A Loss for Words: How the US Failed COVID-19 Communication

This article is part of Contagion’s one-year COVID-19 series, which will run in 3 parts, March 17-19. You can share your thoughts, questions, reflections, and concerns from this last year in the pandemic through our channels on Facebook, Twitter, and LinkedIn.

Donald Alcendor, PhD, sets out through Nashville, TN, with the mission of spreading the truths of the COVID-19 vaccines.

Few people may be more qualified for the task. Alcendor is a professor of microbiology and immunology at Meharry Medical College. He also teaches cancer biology at Vanderbilt University. He is a well-published molecular virology researcher, an expert with the Department of Health and Human Services, and a consultant for the US Food and Drug Administration (FDA).

He is also a black man from Louisiana, who understands the proclivities of American regions and ethnicities who largely believe they have been neglected, if not adversely targeted, by modern medicine. Alcendor can understand the fear and paranoia of his community as well as he can explain the SARS-CoV-2 genome. On these trust-building trips, he seeks the middle ground between these matters.

Sometimes, he explained to HCPLive last month, he will hear one of the original COVID-19 conspiracy theories: “This is all a hoax,” or “This is no worse than the flu.” A rural Tennessean will cite a friend who recovered from a mild case as substantial proof that no vaccine will be necessary. A neighbor, more thoughtfully, will suggest they need more vaccine trial data, “to see what happens later on.”

Another man just a mile down the road will confront Alcendor mid-conversation in a barbershop and ask him, “Why are you coming in here with this poison to kill our people?”

And when he finally gets a win, when a woman hears his message on the importance of the COVID-19 vaccines, he learns that she is afraid for her life. A neighbor died suddenly from the virus earlier last year. Terror was driving her rationale.

This is only a small, regional sample of the US public’s reception to vaccines, only among the most recent COVID-19 topics to become dichotomized and contested on a national scale. But it is representative of 2 greater trends exacerbated by the pandemic.

First, it shows the extremes of public perception, which Alcendor and his peers have been addressing for this last year: completely contrasting perceptions of what the issues, perpetrators, and goals of COVID-19 response should be, among people in the same neighborhood.

Those who disagree with scientists like Alcendor do so with severity; they claim he comes from a community of liars, scammers, maybe even killers. Those who agree with him are so deeply affected by the pandemic that their motivations may be skewed by fear. In either instance, his lessons on vaccines, the virus, any of this, is not heard.

And that is the second trend: the communication from experts to the US public has failed during the COVID-19 pandemic.

In this last year, academic information sharing was streamlined, awareness and education campaigns were prioritized, and public interest in the machinations of medical science piqued.

So how did COVID-19 result in further divides in the communication of science?

The Top-Down Influence

This is a question which K. M. Venkat Narayan, MD, MSc, and colleagues spent weeks discussing. Like many others in his position, the professor at the Rollins School of Public Health and School of Medicine at Emory University was concerned. It was early 2021, the first vaccines from Pfizer-BioNTech and Moderna had been authorized by the FDA, more were on the way, and treatment options were well-defined by the last 9 months of globally-coordinated assessment and review.

But these byproducts of “tremendous science and technology” were not equating to control or prevention of COVID-19 in the US, Narayan told Contagion. His team spent weekly phone calls dissecting the factors at play.

The culmination of their conversations, a viewpoint published in JAMA in early February, presented more questions to answer, in summary:

• How can public communication and education of science be improved to assure health interventions are understood and supported? And how can public trust be improved?
• How can the iterative and evolving nature of scientific research become better appreciated by the public?
• How can science and humanities become more cohesive through public policy and societal embrace?
• What models of funding and governance could best be implemented to assure public health institutions are informing and serving the public, especially in public health emergencies?
• Could the US Centers for Disease Control and Prevention (CDC) and FDA leadership models be restructured to assure terms do not align with presidential elections, to reduce likelihood of partisanship?
• Could governance restructure assure improved oversight of public health agencies that would harbor strong political will, mechanisms for consensus, and advocacy for appropriate resourcing?
• What mechanisms could protect the function of scientifically-independent research publications under public health agency control, such as the CDC’s Morbidity and Mortality Weekly Report?
• How can global health institutions and agencies become more collaborative in scientific and public health ventures?

