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What to Say When a
Pandemic Looks Imminent:
Messaging for WHO
Phases Four and Five

by Peter M. Sandman and Jody Lanard

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En Français: Quoi dire lorsqu’une pandémie paraît imminente:
Transmission de message pour l’OMS Phases Quatre et Cinq – Page 3 de 4)

Imminent Pandemic Standby Messages (cont.)

Imminent Pandemic Standby Message #13

Hand-washing is far from a panacea. But it’s easy, it’s under your control, and it has no significant downside.

Flu is believed to spread in three main ways –

mostly through droplets, large particles that are sprayed when an infected person talks, coughs, or sneezes;
sometimes through aerosols, much smaller particles sprayed much further; and
least often through touching something that carries the virus, such as a doorknob, a sink faucet, or another person’s hand.

Surprisingly, scientists still aren’t certain how important each of these three transmission routes is, even for the ordinary seasonal flu. They’re working on it.

Washing your hands doesn’t protect you from being sprayed by droplets or aerosols. But it is pretty effective in reducing contagion via touch. And of course it’s easy and free in places where soap and water are available. The more often and the more thoroughly you wash your hands, the less likely you are to get the flu … or to pass it on to the people around you. We don’t actually know how much less likely – but nearly all experts agree that hand-washing is useful against the flu. Now is the time to make sure everyone in your family (and your workplace) gets into the hand-washing habit.

It may sound silly, but when people do wash their hands, they often do a bad job of it. Here are some hand-washing tips…. For times when it’s not convenient to wash your hands, hand sanitizer gels are also effective.

Sources preaching pandemic preparedness have tended to oversell hand-washing. Official websites and brochures often state in one place that “hand-washing is one of the most effective ways to reduce flu transmission”; someplace else they point out that “droplets are the main route of flu transmission.”

We’re not worried that overselling hand-washing will lead to a false sense of security, creating an overconfident public that won’t bother with more difficult precautions. We’re worried that people will smell a rat. We’re worried that people will react to the mismatch between the experts’ urgent pandemic warnings and their paeans to hand-washing by losing confidence in both the experts and the hand-washing. It’s just not credible to sound like Cassandra one moment, talking about the coming pandemic that may disrupt normal life for months, and then to sound like Pollyanna (or mommy) the next moment, talking about the wonders of hand hygiene.

It’s also worth noting that officials and experts mostly ignore the problem of recontamination after hand-washing. How many campaigns have there been for changing public washroom faucets and doorknobs so they can be operated without using your hands?

Why do sources end up sounding more enthusiastic about hand-washing than the available data justify? Partly because they really want to get people to wash their hands frequently. And partly, we think, because they feel terrible about not having better solutions to offer. Lacking a silver bullet (such as an effective vaccine), they feel a need to oversell what they have.

This is natural but all too likely to backfire. People are probably likelier to end up deeply committed to hand-washing if you admit “it’s not much but it’s better than nothing” than if you pretend it’s a panacea.

At a pandemic communication seminar in Malaysia, Jody urged health officials to be more candid that hand-washing is strongly recommended not because it’s perfect but because it’s (almost) all we’ve got. When they tried out their revised messages on a test audience of hotel employees, the employees expressed a lot of interest in learning how, and how often, to wash their hands. “We must have oversold it,” Jody’s students concluded. “Ask them,” she advised. “Oh, no,” the hoteliers replied. “We get it that hand-washing isn’t a cure-all. But at least it’s something we can do, and we want to do it right.”

Imminent Pandemic Standby Message #14

Like washing your hands, wearing a facemask may help a bit. But it has more downside than washing your hands.

Just as hand-washing may help reduce transmission via touch, facemasks may help reduce transmission by droplets. If you’re infected, masks can help keep you from giving the flu to others when you cough or sneeze. If someone else is infected, masks can help keep you from catching the disease.

The kind of facemask called an N-95 mask (more properly called a respirator) is more effective than an ordinary surgical mask. Because it filters out even small particles, it works against aerosols as well as droplets. But N-95 masks have four big disadvantages: (a) They’re expensive; (b) They’re likely to be in short supply; (c) They’re difficult to fit properly; and (d) They’re uncomfortable to wear. N-95 masks are impractical for everyday use, even in a pandemic. But if you have to go to the hospital or care for a family member with the flu, they’re worth considering – and learning how to use correctly.

