Assessing Ottawa Public Health’s ongoing response to the endoscopies infection scare

Guest post by Josh Greenberg, PhD

Hepatitis: autoimmune cell

Establishing the scenario

In a hastily organized media conference on Saturday, October 15, 2011, the City of Ottawa’s chief medical officer of health, Dr. Isra Levy, announced that a local, privately owned “non-hospital” medical clinic failed to follow proper infection control measures, resulting in the potential exposure of 6,800 patients to Hepatitis and HIV.

According to Dr. Levy, there was no evidence that a single patient had been infected as a result of treatment, and following consultation with infectious disease specialists he confirmed that the estimated rate of possible infection was “very low”:

  • 1 in 1 million for Hepatitis B
  • 1 in 50 million for Hepatitis C
  • 1 in 3 billion for HIV

On his Twitter feed Dan Gardner, author of the critically acclaimed book, Risk: The Science and Politics of Fear, described the risks cited in this case as “indescribably tiny…dwarfed by the risk of driving to the corner store.”

Despite the exceedingly low possibility of infection, the announcement by Ottawa’s health authority predictably generated outrage and intense public and media scrutiny.

Situation summary

Ottawa Public Health (OPH) first became aware of this clinic’s problems in July 2011, when the Ontario Ministry of Health and Long Term Care advised that an inspection by the College of Physicians and Surgeons of Ontario discovered infection prevention and sanitation protocols had not always been followed. It was then that OPH began its own investigation to assess the risk to public health and identify all patients who might be affected.

This involved a lengthy process of tracing several thousand patient records over a 10-year period. This volume of patient records, combined with restrictions on patient confidentiality set by Ontario privacy laws, made the task of informing those affected extremely difficult.

The final list of patients who may have been exposed to infection was not confirmed until Thursday, October 13th. On Friday, October 14th, OPH put its risk communication plan into effect. The first step involved finalizing the preparation of registered letters that would be immediately sent to all 6,800 patients. This included coordinating with the physician at the centre of the health scare, a professional obligation involving medical errors. Second, it involved notifying local physicians to ensure they would be able to address public demand for information and requests for blood testing. And it involved training as many as 50 public health nurses who would be redeployed from other units (e.g., sex education, home visits with new parents, etc.) to staff a call response hotline.

This plan was developed over the course of the health department’s three-month investigation. Given the possibility of an information leak, only a select number of key individuals were involved in the investigation and planning process.

A threatened media leak

Ottawa Public Health originally intended to hold its media conference on Tuesday, October 18th, at which time all information about the findings would have been disclosed. By this point, all affected patients would have been informed directly about what had occurred, physicians would have been prepared to respond to demands for information and testing, and the call response unit would have been up and running.

On the morning of Saturday, October 15th, Dr. Levy’s office was informed that a national news organization had become aware of the investigation and was preparing to break the story on the basis of inaccurate information.

This placed the public health authority in a difficult situation: the risk that a news report containing misinformation was real—certainly not unprecedented—and had the potential of creating vastly more harm than good.

OPH was faced with three options:

1.  Do nothing and respond to the report and the fallout that would ensue after the fact.
2.  Provide full disclosure of the situation, including identifying the name and address of the clinic and physician and the types of procedures which had placed patients at risk.
3.  Provide partial disclosure that would strike a balance between patient needs, the public interest and the capacity of the system to absorb increased demand for information, testing or treatment.

Communicating risk

The risks that kill people and the risks that upset people are completely different. Sandman, 2007

The health department scrambled to organize a media conference for later that afternoon. At this time, Dr. Levy announced what had occurred, confirmed that there were no known cases of anyone becoming ill and reported the very low numerical probability of infection. He acknowledged that some people might feel anxious or nervous about the announcement, and offered an explanation about what actions his office had put into place and would be following in the coming days, including a promise for new information early in the week.

To this extent, he acted in a manner consistent with the basic tenets of risk communication. He did not over-reassure, acknowledged that people would feel anxious about the announcement and described the discovery and response processes.

However, when pressed by journalists for a fuller disclosure of information, Dr. Levy refused to identify the name or location of the medical facility, the physician who operated it, or details about the patient population affected (i.e., children, adults, seniors, etc.).

This was a risky move for two major reasons.

First, it guaranteed that the health department would clash with the media over competing values: whereas the health department values only pertinent information in the interest of protecting public health, journalists value full disclosure, immediacy and thrive on controversy and outrage. Second, the decision to provide only very general information risked intensifying ambiguity and uncertainty, where the objective of risk communication is to lessen it. People aspire for control over their lives, even if they cannot change what might happen.

Ottawa Public Health called a second media conference on Monday, October 17th, where Dr. Levy disclosed all of the known information about:

  • where the breach had occurred (a private health clinic operated by Dr. Christiane Farazli on Carling Avenue in the city’s west end)
  • what caused the lapse in infection control (improper sanitation of equipment associated with the performance of endoscopies)
  • what patients should do next (contact their physician or the public health department’s call response centre to discuss whether they should be tested)

Media response

The news media’s framing of risk has more to do with its reproduction of moral outrage than with “scientific” notions of calculable risk.Brown, Chapman & Lupton, 1996

Ottawa Public Health and Dr. Levy in particular, came under fire for the decision to provide only partial disclosure in its first media conference.

In a post to his Greater Ottawa blog on October 17th, Ottawa Citizen reporter David Reevely initially described Dr. Levy’s shift from partial to full disclosure as a “volte-face” move, a “classic emergency communications error,” and mused about whether the public health unit might be “sitting on something more shocking.” (He later revised his position, explaining the full context of Dr. Levy’s shift in tactics, characterizing it as a “judgment call…that makes a whole lot of sense when viewed from inside.”)

