"Better Messaging" in Public Health Apologia

When I hear public health self-deprecating over their disastrous public health responses I only see "If only we had found a way to spread disinformation better there would be no questions."

Across nearly every major outbreak and pandemic of the last 50 years, post-crisis reviews have landed on “better communication” as a primary lesson — often as a way of deflecting from deeper structural, scientific, or policy failures. This is a well-documented and recurring pattern in public health history.

Critics like Dr. Harvey Fineberg (1976 postmortem), Peter Sandman (H1N1), and Gursky, Inglesby & O’Toole (anthrax) have consistently argued that “better communication” is sometimes used as a scapegoat to avoid confronting more difficult institutional and scientific failures. The 2003 SARS episode prompted WHO to formalize risk communication as an IHR core function — the most structural response to this pattern — yet as COVID-19 demonstrated, institutionalization did not resolve the underlying problem.

Is this a real thing, or just a placeholder conclusion that stops further questions? Is it a coincidence that those in key positions in public health during major events are really, really bad at communication?

Here are the key historical cases. You decide.

1976 Swine Flu Vaccination Program — Fort Dix, NJ

In 1976, an outbreak of swine flu at Fort Dix, New Jersey caused one death and led to a mass immunization program. The immunization program was ended after approximately 43 million U.S. citizens had been vaccinated, following reports of Guillain-Barré syndrome in vaccinated patients. Wikipedia The program collapsed both because no pandemic materialized and because of adverse events.

In retrospect, CDC’s own after-action analysis concluded that “periodic press briefings would have served better than responding to press queries,” and that “health communication should be by health personnel through a regular schedule of media briefings.” CDC A commissioned postmortem by Dr. Harvey Fineberg (later president of the Institute of Medicine) specifically stressed the need for “communication and clarity about the nature and change in the uncertainty over time” so that experts could be heard and policymakers could make informed choices. PubMed Central The program’s director, CDC Director David Sencer, was dismissed by incoming HEW Secretary Joseph Califano in February 1977. One of the biggest “lessons” CDC took away was the importance of communicating clearly to the public.

2001 Anthrax Letter Attacks

The CDC and other clinical and public health experts struggled to effectively communicate risk to the public and healthcare professionals in the absence of complete information. As new information became available, public messaging evolved, at times significantly changing or contradicting previous communications.

One of the most damning episodes involved the Brentwood postal workers in Washington, D.C. The CDC initially believed that sealed envelopes did not release anthrax spores and assured Brentwood postal employees that they faced minimal risk. Once their fellow employees fell ill, however, the workers questioned the effectiveness of the CDC’s response. Johns Hopkins Center for Health Security A CDC official acknowledged the underlying problem directly: “We lacked scientific data to address issues. We could not inform public health decision-making regarding issues such as exposure, isolated cases, letters in transit, and cross-contamination.”

After-action reviews published by the Johns Hopkins Center for Civilian Biodefense (Gursky, Inglesby, and O’Toole, 2003) and the GAO found that city, county, and state health officials had difficulty acquiring and sharing information; public health guidance was not being issued fast enough to guide clinical decisions; strategies for responding to the media were not in place; and the public health system lacked sufficient personnel, resources, and operational systems. The formal lesson extracted was better communication — though critics noted the deeper problem was scientific unpreparedness and interagency dysfunction.

Focus groups with Brentwood postal workers and Senate staff found that participants’ trust in public health agencies had eroded, and that this erosion could threaten the effectiveness of communication during future public health emergencies.

2003 SARS Outbreak

Inadequate communication about the SARS outbreak in Hong Kong in 2003 meant that “panic developed in the community and weakened cooperation and support from the public.”

A CDC-published lessons-learned analysis in Emerging Infectious Diseases (September 2003) concluded that timely communication and exchange of complete, accurate information are critical during any epidemic, and that leadership is essential to coordinate activities and information dissemination in order to minimize confused messages and public panic.

The WHO formally responded to the SARS crisis by codifying risk communication as a core institutional function, and the failure of early transparency — particularly by Chinese authorities, who suppressed information for weeks — became the canonical example of how communication failure can accelerate an outbreak.

2009 H1N1 “Swine Flu” Pandemic

The GAO’s 2011 report (GAO-11-632) found that the credibility of all levels of government was diminished when the amount of vaccine available to the public in October 2009 did not meet expectations set by federal officials. U.S. GAO A Canadian review in CMAJ (November 2010) was more direct: the communication of risk to the public failed, and learning how to deliver the right message to the public should be at the top of the list of gaps to fill before the next pandemic.

Risk communication expert Peter Sandman, in a detailed 2010 analysis, identified a specific and consequential messaging error: HHS, the CDC, and all the local health officials who followed their lead overemphasized the risk of H1N1 to children and young adults at the cost of underemphasizing the risk to older adults and seniors — a decision made in the face of knowledge that adults 50–64 had the highest death rate.

This, of course, underscores HHS’s current focus on the importance of getting risk stratification right.

