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November 25, 2014
Christopher F. Koller, President
Back to President’s Blog: The View from Here
For state leaders, Ebola has been a “Pac-Man” issue—inexorably gobbling up resources and time and, like the disease itself, constantly threatening to break out of control. The public health response to the outbreak of a new and life-threatening infectious disease is complex; it involves unclear authority, necessitates changing policy responses, and guarantees lots of media attention. All in all, it’s a flammable brew for health policy.
In the United States’ response to the Ebola outbreak, we have witnessed acts of courage and public service, but also poorly interpreted science, ill-informed opinions, government tail chasing, unfair scapegoating, and unwise policy responses. It need not be this way: good planning, clear authority, and consistent communication can prevent the mania from spreading.
The arrival of the first Ebola case in the United States hardly came as a surprise; the question was not if but when. State public health officers had time to plan—to understand and explain evolving guidance from the Centers for Disease Control and Prevention, to consult with peers, engage stakeholders in the provider community, sister agencies, governor’s offices, and local health authorities in “tabletop exercises” or emergency response simulations, and identify and respond to new questions and issues. Some state-level planning was more effective than others, judging from the surprises in Texas and New Jersey.
Planning not only improves preparation, but also establishes lines of communication so that when the inevitable arises, people know who to call. At a time when policies need to be established and implemented, poor planning and unclear channels of communication can contribute to ineffectiveness and confusion. Good planning, on the other hand, is a quiet victor; no one pays attention when things go right.
Complicating the state response to infectious disease outbreaks are unclear lines of statutory authority. In a nod to federalism, the primary authority in these situations usually rests with the state health officer, who is responsible for issuing orders and directing the actions of providers (for instance, emergency treatment plans) or citizens (such as quarantines). State health officials also rely on federal officials for good information and guidance and on the governor’s office for coordination and direction.
Complicating matters, the governor’s office retains a level of emergency authority that varies greatly by state. For instance, in Connecticut, the governor must declare a public health emergency before the state health officer can use his or her authority. Finally, state health officers have different levels of authority over local (county or city) health agencies. It is far more desirable for state health officers to understand and clarify the chain of command as part of a planning exercise rather than under the glare of media attention.
Regardless of what the law says, using authority—granting it and exercising it—becomes very important in an infectious disease outbreak. The governor should publicly designate the health officer as the lead on the outbreak, ensure interagency coordination, and make communications needs known early. Repeated and unscheduled “emergency meetings” or poorly coordinated outbreak-related policies are symptoms of poor planning and unclear responsibilities that divert officials from more important tasks.
Once granted the power to act, state health officers must assume and exercise authority in clear, decisive, and public ways, the better to build trust. These skills should be developed and practiced beforehand, rather than first tested in the heat of an outbreak.
The public will need guidance. What is the risk of infection and how can it be reduced? When should screening occur? Who should be monitored and how? When is quarantine necessary? Who will diagnose and treat? What protective equipment will be used? How is contact tracing to be done? Who educates the public and answers their questions? Government cannot do all this work: hospitals, providers, public health workers, and other stakeholders are willing to assume appropriate and often heroic roles and responsibilities—if these roles and responsibilities are established in a fair and comprehensive fashion.
The very nature of epidemiology—the science and monitoring of infectious diseases—involves uncertainty. The answers to the questions above can and will change based on new information. New questions will emerge. Moreover, in public health, the risk to public safety can be reduced but never eliminated. These realities of uncertainty and risk are hard to accept for both politicians and citizens. Health officials need be comfortable with these ambiguities, take appropriate actions, be able to explain themselves when circumstances change, and to have the support of their administration colleagues.
Herein lies the third key to an effective infectious disease response. Good planning and clear authority will collapse without reliable public and internal communications. Sometimes more infectious than a disease itself is the misinformation and undue concern it can generate in the public, resulting in opinions and actions that endanger personal liberties and collective well-being. Media management and stakeholder communications are essential to the dissemination of accurate information. There is a specific, systematic methodology for “risk communication”—educating people about the nature of the risks presented by a particular situation and the steps to reduce them—that should be required practice for public health professionals. Good health officers understand the importance of their role as communicators. They communicate constantly and reliably.
This task is even more complex in the world of social media. Workers at Yale-New Haven Hospital were tweeting the arrival of a possible Ebola case before the hospital or the state health department could communicate about the event. These immediate communications mechanisms create both opportunity and risk for officials trying to respond to disease outbreaks.
It is fashionable to dismiss government—until we need it. Infectious disease outbreaks are one such occasion. They tax the ability of state officials to plan—and state health officers to lead—with evidence-based policies and expert communications. These activities are made more complex in an environment where communications are instantaneous and sources of authority numerous.
In the seeming absence of such planning and clear communication, private citizens and stakeholders cannot be blamed for questioning the competence of our leaders.
But we also need to accept the uncertainty inherent in an infectious disease outbreak and the challenge of creating sound policy in a charged and changing environment. As one health director told me, “Any claim to judgments about competence needs to take chaos theory into account. This stuff is complicated, and the challenge for government is to know what is known, to accept what is unkno wn, to have the humility to know the difference, to prepare, and internally and externally communicate obsessively, understanding that (stuff) happens.”
Good planning, firm but humble leadership, and communicating “obsessively”—these are the elements of a public health response that will harness the willing assistance of health care providers to detect and treat an infectious disease outbreak and encourage the public to help reduce its spread. And we should always be quick to express our gratitude when that leadership is well provided.
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