In a story published on October 18th, the Ottawa Sun did not report the low levels of infection risk but did note the “potentially fatal” nature of Hepatitis and HIV and cited demands from evidently uninformed patients for full disclosure: “You can’t keep the public in the dark…We have the right to know—it’s not fair…. Especially HIV, when there’s no treatment.”

On CTV National News, public relations consultant Barry McLoughlin characterized Dr. Levy’s decision to not release all of the information at once as “a mistake” that intensified public anxiety.

And in an October 18th editorial, the Ottawa Citizen blamed Dr. Levy for causing “undue public concern by mismanaging the release of the information.”

Risk communication: normative and situational perspectives

These criticisms and the demand they represent regarding full disclosure are consistent with normative recommendations for risk communication.

The World Health Organization defines risk communication as “an interactive process of exchange of information and opinion” among authorities, citizens, news media and other stakeholders.

In the past authorities typically acted on the basis of what they believed was the best course of action. Oftentimes this meant shielding the organization itself from blame. Risk communication hinges on the recognition that citizens deserve to be treated honestly, respectfully and with a view to enhancing their autonomy. The objective is to reduce uncertainty so that people will be capable of making informed decisions that affect their lives. Organizations achieve this objective, in part, by communicating as openly as possible.

Notwithstanding the normative appeal of full disclosure, the ability to report all information needs to be considered against a variety of situational factors, including the seriousness of the threat (i.e., the scientifically measured level of hazard or harm), the organizational resources required to manage the response that full disclosure will produce, and the conflict between patient rights to privacy and the public and media’s right to know.

Focus assessment

The focus on whether the release of partial information was sufficient needs to be determined in light of the probability of harm and in relation to the ability of the health system to absorb the effects of full disclosure.Given the low hazard for harm and the state of system readiness, and the fact that this event was not caused by the public health department itself, it’s not unreasonable that OPH proceeded cautiously in its first communication with the media and public.

The problem, however, is that this limited the flow of information to journalists, whose occupational values—more information is always better—and “nose for outrage” positions them in opposition.

According to the U.S. Centers for Disease Control and Prevention, “scientists want data to be released when it’s ‘seasoned’—the media want fresh data now.” Consistent with previous cases of low hazard/high outrage events, the Ottawa health department and media differed not only in their treatment of information, but also their definitions of how to define what’s in the public interest. The health department’s partial disclosure not only strained its relationship with the media; it also kept the wider public under-informed and in a state of uncertainty.

Risk communication conclusion

The question of when to release risk information is a serious one, not to be taken lightly. It is vitally important to communicate openly and to communicate early. As the CDC advises, public health authorities need to “be first, be right, be credible.” And according to the World Health Organization, “the benefits of early warning outweigh the risks,” even when faced with uncertainty and the possibility of error.

Although prescriptive recommendations such as these are important in guiding decision-making about disclosure, such decisions cannot be made by virtue of normative standards alone.

Rather, as argued here, they must be made in relation to situational factors. They need to be made in a context that acknowledges:

  1. It guaranteed that the health department would clash with the media over competing values.
  2. The resources that will be required to manage the system impacts such announcements tend to produce.
  3. The legislative environment that balances patient privacy rights against the rights of the public to know

In this case, it’s possible that a full disclosure of all available information in its first media conference would have created undue pressure on local physicians, public health clinics and hospital emergency rooms. Keeping in mind that risk is about both uncertainty and possibility, the scenario of an overwhelmed healthcare system surely played out in the health department’s decision making.

It’s important to note that this risk event was not caused by the health department itself, but by a private clinic regulated by the province of Ontario. Ottawa Public Health responded to an investigation by the College of Physicians and Surgeons of Ontario, and to an alert by the Ontario government. It proceeded with its own investigation and a strategy of public disclosure only when it became evident that the other agencies involved would not do so. The decision to provide only partial disclosure was made on the basis of the health department’s interpretation of the scientific evidence relating to infection risk. That this decision was allegedly forced by a news organization threatening to break the story with erroneous information, is significant in terms of assessing the response.

Ottawa Public Health acted appropriately in balancing the needs of patients in relation with system capacity, but only to the extent that this event involved infinitesimally low levels of health risk. Had the probability of infection been higher, or had there been evidence of patients who had actually been infected, its response (and this assessment) would likely have been different.

Response problematic in one area: social media

The OPH response is problematic in one other way.

In the most recent edition of his book Ongoing Crisis Communication, W. Timothy Coombs describes the “increasingly important” role of social media for issues management and as a channel for responding to public questions and sharing information. It’s unclear to what extent social media sites are used by Ottawa Public Health to scan or monitor media and public discourse; but for the dissemination of public information sites have been used only sparingly.

For example, (at the time of writing this post) the health department’s under-used Tumblr account does not contain a single update about the infection scare, although it’s been used for other health information purposes during this time. And while its Facebook page and Twitter account have posted synced updates to a low number of fans (363) and followers (5,000+), the fact that both were dormant in the 36-48 hours following the initial media conference suggests social media outreach represents a low priority within the health department’s communication plan.

Given that the period immediately following a public announcement is a critical time when reporters and members of the public are discussing an event and forming their initial impressions, social media platforms present an important space not only for assessing the tone of the public conversation, but for also correcting misinformation if and when it occurs.

Risk events such as the Ottawa endoscopies infection scare can be disorienting because of the intense feelings of uncertainty, anxiety and fear they produce. But to the extent that these situations are potentially destabilizing, they also afford unique opportunities to think critically about how we discuss and practice risk communication.

