In the
spring of 2014, Vietnam's state-controlled news media reported that dozens of
children had died after turning up at hospitals in the capital, Hanoi, with
rashes and high fevers. Doctors said the cause was a measles outbreak – the
worst in Vietnamese history.
Parents
of victims rushed onto Facebook to share their grief and outrage. So did their
friends and neighbours, who wanted to know how the outbreak was spreading, and
whether it was even safe to take children to hospital.
The authorities
distributed information about the measles deaths via leaflets, loudspeaker
bulletins and updates on the health ministry's website, recalls a nurse at a
state-run hospital in Hanoi, who requested anonymity in order to speak frankly.
"But there was so much information online that some people became
panicked."
Vietnam
is a one-party state that has responded efficiently to many natural disasters
and health emergencies. During a 2005 outbreak of avian flu, for example, the
Vietnamese agriculture minister famously ate chicken on national television in
an effort to calm public fears about widespread poultry infections. But when
the 2014 measles scandal broke, millions of Vietnamese were using Facebook,
compared to almost none just a few years earlier. And the government, which
sporadically blocks the network, was unable to extinguish a Facebook-fuelled
bush-fire of fear, anger and recrimination that swept the nation.
Much of
the criticism landed at the feet of the health minister, Nguyen Thi Kim Tien,
who refused to call the deaths an 'outbreak' even as the child death toll
approached 130. Even before the measles crisis the health ministry had been on
the defensive, following a string of previous scandals at public hospitals that
had included mistaken diagnoses, faulty vaccinations and cases of bribery in
surgery wards. So when Tien said that only 25 deaths were directly attributable
to measles – while doctors at a Hanoi hospital said scores had died from
measles-related complications – many ordinary Vietnamese viewed her comments as
brazen obfuscation.
"The
public saw a lot of people dying," recalls Dinh Duc Hoang, a contributing
editor at VnExpress, a Vietnamese online newspaper. Ministry officials, he
says, did publicly explain their epidemiological rationale for not declaring an
outbreak, "but not enough, especially on social media," he says.
"People didn't understand and thought the ministry was trying to hide the
outbreak."
Since the
turn of this century, the rise of online search engines and social media applications
has allowed ordinary people around the world to find information during public
health scares at an ever-faster pace. The change has been especially dramatic
in the Asia-Pacific region, a global epicentre of internet users, smartphone
sales and infectious-disease outbreaks.
This new
environment presents a complex mix of opportunities and challenges for health
officials. On one hand, increased public engagement during a health crisis can
allow officials to communicate more directly with citizens. But every new
online platform is also a conduit for spreading criticism or misinformation.
The rise of social media makes it "harder for governments to shut down the
flow of information, but the information itself may be unreliable," says
Crawford Kilian, a Vancouver-based writer who covers the politics of public
health.
Health
officials are increasingly aware that online rumours and criticism during a
health scare can fuel panic, undercut their credibility and weaken public
confidence in the very healthcare systems that are meant to fight disease. And
some of them are trying to close the digital gap by engaging their citizens –
and critics – on social media. During the measles crisis in Vietnam, for
example, senior health officials asked Hoang and around eight other well-known
journalists to help improve the health ministry's social media presence and
disseminate official updates to the public during health emergencies.
"Because
of my job, I'm famous, and I know a lot of celebrities," Hoang explains.
"I can contact people to get them to post correct information for people
to read."
The
premise – helping the ministry distribute 'correct' information through social
media – was simple enough. But could, or should, a group of journalists and
celebrities really help a one-party government restore public faith in a
beleaguered health bureaucracy? And why did the ministry need their help in the
first place?
Social
media is only the latest digital 'disrupter' to change the public conversation
around health scares; the first was the internet itself. And the first major
health scare in which the internet played a decisive role in shaping public
opinion was the severe acute respiratory syndrome (SARS) outbreak – the first
influenza pandemic of the 21st century.
