V38 N1 / 2023 ©2023 American Medical Writers Association. All rights reserved. ISSN 2163-5315 AMWAJournal.org 12 The Walter C. Alvarez Award is named in honor of Walter C. Alvarez, MD, a pioneer in the field of medical communication. The award is presented to either a member or nonmember of the American Medical Writers Association (AMWA) to honor excellence in communicating health care developments and concepts to the public. The Alvarez Award is presented during AMWA’s Medical Writing & Communication Conference. Hello everyone, it’s a pleasure to be with all of you. And as I start, I want to first of all acknowledge the people who’ve made this AMWA conference possible and the annual con- ference chair, Dr Kimberly Korwek. I’d also like to thank the AMWA executive director, Susan Krug, and all of you at the American Medical Writers Association. All of you at AMWA have also been on the frontlines in this confusing and frightening time. We are working with incomplete information, interpreting new science, helping people with news that they need to use in their daily lives to navigate huge uncertainty and protect themselves and their families, and to understand changing policy impli- cations that often are changing by the minute. All of you are on the frontlines, not just with COVID, but also with all other aspects of health and wellness. Your work is so important, and I want to thank you for what you are doing every day. I’m also delighted to join virtually another award winner, my colleague, Dr Peter Hotez, who as you know, is being honored for his exceptional work in medical commu- nication and is a superb clinician and researcher, and who, along with his colleagues, has developed a COVID-19 vac- cine. So, what great company we are all in. Well, in my presentation today, I would like to talk about communicating public health in times of conflict and con- troversy, and my discussion is going to be in 2 parts. First, I want to talk about what we have learned from COVID-19, touching on the role of journalists, medical writers, and communicators, and then I want to discuss what we can do moving forward. And for each of these 2 categories, I want to give 3 lessons and move from less controversial to more controversial. And I look forward to engaging with all of you during this event and going forward as well. So, first category of what we have learned from COVID, 3 things. The first—and again going from the more obvious, less controversial to perhaps more controversial—the first is that there are many neglected issues that have been bared for everyone to see. Not a surprise to any of us who work in health, but I think these may be some issues that much of the American public may not have had as much awareness of—for example, health disparities. Disparities did not start with COVID, but COVID certainly amplified them. We saw this early on in terms of who has the ability—the privilege of social distancing, and who does not. We also saw this in the way that vaccine distribution first occurred, and when something was in extremely short supply like COVID vaccines, it was those who were able to get their smartphones and have all their friends and family start find- ing vaccine appointments who were able to get them first. Now, we also see those disparities don’t go away on their own, and we’re now seeing many of these same disparities playing out in monkeypox. We’re seeing the same dispari- ties playing out in virtually every other health issue that we can think of. But that, I think, is a neglected issue that more people are seeing now more than ever. 2022 Walter C. Alvarez Award Address Emerging Issues Following COVID-19: Public Health Communication Leana Wen, MD, MSc, FAAEM / George Washington University, Washington, DC CONFERENCE http://www.amwajournal.org AMWAJournal.org 13Emerging Issues Following COVID-19: Public Health Communication Similarly, with the concept of social determinants of health. Now again, all of us working in health and in health care know that you can’t separate someone’s health outcomes from the housing that they have access to, from the food that they have access to, or from working conditions, but I think those issues also really played out during COVID in a way that shed awareness for the first time for many individuals. One more issue, too, is that this country is really lacking in public health infrastructure, and one could even argue that we don’t have any kind of functional public health infrastructure. It was mentioned that I ran Baltimore’s health department. And I saw for myself every day how it was all about robbing Peter to pay Paul, that already— those of you who have a public health system for local and state health departments across the country know what I’m talking about here—people are already wearing multiple hats. The same people working on school health are also being pulled to staff shelters for individuals experiencing homelessness in the winter. And then you have something like COVID come along, and those same people are being moved from school health to now working on setting up vaccine clinics or setting up testing. And then now there’s monkeypox, or now there’s the reemergence of polio, and now these people are being pulled off these other crucial priorities to emerging issues, too. And I think this has been another issue bared for everyone to see, that there is no face of public health. Now, by definition, public health works when we are invisible. But the problem when we’re invisible is that public health becomes the first thing on the chopping block when it comes to budget time, and as a result, we’re seeing the consequences of neglecting public health throughout. Well, I just hope that we have learned from all of this that the cost of doing nothing isn’t nothing. Just something that my former mentor, the late Congressman Elijah Cummings, used to say, “the cost of doing nothing isn’t nothing.” Now, when we neglect public health, there are severe conse- quences, some of which we have seen during COVID. The second lesson