Update: Thank you to the Canadian Journalism Foundation for reprinting this PR Conversations guest post in full (on October 26th) and introducing Canadian journalists to Josh Greenberg’s risk communication assessment post and PR Conversations.

April 2013 Addendum: In the recently published Journal of Professional Communication ( Vol. 2: Issue. 1, Article 6). Josh Greenberg has contributed a more fully fleshed-out research article, “Risk Communication and the Disclosure Dilemma: The Case of Ottawa’s Endoscopy Infection ‘Scare”.

In the Acknowledgements section he thanks “PR Conversations for hosting a real-time assessment of the case that served as the ‘first draft’ of this paper.”

* * *

Josh Greenberg, PhD, associate professor, School of Journalism and Communication, Carleton University, teaches graduate and undergraduate courses in health communication, public relations and communication theory. Research interests and areas of publication include public relations, research methods, media representation and social movements.

Josh’s experience includes working in a consultancy capacity for government, business and nonprofit organizations, offering research support and strategic advice on risk and crisis communication, issues management, social media integration and campaign development and evaluation. Read his blog, follow him on Twitter or contact him by email.

Hepatitis: autoimmune cell image from the World of Health blog (Creative Commons).

Please follow our blog:

30 Replies to “Assessing Ottawa Public Health’s ongoing response to the endoscopies infection scare

  1. In the recently published Journal of Professional Communication ( Vol. 2: Issue. 1, Article 6). Josh Greenberg has contributed a more fully fleshed-out research article, “Risk Communication and the Disclosure Dilemma: The Case of Ottawa’s Endoscopy Infection ‘Scare‘”

    In the Acknowledgements section he thanks “PR Conversations for hosting a real-time assessment of the case that served as the ‘first draft’ of this paper.” (Anytime, Josh!)

  2. Very interesting analysis. I’d just like to point out that yes, the Ottawa Sun story published to the web on Sunday, Oct. 16 (http://www.ottawasun.com/2011/10/16/clinic-flooded-with-calls-over-infection-fears) and in print the following day did not state the infection risk, but the story published the day before (http://www.ottawasun.com/2011/10/15/ottawa-patients-exposed-to-infection-risk) did. The story you linked to above was a followup to highlight the fact that anxious patients were flooding clinics with calls due to the limited information provided by Dr. Levy.

    1. Thanks for pointing this out, Kris. It’s an oversight that my post did not mention the online story published on October 15 included the risk information. Could I ask you to respond to a few questions, as you appear to be commenting on behalf of the newspaper:

      1. Why was the risk information not noted in the first print story discussing this event? I assume you have a wider readership of your Monday print issue than Saturday online (correct me please if I’m mistaken).
      2. The October 16 story states that Ottawa clinics were “flooded” with calls from anxious patients (a point you repeat above). Is there any actual evidence for this? The story provides anecdotal remarks from one employee at a single clinic in the city. I’ve been trying to gauge the actual public response during the weekend in order to compare to how media framed the reaction from residents. This touches on a comment from another reader above.
      3. The story concludes by quoting a source who says that there is “no treatment” for HIV. Regardless of the infection risk level and the anxiety of a single patient, this simply isn’t true. In the interest of providing accurate health information to your readers, do you think the report should have stated otherwise?

      Thanks again for the feedback.

      1. Just to be clear, though I’m a city editor at the Sun and was working that day, I am not commenting on behalf of the paper, merely offering some insight into how we approached the story.
        The story with the risk information ran in the Sunday print edition of the Sun (Page 6). The Sunday paper has a circulation that’s roughly 10,000 higher than on Monday (about 55,000 versus 45,000).
        The Monday story stated that an Ottawa clinic (singular) was ‘flooded’ with calls. Since our information was purely anecdotal, and based on us talking with people at a single clinic, we figured we couldn’t ascribe this to all clinics. The online headline reflects this too: “Clinic flooded with calls over infection fears.” We got that information from employee who spent much of the day fielding calls. It’s possible the print headline had the plural ‘clinics,’ but I can’t verify that immediately.
        As for the final quote, in which a student and client of the clinic says there’s ‘no treatment’ for HIV, we could perhaps have cut that out, though we felt readers would understand that she meant ‘no cure.’
        Overall, given the utter information vacuum from the city between the press conferences on Saturday and Monday, we felt we needed a story that would illustrate citizens’ reactions to the way the issue was handled by Public Health. We didn’t have to look very far, and as the sentiments our sources expressed were very similar to those we heard from friends and colleagues we felt we hadn’t torqued the story in any way.
        As a final note, these stories broke at a very difficult time as our friend and colleague Earl McRae passed away in the newsroom on the Saturday afternoon. Our editing may not have been quite up to par that weekend.

        1. Kris — thanks for your clarifications and the responses to my questions. It’s greatly appreciated.

  3. What an interesting case study you’ve written here. What a nightmare this must have been (of course for the patients and their families but also) for OPH’s communications team. Yikes! I like the quote you included about the CDC framing health teams as wanting to season information while journalists want it raw. If it bleeds it leads, no? What I found the most interesting about this case was the public response on CBC’s news blog. While there was, of course, some outrage and fear, lots of readers pointed out that the levels of risk were relatively low, despite little mention of this in the article. I feel like the public’s understanding of risk and risk assessment have changed as a result of recent public health “crises” of the last decade (e.g. swine flu, SARS, listeria) and so maybe we will be better prepared in the future. It’s a shame that the relationship between public health and the media is frequently so strained and adversarial in their pursuits of transparency, accountability, etc. Media is such an important source of news and information for so many people and the harm in terms of the fear, panic, distrust and anxiety generated from sensationalized stories is a real problem. That said, public health’s gotta amp up its media strategy if it wants to remain a trusted and authoritative source and that means meeting the public where they are- via social media channels and providing a forum for discussion to take place. It will be interesting to see how this plays out in the next few months, as the internet is a vital terrain for patients to organize and mobilize around specific issues. I hope information and appropriate treatment gets out to those whose health is now seriously at risk.

