Investing in a cohesive, localised public health communication strategy will be essential in the coming months.
The Pakistani government’s decision to all but lift a lockdown on May 9 coincided with the country entering a period of acceleration in Covid-19 infections. Since then, all caution has been thrown to the wind — malls bustle with shoppers, roads are jammed with traffic, mosques remain filled with worshippers with little to no adherence to physical distancing, and large social gatherings are commonplace.
Pakistan’s cases have increased five-fold since April 25, with 48% of total deaths happening in the last 15 days, on a 90-day scale since Case 0. Its per-capita indicators are the worst among all South Asian countries — cases per million for instance are 2.5 times higher than neighbouring India’s. For two consecutive weeks, it has been among the top 10-12 countries for daily new cases, despite a testing rate that is in decline, with an average daily negative growth of 1.41% in the same period. Multiple large hospitals are at capacity, and countless health workers are infected.
It is in this backdrop that Prime Minister Imran Khan told Pakistanis that they must live with the virus, the Supreme Court ruled that Covid-19 is 'not a pandemic' and ordered the reopening of shopping malls, and ulema urged the faithful to fill up mosques for Eid prayers.
Covid-19 is the first pandemic of the information age. Never before have as many people relied on the words of leaders and experts to make critical health decisions. This outbreak is not only a public health crisis, but also a public communication crisis. At the same time, it's clear that transmission is dictated by human behaviour and not policy measures, with the trajectory of the disease mirroring the public's perception of the risk involved.
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On this front, the deny-and-censor strategy of the government has caused irreparable damage — both to its credibility and to the country’s Covid-19 outcomes. For over two months now, even as health experts cautioned the public, politicians have played down the risks posed by the virus. Their false bravado and reassurances have sent a lethal message to citizens, with commentary ranging from trivialising the threat with false and insincere messaging, such as 'the disease is slowing down', 'more people die from traffic accidents', 'we are doing better than other countries', to propagating misinformation straight up, such as 'summer temperatures will curb the spread' to abdication on the pretext that 'countries with lockdowns have also failed at containment, so let us learn to live with it'.
The prime minister has made no secret of his opposition to any flavour of lockdowns, strict or loose, from the start. Every decision made by his government — asking provinces to resume public transport, lamenting the strictness in enforcement of safety protocols for small businesses — has sent a signal to Pakistanis about the severity of Covid-19’s spread. Statements from his top deputies framing the country’s outbreak as mild, and its mortality as unusually low, have provided validation for undeterred socialising. Divisions between federal and provincial governments along familiar party lines have caused widespread confusion about the need for mitigation.
The complacency and denial that unites a vast majority of the public — from every class and education level — is neither a coincidence nor an inevitability of the country’s low literacy. The government’s "pro-poor" easing of the lockdown has been accompanied by muddled communication that has misled the very public that it claims to be protecting. Pakistanis no longer consider the virus a grave threat; many do not believe it exists at all.
Pakistan’s literacy rate has frequently been brought up to explain non-compliance. But low literacy is more reason — not less — for our leaders to engage and prioritise effective public health communication. Gaining citizens’ cooperation to reduce transmission requires ensuring that they understand the risks they are taking. Creating reliable channels for scientifically accurate information that is readily accessible, frequently repeated, and is shared in an easily understandable form for the average person is crucial for less educated populations. The absence of this has left millions of Pakistanis vulnerable to misinformation and conspiracy theories.
In stark contrast to Pakistan, world leaders at the helm of successful Covid-19 responses have used every tool in their arsenal and every opportunity at their disposal to persuade the public to adopt new behaviours and adhere to new rules. Engaged and visible throughout the crisis, they have explained the 'why' behind their decisions, linking them convincingly to favourable outcomes.
A few examples of effective public messaging for Covid-19 from around the world stand out in particular. With 326 cases and 0 deaths, Vietnam has among the most successful Covid-19 responses in the world — despite having one of the highest population densities in Southeast Asia, a shared border with China, an under-resourced health system, and limited testing infrastructure.