that I believe we’ve learned from COVID is that public health depends on public trust, and when that’s eroded it’s very difficult to get back. When I look back at the very beginning of the pandemic—I think in ret- rospect with 20/20 hindsight—things could have been done differently. And actually, probably the top thing that I wish that I and others had done a better job of communicating early on and throughout is that change is to be expected. Actually, change is the bedrock of sound public health policy when you’re in the middle of an ever-changing situation like a new virus and a new pandemic. Now, when you look at many of the arguments against vaccines or various COVID protocols, it’s that public health officials are accused of being flip-flopping, but it’s not flip-flopping when circumstances change. In the beginning, as you all remember, we didn’t know that COVID was air- borne. We were really worried about surfaces, and we were advising people to wipe down groceries. There were no rec- ommendations for masking early on because we just didn’t know about transmission, and then we recommended masks. But then, it looks like flip flopping even though it was that the science evolved, and also that circumstances changed. Similarly, when vaccines first came about, we believed that in addition to preventing severe illness, they also pre- vented infection. Well, that changed with evolving time, with the arrival of the Omicron subvariants that the vaccines were less protective against infection during Omicron spread. And so, there is less a case for mandates than there were before, and so recommendations have to change with those growing circumstances with those changing circumstances in mind. And that’s actually something that in clinical medicine is really apparent because, in clinical medicine, you would absolutely expect that if you’re treating a patient with cancer, as an example, and there’s a new chemotherapy regimen that comes out, you would absolutely expect that your clini- cian is going to be offering that new regimen. You want your doctor to stay up to date with the science. And also, changing circumstances matter too. Using the same analogy, if some- one’s body is responding one way to one treatment and not responding as well as it should maybe to another, you would expect those recommendations to evolve. Well, that should really be the case when it comes to public health policy as well. And again, looking back, one thing that I wish we had done a better job of is to communi- cate that change is the bedrock of good public health policy. And I think by communicating the change, communicating not just what changed but why, over and over again, I think that is going to be crucial to reestablishing trust. The third lesson that I believe that we’ve learned from COVID is that public health has become very polarized. Now, my great concern prior to COVID was that people were not thinking about public health. Now, we had to make the case for why public health matters to public safety, or why it matters to education, and why it matters to the economy. But it was a fairly neutral topic—it just wasn’t something that people really thought about. And a major concern, having run a local health department, was that public health was always underfunded. Well, I have a different concern now, and I think it’s an even more significant concern. Let me take you back to a http://www.amwajournal.org AMWAJournal.org 14Emerging Issues Following COVID-19: Public Health Communication focus group that I had the opportunity to participate in for the Bulwark, and we did a podcast based on this. But the focus group was looking at the various mitigation measures, and they were interviewing Republicans, Democrats, and Independents, and what really came through in the focus groups was that masks and vaccines means something other than what they are, which are public health measures that help to reduce virus transmission. For one group, and you can guess which group, but for the group that’s anti- these measures, they see masks and vaccines as being about control, about government con- trol over individuals. This was a fight for individual liberty, versus for the other group that very much wanted masks and vaccines—one would argue perhaps even want mask mandates and vaccine mandates still. For the other group, it was almost a reaction to that first group, and masks and vac- cines equaled caring for others and equaled not being part of that antimask, antivaccine “Republican” group. And so, I bring this up because I really worry about this. I mean, public health has always been hard because it’s about balancing individual liberty versus what’s best for all and protecting the most vulnerable. It’s not clear where that pendulum is going to be, someone is always going to be accusing you no matter what policy you set of having the balance wrong. You’re either weighing more toward indi- vidual liberty or more toward doing something that protects all but at the cost of individual liberty, and that’s not an easy balance to strike. I mean, even thinking about something as basic as whether somebody with multidrug-resistant tuberculosis should be required to quarantine or be required to isolate for the duration of their illness. I mean, even something like that that I think for most of us in public health would be pretty easy to say, “yes, that person should be in isolation.” But enforcing that, especially against that person’s will, that’s still a matter of saying what’s best for people—for all people, is going to outweigh individual liberty. So that bal- ance has always been hard to strike. But I would say now that balance is many times harder to strike because we are now seeing a substantial backlash against public health in a way that we have not before. We have more than half of states passing laws and legislatures passing laws that restrict public health authorities in some way. That’s not just going to affect COVID, but many other issues down the line. For example, if there is a bill that pre- vents