SARS
appeared in southern China in 2002 and created an international crisis in
February 2003, after a 64-year-old medical professor from the Chinese city of
Guangzhou checked into a Hong Kong hospital with respiratory failure. A guest
staying at the same hotel as the professor then unwittingly infected more than
100 medical and nursing staff at a second Hong Kong hospital, and six other
guests unknowingly spread SARS to Vietnam, Singapore and Canada. This was just
the first phase of an outbreak that would spread to more than two dozen
countries, infect 8,098 people and kill 774.
Within
months of the first SARS infection, hundreds of thousands of 'SARS' searches
had popped up on a newish platform called Google. Baidu, a popular Chinese
search engine, also reported during the epidemic that 'SARS' was its top search
item. Both sites were allowing ordinary people in China and beyond to instantly
find information about the disease, rather than wait for updates from a local
newspaper or television anchor.
"Back
then, it was Web 1.0, where people go to a site and download information, and
there's no sort of participation," says Randall N Hyer, a
risk-communications specialist who worked on a World Health Organization (WHO)
risk-response team during the SARS crisis.
But not
all the information that turned up in the search engines was accurate, and
false rumours quickly went viral – faster, in fact, than the virus itself. One
of the most damaging came from an unlikely source: a 14-year-old Hong Kong boy,
who announced online that the city would soon be placed under quarantine and
designated an "infected port". His prank post gained attention and
credibility because it mimicked a local newspaper's website. It sparked a
frenzy of panicked grocery shopping, which fed perceptions that Hong Kong was
under siege.
According
to At the Epicentre, a 2004 book coedited by Christine Loh (who is now Hong
Kong's undersecretary for the environment), the mood in the city felt
"eerie", in part because there was widespread confusion around how
the disease was spreading. Even a public disavowal of the teenager's prank by
Hong Kong's then health director, the book states, did little to quell the
eeriness.
But the
internet wasn't an entirely bad influence during SARS. For example, as
infections piled up in Hong Kong, a group of concerned residents created a
crowd-sourced website, sosick.org, showing a list of buildings with suspected
or diagnosed SARS cases. Two weeks after the site appeared, the Hong Kong
government began publishing the same information on its official website.
"The
internet proved to be an invaluable tool for concerned citizens to use in
challenging government secrecy," Loh and her coauthors wrote.
Gabriel
Leung, Hong Kong's former undersecretary for food and health, says the SARS
experience helped convince Hong Kong authorities of the need to be transparent
with the public about the knowns and unknowns of an outbreak as it unfolds –
well before a website such as sosick.org might challenge the government's
credibility. He applied the lesson during the city's response to its next major
public health emergency: an outbreak of H1N1, a deadly respiratory virus known
as swine flu.
Swine flu
was discovered in April 2009 in the USA, and at the time outbreaks had not been
known to occur among humans. But as H1N1 quickly spread to Canada and Mexico,
WHO declared it a Public Health Emergency of International Concern, and health
officials on other continents braced themselves for its arrival.
It landed
in Hong Kong in May 2009, when a 25-year-old Mexican tourist fell ill with
swine flu in his hotel. Within hours, health officials had quarantined all of
the hotel's guests and deployed Leung to television stations to explain the
rationale for a decision that was certain to make Hong Kong residents deeply
anxious.
Internet-fuelled
rumours about the disease proliferated, but Leung says he mostly stayed ahead
of them by explaining the knowns and unknowns of the disease at daily press
briefings, and by promising to show up every afternoon at the same time for as
long as reporters had questions.
"So
long as you keep your promise, people will not be susceptible, or as
susceptible, to the rumour mill, because they know the maximum time they have
to wait is 24 hours before you will come out and give the facts again," he
says.
A daily
press conference might have kept rumours and medical misinformation at bay
during a health scare in the mid-2000s. But today, when fresh social media
trends go viral every few minutes, a 24-hour information cycle can feel like an
eternity. Social media can also challenge any official narrative that a health
ministry tries to promote.
"Rumour
mills will always be there… and social media by and large fuels that,"
says Leung, now the dean of medicine at the University of Hong Kong's School of
Public Health. "It's not all negative, but social media is fast, it's
furious."