On the issues of COVID-19 communication breakdown between Alcendor and his neighbors, Narayan points to the top: the FDA, CDC, and the White House are federal agencies who appeared dated and uncoordinated in their collaborative response to the pandemic. Their early and frequent failures to align on messaging and strategy reflected in the public.

“The systems we constructed 50 to 70 years ago were before the time of social media, before the time of rapid globalization, the spread of information and the speed of science,” Narayan said. “Do we need to rethink the structure and the relationships of these institutions?”

Narayan pointed to key moments of failed federal messaging: early CDC guidance to prioritize available masks for healthcare workers was misconstrued as an anti-mask recommendation for the public. At one point, it was reported that White House officials were interfering with internal CDC communication and influencing their research-led public guidance and reporting.

Top-level contention allowed for the frequency of another public health messaging flaw inherent to the US: state-level policies and messaging.

“I think the challenge we have with the United States is that it's a federation of states,” Narayan said. “(The CDC) conveyed messages that were good for the country and synchronous across the states. But then when you have different states, even different counties coming up with their own arguments.”

This was a predictable issue: regional health literacy and outcome disparities are stark, and historic, in the US. Life expectancy among the best and worst US counties could differ by 20-plus years, Narayan pointed out. Cardiovascular disease mortality and diabetes prevalence is eight-fold greater in some areas. The opioid epidemic is not a wholly national crisis: it is rampant in some regions, unnoticeable in others.

“For a country of our size, our diversity, and our technological and science expertise, these issues are important, so that we are able to implement the benefits of science for the right people,” Narayan said.

But in the matter of COVID-19, it was largely federal contradictions that allowed state and regional disparities on masking, distancing, and business mandates, he explained. And all of it harbored a politicization of the pandemic at the public level.

Whac-A-Mole

It is because of this wide variation of jurisdiction-dependent COVID-19 response and messaging that Brad Spellberg, MD, sees the issues as more than 1 pandemic. The US is addressing a thousand different pandemics, he argued to Contagion—1 for every responsibility falling on a local agency or office.

Spellberg, chief medical officer of the Los Angeles County and University of Southern California Medical Center and a critical author of the US healthcare system, concurred with Narayan’s point that science’s COVID-19 response is being hindered by political interactions and failing discourse.

He also echoed Narayan on the issue of the country’s makeup, and how it specifically benefits a highly transmissible virus: a federation of states with differing stances and interpretation of pandemic risks allows COVID-19 to fluctuate in prevalence, just the same as individual perspective of it.

“I think many states have effectively handled their initial peak, only to see it return,” Spellberg said. “One state that’s doing really well today, next month will not be, because the other states weren’t doing well and it spreads.”

At the time of this publishing, 8 states had partial business closure mandates due to COVID-19. Six had stay-at-home advisories. Another 29 had mandatory mask mandates. A majority of states with such restrictions in place neighbored at least 1 state without a similar mandate.

Spellberg borrowed the term “the Whac-A-Mole phenomenon,” to describe an interconnected country without a unified approach to COVID-19. Speaking to Contagion in late September 2020, he expressed an almost disinterest in the most recent trend of new cases—national accumulations oversimplify region-specific challenges or successes in COVID-19 management and encourage more public disagreement on the current state of the pandemic.

“You can’t get everybody to agree to do something if everyone is so busy yelling at each other because they won’t share a common framework of understanding,” Spellberg said.

The Preprint Factor

Other more protected and practiced means of public health discourse came under scrutiny due to their conflicting agendas at crucial moments of the pandemic.

Peer review journal-published researchers found themselves fielding more feedback from the public audience than ever before. Mainstream media was picking up COVID-19 journals as A1 stories, data points were streamlined into press release headlines, and laypeople were beginning to apply investigative outcomes to their own pandemic responses.

The merging of the medical academic and media consumption communities was crude, and not always conducive to one or the other. What ended up mattering more than assured quality and science-traditional scrutiny was the factor of speed, said Neil Schluger, MD. Who could give a worried public the most information about COVID-19, the moment they knew it?

“I think (COVID-19) obviously created an enormous need to develop and communicate scientific knowledge very, very quickly,” Schluger said. “The question is, how does that get done?”

As Schluger, of the New York Medical College, pointed out to Contagion, many prominent peer-reviewed scientific journals have offered its COVID-19 material for free to the general public—a standard practice in instances of public health crises.

