Anne Schuchat: Slings, Arrows, Outrage, and Fortune

Anne Schuchat, MD, CDCWe at The College of Physicians of Philadelphia were honored to host Anne Schuchat, MD, Acting Director, CDC’s Center for Global Health, on February 26. 2013. Dr. Schuchat was here to accept—symbolically, because as a government employee, she was unable to receive the actual medal—the Jonathan E. Rhoads Medal. The College, the American Philosophical Society, and University of Pennsylvania’s Department of Surgery award this medal annually.

Schuchat has worked for the CDC since 1988, when she was an Epidemic Intelligence Service officer. Her biography, which includes a description of her important work on preventing Group B streptococcal disease in newborns, can be found here.

The title of Dr. Schuchat’s fast-paced talk was “Slings, Arrows, Outrage, and Fortune: Navigating the Noise for the Nation’s Health.” In it, she surveyed the media and sociological landscape of health messages, disease outbreaks, and vaccination.

She described the sometimes overwhelming confusion about health behaviors the average person faces: we must eat our cantaloupes because they’re good for us, but wait! they are contaminated! (This in regard to the 2011 incident with Listeria-contaminated cantaloupes that killed dozens of people.) And what was the average person to make of Michele Bachmann’s ill-informed remarks about the safety of HPV vaccines in the 2011 Republican candidate debates? That incident added to confusion about vaccines created by, among other things, a Time cover article, “The Truth About Vaccines” in June 2008, that, while portraying vaccines in a good light overall, was accompanied by a cover image suggesting the opposite.

Schuchat posed the question, How do busy laypeople keep up with the controversies and know how to evaluate conflicting information? And what are the consequences of an environment of doubt? She suggested that one consequence could be the low US rate of completion of the three-dose series of HPV vaccination. In Canada, completion rate for girls is around 80%; in the US, it hovers around 35% (Annual Report to the Nation on the Status of Cancer…,  2013). Schuchat suggested that rumors and misconceptions about vaccine interfere, and she noted that the Time cover story about vaccines was published not too long after the new HPV vaccine was released.

Media coverage of disease outbreaks and vaccine shortages is intense, but this same focus does not apply to stories about declining incidence of disease. For example, Shuchat pointed out the reduction in deaths from rotavirus illness in developing countries that have deployed the rotavirus vaccine. It’s important to keep track of these changes; Schuchat noted a recent letter from vaccine philanthropist Bill Gates, in which he wrote, “I have been struck again and again by how important measurement is to improving the human condition.” Measurement can help us focus on the progress we’re making, while helping us set attainable goals.

On her theme of outrage, Schuchat noted that it’s always easy to find outrage-inducing headlines, such as the recent ones trumpeting the finding of horsemeat mixed with ground beef. But sometimes outrage is misplaced, as was the case in 1981: in the first half of that year, newspapers obsessively followed the Jean Harris/Scarsdale diet murder case while AIDS was emerging among gay men in Los Angeles. (The CDC MMWR about the first cases was published on June 5, 1981.)

Schuchat next moved on to the work of Peter Sandman on risk perception, and his formulation that

Perception of risk = outrage + hazard
(outrage being cultural perception regarding the specific risk)

 

Outrage increases with risks that involve coercion (such as vaccination mandates), that are human-made (such as with the anthrax bioterror attacks), that are exotic and catastrophic, and that are controlled by others.

Schuchat with Clyde F. Barker, MD, Jeffrey Drebin, MD, George M Wohlreich, MDAll of these factors should come to play in our perception of the recent outbreak of fungal meningitis caused by a contaminated injected steroid. About 14,000 people are thought to have been exposed to the fungal pathogen Exserohilum rostratum. So far, 697 cases of meningitis and 45 deaths have resulted from use of the steroid. Writing in the New York Times, Lawrence Altman, MD, called this incident “one of the most shocking outbreaks in the annals of American medicine.”

In an example of an outrage-inducing incident that led to meaningful change, Schuchat described the US measles resurgence in 1989-91. About 55,000 cases and 123 deaths were reported. Many of the stricken children were of lower socio-economic status, and parents reported, in some cases, difficulty getting measles vaccinations for their children. Barriers arose when their insurance didn’t cover the immunization and doctors suggested they go to the local public health department to get the vaccines. Parents were not always able to follow through, and the children were left unimmunized. But something happened: the Vaccines for Children program emerged in part due to this epidemic, and millions of doses have since been distributed to un- and under-insured children.

Credibility and communication                  Schuchat next referred to the findings of Randall Hyer (2005), who looked at how people evaluate credibility of a source in low-concern versus high concern settings. In a low-concern setting, competence and expertise determine credibility (accounting for about 80% of an individual’s evaluation). In a high-concern setting, competence and expertise fall to 15-20% of the evaluation, and listening and empathy account for 50%.

What works, then, in regard to high concern and outrage, is to listen to people and ask them what they are concerned about. It’s important to be open and honest about risks and about what you don’t know, as well as what you do know. Schuchat noted that it can be difficult for doctors to show and share emotions, because they are trained, in general, to moderate emotion.  

And for the intelligent layperson, she should get comfortable with complexity, beware of absolutes, rely on reliable sources, remember that news outlets highlight extremes, and remember that anyone can create a website.

In closing, Schuchat referred to the progress that’s being made globally in the Millenium Development Goals: much has been done to help the poorest in the world achieve healthier, happier, longer lives.

Many thanks to Dr. Schuchat and all of our partners for a great talk! Shortly, we’ll link you to an interview the College’s CEO George M. Wohlreich, MD, conducted with Dr. Schuchat.