Take Note: Penn State Prof. Nita Bharti On Public Health Messaging Around Coronavirus
On this Take Note, we talked about public health messaging, specifically how the U.S. government has communicated about and reacted to the coronavirus outbreak. Also, how dealing with a pandemic is different in a democracy than in an authoritarian country.
Our guest was Nita Bharti, an assistant professor of biology and the Lloyd Huck Early Career Professor in the Huck Institutes of the Life Sciences at Penn State.
This interview is from the Democracy Works podcast, a collaboration between WPSU and the McCourtney Institute for Democracy at Penn State. The Institute’s Jenna Spinelle interviewed Bunyasi and Smith.
Jenna Spinelle: This is Jenna Spinelle here today with Nita Bharti. Nita, thanks for joining us on Democracy Works.
Nita Bharti: It's my pleasure. Thanks Jenna.
Spinelle: We are going to talk today in the midst of the corona virus outbreak about the relationship between information, government and the public in the midst of an outbreak. That's a complex topic. We're going to kind of come at it from a couple of different angles. But maybe to start off, can you talk about, as someone who has studied and works in this field, what are some of the considerations that go into public health messaging during an outbreak?
Bharti: The government and public health officials are constantly assessing and reassessing and triaging during times like this with new emergence events, so think about things like SARS, the first time we saw HIV in the 80s, the current situation with this coronavirus. Those are all very different things, but the thing that they have in common is that really nobody knows what's going on in the sense of what to expect with projecting trajectories, projecting morbidity and mortality and understanding what the most effective way to act is. How do you put in place policy when they're not really sure what the situation is?
Spinelle: Right, and it seems like there might also be a balance to strike between providing clear and accurate information but also not maybe causing a sense of panic unnecessarily. Can you talk about what that balance looks like?
Bharti: Yeah, I think that's a really important and difficult balance. How do you maintain transparency but sort of leave things in a maybe “need to know” kind of realm where people maybe don't need to know something that would incite panic if they can act on information that's true and transparent without making the situation worse. That's really the trick with under-reacting versus overreacting. If we've done our jobs, it should always look like we overreacted.
Spinelle: And I would say that that is not how someone looking back would describe the early stages of corona virus response in the U.S.
Bharti: I think that's absolutely true. I think that the early response in the U.S. was essentially no response.
Spinelle: What do you think were some of the factors that went in to that line of decision making and how have things changed since then?
Bharti: So if we back all the way up to sort of December of 2019, when there was a mysterious cluster of cases of pneumonia in Wuhan City and really nobody knew what was going on, there was some sort of on-the-fly decisions being made by the Chinese government and there is things that probably would be done differently, that hopefully would be done differently about transparency and messaging during that time. What really happened was that we saw the outbreak unfolding in China and that gave kind of the whole rest of the world time to prepare. They bought us really important time to prepare and we wasted it. We didn't react the way we should have reacted in America and with public health policy and preparedness, the way we should have, instead of responding to what was obviously a very easily transmissible devastating disease. We pretended like it wasn't going to happen here.
Spinelle: I know people often compare the U.S. to South Korea. Can you talk about how their approach differed than any, maybe some other countries that took a different course of action with the same information that we saw coming out of China early on?
Bharti: Every country is going to handle things differently and there are different amounts of regulation that are acceptable under different government organizations or under different governments just in general. I think that without even having to look at what other countries did that was successful or not, within the U.S.'s normal amount of oversight and power and regulation, there was a lot of preparedness that could have happened and there was a lot of transparent messaging that could have happened about taking this virus seriously. Getting resources in place not just for health care workers and health care providers but for the general public and messaging on what people need and don't need. And a lot of that really basic stuff, they didn't really require a lot more than a couple of really clearly worded statements from a high up official. Instead, I think a lot of the messaging was surrounding xenophobia and racism and not preparedness and I think a lot of the action reflected that and reflected that people were not taking this virus very seriously, when in fact they have the data in hand by then to know that it should be.
Spinelle: Right, so what does that process look like to the extent that you know inside the government? I know we hear about the CDC. Of course now, we see Dr. Fauci all over the place but there's kind of a number of government agencies, there's a bureaucracy that's sort of a part of this. I mean, what is that like information chain of command look like?
Bharti: I think a lot of the scientist early on, including people at the CDC, were well aware that this needed to be taken seriously and were well aware that there were things that could be done without infringing on human rights, there were things that could be done with the data that we had in hand, it would have set us up for being prepared at the early stages of this outbreak. That information and those warnings and those actions didn't really make their way to the current White House administration. I think that the messaging that came out of the president and certainly when Mike Pence was put in charge of this outbreak, I think a lot of that messaging really was based on this idea that it wasn't going to be a big deal. They weren't that worried about it.
