On March 23, 2014, the World Health Organization posted a report on its website of a surprising outbreak of Ebola virus disease (EVD) in the West African nation of Guinea,1 marking the first time it had appeared in this part of the continent. At that time, at least 29 had died and 49 people had been infected with a highly lethal species of the virus known to kill up to 90 percent of its victims. The global news media paid scant attention.
The international media wake-up call came four months later, with back-to-back events that warned the world this fast-moving EVD epidemic was already the worst in history.2 By then, the disease had already struck 1,600 people and claimed 880 lives in Guinea and the neighboring countries of Liberia and Sierra Leone.3
Alarm one: On August 2, 2014, Ebola arrived in the United States when a physician who contracted the disease while treating patients in Liberia was airlifted 4,750 miles to Emory University Hospital in Atlanta, Georgia. Dr. Kent Brantly4 underwent intensive care there in a medical isolation unit designed to handle hazardous infectious diseases like Ebola. This frightening disease now had an American face, and the US and international news media stepped up coverage.
Alarm two: On August 8, 2014, World Health Organization (WHO) Director-General Margaret Chan5 garnered global headlines when she officially declared the Ebola epidemic a public health emergency of international concern. An emergency committee had unanimously advised her to do so, warning that the EVD outbreak constituted such an “extraordinary event” that “a coordinated international response is deemed essential to stop and reverse the international spread of Ebola.”6
Alarm three: On September 30, 2014, EVD was diagnosed for the first time on American soil. A Liberian traveler, later identified as Thomas Eric Duncan, flew commercially to visit family in Dallas, Texas. When he fell ill four days later, Duncan sought emergency care at Texas Health Presbyterian Hospital but was mistakenly diagnosed with a sinus infection.7 Duncan returned to his family’s apartment in a densely populated part of Dallas that was home to many African immigrants. When his condition worsened, he was taken by ambulance to the hospital’s isolation unit for round-the-clock care and was finally diagnosed with EVD. While medical missionary Brantly survived, Duncan died on October 8, 2014.8
Despite the tragic Ebola epidemic then unfolding in West Africa—with 121 deaths in a single day in Sierra Leone alone9—the Texas case attracted massive American and global media attention. “I think unfortunately, in the Western media, there are first-world diseases and third-world diseases, and the attention devoted to the latter depends on the threat they pose to us, not on a universal measure of human suffering,” said one media commentator.10
For an unprepared American and European public with limited knowledge of EVD, buzzwords such as infectious, exotic, lethal, epidemic, and quarantine naturally provoked fear that this deadly disease could spread widely abroad despite authorities’ assurances that stronger public health systems and advanced medical care minimized chances of an Ebola outbreak outside of the African continent.
Flawed media coverage of the epidemic raised several red flags described below, signaling failures to communicate with the public, both inside and outside of Africa, in a responsible and timely manner.
Gross mismatch between the magnitude of the West African Ebola epidemic and media coverage. Western news outlets’ coverage of the disastrous human and societal tragedy unfolding in Guinea, Liberia, and Sierra Leone was generally too little and too late. When foreign media outlets sent reporters to these countries, they often focused on foreign medical workers or medical resources from their own country. Images of dead bodies in the streets and medical workers in hazmat suits dehumanized the tragic situation and failed to connect the dots between EVD and the underlying poverty, poor hygiene, and precarious health and political systems in Western Africa.
Parochial performance by many mainstream media outlets. A few imported EVD cases in the United States and Europe received a vastly disproportionate amount of coverage and commentary. Sharp financial cutbacks in specialty beat reporters in areas such as science, medicine, and health, as well as in foreign correspondents, also meant that American print and electronic coverage often lacked in-depth knowledge and perspective. The news media have been democratized and globalized, turned upside down by the emergence of the Internet as a 24/7 source of often unverified information.
Rumors, misinformation, and fear spread by social media and cable television news channels. A Twitter storm and political grandstanding by “talking heads” created controversy, confusion, and knee-jerk reactions in terms of quarantine or travel restrictions. A Washington Post-ABC News poll11 found two-thirds of the American public feared a widespread outbreak of EVD; it was dubbed “the next American panic—an anthrax or SARS [severe acute respiratory syndrome] for the social-media age.”12 A New Jersey survey13 also suggested that those who followed the EVD story most closely had the least accurate information about the disease, seeing it as more contagious than it actually is.
