As Ebola in West Africa dominated global news coverage during the spring and summer of 2014, federal officials repeatedly offered assurances that the American health system was well equipped to seamlessly handle the virus if it arrived on US soil.1 President Barack Obama weighed in, saying several times that he had confidence in the US Centers for Disease Control and Prevention (CDC).2 But when a patient died of Ebola virus disease (EVD) at Texas Health Presbyterian Hospital (Presbyterian) in Dallas, Texas, after a botched diagnosis, and two nurses there also became infected, public confidence in CDC plummeted.3
CDC Director Thomas R. Frieden acknowledged at a news conference on October 14, 2014, that the agency should have responded sooner to the first case in Dallas and done more to prevent additional infections.4 Those comments marked an about-face in the tone of CDC’s communication: The agency that had appeared so confident about its preparedness to handle Ebola in the United States was now contrite about its missteps. CDC officials were lampooned in editorial cartoons for a lack of credibility and criticized in news stories for offering conflicting advice—and sometimes no timely advice at all—about how to prevent the spread of the virus.5
Previous chapters have discussed the public health messages disseminated during the Ebola outbreak and how they were delivered to the public through the news and social media. But what about the senders of those messages? Who did journalists rely on as sources of information about Ebola in the United States? How did their communication, or lack of timely communication, aid or harm the situation? Did they help, clarify, or confuse? Reassure or alarm? And how could they have communicated more effectively?
These questions matter because the public gets much of its information about health and science from the news media.6 The news media serve as brokers between health, science, and the public, shaping public consciousness about events and helping to set the agenda for public policy.7 The news media also forcefully shape how policy issues related to health and scientific controversies are defined, symbolized, and resolved.8
Americans were drawn to media coverage of Ebola at historically high rates.9 Nearly half of US adults (49 percent) reported that they followed news about the outbreak very closely in mid-October 2014, up from 26 percent in early August 2014.10 The only news topics that drew more attention in the United States during the previous two years were the Boston Marathon bombing (63 percent), the 2012 Congressional election (60 percent), the school shootings in Newtown, Connecticut (57 percent), and Hurricane Sandy (53 percent).11
Newsgathering is a collective activity in which journalists depend on others—and especially on official sources—for much of the content of their stories.12 In turn, journalists’ choice of sources significantly influences how their stories are shaped and told.13 Health and science reporters tend to turn to a relatively small roster of sources: scientists, physicians, government and industry officials, and bioethicists.14 Reporters work most efficiently when they know in advance what the sources they plan to interview will say.15 Journalists thus develop a small cadre of “go–to” sources on whom they can rely to provide certain information or the opinion needed to complete a story.16 Reporters “find it easier and more predictable to consult a narrow range of experts than to call on new ones each time.”17 Sources with highly visible names, titles, affiliations, and even a touch of celebrity are prized.18
Journalists need sources for information, explanation, context, implications, and opinion. But what journalists really want from sources is accessibility; exclusivity; rapid response; quotes that are pithy, colorful, and memorable; and comments that promote controversy and sensationalism.19 In other words, journalists would like public health officials, scientists, and physicians to communicate in ways antithetical to their professional training. That’s because of the differences among the fields of science, medicine, and journalism and the missions of physicians, scientists, public health officials, and journalists.
While science and medicine are “slow, precise, careful, conservative and complicated,” journalism is “hungry for headlines and drama, fast, short, dramatic, (and) very imprecise at times.”20 Scientists, physicians, and public health officials care greatly about context, precision, qualification, and nuance.21 In contrast, journalists care about timeliness, accuracy, balance, and, above all, getting a story—the bigger and juicier the better.22 As a result, journalists may ferret out inconsistencies in what a source says, challenge discrepancies between sources, question pat answers, and criticize slow response or lack of response.
