Inside Story

Public messaging when it matters most

What are the lessons of overseas Covid-19 responses for Australian policymakers?

Matthew Sussex 12 March 2020 3100 words

Rapid response: a transport official checks passengers’ temperature at a bus terminal in Taipei, Taiwan, on 28 February. David Chang/EPA

The global public health emergency triggered by Covid-19 demonstrates how important it is for policymakers to engage with the public in combating major health security threats. Panic is always a danger in the absence of accurate, clear and engaging communication to encourage broad public compliance. Many people are already turning to the cluttered digital infodemic on Covid-19, much of which is inaccurate and misleading. The challenge for governments and public health officials is particularly acute at a time when trust in democratic leadership has been markedly declining.

The government’s aim should be to shape public understanding and behaviour in a way that contributes to mitigating the spread of Covid-19. Backed by clear and effective policy planning and implementation, public messaging can be a highly effective way of mobilising populations to become stakeholders in damping down widespread “black swan” societal threats like this virus. Can the experience of governments overseas help Australian policymakers to do this as effectively as possible?

Authoritarian versus democratic responses

Because they can use coercive measures much more swiftly, authoritarian governments might seem to have an advantage over democracies when it comes to dealing with diseases like Covid-19. But there’s a clear caveat: pandemics require whole-of-society efforts, and that means the “authoritarian advantage” only kicks in when the iron fist has a velvet glove. Regardless of their political system, populations will only put up with aggressive quarantine measures, for instance, if they feel they have a stake, their basic human needs are still broadly taken care of, and their collective efforts are having demonstrable results.

Despite signs that China’s efforts are paying off, other nations have been reluctant to follow its tough example. China specialises in speed, scale and obedience, things that decentralised democracies find very difficult to match. But already Britain and other countries have been warning their publics that life may need to change substantially if efforts to flatten the Covid-19 epidemic curve fail, and that they should be prepared for constraints on their liberties and choices for the broader public good.

So far, Australia’s navigation has been broadly creditable. The federal government’s pandemic action plan needed to be amended to deal with the specifics of Covid-19, but that effort didn’t need to start from scratch. The immediate emphasis on detecting illness among people arriving from overseas helped buy time, and testing and tracing has helped identify those who slipped through the net and might start local transmission clusters. The government has acknowledged that surge capacity and supplying protective gear to frontline workers remain challenges. And it urgently needs to engage with general practitioners about their role in the battle, engage better with the general public about what part they can play, and coordinate more effectively with state and territory governments and other authorities.

Maintaining a balance between encouraging wariness and preventing hysteria is crucial, as the perplexing panic buying of toilet paper shows. The rush on supermarkets is an indicator of a level of public fear and a lack of confidence in government. Panicky behaviour like this suggests that the official response can’t afford to become complacent and take public compliance for granted.

Denial, delay and distrust: what not to do

Iran is the leading example of failed policy and flawed messaging. Tehran hid its Covid-19 outbreak until well past the point when doing so was rational, even if the primary goal was to protect the regime rather than the public. Members of the elite have been infected, and some have died. The country’s relatively robust health system is verging on collapse, yet the regime failed to use its brutal but effective power to prevent the movement of people. In fact, its messaging has only recently begun moving from “everything is fine” to “this is a challenge we will overcome,” and public trust has crumpled as a result. The government reacted too slowly in preventing dangerous behaviour, with the most chilling example being videos circulating of devout worshippers licking shrines in Qom in order to prove that their faith could overcome any virus.

Japan’s early responses to Covid-19 are another good example of what not to do. The Abe government badly botched its quarantine of the Diamond Princess cruise ship: not only were people still being infected while the ship was in lockdown, but authorities subsequently let twenty-three people go without testing them. And with Tokyo desperate to host the Olympics later this year — a prospect that looks increasingly unlikely — the government decided to keep official infection numbers down by testing as few people as possible. Coupled with the social distancing measures being rolled out throughout Japan, the recent decision to close schools in Hokkaido for two weeks makes clear that the situation is by no means under control.

Italy’s performance has also been poor. Because the government missed the chance to catch local infection clusters early, it was forced to take the aggressive step of quarantining the Lombardy region. Regardless, Italy’s disease burden has increased markedly, making its next step, nationwide quarantine, also virtually its last resort. The sheer number of cases Italy has exported to Europe and elsewhere makes clear that its infected population — like Iran’s — has been badly undercounted, dramatically eroding domestic and international confidence in the Conte government’s ability to rein in the outbreak.

Britain’s response to Covid-19 has been mixed. Concerns about the capacity of the National Health Service to “surge” against Covid-19 were reflected in a poll of 1600 doctors, which found that 99 per cent of respondents believed the NHS was not ready for the task. No doubt keenly aware that Britain has only 2.5 hospital beds per 1000 people, health secretary Matt Hancock announced plans to recruit an army of retired health professionals — nearly all of whom are in the age group most at risk of severe complications or death from Covid-19 infection. And whereas Hancock has tried to raise public awareness with a “catch it, bin it, kill it” campaign, he has also faced criticism for statements that seemed to suggest Britain was giving up on containment and preparing the nation to take the outbreak on its chin. For his part, prime minister Boris Johnson has faced questions about his lack of visibility during the crisis.