local health authorities from issuing mask mandates in the future, a patient with multidrug-resistant tuberculo- sis, or somebody with measles, which is a most contagious illness—things like that will also be affected as well. We know that routine childhood immunizations are falling, and that’s something that’s also very concerning. We’re seeing that immunizations that previously were just accepted as something that children should do, was an opt- out. Now a lot of parents are beginning to question whether certain immunizations should go forward or not. And I have this very significant concern that the back- lash against COVID restrictions, because of how politicized COVID has become, is now bleeding into these other things, and there are really significant consequences here. We’re talking about infectious diseases, but we’re also talking about other aspects of public health. Again, if public trust is eroded, it’s very difficult to get back. And I’m very con- cerned that we’re going to lose trust from the public for the next virus that could be a pandemic, or we could even lose trust from the public for other routine public health matters that previously were not questioned. Now, it’s unfortunate that many public health officials and experts during COVID have been attacked for our views. Dr Hotez is certainly one who’s come, unfortunately, under attack. I have had similar experiences, and I would just say that from my standpoint, I think there is a reflex— sometimes blame, if you will—of saying, “well, it’s one side. It’s the antimaskers or the antivaxxers who are attacking us for our views.” But I actually think that these attacks come from all sides. And again, this backlash I really fear is going to hurt what public health is able to do in the future. And so, here’s the controversial statement that I’m going to state and leave us on before we move to the second part of this conver- sation. And the controversial statement that I have is that the more we keep focusing on COVID, the more it’s going to bleed into and have consequences on other aspects of public health. And I actually believe that when restoring trust in public health, we have to recognize that good health is not just the absence of COVID, and we have to recognize that, like it or not, COVID has been inserted in the middle of culture wars. And that if we are going to have any chance of depoliticizing public health and bringing public health back to this non- partisan state that it should be in, I believe that we need to put the focus away from COVID and more on other health issues that also very much impact health and well-being but are not subject to that same polarization as unfortunately, COVID-19 has been. I now want to move to the second part of this discus- sion, which is “What can we do moving forward as medi- cal communicators, as journalists, and as people who are public-facing?” And here, I have 3 recommendations, and http://www.amwajournal.org AMWAJournal.org 15Emerging Issues Following COVID-19: Public Health Communication they’re going to move again from more obvious and less controversial to perhaps a bit more controversial. So, 3 things on how we can propel the conversation forward. The first is that we need to be transparent and intellec- tually honest with the public. Let me explain to you what I mean here by giving you an example of something that happened at a conference several months ago. I went to a conference that was a lay audi- ence conference, was talking about COVID, and at that time just doing an explainer on boost- ers, vaccines, and immunity. And at the end of the conference, 3 people came up to me and almost whispered a question, and it was said to me as well, basically, “I didn’t want to raise this issue in this forum in front of everyone, but I want to ask you about natural immunity—is that a thing?” Of course, it is a thing. I mean, it is true that there is such a thing as “natural immunity,” also referred to as immu- nity after recovering from COVID or from other infections. I think what’s happened, and the reason why these very well-educated individuals who are very much pro-vaccine were afraid to ask the question, was that they feared a back- lash. They feared a public response of other people in that audience accusing them of being antivax for asking the question about whether natural immunity exists. But you know what? It does exist, and I think if we are not honest about it with individuals. Because look, I understand all the reasons at the beginning of the pandemic—I think especially right after vaccines first came out—I think there was this fear that if you talked about immunity after recover- ing, that people are not going to want to get vaccinated. But the thing is, you can say 2 things are true are once. It is true that you have some level of immune protec- tion after getting infected. It is also true that you could get even better, more robust, and more lasting protection if, in addition to recovery from infection, you also got vaccinated. And, in fact, we have many studies now showing that this hybrid immunity conveys probably the most durable, the most consistent, and the strongest level of response. But acknowledging natural immunity isn’t being anti- vax, and actually, not acknowledging it makes people think that you’re hiding something from them and that you’re not being intellectually honest. And so, I think part of this is what we can do, I believe, as medical communicators are really being honest even when that topic is nuanced and difficult. Now, we talked a little bit about masks earlier. I think that one of the reasons why the World Health Organization and the Centers for Disease Control and Prevention were not recommending masks early in the pandemic, very early in the pandemic, was that there was a very limited number of masks, especially N95 and new prevalent masks. And I think that we should have been honest and said masks could be helpful. We’re not sure because at that point in the pandemic— we’re talking March of 2020—we didn’t know