed, at least to most, to be advisory at best. 

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New Scientist was one of the first in the queue to criticise the government’s evidence for what seemed, to the rest of the world, a painfully slow response. An outlier in reflex response when considering the actions of the rest of the affected countries. Examining the government’s evidence, which was published on Friday 20th March, New Scientist decried the dearth of mentions of the World Health Organisation’s approach to testing, in particular. Not once was ‘contract tracing’ (attempting to contact those who might have been infected by a confirmed case) even considered. Paul Hunter, of the University of East Anglia, was scathing in his discussion of how the UK government were basing everything on one model by Imperial College. Other scientists quoted called the strategy “risky” and said it was “flawed”, with “incorrect assumptions”.

“Only the good die young”

Each announcement has been met with confusion and queries from a stunned (and in some cases defiant) population. The messaging that the young are usually unaffected is now unravelling as more and more younger people are being infected and struggle to recover. Indeed, just today, it was announced a 21 year old woman, with no underlying health issues (which is always the phrase that traditionally accompanied the description of those elderly victims of Covid-19) has died. 

Telling the young that they would just carry the illness and likely just be mildly inconvenienced by it seemed to embolden them. One man, interviewed on Oxford St on Sky News, when asked why he was sauntering along the road, simply said that he’d be fine. When pushed to answer whether or not he cared that he could infect others, he arrogantly said that the vulnerable should be at home anyway, seemingly unaware of how a virus could jump from him, to his mate and then his mate’s girlfriend who is a carer to 96 year old Doris, who will succumb in no time due to her COPD.

Pubs and beaches – social distancing defied

Without ordering the closure of pubs and restaurants and simply asking people not to visit them, Johnson not only condemned many responsible businesses to closure without insurance, but sent out a conflicting message about what was acceptable. His Dad, Stanley Johnson’s proclamation, that he’d be going out for a pint didn’t really help, of course. 

Social distancing was also a phrase that few had heard before. The interpretation and meaning changed quickly from ‘reduce social contact’ to ‘stay two metres apart’ very quickly and seamlessly. On the 18th March, there was no mention of how far apart to stay from others and the BBC was still advising one metre on its ‘social distancing’ explainers online until at least 15th March but it wasn’t part of the national conversation about reducing unnecessary social contact until much later.

It was the 22nd March that the guidance to stay 2 metres away from other people was first mentioned. It was just suddenly part of what we were supposed to be doing. That was the very first time the notion of a distance between you and your fellow man had been introduced by the Prime Minister himself – with the words “You have to stay two metres apart; you have to follow the social distancing advice.”

Except that had never been advised before in an actual, measurable distance. Trust me, I’ve checked all the announcements on The internet responded with memes suggesting you imagine the outline of a dead relative between you. A bloody tall one, at 6ft 5”.

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Indeed the New Scientist piece bears out the confusion over these unfamiliar notions, explaining “vague terms” like ‘social distancing’ should be replaced with “clear advice, such as to keep a physical, 2-metre distance”. New Scientist also detailed responses to an Imperial College survey revealing widespread confusion among more than half of respondents, who revealed they weren’t avoiding social events.

The young, as previously discussed, were the worst for not changing their behaviour – just 53% of 18-24 year olds said they’d changed their behaviour at all.

Just before we were taken into what no one officially would call a lockdown, the last weekend of freedom, as many suspected it would be, people packed out eateries, pubs, National Trust locations and beaches, supping their takeaway beers and spreading this terrible virus around. 

“Stay home and practice social distancing” clearly wasn’t working. 

Lessons from previous public health messaging

Way back in 2012, I was at a conference known as QEDcon or Question. Explore. Discover. Part of their line up was Elizabeth Pisani, an epidemiologist who came to talk about her new book, ‘The Wisdom of Whores’. Snappy title, but what was a talk about sex workers doing at a science and scepticism conference? The truth was that Pisani, who describes what she does as ‘sex and drugs’ was going to speak to us about the spread of diseases (specifically AIDS) and Public Health messaging. Having researched ‘sex and drug injection around the world’, Pisani went on to discuss key points about the advantages and drawbacks of the highly effective public information campaigns for AIDS.

Back in the 80s, as she describes in the book, the AIDS epidemic in Africa “was a shameful monument to failed HIV prevention”. Pisani also details how [in Indonesia] “provincial health officers entered their data into the wonderful software, saw the infection curves headed skywards, and did nothing to improve prevention programmes”. So far, so familiar, right?