Forget China, worry about America

The United States’s Covid-19 response has been hamstrung by political infighting, a lack of coordination and a number of bizarre errors. Many Americans already distrusted Donald Trump’s leadership; many among his support base, as well as media organisations like Fox News, have continued to back him even when the advice he gives is dangerous.

Trump’s incoherent press conferences on the epidemic have revolved around boosting his image in an election year rather than reacting quickly with the best possible expertise. His decision to put vice-president Mike Pence in charge of the US response — a man whose belief in prayer and gay conversion therapy led to a massive spike in HIV infections in Indiana — seemed more about finding someone who could be blamed for failure than identifying the best candidate for the job.

Press conferences featuring Pence and Trump’s health and human services secretary, Alex Azar, have devolved into obsequious fawning over Trump’s leadership of the kind we associate with the world’s most autocratic regimes. Trump himself has continued to hold mass rallies, even referring to concern about the virus as the latest Democrat “hoax.” He demonstrated his wilful ignorance of the emergency by falsely claiming that a vaccine was mere months away, and also claimed that Covid-19 would vanish like a miracle. He asked a team of health professionals to prepare a strong version of the influenza vaccine (which treats a different virus altogether) to be used against Covid-19. And in a phone call to Fox News he seemed to suggest that the majority of Covid-19 sufferers could simply go to work as usual.

America’s disease coordination agencies have also reacted poorly. The recently defunded US Centers for Disease Control and Prevention, or CDC, in Atlanta has dropped the ball on several occasions, allowing the virus to circulate for at least six weeks. The CDC allowed a patient in San Antonio who tested positive to the virus to go home, only to hastily recall him. It rarely updates its public guidance.

Having eschewed the World Health Organization’s recommendations on testing in favour of developing its own field kit, the CDC discovered that its test was faulty. But instead of letting other jurisdictions develop their own tests, it simply stopped testing anyone who didn’t fit a very strict set of criteria: air travel to China, exposure to a known positive Covid-19 case, and all the known symptoms of a disease that often affects patients differently.

What made matters worse was that once the United States did declare Covid-19 a public health emergency, any new test needed to be approved by the US Food and Drug Administration. When an FDA official arrived at the CDC to inspect their initial test kits for contamination he was denied entry for twenty-four hours. We should be deeply concerned about the capacity of the United States to weather the epidemic.

Many commentators in the West have claimed the disease will be China’s “Chernobyl moment.” At the very least they foresee a Hong Kong–style flowering of dissent born of a public realisation that the Chinese leadership cares more about politics than the population. Above all, they stress that China cannot be trusted: that the Silk Road is a transmission belt for disease as well as development. Hence, this thinking goes, there is an urgent need for other nations to economically decouple from the People’s Republic.

These predictions are flawed. If anything, China’s ability to blunt the advance of Covid-19 will allow it to deepen its internal control, tracking and tracing a population that willingly signed up to forced quarantines, movement checks and colour-coded travel statuses. More than that, the epidemic has had a mobilising effect on the Chinese population, which the leadership in Beijing will exploit. China is likely to try to turn what should be a global PR disaster into a soft power coup, the gold standard model for containing major threats to societies.

For other countries, decoupling from China may make strategic sense in the name of diversification of supply, but precisely how and where nations will recouple remains unclear. China will be an integral part of the global recovery from Covid-19, in terms both of its experiences and of its capacity to keep global supply chains moving.

Success stories

So far it’s the countries that have combined rapid responses with effective public messaging that are weathering the storm of Covid-19 most successfully. Taiwan and Hong Kong are good examples, but Singapore’s response has been particularly noteworthy. Pragmatically, officials stressed from the outset that the government could not ensure complete safety. Instead, it focused on immediate isolation and forensic contact tracing of cases, along with consistent messaging stressing that it is a civic duty to seek assistance in the event of infection. As a result, local outbreaks are relatively well controlled.

South Korea’s misfortune was that its outbreak quickly reached the Shincheonji cult, a closed and secretive religious organisation, many of whose members are now contributing to the nation’s large caseload. But Seoul’s decision to test as many people as possible, combined with best-practice social distancing and a blizzard of information for the public, seems to have contributed to a declining infection rate. It has also provided a wealth of data about Covid-19’s attack rate, not to mention more reliable information about disease severity and mortality.

While China’s response has been criticised as overly draconian, it has clearly had a major impact in bringing infection rates under control. As a visiting World Health Organization team noted, China’s response combined aggressive control of population movement with rapid deployment of medical staff to hotspots, swift updating of treatment plan guidance, and the use of big data to trace infection spread and predict future outbreaks. This was not only effective in flattening the epidemic curve; it also arguably saved many lives and prevented the spread of the disease outside Hubei province.

