The Importance of Crisis Communications in Public Health

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: the value of a strong crisis communications effort; delivering critical public health information during the pandemic.

DR. UMAIR SHAH:
Well, I think crisis communication absolutely is key. It's actually, in many ways, just as important as those other tools. You know, those tools in your toolbox—whether it's vaccines, whether it's masks, whether it's, you know, making sure that people are doing the right thing from a prevention standpoint—they're only as good as people know about them.

DR. KHALILAH LEGRAND:
Remember that every person in your agency is a spokesperson, not just the communications person.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: how communications helps audiences connect with public health policies; messengers tested by social media, disinformation, fast changing policies, endless media cycles—all driven by a relentless virus and unprecedented political backlash.

Like so many in public health, our guests have endured the messaging crisis, each a communicator—one appointed to lead a department, the other helping to guide one.

Dr. Khalilah LeGrand is the director of communications for the Nebraska Department of Health and Human Services. Her team coaches public health experts on media relations, messaging, and strategy, making sure their work is understood and appreciated. She's along in a bit.

But first, we hear from Dr. Umair Shah, secretary of health for the state of Washington, about the value of crisis comms as a public health tool.

When you think about your tools for responding to the pandemic—things like vaccines, masks, contact tracing—how does a strong crisis communications approach rank among those tools?

SHAH:
Well, I think crisis communication absolutely is key. It's actually, in many ways, just as important as those other tools.

You know, those tools in your toolbox—whether it's vaccines, whether it's masks, whether it's, you know, making sure that people are doing the right thing from a prevention standpoint—they're only as good as people know about them, and people understand them, and people embrace them, and people then utilize them in order to protect themselves.

And so, you know, just having a tool in the toolbox—if you don't actually use the tool or have the ability to have others understand why the tools are important and utilize them themselves, then becomes not effective. And I think that's really the key. So, you can't have one without the other. You can't, obviously, communicate when you don't have the tools, and you certainly can't have a tool and not even for people to know what you're to get across.

I think that's the biggest challenge that's been throughout this pandemic, has really been people not understanding fully or getting misinformation, which has really divided on what really needs to be done in order to fight a global pandemic.

I think if we had all gone back 10 years, 20 years, we would have thought this would have played out differently. We would've thought that you start off with a pandemic. You start off with what's happening from an infectious disease standpoint, you then respond to it.

How do you respond to it? Well, you put those tools in place, those measures to help people, which at first was social distancing, and physical distancing, and masks, and the hand washing, and stay out of crowds, and, you know, stay at home at times, all those things.

And eventually, we were waiting, waiting, waiting to buy time to get the vaccines. And vaccines then came and you would've thought, “Well, everybody would have run to get vaccines”—which obviously the vast majority of people have—but unfortunately where we have fallen short is that the very tools have been politicized. And so, that’s where communications becomes so critical. It's trying to fight this information battle when 24/7 news cycles or, if you will, even misuse and mis-news cycles, right—they're misused and they're mis-news because you get inaccurate information is out there and then we're trying to really play catch up.

JOHNSON:
Dr. Nirav Shah over in Maine—he's ASTHO's president, I'm sure you know him very well—on this show, just a few episodes ago, he was talking about vaccine misinformation, and he was noting how he looked at his commercials that he was running four months ago. Now, he says that messaging is out of date—it wouldn't work today. What's the best way to make sure your pandemic messaging is always current?

SHAH:
Well, we can relate to that, absolutely.

I mean, you know, we're always trying to assess, and reassess, and focus groups, and try things out, and innovate, and be as clear as we can that what worked sometimes a week ago, a month ago, even especially a year ago, those are not the same messages even now. And so, you know, one of the things that we have to remember is that—and I said this last summer and it got picked up in a different way.