Blame the messenger? While many news outlets and social media certainly deserve criticism for hyperbolic coverage, there is plenty of blame to go around. Other key stakeholders in the global health communication chain failed to provide clear, coordinated, timely, and useful information to the news media and the public. The WHO came under strong criticism for failing to respond more swiftly to the epidemic’s early warning signs; its leadership—and that of other agencies—also failed mass communication 101, with overcharged language such as “catastrophe” fueling overblown media coverage. Political leaders making ill-considered comments often sought media attention.
Failure of risk communication. Communicating the risks of Ebola transmission—particularly who was at greatest risk, how, when, and where—was indeed a major challenge. Risk communication messages from public health officials and the news media needed to be better tailored to differing global audiences. Clearly, many West Africans faced enormous personal risk of contracting Ebola, and their countries’ weak health systems meant patients there initially received poor to little care. Health workers and foreign journalists in West Africa who wore protective gear greatly reduced their personal risk of contracting Ebola. Under most circumstances, American and global publics were at virtually no personal risk of contracting Ebola.
Many of the communication problems posed by the EVD epidemic are not new. Age-old infectious disease scourges such as cholera, measles, or tuberculosis attract little fanfare, despite their deadly toll. Novel lethal diseases such as SARS and Middle East respiratory syndrome, or MERS, garner headlines when infected travelers carry diseases into areas not expecting an exotic microbial adversary. Medical teams, public health officials, policy makers, politicians, airline executives, and members of the news media at the local, national, and global level seem to play catch-up with each novel public health emergency.
First detected in 197614 in remote areas of Central Africa, Ebola emerged as a ferocious infectious foe that killed more than half of its victims (and fueled frightening nonfiction books such as the 1994 bestseller The Hot Zone,15 as well as dramatic novels and films). The 1976 outbreaks in Zaire (then Democratic Republic of the Congo) and neighboring Sudan claimed 431 lives.16 Sporadic outbreaks over the years have been localized and contained.
The 2013–2016 EVD epidemic was historic in its magnitude and in its location, appearing for the first time in West Africa and moving into urban as well as rural locations. It was initially not recognized locally, and even after Ebola was detected, the global public health community and the news media were slow to wake up to this fast-moving epidemic.
“When you look at the evolution of the crisis, the international community really woke up when the disease got to America and Europe. And yet we should have known that in this interconnected world it was only a matter of time,” said former United Nations Secretary-General Kofi Annan,17 who told the BBC that he was “bitterly disappointed” by the slow response in richer countries.
“The task of covering Ebola is a tricky one for the media. Too much coverage, and we look like we’re being exploitative with scare tactics. Too little coverage, and we get blamed for not enlightening our audience of its scope,” noted broadcasting consultant Ken White18 on the respected Poynter Institute global journalism website.
While the term “news media” is often used as if a singular entity, the term is of course pluralistic, reflecting a diversity of outlets whose coverage of the outbreak has ranged from outstanding to abominable.
At one end of the spectrum, the New York Times’ exceptional coverage of the EVD outbreak within West Africa earned the newspaper two 2015 Pulitzer Prizes, one for International Reporting and another for Feature Photography. The Times’ website19 noted that the newspaper “mobilized dozens of reporters, photographers, video journalists and others over the last year, producing more than 400 articles, including about 50 front-page articles from inside the Ebola-afflicted countries.” The sheer amount and quality of the Times’ coverage demonstrated the opportunities available when a prominent news outlet makes an institutional commitment to use its print and multimedia resources to tackle a challenging, complex story like the EVD outbreak.
When news outlets did have specialty health and science reporters, the coverage generally got high marks. “For the most part, the reporting on medical aspects of the disease has been straightforward and responsible, with many stories emphasizing the relatively low risks of infection,” wrote Washington Post media reporter Paul Farhi.20
A Columbia Journalism Review (CJR) article21 by this author reached a similar conclusion: “The most effective Ebola media coverage thus far has been due in part to the steady hands of experienced—and highly credible—federal medical leaders as well as health and science specialty beat reporters on news teams at major print, radio, and television outlets.”