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The trouble with the public health messaging around AIDS was that it was, in some cases, almost too effective in some ways. The much-recognised image of a gravestone with AIDS emblazoned on it coupled with “AIDS: DON’T DIE OF IGNORANCE” meant that those who did discover they were HIV positive were suddenly taking the decision to end their lives. The messaging that anyone infected would die a terrible death was killing people before their time, especially at the point that new drugs were being developed to prolong life and preserve the quality of that extended timeline. It was very hard, she explained, to get across ‘hey, you really don’t wanna get this because it’s pretty dire, but hey… if you do get it… don’t worry! It’s not bad enough you should kill yourself!”

The truth is that public health communication is pretty tough and messages have to be clear, concise and easily understood. Nuance is quite frankly anathema to public engagement. In the book ‘Bumpology: the myth-busting pregnancy book for curious parents-to-be’, Linda Geddes tackles all of the advice that those who see those two lines on a pregnancy test are subjected to. From what we should consume whilst pregnant right through to tackling labour myths and gender selection, the book is a complete, evidence-based guide to procreation. 

Abstain because it’s too complicated to explain

When I was first pregnant, in 2015, I scoured websites for advice, asked friends and family and was determined to know the truth behind every little nugget of information I could. Being scientifically minded, however, much of what I read confounded me since one seemingly legit website directly contradicted advice from friends who had already had kids. Advice from the older generation was even harder to square with modern information. Bumpology was just the ticket for someone like me. That’s when Elizabeth Pisani’s words from that conference came back to mind. The current official advice for those carrying a foetus in their reproductive organs is that there is no such thing as a safe amount of alcohol to drink. But the evidence really doesn’t bear that out. The evidence is usually a lot more complicated than that. The answer, as with most things, is that it’s a very complicated thing to predict how much alcohol is too much alcohol. It depends on your gestation, your weight, your body’s ability to metabolise alcohol and a range of other factors that are far too complex to get across in a public health message. So the easiest thing to do is to recommend not to drink at all. To be clear, I’m far from advocating drinking when pregnant – just making a general point that public health messaging has to be crystal clear to prevent unnecessary harm. No harm will come to anyone from abstaining from alcohol for the duration of their pregnancy.

Two books which have a lot to say about public health messaging

Misinformation, myths and public health messaging in the age of technology

“A lie can go around the world before the truth has even got its trousers on” goes the adage. Never has that been more pertinent. Public health messaging has got to be clear, concise and easily intelligible to everyone. “Wash your hands” would have been a success were it to have been a good enough protection against the virus. 

The problem is, that life is complex now. The reason the Chinese had such success with their draconian measures seems to be their inbuilt cultural compliance and the general dampening of questioning and dissent that they have instilled in their people. It’s not the done thing to question ones elders nor to publish messages that disparage the government. You do what you’re bloody told there and you like it.

The British, obsessed as we are with “stiff upper lips” and “keep calm and carry on”, “blitz spirit” simply don’t like to be told what to do. If they bloody want a pint on Whitstable beach on Mother’s Day weekend, snuggled up with countless infected others on a flood defence wall, they bloody well will have one.

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Whitstable sea front last weekend

Whatever prompted the newer measures – closing leisure establishments, forcing people on pain of police action to stay at home unless they had good reason to leave – we now have a clear message this is serious.

We know this virus is going to kill significant numbers of our population and signs are good that people do seem to be listening. That’s not to say that people aren’t still popping out for more than their mandated one form of exercise or aren’t trying to find loopholes or aren’t still gathering friends and their children together in gardens.

That’s not to say that people aren’t still putting the lives at others at risk. But, crucially, fewer of them are. It remains to be seen what effect these measures will have. It will take 14 days or more to really grasp it, probably longer. Perhaps even further, harsh measures are to come.

But it comes to something when even the Mayor of Bergamo, in Italy, chose to fly his two daughters home from England because he believed they were safer there, at the epicentre of the Italian Covid-19 crisis, than here, in the UK. 

Do us all a favour. Sit on your arse. Stay at home. It’s not too much to ask. At least the memes are good.

“ello ello ello, this better be your first walk of the day, madam” [Image Credit: Hot Fuzz]

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