And in fact, one of the rappers actually pick this up and, and it was, you know, the comment that, you know, “We may be tired of this virus, but the virus is not tired of us.” There's a true rapper that picked that up, actually about a week after I said that. So, I thought, oh wow, I finally hit the popular media, right. But it really speaks to, in some instances, it really is misinformation. It's truly people getting the wrong information and not going to trusted sources. In some respects, you also have people who, at times, don't want to even hear the other side.

And I think that's a real dilemma that we have in political discourse in the U.S. right now, in America, which is that we have lost the ability to dialogue; and to really recognize that there is science, there are truths, and there are ways to communicate the science and the truth.

And I think the other thing that Nirav Shah—who I have an incredible amount of respect for—the other thing that he will agree to is that there is a science to medicine and an art to medicine. There's also a science to public health and an art to public health. And, while you have to always be based in science, you have to also be willing to understand the context of what's happening.

And so, he is absolutely right that if you go back several months and look at what we thought would work or how we would frame things or talk about things or engage the public, it's different even than it is today. And I guarantee you today will be different than it will be two months from now, four months from now, six months from now, because this pandemic continues to shift. It's, as I've been saying, it's a super squirrely virus that keeps changing on us and we have to respond in kind; and if we stay just true to the way we did things, you know, a month ago, six months ago, or a year ago, then, honestly, we fall behind. And that's been a real challenge throughout this pandemic.

JOHNSON:
Let's talk about the fall. It's right around the corner—in some places in the country, it's here already. The Delta variant's going to be the big story this next few months. How are you adjusting your messaging to stay ahead of that, to push back on it?

SHAH:
Well, I think there was a point in time, a really short period of time, where all of us thought that COVID vaccine was the entire sole solution to end the pandemic. You know, that window obviously has closed.

And now, we know it's really critical to re-engage not just for people to get vaccinated—and what we've been saying, "Don't hesitate, vaccinate"—but we're also asking people to do the very behaviors that they had to do prior. We're asking people, or even requiring people, to wear masks indoors, or get a COVID vaccine, or stay out of large groups, making sure that they get tested when they feel sick. This is really—it feels like Groundhog Day because we are back to the early days of the pandemic, and people are tired and they're frustrated.

So, when we look ahead to the fall, we look ahead to what is coming down the road, we know—for example, in Washington, almost every now geno-sequenced case of COVID-19 is due to the Delta variant. The Delta variant is going to be one big issue for us, but I will tell you, it is not going to be the only variant. We're going to have other variants, and we're going to have fall. And then, we're going to winter and it's going to start to get cold, and people are going to be indoors. People are going to be tired of wearing a mask, or being out of, you know, their social environment. Kids are going to be back in school. You know, there's a lot that's really up ahead, and that's why it's so important that we continue to rely on those communication tools because we cannot be effective with all the other tools, and preventive precautions, and guidance, and requirements at times, if we just can't get everybody to understand why we're doing these things.

None of us in public health want to be in the positions where we are right now, none of us. In fact, as you know, many have left the field. None of us wanted to be in a situation where we had to have some really difficult decisions and have to say to people, "Here's what's going on. Here's what we're asking you to do. We know it has socioeconomic impact on your lives, but we're asking you to do it regardless." None of us wanted to be in that position. And yet, that's what this pandemic has required in order for us to be able to fight it. So, the enemy is not each other. It's the virus. And the variants will continue and all the other transmission and all the other actions that are required to fight that transmission will continue. That's going to be up to us to really look ahead and be all on the same page. And unfortunately, that's been really hard to do in America thus far, and that's been the biggest challenge.

So, that's what I unfortunately see, is more of this not being collective towards what the solutions are and unfortunately being divided. And I think that's going to be a real challenge for us as we move forward into the fall and winter.

JOHNSON:
How much more time do you spend communicating now during this crisis than maybe you did before?