Surgical masks cost less and are more readily available, though they too may be hard to find during a pandemic. They are less uncomfortable and easier to use. They work fairly well against droplets, but not nearly as well against aerosols. Research on the relative efficacy of surgical masks and respirators (properly worn) shows that respirators are better – but how much better is still hotly debated. Surgical masks were extensively used during the 1918 pandemic, and they’re likely to be in demand again if we face another severe pandemic.

When the pandemic arrives, masks of one kind or another will sometimes be required or strongly recommended. Other times, it will be up to you … if you can find any. If masks are unavailable, experts may recommend covering your face with a bandanna or a home-made mask. Even the “wrong” kind of mask may remind you not to touch your face, and that in itself helps reduce the spread of flu. And if you have no mask of any kind, coughing into your elbow is thought to be better respiratory hygiene than coughing into the open air.

Unfortunately, no mask or “cough etiquette” practice will provide perfect protection for any of us. We will have to make do with what we can find. Recommendations about masks are likely to change as the experts learn more about what works – and what’s available.

All used facemasks should be considered dangerous objects. After all, if a mask has stopped some flu-containing droplets or aerosols (on the way in or on the way out), then for some period of time the mask itself can give someone the flu. So if you’re going to use facemasks, you need to change them often; you need to dispose of them properly or wash them carefully (if they’re reusable); and you need to wash your hands thoroughly after touching a used mask.

The very same sources who have oversold hand-washing have often refused to recommend facemasks at all, except for healthcare professionals. When asked why, they sometimes say they’re worried that wearing a mask, especially a surgical mask, will give people a false sense of security – an objection they never voice with respect to hand-washing. During the SARS outbreaks, paradoxically, officials in Toronto opposed mask-wearing on the opposite grounds; they thought seeing other people in masks would be unduly scary to the public.

Some experts also argue, accurately, that masks aren’t completely effective. But of course hand-washing isn’t completely effective either. The difference between the two isn’t that hand-washing has been proved more effective than mask-wearing; it’s that hand-washing has no significant downside, while mask-wearing has several real drawbacks.

The sound risk communication response, of course, is to tell people the drawbacks and let them decide for themselves. It is understandable that officials promote readily available hand-washing more than hard-to-get and hard-to-use masks. But it makes very little sense that so many sources of pandemic information have expressed outright opposition to the public use of masks.

Part of what’s going on is competition. Both kinds of masks, but especially N-95 masks, are already in short supply. Public stockpiling competes with healthcare stockpiling, and with ordinary use in healthcare settings. Fair enough. So tell people masks are in short supply and may not be available. Don’t tell them masks won’t be useful in crowded public places – and then expect to be trusted when you explain that people can transmit the flu before they have symptoms, when you advise social distancing and voluntary self-quarantine, and when you require mask use in hospital waiting rooms.

As a possibly severe pandemic approaches, people will be desperate for ways to protect themselves and their loved ones. Knowing that there are potentially useful things you can do – that is, feeling efficacious rather than impotent – is a key to coping well in crisis situations. Busy, efficacious people can bear their fears better; people who see themselves only as victims are likelier to sink into apathy or denial. So in addition to being useful on practical grounds, it is also useful psychologically to give people things to do.

Better still: Give people choices of things to do, so they’re not just blindly following your instructions, but also thinking through how best to act. People with choices to make learn more, feel more efficacious, and follow through better on the choices they end up making.

Of course the psychological value of “things to do” doesn’t mean the experts should oversell any precaution – be it hand-washing or mask-wearing. Precautions that look likely to do more harm than good should be discouraged. But if wearing a facemask looks likely to do more good than harm, it should be encouraged, with appropriate attention to its downsides.

This isn’t just about masks. It is about people’s attitudes as they face a potentially severe pandemic – and our attitudes as we prepare to guide them through it. It’s a serious mistake for authorities to head into hard times believing that they should recommend only perfect precautions with no disadvantages. And it’s a serious mistake for authorities to head into hard times believing that all precautions should be either forbidden or required, and that all decisions should be made by professionals. We will need people to be (and feel) informed and self-reliant, able to choose their own precautions after hearing our advice. And we will need people to accept that imperfect precautions are all we’ve got. (That will include the eventual, longed-for, imperfect vaccine.)

Imminent Pandemic Standby Message #15

Getting ready for a pandemic is largely about preparing for possible shortages.

In a severe pandemic, it may be necessary for households and businesses to cope largely on their own for a while. This is true for any emergency, but it is even truer for a pandemic than it is for a natural disaster like a hurricane or an earthquake. Some manufacturers may have to shut down temporarily because employees are out sick or supplies haven’t arrived. Some goods that have been manufactured won’t get to market because of transportation disruptions. Some services may be stretched to the breaking point.