American cable news networks with global reach have rightfully come under considerable criticism for their misleading, fear-mongering Ebola coverage. In their fierce round-the-clock competition for viewers, CNN and Fox News performed especially poorly during live coverage of the first Dallas EVD case, which involved medical mishaps as well as the subsequent infections of two hospital nurses who cared for the Liberian patient.
For example, Fox News Sunday anchor Chris Wallace22 pushed the federal government’s senior infectious disease official Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases (NIAID), to comment on some farfetched hypotheticals, including whether immigrants on the US southern border were bringing Ebola into the country or whether the Ebola virus would make a good bioterrorism weapon. Fauci quickly dismissed Wallace’s scenarios.
Cable network CNN linked two frightening terrors in a shrill on-screen headline: “Ebola: ‘The ISIS of Biological Agents?’”23 CNN anchor Ashleigh Banfield even suggested ISIS could “send a few of its suicide killers into an Ebola-affected zone and then get them onto mass transit.”
“I wish everybody could take a deep breath and take a break from trying to pull viewers in by scaring them,” said PBS NewsHour science correspondent Miles O’Brien.24 “It borders on irresponsibility. … But there is a perception that by hyping up this threat you draw people’s attention.” O’Brien, a former CNN science correspondent, also lamented the lack of television health and science expertise: “Science coverage is important. … Why in this world where climate change is a big issue, Ebola is a big issue, missing airplanes are a big issue, why is it big entities don’t maintain science units anymore? They’re gone!”
When Western media outlets did go to West Africa to cover the larger Ebola story firsthand, many drew criticism for their portrayal of the disease and its victims from a foreign perspective. Columbia University journalism professor Howard French25 sent a letter signed by over 150 academics to the US television network CBS complaining about an Ebola segment on its “60 Minutes” broadcast:
Africans were reduced to the role of silent victims. They constituted what might be called a scenery of misery. … Liberians not only died from Ebola, but many of them contributed bravely to the fight against the disease, including doctors, nurses and other caregivers, some of whom gave their lives in this effort. Despite this, the only people heard from on the air were white foreigners who had come to Liberia to contribute to the fight against the disease.
Within West African countries, delays in getting Ebola information to the citizens there also posed a problem. Wade C.L. Williams,26 an investigative journalist in Liberia, wrote that the panic-stricken government delayed declaring a full state of emergency for four months: “Fear, misinformation and flat-out denial have been far too common … Among the government’s first reactions was to limit journalists’ coverage of it. That, in my view, is a major reason the virus has spread as fast as it has … The effect was to quarantine information about the disease, rather than spread information about how people could protect themselves.”
The news media often do an inadequate job of communicating complex information involving risk, uncertainty, and options for preventive or remedial action. But here again, key stakeholders in the medical, public health, government, political, and private sectors generally do a poor job in communicating risk.
Risk is a three-legged stool involving risk analysis (What is the problem?), risk management (What can be done about the problem?), and risk communication (What should we say to the public?). The first two—analysis and management—get the lion’s share of effort from public and private authorities. However, risk communication is often an afterthought rather than a professional discipline requiring training and preparation in its own right. (This is not to be confused with media “spin” by parties more interested in manipulating a message for their own purposes than crafting a clear message to improve public understanding in a crisis.)
For more than three decades, researchers in psychology and communication have sought to understand what drives public concern about health, environmental and technological risks.27 The conventional wisdom was that providing facts and numbers should persuade the public to agree with experts’ assessment of the largest problems. However, studies found that public perception of risk often did not fit this fact-based model.
Simply providing more information, generally through the media, did not necessarily change people’s minds or behaviors. Emotional and cognitive factors were at play, with greater concern about risks that were imposed, unfamiliar, uncertain, or catastrophic. (Flying is often incorrectly seen as more dangerous than driving, for example.) Lack of trust also increased concern.
Even though their individual chance of exposure was exceptionally low, people in Texas were more likely to be alarmed about the arrival of a deadly, exotic disease like Ebola and less likely to be worried about everyday dangers of driving, drinking, or getting sick from seasonal influenza.
