“Give it to me straight”: Media in Singaporean healthcare

Social and news media (SNM) are ubiquitous, high-potential communication and surveillance platforms for health issues. SNM is crucial in dictating a relevant public focus on health issues.(1) SNM can enhance communication speeds, which is crucial during public health emergencies in mobilizing action, facilitating behavioral changes, aiding public understanding and awareness, and engaging participation.(2) This is particularly important when dealing with contemporary communicable diseases (CCD) as SNM can reach the general public, policy-makers and financiers.(3)

CCD are infections that clinically manifest disease and are significant public health concerns due to their capability for significant mortality.(4) In our increasingly globalized world, people are increasingly susceptible to CCD due to several factors including the close proximity of human and animal spaces, population growth and climate change.(3,5) This is especially important as many of these diseases are emerging or re-emerging, and apart from the health burden they pose, CCD affect social factors and the economy of a country, especially in low- and middle-income countries.(3) Control and management of communicable diseases can be primary (reducing disease incidence), secondary (reducing disease prevalence) or tertiary, (completely eradicating the disease).(4) However, at all levels, adequate awareness and response are crucial for management and control of CCD outbreaks.

As CCD outbreaks are difficult to predict and medical interventions take time to develop, the first course of action is creating awareness through education.(3) It is vital to ensure that the information distributed by the SNM is accurate as misinformed SNM reports can cause public panic and cause chaos, impacting the economy.(3) Irresponsible or inaccurate reporting and sensationalism of news can adversely affect public health.(3)

Singapore is a land-scarce, tropical island nation in Southeast Asia. Being land scarce, animals and people live in close proximity, creating high opportunities for disease transmission and CCD outbreak.(5) This is exacerbated by Singapore’s high tourism rate, creating a high population flux throughout the year.(6) The Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 brought to light the issue of rapid disease transmission.(3) Globalization, bringing about increased international travel, particularly for tourism or trade, was a factor in the rapid international spread of SARS.(3) However, due to foreign media reports in Northeast Asia, Singapore was able to anticipate problems and monitor the situation from the first infection.(7) Through the use of a SARS-dedicated television channel, Singapore was able to create a means of information dissemination to the masses.(7) However, this means was a limitation in Singapore’s strategy as the channel had low viewer engagement, rendering it ineffective.(7) The media was also recruited to work with healthcare personnel and government officials to alleviate fear and build the people’s trust in their leaders so as to work together to control the outbreak.(7)

The social factors impacting the use of SNM in CCD outbreaks include socio-economic status and education levels. During the SARS outbreak, the government implemented numerous social media strategies to ensure that lack of access to pertinent information was not an obstacle for Singaporeans. Apart from print media outlining the main features of SARS and the precautions to be taken, general information and symptoms education were provided to every household in Singapore.(8) However, it is also important to acknowledge the potential of social capital in improving awareness of CCD. A study in Cambodia found that use of social networks, due to the close proximity of homes to one another, was a significant factor in educating the public about CCD and enacting behavioral change.(9) Perhaps the most crucial social factor leading to the success of SNM in communication during a CCD outbreak was the reported high levels of public trust and confidence in the government and public health communications.(10) However, this is likely due to the cultural traits of Singaporeans, who often prioritize the greater good over their own rights.(7) Further research is required to determine if this is applicable to other international communities.

In terms of the politico-cultural factors of SNM in CCD outbreaks, the SARS outbreak highlighted the linguistic factors and cultural sensitivities of Singaporeans. While the government has policies that discourage the use of dialects in favor of promoting the 4 major languages, English, Malay, Tamil and Mandarin, in times of crisis this rule was relaxed.(7) This was implemented when elderly ethnic Chinese reported feeling marginalized as the interventions during the SARS period were difficult to understand.(7) In due course, materials in dialects were produced and distributed to the masses.(7) Another political factor impacting the use of SNM in CCD control and management are the obstacles to free speech within the media in Singapore. It is difficult to find information on the shortfalls of Singapore’s approaches due to the strict curation of media within the country.(11)

However, Singapore has advanced in the use of SNM during CCD outbreaks. Following the SARS outbreak, Singapore implemented the National Influenza Pandemic Readiness and Response Plan, which was activated during the H1N1 outbreak of 2009.(10) From 2001–2011, 51% of outbreak information was initially obtained via SNM, proving that collaboration between SNM and the public health sector is important for strengthening mechanisms during CCD outbreaks.(3) The benefits of SNM is that it can be a tool to ask difficult questions to elicit urgent responses from the government. For example, during the 2003 SARS outbreak, the media criticized the lack of transparency in several Northeast Asian states.(3) This led to the Singapore government’s dedication to transparency within Singapore. While this approach also led to international media criticism, namely of the stringent measures undertaken, the government was able to use this to build the people’s trust in them.(7)