Indirect impacts from such disruptions can pile up quickly. The result may be shortages of food, safe drinking water, medicines, energy, and everything else.

Items that will inevitably be scarce include those having to do with influenza itself, such as facemasks and antiviral medicines. Hospitals will be overstretched, both in their ability to treat influenza patients and in their ability to treat unrelated conditions.

Nobody knows how severe the shortages will be. In 1918, the worst flu pandemic in modern times, most people continued to have enough food, water, and energy. And many governments and companies have worked hard recently to improve our ability to keep things going during a pandemic. Even so, supply systems are much more fragile and much more global today than they were in 1918. Most people live in cities; most cities import almost everything they need from someplace else, often on another continent; most organizations run on just-in-time inventories that will run out quickly if the supply falters.

Bottom line: We simply don’t know whether shortages of essential goods and services will be a major problem when a pandemic spreads around the world. Most experts think that if the pandemic is mild, only the healthcare sector will be seriously affected. Hospitals will be crowded with sick people, but everything else will run close to normal. That was the case in the mild pandemics of 1968 and 1977. But if the pandemic is as severe as 1918, or worse, most experts think the resulting shortages are very likely to be severe as well.

To help cope with these shortages, some local governments and some manufacturers and retailers will probably try to ration what’s available, in the interests of fairness and social stability. There may be quotas on how much of various goods you are allowed to buy.

Some goods – antiviral medications, for example – may be saved for certain categories of people. Inevitably this will lead to controversy, as much of the public confronts difficult questions for the first time. For example, which is a higher-priority use for an antiviral dose: keeping a healthcare worker healthy, keeping a police officer healthy, or treating a patient who already has the disease? The answers to questions like this one will depend partly on values that are always debatable, and partly on facts that are still unknown, such as how severe the pandemic ends up being. Nonetheless, we will have to come up with answers.

Some experts and officials have been shouting for years about the possible infrastructure impacts of a severe pandemic. Others have been reluctant to deliver such a terrifying message. Most of the public has so far managed not to hear it or not to believe it. They will be shocked and angry to learn it. (If you’re one of the sources who tried to warn them, it won’t help anything to remind them of that now.)

So should impending shortages be a major message when a pandemic is imminent, and people are at last paying close, appropriately fearful attention? Many officials will say it shouldn’t. They’ll argue that this message is too scary, and too late, and maybe unnecessary since we’re not sure the shortages will actually materialize.

We think it’s a crucial message. In some cases there will be practical last-minute steps people can take to prepare for shortages. At the very least they can start conserving what they have.

More importantly, people need time to get shocked, angry, frightened, and depressed – and get over it and ready to cope – before the pandemic arrives. This is called an “adjustment reaction.” Like the stages of grief, the stages of crisis response are increasingly well-established, and one of the things we know is that after hearing about a terrifying new risk, people need to get through a series of emotional shocks – we sometimes call them “oh-my-God moments” – before they are ready to soldier on. Going through these shocks long before the pandemic would have been better than going through them just days before the pandemic. But days before the pandemic is better than after the pandemic begins.

Another reason for pre-pandemic and pandemic-onset candor: When the shortages start happening, the sources who warned they were coming will gain credibility (even though people will be mad), while sources who blindsided the public (by omission or over-optimism) will rightly be judged untrustworthy.

It’s not as if this knowledge will be long in coming. Even if you say nothing about potential shortages, enough people will anticipate the worst to produce an immediate pre-pandemic run on supermarkets, hardware stores, drugstores, gas stations, banks, etc. You don’t have any good choices – only a dilemma you cannot escape. If you warn of shortages, you’ll be accused of contributing to panic buying. If you don’t warn of shortages, people will rush to the stores anyway, and you will be seen as an unreliable source. Warn of shortages. And share that communication dilemma with the public.

Imminent Pandemic Standby Message #16

It’s probably too late to stockpile much now, but do what you can.

In preparation for a possible pandemic, some individuals and organizations have already stockpiled food, medicines, and other essentials. Some have enough for a few days, others for a few weeks or even months. And of course many people and organizations haven’t yet accumulated any stockpiles at all.

Is it too late now?

