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“Fear Is Spreading Faster than SARS” –
And So It Should!

The first half of our title was the headline of a recent New York Times article on SARS. The second half is a risk communication lesson that most health officials and many journalists have been slow to learn. It isn’t only about SARS. Regardless of the hazard, fear is a tool, not just a problem. The purpose of fear is to motivate precautions – that is, self-protective behaviors that diminish the risk of bad outcomes. To be useful, then, the fear has to outrun the thing that is feared; fear that lags behind its object is useless. Yet somehow the public is being told that it is wrong, irrational, panicky, or hysterical to be fearful of SARS just yet.

We’ve all seen these news stories. They describe the ways some local residents are responding to the SARS scare – curtailing their travel or wearing surgical masks or avoiding Chinatown restaurants. Then they offer statistics on the small number of SARS deaths so far worldwide, and the infinitesimal number of SARS deaths so far right here in River City … usually compared to the much larger number of deaths from flu or auto accidents or some other familiar risk. Then they quote a hospital infectious disease expert or a city health officer to the effect that people are being irrational, and a politician or an economist to the effect that their irrationality is damaging the economy. The implied conclusion: Don’t worry about SARS until it has shut down a local hospital, as hospitals have already been shut down in Toronto, Singapore, Hong Kong, and several cities in China.

Meanwhile, SARS keeps getting worse. It may not continue getting worse; the early days of catastrophic epidemics look a lot like the early days of soon-to-be-minor outbreaks. But the chance of a future SARS outbreak – yes, right here in River City – is high enough to make it reasonable to start taking precautions. Or at least to start planning the precautions we may soon need to take.

Imagine a huge hurricane working its way toward town. It is three days away, and headed right for us. We know it may well change course or blow itself out. Or it may hit us full-force in about three days. Forethoughtful people go buy extra food and duct tape for their windows now – even though the weather today is clear and balmy. “Fear Is Spreading Faster than Hurricane”? Well, duh!

There are some important differences between SARS and hurricanes. People who live in hurricane territory are comfortably familiar with hurricane-ology. They understand that the risk is serious, but not yet present; they get ready for what may be coming their way, but they know it isn’t here yet; their concern is future-oriented. Epidemiology (for most of us) is a much less familiar science, and SARS epidemiology (even for experts) is little more than some half-understood guesses. So our anticipation is tinged with ignorance and uncertainty, exacerbating the fear. We don’t entirely understand that SARS, too, may head right for us or veer out to sea or dawdle somewhere else for a while before it starts moving again; that it may strengthen or attenuate; that it can do some things hurricanes can’t do: disappear for a while and then come back next March; mutate into something more or less dangerous than what it is now. We may miss the distinction between personal risk and societal risk. Even if a SARS epidemic does strike a community, the probability that any individual resident will catch the disease is fairly low – but the probability that it will devastate the community’s health care system, economy, and quality of life is quite high. Perhaps most important, we tend to get the time frame wrong, translating what we are learning about the possible future crisis threatening our community into an unrealistic assessment of our current personal risk. This is not panic. It is how people adjust to new realities.

None of the above is a reason to try to persuade people not to take SARS seriously. Rather, it is a reason to teach people how to take SARS seriously. The three Golden Rules for addressing legitimate fears:

Soft Cover-Up

China is universally condemned for covering up SARS and putting the world at risk. Covering up an epidemic is about as bad a communication strategy as we can imagine. Among its outcomes: China actually does face a panic problem, as its people confront not just a raging epidemic but a government that lies to them about it. The West’s “soft cover-up” is much gentler and less dishonest – a cover-up of over-reassurance and minimization rather than of lies. But if SARS does keep getting worse in the West, as it has in China, the soft cover-up will also fail … and may also provoke panic.

Public anxiety can lead to genuine panic or to astonishing resilience. The paradox is that efforts to squelch the anxiety (“allay the public’s fear” is the usual phrase) can actually induce the panic it aims to prevent. Resilience is likelier when authorities ally with the anxiety, harness it, and steer it instead of trying to prevent it. Of course even superb handling of the public’s fears may not prevent panic if the epidemic gets bad enough. There has often been some panic during the great epidemics of the past. But panic will be likelier and more widespread if the authorities have been minimizing the risk than if they have been acknowledging it candidly and compassionately.

