Tonight’s Top Story: Ebola and the News Media

When the first few cases of Ebola came to the US in 2014, it seemed as though it was impossible to watch or read the news and not hear about the disease.  At first, news coverage of Ebola rose in response to the return of media personnel diagnosed overseas.  Then news coverage increased greatly after the diagnosis of the first case on American soil in late September, 2014.

Most of us can agree that the intense public and media reaction to the limited number of cases in the US was unwarranted when considering the actual risks involved in the situation.   In fact, many actions were put forth, out of an abundance of caution, which were unnecessary and counter-productive, such as border closures and excessive quarantines. But what was the source of this reaction? Was the news media responsible for stoking people’s fears? What messages were people receiving about the risks of and policy responses to the occurrence of Ebola in the United States? 

To investigate this, colleagues and I set out on a news media content analysis, reading over 1,200 news articles from 12 news sources spanning the time frame from the beginning of July through the end of November 2014. Each time we read an article, we searched for a set of messages relating to risk and policy using a coding instrument that had been piloted on a separate set of articles. We used Paul Slovic’s risk perception framework to determine if some messages would likely have increased perception of risk or decreased perception of risk. Our methods and findings can be found here and here.

We found that nearly every article in our sample (96%) had at least one risk-elevating message while approximately half (55%) had at least one risk-minimizing message. However, although skewed towards risk elevating messages, news coverage from the main stream news sources we analyzed did not seem to report on Ebola in a hyperbolic or overly irresponsible manner – for instance, we found relatively few mentions of use of Ebola as a bioterror weapon or the suggestion that, once introduced, the disease could not be stopped in the US.  In fact, messages about the ability to interrupt transmission in the US were more frequent, when directly compared to messages about an inability to interrupt transmission. It may have been that the news media played a smaller role in hyping the Ebola outbreak than expected, and the nature of the disease itself played a stronger role than was originally recognized in increasing public concerns.

Perhaps most importantly from a risk communication perspective, it was clear that public health policy messages were frequently eclipsed by more controversial messages.  The most frequent policy messages we found were focused on isolation (47%) and quarantine (40%), which were often confused with each other (isolation is the separation of someone who is ill from those who are not sick while quarantine is the separation of someone who may have been exposed to a disease from those who have not been exposed). In contrast, one of the more central public health response policies – assigning different levels of risk and associated movement restrictions for potentially exposed individuals – was rarely found (5%). This difference could be due to the newsworthiness of controversial issues – quarantine was controversial while a measured public health approach was not.  As a result, Americans may have gained a skewed or incomplete understanding of the response activities that public health agencies were putting into place in the midst of the crisis.

At the end of the day, the news media played an important role in delivering messages about Ebola to the public and will no doubt perform a similar role in future outbreaks.  Although our study methodology prevents us from drawing conclusions about the public’s understanding of the risks posed by Ebola and associated response activities, it allows us to gain a more granular understand about the messages the public may have been exposed to via the news media. Although the news media frequently mentioned risk-increasing messages, some of the most inflammatory messages were not found as frequently as expected (though they may have been present in more “fringe” news sources that were not included in our analysis). However, we did find that communication of important scientific principles and policies can struggle to gain traction in the face of controversial issues. In the future, public health communicators should keep these factors in mind when communicating via the news media and emphasize the scientific underpinning of our understanding of the disease and appropriate responses. 

The Devil You Know vs. The Devil You Fear

During Ebola, a consistent concern was that healthcare workers could bring the pathogen home because of suboptimal infection control. This concern formed part of the rationale for sequestering patients with Ebola-like symptoms at designated facilities adept at infection control—a protocol I strongly endorse.

However, the idea that only headline-grabbing contagions can be transmitted by healthcare workers gives rise to a serious threat misperception. Consider these statistics:

It is not a stretch to assume that a proportion of healthcare workers are also colonized with carbapenem-resistant enterobacteraciae and multi-drug resistant Acinetobacter (which contaminated 9% of gloved healthcare workers hands in one study). And you know how well we all wash our hands.

