RISK COMMUNICATION OR COMMUNICATION RISKS?

Innovate UK has recently awarded a team led by Dr Michael Jarvis at the University of Plymouth UK with a £408,000 grant to develop a new vaccine against zoonosis.

About 75% of newly emerging diseases and 60% of all known human infectious diseases are likely to be zoonosis.  The main idea of this new project is to develop a self-disseminating vaccine vector, called Zoonosis Barrier Vaccine (ZBV), targeting pathogens in the animal species from which they are emerging. By exploiting CRISPR/Cas9 technology, the team will aim to construct engineered viruses, which express target antigens from relevant Emerging Infectious Disease (EID) pathogens. Recombinant viruses will be then inoculated in few animals. They will spread through the whole host populations, producing EID-specific immunity in the targeted populations.

For now, the team will develop a ‘proof-of-concept’ vaccine vector, designed to halt the spread of Rift Valley Fever Virus (RVFV) and Q Fever (QF) among ruminant populations (i.e., sheep, goats and cattle).  The vaccine will prevent zoonotic transmission by using an attenuated bovine herpesvirus. The recombinant herpesvirus – which will replicate only for a short period of time for safety reasons - will infect domestic and wild animals, stimulating also immunity against RVFV and QF.  

The Zoonoses Barrier Vaccine strategy presents several advantages.  Self-disseminating vaccines allow addressing both domestic and wild animals. The transmission of infectious diseases between wild and domestic animals is particularly relevant to EIDs, as most EIDs originate from wildlife. The vicious circle of infections and re-infections between domestic and wild animals is likely to play a pivotal role in EID epidemiological cycles. Moreover, many emerging zoonotic pathogens are poorly adapted to the human hosts in their initial phases, this offers the opportunity to halt the zoonotic transmission by targeting the animal populations, and decreasing the “probability of complete adaption to the human host with global significance”. Finally, the approval requirementsfor animal vaccines are lower than those for human  vaccines, so reducing time to commercial availability. 

The Zoonoses Barrier Vaccine project presents, however, some Significant communicational challenges. Infecting wild and domestic animals with recombinant viruses is the typical project, expected to fuel conspiracy theories. People might also fear a sorcerer's apprentice phenomenon, with recombinant viruses that escape from human control and become dangerous for humans and animals.  Negative reactions can be also related to ecological considerations connected to the spread of engineered virus vectors in the natural environment. Finally, one should not underestimate the risk that some people may feel outrageous that livestock products for human consumption (including meat, milk, and eggs) could be theoretically “contaminated” by recombinant viruses. 

Researchers should carefully consider these communicational aspects. They should develop effective communication plans, to explain the rationale of their project and the way in which they intend to mitigate potential risks (even the most unlikely ones).  It is extremely important that full information on the Zoonosis Barrier Vaccine project is publicly available, in a format understandable to the public. Social media should be carefully monitored; worries, fears, myths, concerning the project should be immediately identified and addressed with appropriate counter-campaigns. Reasons of worry should be proactively addressed as they emerge. Finally, it is paramount that economic interests are completely and fully disclosed, without any ambiguity. People trust in scientists more than one usually imagine, but they do not  put up with researchers who are perceived not to be fully transparent. Suspects (even remote) of conflict of interest could have devastating effects on future research in this field.   

UNSEEN ALLY

In early April, CNN FILMS, SIERRA/TANGO PRODUCTIONS & VULCAN PRODUCTIONS have presented a new documentary,  Unseen Enemy, devoted to emerging epidemics. Co-produced with WESTDEUTSCHER RUNDFUNK KÖLN in collaboration with ARTE, the movie is directed by Janet Tobias, an Emmy-Award winning filmmaker with parallel careers in film television and medicine. Jenny worked as a producer at ABC News’ Prime Time and as the editorial producer for ABC’s legal and criminal justice coverage. Later, she worked as a national producer at Dateline NBC. In 2001, she created her own television-film production company,  which has produced several documentaries on medical and social issues. In the while, Janet has become adjunct assistant professor of Medicine at Mount Sinai School of Medicine and research professor of Global Public Health at NYU.

In 2012 Unseen Enemy  was initially thought as a documentary about the threat of epidemics in the 21st century. Almost by hazard, it happened that the production team was filming at the same location of the first recorded outbreak of Ebola.  The documentary crew found themselves involved in a real epidemics and soon the film turned into a running commentary of an actual epidemic. Two years later, the Unseen Enemyteam decided  to give a further running commentary of another emerging epidemic, Zika. They went to Brazil to document the outbreak from inside, collecting stories, tragedies, acts of bravery, altruism and dedication. Unseen Enemy has been already broadcasted  in Estonia, Venezuela, Hong Kong, France, Germany, Israel, Poland; it is still available on CNN.com/go until May 8th; and it will be available on Video on Demand and DVD in the coming months.  