exactly how help- ful they were, but we could have said, “They probably are helpful, but right now we need to save them for health care workers.” I think that that type of intellec- tual honesty would have also avoided some of the accusations against flip-flopping later. Similarly, with monkeypox vaccines, I think we should have been honest to say that they need to be rationed when there’s a limited supply and a lot more people interested in getting the vaccines than the supply initially was for. I know that rationing is a bad word, but it’s also the truth that at that time rationing had to occur. I think sometimes in communication in general, there is a need to try to simplify for our audience—and look, I’m not saying that this is easy at all. But I also think that our audience deserves the truth from us, and the truth is that science isn’t always clear-cut, and that medicine exists in the area of gray. Two things—or multiple things—can be true at once. For example, mitigation measures can and do reduce the spread of the virus, but they all come at a cost. Telling people, for example, to not gather with one another, having physical distancing, even mask-wearing—yes, they reduce spread, but they also have a cost. And so, I think those people who are trying to again get people to do something that they don’t want to do and follow mitigation measures sometimes feel like, well, we have to emphasize only the benefit. But then, I think we’re not being intellectually honest if we don’t also talk about the cost. And I believe that our duty, as communicators, has to be to give the full truth, not just the truth that we think others can handle. Because if we do that, if we try to limit the truth and censor those who are trying to tell a fuller story, then  And I believe that our duty, as communicators, has to be to give the full truth, not just the truth that we think others can handle. Because if we do that, if we try to limit the truth and censor those who are trying to tell a fuller story, then I believe we’re actually undercutting public health further and eroding trust further. http://www.amwajournal.org AMWAJournal.org 16Emerging Issues Following COVID-19: Public Health Communication I believe we’re actually undercutting public health further and eroding trust further. The second thing, and again, 3 things here on things that we can do differently. The first is to be transparent and intel- lectually honest. The second is to acknowledge that follow- ing science is not a sufficient motto—that public health is, of course, based on the science, but ultimately, it’s about values. There’s been a lot of discussions now as we are moving through the emergency phase of COVID-19 about when mit- igation measures end, and that is in some ways based on the acceptable number of infections, acceptable number of hos- pitalizations, and acceptable number of deaths. Some people might say that as long as hospitals are not getting overwhelmed again, then mitigation measures can end. Others will say that as long as infection levels are high, as long as there is long COVID, then we need to keep up mitigation measures. I mean, these questions are based on the science because modeling, for example, can help us to understand where we’re at and where we’re going. But this is not just a scientific question, this is a question just as much societal value. I think it’s important for us to again be intellectually honest about that. We also, crucially in public health, have to consider where the public is at. There is no point in recommend- ing something if people literally won’t follow it. My sister’s partner is Dutch, and we were recently having a conver- sation about how in the Netherlands bike helmets are not required, and very few people are actually wearing bike helmets. And for us, in this country, it seems rather shock- ing that you have all these people biking but with no hel- mets. And the point that my sister’s partner was raising is, well, let’s say that you actually are now saying that helmets are going to be required, but if half or more of the popula- tion literally are not using helmets, it’s going to be impos- sible to enforce. And then if people start questioning this law or this regulation, you may have the issue of the boy who cried wolf. If they don’t trust you on this, and this thing cannot be enforced, then why trust you on other issues? And I think that’s been one of my considerations in thinking through when our mitigation measures need to end. It’s a values question, but the value also has to take into consideration where people are already. If most people are already not wearing masks, if most people have already returned to going to indoor restaurants and going to travel, it’s not going to work to say, “oh no, don’t do those things.” Rather, we need to work on, in a sense, harm reduction. We need to help people to do the things that they want to do and make it safe for other individuals who are more vulnerable, so doing things like recommending same-day testing for individuals before they go see their elderly rel- ative in a nursing home or making sure that people have access to vaccines and boosters. And that we’re also making treatments readily available and reducing all barriers to treatments and making sure that there are lots of other treat- ments that are actually hugely underutilized like Evusheld, the preventive antibody—for example, it was hugely underutilized. How can we make sure that those things are pretty low-hanging fruit? I mean, these are not things that there is a societal objection against, but they are things that as a policy matter, we can try to make them more available. And I think that that’s one way of considering where the public is at and knowing that you’re not going to force people to do something that they don’t want to do. But you can still work around where people are to get to the point that we all need to get to, which is protecting the most vulnerable. This is another call for understanding and accepting the nuance that circumstances