It may be. If everyone heads for the market and the hardware store right now, the shortages will be almost instantaneous – and we can’t discount the potential for antisocial behavior as too many desperate people vie for too few cans of tuna and boxes of facemasks. On the other hand, nobody knows how long we have till the pandemic, if it happens, spreads to our area. If supply lines keep operating for now, we may have time for stores to restock. It’s a tough call. On balance, we recommend that you do what you can to stockpile things you really need. Your first priorities should probably be prescription medications and food.

It’s probably impossible at this point to stockpile as much as you need of everything you need. If the pandemic is severe, many people will inevitably run out of some essentials. Then they will have to do without, or they will ask for help from their neighbors, from civic groups, or from local government. But it is sensible to stockpile what you can.

The question of whether or not we should recommend last-minute stockpiling is one that divides even our own agency. Some of us worry that the recommendation could easily worsen the very shortages we are warning against, and might lead to fights, robberies, and similar disruptions. Others think there may yet be time for people to stockpile and for stores to resupply, and they argue that telling people the whole truth is important for its own sake. We realize that urging you to stockpile what you can now will probably do some harm and some good. We hope on balance it does more good than harm.

The stockpiling message is most appropriate before the period contemplated in this column – in other words, right now – while there’s still no reason to think a pandemic is imminent, while preparedness is still abstract in most people’s minds, while stockpiling can be spread out over weeks and months (if we stay lucky), and while there’s probably ample time to resupply. Did you cringe when you read the paragraph telling people to rush to the store in pre-pandemic desperation? Then put more effort into getting them to build up their stockpiles now instead!

We’re more than a little nervous about recommending sudden stockpiling in Communication Phase 4. If everyone rushes out to the market at the same time, the message is likely to worsen the very shortages the messengers were trying to help people prepare for. But whatever sources say or don’t say, millions of people will rush out to the market at the same time. It’s better to affirm and guide people’s urge to stockpile than to ignore it. And shortages when a pandemic looks imminent are preferable to shortages after the pandemic has arrived. There’s reason to hope that manufacturing and transport won’t be too badly affected yet; there may be enough time and resources to partially replenish the shelves after a Communication Phase 4 run on the markets.

The last paragraph of the message shares this communication dilemma. It tells people there is internal debate over whether to recommend stockpiling, and it tells them why. This is grounded in our crisis communication advice to share dilemmas and let opinion diversity show. We believe it is never a good idea to make a difficult, angst-ridden, hotly debated decision sound like a no-brainer. But we must concede that this advice is itself hotly debated, especially our dissent from the conventional wisdom to “speak with one voice” in a crisis. (See Peter’s July 2006 column, “‘Speak with One Voice’ – Why I Disagree.”)

It will certainly be controversial to urge people to stockpile in Communication Phase 4. It will be especially controversial to urge them to stockpile supplies that are directly relevant to the pandemic, such as antiviral medications and facemasks.

Though many are opposed to the advice, we are very comfortable advising people to buy Tamiflu and masks now, during WHO’s Phase 3. We’ve been in Phase 3 (or its predecessor) since 1997; as long as we stay in Phase 3, it seems fair to assume that there will be time to cope with shortages induced by public stockpiling. But once a pandemic is imminent, people will be competing for these potentially life-saving supplies – not just with each other but also with healthcare professionals and those in charge of keeping society’s infrastructure running.

If the supplies will be as limited then as many experts think they will be, it may make sense to centralize or nationalize what’s available rather than letting it go on a first-come first-served basis. If this becomes the policy, there will need to be messages that explain it and justify it, and messages that acknowledge the inevitable fear, resentment, and outrage it will cause.

Imminent Pandemic Standby Message #17

Now is also the time to think about how you will care for loved ones at home.

Nobody knows how many people the pandemic will strike. But even a mild pandemic is likely to infect more people than our nation’s hospitals can handle. There are plans to set up special flu hospitals in civic arenas and other public buildings. Still, if someone in your household gets the flu, you will probably need to care for that person at home. And if you get the flu, that person will probably need to care for you at home.

There are four key questions to ask yourself now about home healthcare:

What supplies will you need to take care of a loved one?
How will you reorganize your life to enable a healthy family member to stay home with a sick one?
How will you reorganize your living space to minimize the probability that others in your household will get sick?
If someone in your household gets the flu, it is likely that the rest of you will be exposed, no matter how careful you are. If you had to, could you self-quarantine at home so you won’t give the flu to others before you know if you have it?

For some answers to these important questions, see….