Unseen Enemy is very well done. Never boring, well directed and photographed, with a good pace, and extreme attention to details, the film offers stunningly intimate observations on the two outbreaks and tells vital human stories. A special mention goes to the original soundtrack, written by John Piscitello an American composer who wrote - inter alia - the soundtrack to No Place on Earth, the story of Jewish families in the western Ukraine who lived over 500 days in caves, coming out into the light only when the German army had been driven from the Ukraine, and to  Dinner with the Alchemist, a dark movie, where “a spider-web of lives come clashing together as Old New Orleans is plagued by mysterious deaths”. Piscitello’s music is not only vital to Unseen Enemy - catching the attention from the very beginning, and maintaining the tension through the whole film – but it is the actual soul of the movie and the key for understanding it.

 

The Unseen Enemy’s model is the gothic movie and music is essential to create that atmosphere. As in a well done gothic film, the public is progressively driven towards the uncanny sensation that the game is not over with the apparent happy end. It isn’t done, it just won't go away.   All music pieces in the soundtrack can't resolve themselves (listen, for instance, to “Outbreaks Everywhere”, the piece that opens the movie) any more than outbreaks are truly defeated.   The last music piece, “What the Future Holds”, is a sad whimper, which goes out slowly and ends with a silence of death. Epidemics can be stopped but never definitely beat; at the very end, notwithstanding human heroism, they will prevail,  this is the depressing message implicitly conveyed by Unseen Enemy.

In conclusion, this documentary leads to a commentary and brings to one big question. The commentary is that Janet Tobias has unquestionably found the right way to speak of infectious outbreaks, without lecturing the public  or resorting to sappy, educational, tales. Maybe she exploits too much the war rhetoric to describe the fight against Ebola and Zika, yet this can be still understandable. 

The big question is whether it can be ever acceptable to create a catching atmosphere by giving the implicit (and consequently more pervasive) message that, soon or later, we will be killed by a deadly epidemic. This message is not only discouraging, but it is also misleading. Our goal is rarely to eradicate infectious diseases. Apart from very few infections, our scope is to control infections. Microbes existed well before humans appeared on the surface of the earth, and they will exist well after our species will be disappeared. We should learn to live together with them, they are our unavoidable travelling companions. Germs must be turned into unseen allies rather than enemies. This is the sole way to win this war, provided that it is a war.

PROVIDERS OF TRUTH

A famous dictum of the 19th century British politician Lord Acton, reads "power tends to corrupt, and absolute power corrupts absolutely”.  Lord Acton would have been probably intrigued by the current debate on social network governance. After the mass hysteria generated by  the fake news issue,  and the proposal in Germany of a new legislation on  social networks, both Facebook and Google  have announced that they are going to adopt fact-checking instruments.

Facebook’s tool is a notification system that warns the user if any news has been flagged as “disputed”. Google’s tool is more complex. It is based on a label, which rates claims made in the news, and in news web sites, under six categories, 1) hard to categorize; 2) false; 3) mostly false; 4) half true; 5) mostly true; 6) true.  “Sites are evaluated in a process similar to page ranking: if the site ranking is high enough, the fact check element can be displayed in search results along with your page. The entire process is conducted programmatically; human intervention only occurs when user feedback is filed as violating the Google News Publisher criteria for fact checks”.  Both Facebook and Google rely on external fact-check sources, which are independent organizations looking at fact checking and authentication. Fact check business is rapidly growing, the Reporters’ Lab at the Duke University, which maintains a comprehensive worldwide database, lists more than 120 international teams active in this field.

A bit improvidently, public authorities and politicians have welcomed Facebook and Google decisions. Yet, though intentions are laudable, the notion of global fact check is quite hazardous. Truth is never mere correspondence between facts and reported facts. The best lies are not made of falsehood but of a clever mix of half and missing truths. For instance, false news that relate Zika epidemics  to  GM mosquitos are purposely constructed by selecting and combining real events, none of them is factually false,  yet the final result is substantially fictitious.

