The 2013 US Government Shutdown (#Shutdown) and Health: An Emerging Role for Social Media

Abstract

In October 2013, multiple United States (US) federal health departments and agencies posted on Twitter, “We’re sorry, but we will not be tweeting or responding to @replies during the shutdown. We’ll be back as soon as possible!” These “last tweets” and the millions of responses they generated revealed social media’s role as a forum for sharing and discussing information rapidly.

Social media are now among the few dominant communication channels used today. We used social media to characterize the public discourse and sentiment about the shutdown.

The 2013 shutdown represented an opportunity to explore the role social media might play in events that could affect health.

Behind the Super Bowl, the government shutdown was the second most talked about topic on Facebook in 2013.¹ The October 2013 government shutdown affected and furloughed millions of people in the Unites States, was the second longest shutdown since 1980, had a projected $2 billion to $6 billion lost in output, and stopped or reduced services provided by several departments and agencies that protect and promote health.² Nothing similar was observed during the 1995 to 1996 shutdown when the Internet was emerging as a social medium. The Centers for Disease Control and Prevention (CDC) surveillance support for infectious disease outbreaks (e.g., tuberculosis, hepatitis), annual flu monitoring programs, and vaccine campaigns was reduced.² Approval of medical products, devices, and drugs by the Food and Drug Administration was delayed.² The Vaccine Injury Compensation Claims process directed by the Health Resources and Services Administration was disrupted. Hundreds of new patient enrollments for certain National Institutes of Health (NIH)-sponsored clinical trials were slowed, along with support services for planned, new, and existing trials as three quarters of NIH and two thirds of CDC employees were furloughed.² The Children’s Hospitals Graduate Medical Education Payment Program, which supports the training of future pediatric health care workforce, stopped.^2,3 Head Start Program grantees, which provide services for more than 6300 children, had to close centers for nine days before being reopened with funding from private foundations or states.² Because of the broad base of health’s social determinants, including nutrition, education, and employment, the impact of the government shutdown on health was much larger than what would be estimated if only those effects on traditional health care were considered.

SOCIAL MEDIA AND REAL-TIME SURVEILLANCE

In the hours surrounding the start of the government shutdown, numerous articles were written, tweeted, and posted online that attempted to answer the questions “What will be open and closed?” and “How might the shutdown affect health?” A fog of uncertainty surrounded the disruption of information and trust brought on by the partisan conflict in the government. National Public Radio tweeted, “Are you affected by the #shutdown?” CNN Health asked, “Were you or your child supposed to start a clinical trial that may be delayed b/c of the @shutdown? Let us know.” Early news stories also covered the potential funding loss for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides nutritional support to low-income women, infants, and children. In response to the National WIC Association’s Facebook posts about the shutdown, several individuals sought more information by asking questions such as, “How bad will it affect WIC?” These online posts quickly generated their own attention, revealing social media’s reach and ability to clear the fog by providing on-the-ground information.

CHARACTERIZING PUBLIC DISCOURSE AND SENTIMENT

Using an observational study design and data publicly available through the Twitter application programming interface (https://dev.twitter.com and keyword search), we identified 2 998 285 English language tweets geocoded in the United States (mapped by state, county, or city coordinates), beginning with the first increase in mentions of “shutdown” and “#shutdown” from September 22 to October 6, 2013. Relative to the week before the shutdown, mentions of several health-related terms and agencies (flu, WIC, cancer, NIH, CDC) increased significantly on or after October 1, 2013 (Figure 1). Other related terms (e.g., US Department of Agriculture, food safety, clinical trials) did not have enough mentions to conduct a time-series analysis. To characterize the emotions associated with the content generated on Twitter, we performed sentiment analyses using sentiment lexicons and natural language processing.⁴ This approach identified the mean positive or negative valence of words mentioned in tweets at the onset of the shutdown. In this timeframe, the sentiment associated with health terms of interest was primarily negative. For example, terms associated with negative valence and WIC included terms such as, “shameful,” “horrible,” “poor,” “abuse,” and “smh” (shaking my head). This suggested Twitter could be used for tracking public discussions in real time and their associated sentiments around disruptive events that affect health. Further information about the volume of people engaged in a topic (e.g., number of followers), topic dissemination (e.g., retweets), and concerns about a topic (e.g., content analysis) could also provide additional information that health care agencies could use to follow public discourse during disruptive events.