Swine
flu, which killed between 150,000 and 575,000 people, was – according to a 2010
study in the journal PLOS ONE – the first global pandemic to occur in the age
of Web 2.0, an era defined by 'participatory' web and social media. Since then,
the dominance of social media has only increased, which has intensified the
need for health officials to develop rapid online responses during health
scares.
The
challenge is now especially stark in countries, like Vietnam, where millions of
people are flocking to Facebook or Twitter for the first time but health
authorities are only just developing an online presence.
As late
as the early 2000s, most Vietnamese found information about public health
issues through state-controlled newspapers, television channels or a national
network of public loudspeakers that broadcasts state-curated news in most towns
and villages at daily intervals. All of those channels still exist, and the
government still promotes them aggressively. The difference is that many urban
Vietnamese now prefer to find information about health issues on health blogs
or Facebook threads – and that some now hardly consult official news sources at
all.
The new
environment can feel liberating, but also scary, for Vietnamese who go online
seeking authoritative information during a health crisis. "Vietnam, 10
years ago, was very poor," says Nguyen Dieu Huong, an academic
administrator in Hanoi and a member of Vietnam's rising middle class. "We
didn't have the internet or ways to update people about, for example,
epidemics. So people didn't really feel anxious or afraid of epidemics, like
they do now."
During
the 2014 measles outbreak, the anxiety bubbled up in a Facebook campaign called
'Health minister, resign!' that earned more than 100,000 'likes' – a rare
outpouring of public dissatisfaction in a one-party state that imprisons
political dissidents. Thousands more Vietnamese logged on to discussion threads
on Facebook and Webtretho, a popular web forum for parents. Among other
questions, they debated whether the health benefits of bringing children to
paediatric hospitals for vaccinations outweighed the apparent risks.
"We
were scared to vaccinate our kids, and, at the same time, to not vaccinate
them. So we were scared of everything," says Thai Lan Anh, a Hanoi yoga
teacher who participated in those discussion threads.
Lan Anh
says her first child, who was born in 2011, had already been fully vaccinated
by the time the measles crisis hit. But she decided not to vaccinate her second
child, who was born in 2014, out of an abundance of caution – and still hasn't.
"I
don't think the Ministry of Health has been totally honest [about the risks of
diseases and vaccinations]," she tells me between sips of fruit juice at a
Hanoi café. "I don't believe what they say."
Even
before the measles outbreak, health minister Nguyen Thi Kim Tien was among
Vietnam's most reviled public servants. An easy way to tell was the extensive
focus on healthcare in Meeting Each Other at Year's End, a hugely popular
television satire that is performed once a year on Vietnamese state television.
A 2013 skit, for example, showed a patient going to a Vietnamese hospital for a
kidney operation, only to find that a doctor had removed the wrong kidney. A
year later, a skit showed a health minister – widely assumed to be Tien – being
placed on a machine that tested her ethical integrity. She failed miserably.
Against
that backdrop, the health ministry quietly reached out to Hoang and other
journalists in 2014 to solicit their ideas on improving the minister's image
and social media presence, according to Hoang. (A ministry spokesman, when
reached for comment by telephone, asked for questions by email but did not
answer them.)
Hoang,
whose mother is a doctor, says he felt a duty to help.
"Ms
Tien wanted to build an image of the doctors and herself as friendly and close
to the public," he says of his early exchanges with the ministry, which he
insisted were informal and entirely pro bono.
Tien was
setting up a Facebook page, and she asked if the journalists would mind ghost-writing
some posts for her, according to Hoang. The journalists refused because they
were too busy, he says. But, as a false rumour about Ebola spreading in Vietnam
circulated on Facebook, they agreed to help staunch the flow of misinformation
by using their Facebook pages to publicise the ministry's Ebola updates.
Hoang
says he also personally helped the minister improve her online image. First, he
advised her to post a more friendly looking photo on her Facebook page. He also
recommended that she interact more with ordinary people.