have changed. And I think part of this nuance is accepting that just because most indi- viduals have returned to normal doesn’t mean that some individuals haven’t, and it also doesn’t mean that societal change has to stop. Sometimes, especially when you look at social media, it seems like there are people who want to simplify and say, “well, if you are in favor of people returning to normal, that means that you don’t acknowledge that COVID is real, or you don’t acknowledge the more than a million deaths from COVID, or that you don’t acknowledge the toll of long COVID.” I think both of those things can be true at once: I think it can both be true that COVID has had this huge, ter- rible societal impact and continues to have an impact, and we need to address societal policy issues like improved ven- tilation, and paid sick leave, and aiming for universal access to health care. You can aim for societal change, but at the same time also acknowledge that Omicron COVID is going to be with us for the foreseeable future, and that we need to empha- size returning to normal in order to get people to see that good health is not just the absence of COVID—both of those things can be true at once. And I think we as commu- nicators should really push back against those who seek to simplify and further polarize where we’re at in this discussion. And so, that makes me move to the third thing. After being intellectually honest and talking about values, we need to embrace our role to seek the hard truths and to act with fairness and empathy. All of you as communicators and journalists, you are finding these neglected issues that http://www.amwajournal.org AMWAJournal.org 17Emerging Issues Following COVID-19: Public Health Communication we begin our conversations with. You are the ones who are finding out about health disparities, and you know that if you don’t dig around for those data often, they’re not being produced. And so, I want to commend you for what you’re doing in this sense to really shed light on disparities, on social determinants, and on these other neglected issues. You also have such a crucial role to play as a communi- cator in accountability. How is the funding that’s being allo- cated being spent? There was funding going to classrooms for improving ventilation, and all this money going to local health departments. Well, where is that money and how is it being spent? You are also the ones helping to make the connections on these various issues related to social deter- minants of health, and I think that your role here is so important. We started this conversation, too, by talking about con- flict and controversy. Well, I want to put another plug in for how a lot of that conflict and controversy is manufactured. Often, it’s someone taking one sentence out of context, and that they want to make you, or me, or all of us about one or the other. And I think that our role as communicators also has to be honest and fair and to really point out when some- thing is being taken out of context. I believe, too, that we have a role to be decent to one another, and when we fight among each other there is a potential harm that it erodes trust for all of us. And frankly, there are so many more issues that we must address together. We have the reemergence of polio, we have routine childhood immunizations falling off a cliff, and we have the opioid epidemic driven by fentanyl that’s gotten worse now more than ever. We have women’s health at a crossroads that’s being threatened across the country, and we have mental health that’s long been neglected and getting worse at this time. And, of course, we have this issue of robbing Peter to pay Paul and not having sustainable infrastructure for public health. There are so many issues that we need to address together. And I hope that coming out of COVID, we’re able to come together and address these other issues, digging up data where needed, and holding people accountable where needed, but also trying to take away that level of anger from the conflict and controversy. We’re trying to depoliticize public health and getting us all back to the place where we’re able to work together on these difficult issues. Now, the work ahead, no doubt, is very challenging. I want to end with a quote and an appreciation for all of us who work in public health and communication. And this quote is by Dr Harrison Spencer, a former leader in public health—as you will see from this quote. And Dr Spencer says that “Public health is filled with heroes, both well- known and unknown. They are visible on the national or international stage, or they work quietly in communities with families and individuals. When they do their job, they often become invisible.” Well, I believe that that is the job that you all do in AMWA every day—you help to make the invisible visible, and you help people to navigate their lives at very challeng- ing junctures. And you’re also helping us to push forward to a time where we’re able to really value public health as the crucial aspect of our overall national security and our well-being, and you’re helping to lay bare all these crucial issues that many people unfortunately are neglecting. And I truly believe that when the long arc of history is written, you will be the heroes, and I am so honored to join you at AMWA today. Thank you. Acknowledgment I thank Kavita Garg, Director of Medical Writing at Saliegral Global, for her help in bringing the transcript to the page. Author declaration and disclosures: The author notes no com- mercial associations that may pose a conflict of interest in rela- tion to this article. Author contact: drwenmedia@gmail.com Author Biography Leana S. Wen, MD, MSc, FAAEM, is an emergency physician, public health professor at George Washington University, and nonresident senior fellow at the Brookings Institution. She is a contributing op-ed columnist for the Washington Post, anchoring the weekly Post newsletter “The Checkup with Dr. Wen.” She is also an on-air medical analyst for CNN. http://www.amwajournal.org