SHAH:
You know, one thing that I will tell you is that I've been an emergency department physician for 20+ years through the VA hospital, serving our nation's veterans, in Houston for a long time coming. And, alongside that, I have responded to a lot of emergencies over the 15, 20 years of public health experience that I've had—from Tropical Storm Allison to Hurricanes Katrina, Rita, Ike, Harvey, tropical storms that are too numerous to name, and H1N1, Ebola, Zika, chemical fires. When you go through the list, there've been just a lot of emergencies. The themes in those emergencies have been very similar to COVID—the difference is that COVID has been a sustained crisis.

This has not been a hurricane where you've got the eye of the storm hits, you have a few days of response, then you have a few days of immediate recovery, and then you're looking at the long-term recovery. COVID has been 18 months and counting, and that means that we are in this for the long haul. So, communication is really hard. If you go from like one mosquito season to another mosquito season, it's really hard, and that's what this is. It's actually one COVID season and now a second COVID season and then a third and then a fourth and then a fifth.

And so, those communication messages are so critical. And yet in emergencies, that's exactly what we've seen. I think the difference is that this has just been such a marathon rather than just a quick up and down, and then you go on with your life. None of us have been able to go on with our lives because, unfortunately, this pandemic rages on.

JOHNSON:
So, how do you manage that? How do you keep audiences engaged when you know they're tired of hearing about the pandemic?

SHAH:
I think you have to do it with both compassion and passion. You have to be both understanding of what people are going through. I think one example of this is that my family grounds me quite a bit.

My wife is a healthcare provider. I've seen her go through—she's a dentist, and having to go through to her practice and wearing, you know, essentially what looks like gas masks, but, you know, for hours and hours and hours, just to be able to serve her patients. And my kids who none of them at this point are eligible for vaccine, although my daughter's about to turn 12—and excited, by the way, to get vaccinated—but the other two boys, seven and four, are not eligible for vaccine. So, trying to see how they are processing things. And then, I have an elderly mother who's in a wheelchair, and she's 84 years old, and trying to protect her. And so, when I think of what people are going through out there in the world, I try to relate it to my own family. I try to relate it to our extended family, our friends.

And so, when our friends, for example, and family members are, right now, concerned and will be for some time, or for an extended period of time, about their kids going back to school in person, that hits close to home for me. So, then, when I'm at a podium talking, or I'm doing some sort of interview, I don't come at it just as a physician, or I don't come at it just as a public health professional—I don't come at it just as anything, but I come at it as part of the community. And I think when we relate to what's happening in the community, that's when we start to really recognize how effective we are and how important our work is every day.

JOHNSON:
Last question—is there any secret to a successful crisis communications campaign, especially when, in the case of the COVID-19 situation, it seems to just have no end in sight?

SHAH:
Well, you have to first have a great team. You have to have a great set of communicators—you know, people on your team that you trust, who have your back, but also have the blinders concept of they have their ears on the ground. They're also, you know, thinking about how to best strategize and how to best communicate. So, I think there's that piece.

And then, the second is really that you have to be persistent; that even when you're in social media getting beat up, or when you're, you know, having a situation where, you know, people are very upset about something, you can't take it personally. You have to understand people's frustration, you have to understand where they're coming from and, ultimately, have to persevere.

If you think that this is a field for the faint-hearted, this is not. I mean, the faint-hearted would drop like flies. I mean, this is really a field where you have to be strong.

Leadership sometimes is difficult, and you have to make difficult choices and decisions, and I think, ultimately, you can only do that when you have a strong team.

And then, you have the ability and the willingness to persevere through sometimes very ugly comments or feedback, but yet you move forward. And I'll share this with you. There was one point last summer, when on Twitter—I'm active on social media and on Twitter—I picked up, I don't know, it was like a couple of hundred followers overnight. And I thought, "Oh, this is great." And then, I realized the next morning that all of them hated me. And so, you know, I thought, "Here's the good, the ying and the yang," right? You have something positive, you pick up more followers or people that are paying attention. And then, you realize that they're negative towards you. And, ultimately, we have to realize that this has really shown the best of us as Americans, but it's also, at times shown the worst of us. And I try to focus on the best of us and being positive and optimistic, but we also have to be realistic about the challenges that we've faced, the challenges that we're facing, and the challenges that we will continue to face until, once and for all, we can end this pandemic.