We are consistently surprised that most pandemic planners we talk with are paying so little attention to home healthcare. Officials are terribly worried about how hospitals and other health facilities will cope with the overload, but shockingly little effort is going into reducing that overload by preparing people to care for their loved ones at home. Yet there is a good case to be made that hospitals – especially grossly overloaded hospitals with inadequate supplies and staff – will have very little they can do for flu patients that can’t be done more safely and more comfortably at home.

In our opinion, this includes the administration of antivirals like Tamiflu (if the pandemic virus is susceptible to that drug). Antiviral medications are believed to work best if given very soon after the onset of symptoms. So society is in a little-discussed Catch-22 with respect to antivirals. We want patients to avoid going to the hospital if at all possible; certainly we don’t want them heading for the hospital unless their symptoms are severe. That means by the time they get there it may be too late to give them Tamiflu. But most authorities oppose home stockpiling of Tamiflu, insisting that it’s better for public health authorities to dispense it when it’s needed … presumably at the hospital.

As production of these drugs increases, a thought-through home healthcare policy should include home stockpiling of antivirals. And the arguments conventionally advanced against home stockpiling, many of which are patronizing and even dishonest, should be abandoned. (See our January 2006 column on “The Dilemma of Personal Tamiflu Stockpiling.”) We see some encouraging movement in this direction. A number of corporations, for example, are not just purchasing Tamiflu for their employees but also distributing the supply now so employees have it at home (along with the other just-in-case medicines that their doctors trust them to use wisely – asthma inhalers, emergency bee-sting kits, angina pills, etc.).

Our support for home antiviral stockpiling is a policy opinion and a medical opinion – outside our field. But it is based largely on research showing that the public is much wiser during emergencies (and the run-up to emergencies) than most officials believe. Sixty years of disaster research is mostly on our side. The pandemic communication implication: Treat the public like grown-ups.

A thought-through home healthcare policy should also include a cadre of visiting nurses ready to help patients’ families learn how to take care of them properly; and a cadre of delivery services ready to provide food and other essentials, helping people stay home during the period when they’re likeliest to be infectious.

Like many of these messages, the homecare message is better delivered way before a pandemic than right before a pandemic. It’s a lot easier to equip a home for flu care now than it will be during Communication Phase 4. But let’s face it: Most citizens are still unexcited about pandemic preparedness. They figure they’ll make do with just-in-time pandemic preparedness. It would be a huge service if governments, community organizations, schools, and retailers created their own stockpiles of prepackaged influenza homecare kits, ready to distribute or sell when the public finally gets interested.

Imminent Pandemic Standby Message #18

To get ourselves through the hard times that may be coming, we will need volunteers. How can you help?

Because pandemics happen everywhere more or less at the same time, there won’t be much help from “outside.” This doesn’t have to mean that every household will be on its own. It probably does mean that every neighborhood, church, and community group will be largely on its own. Now is the time to reach out to neighbors, friends, and fellow members of groups, to plan together how best to cope together through the hard times that may be coming.

Now is also the time to plan together how best to make use of the most valuable pandemic-fighting resource we will have: survivors. The World Health Organization’s Influenza Pandemic Preparedness Checklist suggests:

Consider how recovered cases, who are presumably immune to the new virus, can be identified by occupation (for example, health-care workers or workers in designated essential services), in order to facilitate the development of a resource of workers presumed to be immune.

In every previous pandemic on record, even the most severe, the vast majority of people who got sick went through one or two weeks of hell and then got better. Think about that for a minute. In the horrific 1918 pandemic, about 97% of the people who got sick recovered. They went on to become the great-grandparents of many of us who will get sick in the next pandemic … and who will also recover.

And once people recover from any particular strain of the flu, they carry antibodies which make them virtually immune to that strain. It’s not quite a guarantee; the virus may mutate enough to make the antibodies less than completely protective, or the volunteer’s original illness may have been misdiagnosed (maybe he or she had a different influenza-like illness). Still, a few weeks after the pandemic reaches our community, we will start to have a cadre of survivors who can do essential tasks much more safely than anyone else. They will be about as safe as people who will later be vaccinated against the pandemic strain. (And “later” is much later: Small amounts of pandemic vaccine will not start to become available for three to six months, or even longer.)

In a severe pandemic, every organization will be shorthanded, and survivors can help take up the slack for organizations whose work is essential to our shared survival. Of course some essential tasks require special skills – firefighting, for example, or long-haul truck driving. Others don’t. When much of the workforce is home sick, we will need flu survivors to answer phones, to change linens at hospitals, to deliver food and other essential supplies, and to perform thousands of other tasks.

