By Taylor Knopf

Stopped on the street, someone asked state health and human services secretary Mandy Cohen, “Are you the ‘three Ws’ lady?”

“Yes I am,” she responded.

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The memory makes Cohen chuckle. More importantly, she said, the slogan is getting into people’s heads. As North Carolina slowly reopens, Cohen and public health officials have continually reminded residents to:

Wear a face mask in public.

Wait six feet apart.

Wash their hands.

It sounds simple enough. But the “three Ws” slogan was a carefully crafted message vetted by multiple people at the state health department and the University of North Carolina Chapel Hill.

These are “memorable, simple actions that really work,” Cohen told state lawmakers last week.

Not only are public health officials trying to relay the latest information about COVID-19, but they’re asking North Carolinians to change their behavior to slow the virus spread, said Tracy Zimmerman, senior director of external affairs for the N.C. Department of Health and Human Services.

Public health messaging can be tricky and there can be dire consequences if information is not communicated properly. Experts say that unified public health messaging can create solidarity and positively impact a community’s ability to rebound after a crisis.

However, misinformation, contradictory statements and conflicting political agendas all hurt the overall health of the community, according to Roxane Cohen Silver, a professor of psychological science, medicine and public health at the University of California, Irvine.

“Insincerity from one’s leaders also impedes community resilience and fostering any kind of community conflict can impede the likelihood of our community bouncing back from this crisis,” Silver said.

She and her colleagues studied community resilience and the role messaging and media played in the aftermath of tragic events, such as the September 11 terrorist attacks, the Boston Marathon bombings and major hurricanes.

“We can promote shared values and community solidarity,” Silver said. “And we can bolster confidence in trustworthy authorities such as health professionals who are fighting the disease on the front lines.”

Three signs on a dirt berm encoureaging behavior to prevent COVID
UNC-Chapel Hill community urged to follow the three Ws. Wash hands, wear a face mask, wait six feet apart. Photo credit: Anne Blythe

Ever-evolving crisis

During the coronavirus pandemic, public health experts have had their work cut out for them as they’ve tried to educate the public about a virus they knew nothing about before the beginning of the year.

“We’ve been really thinking through, how do we communicate effectively with such a rapidly evolving situation and pandemic that we’ve never been in,” said DHHS Chief Medical Officer Betsy Tilson. “Communication has really been key to our response.”

Tilson emphasized that her department has always based its recommendations on the current data and science available.

“I think that that has been a little bit of a challenge as that science and data is evolving,” she said.

This virus is “brand new,” she said. And her team has changed some recommendations as they’ve learned more about the coronavirus. Tilson said she believes that transparency about what is known and unknown due to limited data is the key to building public trust, as well as regular public updates through media briefings.

“But we anticipate and know that there will be new science and data,” she said. “Then we may need to change our policy based on that new science and data.”

One prominent example of this is the great debate over wearing masks.

At the beginning of the pandemic, public health experts including infectious disease expert Anthony Fauci, U.S Surgeon General Jerome Adams and North Carolina’s own health secretary did not recommend face coverings for the general public.

But as a trickle, then a flood of studies on the effectiveness of face coverings emerged, the recommendations changed. Today, many states have mask mandates for those in public spaces, and many public health experts attribute widespread face covering use to reductions in case numbers.

February tweet from U.S. Surgeon General Jerome Adams. Later, Adams walked back this comment, noting that as time has gone on, evidence has evolved and masks have become more available for medical workers, masks have become a necessary part of the fight against spreading COVID-19.

State officials believe that most North Carolinians have embraced the mask mandate. However, there’s still work to be done to ensure people are wearing masks consistently and correctly, Zimmerman said.

“One of the things we’re learning is that we need to start talking a little bit more about what we mean by public, because that may be something that people define differently,” she said.

While most people view grocery stores and pharmacies as public spaces and are willing to wear masks there, Zimmerman said not everyone views hanging out with friends in a public space as a situation where they should wear masks.

Crossing party lines

Although in late June, Pew Research found that the majority of Americans now agree that masks should be worn in public, there’s still division along political party lines on this issue.

Of those surveyed by Pew, 63 percent of Democrats responded that masks should always be worn in public, while 29 percent of Republicans responded in the same way. Meanwhile, 23 percent of Republican respondents said that masks should “rarely or never be worn.”

Even the president of the United States was reluctant to wear a mask several months after the Centers for Disease Control and Prevention recommended that all Americans wear them to prevent the spread of the virus.

Donald Trump didn’t wear a mask in public until last month and didn’t endorse wearing one until a few weeks ago.

