POLICY & PRACTICE
Transparence dans le cadre des urgences de santé publique : de la rhétorique à la réalité
Transparencia en las emergencias de salud pública: de la retórica a la realidad
P O'MalleyI; J RainfordII,*; A ThompsonIII
ICentre for the Study of Democracy, Queen's University, Kingston, ON, Canada
IIIHR Coordination, Country Surveillance and Response Strengthening, World Health Organization, Lyon, France
IIIJoint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
Effective management of public health emergencies demands open and transparent public communication. The rationale for transparency has public health, strategic and ethical dimensions. Despite this, government authorities often fail to demonstrate transparency. A key step in bridging the gap between the rhetoric and reality is to define and codify transparency to put in place practical mechanisms to encourage open public health communication for emergencies. The authors demonstrate this approach using the example of the development and implementation process of a public health emergency information policy.
Une gestion efficace des urgences de santé publique exige une communication ouverte et transparente en direction du public. Les arguments en faveur de cette transparence sont d'ordres sanitaire, stratégique et éthique. En dépit de cela, les autorités publiques échouent souvent à communiquer de manière transparente. Pour franchir le fossé qui sépare la rhétorique de la réalité, une étape clé consiste à définir et codifier la transparence afin de mettre en place des mécanismes pratiques pour encourager, dans les situations d'urgence, une communication ouverte en matière de santé publique. Les auteurs exposent le fonctionnement de cette approche en utilisant comme exemple le processus de développement et de mise en œuvre d'une politique d'information en matière de santé publique pour les situations d'urgence.
Para gestionar eficazmente las emergencias de salud pública se requiere una comunicación abierta y transparente con el público. La transparencia se justifica por razones de salud pública, estratégicas y éticas. Pese a ello, a menudo las autoridades gubernamentales no transmiten esa impresión de transparencia. Una medida clave para cerrar la brecha entre la retórica y la realidad consiste en definir y codificar la transparencia para implantar mecanismos prácticos que propicien una comunicación abierta de la información de salud pública en las situaciones de emergencia. Los autores ilustran esta perspectiva utilizando como ejemplo el proceso de desarrollo y aplicación de una política de información para las situaciones de emergencia de salud pública.
Ongoing work to address the challenge of public health emergencies has increasingly recognized the role that public communication plays in their effective management. Pro-active communication, as one example, allows the public to adopt protective behaviours, facilitates heightened disease surveillance, reduces confusion and allows for a better use of resources, all of which are necessary for an effective response.
The severe acute respiratory syndrome (SARS) crisis of 2003 stands as a recent example of the risks and benefits arising from open information associated with a public health threat. Reluctance by authorities to acknowledge and communicate a potential problem in the first stages of the outbreak aided in the quick global spread of the disease.1 In contrast, the eventual break in transmission and international control was rooted in public awareness, community surveillance and behaviour modification - all of which was directly supported by a massive international public health information effort. Food safety crises, chemical events and bioterrorism threats of recent years have similarly underscored the crucial role that proactive communication of risk plays in public health emergency management.
The final report of the WHO Global Conference on Severe Acute Respiratory Syndrome held in 2003 in Kuala Lumpur was clear in its conclusions:
"Information should be communicated in a transparent, accurate and timely manner. SARS had demonstrated the need for better risk communication as a component of outbreak control and a strategy for reducing the health, economic and psychosocial impact of major infectious disease events."2
This emphasis on proactive dissemination of risk-related information has been echoed time and again when senior public health representatives meet to discuss public health emergency management. But beyond a rhetorical commitment to transparency, does this translate into substantive action by public health authorities and governments?
Unlike many other public health indicators, transparency by public health authorities can be difficult to track. Definitions of transparency may vary, measurement norms are ill-defined and, ultimately, assessments may be subjective. The strong sense among those closely involved, however, is that transparent public communication during crisis situations remains an elusive goal. Indeed, interviews conducted with WHO communication staff who were involved in various high profile public health emergencies between 2004 and 2008 reflect several persistent challenges that tend to undermine transparency:
reluctance to announce a potential health threat and inform an at-risk population of appropriate precautionary measures until all information is scientifically confirmed and formally endorsed;
a tendency to withhold information that is potentially damaging to an economic sector - often against the recommendations of public health experts;
an emphasis on strict information control within organizations, making constructive engagement of potential partners in coordinated public communication difficult.
With the coming into force of the International Health Regulations (2005), the global community is working to confront barriers to improved health security. With risk communication now identified as one of the eight core capacities of IHR implementation under surveillance and response, an opportunity exists to consider and promote practical steps to ensure that the rhetorical commitment to transparency translates into practice.