This is partly about false positives and false negatives – what the medical profession calls “the worried well” and what we might appropriately call the complacent sick. One of the lessons the SARS epidemic has taught us, or retaught us, is that a few sick people who are insufficiently concerned (or insufficiently screened) can wreak havoc. It is true that anxious people sometimes imagine they have SARS when they don’t, much as medical students traditionally imagine themselves into whatever disease they are currently studying. And it is true that this is an irritation, a distraction, and an expense for the health care system, at a time when the system is already overburdened. But even thinking purely in medical terms, are false positives really too high a price to pay to reduce the number of false negatives – that is, to achieve a vigilant patient population less likely to shrug off a symptom or a voluntary quarantine?

And thinking purely in medical terms is a mistake. SARS anxiety not only keeps us alert to the possibility that we might have SARS … or that our neighbor or coworker might. It has other benefits as well:

• It helps us prepare ourselves emotionally for the bad times that may be just around the corner. (Risk communicators sometimes call this “emotional rehearsal.” ) Then if the bad times come, we are less likely to sink into depression, flip into denial, or escalate into panic.
• It helps us prepare ourselves logistically. Do we still want to send the kids to camp this summer? Should we change our own travel plans? Is this a good year to socialize less and stay home more? What are the investment implications of a possible SARS pandemic? Is it time to stop using salad bars yet?
• It helps us consider our position on a wide range of relevant public policy issues – from the pros and cons of quarantines and travel bans to the advisability of upgrading hospital isolation facilities. Policy-makers who share these SARS policy dilemmas with the general public will find more understanding, support, and even good advice than they imagine.

So why do health officials, political leaders, and authorities of all sorts characteristically violate the three Golden Rules? Why do they contemptuously label people’s fears as hysterical and irrational, understate the seriousness of the risk by burying worst-case concerns in reassuring generalizations, and pass up the opportunity to harness and guide our emotions instead of condemning them? Five hypotheses are worth considering:

The ignorance and skills-deficit hypothesis

Many of the people managing public health crises are not risk communication experts. Many of them don’t have access to risk communication experts. In fact, many of them don’t know there is such a field as risk communication. Ignorant even of their own ignorance, lacking skills they don’t know they need, they do what they know best. For physicians, that may well be ex cathedra pronouncements about what people ought to be feeling and doing; for politicians, it may well be carefully crafted sound bites aimed at coming across as confident and in control. Underlying these communication efforts are several reasonable-seeming but false assumptions: that panic is the principal threat; that over-reassurance is the best way to prevent panic; that fearful people benefit from being told their fears are foolish. Our contention that SARS crisis managers need risk communication counsel is of course a self-serving contention; that’s what we sell. Nonetheless, SARS crisis managers do need risk communication counsel.

There are exceptions, most notably the U.S. Centers for Disease Control and Prevention (CDC), which has considerable in-house risk communication expertise, brings in outside consultants often (including one of the authors), and is working hard to provide risk communication training to state and local agencies. But the typical county health department or big-city hospital is lucky to have a single health educator doing double duty as risk communicator … and senior management probably does most of the really serious risk communicating without asking her opinion.

The irritation/convenience hypothesis

Health officials might understandably find it maximally convenient to keep their crisis management worries to themselves early on. They might prefer the public to stay in the dark, out of the way, and perfectly calm until there is some action they want people to do now. This “push-button public” model has obvious appeal to those in authority. Fearful and demanding publics are a pain in the neck. They are a bother and an irritation. An uncharitable view would stress that too many officials dream of dictatorial powers; would-be SARS Czars feel they shouldn’t have to put up with the fears of the peasantry. A kinder view notes that people in the midst of managing a health crisis are busy and frazzled; they can’t spare much time or energy for soothing – much less guiding – public fears.