Three official sources—CDC Director Thomas R. Frieden; Dr. Daniel Varga, chief clinical officer of Texas Health Resources, Presbyterian’s parent company; and Dallas County Judge Clay Jenkins—prominently figured in news coverage of Ebola in Dallas. Frieden is a physician and former New York City health commissioner who has been CDC director since 2009.23 Varga joined Texas Health Resources in 2013 as its first chief clinical officer.24 Jenkins is Dallas County’s chief executive and its director of homeland security and emergency management.25
Americans have near-record low levels of trust in the federal government.26 Only 24 percent of Americans surveyed say they can trust the federal government to do what is right nearly all or most of the time, while 75 percent say they trust the government only some of the time or never.27 After the often-frenetic news coverage about the Ebola outbreak in West Africa, which both reflected and magnified public fear and uncertainty, CDC’s initial approach to communication about Ebola in the United States was to inform and reassure. Frieden told journalists in August 2014 that US hospitals were ready if Ebola surfaced in America:
CDC officials have said repeatedly that any hospital in the United States can safely provide care for a patient with Ebola by following their exacting infection-control procedures and isolating the patient in a private room with an unshared bathroom. “What’s needed to fight Ebola is not fancy equipment,” Frieden said. “What’s needed is standard infection control, rigorously applied.”28
But these reassuring words ultimately rang hollow at Presbyterian. For weeks, the hospital was the epicenter of the Ebola story in the United States after Thomas Eric Duncan, a Liberian man who became ill while visiting relatives in Dallas, went to the emergency room with a high fever on September 26, 2014, but was sent home without being diagnosed with EVD.29 Duncan returned by ambulance two days later after his symptoms worsened. He was diagnosed with EVD on September 30, two days after he was admitted.30
Even after Duncan’s case was confirmed, US health officials continued to play down fears of Ebola.31 Frieden told reporters that methods to track down people who may have been exposed to Ebola through contact with Duncan were “tried and true,” adding, “I have no doubt that we’ll stop this in its tracks in the U.S.”32 At the same time, however, news stories noted that health officials had delayed for more than a week the cleanup of the Dallas apartment where Duncan had stayed with relatives before entering the hospital, leaving potentially infectious bedding and other items in place.33
Frieden also said there was no reason to move Duncan to another hospital, reiterating that any US hospital capable of isolating patients for other infectious diseases could safely handle Ebola cases.34 And Presbyterian’s epidemiologist, Dr. Edward Goodman, told reporters: “We have had a plan in place for some time now for a patient presenting with possible Ebola. … We were well prepared to care for this patient.”35
Duncan died at Presbyterian on October 8, the first Ebola fatality in the United States. His death would have been major news in itself, but media attention magnified after two nurses who cared for Duncan also contracted EVD. News stories described those new infections as “the straw that broke the camel’s back,” diminishing public confidence in how Ebola was being handled in Dallas.36
Journalists also complained that Presbyterian initially provided scant additional information to the media:
Presbyterian has routinely refused requests from … news organizations to provide more information about the Duncan case and the subsequent infections. Even general questions about the record-keeping system have been ignored—or are indefinitely “under consideration” for a response—and the strategy seems to primarily include offering as little information as possible.37
Lack of communication opened Presbyterian to even more media scrutiny and criticism. News stories described Presbyterian as “a hospital under siege” after “a cascade of mishaps”38 and as experiencing “a nightmare without end.”39
When the two nurses with Ebola were moved to hospitals in other states for treatment, news stories highlighted the inherent mixed messages. On one hand, the moves meant that the nurses no longer presented a risk of infection to co-workers, other patients, or the community. On the other hand, it signaled that despite Presbyterian’s repeated claims that it had been prepared for Ebola and CDC’s assurances that any hospital could safely handle Ebola cases, Presbyterian was deemed incapable of offering its own nurses the best possible treatment.40 Both nurses recovered.
Two national public opinion polls released on October 21, 2014, showed a simultaneous increase in public concern over Ebola and a decline in trust in government officials managing Ebola in the United States.41 A survey by the Pew Research Center found that 41 percent of Americans said they were worried that they or someone in their families would be exposed to the virus, up from 32 percent two weeks earlier. Meanwhile, a Gallup poll showed a decline in Americans’ confidence in the “federal government’s ability to handle Ebola” from 60 percent to 52 percent in a single week.42 Those numbers raised the communication stakes even higher.