While medical experts can disseminate information, it may be difficult to communicate this in a compelling way or in layman’s terms. SNM is able to fill this gap and disseminate information to people in a comprehensible manner, particularly during an outbreak when people are reported to have “greater faith in media reports than government messages”.(3) Furthermore, policies are ineffective alone, behavioral change is key and SNM, through the exposure of dangers, is crucial. In addition, a constant flow of information, with different angles, is helpful during an outbreak as it allows the issue to reach different populations. Framing gives SNM the capacity to set the public discourse.(12) Therefore, SNM reporting that focuses on building trust between the people and public health sector has the potential to save lives by guiding people to make informed decisions. If SNM fails to provide adequate scrutiny or coverage on potential decisions, the long-term impacts include loss of public trust in the government and a vulnerable public.

Unfortunately, today, a disconnect remains between the public health sector and SNM. Corporations use catchy or sensationalized advertising to sell their products.(3) This forces the health sector to compete with these well-funded giants for the public’s attention to communicate their health message. The media is often an unreliable means for communicating risk or sustaining meaningful public discussions on complex health issues.(12) For example, during the SARS outbreak, the Singaporean media and public called for the release of patient names, however, the complexities of this action were not discussed.(13)

Ultimately, SNM is a perishable commodity that must be relevant to the audience and meet deadlines. Once the deadline is missed, the story and its public health message is no longer deemed relevant and is not disseminated. In the same vein, SNM stories require representatives from the health sector to lend credibility to the story, but in times of emergency, this is not always feasible of the health sector.(3) Unfortunately, this can result in SNM obtaining credibility from a mediocre source, creating the potential for irresponsible or incorrect reporting. This also raises the issue of the disconnect between healthcare personnel and healthcare representatives. Many a time, the people analysing the data are not the ones liaising with SNM.(3) This creates additional opportunities for miscommunication.

SNM has driven our need for instant gratification. Citizens are focused on current news. This can push SNM to report information and data as they emerge, instead of waiting for complete data.(3) Unfortunately, data can often be misread out of context, creating panic. If SNM reports on a pressing issue before the health sector, it can also negatively impact the people’s view of the public health sector.(3) Changes in SNM ownership laws has led to the rise of opinion-driven news coverage, which has pernicious effects due to lack of curation.(12) Sensationalizing of unfiltered data can lead to inappropriate political responses, public panic and an inequitable allocation of resources. These impacts are long-lasting as they can lead to ineffective medical investments, strains on medical resources and other poor cost-effective control measures.(12) These economic repercussions are potent threats to a nation’s security.

Finally, health journalists can do a lot of good or bad. The potential for harm typically drives SNM coverage. Reporters without sufficient health knowledge may not be able to grasp the complexity of the issues or the terms involved.(3) This knowledge gap can lead to misreporting, causing greater public anxiety, especially since the Singaporean audience is diverse and variable.

That said, Singapore’s response to the 2003 SARS outbreak has been commended. Not only was a SARS-dedicated TV channel launched, Singapore has used SNM to alleviate public fear through dialogues between leaders and the community. Foreigners, diplomats, religious groups and trade associations were briefed, and various modes of communication, such as adverts, booklets, cartoons and even a SARS song was utilized to create awareness.(7) In addition to creating awareness, SNM was used to promote transparency and broadcast rebuttals of negative claims to clear up misconceptions. Promotional campaigns and use of the 4 major languages in issuing home quarantine orders were additional methods used to manage the outbreak. Some limitations to Singapore’s approach was in regard to its commitment to transparency.(13) In the beginning of the outbreak, contradictory information was a source of confusion.(13) However, this became less of an issue as the outbreak progressed and the Ministry of Health resolved to hold daily press briefings at 9 pm, against public outcry, so as to be able to verify information before dissemination. Another shortcoming of the use of SNM in CCD management during the SARS outbreak was the publication of nurses in full protective gear at the airport. This image was disseminated internationally, portraying Singapore in a poor light and negatively impacting tourism to the country, despite the extensive management measures in place.(13)

However, while this approach has worked well in Singapore, there is a general consensus that citizens were amenable to “infringements on individual rights for the greater good”.(7) This is in conjunction with the high amount of SNM control by the government, which has made it easy to manage CCD outbreaks. It is important to understand that Singapore is a tropical country with shared human and animal spaces and a high population influx. CCD outbreaks are likely and the country must be prepared to address weaknesses and strengthen the use of SNM for communication during a CCD outbreak.

