Effective Risk Communication for Public Health Emergency: Reflection on the COVID-19 (2019-nCoV) Outbreak in Wuhan, China

Risk communication is critical to emergency management. The objective of this paper is to illustrate the effective process and attention points of risk communication reflecting on the COVID-19 (2019-nCoV) outbreak in Wuhan, China. We provide the timeline of risk communication progress in Wuhan and use a message-centered approach to identify problems that it entailed. It was found that the delayed decision making of the local government officials and the limited information disclosure should be mainly responsible for the ineffective risk communication. The principles for effective risk communication concerning Wuhan’s outbreak management were also discussed. The whole communication process is suggested to integrate the accessibility and openness of risk information, the timing and frequency of communication, and the strategies dealing with uncertainties. Based on these principles and lessons from Wuhan’s case, this paper employed a simplified Government–Expert–Public risk communication model to illustrate a collaborative network for effective risk communication.

In sum, this study proceeds as follows: (1) a timeline concerning risk communication of the 2019-2020 Wuhan COVID-19 outbreak is given, (2) the case is then analyzed using the message-centered approach, and (3) a simplified model of effective risk communication is formed in the discussion section.

Background
Wuhan (29 • 58 N-31 • 22 N, 113 • 41 E-115 • 05 E) is the capital city of the Hubei province and is the seventh largest city in the People's Republic of China. As of January 2020, many patients have been found and identified as being infected by a novel coronavirus in Wuhan. Since 12 December 2019, when the Wuhan Municipal Health Commission reported 27 cases of viral pneumonia, including seven critically ill cases, the pneumonia outbreak has received considerable global attention. The COVID-19 cases have covered all provinces in China and have also been reported in other countries, severe areas including Italy, Japan, Republic of Korea, and the US, and all of these cases were exported from Wuhan [16,17]. Chinese scientists have argued that the virus source comes from a seafood market in Wuhan, but a few infected people in Wuhan say they did not visit this seafood market. Pinpointing the actual source of the virus is a main task for current research-different findings have been published [18,19]. An early epidemiological investigation revealed that bats may be the native host of COVID-19 [20]. The available investigations indicate that the virus has the characteristic of human-to-human transmission and is even infectious during incubation. These infections may either be asymptomatic or have symptoms that include fever, cough, and shortness of breath [21,22]. There is no consensus on its basic reproduction number (R 0 or R-zero), although current scientific studies demonstrate that the range of R 0 falls within 2.5-6.5 [15, 23,24]. There is no complete knowledge on this virus, and epidemiological investigation in ongoing.

Risk Communication Timeline of COVID-19 Outbreak Management
Risk communication is a combination of two aspects, namely, internal communication and external communication. Internal communication refers to a situation where risk assessors and managers develop a common understanding of their tasks and responsibilities. It enables risk assessors and managers to appraise the potential impact and all possible outcomes based on the available information. Meanwhile, external communication enhances stakeholders' awareness of the negative impact of the risk and their recognition about their roles in risk governance and initiation of different behaviors [25,26]. Following this distinction and referring to China's regime, we define internal communication as the communicative process among governments and the academic community, because the majority of academic institutions are affiliated to the government or funded by officials. Furthermore, we posit that external communication is related to the information sharing between the government and the public. In accordance with the development of the COVID-19 outbreak, Table 2 illustrates the processes of internal and external communication with other events related to COVID-19 information. The period is from the initial report to Wuhan's lockdown.

Analysis on Risk Communication in COVID-19 Management: A Message-Centered Approach
From the timeline of risk communication in Wuhan, we can generalize three aspects related to risk communication: government's decision making, government's information dissemination, and risk interpretation. Following nine aspects in the message-centered approach, we selected four aspects relevant to three aspects of COVID-19 risk communication to analyze this example of ineffective risk communication.