Spinelle: You have a new piece out in “The Conversation.” You argue there that it really might have been the NBA and other kind of public figures that really started to help drive the message about how serious the corona virus is, given this lack of government action early on. Can you talk more about what that looked like?
Bharti: I felt like we were consistently getting a message from the government that this wasn't a big deal, we just had to keep it out of the country. Which at the time where that messaging was continuing, we certainly already had sustained local transmission of the virus inside of the U.S. That general idea of this isn't very serious, I think was heard by a lot of people who are not scientists and could not make a different decision based on data themselves. A lot of that guidance about what we should think of this and how we should react to this, that was coming from political figures really downplayed what was going on while the scientists were saying entirely something else. I think that the reach of major league sports in general, certainly nationally but also internationally, I think the reach of major league sports cuts across political parties. And I think that the really immediate and powerful decision by the NBA to suspend all games in the league and the obvious financial hit that that would have on the league really showed that we should be taking this seriously. This isn't about money or finances and this isn't about entertainment. This is about human health and human lives. And in doing something so big and so unprecedented, I think a lot of people, a lot of Americans took notice and that really put the pressure on the other leagues other than the NBA, right, so then the NHL followed, the NCAA after. Kind of going back and forth on a few different ways of how to handle this, whether they should cancel live crowds or do things a little bit differently. They finally went ahead and canceled all their games so there's obviously no March Madness this year but I think all of these things that seemed unbelievable and unprecedented and like they would never happen, they all happened very quickly and I think that was a real turning point for the American public about what is going on and is it serious?
Spinelle: From your previous work in this area, I mean, what types of messaging and how often do messages need to be reinforced to the public to really make a difference in people's behaviors when it comes to outbreaks and to public health?
Bharti: Yeah, so this is a really good question and this lies at the heart of a lot of outbreak control. The real point of messaging, the end game with messaging, is to deliver something that will be effective and that will garner a high rate of compliance. You can have messaging that suggests something very effective, but people will not comply with it because it's either too extreme, it's too difficult, or it flies in the face of their beliefs. So you need to be able to reach that medium of something being effective, being compassionate to people's needs and beliefs, and being something that will achieve high compliance because effective messaging is not effective if you don't get behavioral changes, right? You need that compliance.
Spinelle: One of the kind of unique features about the U.S. is that when one state or a couple of states tend to do something, others like follow suit. I don't know if it's like state level FOMO or what happens but there's like, everybody just kind of wants to follow along. It seems like some of those things might be certainly keeping in mind like the health and safety of the residents of that state but maybe like, also trying to send a bigger message out to the other states to the rest of the country that look, even in like the absence of action from Washington, we as a state are going to stay that we'll do this and maybe others should kind of follow suit.
Bharti: Yeah, I think that that has been really important for this particular outbreak. I think as in the early weeks, when the federal government seem to not be taking this seriously, I think a lot of cities and mayors made important strides and statements towards trying to control something and trying to send message that were reassuring, a couple of states or a couple of cities and then states did a good job of messaging that testing would be free and people wouldn't have to worry about the cost of that. I think New York and probably Seattle would have led the way on that. But I think that there is a lot of power in that kind of local messaging. The state level FOMO I think is a little bit more about not wanting to look reckless. Not wanting to be the one state that was like “no, it's okay, do whatever you want” and then you're going to see consequences. I think that the need to exercise caution when it comes to human health and human lives is -- despite everything going on around this -- I think that it's pretty well ingrained in most leaders, that you would rather err on the side of caution when you're facing something like a pretty uncharted epidemic.
Spinelle: What else can we learn from history about what types of mitigation tactics or messaging work or don't work. I know you and I were talking before we started recording. There's another example from the Ebola era where screening travelers coming into and out of the country might not be effective even though on its face, you could maybe think of a world in which that could potentially be the case.
Bharti: Movement restrictions, travel screening, things like that tend not to be super effective. Those types of control measures are really focused on importation or exportation of a pathogen and in general by the time we've seen the effects of an outbreak and we've understood how it's spreading or how widely it's spreading, it's a bit late to be stopping introduction. It's already there. That tends to be a little bit ineffective. We know that stopping local transmission is really what we like to do and some of the restrictions surrounding local movements are really, really difficult to enforce and results in very low compliance and that creates its own issues. That makes it very hard to do any kind of contact tracing. It makes it very hard to actually get an idea of spatially where things are a problem because if you ban movement and people are going to move anyway, because they need to for personal and financial reasons, just going to work, whatever, then you're going to end up with these really sort of unknown spots of how people were moving and how they became infected. Whereas if you're able to be honest and open and get realistic restrictions in place, people will be compliant and they will be honest.
