Long before COVID-19, the journalists of North Carolina Health News were among the few still dedicated to covering health care, health policy, and public health with a state and local focus. A changing media environment and consequent budget cuts had led to layoffs at most local newspapers around the country, and it became increasingly rare to find a reporter whose sole job was to cover health news and its impact on communities. Nurse and reporter Rose Hoban founded North Carolina Health News in 2011 to fill that gap in North Carolina. But, as she explains, all the well-resourced journalism in the world cannot stand in for effective health communication from providers and institutions.

In this interview with the North Carolina Medical Journal, Hoban shares her perspective on the reasons for the public’s mistrust of health information and how members of the health care and health research communities can more effectively share their messages.

NCMJ: What are the trust gaps that you see as a journalist reporting on health in North Carolina? What do you think is the root of the problem from the media perspective?

Rose Hoban: One thing many people don’t understand right now is the intense crisis in journalism, and how that is related to broader trust problems—the absolute collapse of the business model that supported journalism that many people relied on. The old business model rested on three things: advertisements, classified ads, and subscriptions. When newspapers went online all of a sudden, they now had metrics, and we could see that there were 500,000 subscribers on Sunday, but 200,000 of them had come for the coupons, another 100,000 had come for the comics, and another 100,000 had come for the sports, and the hard-hitting news had a much smaller audience that you couldn’t sell advertising against. It’s very, very hard to sell advertising for the same rate online as you could in print, and that thoroughly undermined the advertising revenue model for newspapers. Plus, why have a subscription when you can get the news for free online? Newspapers kept that free model for a very long time, and when they introduced paywalls they did it in a very ham-handed and clumsy way. This turned off readers, who went to alternate spaces, like social media. When I arrived in North Carolina in 2005, the Raleigh News & Observer had five people covering health care. By the time I launched North Carolina Health News in 2012, all those people were gone. There’s only four or five reporters left at the Greensboro News & Record to cover a city of 300,000 people; you can’t send anyone to cover the City Council or the local health board meetings.

We lost all the reporters, and so we had no capacity to report on things like the implementation of the Affordable Care Act, just as social media was rising, so social media stepped into that information void. As a friend of mine said to me years ago, you can find anyone with a PhD to say anything on the record. They may have a political agenda, they may have an economic agenda, they may be a conspiracy theorist, but in the breach left by the falling tide of news organizations, they’ve had penetration into information markets.

NCMJ: How does this journalism crisis affect health reporting?

Rose Hoban: There are some health systems that have been savvier than others. They’ve done things like writing up what’s happening in their hospitals and offered that to these personnel- and money-strapped news organizations and said, here, here’s coverage of your local hospital. When I was looking to start North Carolina Health News back in 2011 and considering a syndication model, I spoke to a leader at a small local paper in the state who asked me, “Why should we pay you for your content when we can get stuff from our local hospital for free?” Well, that backfired, because CMS [the Centers for Medicare & Medicaid Services] ended up finding that the hospital had profound problems; all those nice stories given by the hospital filled up the pages and the paper had missed the profound quality problems.

In another example, researchers at Duke helped create as one of the first places where academics would have their research reported by all of these laid-off journalists who now worked in hospital communications. We want to amplify the voices of researchers because this stuff is not getting covered in the media anymore, so they thought, “we’ll do it ourselves.” This was not bad in itself, but newspapers were misusing this content, publishing it with a byline but not saying that it came from the communications office at Duke or Stanford or Yale. We need to be really careful as journalists about how we use and brand content like this for readers.

NCMJ: How do you think about presenting your work to people who might not be able to tell the difference between a reported story and a press release, or know whether something they’ve seen on social media is trustworthy information?

Rose Hoban: It’s a conundrum for me as an editor and publisher. It’s really hard. We are very clear when we run a story that is from Kaiser Health News or one of our not-for-profit publication partners in North Carolina—we signal that, but readers skim right over the byline. We made our content free in 2019, and something like 130 publications use our content— that’s state and national outlets, and places like WRAL TV and “Southern Scoop”—so we have tried to position ourselves as a trusted voice. It’s so hard to measure trust, but my metric for that is that probably once a week, especially during legislative season, I’ll have a lobbyist or a legislator say to me, “You know, we don’t always like what you write, but we know you’re always going to be fair.”