Infuse Risk Communication into Policy Decisions
At the beginning of the outbreak, the Wuhan government did not infuse a scientific risk communication into decision making and regarded the outbreak as a common public health issue instead of an emergency without a precise investigation and consensus about the epidemiological characteristics of COVID-19. A comment published by the New York Times speculates that the decision making was based on social stability [27]. Therefore, there was no adequate preparedness for outbreak management, including a timely warning to the public and active countermeasures for the risk. Organizational characteristics should be taken into consideration in the analysis of risk communication.
Organizations often have a vested interest in a particular interpretation of risk [28,29]. The occurrence of the outbreak corresponded with China's political season, when officials gather for annual meetings of the People's Congresses-the Chinese Communist Party (CCP)-run legislatures for discussing policies and praising government. Bad news is inappropriate at this time. As the governor of Hubei, Wang Xiaodong, pointed out, "political issues are at any time the most fundamental major issues" [27]. At the same time, the harmonious and happy atmosphere brought about by the Chinese Lunar Year Festival in society foreboded the start of the most massive annual population migration, which is called the "Tide of Going Home". If the outbreak information were to spread, it would influence migration and intensify social fear. Based on balancing various considerations, the government's decision making had to depend upon maintaining political image and social stability, because the outbreak management might disturb the social order. In an interview, Zeng Guang, the chief scientist of epidemic of Chinese Center for Disease Control and Prevention, indirectly admitted that the main problem came from the local government's decision making. Zeng said that the government is prone to balance many factors in decision making, such as politics, stability, and economy, and expert opinion is often partly considered by the government [15]. In addition, a prediction of the epidemics trend of COVID-19 in China conducted by Dr. Zhong Nanshan's group indicates if government control was applied five days earlier, the epidemic would have been effectively suppressed [30]. We can infer from this research that the government's reactive action should have been adopted earlier.

Present Risk Messages with Honesty
Designing open, accurate, and consistent messages is a vital premise for communication preparedness [31] (p. 105). In the management of COVID-19, the whole external communication reflects the possibility that the government concealed information about the outbreak. During the political congress, officials did not report new cases and repeatedly stated that no medical workers were infected, but the reality was that new cases were being diagnosed every day [11]. Interestingly, officials reported new cases after the congress lowered the curtain. Figure 1 shows a timeline of official reports about infected cases by the Wuhan Health Commission.
preparedness [31] (p. 105). In the management of COVID-19, the whole external communication reflects the possibility that the government concealed information about the outbreak. During the political congress, officials did not report new cases and repeatedly stated that no medical workers were infected, but the reality was that new cases were being diagnosed every day [11]. Interestingly, officials reported new cases after the congress lowered the curtain. Figure 1 shows a timeline of official reports about infected cases by the Wuhan Health Commission. Besides, the way that the government handled the information of the outbreak made the information more ambiguous. After the initial outbreak of COVID-19, conspiracy theories and rumors spread online regarding the origin and scale of the virus. Various social media posts claimed that the virus was a bio-weapon or an American conspiracy aimed at containing China [32]. The government was busy refuting these rumors. The Chinese Medical Doctor Association makes a daily statistic of rumors on social media. From 18 January to 10 March, the government has refuted 434 rumors covering virus source, preventive measures, disease impact, research achievements, etc. [33]. Besides, the way that the government handled the information of the outbreak made the information more ambiguous. After the initial outbreak of COVID-19, conspiracy theories and rumors spread online regarding the origin and scale of the virus. Various social media posts claimed that the virus was a bio-weapon or an American conspiracy aimed at containing China [32]. The government was busy refuting these rumors. The Chinese Medical Doctor Association makes a daily statistic of rumors on social media. From 18 January to 10 March, the government has refuted 434 rumors covering virus source, preventive measures, disease impact, research achievements, etc. [33]. From a theoretical perspective, such an information chaos may impair the government's credibility. Trust is one major objective in risk communication. The timely disclosure of relevant information has a positive impact on building trust. On the contrary, stalling or delaying reporting will undermine the trust in risk communication and governance [34] (pp. 214-215).

Account for the Uncertainty Inherent in Risk
The literature of risk communication indicates that risk combines the known unknown and the unknown unknown, remaining equivocal in risk messages means acknowledging that uncertainty exists and framing messages within that inherent uncertainty, for example, "We do not yet have all the facts" and "Our understanding of these factors is always improving" can be used to preface risk messages [8,35]. Incipient risk external communication used a series of certain expressions, which conveyed the wrong perception of COVID-19 to the public. The actions of the authorities in attacking whistleblowers who privately delivered the clinical characteristics of the coronavirus on social media further enhanced people's risk perception about the outbreak. The public tended to believe that the disease had no characteristic of human-to-human transmission. As the epidemiological investigation went deeper, new conclusions made the authorities change their statement, using expressions such as "no evidence shows the disease has the characteristic of human-to-human transmission". However, the public could not realize the characteristic of human-to-human transmission from such an expression, and thus had no perception for self-prevention. On 20 January, Dr. Zhong Nanshan confirmed the epidemiological characteristic of human-to-human transmission, which was a sudden turn in the content of risk communication. Therefore, the risk communication was not evidence-based but arbitrary, because it failed to conform to a dynamic process as the understanding of the risk evolved.