Unfortunately for health officials, there is no push-button public, willing to ignore a growing crisis until ordered to mobilize into instant action. This doesn’t work even in China, much less in liberal democracies! If you want people to mobilize into action later, you need to get them ready now, not pacify them with over-reassurance.

Over-reassuring the public is a way of discounting the future. You might get lucky; if SARS fades away, look at all the time and irritation you’ll have saved. But if SARS spreads to many more large cities, including yours, you may be left with a public that is unprepared, mistrustful, and likelier to panic.

The “Do what I say, damn it!” hypothesis

In crisis after crisis, we have watched huge numbers of ordinary people demonstrate remarkable resilience, figuring out how to prepare and how to cope, and then implementing their decisions with calm speed. But often their decisions were different than what official “decision-makers” were prescribing – at which point officials were quick to brand the disapproved behavior as panic.

During the anthrax attacks of 2001, the clearest example was the 250,000 Americans who finagled a prescription for Cipro. Health officials didn’t want us accumulating our own antibiotic supply because they feared we might take the drug unnecessarily, potentially hurting both ourselves and our society. But lots of citizens felt safer with the Cipro waiting in the cupboard right next to the Ipecac, so they wouldn’t have to wonder just how efficiently an untested government emergency drug distribution system might work (in a snowstorm, maybe, with the truck drivers afraid to enter the city). This was a rank case of disobedience, not panic – but many officials called it panic.

Similarly, there are people now wearing masks in public places, wiping doorknobs with disinfectant before handling them, developing their own personal “travel advisories” for Chinese restaurants, and deferring inessential trips to hospitals. Any or all of these behaviors may be unnecessary, overcautious, or at least premature; and clearly they have downsides, in some cases huge downsides. But they have upsides too. They are signs that at least some of us are girding our loins for the possibility that this might be The Big One … and that even if it isn’t, The Big One might be coming soon. They are not panicky – just disobedient. So consider this tongue-in-cheek definition of panic: “The inclination to take precautions different from those recommended by the authorities.”

The projection hypothesis

Projection is disavowing your own uncomfortable feelings by imagining that others are feeling them instead. Angry people trying to stay courteous tend to imagine that others are angry. Panicky people trying to stay calm, similarly, tend to imagine that others are panicky. Officials managing the response to the SARS epidemic are on extraordinarily unfamiliar turf. In a variety of ways, SARS is unprecedented; it is the first new respiratory disease since the invention of the airplane that is not geographically confined, that kills a high percentage of those it infects (including many who were previously healthy), that can stretch even a modern medical facility past its breaking point, and that passes readily from person to person. For the officials in charge, this is their Rudy Giuliani moment. It seems reasonable that they are feeling a bit panicky – about the disease itself, about their ability to manage it wisely, about the recriminations that will come their way if they under- or over-respond. Yet their jobs and their self-esteem require them to keep these feelings well hidden, often even from themselves. Little wonder they misdiagnose an appropriately anxious public as dangerously panic-stricken.

The wishful thinking hypothesis

This probably applies more to political officials than to public health officials. But even the most rational, data-oriented experts are surely hoping against hope that SARS will burn itself out, weaken, or get contained. Voicing their more pessimistic fears may feel superstitiously unwise – so they may end up sounding more optimistic than they intended. Finding a way to express the wish directly may help prevent it from leaking out in the form of over-reassuring statements: “If only it would mutate into something easier to treat….”

Good Examples

For the most part it is not the highest-level public health officials who have been guilty of this soft cover-up, this desperate effort to allay our fears instead of helping guide our fears. To their credit, the leaders of several important organizations are calmly saying very alarming things.

Director Julie Gerberding of the U.S. Centers for Disease Control and Prevention is a master at not over-reassuring us, at helping us hold onto good news while worrying about bad news, at acknowledging uncertainty. Her frequent SARS “telebriefings” for journalists have been the most consistently good SARS risk communication we’ve seen.