He saw an
opportunity when a Vietnamese cancer patient wrote to a local newspaper to
complain that a state-funded insurance programme was expiring, thus threatening
to deprive her and other cancer patients of live-saving healthcare benefits.
Hoang forwarded the patient's letter to the minister, who drafted a reply that
empathised with the patient's predicament and explained the ministry's
insurance policy in accessible language. Hoang then publicised the exchange on
the VnExpress website and his Facebook account, which has more than 30,000
followers.
But even
then, the exact effect of the intervention was unclear.
"I
made the two letters a campaign for the awareness of cancer and the image of
the minister," he says. "The campaign helped people understand the
policy, but I can't tell if it helped her image or not."
This
problem – of how to use social media effectively to benefit public health –
spreads beyond Vietnam.
Careful
study of health-related social media trends could eventually help scientists
and health authorities better understand person-to-person disease transmission,
in part because social media tends to be "highly contextual and
increasingly hyperlocal", says Marcel Salathé, a researcher at the École
Polytechnique Fédérale in Lausanne, Switzerland, and a specialist in an
emerging field scientists call 'digital epidemiology'. But for now, he says,
they are still struggling to understand whether social media chatter about
health problems actually mirrors epidemiological trends or not.
"There
have been some successes, but many failures," says Isaac Chun-Hai Fung, a
digital epidemiologist at Georgia Southern University in the USA.
An early,
and humbling, experiment in digital epidemiology occurred at Google, where
engineers launched the disease-forecasting tool Google Flu Trends (GFT) in
2008. The company planned to analyse Google search data for mentions of
symptoms and other telltale words. It would then, it was hoped, crunch the data
to accurately 'nowcast' the likely contours of flu and dengue outbreaks, two
weeks earlier than the Centers for Disease Control and Prevention (CDC) – the
gold standard of epidemiological research – could.
That
never happened. In 2009, when panic spread across the globe during the swine
flu outbreak, GFT underestimated the outbreak's impact. One potential cause of
the error, according to a study in the academic journal PLOS ONE, was that the
pandemic occurred in summer rather than winter, the traditional flu season.
Google
shrugged off the mistake as a correctable glitch. But during a flu outbreak in
December 2012, GFT's estimate of the percentage of Americans who had
influenza-like illnesses was over 10 per cent – a prediction that the
scientific journal Nature said had "drastically overestimated" the
outbreak compared to CDC surveillance data, which put the actual figure at
around 6 per cent. Experts concluded that internet search algorithms were not
yet a reliable replacement for the CDC's traditional epidemiological
surveillance. GFT was quietly shelved in 2014, and Google said in a note to the
public that it was "still early days" for digital applications that
track the spread of infectious diseases.
Other
projects have picked up where GFT left off, with some success. Models built
using Google search data from between 2005 and 2010 in Thailand were able to
"adequately" estimate malaria trends in the country, for example,
according to a 2013 study in the Malaria Journal. Another study that year noted
that an algorithm built to track health trends on Baidu, China's primary search
engine, successfully predicted the contours of seasonal influenza infections
over an eight-month period.
But
"social media is still a relatively recent phenomenon in human
history," Fung says. "There are still a lot of unknowns here, both in
terms of whether we can invent an algorithm to make better estimates or
understand what people really are communicating."
Even so,
health officials are still attempting to engage social media chatter in a way
that keeps citizens informed about health scares in real time and tamps down
misinformation, all without appearing to silence critics in a heavy-handed way
or losing the public's trust. That balance can be hard to strike, even in a
rich country with a high rate of smartphone penetration and the highest
internet speeds on earth.
That was
clear in the spring of 2015, when the South Korean capital, Seoul, became
ground zero for the largest outbreak outside the Middle East of Middle Eastern
respiratory syndrome, or MERS.
MERS,
which was discovered in 2012 in Saudi Arabia, was bound to cause anxiety
wherever it landed because it kills 30 to 40 per cent of its victims. Moreover,
because the disease's inner workings are still poorly understood, it can be
hard to detect if a doctor isn't looking for it.
