Messaging — the unrecognized coefficient in pandemic control — matters

A little over a century ago, scientists working in laboratories discovered that microbes were the cause of many epidemics. Once they understood that, they began to put their faith more and more in laboratory science. This major transformation, called the bacteriological revolution, began in the 1880s.

During this period, diphtheria was one of the leading causes of death among mostly poor children in New York City. Physicians and government authorities believed that the disease was uncontrollable, and New Yorkers were told that they just needed to live with it. But as historian Evelynn Hammonds points out in her powerful book, “Childhood’s Deadly Scourge: The Campaign to Control Diphtheria in New York City, 1880-1930,” public health authorities were more optimistic — and more pragmatic.

They mounted a robust campaign in newspapers to raise money to make testing available to people who needed it and in so doing kept alive news of the diphtheria epidemic. Public health authorities insisted that they should be the ones responsible for disseminating antitoxins to those who were both infected and exposed to the bacteria, not physicians whose primary focus was on people who were sick. Public health officials combined distributing antitoxins with messaging about preventive measures, arguing against physicians’ prejudice that the poor were inherently vulnerable to the epidemic. They instead emphasized how crowded, unsanitary living environments led to the outbreak.

Public health officials circulated in immigrant communities and created posters in locals’ languages to explain the value of using disinfectants and isolating sick people. They hung posters that warned against the presence of diphtheria in apartments. One poster read, “This Card is Not Punishment It Is Protection to You and Your Neighbor.” They also invented some the first-ever testing kits.

Diphtheria eventually faded away, not because of advances in laboratory medicine, though that was essential, but because public health officials were relentless in efforts to continue to promote information about the epidemic.

Messaging is a core part of public health. From the handwashing reminders in restaurants and hospitals to the safe food handling labels of raw meat, constant reminders of important public health actions are everywhere. This isn’t unique to public health. Even the largest brands know that they need to stay visible or customers lose interest — think about how many advertisements you’ve seen today on television, newspapers, internet websites, billboards, buses and taxis, and even unsolicited mail to your home, office, email, or text messages.

That’s a lesson that must be heeded today.

President Biden’s assertion that Americans need to learn to live with Covid-19 seems to follow the logic that government authorities and some physicians articulated in the wake of diphtheria: that if society can’t fix a problem, there’s no point talking about it.

But that logic is as wrong now as it was then. Biden and others need to understand that messaging matters. If people don’t keep talking about a problem, then as a society we’ll never fix it.

In a letter to the editor The New York Times published on Dec. 3, 1927, George J. Nelbach, a New York public health official, attributed the eradication of diphtheria to not just scientific innovation but messaging. “The progress in this campaign of education is due to a great extent to the cooperation of the press. In addition, the campaign has developed a wide range of instructive and readable leaflets, posters, films, exhibits and other material best calculated to inform parents of the safety and harmlessness of the toxin-antitoxin treatments.”

Nearly a century later, scientists know much more about how to prevent and treat infections, and have developed helpful vaccines and promising therapeutics. Despite these advances, the acquiescence of Biden and other medical authorities to Covid as the new status quo is damaging. Science and history tell us that messaging implying that Covid is over, further amplified by recent policy changes such as ending free rapid tests, will inevitably lead to fewer people getting tested, getting vaccinated, staying home when sick, or taking other precautions. And Covid will continue to spread.

Creating tests, vaccines, and antivirals is vital to controlling the pandemic, and their development has been a victory for science. But they are by no means the only public health tools the country should depend on. Non-pharmaceutical interventions like masks, sick leave, and better indoor air ventilation also matter, but there is, as well, a real urgency in making sure that Covid-19 stays in the headlines. Fatigue and frustration with the pandemic are not reasons to stop talking about it.

Instead, U.S. public health leaders need to get better at messaging. They should consider taking a page from meteorologists: clear, transparent, actionable, regular, and frequent updates on hurricanes and heat waves ensure that these disasters are mitigated. We get similar messaging on the economy, and this predictability allows people plan for the future.

If Biden were to announce that the economy faces no risk for a recession, would Americans empty their saving accounts and take vacations? Not likely: most would manage their finances with caution even if they were relieved the worst part was over, because they know that the end of a recession doesn’t mean there won’t be another one. Just like knowing that hurricane season has ended doesn’t mean it’s time to throw away emergency supplies.

Covid is starting to be predictable, and the winter Covid season is coming. The message should be to prepare for it, not live with it.

Lessons from the past show that it matters how people — especially leaders — talk about epidemics. If they just throw up their hands and proclaim that the county is now in a so-called new normal, the pandemic will not end. The most effective way to combat Covid-19 is to continue to keep talking about it.

As public health authorities did with diphtheria, government leaders ought to continue to promote the dangers about the continual spread of Covid and how to prevent it.

Jim Downs is a historian, a fellow at the Hutchins Center for African and African American Studies at Harvard, and author of “Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine” (Harvard University Press, 2021). Eleanor J. Murray is an epidemiologist and an assistant professor at Boston University School of Public Health.