These individuals serve as vectors for household and community transmission of these epidemiologically significant organisms that kill thousands annually. Yet when it becomes public knowledge that someone has cared for an Ebola patient, panic ensues, which results in political pressure to implement non-evidenced based interventions, like excluding the children of healthcare workers from school.

This kind of threat misperception hampers every outbreak response as public health authorities act increasingly to placate a panicked public and their elected officials, yet fail to place risk in its proper context.

In reality, the bigger threat to the human race is not Ebola or some exotic virus lurking on the hands of the nurse or doctor dropping off their child at daycare or school (which hopefully has high vaccination rates), but rather the usual suspects. that have proven, time and again, to be much more prolific threats to the human race.  While my aim is not to incite panic over what might be on healthcare workers’ hands, I do believe a little dose of reason goes a long way towards gaining a proper perspective of contagion risk. 

Assessing Global Risk: Comparing Apples and Orangutans

From: http://www.weforum.org/

From: http://www.weforum.org/

Last week, the World Economic Forum (WEF) released its 10th Annual Global Risk Report for 2015 ahead of the annual meeting in Davos, Switzerland. This very ambitious report seeks to identify the biggest risks to the world, their causes, and potential solutions. The report is a flagship effort of the WEF and is used as a tool to help decision makers prioritize resources and implement efforts to prevent or mitigate economic impact of global events. Stakeholders of the report have also identified its importance in building scenarios and exercises, informing vulnerability assessments, and in galvanizing more detailed risk modeling efforts.

The major value of this report is its role as an awareness raising tool. The report highlights the interconnectedness of major global events that–while they may occur in one part of the world or in one sector–inevitably affect economies and governments throughout both the developing and developed world.

Methodology

The data collection and resulting report are organized into 5 categories: economic, environmental, societal, and geopolitical risk. Within these 5 categories, each year the WEF chooses 28 risks for experts to rank in terms of likelihood and impact (consequence). The Global Risk Report defines global risk as: “an uncertain event or condition that, if it occurs, can cause significant negative impact of several countries or industries within the next 10 years.”

The 5 categories and most of the 28 risks identified remain the same each year, although risks may be substituted in and out by the authors. Examples of risks in the report include interstate conflict, extreme weather events, water crises, cyber-attacks, energy price shock, etc. These identified risks are each accompanied by a brief description. Additionally, this year’s report for the first time identifies 13 trends that may be driving global risks. A trend is defined by WEF as “a long term pattern that is currently taking place and that could amplify global risks and/or alter the relationship between them.” Examples of trends are: ageing population, climate change, urbanization, etc.

To collect data for the report, the WEF Staff constructs and distributes a Global Risks Perception Survey. The survey is sent to an undefined denominator of WEF “global multistakeholder community members” including  leaders from business, government, academia, NGO’s, and international organizations. It’s worth noting that economic subject matter expertise appears to be predominant in their sample.  For this year’s report, 896 members of the WEF community completed the survey.

The survey asks community participants to do the following:

  • For each of the 28 risks, rank the likelihood of occurrence in the next 10 years from 1-7 (1 being low and 7 being high).
  • For each of the 28 risks, rank the impact from 1-7 (1 being low and 7 being high).
  • Identify 3-6 pairs of risks that are “strongly interconnected”
  • Identify 3-6 pairs of risks and trends that are “strongly interconnected”
  • Select the top 5 global risks that are of highest concern in the next 18 months and 10 years respectively
  • Identify the top 3 risks for which they feel the most progress has been made over the last 10 years
  • Identify the top 3 risks for which they feel the least progress has been made over the last 10 years

Findings and Comments

The findings of the report include composite rankings of each risk by impact and by likelihood, as well as graphics illustrating the interconnectedness of risks and of trends and risks.