Singapore Prime Minister Goh Tok Cheng has also done some astoundingly good risk communication. His gracious acknowledgment that it made sense for other countries to restrict travel to Singapore until it got its SARS epidemic under control was a startling contrast to Toronto’s temper tantrum on the same subject – and leads us to predict that post-epidemic travel to Singapore will rebound more quickly and completely than travel to Toronto. Given Singapore’s rocky start in the early days of the epidemic, and the country’s autocratic tradition, Prime Minister Goh deserves our admiration. (See http://www.psandman.com/articles/sars.htm for a recent Asia Times article with our take on how much better Singapore has done with SARS communication than Hong Kong or, obviously, China.)

A veteran of the 2001 anthrax attacks, Dr. Gerberding is a less surprising standout. Whenever she is asked if SARS could be terrorism, for example, she answers that while there is a lot of evidence suggesting that SARS is of natural origin, “we have an open mind and will be keeping an open mind as we go forward.” Other officials say only the first half: “There is no evidence of a terrorist attack.” Dr. Gerberding’s version is paradoxically more reassuring; we know she is still looking, just in case.

Dr. Gerberding doesn’t sugar-coat SARS uncertainty and the possibility of a widespread crisis. “The stakes are high … and the outcome cannot be predicted,” she says. She expects us to bear this uncertainty with her, though she expects it may be hard; this combination of high expectations and empathy makes the public more likely to cope well with the crisis. Rudy Giuliani did the same thing in the hours after the September 11, 2001 terrorist attack. Asked how many had died inside the Twin Towers, he answered, memorably: “More than we can bear.” He was clearly bearing it, and bearing it with difficulty; he clearly expected us to do the same; and for the most part we did.

A wonderful Gerberding quote illustrates how to help the public balance good news and bad news without losing track of either. The trick is to focus on the negative, but include the positive in a subordinate position. Here Dr. Gerberding wants us to hold onto both comforting information about the present and alarming information about the uncertain future: “We still have no capacity to predict where it’s going…. The last thing that we can do at this point is relax and say, ‘Thank goodness we don’t have very many probable cases in the United States, and therefore maybe we’re not ever going to have any subsequent spread….’” Another time she reminded her audience that even though there were only 39 probable SARS cases in the U.S., and no U.S. SARS deaths to date, “we’re not out of the woods yet.”

While Dr. Gerberding endlessly repeated that the U.S. had been lucky so far and might not stay lucky forever, hundreds of over-reassuring news headlines in the U.S. read “SARS Risk Small” and “SARS Risk Near Zero” – systematically confusing our low present risk with our potentially high future risk. The over-reassuring sources and the anxious public both get the time element wrong. The over-reassurers imply that since the present is safe the future will be safe too. The public imagines that since the future looks dangerous the present must be dangerous too. Dr. Gerberding keeps trying to correct both errors, insisting that the present is indeed safe in the U.S., and the future may well not be.

World Health Organization officials are also not sugar-coating the long-term risk of SARS. “If there are people who have the virus and don’t show symptoms, we are lost, because that would mean it had spread throughout the world, as it is easily contracted,” WHO infectious disease chief David Heymann said on April 8. A week earlier he said, “We’ve had killer outbreaks of new diseases before, like Ebola, but they have never spread internationally…. We’ve never faced anything on this scale with such a global reach.”

While the CDC and WHO have made sure their own communications were not misleadingly optimistic, they haven’t always done all they could to counter the misleadingly optimistic communications of others. When an accurate, balanced CDC telebriefing is transmuted by reporters into hundreds of over-reassuring news stories, the CDC has ways to know it. (Everyone has access to Google News.) The next telebriefing should call the problem to the reporters’ attention.

An example of this is the unavoidable uncertainty about the ultimate SARS mortality rate. This rate cannot yet be known; the answer depends on how many “probable SARS” diagnoses are actually SARS, and on how many currently sick patients die or recover. The information used by the CDC and WHO to come up with an interim mortality “rate” has been confusing to many journalists, despite both agencies’ efforts to be clear. In hindsight, it wasn’t enough for the CDC and WHO to explain how the “rate” was derived. They needed (and still need) to acknowledge ever more emphatically that early mortality information can be misleading and the real SARS mortality rate isn’t known yet, especially as it became clear that news reports on their statements were sounding misleadingly definitive and misleadingly low – a set-up for public alarm and even impaired credibility if the estimates keep rising. The risk communication problem is much tougher when things seem to get worse over time than when things get better – so a mortality estimate in the news that sounds confident and then goes up is worth avoiding.