Just as the pandemic ramped up in the U.S., public health experts from Harvard University released strategies for building solidarity during this health crisis. They urged leaders to not only “talk the talk” but “walk the walk.”

“Messaging should encourage citizens to embrace shared vulnerability and shared potential for overcoming adversity around a common identity,” Harvard researchers wrote. “While that may seem intuitive, the historical record and recent moves by various political leaders in the face of COVID suggests that this approach is not obvious.”

Instinctively, some politicians want to distance their supporters from the virus, seeing association with it as “a sign of weakness or stigma,” the researchers explained.

“Denial of risk to one’s own community is standard practice in epidemics,” they continued. “While ‘othering’ is a powerful strategy for building some types of solidarity — such as team play or warfare — it is self-defeating in the case of public health.”

shows the mnemonic used for COVID prevention
The three W’s is the cornerstone of the messaging campaign created by North Carolina’s Department of Health and Human Services.

Sowing this kind of division among the public feeds into denial of risk, endangering the community, the Harvard researchers concluded.

In North Carolina, DHHS officials said they’ve had frequent briefings and conversations with state lawmakers on both sides of the aisle and been available to answer questions.

“Conversations are constant and they are beyond party,” Zimmerman said.

Let health experts lead

To build trust in a pandemic, public health experts should lead the COVID-19 messaging, not politicians.

Polling conducted after SARS and Ebola showed that citizens want to hear directly from public health experts, said Gene Matthews, a senior investigator at the North Carolina Institute for Public Health who spent 25 years at the CDC as chief legal officer.

But he said it’s tempting for political leaders on both sides of the aisle to want to step in the spotlight and take charge.

“And when you do that, it takes on a political cast even in normal times,” Matthews said. “A scared public citizen doesn’t want any more spin. They’re wanting facts from somebody who speaks with authenticity.”

Trust and willingness to listen to those in leadership is key to building solidarity, Harvard researchers wrote in a March paper on COVID-19 messaging strategies.

“In many contemporary democratic societies, particularly in a highly polarized one such as the United States, large segments of society do not trust many or most of their leaders,” the researchers explained. “This sentiment is not unique to the current administration.”

They recommended invoking the help of trusted individuals — such as public influencers and community or religious leaders — to help spread public health messages.

So how are we doing?

It depends who you ask. There’s still a partisan divide when it comes to critiques of North Carolina’s public health messaging.

William Munn, policy analyst at the left-leaning think tank NC Justice Center, said he thinks DHHS has done “an excellent job promoting healthy habits during this pandemic.”

The “three Ws” have “been distributed strategically and have been repeated by leaders all over the state,” he said.

As for those not following the COVID-19 health recommendations, Munn believes “that public health messaging has not failed to inform residents of best practices in the midst of a pandemic, but rather a subset of the population — leaders included — who refuse to acknowledge that the pandemic is serious enough to warrant a change in personal behavior, have ignored and sabotaged the state’s collective effort to fight against COVID-19.”

On the flip side, Jordan Roberts, health policy analyst at the John Locke Foundation, a right-leaning think-tank based in Raleigh, said he does not think the messaging has been “as effective as it could be.”

“In my opinion, the Cooper administration seems to be making arbitrary decisions with regard to what can be open and what can’t,” he said. “I believe people recognize this and it sows distrust among the public which undermines messaging.”

While Roberts said he doesn’t envy public officials making decisions during a pandemic, he believes that the state has not released enough data.

“I don’t believe they’ve released everything they are using to make these decisions, and I especially believe they have not provided necessary context that is needed to interpret the presented data,” Roberts said.

Several North Carolina-based news organizations, including NC Health News, have sued Cooper and his cabinet agencies for more data and records during the pandemic.

But according to Matthews, the former CDC chief legal officer, North Carolina is doing as well as can be expected with its COVID-19 response given the lack of federal leadership.

He noted that the CDC fumbled in its response to COVID-19 at the very beginning, particularly with early testing. The CDC has a several hundred-page playbook for handling public health emergencies that was put together after the SARS outbreak in 2003, Matthews said.

“[The playbook] is still apparently sitting on a shelf,” he added.

Ideally, CDC would have daily COVID-19 briefings, according to Matthews. But instead, he said a small percentage on the far right and far left have weaponized a public health crisis during an election year for their own political gain.

Federal leaders “passed the buck” to the states, he said, and Cooper has followed the playbook by letting his health expert lead the public health message. Matthews said he thinks Cohen is very experienced given her time at Centers for Medicare and Medicaid Services.

“She’s seasoned. She’s very smart, and she has that ability to speak with authenticity, which is critical,” he said. “And the governor defers to her.”

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Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...