NCMJ: What are some of the challenges and opportunities for communication you’ve noticed when you interview health researchers and health care providers?

Rose Hoban: There is a defensive crouch. I understand why people are defensive, especially the past couple of years. You had public health officials who were savaged in social media. But I will tell a story as an example of why this is a problem: One of my reporters was doing a pretty straightforward story on a study out of UNC, and the researcher said to her, “I was told never to talk to reporters because you’ll get it wrong.” She said, “Let me record you,” and this person said, “Oh, no, definitely not. Everyone in my department has said, ‘Don’t let a reporter record you, because then your recording will get out there, and it’ll be manipulated.’” So, instead of taking her a week or a couple of days, they ended up in a protracted email exchange and it took her weeks to get the information and do an interview with this person. Ironically, the week that story came out I was doing a presentation for a group of epidemiologists and the head of this researcher’s department was in the audience. I related that anecdote, and this person came up to me after and said, “Well, that’s not our departmental policy.” I said, “No, but this is the conversation that people are having.”

I credit a lot of my thinking around this to Gene Matthews, at the UNC Gillings School of Global Public Health. He helped create the Network for Public Health Law and he was doing that presentation with me for the epidemiologists. His stance is: If you don’t tell people something, they’ll go out and make up their own facts. We’ve seen this in spades in the 2010s and 2020s, with the rise of “alternative facts.” There are people who are afraid reporters will misinterpret what they do, but if you decline to speak to a reporter and they’re on deadline, they’re going to find someone to tell them something, and what they get told might not be correct. You might not like talking to reporters, it might be awkward, but if you don’t, you’re contributing to the information problem.

On the flip side, reporters need to have more humility to say they don’t understand, and get clarification. I always tell people to Google the journalist who is reaching out to figure out what they’ve written and whether this person knows what they’re doing, or if they were covering City Hall last week and the school board the week before. Back in the day, there used to be health reporters that academics could talk to and know they would get what was being said, but those people are gone. So that means that you, as a source, need to treat reporters differently. Also, call the reporter up when there’s not a crisis. Explain your expertise and how to get in touch with you. It takes time, but when you do these things, you position yourself as a trusted expert.

NCMJ: What are some other solutions for better communication of health information, especially when it comes to public health?

Rose Hoban: We have some champion public health communicators in this state. [Granville Vance Public Health Director] Lisa Macon Harrison was never afraid to answer my calls; David Wohl from UNC’s Division of Infectious Diseases is an incredibly personable communicator who does a terrific job of putting things into layman’s terms and breaking things down. I’m always telling researchers or health care professionals that even though they know I’m a nurse, they should talk to me like I’m their 15-year-old niece who’s really sharp but doesn’t know all the context.

When someone’s doing research, they know they need to think about the larger implications, how it affects society, how it affects their neighbors. I’m always telling my reporters to think about the statewide relevance of a story and the policy solutions that members of the public can get behind to help solve a problem statewide. It would help if the interviewees thought about things the same way, and a lot of them do.

I always say that North Carolina is at the bottom of funding in the United States for public health, but we still get really amazing outcomes from the pittance that we spend, and the reason for that is that we have a lot of really talented public health practitioners in this state. I don’t want that to get lost in this conversation; there are a lot of really talented people in this state, so they need to share their talents with the rest of the polity around them. Interviewees will say they need to prepare for an interview, but I tell them, “You do this at dinner every night. You think of this in your sleep. Have the confidence to know that you know how to explain your work, and that what I might need you to do is break it down a little bit more so that it’s understandable to the average person.” I understand why people are frightened, but this is not the time to retreat from the public space. Earning trust is really hard, and there’s a cacophony of voices that are muddying the conversation. We need people who are terrific communicators to step up to the plate and communicate what they know.