Even in the early weeks of the epidemic, the CDC and WHO were calmly candid about uncertainties and worst-case scenarios. Yet in the U.S. the growth in public and journalistic concern in those early weeks was slow, with the SARS threat greatly overshadowed by the war in Iraq. As the epidemic spread, of course, public and media attention increased. Should the agencies have sounded the trumpets of alarm even more aggressively than they did, trying to arouse as much public concern in late March as they finally achieved in mid-April? We are not sure. The essence of fighting an epidemic, of course, is getting ahead of it – trying to provoke concern and protective action where the disease hasn’t reached yet. The problem is how to outrun the disease without outrunning the data, how to forewarn people without sounding inappropriately shrill, alarmist, even unscientific.

The CDC and WHO were more alarming, earlier, than the vast majority of public health agencies in the vast majority of serious situations. It’s hard to say they should have gone even further. Where they really could have gone further (and still could) is in their responses to the communications of others. We would have liked to see the CDC and WHO diplomatically but explicitly disavowing, criticizing, and correcting some of the over-reassuring statements coming out of many local health officials and journalists. (They may have done this privately, of course.)

But these are comparatively minor quibbles. On the whole, the CDC and WHO have operationalized the three Golden Rules well.

Another good risk communication practice modeled by the CDC and WHO has been open and apparently courteous expert disagreement. When the two organizations differed on issues of case transmission and case definition, they talked about their differences openly. Attentive observers got a chance to see some of the debates that need to take place in evolving science. And no one got the impression that either agency was hiding anything. Later, when the CDC decided to change its reporting of probable cases to conform to WHO’s definition, Dr. Gerberding told reporters about the switch well before she implemented it. Less adroitly handled, a sudden massive decrease in the reported number of probable SARS cases in the U.S. might have provoked skepticism, even paranoia. (Imagine mainland China announcing that it actually has far fewer cases than previously stated.) Dr. Gerberding’s clear forewarning put the story into the right context; most reporters led with something like, “As expected, the U.S. today reduced….” This models another risk communication principle, anticipatory guidance.

Bad Examples

While senior national and international health officials are appropriately raising alarm, and expecting us to bear it, local officials and experts, apparently unable to bear public anxiety, are still fantasizing about that push-button public. They wish we would stay perfectly calm and still until they tell us exactly what to do. They translate our insufferable anxiety, and perhaps their own SARS fears and feelings of inadequacy, into barely disguised disdain for the public.

“There’s been much more SARS hysteria than there is SARS,” Dr. Neil Fishman told MSNBC on April 23. Dr. Fishman is director of health care epidemiology and infection control at the University of Pennsylvania Medical Center. What does he see as “hysteria”? Well, “The physicians in internal medicine are getting two to five calls a day from people concerned they have SARS.” Two to five calls a day? They get more than that when an ad for a new arthritis drug comes out.

Dr. Fishman went on to explain to the MSNBC reporter that patients call with runny noses, which he says is “a sure sign that it is not SARS.” The CDC’s Dr. Gerberding and WHO’s Dr. Heymann would love to be as sure as Dr. Fishman! But they are keeping open minds as they follow the evolving picture of SARS.

Even if he is actually more sympathetic than he sounded on MSNBC, Dr. Fishman’s apparent disdain for the public’s concerns, combined with his overconfident and categorical statements about how SARS presents, can have some unintended but dangerous consequences. The consequences we are most focused on have to do with helping the public prepare for a possible SARS crisis – helping people bear their feelings and channel them into constructive action. We can’t think that Dr. Fishman’s communication approach is a contribution to these goals.

