First, the Centers for Disease Control and Prevention (CDC) said that only health care workers and people who were sick needed to wear masks. Now, the White House is reportedly backtracking on that advice, and it may recommend that everyone wear face coverings when they’re out in public. Confusion over the whiplashing policies is likely to linger. Clear and consistent communication is one of the most important parts of pandemic response, and the federal government has already gotten that wrong.
Calls for the change escalated over the past few weeks: experts started to highlight research showing that masks may offer some degree of protection, and many began pushing for universal mask-wearing as case numbers continued to climb.
Changing policies during a crisis event like this one shouldn’t be a big surprise. The coronavirus is new, and when it first appeared in December, scientists didn’t know how it would behave. Researchers are collecting new information on the virus as fast as possible; public health agencies are working to incorporate that new information into the guidelines they give the public.
The problem is that messaging from public officials hasn’t done a good job of preparing people for those changes. Instead, the pandemic response in the US has been characterized by inconsistent messaging — notably, around masks and testing — without clear signals why policies might be changing. “That creates cumulative effect, which is to reduce credibility, lower trust, and foster confusion,” says Glen Nowak, director of the Center for Health and Risk Communication at the University of Georgia and former director of media relations at the CDC.
The White House is well aware that the shift in mask messaging (first reported by Stat News) directly contradicts previous advice. Worries over how that change would be received led to a delay in the announcement, The Daily Beast reported.
The White House’s coronavirus task force set itself up for a big messaging fail because it hadn’t laid the groundwork that would support changes in approach. “You have to prepare people for contradictions. Contradictions are what pandemics are all about,” says Rob Blair, an assistant professor of political science and international and public affairs at Brown University.
The CDC tried to do that: during press briefings in January and February, the agency noted that its guidance might change as the pandemic progressed. But recently, the CDC has been silent — the agency last held a press briefing on March 9th — and it’s been regularly undercut by comments from the White House.
“What we have is inconsistent messaging, sometimes from the same source,” says Blair, who has studied how public trust in government officials influenced the response to the Ebola outbreaks in West Africa. “What we have is utter cacophony. That’s detrimental not only for the quality of the response, but for trust more generally.”
The mask debate
When the novel coronavirus first started accelerating around the world, scientists were fairly sure that people were only contagious when they had symptoms and that the virus could only be spread through close contact with the droplets of saliva sick people produce through a cough or sneeze. It’s clear now, that people without symptoms can infect others and that the virus may spread through tinier droplets that people produce when they talk or breathe.
That’s one of the arguments in favor of masks for everyone: if people who aren’t visibly sick can still spread the virus, asking everybody to wear a mask may block their virus-laden exhalations from entering a space. In addition, if the tiny droplets full of virus linger in the air, wearing a mask might stop people from breathing them in.
The basis for our recommendation is simple: anything that combats the spread of the virus is absurdly valuable due to the resulting reduction in mortality risk (not to mention accelerating resumption of normal economic activity).— Jason Abaluck (@Jabaluck) April 2, 2020
There’s no debate that masks help protect health care workers who are far more likely to be in the direct path of an infected person’s breath or cough, so it’s especially important they have high-quality masks. What isn’t as clear is how well a mask would prevent the general spread of disease. People out in their daily lives are far less likely to be in the line of fire. Masks probably stop them from spraying virus-laden particles into a room, but there isn’t great evidence that people who wear masks are less likely to get sick with a respiratory illness like the flu.
Part of the reason for the gap is that there hasn’t been much research on masks and disease prevention. A few smaller studies indicate that they might be better than nothing at all. Experts told Wired that having something in front of people’s faces would probably be helpful. “If you put something in front of your face, it’s going to help more than not,” said virologist Julian Tang.
The US, though, is facing a severe shortage of medical-grade masks, and there are barely enough for the health care workers who actually need them. The makeshift face coverings and cloth masks the general public will likely be asked to use as alternatives don’t block as many spit particles as medical masks, and have even less evidence supporting their use to prevent disease. Those limitations make the task of explaining the shifted recommendations to the public even more challenging for officials.
In many ways, the White House dug the communications pit that it now finds itself in. The federal government was responsible for ensuring that the country had enough high-quality masks to respond to a crisis. It didn’t. Now, officials have to stress that medical masks should only be used by health care workers — not because they don’t work for everyone, but because there aren’t enough for everyone. To top it all off, they then have to tell the general public to use materials that aren’t as effective, while highlighting that they’re better than nothing.
It’s not like they have any other choice at the moment. When resources are limited, public health officials have to refine recommendations so that resources go to the people who need them most. They also have to figure out how to tell people that those limitations mean they can’t follow the most evidence-based advice.
“In the long term, to the extent people believe that the government is providing them with trustworthy information, honesty is probably going to end up being the best policy,” Blair says. “If that means telling people that we just don’t have the resources, that’s fine.”
Officials faced the same problems around testing. For weeks, President Trump and others on the White House coronavirus task force said that tests were available for everyone who needed them but that people only needed to be tested if they had symptoms of COVID-19. At the same time, there were regular reports from people with symptoms who weren’t able to get a test. Evidence that people could be contagious even when they didn’t have symptoms also contradicted the task force messaging — as did stories of high-profile figures like NBA players and senators obtaining tests before they had symptoms.
Like with masks, mixed signals and obfuscation around testing reflected limited and lagging resources. “You had the competing messages to the White House saying no, that’s not true, we only have a limited number of tests, and that has to be used to test people who have significant symptoms,” Nowak says.
The sheer mess was an obvious sign of under-preparedness, Blair says.
“When you’re preparing for something like a public health disaster, you prepare for contingencies,” Blair says. Just because, at one point, experts did not think people would need to wear masks doesn’t mean that public health agencies shouldn’t have prepared for the possibility that the advice might change. “Surely anyone at CDC would have been saying, the science is unclear, and we should be putting as many irons in the fire as we can with reason,” he says.
Nowak thinks it’s still possible to salvage messaging around masks in the US. “If we go down the path of recommending masks, one problem is obviously that you appeared to completely switch course,” he says. One way to reframe the change would be to highlight that experts want to study how well masks or cloth masks actually help blunt the spread of the virus.
“It’s better if you frame it as, ‘we want to try something,’” he says. Doing that research also sets the CDC up for better success in the future because the agency will have more evidence to support guidelines around masks. “Otherwise, we end up with nothing more than anecdotes again.”
Blair, though, thinks that the federal government’s failures around testing, masks, and other aspects of the coronavirus response will significantly erode public trust in the US public health system. “Part of the question is the extent to which people will be able to separate the reaction to this pandemic from the public health infrastructure as a whole,” he says. He suspects they won’t separate it. “The CDC will take a lasting hit from coronavirus.”