1. It is important that SNM is used to report localized data rather than international or regional data. Regional data is not effective in creating awareness as it is not relevant to the audience who do not always understand the intricacies in the region. Furthermore, as in the SARS case, it can cause negative misconceptions leading to increased public panic.(3,7)

2. While an ongoing flow of information is helping in reaching the masses, it is equally important for health authorities to liaise with journalists, particularly on new and emerging health concerns. This also helps SNM gather credibility from trusted sources and spokespersons.

3. SNM should be trained to understand the mandate and role of the Ministry of Health to better facilitate the checks and balances needed for governmental accountability. A lack of consensus on problematic or negative processes or qualities of SNM coverage drive the generation of negative responses.

4. During a CCD outbreak, it is important to curate images and news stories that can further harm the economy, as in the case of the picture of nurses in full-protective gear. During this period, SNM should focus on building public trust as this will help people make informed decisions and inform decision makers on appropriate treatments or responses that can save lives. That said, after the crisis, curation of media leads to a lack of information that can make a country myopic, creating harm in the long-term.

5. In a diverse nation, such as Singapore, it is also prudent to regularly research community consensus and sensitivities. For example, during the SARS outbreak, it was retrospectively found that older generations felt marginalized by initial interventions as they were not targeted at the dialect-speaking population.(7) Therefore, cultural, socio-economic and racial sensitivities should be researched regularly so that in times of outbreak, initial interventions can target and impact the masses. In the same vein, governments should monitor the efficacy of communication and install feedback mechanisms. If information dissemination is ineffective, strategies to fine-tune communication should be implemented.(8)

6. While it is important to report localized data, it is equally important for SNM to share information internationally. Singapore was able to preempt the impact of SARS due to the lessons learnt from other countries.(7) However, as negative international news did create some problems, it is important to have a consensus on the quality of information sharing between countries so as to help one another without causing unnecessary panic.

7. On the part of the health sector, understanding of the rapidly changing nature of SNM, including health coverage, due to technological advances and social media is required. The health sector and SNM need to find common ground to make media coverage a healthcare priority and health a media priority.(3)

8. Prioritizing risks, setting clear objectives, and identifying ways to integrate social media into a comprehensive communication plan will aid the collaboration of SNM and the health sector. This should also include measuring and evaluating the impact of SNM activities.(2)

In conclusion, SNM and the healthcare sector can be effective partners during CCD outbreaks. However, it is important to lay a strong foundation that is responsive and flexible. While Singapore has done well in responding to outbreaks in the past, this is likely due to the significant trust of the people in its leaders and the deep collaborative spirit between SNM and the healthcare sector. It is important that Singapore avoid complacency and continue to build SNM infrastructure as CCD outbreaks are rarely routine.

References

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2. European Centre for Disease Prevention and Control. Social media strategy development — A guide to using social media for public health communication. Stockholm: ECDC; 2016.

3. World Health Organization. Developing tools for strategic communication to the media on emerging infectious diseases (EIDs). New Delhi: World Health Organization; 2012 p. 1–38.

4. Kim-Farley R. Principles of infectious disease control. Oxford Textbook of Global Public Health. 2015;:1484–1506.

5. Thornton J. Where humans and animals collide: Emerging infections and newfound resistance | LSHTM [Internet]. LSHTM. 2017 [cited 8 October 2017]. Available from: https://www.lshtm.ac.uk/research/research-action/features/where-humans-and-animals-collide-emerging-infections-and-newfound

6. Singapore Tourism Board. Tourism sector performance. Singapore: Singapore Tourism Board; 2016 p. 1–7.

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10. Tay J, Ng Y, Cutter J, James L. Influenza A (H1N1–2009) Pandemic in Singapore — Public Health Control Measures Implemented and Lessons Learnt. ANNALS Academy of Medicine Singapore. 2010;39:313–24.

11. Article 14(1). Singapore: The Republic of Singapore; 2017.

12. Hooker C, Leask J, King C. Media Ethics and Disease Outbreaks. In: Enemark C, Selgelid M, ed. by. Ethics and Security Aspects of Infectious Disease Control. Farnham: Ashgate Publishing; 2012. p. 161–178.

13. Menon K, Goh K. Transparency and trust: risk communications and the Singapore experience in managing SARS. Journal of Communication Management. 2005;9(4):375–383.