FIGURE 1—

Health-related terms and agencies discussed on Twitter around the time of the US government shutdown.

Note. CDC = Centers for Disease Control and Prevention; NIH = National Institutes of Health; WIC = Women, Infants, and Children. The volume of select health-related content generated on Twitter around the start of the US government shutdown. The x-axis shows days preceding and following the start of the shutdown on October 1, 2013. The y-axis represents the standardized relative frequency, computed as the standardized percentage of tweets for each day that contained a given term across all days in the sample timeframe. The vertical line represents the start of the shutdown on October 1, 2013.

RAPIDLY LINKING RESOURCES WITH UNMET NEEDS

In the hours immediately following the start of the shutdown, a major unmet need was the public’s access to detailed information regarding which federal health programs were affected. As updates from some federal health departments and agencies became limited or absent from the social media discussion, other health care organizations stepped up to provide both information and services. HealthMap.org tweeted, “Help us track the #flu while the CDC is temporarily not allowed to do so. Join @FluNearYou here: flunearyou.org #shutdown #alert.” Use of social media by federal health agencies varied; some posted that they would not be updating their accounts, some stopped posting, and some posted throughout the shutdown. The Veterans Health Administration, for example, used its Facebook (> 92 000 likes) and Twitter (> 40 000 followers) accounts to specifically inform patients about their current status, status of previous arrangements, and how to find additional information via nonsocial media channels.

All VA medical centers and clinics will remain fully operational and will continue to provide health care services to our nation’s Veterans during the government shutdown. Previously scheduled VA health care appointments are not affected.

These messages were accompanied by telephone numbers and links to Web sites with additional information. The Veterans Health Administration and others’ use of social media for providing timely communication about services in a disruptive event could serve as a model for the several other health agencies that were not able to use their “last tweets” to provide resources about where the public could turn for answers or assistance if needed. Previous work highlighted best practices and lessons learned for social media communication during disruptive events, and further work is still needed to evaluate optimal messages and message platforms.⁵

LIMITATIONS OF SOCIAL MEDIA

Although social media can play a unique and important role during disruptive events that affect the health care infrastructure, social media also present unique challenges.^5–7 Determining the best approach to detecting a true signal from the noise can be challenging. Terms used on social media may carry multiple meanings, depending on the context in which they are used. In addition, social media users may not represent a national sample of the public, limiting the generalizability of discussions and sentiments. Although the “crowd” often identifies and dispels misinformation and misinterpretation, incorrect information can spread rapidly, and identifying how authoritative sources can best moderate these online forums is still being determined. Finally, although social media data have been extracted and analyzed to improve public heath emergency response or recovery by government agencies,^5,8 determining how these data-mining approaches can be scalable for a multitude of public health organizations requires further study. The Department of Health and Human Services and other departments and agencies have launched innovation challenges to partner with public and nongovernment groups to use social media for tasks such as tracking local health trends, improving emergency preparedness of individuals with durable medical equipment, and creating a Facebook app for disaster preparedness and response.⁹

While the impact of the US Government shutdown of 2013 on actual health outcomes may not become evident for some time, the ability to understand the public’s perceptions and identify concerns at an early stage could be useful for determining how to best address the needs of the public in a temporarily disrupted health care system. Previous reports illustrated how social media could be used by health care organizations in public health emergencies (e.g., pandemics, natural disasters, terrorist attacks) for timely information exchange and situational awareness.³ Political events across the world (e.g., Egypt, Turkey) illustrated how social media could be a critical communication channel when Internet service is significantly disrupted across geographic regions.³ The 2013 shutdown represented a different use of social media that occurred when significant contributors (e.g., government health agencies) were unable to fully participate in the conversation. In this context, social media could allow for identification of potential problems and facilitate mobilization of temporary solutions. Social media generated more than 45 million tweets, posts, images, videos, and other related output during the shutdown, and it could serve as a unique tool for identifying problems through real-time surveillance, rapidly disseminating information, and connecting individuals to resources.^5,10,11 Lessons learned from the use of social media during the shutdown could be applied to other events in which policymakers must decide how to disburse limited resources. The social media accounts of some US federal health departments and agencies were figuratively “furloughed,” but they could have provided key information to the public before going offline. In addition, social media could be used to guide the discussion around the shutdown by identifying public perceptions and concerns about important health-related topics.