Days after his election to the presidency, Joe Biden and his transition team released a plan outlining how they would tackle the coronavirus pandemic. In addition to calls to increase production of protective equipment, expand testing and tracing, and distribute vaccines was a recognition that the government had to provide “clear and consistent guidance” to people and communities on how to navigate the pandemic.
This is welcome news, as the country appears increasingly divided over the pandemic. While one person may be isolating themselves, going out only for essential goods, and wearing a mask, their neighbor may be taking no precautions whatsoever, shunning masks, and ignoring social distancing. Most Americans report wearing a mask in polling, but certain states, including Ohio, Wyoming, and North Dakota, report low compliance. There are also intense debates about mask ordinances—as of this writing, at least 13 states do not have an ordinance and some officials have rejected calls to enact one. With more than 280,000 dead and rising, public health officials across the country are struggling with how to communicate with the public about the how and why to stay safe.
Research has been done on how to appeal to people’s sense of personal safety to get them to wear masks; articles have been written about ensuring we don’t shame people while we try to get them to adopt the best practices. In the midst of all this discussion, we may be missing the bigger picture. Surely the Trump administration’s failure to communicate clear, evidence-based guidelines and a sense of solidarity in fighting the pandemic is part of the problem. But that’s not all that’s missing. What if it is not the type of messaging but the concept of public health messaging itself that is falling short?
Around the 1970s and ’80s, a new field emerged within public health that sought to use the power of communications to change people’s individual behaviors by convincing them to make healthier choices; it would become known as health communications. It aims to do this by making people aware of the risks of certain conditions, promoting positive health behaviors, and encouraging people to take control of their own health. Over the past 40 years, health communications has been employed to address drug use, smoking, safe sex, and nutrition, among other topics. From Nancy Reagan’s “Just Say No to Drugs” campaign, to the Truth Initiative’s anti-smoking ads, to Michelle Obama’s “Let’s Move” initiative, many of the most high-profile public health campaigns in America have relied on the power of persuasion to improve population health behaviors. Messaging for public health campaigns is a key part of any public health strategy, but in America, it often forms the core pillar. It is a cost-effective strategy that puts the onus on the individual to take care of their own health care and avoids meaningful government investment in addressing structural factors that contribute to ill-health.
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The “Let’s Move!” initiative had an ambitious goal to cut childhood obesity to 5 percent by 2030. It aimed to increase the amount of daily physical activity students got and increase Americans’ access to fresh fruits and vegetables, while decreasing consumption of packaged goods and sugary snacks. A massive media campaign followed—talk show hosts like Ellen DeGeneres and Jimmy Fallon were frequently involved in skits about getting more physical activity. However, the campaign was criticized for failing to pursue a real legislative agenda, such as forcing companies to change advertising practices or reduce the amount of sugar and fat in processed food. Instead, it focused on establishing private-public partnerships, for instance, working with Walgreens to introduce fresh food into drugstores. (Some companies the campaign partnered with, including Walgreens, ended up reneging on some of their commitments.) At the same time, the Obama administration cut food stamps by nearly $9 billion in 2014. The campaign was also criticized for perpetuating weight stigma through its messaging and metrics, focusing on children’s body size as a problem. A better, alternative campaign could have focused on ending childhood hunger by improving food access, rather than focusing on obesity. The former, however, cannot be “messaged” as easily.
For public messaging campaigns to have their intended effects, people need to be provided with resources to follow the guidance. The Let’s Move campaign didn’t significantly increase the ability of Americans to access food directly through vouchers or increased SNAP amounts. The campaign did have some success—from 2010 to 2016, the share of Americans who lived in an area with limited supermarket access declined from 6.8 percent to 5.6 percent. However, racial disparities persist, with 30% more non-white people living in these areas than white people. It also not clear if access increased in areas or if the population living in those areas decreased. In terms of the campaign’s own criticized metric of lowering childhood obesity, the results are more mixed—with decreases in obesity recorded amongst children age 2-5, but an overall increase for children aged 2-19. Campaigns like Let’s Move can have some success, but it is often incremental and limited without significant legislative action.
The same limitations of health communications apply during the pandemic. As the coronavirus has spread, public officials have spent a lot of time urging people to wear a mask and socially distance, when they can’t stay home—and offered not much else. While some Americans were able to shift to working from home and found new quarantine hobbies, others were deemed essential workers and had to go to work. The coronavirus relief packages passed by Congress provided support for industries, state governments and provided extended unemployment relief. While it did provide paid sick leave, many workers were left out as the legislation did not apply to companies with 500 workers or more. A study released last month showed that limited sick leave provision may have prevented some cases; an expanded sick leave provision may have done more. The package also only provided one payment of $1200—which many did not end up receiving. In the first month of the pandemic—before masks were widely accepted—this especially had disastrous consequences as people had no way of mitigating the spread of the virus short of not gathering at all. This essentially forced people to go back to work in unsafe conditions when states reopened prematurely. Things were further made worse when Congress refused to extend the enhanced unemployment benefit and stalled on providing a second stimulus.
Besides health care workers, especially impacted were workers in grocery stores, meatpacking plants, and warehouses. Amazon, for instance, has reported that nearly 20,000 of its workers have tested positive for Covid-19. Rather than provide a steady source of government income and force employers to limit hours and provide hazard pay, the government willfully ignored employer violations reported to OSHA. Instead of instituting strict safety protocols, the CDC often suggested flimsy guidelines that did not force employers to take any protective measures or accurately reflect the conditions workers faced. You cannot socially distance in a cramped meatpacking facility; you cannot take paid sick leave if it is not offered to you. All the while, workers face retaliation for demanding better protections and are afraid of repercussions if they test positive. People who have tested positive have told contact tracers that they fear losing their jobs. Last month, In These Times reported that workers at meatpacking plants were still going to work because of a punitive points system that penalizes missing work. Looking to the future, unfortunately, Biden’s plan also does not mention providing cash payments to all Americans or mandating paid sick leave—instead, it calls for funds to be provided to businesses to reopen safely.
