Cutting through the noise of COVID risk: Real-life consequences of oversimplification
Confusion about COVID-19 abounds. Determining how the U.S. population is doing in combating COVID is a challenge, as we are flooded with a bewildering array of measures that provide seemingly contradictory indications. If the omicron variant is “milder” than delta, why are many hospitals “overwhelmed”? Are schools opening in person “safe,” and what does “safe” mean for schools anyway? Is the U.S. truly ready now for a “new normal” living with COVID-19?
We believe that the language used in COVID communications is one key contributor to this confusion. Separate from the issue of willful COVID disinformation, oversimplification of messaging often conflates individual level risk (“What COVID risk do I run if I…?”) with population level risk (“How do my individual choices affect the COVID risks of my family and the people around me?”) Here we offer suggestions for public health agencies, news organizations, and health pundits — as well as all of us consuming information from such sources — to cut through the noise.
When discussing strategies to reduce the risk of acquiring or transmitting SARS-CoV-2, the word “safe” (or “unsafe”) is troublesome. Persons receiving the message may have very different definitions of this term, as can be seen in the raging debate over whether schools should open. Virtually everyone wants children to learn in-person — but in “safe” environments. However, there are widely differing points of view of what safety actually means to students, teachers and their surrounding communities.
Risk is best described as a continuum, not an absolute state. As such, it’s far more useful to provide a clearly worded description of the type and extent of risks associated with a given set of circumstances surrounding a school operations policy.
Vague words like “mild” are especially problematic since they offer little actionable information. More useful would be the knowledge of what fraction of non-hospitalized persons living with COVID have substantial symptoms that negatively impact their activities of daily life. Sadly, there is no organized system of data collection to track this metric at present (though the Census Bureau’s Household Pulse Survey measures other aspects of COVID-related social disruption). However, as a proxy, one might use internet search engine data to monitor trends in searches for symptom-related terms. The terms “sore throat,” “cough,” and “fever” in Google Trends show a clear up-tick in searches in mid-December. Similar search trend tools have been used to detect patterns in seasonal influenza.
Further, overreliance on terms like “mild” can lead to underplaying the remaining COVID-related risk. Catch phrases, like “new normal,” can get spun into a variety of meanings, even if the originators didn’t intend them to be understood in this way. Witness a recent set of viewpoint articles in the Journal of the American Medical Association (JAMA) that called for the need to have a national COVID strategy focused on a “new normal” in which the U.S. plans for the eventual endemic phase of the COVID pandemic. Many headlines followed and implied that the country should now learn to live with COVID. But when the authors took to the airwaves, they were quick to point out that wasn’t their meaning, given that we are still in a critical pandemic phase with COVID; rather, they meant that we should start to plan now for an endemic phase in the future (that will hopefully be here sooner rather than later). Catch phrases may get attention, but they can also lead to serious misunderstandings.
Blurring science with subjective assumptions will only result in confusing messages.
When a public health agency makes a science-based recommendation but recognizes that it may be a “heavy lift” for some to follow, it should:
(a) clearly articulate the science behind the recommendation;
(b) acknowledge that some may be challenged in following the recommendation; and
(c) provide a “harm reduction” message for those who are unable to follow the precise recommendation but still want to minimize their risk. The harm reduction message should also include information about the relative effectiveness of the stated harm reduction strategy.
Using vague terms like “winning” and “peaked” are concerning when deaths are still increasing and hospitalizations remain high; even if reported cases are starting to fall, one cannot ignore long lines for COVID testing, recognizing that the results of positive tests at home are not reported to a central surveillance system — leading to an underestimation of infections. More illuminating is information about the exact capacity (both used and in reserve) for hospitals and other health care providers. Also useful would be more information to help consumers maneuver crowded health care systems such as emergency rooms and COVID testing systems.
An undeniable challenge of COVID messaging is that the meaning and consequences of risk at the individual level are not the same as the meaning and consequences of risk at the population level. COVID is a public health challenge, not strictly a medical one. Public health messaging must convey both individual- and population-level information so that people understand the consequences of actions both individually and at a community level.
In 2020 COVID was the third leading cause of death — and likely secured that designation again for 2021. At the current level of over 2,400 deaths per day, COVID is already on track to be the third leading cause of death in 2022. But we won’t control this epidemic without the support of the community at large; to gain this support, we must engender trust, which calls for clear, accurate, timely – and, yes, sometimes complicated communication. The virus evolves rapidly enough that describing its risks and the strategies necessary to prevent its further spread will be complex and evolving in any case.
David Holtgrave, Ph.D., is the dean of the University at Albany School of Public Health and SUNY Distinguished Professor. His three-decade career in public health has included senior positions at CDC, Emory University and Johns Hopkins University, and he served on the Presidential Advisory Council on HIV/AIDS during President Obama’s administration. (The opinions noted here are not to be interpreted as a position of Holtgrave’s current or former employers.)
Ronald O. Valdiserri MD, MPH is a professor in the Department of Epidemiology, Rollins School of Public Health, Emory University. Prior to joining the faculty at Emory, he served as senior research associate and distinguished scholar at the Johns Hopkins Bloomberg School of Public Health. Before his academic appointments, Dr. Valdiserri worked for nearly three decades in federal service, holding senior leadership positions at the Centers for Disease Control and Prevention, the Department of Veterans Affairs, and the Office of the Assistant Secretary for Health, Department of Health and Human Services.
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