To alert citizens to the urgency of the situation, it declared SARS-CoV2 a pandemic before WHO did. Its government-citizen cooperation owes itself to a mass public awareness campaign, and organised debunking of fake news through scientific journalism. The country's health ministry website provides a constant stream of information about latest outbreaks and exposure risks, videos from the Deputy Prime Minister, and infographics to reduce Covid-19 stigma. Creative state-led campaigns increased awareness, such as partnering with a pop singer to produce "Ghen Co Vy" — a song that went viral and was promoted by Unicef — and commissioning young influencers to broadcast messages of optimism and solidarity for quarantined populations. Patients were encouraged to share their experiences at isolation centres on social media, bolstering trust in the conditions at these facilities.
Vietnam also made mistakes in managing risk perception that highlight the balance between over-assurance and under-assurance that risk communication must achieve. The country’s tourism agency attempted to promote "Vietnam — Safe Haven", a campaign to inform foreigners that the country had successfully managed the crisis, while the spread was still in its early stages. Due to this premature positive messaging, 41% of the cases in Vietnam's second outbreak cluster were tourists.
In New Zealand, which has one of the flattest epidemic curves in the world, Prime Minister Jacinda Ardern's message to citizens was this: life as they knew it was temporarily over, and everyone must start "acting as though you already have Covid- 19". Germany’s success seems unsurprising when one watches Angela Merkel's press conferences. In language accessible to the average German, she spoke about the sensitivity of the country’s health systems to R0 or the virus’ reproduction number. If our R0 goes from 1.1 to 1.2, so everyone infects 20% more people, our hospitals will get overwhelmed three months sooner, she explained. And while the American pandemic response is certainly not one to aspire to, New York governor Andrew Cuomo’s proactive and transparent communication made headlines for providing clarity to millions of residents as their state became the global epicentre of the pandemic. His daily, televised briefings displayed graphs on hospitalisation, ICU and intubation rates, motivating New Yorkers to continue slowing the spread by staying home, and providing a window into what was coming up ahead.
By emphasising the magnitude of the crisis instead of concealing it, these leaders created leverage for harsh policies that caused unprecedented disruption to lives and livelihoods. They paved the way for local bodies to enforce these policies. They set and re-set expectations about lengths of lockdowns, spikes in infections, and what life would look like once measures were relaxed. They continued to advise and demonstrate hyper vigilance long after community transmission had been eliminated. Above all, they did not peddle misinformation. The ones who did — such as federal leadership in the UK, United States and Brazil — are still paying a hefty price.
The Kerala model, already hailed for its preparedness in testing, tracing and isolation, is also a case study in public communication. It utilised both traditional and new media to communicate in several local languages, with a focus on migrant-dominated areas. The government’s 'Break the Chain' campaign and Corona Literacy Mission reached out aggressively and proactively to families with educational content, including a coordinated effort from the Kerala Police’s Media Center to produce localised videos, poems and dances. It is no coincidence that the Kerala Police’s Facebook page is one of the most popular police department pages in the world, with 1.4 million followers. A mobile app called GoK Direct regularly checked the spread of misinformation.
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Kerala’s communication strategy boasted the additional element of political unity. Not only did the state's chief minister build faith in the state’s response by speaking to the people of Kerala for an hour every evening, he also jointly addressed local body representatives with the opposition leader by his side. "We must close down all our doors before the enemy enters" was their common message of caution.
These communication strategies owed their success to a few common elements, each of which built trust. They were: (1) early and proactive, (2) honest and transparent in disclosure, even when numbers painted a dark or uncertain picture, (3) careful in putting facts before politics, creating a common national narrative (4) frequent, ongoing, and evolving with the pandemic, (5) erring on the side of over-caution instead of over-confidence, (6) simple, clear, and unambiguous, breaking complex topics into bite-sizes.
If the government fails to earn back citizens' buy-in and trust, measures to track and isolate will also fail. Contact tracing only works when individuals understand the urgent need for it, and provide honest, detailed accounts of their interactions. Acceptance for antibody testing or isolation requires confidence that those testing positive will not be maligned or mistreated. Higher social disparities across the developing world require communication strategies that account for various capacities for scientific concepts and difference in risk tolerance.
Of all the tools leaders and governments have at their disposal in crisis management, public communication preparedness has the highest impact on transmission reduction, for the lowest cost. Investing in a cohesive, localised public health communication strategy will be essential in the coming months if we have any hope of mitigating the spread of Covid-19.
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