Tuesday, September 11, 2012

Health communication: what not to do

To be effective, public health professionals must be well-informed not only in the science of their disciplines, but also in methods of communicating the implications of scientific findings to the general public. Dr. Tomas Stockmann, the protagonist of Henrik Ibsen’s A Public Enemy, provides a case study in (mostly) what not to do when a public health professional discovers a serious threat to his or her community. Stockmann’s message is further complicated by the fact that germ theory was not well established in the 19th century, making it critical that he enlist the support of other stakeholders in order to persuade the public of the necessity of immediate and decisive interventions (closing the municipal Baths and re-routing its water conduits to avoid contamination).

Act One of A Public Enemy establishes the importance of the “splendid, handsome new bathing establishment” that Stockmann’s brother, the Mayor, predicts “will become the very heart of our municipal life.” Speaking with Hovstad, editor of an influential newspaper, the Mayor observes that the popularity of the Baths has increased property values, reduced unemployment, and decreased the tax burden on the wealthy for supporting poor citizens. Foreshadowing the bad news to come, however, Dr. Stockmann is troubled by the news that Hovstad intends to soon publish his “confounded” article on the “excellent health record” of the town and Baths. After receiving a letter that contains a microbiological analysis of a sample of water from the Baths, Dr. Stockmann shocks his guests by indiscreetly proclaiming that the town’s major attraction is, in fact, a “pesthouse” and “the greatest possible danger to health.” Apparently, the Baths’ water source has been polluted by upstream industrial waste from his father-in-law’s tannery, among other sources. In Dr. Stockmann’s terminology, the water contains “putrefying organic matter” and “millions of infusoria,” and, rather than being salutary, is a “menace” to the health of everyone who uses the Baths. Basking in the reporter Billing’s prediction that this announcement will make him the “most important person in the town,” Dr. Stockmann incorrectly predicts that his brother will be “glad that such an important fact has come to light.”

As Act Two reveals, however, the Mayor is anything but pleased. He challenges the necessity of such an extreme remedy to the problem and observes that the financial effect on the Baths and the town from Dr. Stockmann’s recommendations would be devastating. “You would have ruined your native town,” the Mayor accuses. Threatened with dismissal from his position as Medical Officer of the Baths, Dr. Stockmann refuses the Mayor’s request to retract his report and postpone saying anything publicly about the matter. This is Dr. Stockmann’s first mistake: alienating the elected leader of the town by feeding their sibling rivalry, rather than negotiating the best way to communicate the news.

Dr. Stockmann believes he can count on the backing of the Hovstad and his newspaper’s financial benefactor, the printer Aslaksen, to communicate his findings over the Mayor’s objections. However, the Mayor soon persuades them that publication of Dr. Stockmann’s report will be ruinous for them and the town, and Dr. Stockmann finds himself completely isolated. Nevertheless, the self-proclaimed “patriot” moves ahead and calls a public meeting where, defying the Mayor and Aslaksen’s wishes, he tries to convince the townspeople of the truth of his findings. By the time he gains the floor, however, Dr. Stockmann is so upset that he instead lashes out at the “overwhelming stupidity of the authorities” and ridicules the remainder of those present as “fools” who “want to found the town’s prosperity on a quagmire of lies and fraud.” As a result, it is easy for the townspeople to “blame the messenger” (Markel 2009); Dr. Stockmann is proclaimed a “public enemy,” dismissed from his position, and his house is stoned by an enraged mob.

In addition to setting aside his rivalry with his brother and exploring ways to achieve both of their goals (protecting the health of the townspeople without bankrupting the Baths), how else might Dr. Stockmann have more effectively communicated the danger to his community? He erred in using the technical language of a scientific report (“millions of infusoria”), rather than simpler messages that people could grasp more easily. Even if Hovstad had published the report, it seems unlikely that most readers would have understood it, much less believed its conclusions. As one commentator noted, contemporary “epoch-making scientists (such as Pasteur and Koch) not only produced convincing and reliable data from a scientific point of view, but also acquired the skills and insights needed to enter into a dialogue with their cultural and societal environment” (Zwart 2004). In fact, Pasteur’s “true success” has been said to have been not proving germ theory, but “transmitting [it] to the greater world” (Matos 2008).

As Dr. Stockmann discovered, relying on his own authority as a “man of science” and taking for granted the support of other key stakeholders (the Mayor, the town paper, and the leader of the townspeople’s association) was a recipe for disaster. Confronted by a public health threat that they may not fully understand, most people instinctively turn to these authorities, who in this case were given no good reasons to endorse Dr. Stockmann’s recommendations. Finally, and most fatally, Stockmann “negates his professional effectiveness by succumbing to his own anger and lashing out at the public. By misfiring his alienating tirades at those he most needs to convince, Stockmann creates an insurmountable public health barrier: distrust of the very official the public needs to trust most” (Markel 2009).

References

1. Markel H. Physician, heal thyself: Arthur Miller, Henrik Ibsen, and the enemies of the people. JAMA 2009;301:2506-7.
2. Matos TC. Choleric fictions: epidemiology, medical authority, and An Enemy of the People. Modern Drama 2008;51:353-66.
3. Zwart H. Environmental pollution and professional responsibility: Ibsen’s A Public Enemy as a seminar on science communication and ethics. Environmental Values 2004;13:349-72.

3 comments:

  1. You - and Ibsen - are spot-on, and this applies to many arenas in the health care system. But I'm curious - did you have a particular topic in mind? The decline of innoculation rates? The campaign to educate about the risks of PSA screening?

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  2. Brilliant and timely. So many in the world of medicine fall into this trap. "truth" uber alles.

    Had he quietly brought this to his brother's attention and enlisted his help to address the "upstream pollution", his brother may quietly have become a powerful ally to correct the source of the contamination.

    thanks for sharing this

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  3. Thank you, Larry. Susan, I didn't have one particular modern-day health communication issue in mind, and I think these principles could apply to many scientific topics, including those you mentioned. Science and health care are inextricably entwined in politics, and need political support to get their messages out to the public, though as you know if you've read this blog before, I don't believe that politics should routinely trump science, especially when doing so harms people.

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