The point is that naked facts cannot exist. The notion of observer is integral to the notion of fact, facts are inherently points of view.  In real life, the notion of “objective truth” is a normative ideal, to be approximated, rather than an attainable goal. When one relays a fact, one relays also one or more perspectives on it. Rigorously speaking, the standard journalistic distinction between reporting, analysis and opinion would be tenable only if all points of view were available, could be disclosed, and faithfully reported, which is usually impossible. Reporting often implies selecting information, and determining which aspects of the fact are more relevant. This is not always apparent and the myth of neutral, factual, reporting is still believed by the majority. This myth hides the evidence that most news are “fine-tuned”, or even grossly manipulated, simply by failing to provide the whole truth, omitting some (apparently minor) facts, emphasizing suggestive details, adding redundant information. For instance, when anti-vax activists provide information on relative risks related to vaccination, they are formally correct, but substantially deceptive, because most people, who confuse relative and absolute risks, are driven to overestimate the danger (admittingly, the same trick is used by medical doctors to induce patients to treat dubious conditions, and justify the extensive usage of drugs such as statins). Finally, news can be manipulated also by altering the context. Think of a news about, e.g., Ebola outbreak. This news could have very different meanings according to the context in which it is included. For instance, if this news is immediately followed by an investigative article on military biological laboratories, or by a lifestyle piece on international tourism, or by an editorial on illegal migration, its likely impact will be rather different. Contexts unavoidably suggest extra meanings; by using them astutely, one could induce deceptive conclusions, though formally respecting the truth.

Yet, the notion of global fact check is distorting also in a further, deeper, sense. If this notion gets going, Internet giants, such as Google and Facebook, will be globally bestowed with the moral authority for assessing the truth (and trustworthiness), or falsity (and untrustworthiness) of single news, news web sites, and news aggregators.  Social networks will be turned into  global “providers of truth”, and their power could not be balanced by any corresponding power, neither by national governments, nor by international agencies and supranational institutions.  Trust in national governments and international institutions is everywhere eroded by different, concurrent, factors. Political institutions, increasingly lacking moral authority and out of touch with citizens, are more and more unable to provide credible, trustworthy, perspectives to look at global facts. Political institutions are thus gradually driven to “outsource” their moral authority.

This is foreshadowed also by the new German legislation, though the proponents are likely to be unaware of it. The “Social networks enforcement law” goes beyond obvious criminalization of hate speech and online propagation of falsity, making social media legally responsible for false contents that they host.  In such a way, this law introduces implicitly the principle, fraught with consequences, that social networks should, and are entitled to, assess “fake news”.  The commentary to the draft text clearly states this principle (see, Begründung - A. Allgemeiner Teil - I. Zielsetzung und Notwendigkeit der Regelungen).  In other words, while the law provides social networks with newer, stricter, obligations, it also crystallizes the structural weakness of democratic institutions. No political institution of the past – endowed with strong moral leadership, trust and credibility -  would have ever enacted such a legislation; standard legal provisions against libel, defamation, and propagation of falsity would have been considered sufficient to deal with online fake. If today a new law is felt necessary, it is hardly because it is required by technological advance, it is chiefly because political institutions have lost their moral authority and governance capacity, and they need to rely on external sources of truth. 

Facebook and Google affirm that they will not assess contents, they will only inform about assessments carried out by independent agencies. Yet, criteria for fact checking are a minor issue in this debate.  The critical issue is power. Today, social networks are more than a “Fourth Estate”, even a networked Fourth Estate. They are becoming the sole Estate, which is taking over all other Estates, the new global moral force. They advise us on where to dine, what humanitarian causes should be supported, what music we should listen to, what is in and out. They offer moral, esthetic, political, spiritual, practical guidance on everything, to everybody. The epochal question at stake is whether tech giants, which are not subject to any democratic scrutiny and transcend all jurisdictions, could be also entrusted with the power to label what is true and false. Lord Acton would have objected to this possibility. 

SPRINGTIME

It is Springtime. The days are getting longer, the weather is getting warmer, mimosa flowers cover the stems, little birds sing their love songs, and politicians sign declarations.

March 25 was a splendid Spring day in Rome and the Leaders of 27 Member States and of EU institutions - convened to celebrate the 60th anniversary of the Treaty of Rome – enjoyed their staying in the eternal city. Even street demonstrations were infected with joy. Instead of livid anti-European protesters, streets were invaded by a jubilant crowd of pan-European supporters.  Could you ever imagine a better scenario to sign a declaration? “The European Union may be a Franco-German construction, - wrote The Economist - but when the project needs a dose of grandiosity it invariably turns to Italy”.

The 2017 Rome Declaration was  eagerly awaited  by most  political commentators, being the first solemn declaration, involving all EU Member States and institutions,  after the Brexit, and after Angela Merkel's statement concerning the two-speed Europe.  The Declaration was prepared by a White Paper on the Future of Europe, and accompanied by a series of parallel initiatives, including a booklet on EU’s past achievements, a dedicated website, various audiovisual products,  60 video testimonials from people across Europe, a GIF competition, and some other activities (even including a European origami).