Notably, a number of risks relating to health security are highlighted in this report, including natural and environmental catastrophes, large-scale terrorism and WMD use, and rapid and massive spread of infectious diseases. In this year’s report, 2 of the top 5 risks in terms of impact are related to health security: spread of infectious diseases and WMD risks. Inclusion of health security risks is important, as it shines a spotlight on these issues in the WEF community–an influential forum for addressing global economic challenges.

However, it is important to take results of this report in context and not place too much reliance on the report as a definitive list or ranking of global risk. The report is a snapshot of expert opinion of risk in a given year. The report is not a sophisticated measure of the relative importance of different risks.

It is also critical to note that the report is qualitative, not quantitative. While experts were asked to assign numerical values to their judgments about likelihood and impact, they did so based on their own experience and opinion. The results reported here are not based on historical data.

In addition to the points mentioned above, WEF methods give me some pause and make interpretation of the report difficult. Some issues with the methodology include:

  • Sampling bias: the WEF uses a convenience sample which includes inherent bias. Responses this year were heavily weighted toward men (74%), toward economics expertise (41%), toward businesses (41%), and toward European views (34%). Other perspectives are comparatively underrepresented in their sample.
  • Risks are predetermined: The WEF pre-selects the 28 risks for the survey based on limited expert opinion from their steering group. The survey does not allow for recommendations of new risks by survey participants. This may result in important risks being excluded from the report.
  • Recency bias: although the report is intended to examine risks over a 10 year time horizon, recent events tend to rise to the top of people’s minds, which may result in a higher ranking in the survey. For example, likely due to the Ebola outbreak this year, “rapid and massive spread of infectious disease” was ranked as the number 2 risk in terms of impact. Whereas this risk had never ranked in the top 5 in any other year since the survey began.
  • Relative risk is not adequately addressed: The survey asks participants to rank 1 risk at a time based on their opinion of likelihood and impact. The survey does not ask participants to compare the likelihood and impact between risks. Yet, the report places a good deal of emphasis on the ranking of risks, which is misleading.

Despite my concerns about the report, I laud the authors for their work; this is a very difficult undertaking and one that no other organization has dared to take on each year.

Risk assessment in its traditional form–focused on one hazard at a time–is hard enough. One never has the perfect data or knowledge to reduce uncertainty about a single risk to zero. The US EPA spends years and many millions of dollars on human health risk assessment for a single chemical or pesticide in order to be able to set regulations or rules about acceptable exposure levels, for example.

A higher level of difficulty in risk assessment is a comparative assessment among hazards in the same class of risk (e.g., comparing human health risk among a number of different chemicals)–this requires standardization of data categories and inputs and data quality that are very hard to achieve.

I would argue that the highest level of difficulty in risk analysis is a comparison of risk between very different types of hazards (apples and orangutans) with different data, different measures of probability, and different types of expected consequence. This is what the Global Risk Report attempts to do. There are problems with this type of risk analysis, but there is a policy need for it as well. I look forward to the next WEF Global Risk Report. Hopefully the authors will continue to strive for improved methodology in years to come.

Cleaning Up is Hard to Do

When Dr. Craig Spencer became ill with Ebola in New York City following his return from West Africa, the City government was faced with difficult decisions about whether to decontaminate the now famous bowling alley, where the doctor bowled a few games before he felt feverish. Available scientific evidence suggests that remediation was probably unnecessary -- once Dr. Spencer became symptomatic, he isolated himself and reported to the New York City health authorities. Yet, the decision was made to retrace Dr. Spencer’s steps in the days before he became ill and to inspect and decontaminate the places he visited, including the bowling alley.