The first and most pressing rationale for transparency during a health emergency is the role that information plays in promoting core public health objectives. When the public is at risk of a real or potential health threat, treatment options may be limited, direct interventions may take time to organize and resources may be few. Communicating advice and guidance, therefore, often stands as the most important available tool in managing a risk.
In addition to serving core public health objectives, transparent public communication also addresses key strategic imperatives - political, economic and psychosocial - which are associated with public health emergencies.
Some of the most well-known research into these strategic dimensions comes out of the experience of the private sector. The literature includes case studies of corporations struggling with an oil spill, product contamination or other incident that threatens the organization's "brand" and share price, and also introduces the issue of legal liability.3 Proactive announcements and ongoing transparency in this context is seen not just as an organizational responsibility but as also the most effective way of seizing control of media reports, public discourse and customer relations associated with the event. Communication control is seen as a strategic tool to ensure perceptions of risk align with actual risk so as to limit negative information associated with the company and, ultimately, help to ensure that the reputation of the organization rebounds to its pre-crisis level. Although this model may not directly transfer to the public sector, public health authorities can not dismiss these purported benefits. Indeed, given the tendency for public health emergencies to be managed by multiple organizations with different perspectives, integrating such strategic arguments into the case for transparency could have particular appeal for actors outside public health.
Beyond the immediate public health and broader strategic advantages of transparency there exists an additional, longer-term rationale, central not only to the management of a particular incident, but also to the capacity of the public health authority to fulfil its ongoing responsibilities - that of preserving and building trust. Recent scholarship in the field of public health ethics and pandemic influenza planning has emphasized the importance of transparency in managing infectious disease outbreaks.4 In this context, transparency not only provides individuals and communities with information needed to survive an emergency, it is also an element of procedural fairness in decision-making and priority setting.5,6 It is also a necessary, if not sufficient, condition for accountable decision-making and for the promotion of public trust.
The reality is that most measures for managing public health emergencies rely on public compliance for effectiveness. Measures ranging from hand washing to quarantine require public acceptance of their efficacy, as well as acceptance of the ethical rational for cooperating with instructions that may limit individual liberty so as to protect the broader public from harm. This requires that the public trust not only the information they are receiving, but also the authorities who are the source of this information, and their decision-making processes. WHO's Outbreak communication planning guide 20087 highlights the crucial importance of information transparency in maintaining trust during an emergency but also in building risk communication capacity to support all phases of emergency management.
As previously acknowledged, convincing public health authorities and governments to be transparent in their communication in the face of scientific uncertainty can be difficult. Transparency, however, about what is not known is just as important to the promotion of public trust as transparency about what is known. Trust requires honest, open and two-way communication. For countries where public trust in government and public health is low, efforts to build and maintain trust are best made in collaboration with stakeholders before a public health emergency occurs. The "bunker mentality" during a crisis results in a less inclusive decision-making process because fewer stakeholders are involved. This in turn results in less transparency and accountability.4 As research on SARS in Toronto has shown, in times of uncertainty and crisis, the notion of accountability is more important, not less so.8 Without it, public trust is diminished and it is difficult to restore. When this happens, the effectiveness of risk communication diminishes and public health emergency management efforts may be significantly less effective.
At times, transparency during public health emergencies can result in collateral damage, such as economic loss, to other sectors. While it is beyond the scope of this paper to explore this in detail, this does raise an important ethical issue. Global public health measures and international trade and travel bans can have significant economic impacts on countries that declare public health emergencies. If countries have a moral duty to be transparent, then the global community has reciprocal moral obligations to compensate and support those countries that may suffer economic or health consequences as a result of transparent communication. This is especially true for those countries that benefit directly from information about public health emergencies to which they may be vulnerable. Exactly to whom in the global community these reciprocal duties apply, however, and how to discharge such duties remains a question for the international community to debate; reciprocity can take many forms such as financial compensation, human resource support, etc. There is little dissent, however, about whether or not reciprocal moral obligations for compensation or assistance exist in situations where collateral damage results from a country's compliance with the moral and regulatory imperatives for transparency.
Given the public health, strategic and ethical rationale for transparency and the ongoing challenge that transparency during public health emergencies can represent, the obvious question is how to bridge the gap between rhetoric and reality?
Like so many other policy dilemmas in the area of public health, transparency will not happen through one initiative alone nor is it likely to be accomplished overnight. One concrete step that public health authorities can take, however, is to codify transparency through an organizational policy or guideline that will identify the goal of transparency, identify the kinds of information that need to be communicated during an outbreak, and suggest the appropriate level of transparency to be applied to each particular type of information. The result would be a public health emergency information policy that, once endorsed by senior decision-makers within an organization, could be used in planning and implementing public communication during a public health emergency.