Spinelle: Right and we talked earlier about what China did early on and some of the ways that they suppressed information certainly but then once they snapped into action, they were able to because it's an authoritarian country and we've seen this in Russia and other places. Two, they're able to really be more strict about where people can or can't go. They put up a hospital in a day, all these types of things. It seems like there's a human rights element to this too of like trying to have that sense of control but also not be so oppressive that you end up having kind of adverse impacts in kind of the other direction.
Bharti: I mean, that sort of individual rights and public health push pull has probably been a part of the conversation for every epidemic we've ever faced. So I think that there are a lot of ways to control outbreaks and not breach human rights and I think that's really important to keep in mind. Sometimes people can think that the end justifies the means and I don't think that that has to be the case. I think we can be really respectful and ethical and not violate human rights and still find effective solutions for stopping outbreaks. In an authoritarian regime, obviously, there's a lot more latitude for what a government can do versus what maybe makes the most sense. We know that the downstream effects on individuals from the total lockdown and quarantine of people in China and particularly in Wuhan have been devastating. You know, I think it's great that there was a huge slowdown of transmission. But I don’t think, at the cost of everything else that happened, I don't think that that was ideal. And I don't know if it was necessary, right? It's hard to sort of ... essentially, I don't want to say it here and blame or second guess anybody, but I think we should take what we see happening in other places and learn from it. I think we should kind of take what we're seeing from really what is essentially massive novel experiments happening around the world under different governments as we all react a little bit differently to this outbreak. We should take that as data collection and learn from it. I would look at what happened in China as maybe something that probably wasn't 100% successful.
Spinelle: Can you talk about what the medical community and the science community have been doing or started doing in those kind of early days when it seems like the White House was not maybe taking this as seriously as they should have and not providing the messages that the public needed to hear. What did kind of the science and medical communities do to step up and fill that void so to speak?
Bharti: Yeah, so in the early days, I think that Twitter was really active. I think it was active with both information and misinformation. It's an easy way to sort of have an opinion and shout it to the world and not necessarily have to have much to back up that opinion. So I think there were really good scientists who were making important points on Twitter and I think that there are some really uninformed people making a lot of invalid points on Twitter early on. But one of the things that happened, I think quite quickly in this outbreak that to me seems really unprecedented is the rate at which scientists started to come together to do research collaboratively and share what they were doing in a very transparent and public way. And I think the preprint servers played a huge role in this. Their process with scientific journals and publishing science and sharing it for our listeners who don't necessarily know how this goes ...
Spinelle: Yes. Thank you.
Bharti: There's this process where scientists sort of do their research and it takes years and then they write it up and they submit it to a journal and the journal has it sent out for what is called peer review, which means other scientists in the field who aren't familiar with the work review it. And that is usually something of a process that goes back and forth between multiple reviewers and the editor and the authors for a while. That can take ... I mean, there's some worst case scenarios but you want to plan on that to take somewhere between six months and a year. So, you've spent years doing research and then you spend maybe a year with that research and review where it's sort of locked into what is a solid state. You're not going to be messing with it and improving it and editing it and it's being reviewed by your peers and after that, it is published and that's generally online these days but it's not seen before that and so, there's this very long delay between doing science and sharing science. And what the preprint servers allow scientist to do is to share things, to basically write a paper and put it online in other place where other people can see it without it having yet gone through peer review. That's good and bad, right? It really increases the rate at which people can communicate, scientist can communicate with each other but it also sort of takes away a level of protection and so, you have a lot more volume with this outbreak, you have a lot more volume of papers coming on coronaviruses and we've sort of taken away the filter for what's high quality, what's low quality. So these preprint servers are a little bit flooded, but if you're a scientist, that means that you have access to all these things and you can probably tell the difference. If you're not a scientist and you can't tell the difference, you probably can't tell the difference, right and that's the problem. A lot of that stuff will end up in Twitter too. You know, there's a good and a bad. Early in this outbreak, I think there was a huge sort of signal to noise kind of shift and I think we've sort of settled in on now, there's a handful of people who are really immersed and working incredible and a lot of us are looking to them.
Spinelle: Thinking again here from like a global perspective do you think that we're seeing the international cooperation that we need to really tackle this virus effectively, should the US maybe taking more of a leadership role than it has thus far do you think?