Official sources, including Frieden, Varga, and Jenkins, attempted to assure the community—and beyond—that Ebola was under control in Dallas, but their confidence did not square with what people were reading, seeing, and hearing in the news. For example, 75 Presbyterian employees involved in Duncan’s care were ordered to stay home and monitor themselves for Ebola symptoms,43 several schools in Texas and Ohio were closed temporarily,44 and Frontier Airlines replaced carpeting and seat covers on two planes on which a nurse infected with Ebola virus had flown.45
Some communication efforts in Dallas appeared awkward or even counterproductive. For example, in an ABC News story headlined “Ebola Scare Turns Dallas Hospital into a ‘Ghost Town,’” Varga was quoted as saying:
I would tell this community that Presby [the hospital’s nickname] is an absolutely safe hospital to come to. We’ve been in communication with our doctors that have private offices in our professional buildings around the campus who are getting 40, 50, 60 percent cancellations just for fear of being somewhere in the geography of the hospital where Ebola is treated.46
But reporters—and through their stories, the public—believed Presbyterian was the opposite of “absolutely safe”:
Long regarded as one of the finest hospitals in Texas, Presbyterian has faced continuing criticism—first for its initial misdiagnosis of Mr. Duncan, which delayed his care and placed others at risk; then for issuing contradictory statements about why its doctors did not suspect Ebola; and now for failures in safety protocol that led to the infections of two of its own. If the hospital has served as a canary in a coal mine for the country’s Ebola response, the results have not inspired confidence.47
Stories included criticism from a national nurses union and even some Presbyterian employees that Duncan’s case had been handled sloppily, putting health care workers and other patients at risk of infection.48 NPR reported that hospital managers “first seemed unsure what sort of protection should be worn. Eventually, it settled on caps, particulate masks, face shields and goggles. That left parts of the head and neck exposed. It wasn’t until … Duncan was finally confirmed by the CDC as positive for Ebola that the hospital issued fully hooded hazmat suits.”49
Presbyterian leaders said that in caring for Duncan, the hospital had followed CDC’s initial guidance on what health care workers treating Ebola patients should wear:
CDC says that health care workers … need only wear gloves, a fluid-resistant gown, eye protection and a face mask to prevent becoming infected with the virus. That is a far cry from the head-to-toe “moon suits” doctors, nurses and aides have been seeing on television reports about the outbreak.50
After Duncan’s death and the infection of two nurses, Presbyterian and CDC strengthened their guidelines on protective clothing. But media criticism of Presbyterian also focused on the hospital’s leadership:
This failure of judgment put the lives of its medical staff and especially its nurses at risk. … Here was a recently traveled patient from West Africa exhibiting effusive and classic symptoms of Ebola. It was senseless not to provide the medical staff with the best protection the hospital had on hand. Varga admits Presbyterian wasn’t ready. They hadn’t trained for Ebola and were not wise enough about the threat the virus posed.51
When CDC belatedly flooded Presbyterian with teams of infection-control experts and crisis managers after Duncan’s death, Frieden acknowledged that the agency should have responded more quickly and aggressively.52 “I wish we had put a team like this on the ground the day the patient, the first patient, was diagnosed,” he said. “That might have prevented this infection. But we will do that from today onward with any case, anywhere in the U.S.”53
Acknowledging its missteps marked the beginning of CDC’s efforts to rebuild public trust. Presbyterian was also ready to apologize and attempt to move on. But after a series of contradictory news releases, inaccurate statements, unanswered questions, and growing criticism over how Duncan was treated,54 damage to the hospital’s reputation was so extensive that Texas Health Resources hired Burson-Marsteller, a public relations agency, to help conduct “an aggressive public relations campaign aimed at rehabilitating its battered image.”55 A few days later, Texas Health Resources bought full-page newspaper ads in Dallas and Fort Worth to apologize for not living up to “the high standards that are the heart of our hospital’s history, mission and commitment” by botching Duncan’s initial diagnosis.56
Varga was out front in the “public relations offensive to restore trust.”57 In prepared Congressional testimony, he said: “Despite our best intentions and a highly skilled medical team, we made mistakes. We did not correctly diagnose his symptoms as those of Ebola. We are deeply sorry.”58 Presbyterian also flooded social media with the hashtag “#PresbyProud” to try to staunch the number of patients continuing to stay away.59 And Presbyterian scored a media relations coup when former President George W. Bush, a former patient, visited employees and patients at the hospital.60 But news stories panned the stage-managed quality of some of Presbyterian’s public relations activities, which undermined their credibility:
The hospital published slick video clips of smiling nurses praising their managers and hosted a brief “rally” of medics wielding pro-hospital placards outside the emergency room for television news cameras. The placards, bearing such slogans as ‘We (heart) Presby’ and ‘We stand with Presby,’ appeared to have been written in the same handwriting.61
How could official sources—and the organizations they represent—have communicated more effectively with the public through the news media about Ebola in the United States? Principles of risk and crisis communication provide several suggestions.
First, communicate early and often, even when not all the facts are known. For example, when Presbyterian provided scant information to journalists after two of its nurses were diagnosed with Ebola, it violated a tenet of crisis communication: If you don’t fill the information vacuum, someone else will.62 In Presbyterian’s case, the “someone else” included members of Congress, pundits on cable television networks, a national nurses union, Duncan’s relatives and neighbors, and personal injury lawyers, all of whom used the news media as a platform to air their views—including criticism of Presbyterian’s handling of Ebola.