JOHNSON:
Dr. Khalilah LeGrand left education PR to take the job as head of communications at the Nebraska Department of Health and Human Services only a few months before the outbreak. Like so many others in public health, she's had to adjust to the non-stop demands of the pandemic, managing the madness with a strong crisis communications approach.

LEGRAND:
I would say it's an absolute imperative.

I don't know that this would have been considered the case prior to the pandemic; but, as we've all seen, crisis communications has been absolutely imperative because we have—you know, remember when we started hearing about the pandemic and we started hearing, you know, about COVID, this thing called COVID. And we all thought, you know, it maybe a few weeks, maybe a month. And you know, now, almost two years later, you know, as we approach two years later, we've been really inundated and it has been an all-hands-on-deck nonstop, if you will, practice in crisis communications.

JOHNSON:
Speaking of others in your department—from your leadership on down—how has their view of crisis communications been impacted by the pandemic?

LEGRAND:
I think their view is they've gotten a lot more breadth and depth and understanding of the need for people to be prepared.

We definitely spent some time—our chief medical officer had not started too long before the pandemic as well, and he came from a surgical background and then came into public health arena and he was learning the job. My boss had been probably 6-8 months on the job. So, all of us were kind of pretty new to the state, and Dr. Anthone had been in the state before, but had moved back to the state.

But understanding, again, just the necessity to be prepared, to kind of think ahead, to strategize—it was a never-ending cycle. And so, you know, the great thing was that many of us had various experiences and expertise from our previous employment paths; but just definitely thinking about how to utilize resources. I had joined NPHIC—of course, the National Public Health Information Coalition—as I started this job, and I will say that was a wealth of resource for me. ASTHO—CEO Smith and Dr. Anthone, they both were very involved with ASTHO.

And so, it was great to be in the—even though all of us were going through this together, you know, and I say all of us, as in all the different states and localities, we at least had some really great resources to tap into and some pipelines for communication from, you know, CDC, FDA.

We were regularly meeting with leadership and other folks in our division. People didn't know what an epidemiologist was probably before that—you know, we saw them and you're like, "Oh, who's that team over there?" And, you know, before you knew it, everyone knew who an epidemiologist was.

So, definitely the need for understanding crisis communication and what that really means. And when you're in that crisis mode and how someone can kind of take messages that are high-level and put it into something that is palatable to the general public, that was a necessity. So, I would sit and often talk to these subject matter experts and then try to say, "okay, can you explain that to me like I'm a third grader so that I can then articulate that out to the public?"

JOHNSON:
Let's talk about some of the communications challenges that have occurred over the last year and a half. First on the internal side—have there been any?

LEGRAND:
Absolutely. I don't think any communications professional would say that there hadn't been any.

I just mentioned this, but I will say that the top one that came to mind—what I, you know, thought about that question is the speed at which info was changing. I mean, we were all glued to the things that CDC was putting out.

Anytime they had a call line, anytime they hit media calls, anytime they had subject matter expert calls, we were all trying to make sure we were staying on top of the information because it was just changing—do you wear a mask? Don't you wear a mask? Do you wear two masks?

And then, trying to make sure that integrated with whatever the state was putting out from its department, and working with the administration and ensuring that we're all on the same page and they're getting the proper information and articulated to them in the appropriate manner.

And so, certainly I think that was a challenge for us, making sure that we got information out in a timely fashion, making sure that it was communicated in a way that people could understand.

Keeping your credibility because when people see that information is changing, sometimes that brings to question, "Well, do these people know what they're talking about," and explaining that yes, but things change.