    1. Thanks Maggie for the feedback, in particular your comments about the audience feedback on the CBC site. So much of what we take as representations of public opinion are the expressions of anger and outrage (or, in other cases, apathy) that are narrated through news reports or the claims of journalists and pundits (a nod to Fraser’s points above). Generally the relationship between OPH and the local media is pretty good — both sides would probably agree. Yet with the exception of H1N1, OPH hasn’t really been tested in terms of rolling out a major risk/crisis communication plan (its experience with H1N1 was similar to many other local health departments), so this case is illuminating in that respect and could provide a meaningful opportunity for learning what works and does not (and without the spectre of tragedy hanging over them). I also hope that journalists will look at this case for the opportunities it provides in relation to understanding the science of risk and reporting appropriately. Several comments from other readers above have pointed to the importance of this point. Anyway, thanks again for reading and commenting!

  4. One of the problems with the original release is that hardly anybody thinks about riskiness in terms of numbers. And even more to the point, they don’t “feel” risk numerically. It might be riskier to cross the street in the middle and not at the light, but mid-street crossing feels okay if you are comparing it to having to waste time walking to the corner and your knowledge that you have violated risk probability a myriad of times without consequence.
    What that means is that organizations such as OPH can’t use 1-in-a-million or 1-in-3-billion explainers without providing a more human felt context. It has to be “like” something people can relate their feelings of risk to. Indeed, I would argue that the comparisons – being struck by lightning, being hit by a car when crossing in the middle of a street – should in any smart release precede the actual risk numbers. The latter reflect the numerology of probability, the former express our emotional, interior, non-numerical estimate-tology.

    In that light I also don’t think lottery winning odds are appropriate analogies as they are about something good happening to you as opposed to something bad. Nobody daydreams about all the bad stuff which will take place if they have bought a losing ticket – au contraire. In regard to all of the above I should point out that numbers of commenters on the CTV.ca site http://www.ctv.ca/CTVNews/TopStories/20111017/ottawa-residents-warned-possible-disease-exposure-111017/ took issue with the failure of the media to translate the numbers into something ordinary humans could relate to.

    With all the preceding observations in mind I have two questions for you Josh

    Must all students of the Carleton journalism/communications program take at least some formal instruction in explaining and translating risk probabilities before they graduate? And if not, why not, as you can’t blame media/PR people for doing wrongheaded things when you aren’t training them to do better.

    Second, why are you so coy about naming the “national news organization” whose lust for a misinformed scoop precipitated many of the communications issues you described in your analysis? It must be an open secret by now and in the interest of true full disclosure I think they actually should be “outed” in this affair.

    1. Thank you, Stephen. Your comments about how OPH framed the health risks are excellent – really spot on and capture more effectively the limits of “very low”. In response to your questions:

      1. I teach on the Communication Studies side of the program, and although I offer a 4th year course on PR it’s really just a survey of the field (its history, debates, etc.) and not a course on developing or honing skills in applied public relations (we do one week on risk/crisis but its theoretically oriented). We do teach skills in critical reasoning, logic, etc. so hopefully those skills translate into the kinds of activities you allude to. On the Journalism side we have a Chair in Science Journalism who tackles these issues in her course — and while it’s a J-school, many of their grads end up in PR.

      2. I’m not being coy — I honestly don’t know. OPH informed me it was a national news organization but stopped short of identifying which one. I can only speculate but there may be legal considerations associated with not doing so (at least for now). As soon as I know I’ll post an update.

      Thanks again for the feedback.

  5. Josh, my response is identified following your points.

    JG –
    1. Scares, panics, risks or outrage are socially constructed and emerge through the competitive framing activities of different players with different roles and stakes in any given issue. This is a point I make in my piece. Did you miss it?

    FL –
    I agree with your statement as a blanket statement. But, there is a difference if these (Scares, panics, risks or outrage) are actual, or just the verbiage used. Just because the media (headline writers; columnists; reporters; bloggers; PR media relations experts; etc.) used the terms doesn’t – and didn’t – make them real. And, with this issue, they weren’t.

    JG –
    Also, I don’t know if you monitored the media coverage of this “non-event” (your words). I did. There were several hundred news articles published about this case in a very short period of time: in Canada, the United States, France, India, China and the Middle East.

    FL –
    Again, I would say: so what. What difference did it make to how things unfolded in Ottawa if a news article was published in say India? The volume of news coverage – especially that of outside the area – is meaningless.

    JG –
    While health officials may have “objective measures” of what a “real” risk may be, that ignores entire bodies of case study evidence and communication theory which suggests that authorities ignore how these are constructed at their peril. Thankfully for OPH they considered this dilemma and responded appropriately (in my view).

    FL –
    Again, I agree with your general statement – and the comments above about openness and transparency. I agree the OPH did respond appropriately, both operationally and communicatively. But, they didn’t need the Saturday conference. In reality, though, it did no harm by holding it. The real risk was to the 6,800 – not to the rest of the population. Therefore, the real risk communication was to them and not to the general public. The bigger story would have been if they had done at poor job with the 6,800.