The Declaration starts by recalling European values and emphasizing the 60 years of peace guaranteed to countries whose main activity was for centuries battling one other (admittedly, not the best argument to advertise “European values”).  Together with peace, the EU has also guaranteed – continues the Declaration –economic growth, democracy, civil and social rights for all. The EU now is “facing unprecedented challenges, both global and domestic”, and the second part of the Declaration is dedicated to a vision of the future. The 27 Leaders commit themselves to work towards, 1) A safe and secure Europe, which includes prevention of crime and terrorism, control on migration flows; 2) A prosperous and sustainable Europe,  which includes growth and jobs, technology innovation, economic convergence, clean and safe environment;  3) A social Europe, which includes  equality between women and men, equal opportunities for all, fight against  unemployment, discrimination, social exclusion and poverty, preservation and promotion of the cultural heritage; and 4) A stronger Europe on the global scene, which includes promoting stability and prosperity everywhere, supporting  European defense industry, collaborating with the NATO, promoting multi-lateralism and a positive global climate policy (too bad, Mr. Trump). Brief, nothing’s missing, but health. “Health” is not mentioned in the Rome Declaration and it has not been included - even implicitly – in the 27 Leaders’ agenda.  This omission is confirmed by other documents produced by the EU for the 60th of the Treaty of Rome. For instance, the booklet on EU’s past achievements – the sole document in which there is a vague reference to health issues – considers them under the wider topic of citizens’ wellbeing, never mentioning health explicitly.  Yet in his first speech on the State of Union, in 2015, Jean-Claude Juncker listed  public health among EU priorities, but that reference completely disappeared in his 2016 speech. Why?

The key for understanding this omission  is in the  White Paper on the Future of Europe,  which describes five possible future scenarios for the EU. The fourth scenario, called “Doing Less, More Efficiently” (the scenario the EU is now going towards, unless the trend is inverted) describes a future in which “the EU27 stops acting or does less in domains where it is perceived as having more limited added value”.  “Public health” is the first domain to be mentioned among non-strategic policy areas to be delegated to national authorities.

Yet, this is not a future scenario, unfortunately it is the present situation. In Europe, there are  as many vaccination policies as Member States and almost no Member State has the same vaccination scheme of another Member State. Even the same words mean different things, in some EU countries the label “mandatory” does not entail any penalty for non-compliance, in other Member States this label implies administrative sanctions (e.g., fines, prohibition to attend school, etc.), in others it could even imply criminal penalties. “Moreover, the enforcement varies in practice. It is possible that in some cases penalties are only theoretical and never applied”. No surprise, then, if a world-wide survey carried out in 2016 shows that Europe has the lowest confidence in vaccine safety. The contradictory message conveyed by EU Member State policies is not certainly made for reassuring their citizens.

National policies to prevent and contain outbreaks were tenable when most Europeans did not cross, or crossed very rarely, their national borders. Today Europeans make over 1.25 billion journeys within the Schengen area every year, 6.5 million of them are currently working in another EU Member State, and more than 9 million students have been participating in the Erasmus Programme. Epidemiologically speaking, there are no longer “national communities” in Europe, but there is a unique community of people, who share germs and infections, and whose health statuses are unavoidably linked.

“Our Union is undivided and indivisible”, solemnly claims the Rome Declaration, adding “we will act together, at different paces and intensity where necessary”. This sounds reasonable in many policy areas, except in public health. A two-speed Europe is perhaps a realistic solution to address economic and political problems;  it is, however, a complete nonsense, when speaking of contagious diseases.

GLOBALIZATION, PANDEMICS AND POPULISM

Reflecting on a series of political events - including the electoral victory of Donald Trump, and the Brexit vote – commentators have argued that the current political turmoil is part of a worldwide backlash to globalization, the rebellion of “globalization’s losers”.  There is indeed a vast mass of people who feel that their life conditions are deteriorating notwithstanding, of even because of, globalization. They mostly belong to the extended middle-class that benefited from the economic boom that followed the end of World War and granted one of the longest period of economic prosperity ever experienced by industrialized societies. Now, these people see their economic conditions and social status progressively degrading, without any actual possibility to invert the trend. Their agency is nullified, vis-à-vis epochal processes such as globalization, digitalization and automation, which totally escape from their control.  They feel (not completely wrong) that the wealth of the West is going to be redistributed at global scale chiefly at their expenses. This social group is only the peak of the iceberg, because many other categories  perceive themselves as globalization losers, although they are not in absolute terms. In other words, losers of globalization are not only those who have been marginalized, but are also those who feel that they haven't profited as much as others from globalization. These people, who feel that that they got just the crumbs of the cake, are still more full of anger and resentment, because they believe they have been misled and used as “cannon fodder”  by politicians, intellectuals, journalists, who advocate globalization.   