You know, one of my friends said something that I thought was so important. When she talked about—we were talking about the practice of medicine. It's a practice because it's changing. You don't know if this is going to work. And we really have seen, you know, as this pandemic has unfolded, we've been able to marvel at science in action. And many of us, you know, before, didn't get those opportunities to really see it unfold.

It's sometimes concerning that did beg the question whether experts knew what they were talking about; but people did, you know, people have to understand that this was changing very quickly and continues to change. And when you are in the throes of an experiment, if you will, you know, trying to see what's going to work, trying to see what's going to be best practice, things are going to change. And so, just making sure that you maintain the credibility and explain kind of the why, if you will, behind some of those decisions was really important.

JOHNSON:
Let's talk about outside challenges, external forces, that have been at play throughout the entire pandemic. What challenges from a crisis communication standpoint have you experienced there and how did you deal with them? How are you dealing with them?

LEGRAND:
I think one of the biggest challenges is certainly public perception, and I touched on that just a little bit, but public perception.

The amount of misinformation that was being thrust at the state trying to put out information, thrust via different vehicles and platforms—certainly social media has its benefits, but it also has provided us with a great deal of challenges because people can put something out and it's not always vetted—so, we had to definitely manage that.

I have a team that monitors our social media, tries to ensure that proper information is getting out there, making sure that we were fully equipped with the most up-to-date information. We put out FAQs, we created a website—a platform that had, you know, valuable embedded information—and tried to continue to encourage people to know who credible sources were in their community, using those credible sources.

CEO Smith and Dr. Anthone, our CEO and our chief medical officer, they went on a bit of a radio tour, if you will. Radio's still pretty popular in Nebraska, as far as talk radio or listening—you know, people listening to the radio as opposed to, you know, some of the satellite type radio that people listen to—we utilized that.

And so, we had a lot of opportunity to get on the radio, you know, have people hear from those folks that we were trying to build that credibility with in the community.

JOHNSON:
Any lesson from all of these challenges come to mind right now? Anything you can share that others listening could take away and maybe use to make their lives easier?

LEGRAND:
Sure.

I think strategizing with people to try to get ahead of what the concerns might be. I mentioned we had key staff on standby—so, from our epidemiology staff, any of our other public health folks that were on the ground as we rolled out vaccination.

Our vaccination team was constantly helping to inform us, we worked with them as we started to work on our Finish Strong campaign, which was our COVID statewide vaccine campaign.

And so, we worked with those folks and had them talk to our creative team so that they could get a perspective that maybe we weren't thinking of from the communications perspective, and just try to keep those lines of communication open. I know that sounds a little cliche, but it really is important. So, you know, think about how you can address your stakeholders. We would have talking points. So, I and my team would develop key talking points on a regular basis, and we would send them out to various stakeholders.

We also would hold calls, so I would have calls with other communications people, whether they were in public health communications, or just any type of communications. I would have a communications call on every Friday, and then it went to every other Friday, to make sure people had good information. If they had questions for me, I might have to write that question down and get back to them.

And then, each of our divisions—public health, behavioral health, Medicaid, long-term care—they all had stakeholder calls where they could talk to those stakeholders and push information out through those networks so that the proper information would get out to the right channels.

JOHNSON:
So, we've talked about challenges and some of the solutions that you've pursued to both internal and external conundrums. Let's talk about things that didn't go that well and how you've responded to those. Anything come to mind?

LEGRAND:
Sure.

So, certainly, you know, as we rolled out vaccination and we were trying to work with federal government folks, and there was a transition happening on the national administration front, there were certainly some challenges.

We would think we were getting a number of vaccinations and we would think we were getting them on a certain day and that might not happen. And then, we had to coordinate with those local health departments and of course people were clamoring to get scheduled for vaccination appointments.

And so, those were some areas of challenge. And making sure that we communicated that out to say, we might have to change something, you know, this isn't going the way that we thought.