Acknowledge Diverse Levels of Risk Tolerance
People have widely varying capacities to process risk messages, including scientific and technical understandings of risk. Diverse levels of risk tolerance or perception amongst different people are due to ambiguity in public health issues, multiple sources of information, and various communication behaviors [36] (pp. 224-265). In the risk communication of COVID-19, some cases have shown that experts or the government failed to utilize understandable explanations about the epidemiological characteristics of the outbreak, the scientific principles in the prevention measures, and the curative effect of therapeutic activity. The public remained ignorant or fearful. Many people used extreme methods for self-protection. Under the media's misleading influence, lots of people snapped up medicines that have not been proven to have a curative effect or hoarded masks and respirators. A research conclusion cited by Xinhua News Agency indicates that a preliminary study shows that Chinese patent medicine Shuanghuanglian can inhibit the novel coronavirus. The consequence was that lots of people queued up purchasing Shuanghuanglian at midnight. An expert clarified that this study is not a detailed research but only preliminary, and indicated that scientific expression should not be exaggerated [37]. In addition, many people had no perception of the outbreak. Some extremists decided against self-protection and even vandalized public facilities that are used to community quarantine.

Principles for Effective Risk Communication: Lessons from Wuhan
The lessons from the outbreak management of COVID-19 in Wuhan stress the need for effective risk communication to prepare in advance for an infectious disease emergency. We can consider the following principles:

Accessibility and Openness of Risk Information
Accessibility and openness enhance the public's perception that they are fully informed about risk and that they are partners in sharing the risk. Risk communication must consist of an interactive process where all parties are given access to multiple messages representing all relevant views. Identifying the points of convergence serves as a means for making sense of these interacting arguments, which leads to forming a consensus on the uncertain issue [8] (p. 17). Wuhan's case reflects the prerequisite of a message-centered approach, which means that the institution can be a barrier to information disclosure. The government's monopoly of information harms the public's right to know, and the fact that politics is the most important issue restricts the voice of the academic community. Reluctant information disclosure hampered the public's self-protection and exasperated negative impacts of the outbreak. As a consequence, the tardy strategy of lockdown broadened the outbreak scope subjectively due to people's migration. Meanwhile, in accordance with the characteristic of COVID-19, namely, that it can transmit in incubation, the public's ignorance of self-protection meant that the disease was able to infect others during gatherings and contact between people in an unperceivable way. Risk communication strategies require information sharing and establishing networks of working relationships among individuals, groups, and agencies. Establishing these relationships necessitates the accessibility and openness of information, which is the premise of collective action.

