A Public Health Leader on COVID's Lessons

You’re a clinician and anesthesiologist by training and education. What inspired you to leave the operating room and transition to public-facing roles in government?
I never left the operating room. I was the first surgeon general in modern times to continue practicing. I would practice about a day a month at Walter Reed, and even before that, when I was state health commissioner in Indiana, I worked nights in the operating room and worked days at the State Department of Health. I did that because I believe that one of the challenges that you have in public health leadership is that when you take someone who's a clinician and you pull them out of their clinical roles and put them in administrative and governmental roles, the more removed they get from the field, the less they understand the consequences of the decisions that they're making.

I often tell a story about a kid I call “Johnny,” a 17-year-old who got shot and came to the operating room. After we fixed him up and sent him back out, he came back two more times. He'd been stabbed and then he'd been shot again. And the more he came back, the more frustrated I and others got with what we were seeing. That illustrates one of the challenges that we face. We provide great clinical care in the United States if you're sick, but we don't do a great job of preventing you from getting sick or injured in the first place. Those public-facing roles allow me to prevent people from falling into the stream in the first place, even as I'm working in the operating room of the hospital to save people from drowning after they've fallen in.

I felt like I could have a bigger impact on more lives in public-facing policy roles than I was seeing one patient at a time in the operating room. Unfortunately, in many cases, people have to choose one or the other, but I've had success doing both, and I feel very fulfilled having done such.

With the rise of new variants, we know COVID-19 won’t disappear and that the need for constant and changing public health communications will continue. How should that communication adjust to reflect where we are after two years?
One important aspect I think about in communications is transparency and giving people real-time data so that they can make their own personal decisions, but also so that they have context for governmental decisions that are being made.

In the beginning of the pandemic, we couldn't even tell the President of the United States how many people had COVID, how many ventilators we had and how many hospital beds we had. We now have better data reporting such that any person can go to their state department of health website and easily find this information, but one of the challenges is that Congress has not yet passed a bill to give the CDC and other entities the authority to continue to collect that data once the public health emergency ends.

We also need to continue to partner with businesses, and this is something I've worked on throughout my time as Surgeon General to make the business case for health metrics. These decisions are going to harm the public, but it's also going to harm businesses. What do I mean by that? We saw that when one airline relaxed their mask mandate, they had to start canceling flights because so many people were out of work. When you don't pay attention to health, it actually has implications that impact our workforce, so we need to continue to engage businesses and help them understand that if you don't have a healthy workforce, you're not going to have a healthy bottom line. That's why we need to continue to engage CEOs and leaders as advocates for health.

What can non-healthcare companies do better to communicate about the pandemic to their employees, customers or other stakeholders?
We have to do a better job of showing people what is in it for them; the challenge is that individuals ultimately are going to judge their individual risk and make many decisions based on their own risk perception. One of the things we can do is help educate people about what's going on in our community and our environment. Many people are not accurately judging their risk because they don't have the information or they don't know how to get it. That's one place that businesses can help them judge their individual risk. But then I think businesses can uniquely say to individuals, “This step is one that individually you don't think is going to benefit you from a health perspective, but if we have an outbreak at work, we've got to shut down the whole factory, the whole office or the whole business. That then means that you don't get paid, or the business suffers, and it actually hurts our ability to employ you long term or give you raises.”

What we have to do is help people understand if we want to stay open, keep travel open and keep schools and businesses open, the way we get back to normal is by getting more public buy-in with these preventative measures, versus trying to scare people with statistics that just don't resonate. The average person across the country still doesn't know someone who's died of COVID, so that's not going to motivate them.

There was confusion around why the CDC extended the mask mandate on public transportation, which was then overturned by a federal judge. What could be done in the future to better explain and educate on the rationale?
I'm deeply troubled by the decision to say that the CDC doesn't have the authority to enforce a mask mandate and also by the public's reaction to it. There are numerous examples of public health authorities working to keep the public safe. From a communications standpoint, this reflects a failure on our collective parts as government officials and as health officials from the beginning to help people understand how they benefit from public health versus individual health.