South
Korea's first patient was not diagnosed until he showed up at Samsung Medical
Center in Seoul with MERS symptoms – nine days after first showing signs of
infection, and after visiting a few other hospitals. That was bad enough. But
for more than two weeks after South Korea's initial MERS case was diagnosed,
the government declined to publish the names of MERS-affected hospitals – just
as the Hong Kong government had declined to publish basic information about
SARS infections in 2003. And as health officials stalled, the outbreak spread
to other hospitals.
Korean
social media erupted with criticism, and on 4 June, a South Korean journalist
published the list of affected hospitals on Pressian.com, an online news
portal. The government, now in full damage-control mode, quickly followed suit,
and a Samsung official later apologised for the hospital's handling of the
outbreak.
But the
government's and the hospital's credibility was already tarnished. It didn't
help that, on the same day Pressian.com published the hospital list, South
Korea's Centers for Disease Control and Prevention made its Twitter account
private, prompting a backlash from the scientific community and fuelling
speculation that the government had something to hide – even if it didn't.
I visited
Seoul during the crisis, and the city did not feel panicked. Perhaps the
biggest visual reminders of the MERS virus, at least for non-native speakers,
were the public health posters with images of a camel – the animals were the
origin of the disease – that I saw in Seoul's Incheon Airport. The camel didn't
look very scary. Yet on the streets and in the metros, many people were wearing
face masks, reflecting the widespread public unease about the virus that was
bubbling up on social media.
Over the
course of a week, I asked South Korean journalists about the MERS situation,
and many of them were highly critical of their government's response to the
outbreak. Officials should have released the names of affected hospitals more
quickly, they said.
Lee Won-jae,
a high school student, had a similar complaint. "Time has passed"
since the first MERS infection, Lee told me, standing a few blocks from Samsung
Medical Center in suburban Seoul on 12 June, at the height of the government's
MERS-news blackout. "Things should be wrapped up, but everything is still
ongoing."
At the
time, President Park Geun-hye was still recovering from handling a ferry
accident that had happened in April 2014, in which 304 South Koreans – mostly
teenage students – were killed. The government had faced criticism over its
rescue efforts. Because of the MERS scandal, Lee said, "there's a bigger
distrust of the government now than before".
A few
months later, as South Korea's MERS epidemic was tapering off, a team of
researchers from Hong Kong and the USA published a briefing about it in the
Western Pacific Surveillance and Response Journal. The South Korean
government's response to MERS, they concluded, was "reminiscent" of
the Chinese government's response to SARS in 2003.
Gabriel
Leung, the former Hong Kong official, agrees. He says one lesson may be that
having a prosperous economy does not necessarily prepare health officials to
respond smoothly to a 21st-century outbreak in real time and in a way that
doesn't damage the government's credibility.
"Despite
the high-income nature of the setting, despite excellent medical care, there
are some lessons that societies generally need to learn experientially rather
than just from a theoretical perspective," he says of the MERS crisis.
In
Vietnam, another public health scare bubbled up this spring, when WHO reported
that an Australian tourist had been diagnosed with Zika virus after vacationing
in the country. But as Facebook rumours began to swirl, the health ministry's
information chief, Nguyen Dinh Anh, began posting international news stories on
his Facebook page and explaining what Vietnam was doing to prepare for a
possible outbreak.
Hoang, of
VnExpress, says the health minister's Facebook page is still relatively sparse,
and should be updated and managed by a professional. But the information
chief's response to Zika, he adds, seems to show that the ministry has at least
recognised the importance of being transparent about public health risks and
engaging the Vietnamese public on social media.
This time
around, "they're posting on their own, without our help," Hoang tells
me between drags of a cigarette in a Hanoi café. "They won't have the type
of crisis they had with the measles outbreak."
Ultimately,
he adds, it would be difficult – if not impossible – for the health ministry to
win the public's complete trust, for the simple reason that Vietnamese
bureaucracy is notoriously corrupt. But he says the ministry could perhaps work
to become a more reliable conduit of information during future health crises.
"The
people still need it, and that's the only source."
No comments:
Post a Comment