We certainly continued to work on improving our own internal processes. Again, communications with stakeholder groups was important, so we wanted to make sure that, you know, we continue to evaluate that.

And so, you have to be in a state of constant evaluation and adjustment. Nobody's perfect, and you have to remember that and you have to give yourself a little bit of grace when you do something that isn't necessarily the most popular to folks and you have to, you know, change course.

So, I think navigating media has always been a challenge and was even moreso of one. The governor's office would do regular press conferences, and that was really helpful because we could then have—you know, some of the media were asking some of the same questions and instead of sending, you know, 20 emails to different media outlets, we could say the governor's going to address this at his press conference, or Dr. Anthone, or one of our public health experts would be at the pressers and helping to do that.

I think H1N1 was kind of maybe the closest thing that we've had to something like this. And so, we did have some historical information on what kinds of communications happen during H1N1, and that was very helpful. So even though it wasn't, you know, a full blueprint of everything, it did give us a very strong foundation on how to avoid some of the landmines and pitfalls.

And then, we've been working on keeping our files together so that, you know, should this happen—hopefully not in either of our lifetimes—but should we have to encounter this again, we can learn from the mistakes that happen; or the areas of growth or opportunity, you know, and influence how the decisions are made in a way that, you know, is what the speed and accuracy that we would, you know, like if we had those areas that, you know, didn't go so well.

JOHNSON:
You and I are communicators. Most of the people listening to this interview right now are not. They are in other jobs in public health—maybe they even lead a department in a state or territory.

So, if you could share any message with them about how to successfully engage with their communications teams, what would it be?

LEGRAND:
One, I would say, remember that every person in your agency is a spokesperson, not just the communications person. And people don't often remember that.

You know, if someone is going out and, you know, kind of talking a little negatively or, you know, when people work for a state department of health or what have you, localities, people know that you do that. And so, you could be, you know, the front desk person, but they're going to ask you for information. And so, make sure that you remember you are a reflection of that agency and everybody is a spokesperson.

I would also say, ask for key talking points from that communications group. That has been a saving grace. When I send those out, people send me emails and say, "Thank you so much, I didn't know what to say on a stakeholder call, and this is exactly what helped me to influence and inform the decision-making at another entity,” if they need it, you know, just those tidbits of information.

Or even just, you know—whether I am on the developmental disability side, but I need to know what's happening relative to, you know, the state dashboard or something like that, I could send that information out and they'd have it at their fingertips. So, I would say, ask for key talking points.

Make sure you're familiar with the communications processes and practices. Certainly, reporters are crafty, and sometimes they'll go straight to program staff and program staff feel obligated to answer, and we would make sure people were reminded that they needed to go through the communications office. And so often I would remind the reporter gently, "Hey, don't forget, you should come to us if you have questions." But because people were so familiar with that process and our internal organization, they knew to send it to a communications person.

And then, I would say definitely don't feel obligated to respond to the reporters. Make sure they go to that communications office.

And then lastly, keep in mind that media doesn't always help solve your problem. Often, they're looking, you know—in this day and age, unfortunately, it's sometimes sensationalism over journalism.

I always liken, you know, organizations to a family. So, when you have issues with your family, you might not—you know, I'm one of six children. Certainly, growing up I had challenges with my siblings. But going out and sharing those challenges versus having the conversation in house really didn't serve any purpose except to perpetuate the strain or the challenge.

And so, I would say, remember, you know, media's function, especially in this day and age. And so, remember that there's chains of, you know, appropriate action in any organization and, you know, talk to the right people first to try to resolve issues as opposed to sharing it with the media, because they're really not designed to try to solve your problems. Certainly, they can amplify it; but again, if you're a family, you kind of want to resolve those issues internally.

JOHNSON:
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This show is a production of the Association of State and Territorial Health Officials. For Public Health Review, I'm Robert Johnson. Be well.