Communicate Early and Often About Risk
Risk communication should begin as soon as a risk has been identified and should continue as new information becomes available [38] (pp. 72-73). For an unknown disease, communication should avoid using certain conclusions or expressions when clinical and epidemiological investigations are ongoing. Once an updated investigation is available, the information ought to be disclosed immediately. Any delay will likely lead to unexpected consequences. The government of Wuhan's first step to respond to the unknown disease was not to initiate a comprehensive investigation, but to silence and punish "rumormongers". The reality proves that "rumormongers" are innocent and that the "rumor" indeed functioned as an early warning. On 7 February, Dr. Li died from COVID-19, and his death unleashed an upsurge of emotion, with the public strongly criticizing the government's management of their response to the initial outbreak [39]. The shocking nature of risk can sometimes paralyze an organization, and even a holistic governance network. Therefore, inadequate preparedness, such as the shortage of goods, loose management in communities, and disordered collaboration amongst agencies, put the Wuhan and Hubei governments into a passive situation and undermined their be abstracted, namely, the government, experts, and the public. The risk communication network reflecting Wuhan's outbreak management consists of these three actors. In order to simplify their complex communications, we employed a model to demonstrate the communicative interaction that will enable a better understanding of the communication strategy and principles. The model is presented in Figure 2 below. In this model, the three components of communicative interaction are government-public, government-expert, and expert-public. The government is the core decision maker in the risk governance process, and all of the government's behaviors will have a profound impact on the effectiveness of governance.
For government-public communication, which is a typical external communication, the government's responsibility is to convey adequate and accurate information to the public, which means that information disclosure is accessible and open. Government officials are often frustrated by what they perceive to be inaccurate public perceptions of risk and unrealistic demands by the public for risk reduction [43] (p. 1). In addition, this communication results in a response from the receiver, which can then be evaluated against the desired response [44]. The public's feedback enables the government to adjust its emphasis of information delivery and provide information in relation to In this model, the three components of communicative interaction are government-public, government-expert, and expert-public. The government is the core decision maker in the risk governance process, and all of the government's behaviors will have a profound impact on the effectiveness of governance.
For government-public communication, which is a typical external communication, the government's responsibility is to convey adequate and accurate information to the public, which means that information disclosure is accessible and open. Government officials are often frustrated by what they perceive to be inaccurate public perceptions of risk and unrealistic demands by the public for risk reduction [43] (p. 1). In addition, this communication results in a response from the receiver, which can then be evaluated against the desired response [44]. The public's feedback enables the government to adjust its emphasis of information delivery and provide information in relation to the public's own interests and values-communication can be most effective when it reflects an understanding of what the public wants to know [43,45]. The existing literature indicates that a challenge identified in implementing openness in risk communication is that it is difficult to decide what to present and what not to present. For instance, complete transparency causes possibly unjustified fear among members of the public [46]. As we mentioned above, the initial intention behind the Wuhan government concealing information was based on the consideration of maintaining social stability. Therefore, transparent risk communication is just as necessary, but is simultaneously difficult to achieve in practice due to many complex decision situations. Information disclosure is a technical measure that needs to balance different factors such as public risk tolerance and possible subsequent outcomes.
Government-expert communication is a primary element of risk assessment and decision making, which can be seen as internal communication. Risk is related to professional knowledge and technology. The very essence of responsible and rational action is to make viable and morally justified decisions in the face of uncertainty based on a range of expert judgments and assessments. At the stage of risk assessment, the consensus of experts' judgments about the risk will ensure to assign an accurate probability for each possible consequence, to initiate each action, and to establish the rational decision as that which minimizes the negative outcomes and maximizes the expected benefits [34,47,48]. Governments ought to empower experts to work on comprehensive and detailed research on the uncertainty of a risk issue rather than restrict experts' voices out of other considerations, including politics or self-interest. The academic community should fully focus on the scientific analysis of the risk and sharing findings, data, and materials. In modern society, risk is an interdisciplinary issue. For public health risk, specialists in life and social sciences, biomedicine, and public health must seek better answers from multiple disciplines. Consensus on evidence-based analysis is the foundation of decision making. Uncertainty due to disagreement (experts, opinions, language) must be analyzed and disclosed, which aims to avoid misleading by ambiguous and diverse information [49].
Expert-public communication is dedicated to bridging the gap between expert and public views on public health issues through strategic communication. It represents external communication. A great challenge of risk communication is not only to convey knowledge, but also to find ways to convey comprehensive information that reflects uncertainty and empowers the public to make fact-based decisions about health [50]. The public always fails to understand the complex professional knowledge about the risk, so experts' responsibility is to translate the professional knowledge into simple and explicit content which can be easily understood. In Wuhan's case, a doctor named Zhang Wenhong said frankly, "You are unable to understand what I am saying definitely, because we read different books. You know every word in my sentence, but you do not know what I mean". Then, Dr. Zhang used quite straightforward language to explain how Shanghai is coping with the outbreak by integrating resources. His explanation received the public's praise and support [51]. The public need to express their appeals of uncovering uncertainty to experts when they encounter their unknown knowledge about the risk rather than seeking some unproven information or even rumors.
Risk communication responsibility should be a balance between being neither too centralized nor too decentralized [35] (p. 112). Different actors must fulfill their responsibility according to their roles and keep the communication network running. Accordingly, this model underscores the importance of partnerships in risk communication. Within the communication network, the government should and must play a leading role in communicating risk, and the proposed model offers a guideline to achieve this goal. Based on Wuhan's case, the government will continue to face challenges as uncertain and unexpected outcomes occur. Therefore, the government must collaborate with other actors to share information in a timely and effective manner, which enables every actor to adopt preparedness in advance for tackling any unexpected incident in the future.

Conclusions
This article focused on how ineffective risk communication impeded the emergency response in Wuhan's outbreak management and discussed principles for effective risk communication. After the timeline of risk communication progress in Wuhan was given, we tried to illustrate the effective process and attention points of risk communication reflected from Wuhan's case. Following the message-centered approach, it was found that the Wuhan government did not infuse a scientific risk communication into policy decision, the local government stalled reporting and handled the information publicity in an ambiguous way which undermined public perception associated with COVID-19, and the authorities failed to treat it with the inherent uncertainty and different levels of risk perception of COVID-19, which worsened the circulation of rumors and led to public panic to some extent. The lessons from the outbreak management in Wuhan suggested that the accessibility and openness of information should be enhanced to form convergent points in the whole communication process, especially when dealing with uncertain issues, should keep the public regularly and timely informed, and should take care of the communication strategies dealing with uncertainties. Then, a simplified model of risk communication was employed to illustrate a collaborative network for effective risk communication. The government, experts, and the public should be involved in time, contributing diverse views and fulfilling respective responsibilities. In China's case, the government normally plays a leading role but sharing information in a timely and effective way needs to be solved in practice in the long run.