We also need to have more marketing and communications experts embedded within public health agencies because doctors don't get training in how to craft targeted messages to the larger population and how to roll them out. You hear the story over and over again about the doctor who can't communicate well with their patient. We need to help these spokespersons better understand the process behind communication and how you roll out a message in a way that is most likely to resonate.

What would you recommend to those trying to communicate the varying protocols and not only its differences at the federal and state level, but by institution and place of work?
One of the issues is that different environments are going to have slightly—or sometimes wildly different—needs for health protocols. A hospital needs to have a different level of protective protocols than an elementary school. What we need to do is explain to people why those protocols are differing from place to place.

We need to understand and embrace the fact that protocols aren't going to be one size fits all, but we need to explain when and why and where they're different.

The other challenge that is embedded in this conversation is the interplay between politics and health measures. From a communications standpoint, it looks disingenuous to the public when they're being asked to do something that's different than what their leaders are being asked to do, or when there are two different standards. That’s a challenge that you're going to continue to have in the pandemic, when White House protocols and congressional protocols differ from what we're asking the public to do.

We also know that many of these institutions have more resources than the general public. We need to help communicate clearly to people why, when and where protocols are different, so that they understand the difference when we're comparing.

COVID-19 sparked discussions about misinformation. Is “misinformation” a useful term, or is there a better way we can name and address the uncertainty around fast-moving epidemiology and technology?
There’s far too much that we've labeled misinformation that has turned out to be true and that's hurt credibility. When people say misinformation, what they're really implying is that this person is not a credible source of information, and likely has an ulterior motive or agenda. I recommend to people that they talk to their doctor, their nurse or their local pharmacist for health information.

I’m not an electrician. I can give you some information, which may occasionally turn out to be right, but that doesn't mean you should trust me over your electrician. Does that mean I'm giving you misinformation? No. It means that I am a less credible source of information than other people out there. We need to do a better job of identifying who is more likely to be credible source, and someone who has the background to be able to give you credible information.

You also see this playing out on social media. The blue check marks on Twitter originally started off being given mostly to celebrities as a way to show this is the real celebrity versus a fake account. That has now morphed into if you've got a blue check mark, then I should trust everything that you say. That's not necessarily the case, because these individuals don't have the education and training to be commenting on everything.

Joe Rogan is not someone who you should regularly trust to get medical advice from versus your own doctor. Conversely, you shouldn't trust your doctor if your doctor's trying to give you advice about how to be a comedian. That's Joe Rogan's world. That doesn't make either one a purveyor of misinformation, but it does mean that you should know who you're talking to and who you're getting your information from. And then we should help people figure out who are credible sources of information for different topics.

On the flip side, these louder voices who have traditionally not spoken about healthcare could be prominent advocates on these issues. Are you saying that their message should primarily be focused on speaking to your doctor and listening to public health officials, rather than speaking from their own perspectives?
What we have to understand is where the information that people are getting ultimately comes from. Some of the best partnerships we've had throughout the pandemic have been when we've paired celebrities and influencers with credible sources of information. A great example of this is Dolly Parton and her advocacy for vaccines. Dolly Parton is not a scientist, but has a tremendous influence in certain populations. She partnered with health officials to be a megaphone for credible information.

When we worked together for the White House Coronavirus Task Force, we produced several videos, including one on how millennials can stop the spread of coronavirus. What could have been done better to message to specific groups? As we gain new data, can targeted messaging play a more significant role?
One of the challenges we've seen throughout the pandemic is that we often try to come up with one-size-fits-all messaging. The message that you need to send to millennials is going to be very different than the message to senior citizens. Seniors need to know they are a high-risk group and could die if they’re not vaccinated. But if you take that same message to a college student, they're going to blow you off.

We know that all groups ultimately play a role in stopping the spread of the virus and in ending this pandemic but in different ways. We need to micro-target messaging to different groups to help them understand how we all collectively can come together to defeat the virus and improve health in general.

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Ninio Fetalvo is an Associate in Brunswick’s Washington, DC office. Previously, he worked for the Centers for Medicare & Medicaid Services, the White House Coronavirus Task Force, and the Office of the White House Press Secretary.

Photographs: Drew Angerer/Getty Images