Journalism’s focus on the novel rather than the norm often prods the public to worry about the wrong things. As Guardian writer James Ball concluded: “It’s worth reflecting what the biggest threat to our collective wellbeing is: rare tropical diseases, or our terrible coverage of them?”28
Risk communication and media coverage of infectious disease epidemics can be improved if health authorities learn to craft more useful and timely messages containing accurate, transparent, and relevant public information. News outlets can convey more meaningful risk information by enhancing stories with multimedia images, video, graphics, and interactive tools.
The following ten tips offer strategies for improving global communication and media coverage of public health risks from EVD and other infectious disease epidemics.
Increase media training and risk communication skills for professionals—in public health, medicine, research, government policy, politics, or other fields—who deal with the press and the public in a health crisis. Increasingly, the public and private sectors are stepping up advance media and crisis management training, using simulation exercises, one-on-one interviews, and video feedback. Content matters, but so does how you look and say it. Transparency builds trust. Accuracy is key but so is acknowledging uncertainty. The media today are democratic: Few people will be professional journalists, but everyone can and should be better communicators.
Know your audience: Who is at greatest risk of exposure to a given harm? Contracting Ebola requires exposure to the virus: Thus, alarm those at greatest risk of being exposed and calm down those at least risk. Too often experts and media hype generalized or universal messages that get everyone alarmed. Directed messages toward those at greatest risk should provide clear actions to prevent or minimize the danger of new infections, whether in community or health care settings. Conversely, calming down communities or individuals at virtually no risk is important in reducing fear and inappropriate panic. During the Dallas Ebola scare, news photos showed a man wearing a hospital mask while taking out his garbage—a completely unnecessary action.
Provide clear and concise messages about how an infectious disease is or is not transmitted. The Ebola virus is spread through intimate personal contact with blood or other body fluids in a symptomatic patient, not through the air (as some scaremongers suggested). The incubation period for EVD symptoms to appear is 2 to 21 days after exposure. This silent waiting period increases uncertainty and anxiety. Troubling new studies suggest that survivors can still transmit the Ebola virus sexually after the disease symptoms are gone.
Fight fear with user-friendly facts. To combat rising Ebola hysteria, the Gannett media chain’s television stations and newspapers in the United States mounted an impressive campaign.29 Using detailed data from the federal Centers for Disease Control, they partnered to post in-depth Ebola “explainers” on their websites, as well as interactive maps, videos, live chats with experts, and Twitter promotion with the hash tag #FactsNotFear. On the first anniversary of the Texas case, USA Today did extensive follow-up stories. Many journalists and commentators sought to put the Ebola risk in perspective, noting that seasonal influenza kills thousands of Americans annually, yet less than half of adults get flu shots.
Remember, “Perception is reality.” Facts alone may not be persuasive enough for some individuals or groups to change their actions or behavior. Recognize that there is no single “public.” A given audience reads, watches and listens through multiple lenses of age, gender, ethnicity, education, geography, politics, and religion. But we often act as if there were a generic “public.” A variety of emotional and psychological factors may have a greater influence on how danger is perceived and what can be done about it than facts alone. Consider the diversity of the audience.
Put EVD numbers in international perspective. As of September 20, 2015, the toll from the current West African epidemic numbered 28,331 cases and 11,310 deaths.30 Of those, only about 24 cases and five deaths were outside of Africa (including 10 cases and two deaths in the United States and the rest in Europe, most of whom were health and aid workers in West Africa who returned home to their countries for treatment).31 By mid-October 2015, the West African epidemic had waned to only five or fewer cases per week. But Ebola’s impact is far from over.32 Many of the 13,000-plus West African survivors have lingering health problems33 and live in poverty-stricken countries with struggling health systems and economies further devastated by the latest Ebola onslaught. Careful monitoring for new Ebola cases suggests that even when the disease seems to have disappeared—and countries declared Ebola-free—additional cases may continue to crop up. Out of sight is not necessarily out of harm’s way.
Choose risk numbers carefully. Differentiate relative and absolute risk. Public health studies often use relative risk numbers, finding that a given action or exposure increases the hazard by a given amount—say, a three-fold increase in getting infected. But in order to understand the significance of that relative risk, it is important to know the baseline, or absolute risk, in the first place. If the risk is 1 in 10,000 to start with, a three-fold increased risk rises to 3 in 10,000—still a small risk. Not all published studies provide the baseline numbers; experts should provide the relevant numbers and members of the news media need to ask.