He’s not a bioremediation expert, but he plays one on TV

Enter Sal Pane and his company Bio-Recovery Corp–contracted by the City to carry out decontamination of the bowling alley and Dr. Spencer’s residence. Upon receipt of the contract to decontaminate, Mr. Pane proceeded to grant interviews to major media outlets, touting his decades of experience and presenting himself as a kind of Harrison Ford of bioremediation. Unfortunately, as reported in a recent BuzzFeedNews article, Sal Pane’s confident claims about his qualifications and certifications as a bioremediation consultant are now being called into question. On paper, Bio-Recovery Corp had the appropriate experience in biological assessment and cleanup, as it had contributed to the post-anthrax 2001 clean-up operation (under another company name and owner) before coming under the direction of Mr. Pane. In reality, BuzzFeedNews reported that while the company “claimed to have certifications from EPA and the New York Department of Environmental Conservation,” BuzzFeedNews “could not find any evidence of this.” In addition, BuzzFeedNews found that Bio-Recovery Corp’s “state permit to haul medical waste expired in 2012, before Pane was associated with the company.” So, now it is unclear whether the work this company did was effective (regardless of whether it was necessary in the first place).

This is not to suggest that the midst of the crisis was the time for the City to be tracking down and verifying the bonefides of remediation companies. I am sure that the City relied on the information it had at hand, which indicated that Bio-Recovery Corp was legitimate–a reasonable approach in an emergency. I do find it disheartening, however, that we are still caught off guard when biological decontamination issues arise.

It’s not as though we didn’t know this could be a problem. In 2001, anthrax spores from the Amerithrax letters contaminated media office buildings in New York City. At that time there were no guidelines available for the cleanup process and no registry of reputable companies qualified for remediation work. And, in 2010, I worked with the US Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism to revisit this issue and research federal progress in preparedness to decontaminate after a bioterrorism attack on a US city. Again, and we found major gaps in preparedness, including gaps in determining safe levels of contamination and in vetting and engaging remediation companies.

For me, this incident illustrates that there are two major outstanding questions which we need to address:

First, what is our process for assessing the risks from biological contamination and making decontamination decisions?

The decision to decontaminate public spaces in NYC was incongruous with the public health messaging that Ebola transmission does not occur unless a person is symptomatic. Based on public health and medical evidence and on CDC guidance, decontamination of public spaces was not necessary in the case of Dr. Spencer, and yet it was still carried out.

Now, the science we have on Ebola is not perfect–there is still some uncertainty about Ebola transmission, and there was also some uncertainty about when Dr. Spencer started feeling ill. This uncertainty, along with a desire to reassure the public, may have influenced the decision to decontaminate, and rightly so. Science cannot be the only factor considered in response to complex situations.

However, the decision to decontaminate, and the public way it was carried out under Mr. Pane, resulted in mixed messages that were intended to reassure the public, but instead confused the issue. What we really needed in this situation was open communication on what we know about the risks to public health, the uncertainties about the science that informs risk, the options we have to manage the risks, and the social, political, and economic consequences of the risk-based decisions we make.

Second, what systems should we have in place decontaminate when it is necessary?

There are many companies that do biological remediation, most of which are legitimate, and some of which have the requisite knowledge, certifications, and skills to perform remediation in a bioterrorism event or other bio-contamination emergency. There are major differences between the routine remediation of medical settings, and the skill-set that will be needed following a large-scale incident. It is likely that snake oil salesmen will try to take advantage of an emergency situation, so how does the responsible local official tell the difference? The key will be to think through these issues and vet companies prior to an emergency. A registry of companies maintained by the state or federal government would be a good start.

Fortunately, despite this example, progress has been made in other areas on this issue since 2010. DHS, in partnership with the DoD, sponsored two major projects on response and recovery for biological terrorism: the Integrated Biological Restoration Demonstration (IBRD) project in Seattle, and the Wide Area Recovery and Resilience Project (WARRP) in Denver. These projects brought the federal government together with state and local officials to develop and pilot remediation plans in those cities. The work resulted in a number of planning documents that may be useful to other cities, research on remediation, and a research agenda for the future. Also helpful was  the 2013 White House Biological Response and Recovery Science and Technology Roadmap, which calls attention to the issues of biological remediation, and lays out a research agenda which DHS has begun to address.

It’s clear that our ability to remediate following a biological contamination emergency remains incomplete. I am hopeful that we are moving the right direction, but let’s not forget that cleaning up is hard to do.