But there are medical consequences too. Suppose Dr. Fishman’s patients – and Penn’s medical residents, fellows, and nurses – sense he is likely to make them feel they’re being hysterical if they approach him with too many concerns about SARS. Suppose they get the feeling he really hates all these false-positive SARS calls. Are they more or less likely to consult him when a suspicious case comes in? Are they more or less likely to ask him early rather than late to look at a puzzling patient with a runny nose (perhaps allergies) along with some other symptoms more typical of SARS? The CDC’s Dr. Gerberding repeatedly advises that the U.S. cast a broad net around suspected SARS cases, false positives be damned. Is Dr. Fishman sending different signals at Penn? We see no way around it: An excessive aversion to false positives implies a substantial vulnerability to false negatives, and to the epidemic risk that false negatives entail.

We recently spent two days at Penn’s major teaching hospital (and the medical school alma mater of one of us). In between appointments, we surveyed outpatient locations for evidence of frontline SARS screening. As recently as April 11, we saw no signs posted in the emergency room. As recently as April 21, we saw no signs in outpatient radiology, where numerous coughing people were checked into crowded waiting rooms for chest x-rays; no signs in the outpatient laboratory waiting area either. We queried numerous receptionists and registrars if they were asking about SARS exposure and travel histories when people come up to their desks. We got mostly puzzled responses. One friendly triage nurse in the emergency room told us, “Oh yes, we are all very aware of SARS. We’ve been briefed. We check when we triage patients.” But we told several intake registrars that we had recently returned from an overseas trip, and nobody asked where. And no one was checking the family members or friends accompanying the patients. Everyone was just sitting around together. For hours.

A day later, at the CDC’s telebriefing for reporters, Dr. Gerberding said with approval, “Already we have been hearing reports about medical care facilities that have put up large signs in the emergency room and immediately access patients with a travel history” so that they can be quickly isolated if needed to protect healthcare workers and others.

We do not mean to demonize Dr. Fishman or his hospital, both of which have extraordinary reputations. Nor is Dr. Fishman’s rhetoric about SARS different from the rhetoric of dozens of other experts and officials around the country … indeed, around the world. To his credit, Dr. Fishman is more willing than most high-stature physicians to spend time explaining his views to the public. During the 2001 anthrax attacks he was also a media source, telling people how dangerous it was for doctors to be giving out Cipro. But when he went on to tell PhiladelphiaWeekly.com that “stockpiling antibiotics is a very strange, very odd consequence” of September 11, it became clear that Dr. Fishman – like virtually all of his peers – knows next to nothing about risk communication … not even that there is something there he might want to learn. It is one thing to believe people ought not to seek their own personal antibiotic supplies. It is something else to be surprised that they want to.

Risk Communication Principles

Our field of study and practice is called risk communication. It draws on fields like cognitive psychology, public relations, health education, game theory, family systems theory, interpersonal psychiatry, and a half-dozen others, merging them into something genuinely new and genuinely useful. (But of course we would think that. You can’t take our word for it.)

Especially since the 2001 anthrax attacks, The U.S. Centers for Disease Control and Prevention has been working hard to incorporate risk communication into public health practice. Just a few weeks ago it published an in-depth risk communication tutorial, available on line and on a CD-ROM, called “Emergency Risk Communication CDCynergy.” If you are reading this column on “The Peter Sandman Risk Communication Web Site,” you presumably know already that we have loaded the site with dozens of articles and columns on our particular approach to risk communication – including a lot of new material on crisis communication (most of it written about terrorism, but directly applicable to SARS). If you are reading this column someplace else, you might want to check out http://www.psandman.com/. Our point: There is a field there.

Public health officials and experts who are unacquainted with risk communication tend to box with the public’s fear, trying to knock it out. Risk communication is more jiu-jitsu than boxing – respecting the public’s fear, allying with it, and helping the public pivot on its fear toward appropriate vigilance, attentive learning, and productive preparedness.

So what are the risk communication principles that can inform SARS communication? Here is a brief list, incorporating some that we have already discussed in this column and some that we haven’t. We’ve tried to put the easier ones near the top. But none of the advice that follows is easy. It is all counterintuitive, and much of it is counter-normative as well.

Copyright © 2003 by Peter M. Sandman and Jody Lanard

Contact information page:    Peter M. Sandman