Second, statements meant to reassure the public can backfire, especially when they are at odds with what is really happening. Crisis communication expert Peter M. Sandman suggests that officials be “as reassuring as you can be so long as you are virtually certain that reality won’t turn out worse than your reassurances.”63 But as the Los Angeles Times noted in an editorial on the CDC’s handling of Ebola: “In an attempt to avoid a public panic, they instead created a worse one by making assurances that were quickly shown to be wrong. … It looked as though government experts weren’t in control, and that sparked fear.”64
Sandman notes that empty reassurance isn’t reassuring,65 a point also made in several editorials on Ebola in the United States:
Even as U.S. health authorities continue to tell Americans not to worry about the Ebola virus, their assurances are being undercut by the increasingly obvious deficiencies in domestic planning. … Frieden … has repeatedly been forced to back away from his calming assertions that U.S. hospitals were ready for the disease.66
USA Today editorialized that while CDC “is known for providing calm expertise in a health crisis,” Frieden at times “let overconfidence get ahead of facts”: “CDC allowed its desire to tamp down fear to ‘get ahead of the science,’ said infectious disease specialist Michael Osterholm.”67
Sandman also cautions officials to never proclaim that anything is “safe.”68 Varga’s comment that Presbyterian was “absolutely safe” not only failed to reassure, but also prompted journalists to catalog in news stories the many ways they believed the hospital was unsafe.
Third, sources—and the organizations they represent—should actively safeguard their trustworthiness. Credibility is a source’s most important asset, and if it is challenged or eroded, their information or opinion is much less likely to be sought by reporters, included in media coverage, and attended to by the public. Sandman points out that one way in which trust can be diminished is over-reassurance: “People sense that you’re withholding alarming information and become all the more fearful. Or they learn later that you withheld alarming information and never trust you again.”69
Fourth, being defensive, dodging responsibility, or attempting to shift the blame to others can hinder crisis recovery.70 In November 2014, Presbyterian officials still maintained that the hospital had been prepared for Ebola despite every indication to the contrary over the previous five weeks. Varga told a public forum in Dallas: “We were completely and adequately prepared to treat a patient with Ebola but less than completely prepared for a patient to come in from the streets and for us to give diagnosis of Ebola.”71 Either Presbyterian was prepared or it wasn’t; anything else is splitting hairs.
Fifth, empathy should be an essential part of communication. Public opinion is shaped by emotion as well as reason, and demonstrating public health expertise isn’t enough when emotions run high. As risk communication expert Dr. Vincent T. Covello asserts: “When people are stressed and upset, they want to know that you care before they care what you know.”72
Expressions of empathy can humanize officials and make their words more believable. Officials could have demonstrated empathy during the Ebola crisis in the United States by acknowledging publicly that they understood why people were upset and frightened—even if they personally believed there was no rational reason for people to feel that way. Although the number of Ebola cases in the United States was small, the number of Americans worried about, and inconvenienced by, Ebola was considerably larger. Yet there was no public recognition of the anxiety experienced by health care workers who may have been put in harm’s way by lax safety protocols, the disrupted lives and lost pay of people ordered to stay home and monitor themselves for Ebola symptoms, the inconvenience to parents whose children’s schools were closed, and the concern of air travelers who were later told they had flown with an infected passenger.
Jenkins, the Dallas county judge, expressed empathy more effectively than the other official sources in Dallas. He drove Duncan’s relatives to a quarantine location and then told a news conference later that day that he was still wearing the same clothes because he was unconcerned about contracting Ebola.73 As one reporter described Jenkins, “No local, state or federal official involved in the Ebola emergency in Dallas has put himself farther on the front lines and done more to humanize and personalize the government response.”74 Yet the most empathetic moment occurred in Washington, DC—1,300 miles from Dallas—when President Obama hugged Nina Pham in the Oval Office on October 24, 2014.75 Pham, a nurse at Presbyterian, had been released from an Atlanta hospital earlier that day after recovering from Ebola.
Finally, reputation-repair efforts after a crisis must be perceived as authentic. News stories noted that some of Presbyterian’s activities to restore its image and regain patients’ trust appeared to be less of a genuine grassroots effort and more of a carefully scripted campaign managed by a major public relations agency, including YouTube videos with high production values, prepared remarks at a news conference at which no questions from reporters were allowed, a brief employee “rally” for the benefit of television cameras, and lack of media access to hospital leaders.76 Reporters also noted that “a good number” of the tweets with the hashtag #PresbyProud “came from official hospital accounts or from those of top managers.”77
Moreover, although offering an apology is an important step to regain trust, it isn’t enough—especially in a severe or prolonged crisis like Ebola in the Unites States. Crisis communicators assert that communication should follow performance: An organization should fix its problems first, then communicate the changes and improvements to the news media and public, and finally, demonstrate over time that the changes actually work.78
In hindsight, applying these principles of risk and crisis communication could have improved public communication through the news media about Ebola in the United States. They may also provide useful guidance during future infectious disease outbreaks.