It’s also not enough to tell people to use PPE without making it widely accessible. For health care workers, more than 1,700 of whom have died from the virus, the first few months were filled with shortages on much-needed protective equipment—with workers improvising with garbage bags and reusing masks; at one point the CDC suggested they use bandanas as a “last resort.” When masks were finally acknowledged as a way of preventing the virus, the government killed a plan by the USPS to provide five free reusable masks to every household in the country. President-elect Biden’s plan calls for the ramp up in production of protective equipment, but it says nothing about distributing it for free.
In addition to providing resources, a public health campaign can be successful only if lawmakers do not take steps to diametrically contradict the point of the campaign. In the current pandemic, the president and his administration have undermined their public health experts by downplaying the seriousness of the virus, ignoring social distancing protocols, and making fun of those who wear masks. Of course, beyond this obvious contradiction, leaders both Democratic and Republican undermined their own advice when they set guidelines that prioritized business’s needs for reopening, rather than public health risk. As a result, when businesses were allowed to reopen again, people also took it as a sign that the pandemic was less serious now.
Nowhere is this clearer than in the case of indoor dining. The CDC found that those who tested positive for the virus and were not knowingly in contact with someone who tested positive were more than twice as likely to have dined indoors than those who did not test positive. In California, the state government told diners to wear a mask “between bites”—which was promptly ridiculed by those on the right. When people flock to restaurants and bars and the cases go up, officials blame members of the public for letting their guard down and letting the situation spiral out of control.
We’ve seen these contradictions again and again. Over the last few years as the overdose crisis killed thousands in the United States, the government began to shift its tone on drug use. Long past were the days of “just say no”; now campaigns were urging people to intervene in an overdose by carrying naloxone. Surgeon General Jerome Adams has repeatedly urged all Americans to carry naloxone and the Trump administration has at least paid lip service to extending our empathy toward drug users and their families. At the Republican National Convention this past summer, Melania Trump implored people to show support for people struggling with addiction. This rhetoric hasn’t been backed up with action. And despite some positive steps, the US drug war continues. For every development like Oregon’s decriminalizing small amounts of drugs, there are plenty of other negative examples to point to: people who use drugs are being prosecuted with murder for the overdoses of friends; police departments across the country have seized naloxone and have used it as evidence to prosecute a drug charge; and people have been denied access to treatment medication in jail, to name a few. For its part, the Trump administration has tried to stop the opening of a safe consumption site and vigorously opposes its opening. All of these policies have the effect of continuing to stigmatize people who use drugs, making it harder for them to stay safe and avoid overdosing.
Relying on narratives of personal responsibility to carry public health messaging has its limits in a pandemic. While people are admonished for behaving irresponsibly, the right has also weaponized the language of personal responsibility to justify not wearing a mask. Right-wingers simultaneously argue that those who want to protect themselves can wear a mask if they’d like; never mind the fact that masks prevent you from spreading the virus to others. To that end, they argue, why wear a mask if it no longer protects you? The language of personal responsibility is ill-equipped to deal with questions of collective responsibility and obligation to others.
The emphasis on personal behavior is also why we haven’t heard much in the way of messaging as it pertains to racial disparities. Black, Latinx, and Asian people have all been impacted heavily, facing higher rates of death than white people. These disparities are caused by racism and would require significant structural interventions addressing workplace safety, housing conditions, and exposure to pollutants, among many other things. These problems cannot be addressed through behavioral messaging—when the surgeon general attempted to address racial disparities, he came off as patronizing and seeking to place blame on affected communities’ behaviors. “Do it for your abuela, do it for your granddaddy, do it for your big momma, do it for your pop-pop,” he said.
For messages to be effective, they have to be understandable. Anyone who has read messages from local health departments during the pandemic can also attest to how confusing information can be. In October 2010, the Plain Language Act was passed in Congress, which stipulated that federal agencies must use guidelines for clarity of expression to ensure that the information they are providing to the public is accessible. A study published earlier this year in JAMA Open Network found that in addition to the CDC’s pages, pages about Covid-19 from each state exceeded an eighth-grade reading level; other countries’ webpages also fell above the recommended reading level. Language also serves as a barrier—not only for contact tracing; in some cases resources are not being translated into commonly spoken languages.
How do we bridge this gap between public health messaging and the realities of peoples’ lives? Imagine if at the beginning of this pandemic the government established a “Health Progress Administration” modeled after the Works Progress Administration. This agency would employ and train a public health corps ready to do testing, contact tracing, and community outreach. Factories would be repurposed to make masks and other protective equipment, distributed free to the population. Artists, writers, and performers—hard-hit by the pandemic—would be hired to work on creative projects that communicate critical public health information. Of course, everyone would get an amount deposited into their account every month to provide necessary relief. Our government has waited far too long to do anything, but it is never too late to start implementing bold solutions like this. Indeed, Biden’s plan does propose creating a jobs corps for contact tracing and reaching communities; this is a promising start.
A pandemic of these proportions demands an imaginative response. We have gotten so caught up in trying to get messaging to work in what seems like an impossible situation that we have forgotten what it takes to build a society in which the messaging can work.