The FDA’s after-action review (Center for Health Security, Johns Hopkins, 2022) specifically concluded that in relation to communication, several components of the FDA’s H1N1 response could have been enhanced: communicating about vaccine production including responding to concerns that the vaccine was risky or rushed through production, and being more transparent about the vaccine manufacturing process.

2014–2016 West Africa Ebola Epidemic

The CDC’s own MMWR supplement (July 2016) — the official after-action record — acknowledged directly that at the start of the response, CDC’s communication products were complex and text-based and did not contain much information that persons could act on to protect themselves from getting Ebola. As media coverage of Ebola expanded, the story goes, the public’s need for information outpaced the ability of public health officials to respond.

In the United States specifically, the CDC was widely criticized for projecting overconfidence in U.S. hospitals’ capacity to manage Ebola. When two nurses at Texas Health Presbyterian Hospital Dallas became infected after caring for Thomas Duncan, the CDC’s assurance that “U.S. hospitals can safely manage patients with Ebola disease” was called into question. When the CDC said the nurses probably became infected because of a protocol breach and it turned out there was no protocol, things got worse.

A peer-reviewed analysis in the Croatian Medical Journal (2015) summarized the structural communication failure: shortcomings of risk communication included unrealistic goals for communication, a lack of integration of social science skills and knowledge in communication guidelines and human resources, and an underestimation of the breadth of communication-related challenges.

COVID-19 Pandemic, 2020–2022

This is the most documented case of the pattern. The CDC discouraged masking early on and then promoted it after April 2020. They changed their website from 20 layers of cloth to 16 and then finally one 1 layer of cloth as protective. The FDA gave emergency authorization to hydroxychloroquine but then reversed course after testing found it ineffective and dangerous. These contradictions made the public mistrustful and confused. Penn LDI

In 2022, CDC Director Rochelle Walensky conducted an internal agency review and publicly acknowledged that the CDC was “responsible for some pretty dramatic, pretty public mistakes, from testing to data to communications.” Among the planned reforms, Walensky emphasized the need to “deliver clear, concise messages about public health threats.”

The Pattern Worth Noting

What makes this history remarkable is how consistent the diagnosis is across decades and how little behavior changed between iterations. From 1976 to 2022, each major public health failure produced a post-hoc report citing “communication” as a primary lesson — yet the deeper problems (scientific uncertainty being overconfidently presented as settled, interagency turf battles, guidance that changed without explanation, and messages that were not culturally or demographically tailored) recurred almost unchanged.

What is YOUR favorite poor communication from HHS during COVID-19 (2020-2022)?

Citations

1976 Swine Flu Vaccination Program

1. Fineberg, H.V. (2009). Swine flu of 1976: lessons from the past — Interview. Bulletin of the World Health Organization, 87(6), 414–415. PMC / WHO

2. Gaydos, J.C., Top, F.H., Hodder, R.A., Russell, P.K. (2006). Swine Influenza A at Fort Dix, New Jersey (January–February 1976): Lessons Learned. Emerging Infectious Diseases, 12(1). CDC / MMWR

3. Neustadt, R.E., & Fineberg, H.V. (1978). The Swine Flu Affair: Decision-Making on a Slippery Disease — Chronology. National Academies Press. NCBI Bookshelf

4. CDC Museum. 1976 Swine Flu Vaccination Program. David J. Sencer CDC Museum. CDC

5. Kreston, R. (2013). The Public Health Legacy of the 1976 Swine Flu Outbreak. Discover Magazine. Discover Magazine

6. History.com Editors. When the US Government Tried to Fast-Track a Flu Vaccine. HISTORY. History.com

7. Wikipedia. 1976 Swine Flu Outbreak. Wikipedia

8. Oshinsky, D. (2021). The 1976 Attempt to Vaccinate 213 Million Americans Against Swine Flu. Slate / Future Tense. Slate

2001 Anthrax Letter Attacks

1. Gursky, E., Inglesby, T.V., & O’Toole, T. (2003). Anthrax 2001: Observations on the Medical and Public Health Response. Biosecurity and Bioterrorism, 1(2). ResearchGate

2. Chess, C., & Clarke, L. (2007). Facilitation of Risk Communication During the Anthrax Attacks of 2001: The Organizational Backstory. American Journal of Public Health, 97(9), 1578–1583. PMC / AJPH

3. Robinson, S.J., & Newstetter, W.C. (2003). Uncertain Science and Certain Deadlines: CDC Responses to the Media During the Anthrax Attacks of 2001. Journal of Health Communication, 8(Suppl 1), 17–34. PubMed

4. U.S. GAO. (2004). Public Health Response to Anthrax Incidents of 2001. GAO-04-152. GAO

5. Center for Health Security, Johns Hopkins. Chapter Five: 2001 Anthrax Letters. Case Studies in Public Health Preparedness. Johns Hopkins

6. Hughes, J.M., & Gerberding, J.L. (2002). Anthrax Bioterrorism: Lessons Learned and Future Directions. Emerging Infectious Diseases, 8(10). CDC / EID