    JG –
    2. My assessment was not written from inside the organization but was based on my reading of several texts: news reports, media releases, public statements, in addition to correspondence with reporters and key players at OPH. It is not an exhaustive study but an (almost) real-time assessment. Having said this, I do note that a key component of OPHs risk communication response was its direct correspondence with patients, its communication with staff and with the physician at the centre of this event. OPH did so out of professional obligation to the physician and in respect of patient privacy. I commend them in my piece for doing so. Did you miss this too?

    FL –
    My suggestion to you was to get inside the actual risk communication activities to the 6,800 in order to balance your piece. That many patients; 10 years of records; limited resources; what to say in the letter: this is the more interesting risk communication story.

    JG –
    3. The threatened release of misinformation was going to link the infection scare to medical services provided by an abortion clinic. Imagine the moralization and fear that would affect what is already a (mostly) at-risk population. One of the key objectives of effective risk communication is to mitigate processes of stigmatization. To ignore this fact and roll the dice by not meeting with the media would have been disastrous and led to far greater problems. I don’t think OPH was willing to gamble on the fact that it was a long weekend and the hope that most residents weren’t clued in to the news. This wasn’t the Kitchissippi Times (a community paper in Ottawa). It was a national news outlet.

    FL – So one of Canada’s premier national news outlets was going to publish a story making this link, which I’m assuming that the OPH would have denied in a statement beforehand when asked by the news outlet. Where did this news outlet get its information? What were the sources? How many sources? Would they have actually published this misinformation if the OPH denied the link? Makes one wonder about their professional credibility if that’s what they were going to do. But, nevertheless, after providing them with a statement about their ‘facts’, I still believe the OPH should not have held the media conference on the Saturday. Since the whole thing was a non-story by Wednesday, there is no evidence to suggests that had this national news outlet gone ahead that it would have been “disastrous.” Seems more like the news outlet would have had egg on its face, and it would have been left to explain why it made the link in its story when the OPH denied it. If it’s a “gamble”, sometimes one has to gamble by maintaining your own operational schedule (in this case including communication directly to stakeholders; privacy issues; etc.) and not be intimidated by the media’s so-called schedule.

    JG –
    4. On the first day of the clinic opening it received on average 100 calls/hour, with more than 1,000 calls in total (again, on day 1). Now we don’t know whether this resulted from the perceptions of real risk by patients or the media coverage that ensued following Saturday’s news conference. So maybe the response would have been light without the Saturday announcement, or maybe not. Who knows?

    FL –
    Agreed, who knows?
    We don’t know if the calls came as a result of the direct communication to patients, the Saturday media conference and resulting coverage, the Tuesday media conference and resulting coverage and/or even some other means. But, what’s important is not the absolute volume of calls, but who the calls were from. If they were all from patients, then the public communication obviously did not confuse them. If they were all from members of the public – scared, panicky and outraged – then the public communication did not work. If they were members of the public who call in regularly when there are health risks regardless of their own status, then the accuracy of the public communication didn’t matter. Talking to an OPH source yesterday, there were many in the third category. Volume has dropped off significantly. I haven’t heard about any of the 6,800 who may have talked about a faulty communication approach.

    FL –
    Finally, to your first point again (Scares, panics, risks or outrage are socially constructed and emerge through the competitive framing activities of different players with different roles and stakes in any given issue.), one has to differentiate between actual players and the play-by-play commentators. Take the commentators out of this story – the Reevelys, the McLoughlins, the editorialists – and there is no scare, panic, or outrage. They were the social constructionalists. Scare, panic and outrage were not real, simply competitive verbiage.

    1. Fraser, these are all fair responses and I thank you for them. Despite differences in how much weight we are giving to certain variables (I think lots of negative editorial coverage, public criticism from the Ontario Minister of Health, etc. is more significant than you do), we agree that OPH performed well overall, under the circumstances. I would suggest that their handling of the risk communication – partial disclosure Saturday, fuller disclosure Monday, operational steps put in place in the interim – is what took so much heat out of the issue, not changes in objective severity. This includes the effective risk communication to patients (which I note in my piece).

      As for what would have happened had the unnamed national news outlet published its threatened story, we have no way to know. It’s my understanding that they threatened to do so with or without comment. So OPH would have responded by denying the story. It would have still provoked fear, outrage, other coverage, more speculation. They would have been forced to say “not an abortion clinic but somewhere else” and then faced demands to know where else. And all this would have absorbed tremendous resources for an already stretched organization that was trying to get an actual patient response system put into place.

      Again, thanks for the comments and follow-up. As with the others, your feedback is very useful in helping me to sharpen my own account of the events.

      Cheers,
      JG

  6. If this health issue in Ottawa is to become a case study in health risk communication that others will refer to in the future, then there are some points that should be noted.

    1. It never was a “scare.” There was no “panic” in Ottawa. There was no “outrage” – except that which was ‘manufactured’ by journalism (editorialists; columnists; head line writers) and Public Relations (pundits; media relations ‘experts’) people.

    2. Josh, your focus on risk communication is really only on the manufactured “hot air” coming from journalists and PR practitioners, particularly in response to the Saturday media conference. There has been no examination of the risk communication direct to the patients, the doctors, the nurses, and other immediate stakeholders. Nor, was there a fulsome examination of all the communication to the public, particularly the Tuesday media conference and the follow-up to that event. It would make a more balanced piece with these two additions.