Only this time, the access to and subsequent valuation of research influenced the means by which it was actually processed by the medical community before publication. Preprint servers, through a combination of public interest and acrimony toward the traditional peer-review process, became prominent providers of COVD-19 news.

Schluger noted even the most popular preprint server medRxiv, bares a red-font, centered disclaimer at the top fold of its home page, reading:

“Preprints are preliminary reports of work that have not been certified by peer review. They should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.”

And yet, preprint research was leading news outlet’s pandemic coverage since the very start. Schluger and his team worried how the public reliance on non-reviewed, preprint data may eventually influence actual COVID-19 care.

“We found that things posted to medRxiv on COVID-19 were very frequently cited and disseminated, in a way that was somewhat comparable to things published to traditional literature,” he explained. Their findings on the issue coincided with a greater public confidence in navigating the discourse of COVID-19 science.

He and every colleague he knew were getting more phone calls, emails, and messages on COVID-19 therapies than imaginable. Zinc, azithromycin—even the debate darling antiviral drug hydroxychloroquine were subjects of non-reviewed research that caught traction with the national media, consumed by an information-starved audience, and regurgitated back to Schluger and company as valid pursuits of the pandemic.

Many people genuinely believed, in their sometimes very first interpretation of scientific research, that they understood COVID-19 as well as—if not better than—scientists. This evolution of Dr. Google into an information hub loosely associated with the rigors of scientific research—only stripped of the key processes—capitalized on initial pandemic uncertainties and federal missteps to give laypeople the confidence to say, “I know I’m right about this.”

Rather than fault the people attempting to engage with science, Schluger looks inward.

“You do a research article, you publish it in a journal, and you think, ‘Okay, that’s truth, and the whole world is going to change’,” Schluger said. “Then you realize that no one reads those things. They’re inaccessible to most people because they’re written in highly technical language.”

Somewhere along the way, as media and information-sharing rapidly expanded, science never adapted its messaging. Their disengagement with popular media ceded ground to more skilled messengers with conflicting or misaligned interests in science. Schluger hears debates on mask-wearing and vaccine hesitancy, and knows those are conversations that should been better led by his community from the jump.

Still, from an optimist’s perspective, this convolution of pandemic research and information-sharing may give way to a breakthrough. Scientists have a second chance at a first impression with a still-worried public.

“I don’t fault anyone in the general public for asking those questions,” Schluger said. “This is a frightening, massive epidemic that affects everyone, and in a way I think it’s good people are engaged. We need to learn how to communicate what we do, what is science, and why we believe in it.”

A Lost Language of Nuance

A virologist describes to Contagion what the average person must think a virologist is. They’re probably a man, “nerdy looking,” in a white lab coat, holding an Erlenmeyer flask.

Who is at fault for that stereotype? Angela Rasmussen, PhD, the virologist in question—who is bearing none of those traits at the time of discussion—blames her trade for having siloed science from the general public. How could the average person understand and appreciate the complexities of science when they don’t feel welcome to the scientific community?

“Scientists have historically not done a good job on communicating the nuances of these complex things to the public,” Rasmussen told Contagion. “There’s tons of jargon, it’s difficult for people to understand. You can talk to your coworkers as a virologist, and sometimes, people from other disciplines may not even understand me.”

And unfortunately, all that is certain in COVID-19 is the nuances. Masks are not perfect. SARS-CoV-2 can spread further than 6 feet. The vaccines do not assure absolute protection. These measures were never meant to be perfect—few resolutions in science ever are.

At least in past public health crises, experts had a baseline of knowledge to support their guidance. Much of COVID-19 was novel to even virologists, Rasmussen explained, and the vast implications of the virus pressured her peers to provide real-time answers. What the public received was a firsthand look at the deliberate, sometimes self-conflicting process of scientific investigation and dissemination.

“It’s very difficult to communicate what we don’t know,” Rasmussen said. “The public is interested in the science—they want to hear about 20% science, and 80% practical advice about how it’s going to affect and impact their lives.”

But a nation of states, partisan by nature, without consistent federal messaging and public inclusion to the industry of science, was predestined to receive an overwhelming and complex pandemic as yet another issue that could be solved with black-and-white logic. That is the preferred language of legislators, the media, and the public.

For the sake of their trade, scientists cannot speak it. Teaching their language to the public while they have their attention may make the difference in mitigating the next pandemic.