Developing and embedding such a policy into an organization's public health emergency communication would require at least three practical steps. First, transparency needs to be defined in a practical manner as a desired communication goal and outcome. The possible limits to transparency also need to be identified and articulated as part of the policy. Second, using a series of questions, the transparency policy needs to be applied to the relevant information that an organization may generate or gather, and that the public will need and may seek, during an emergency. Third, responsible staff could then identify practical dissemination tactics in their communication plans to reach the appropriate audiences with the information they need and seek during the course of an emergency. This last implementation step is crucial but its elaboration is beyond the scope of this paper, in part, because it deals with communication tactics and, in part, because of the need to tailor such tactics to specific contexts and communities.
Developing a policy on transparency requires, at the outset, a useful and relevant definition of what transparency means in the public health setting. In this regard, the WHO outbreak communication guidelines describe two inter-related aspects of transparency.7 The first refers to the quality of communication on information that is needed by people and communities during an emergency so as to avoid disease and stop its spread. To be effective, this type of public health guidance needs to be factually accurate, easily understood by the intended audience and presented in a manner that promotes adoption of the desired behaviours.
The second dimension to transparency aims to promote trust between the public health authorities and the public by being forthcoming and open on all aspects of an emergency, including the evidence and assumptions used by authorities in making decisions, the manner in which those decisions are being made and by whom.
Transparency in outbreak communication envisions two outcomes. People at risk and/or interested are informed in an accurate, accessible and timely manner about an actual or potential health threat, about behaviours they should adopt to treat or avoid disease and to control its spread, and about control measures undertaken by public health authorities. And also public health stakeholders and interested individuals not directly involved in management decision-making are given timely access to the evidence and assumptions used to inform management planning, policy and control decisions, as well as information about decision-making processes and outcomes. As well as reflecting the definition of transparency in the WHO outbreak communication guidelines, this definition conceptually reflects Florini's definition of transparency.9
The limits to transparency
While the goal of transparency suggests that all relevant information ought to be communicated or made accessible, it has to be recognized there may be legitimate reasons for withholding certain types of information in any public health emergency. For example, the following types of information might justifiably affect how information about risk is communicated:
information that jeopardizes national security or an ongoing police investigation;
information that unnecessarily violates the privacy and confidentiality rights of individuals;
information that might lead to undue stigmatization of individuals or groups within society; and
information that, if released, might lead to behaviours that would result in increased spread of disease.
When determining who needs what information to achieve public health goals, and the limits to transparency, it is important that the views of relevant stakeholders are solicited and included. This includes people who are most affected by the decisions being taken as well as their proxies, including leaders of representative organizations and news media. Under conditions of scientific uncertainty, it may be difficult to determine what information is needed and by whom, and when to favour other considerations, such as those listed previously, over protecting the public from harm. Given the relationship between transparency and trust, a precautionary approach would support disclosure, rather than withholding information.
Applying the policy
Once a transparency policy is agreed to and adopted, officials then need to apply it to all the categories of information that are needed by citizens to promote behaviours that will reduce the incidence and spread of the threat, and to allow them to understand emergency management decisions made throughout the various phases of the event.
In an infectious disease outbreak, for example, typically relevant information would include information about:
specific actions that need to be taken by health workers, communities, families and individuals to protect their health and control the outbreak;
the incidence, spread and containment of the outbreak;
risk assessments used by decision-makers;
what is known and not known about an outbreak and about control measures;
ethical considerations and/or key policies that may underpin outbreak control decisions; and
how and by whom outbreak management decisions are made.
To apply the public health emergency information policy during an event, officials can ask a series of policy-based questions to identify the appropriate level of public transparency to be applied to any of these types of information, as listed in Box 1.
There are ethical, strategic and public health imperatives that point to the need for transparency in communication of information during a public health emergency. The strategic communication of information is a fundamental public health emergency management tool and needs to be recognized as such. At the same time, it acknowledges that, in practice, global public heath too often fails to match reality with rhetoric and that practical new steps are required to address such failings. Although not in itself a guarantee of transparency, the development of a public health emergency information policy by responsible authorities is a practical step that may help governments to fulfil their responsibilities during public health emergencies.
Alison Thompson's research is supported by the Canadian Program of Research on Ethics in a Pandemic funded by the Canadian Institutes of Health Research.
Competing interests: None declared.
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(Submitted: 6 November 2008 - Revised version received: 11 March 2009 - Accepted: 16 March 2009)