    3. I would argue that the only communication mistake the OPH unit made was holding that Saturday conference. It should not have. It had not completed the implementation of it’s operational and direct to stakeholder communication plans. It may have faced some “misinformation” in the media if it had not – but, I would argue, this was the lesser of two evils. By holding the Saturday media conference, the OPH unit opened the door for the manufacturing of “outrage” and the inflammation of language: “scare”; “panic”.

    It should noted that this was a long holiday weekend in Ottawa when few were paying attention to the media – and that the media was typically shorter-staffed.

    4. The real learning out of this is that it’s the usual subjects (reporters; columnists; head line writers; commentators; talking heads; PR media experts; journalism experts; etc.) who will inflame the language. And, in the absence of any real story, the media will follow a new media line: the reporting of the reaction by the so-called communication experts. But, what’s more telling, there is no evidence to suggest that the general public in Ottawa was influenced by the reporting of this reaction by these communication ‘experts’. Maybe it was because it was a long weekend. Maybe it was because the inflamed language was over the top. Maybe it was because the journalism and PR people are not seen as influentials.

    5. But, regardless the reason, in the long run there was no risk to holding that Saturday media conference. It would have been better without it, but all it did was manufacture hot air – air that was effectively cleared on Tuesday. (Of course, the manufactured sense of indignity did influence the newly appointed and obviously ill-advised Minister, who, for whatever reason, then threw the head of the OPH under the bus. Wonder what their relationship is like today?)

    As I said above in my earlier post, the OPH did a good job, operationally and communicatively – particularly given that it was not their responsibility in the first place and given the resources available to the unit. Surely, any examination of their risk communication should focus on all aspects and not simple one media conference and the hot air ‘manufactured’ by the communication experts.

    1. Fraser

      Thanks for your comments. I’m glad you agree with my overall assessment that OPH did a good job given the circumstances in which it was placed. I will address each of your comments in turn.

      1. Scares, panics, risks or outrage are socially constructed and emerge through the competitive framing activities of different players with different roles and stakes in any given issue. This is a point I make in my piece. Did you miss it? Also, I don’t know if you monitored the media coverage of this “non-event” (your words). I did. There were several hundred news articles published about this case in a very short period of time: in Canada, the United States, France, India, China and the Middle East. While health officials may have “objective measures” of what a “real” risk may be, that ignores entire bodies of case study evidence and communication theory which suggests that authorities ignore how these are constructed at their peril. Thankfully for OPH they considered this dilemma and responded appropriately (in my view).

      2. My assessment was not written from inside the organization but was based on my reading of several texts: news reports, media releases, public statements, in addition to correspondence with reporters and key players at OPH. It is not an exhaustive study but an (almost) real-time assessment. Having said this, I do note that a key component of OPHs risk communication response was its direct correspondence with patients, its communication with staff and with the physician at the centre of this event. OPH did so out of professional obligation to the physician and in respect of patient privacy. I commend them in my piece for doing so. Did you miss this too?

      3. The threatened release of misinformation was going to link the infection scare to medical services provided by an abortion clinic. Imagine the moralization and fear that would affect what is already a (mostly) at-risk population. One of the key objectives of effective risk communication is to mitigate processes of stigmatization. To ignore this fact and roll the dice by not meeting with the media would have been disastrous and led to far greater problems. I don’t think OPH was willing to gamble on the fact that it was a long weekend and the hope that most residents weren’t clued in to the news. This wasn’t the Kitchissippi Times (a community paper in Ottawa). It was a national news outlet.

      4. On the first day of the clinic opening it received on average 100 calls/hour, with more than 1,000 calls in total (again, on day 1). Now we don’t know whether this resulted from the perceptions of real risk by patients or the media coverage that ensued following Saturday’s news conference. So maybe the response would have been light without the Saturday announcement, or maybe not. Who knows?

      Thanks again for contributing your comments.

      JG

  7. One issue left out is the risk of other diseases that are deadly, and are not tracked by Public Health either in Ottawa or anywhere else in Ontario.

    MRSA, C.Difficile and HPV are all easily contracted by contaminated hospital equipment, as well as any number of infectious organisms. They kill 1000s every year, and public health doesn’t even discuss them. And every single person who has gone through that clinic has been put at risk for those–their GPs may tell them, perhaps some people may read up and discover their risk is a lot higher than 1 in a billion or 1 in a million and get tested.

    This Josh, is why full disclosure is critical. And why I am generally critical of public health on these issues. They track bubonic plague and rare diseases we never see in North America, and they limit their scope precisely to that list of diseases. Ethical medical practice demands that they look at all risks, and ensure that any possible victims be reached, not just with a paper letter that may be lost, but with actual human contact, either through phone calls, or family doctors helping, or even visiting.

    And yes, full disclosure in the media, and the social media of actual details of which clinic and which procedures and dates, can go a long way towards that.

    How many people have died from C.Difficile after going to this clinic? Maybe zero, maybe many. But we’ll never know because OPH is sticking to it’s out of date guidelines. Precisely. And that is a problem.

    1. Aurelia –

      Thank you for the comments. You raise valid points (thought I don’t agree with them all). A couple responses:

      1. My analysis was restricted to a single case and I’m not comfortable with generalizing how decisions should/could be made in one case to EVERY case involving risk to public health. That’s the thrust of my argument, but it’s obvious we won’t agree there. The point you raise about the lack of “visibility” regarding public attention to everyday infection risks is relevant. But I do not think this is the responsibility of public health departments alone: private medical clinics and the physicians that work in them, government regulators, journalists (especially those with subject matter expertise) and patient advocacy groups all have a role to play in ensuring a balance between what patients should and need to know about the risks they face when they visit the doctor, a walk-in clinic or the hospital emergency room. I think one of the upshots of this (thankfully not tragic) event is the need to increase public and media understanding about risk, a point raised by Heather above.