Even public health issues, notably those related to infectious diseases, are affected by the backlash to globalization. Not only many militants of populist movements are involved in anti-vaccine movements (for instance,  President Trump appointed Robert Kennedy Jr, a prominent vaccine conspiracy theorist, to chair a commission on "vaccination safety and scientific integrity"), but it is the very cultural climate, which surrounds populist movements, to be the same that  has fed, in the recent past, suspect, skepticism, mistrust, towards global health initiatives and vaccination.  

Economic and health globalization are indeed the two sides of a same coin. Germs travel together people, animals and goods; the increasing global mobility corresponds, epidemiologically speaking, to the confluence of all germs in one world pool. In the while, advances in sequencing technologies and in bioinformatics are making possible to explore interaction between germs, people, animals, and the environment at global scale, and mapping the global microbiome (the genome of the Earth's microbial community) and its role in the biosphere and in human and animal health.  This is providing concrete foundation for the concept of One Health, which was once a purely theoretical notion, and is today a concrete research strategy. Finally, Internet based epidemiological surveillance and outbreak intelligence play more and more a pivotal role in early detection and monitoring of infectious diseases; this has led, inter alia, to blurring of the distinction between civil and military (including bioterrorism) applications of epidemiological research,  as witnessed by the new concept of biodefence field.

Three conceptual political tools emerged to deal with these profound modifications of the epidemiological context, 1) the notion of global public goods for health; 2) the concept of global health governance; and 3) the model of global public–private partnership.  These three conceptual tools are today under attack.

The idea of global public goods for health is contested by people who argue that an increased global integration is not the right answer to infectious diseases. It is obvious – they argue -  that infectious diseases do not know national borders, but it is false – they add – that outbreaks can be addressed only at global scale. Instead of relying on buzzword such as "health as a global good",  one should consider  that epidemic risks are increased by global interconnectivity, which is altering "the geographic distribution of pathogens and their hosts, causing the emergence, transmission, and spread of human and animal infectious disease". To these people, less globalization would be the right answer to pandemic risks. Migrants are often accused to bring with them germs and infections, and research shows that the public perception of risks of outbreaks is strictly associated to social acceptance of migrants among resident population.

Still the notion of global health governance is harshly criticized.  Even admitting that protection against epidemics is a global good, shared by the global human community, this would not imply – criticists argue – that such a good needs to be governed at global scale. To be sure, some kind of international collaboration is necessary, but this is a truism. Apart from that, each nation is perfectly fit to deal with infectious outbreaks occurring within and across its national borders, as it was in the past, with the advantage that national approaches can pay more attention to the national context, its economic, social and cultural specific features. The notion of global health governance would then be – according to the populist perspective - just the gimmick used by global elites to infiltrate and weaken national governments. 

Finally, also the global public–private partnership model is strongly rejected. In the view of populist movement, this formula would hide a business alliance between major industrial players, world bureaucratic and technocratic elites, and global financial capital.  They would be responsible for creating and diffusing new germs, such as HIV, Ebola, ZIKA  (conspiracy theory supporters are quite common in populist movements); for experimenting dangerous medications and vaccines on indigenous populations;   for exploiting natural resources of low income countries and biopiracy; for altering and threatening natural environment and agriculture through genetic manipulation (populist groups are often also involved in anti-GMO movements).

Bill  Gates  and Mark Zuckerberg have recently taken position in this debate.  In their praise of globalization, and explicit polemics against anti-global populism, they both play the card of infectious outbreaks. The risks of new, deadly, pandemics would provide,  in their views, one of the strongest arguments in favor of globalization.  It is difficult to predict whether Gates and Zuckerberg’ support to globalization could be effective or risk to produce opposite results. Although they advocate more globalization, they speak eventually the same language of populists. By reading carefully Gates and Zuckerberg's texts it is evident that their ideal (at least, the ideal that they both advocate)  is a communitarian ideal, as it is the ideal of most populist movements. While populists dream of national communities, Gates and Zuckerberg dream of a global online community,  yet  both parties  share the same vision of an integrated, organic, community as an answer to contemporary challenges. Should one eventually opt for the Facebook global  gemeinschaft, to avoid falling back again into a national gemeinschaft?

I am not able to answer this question, it is difficult, however, to escape the impression that infectious outbreaks are only instrumentally evoked by both parties.