7. Blendon, R.J. et al. (2004). In Their Own Words: Lessons Learned from Those Exposed to Anthrax. Biosecurity and Bioterrorism, 2(1). PubMed

8. OJP / NCJRS Abstract. Anthrax 2001: Observations on the Medical and Public Health Response. OJP / NCJRS

2003 SARS Outbreak

1. Tsang, K.W. et al. (2003). Lessons from the Severe Acute Respiratory Syndrome Outbreak in Hong Kong. Emerging Infectious Diseases, 9(9). CDC / EID

2. CDC. SARS: Lessons Learned in Community Containment. Guidance Document. CDC Archive

3. New York State DOH / CDC. Communication Response to SARS. Preparedness Guidance. NYSDOH / CDC

4. University of Louisville / CDC. Quarantine and Isolation: Lessons Learned from SARS. Report. LSU / CDC

5. Lo, T.Q. et al. (2019). Progress in Public Health Risk Communication in China: Lessons Learned from SARS to H7N9. BMC Public Health, 19(1). BMC Public Health

6. Wu, T.N. et al. (2017). Risk and Outbreak Communication: Lessons from Taiwan’s Experiences in the Post-SARS Era. Health Security, 15(2). PMC

2009 H1N1 “Swine Flu” Pandemic

1. U.S. GAO. (2011). Influenza Pandemic: Lessons from the H1N1 Pandemic Should Be Incorporated into Future Planning. GAO-11-632. GAO

2. HHS / ASPR. An HHS Retrospective on the 2009 H1N1 Influenza Pandemic. HHS After-Action Report. HHS / ASPR

3. Center for Health Security, Johns Hopkins. Chapter Four: The H1N1 Influenza Pandemic of 2009–2010. Case Studies in Public Health Preparedness. Johns Hopkins

4. CDC. The 2009 H1N1 Pandemic: Summary Highlights, April 2009–April 2010. CDC Archive. CDC Archive

5. Low, D. (2010). Pandemic (H1N1) 2009: Assessing the Response. CMAJ, 182(17), 1874–1878. PMC / CMAJ

6. Fineberg, H.V. (2014). Pandemic Preparedness and Response — Lessons from the H1N1 Influenza of 2009. New England Journal of Medicine, 370, 1335–1342. NEJM

7. Sandman, P., & Lanard, J. (2010). Swine Flu Pandemic Communication Challenges and Lessons Learned. Peter Sandman Risk Communication Website. PeterSandman.com

8. Crosier, A., McVey, D., & French, J. (2015). ‘By Failing to Prepare You Are Preparing to Fail’: Lessons from the 2009 H1N1 ‘Swine Flu’ Pandemic. European Journal of Public Health, 25(1), 135–139. Oxford Academic / EJP

9. Maher, J. et al. (2010). Pandemic Response Lessons from Influenza H1N1 2009 in Asia. Influenza and Other Respiratory Viruses. PMC

2014–2016 West Africa Ebola Epidemic

1. CDC. (2016). Overview, Control Strategies, and Lessons Learned in the CDC Response to the 2014–2016 Ebola Epidemic. MMWR Supplements, 65(3). CDC / MMWR

2. CDC. (2016). CDC’s Response to the 2014–2016 Ebola Epidemic — Guinea, Liberia, and Sierra Leone. MMWR Supplements, 65(3). CDC / MMWR

3. CDC. (2016). Lessons of Risk Communication and Health Promotion — West Africa and United States. MMWR Supplements, 65(3). CDC / MMWR

4. Dixon, M.G. et al. (2015). Lessons from the Ebola Outbreak: Action Items for Emerging Infectious Disease Preparedness and Response. EcoHealth. PMC

5. Mouchtouri, V.A. et al. (2015). The Communication Aspects of the Ebola Virus Disease Outbreak in Western Africa. Croatian Medical Journal, 56(5), 496–499. PMC / CMJ

6. Atlani-Duault, L. et al. (2018). Crisis Communication During the Ebola Outbreak in West Africa: The Paradoxes of Decontextualized Contextualization. Springer Nature. Springer

7. Rosenbaum, L. (2015). Communicating Uncertainty — Ebola, Public Health, and the Scientific Process. New England Journal of Medicine, 372, 7–9. NEJM

8. Balog-Way, D. et al. (2016). Delivering Risk Information in a Dynamic Information Environment: Framing and Authoritative Voice in CDC and Primetime Broadcast News During the 2014 Ebola Outbreak. Health Communication. PubMed

COVID-19 Pandemic, 2020–2022

1. Jamieson, K.H. et al. (2024). Better Communication for the Next Pandemic: Examining Lessons Learned from COVID-19 Communications. Penn LDI / Perspectives on Psychological Science, February 6, 2024. Penn LDI

2. Sridhar, D., & Gostin, L.O. (2022). Overcoming Cacophony in Public Health Communication after COVID-19. Think Global Health, Council on Foreign Relations. Think Global Health / CFR