      2. I disagree that there is a better way than registered mail, combined with a call response line, to contact everyone directly affected. I can’t imagine how long it would have taken to inform all 6,800 patients in person by telephone or a home visit. I expect OPH would not have had the capacity to do this in a timely manner that would not in itself have generated additional communication problems: how do you decide whom to contact first? News stories, blog posts, Facebook updates, etc. would no doubt arise following the first wave of patient notifications, leading to exactly the same problem as occurred here (or worse, I predict). Perhaps assistance from the Ministry of Health and Long Term Care might have helped, although it seems to have taken an arm’s length role in the whole process (despite having been the source that alerted OPH to the issue). Local health departments simply don’t have the resources to provide patient notifications in the manner you suggest.

      Thanks again for the feedback.

      1. Aurelia – I put quotation marks around “visibility” but this was not a term you used, but one I was using to signify what I took to be your argument that everyday health risks are rendered invisible by the unwillingness or refusal of health officials to talk about them. Didn’t want to confuse your intent with my own language.

  8. I just came across this review of the new disaster movie “Contagion” on the BBC

    http://www.bbc.co.uk/news/health-15390209

    It kind of reminds me that given how this movie expresses our worst fears and expectations, that even the most rational explanation of a potential or real public health scare connects with an audience that views everything through the mindset of looming catastrophe. In that light, remaining silent about theoretical public health scares such as swine flu might be more beneficial than voicing opinions in any form before we really need to. That’s because if people fear the worst, the absence of proof is rationalized as demonstrating variously to different audiences 1. an Establishment cover 2. a corporate conspiracy to sell more product 3. Just a matter of time before science catches up with reality…because we’re doomed anyway, so let’s panic regardless of the reassurances from experts. I’m suggesting that given the excited state of these conflicting mobs, it might be socially responsible to remain silent more often than we do. Meantime, let’s set about creating a less doom-laden and more rational climate of opinion.

  9. The most important lesson learned from the above presentation and discussion is that … it’s risky to drive your car to the corner store.

    Save for the immediate stakeholders (the 6,800 patients who were alerted directly; the physicians and nurses who had been prepared to act; related public health authorities; etc.), this is a non issue for the other million people in the Ottawa area (full disclosure: that includes me). As a taxpayer, citizen and health care system user, seems to me that those in charge of the system ACTED well.

    Seems no one (media; the punditry and talking heads in Ottawa; PR Conversationalists) wants to give them credit for their actions. That is, their operational actions and their risk communication to those who needed to know and then act were both done well. Certainly, if I was among the 6,800, I’d be happy with their response. So the notice to the rest of us came out in two spurts, to which I say: so what!

  10. A very useful realworld case through which to consider many of the issues that occur in risk communications – so thanks for the post Josh. A few points come to mind.

    First, the notion of a normative open approach implies this is the “ideal” but as you highlight, there are so many situational considerations that relate to a particular case, it seems to me naive to determine any strategy as “ideal”. So I wonder if the notion of normative should be avoided in preference to emphasising a considered, contingent approach in risk communications. I believe that if PR presents itself as having the secret (what Paul calls a trick) to address any emerging scenario, it is doomed to criticism and failure. Rather our role should be one of informed, intelligent, counsel that takes into account the various factors of an individual situation (weighs these against the possible outcomes etc) and then makes a rational recommendation. All this needs to be done as quickly as possible, whilst recognising (and communicating) that situations change and develop and hence any position needs to be adaptive rather than rigid.

    My second thought is that openness and “public interest” are flawed concepts. As we’ve debated before on PRC, there are many public interests and openness is not absolute. In the case of a health situation, there are very good reasons for managing information. You indicate the difference between disclosure and transparency, which seems a good approach. It seems the media (whilst claiming the moral highground of “public interest”) often forget the rights of individuals rather than wider interest. The interest of the majority should not always dominate in any ethical situation (hence a need for PR practitioners to be knowledgeable in ethical matters).

    Thirdly, I feel there needs to be greater debate away from such situations into areas of risk and the role of the media. There is a general lack of public understanding of risk – as is evident in many issues and crisis situations. The heat of a crisis is not the time to educate either the public or the media, but if society does not address this matter, it is all too easy for politicians, organizations, media and so on, to manipulate and misrepresent statistics and other data.

    In this case, risk was not as simple as the 1 in x million presented. For most people, there was zero risk as they were not involved in the health scare. When you are involved, your risk is more definite – have you contracted a virus or not? It is a yes/no situation and no matter how low the risk is, the fact it is either/or is your dominant concern. We should also bear in mind that such risk statistics are estimates based on best guess or previous situations. So often health communications hide behind statistics because the truth is that there is no precise knowledge. The media (and the public to an extent) will not, or cannot, engage in such nuance of understanding and hence the hype and misrepresentation of situations results.

    Without any of us engaging in informed and intelligent discussion of risk, we will always have a simplistic defence vs offence situation, which surely only muddies public understanding further.

    1. Heather –

      Thank you. These are excellent comments (like the others), which help me sharpen my own sense of the case and the argument I’m developing.

      I’d like to comment on each of your points in turn:

      1. I agree entirely we should seek to avoid leaning on normative principles to understand and/or manage highly contingent events. Your use of the term “strategy” is significant here – we wouldn’t need to think “strategically” if clear standards of practice were all that are required in these circumstances. The risk communication literature does advise the use of certain “best practices,” which imply that there are core principles which shall or “ought to be” followed regardless of the situationally unique factors of the case. Perhaps instead of normative v. situational, Herbert Blumer’s distinction between “definitive” and “sensitizing” concepts is useful here: “Whereas definitive concepts provide prescriptions of what to see, sensitizing concepts merely suggest directions along which to look” (see his classic essay “What Is Wrong With Social Theory?” from the ASR, 1954).