Although these controls would be difficult to replicate in Australia, China’s approach is still instructive. Many Chinese citizens may not have believed official figures, and there was significant evidence of corruption, but centralised messaging ensured that citizens understood their roles and responsibilities in the plan to fight the outbreak.

The experiences of Singapore, South Korea and China all illustrate that no “one size fits all” model exists for responding to Covid-19. Singapore in particular can readily trace people within a very small geographic area, but a large-scale outbreak would threaten national stability very quickly. Australia probably faces the reverse problem: pockets of transmission in urban hubs that crop up quickly and require drastic action to contain their spread. Even if each nation is successful in mitigating its own outbreaks, though, the struggle against Covid-19 will continue to face the risks created by imported and sleeper cases.

Lessons for Australia

Enlisting broad public support with well-communicated information coupled with rigorously implemented policy will be critical to how well Australia emerges from the Covid-19 epidemic. A whole-of-society approach, not just a whole-of-government one, is fundamental. Drawing on the experiences of other nations will help considerably to target our response for the best possible outcomes. These ten points are therefore intended to identify what has so far worked well in other nations and apply it to an Australian context.

1. Messaging should be clear, transparent and, above all, agile. We still don’t know enough about Covid-19, but our understanding of case–fatality ratios, attack rates and vectors of transmission will firm up with more reliable data. This information should be shared as soon as possible, and officials should make clear why new approaches may differ from past practice. A national Covid-19 information centre should be established to share reliable, user-friendly information in a variety of media, as well as combating fake news.

2. Depending on the severity of the outbreak, it may be necessary to adopt increasingly tight movement controls. The reasons for each step in this process must be clearly spelled out to minimise confusion, and every effort should be made to avoid politicising unpopular decisions or crowing about government success. As the experience in Italy and Wuhan demonstrates, any decision to close off an area needs to be implemented swiftly to avoid people fleeing and potentially spreading the virus outside containment areas.

3. Australia’s messaging should draw the link between top-level decisions in the public interest and individual circumstances. Panic buying partly reflects a desire to preserve a degree of control. Maintaining public confidence in supply chains and the ability of government to maintain order will be necessary, but even more crucial is to enlist public compliance. Examples of risky behaviour should be outlined just as clearly as safe behaviour, with messaging deployed along the lines of “we will not overcome this challenge without your help.”

4. In spite of the best efforts of government, many individuals will resist official guidance out of a lack of trust. Government should therefore consider enlisting civil society champions to reinforce its messaging. This should especially be available on social media, where much of the public gets its news, as well as via conventional TV and print media.

5. Information vacuums will inevitably be filled by fearmongering and misinformation. This is especially true when reliable news is often paywalled whereas fake news is free and readily accessible. People come to rely on daily case counts and the location of victims, for example, so they can assess risk. This information can and should be provided without personal information being compromised. China and South Korea have successfully developed apps that show where cases and clusters are located, and similar tools should be considered in Australia.

6. Health services may become overwhelmed at the peak of an epidemic, and the national ability to enforce order may be challenged. Coercive measures can be effective in minimising rule-breaking if they are judiciously applied and communicated, including as a sensitisation measure before an outbreak deepens. Mandatory isolation backed by penalties have helped Singapore and China to maintain compliance; Korea, by contrast, vacillated on penalties before deciding to threaten Lee Man-hee, the leader of Shincheonji, with murder charges for covering up the spread of the virus.

7. The public is unlikely to tolerate buck-passing. Commonwealth–state relations may present legal and practical challenges to implementation, but the public will not be persuaded that interruptions to essential services are unavoidable problems of federalism. They will look to the Commonwealth to lead, backed by the best information from the states and territories. This underscores the need for a unified national effort to communicate what the public should do, and how and where individuals can seek help. Access to welfare payments will be crucial for casual and “gig” economy workers who decide to self-isolate, as will rent support for small businesses and other assistance for those cut off from their regular sources of income by quarantines.

8. Media and government catastrophising is unproductive — even though the public need to be sensitised to the likelihood of significant disruptions to their lives, as well as the potential for Australians to die during the outbreak. Messaging should therefore be as neutral as possible when conveying information about deaths and new infection hotspots, and the mainstream media should be enlisted to assist. Conversely, downplaying or softening information may lead to riskier behaviour or public disappointment if the situation worsens. Factual information based on the best evidence — even when it is distressing — can and should be communicated in the context of how society will be able to move to a recovery mode as swiftly as possible.

9. Mistakes will unavoidably happen. When they do, government must take responsibility, and explain what is being done to mitigate the problem, and how this will ensure that it does not recur.

10. Measures to encourage people not to place additional strain on healthcare resources are vital. Telemedicine, medical hotlines and clear messages about whom to contact before travelling to a healthcare facility will relieve the burden from the “worried well” and reinforce public confidence.

Much more, of course, will be required to contain the spread of Covid-19. The disease will have deep and far-reaching effects on Australia, the region and the global economy. But a more visible public messaging campaign will do much to help Australia ensure that its most critical resource — its people — are a part of the solution. •