Bharti: So I am honestly a little bit worried about where international relations are going to go after this outbreak. Every time Trump closes a new border, I worry about what that means for relationships with those countries. Certainly when he closed the borders to Western Europe, I don't know, a lifetime ago, last week, two weeks, when was that? When he closed those borders it was not received well by the leaders of the countries that were within that block and I think that that's a fair reaction. That was a useless measure and it did nothing. It was not going to be an effective public health step to take and it sent a very negative signal about international cooperation. You know and I worry, coming out of this, I'm surprised more countries haven't blatantly just said that they're closing their borders to the U.S. I know that that has been talked about a lot but, yeah, I do worry about the long-term effects on international relations as a result of some of these slightly bizarre and ineffective policies. I think international cooperation in general is really the only way to get through infectious diseases and outbreaks because we don't have administrative borders for diseases, right? They go where we are and we're everywhere. And so it seems really, really sort of short sighted to try and close borders when really what we should be doing is working together.
Spinelle: Switching gears just a little bit here before we start to wrap up, what do you make of the testing approach that the U.S. has taken thus far. Are there things that you think we could or should be doing differently to help mitigate and help prevent further spread of the virus?
Bharti: I think the lack of testing that's happening right now is probably the greatest weakness out of everything that's gone wrong here. The lack of testing is really the thing that is holding us back. We don't know what's going on. We have a good sense that there's a lot of mild infections that are transmitting and we have a good sense that there's probably a ton of unreported cases out there, so we're underestimating it, under-reporting the impact of this. All of that means, that we can't get ahead of it. We're constantly reacting. The lack of testing and the shortage of testing kits has I think absolutely been probably the biggest hindrance on the entire US response. We should be testing everybody. We should be testing everybody in drive through clinics like South Korea setup almost immediately. We should be making this really easy and instead what we're hearing is that people who have either travel history or symptoms or sort of high-risk contacts, they're not being eligible for testing unless one of their contacts has been already tested positive. I think that that, not just for understand how to stop this current outbreak but for understanding how future viruses might spread, right, this isn't the last respiratory virus we're going to see. For understanding really what's happening here, how interactions are playing a role in transmission and understanding different kinds of vulnerability, who's more vulnerable to infection versus severe infection versus high levels of transmission. We're really just hamstringing ourselves. We've gotten to a point where we don't know what's going on. Everything is so reactive that we can't get ahead of it and we've wasted so much time not getting the important information and testing everybody that we backed ourselves into a corner.
Spinelle: All right, do you think it is possible at this point to try to reach a point where we are getting ahead of things at all?
Bharti: I don't think that that's impossible, but I do think that you lay the groundwork for something and you see the results of it, weeks or months later. We haven't laid the groundwork. So the time that we lost not reacting early in the outbreak when the government wasn't taking this seriously was when we should have been stocking up on tests and PPE and protecting health care workers and getting bills into place to have paid sick days and everything else that is going to now, hopefully, best case scenario happen and this is what should have been happening in January. Yeah, in a couple of months, maybe. I don't think it's impossible. I don't think that we should not act, obviously, late is better than never and that we didn't do something before, doesn't mean it shouldn't stop us from doing it now but I think that we have to be realistic about why it's so important to be prepared and what that ... really, what is the way to that word, being prepared means having stuff done in advance and we are now doing stuff only reactively because we fail to do anything effective in advance.
Spinelle: Right. Last question here Nita before we let you go. As states and cities have tried to enforce the social distancing and breaking up large gatherings. How long do you think that we're likely to see these types of restrictions in place or these types of social distancing measures enforced?
Bharti: So I think there's two parts of this that are equally important. I think it's important that we all realize that whenever these official restrictions are scheduled to be lifted in a couple of weeks for some of us, that's not the end of this. This idea of flattening the curve which probably people have seen on social media, which means that you basically slow down the trajectory of the epidemic so that you don't have a ton of cases all at once, because that overwhelms the health care system. Flattening the curve means this is ... which is really our only option right now but it means what we're trying to do is keep infections from happening. In a couple of weeks when, we think, we're all looking ahead to maybe getting back to normal, if we actually get back to what was normal before, we're going to see a huge surge in infections. We're going to see exponential growth in transmission and that really isn't why we're doing all of this, right? So it's really important that we all get into our heads right now, that we're going to have a new normal and we're going to have to be okay with that because pushing back against it is pointless. So I think that we will start to see changes in restrictions, but I don't think that it's reasonable to think that they're going to be lifted, if that makes sense. It will look different.
Spinelle: Nita, thank you so much for joining us today.
Bharti: Thank you so much Jenna. It was great to talk to you.