      2. I agree with you about the conceptual shortcomings of “openness” and “public interest” precisely because these are both debatable and subject to interpretive latitude. Cases such as this illustrate the extent to which risk events become the battle ground for definitional struggles not only over the actual meaning of these terms, but also the values that underpin each definition. Moreover, the definitions of these and so many concepts are never fixed, not only because different social actors understand and use them in different ways, but because their meanings also change in relation to changes in the empirical world.

      3. This is a very important point. In the J-School at Carleton we have a Chair in Science Journalism whose courses (ideally) provide an opportunity for young journalists to learn about and understand the nature of scientific risk and how to report issues like this one responsibly and in a way that’s sensitive to nuance and uncertainty. So on the one hand, better journalism education will help, but so too will having subject matter experts in newsrooms to help cover these kinds of events. These events are becoming more, not less, frequent.

  11. Josh, this is a very insightful post. Full disclosure and full debate are both must haves if we are to manage such issues. However, the reason that so many seriously-minded people advocate restricting discussion and disclosure is because their experience in the public realm has made them fearful of losing control. Two recent examples have reinforced their cynicism. 1. The farcical response of the WHO to the threat of swine flu in 2009 caused worldwide panic; yet their communication strategy was supposedly designed to allay such fears. The result was that efforts to combat the seasonal flu that is real killer year after year were undermined 2. The UK medical establishment recently disastrously lost control of the MMR vaccination debate when an unfounded fear about its link to autism took hold of the imagination of the media and campaigners. The result was that people stopped having their babies vaccinated and measles remerged as a killer disease (it was an absolute scandal).

    I don’t think there’s a clever PR formula that we can pull out of a hat – like magicians with their rabbits. Nevertheless, for my next trick….

    Part of the solution lies in persuading those involved in potential scares to hold their nerve and to stay calm as they present the full facts. But that’s not so easy in a world prone to play the blame game. That WHO’s dilemma. It perhaps explains why the WHO sometimes creates problems that don’t exist by generating unfounded fears; just in case something bad does possibly occur, however unlikely that might be statistically. Ironically, that’s their risk aversion in misdirected action. Another useful way forward would be to persuade the medical establishment to spread informed-skepticism by every channel available to us. We could also ask our politicians to stop playing politics with public health issues… but don’t hold your breath waiting for the outcome to that part of the potential solution.

    It is a tricky field…

    1. Thanks for the feedback, Paul. I appreciate your response and glad you found the post insightful. I tend to agree that the more information that gets disclosed in times like these the better. But there are always structural limitations in every case, and too many contingencies to say that a specific course of action must be pursued in every instance (I say this recognizing that it is a potentially dangerous position to take as it can lead to the very abuses of power that normative prescriptions, among other things, help to resolve).

      I also think it’s useful to distinguish between disclosure (what I would define as the communication of information) and transparency (communication of reasons). Full disclosure may not have been desirable for the reasons I provide in my post, but full transparency surely was. There were arguably legitimate reasons, in the interest of public health, to slow the release of information. Why not say up front and in your first statement to the media and public what all of those reasons are (including the threat of a news leak containing misinformation), explain why you need just a day or two (no immediate threat of infection/outbreak, system not ready to handle public response, etc.) and then tell people when the information they want will be available to them?

      As you say, it’s a tricky case. And, as Toni notes above, officials need to decide and to act quickly (and then deal with the consequences of their decisions). There are numerous lessons to learn from this event and thankfully it’s one that did not, as far as we know, produce tragic results.

  12. What a challenging post!

    Besides all the interesting, relatively new and detailed information on the so-far conceptualized pillars of risk communication, the case in itself faces our profession with some serious questions.

    Certainly the most precious lessons for me reside in:

    a) the balance of normative/situational paradigm that -in more general terms- appears to me to be perfectly aligned with the generic principles/specific applications pillar of our body of knowledge;

    b) the confirmation that responsible public relations practice, well before deontological considerations, needs to be always top of mind and prioritize a situational analysis of all the consequences on the many specific publics of any risk announcement format is selected… however knowing that amongst the principles of responsible communication are also timeliness, situational completeness and effective management:
    the latter implying that one needs to decide and to act.

    A question, how did the ‘news organization’ that was coming out with the scoop react and cover the story?

    Thank you Josh, your post deserves a special place in my head and repository…

    1. Thank you for your feedback Toni. The epistemological issue for me is interesting and of potentially greater value than just the particularities of this case as it engages with broader debates about methodology (the limitations of analytical ideal-types, for example). This is a theme I’m hoping to develop further for a journal article.

      As for your question about the news organization and its reaction, I don’t know which one it was so I can’t say for sure. The only information I was given is that it was a national outlet and the story was going to contain a significant inaccuracy that would have generated moral outrage and stigmatized a specific population. If/when the news organization is ever identified it will indeed be interesting to see how the reporter/organization actually covered the event and its fallout.

  13. This is a great case study of public health and risk communication– thank you for sharing it! I am slowly working toward a masters in public health degree with an idea that I would like to work in health communications (as my background is in journalism and PR). I appreciate that your assessment of this situation included the social media response, as that is an increasingly important means with which to keep the public informed. Risk communications plans moving forward need to make full use of all media to keep the pubilc informed and appraised of the situation.

Comments are closed.