Avoid inflammatory words. Using inflammatory words in a public health emergency will of course fan the flames of concern and fear. Ebola is scary enough to start with: Words such as infectious, epidemic, deadly, and quarantine need to be used appropriately. “Catastrophe” and “catastrophic” were often used—from the WHO to CNN—to stress possible consequences, but these words also promoted a doomsday scenario that fed international hysteria. A headline on a WHO six-month update of the epidemic asked, “Ebola in West Africa: Headed for Catastrophe?”34
Watch out for seesaw coverage. A Washington Post colleague once quipped that there were two kinds of front-page medical stories: “No hope” and “New hope.” Journalists often emphasize the dramatic over the ordinary, but so do experts. In 2014, health and government officials painted an increasingly dire picture of the devastating West African Ebola epidemic. However, many swung toward great optimism when a preliminary 2015 study in the journal Lancet35 reported that human trials in Guinea of a new Ebola vaccine had proven “100 percent” effective. “This new vaccine, if the results hold up, may be the silver bullet against Ebola,” waxed Norway’s foreign minister Børge Brende.36 Words such as “silver bullet” or “breakthrough” should generally be avoided. They tend to overpromise solutions that usually take far more time to test and bring to market.
Distinguish personal risk from societal risk. The news media provide a bullhorn for global awareness of emerging disease threats at the local, national or international level. When the WHO declared Ebola a Public Health Emergency of International Concern in August 2014, it was a belated SOS to the world. The global societal risk was high, requiring immediate support—in manpower and money—to help affected West African nations in caring for patients and communities, while reducing possible spread, particularly into adjacent parts of Africa. But the global personal risk to individual citizens around the world was always extremely low. Both the societal and personal Ebola risks were very high in many parts of West Africa.
The biggest challenge ahead is keeping public attention focused not only on ending this lingering Ebola virus disease epidemic but also getting better prepared for the next public health emergency, EVD or otherwise. It’s not a question of “if,” but “when.”
“The biggest threat we face now isn’t the Ebola virus—it’s our short attention span. Whether fueled by apathy, boredom or both, the public’s short attention span imperils public health both in developing nations and in the United States,” said Dr. Bruce Ribner,37 director of the Emory Serious Communicable Diseases Unit.
His unit’s successful treatment of four Ebola cases from West Africa demonstrated that, although there is no cure, the disease could be managed with sophisticated, supportive care of the kind not available in West Africa. Now he and others at US medical facilities have joined forces with federal health officials to help improve emergency preparedness for future infectious disease threats.
“I’m often asked when the next outbreak will be, and I always say that I can promise you two things: There will be another infectious disease emergency in the next few years, and it won’t be a disease we anticipated. The ‘next Ebola’ probably won’t be Ebola at all,” said Ribner.
“Each state and locality should have an epidemic response plan. What happens when you fail to plan is that you get caught up in the hysteria, and then politics rules,” said Lawrence Gostin,38 director of the O’Neill Institute for National and Global Health Law at Georgetown University in Washington.
Future emergency preparedness for infectious disease outbreaks should include risk communication and media training as a key pillar, not an afterthought. That includes making better risk communication resources available not only to public health and medical experts but to public information officers, the media, and the public.
At the same time, journalism programs, professional organizations, and mainstream media outlets need to improve training not only of health and science reporters but also of a new generation of general assignment journalists nimble enough to understand and interpret information about emerging infectious diseases. In addition, as the historic Ebola outbreak made clear, the twenty-first century poses new communication challenges and opportunities in a world increasingly connected by travel and technology.
Media coverage of the recent Ebola epidemic illustrates the challenges involved in communicating to the public about a deadly infectious disease. The media shares much of the blame for the hyperbole that surrounded Ebola, especially its limited arrival in America. But there were countless mistakes among many stakeholders in the communication supply chain, especially those who jumped in and politicized the Ebola epidemic, fanning the flames of public concern. What’s needed going forward is a proactive effort by the public health community to improve communication to the media as well as the public. Responsible media also share the responsibility to be more prepared and knowledgeable for the next international disease epidemic.
We should all be expecting it.