There’s no way to tell in advance if you will get the flu, get better, and be ready to help. But here’s a question you can answer now: If you get the flu and get better, will you want to help? If you think you will, call this number now so we can get your contact information and ask you what sorts of jobs you’d consider. Then all you’ll need to do when the time comes is call us for an assignment. You may also want to get involved now in the urgent effort to put together a local registry of prospective volunteers.

“Call this number now….” As of this moment there are only a few such numbers to call. Every time we do a seminar or consultation on pandemic risk communication, we harangue the group about the need for a Pandemic Survivor Volunteer Corps. Responses range from skepticism (“but what about liability?”) to puzzled support and embarrassed silence (“I wonder why we never thought of that ourselves”). But we haven’t seen a lot of follow-through.

Volunteer recruitment has not been a top pandemic preparedness priority. There are many programs to recruit and organize volunteer professionals – retired doctors and nurses, for example. But there has been very little effort to recruit and organize ordinary citizens – especially those who (by the luck of the draw) will end up getting the flu and then recovering. Even companies have been slow to develop registries of employees whose skills (or even just their availability) will be invaluable if they turn out to be pandemic survivors.

Though there are signs that this may be changing, volunteer skills registries are still scarce. Such registries – a crucial tool for critical infrastructure preparedness – can be compiled by local governments, or by schools, faith-based organizations, and community service groups.

There are of course some real problems to be solved, including liability law. But the biggest barrier to a Pandemic Survivor Volunteer Corps is attitude. Many health professionals, for example, are ambivalent at best about volunteers. They see their jobs as requiring proper professional training and credentials, and are reluctant to cede it to amateurs, even under crisis conditions. Emergency response professionals, meanwhile, have been taught that centralized command-and-control is essential to an effective response. (Katrina made them feel this all the more.) So they’re ambivalent about volunteers too.

In addition to attitude, some of the problem is a failure of imagination – and perhaps some understandable denial. Pandemic or not, ordinary citizens really can’t pinch-hit for medical and emergency response professionals. But in a severe pandemic, volunteers will be desperately needed for less highly skilled tasks as well. Medical and emergency response professionals seem to lose track of this crucial distinction.

These professionals all know (and say) that a severe pandemic will swamp their ability to cope. They know (and say) that to get through the pandemic ordinary citizens will have to help themselves and their neighbors. If volunteer networks spring up on their own, the professionals will be grateful for the lightened load. But we have found very few pandemic professionals interested in organizing nonprofessional volunteers.

In fairness, it’s not clear that the general public is all that interested in volunteering anyway – yet. Pandemic awareness is still low. So maybe just-in-time volunteer recruitment efforts during Communication Phase 4 are actually our best bet.

As a piece of risk communication, you can’t do better than asking people to think about joining a Pandemic Survivor Volunteer Corps. It is asking them to imagine this scenario:

A pandemic happens.
You get the disease.
You recover.
You want to help.

This is the ideal frame of mind with which to contemplate pandemic preparedness – whether it’s now or when a pandemic starts to look imminent.

Imminent Pandemic Standby Message #19

If the pandemic is severe, the hardest job won’t be coping with the disease itself. It will be sustaining the flow of essential goods and services, and maintaining civil order.

In a severe pandemic, we will have only a little control over how much illness and death will be caused directly by the pandemic virus. The big question is how much additional damage will be done by collateral disasters. Can we sustain the supply of food, safe drinking water, electric power, and medications for chronic illnesses? Can we keep the telephone and internet systems operating? Can we make sure that ATMs have some cash and gas stations have some gas? Will paychecks and welfare checks keep coming? Will the fire and police and environmental protection departments be able to keep responding to important calls?

The question is not whether organizations will be able to continue their normal operations. We know the answer to that question is no. In a severe pandemic, normal operations will be disrupted. Whether essential operations will also be disrupted depends on how well organizations have prepared … and how well they prepare now, in the days or weeks we have left. The goal for a severe pandemic is not “business continuity.” It is well-managed business discontinuity.

The single most important thing organizations can do now, if they haven’t done it already, is to figure out which of their operations are dispensable and which are essential. Only then can they focus their energies on the latter. Besides last-minute stockpiling of essential supplies (which every company in the world is now attempting at the same time), that also means last-minute cross-training of employees for essential functions. Experts are guessing that up to 40 percent of the workforce may be absent in the worst moments of a pandemic – sick, or taking care of sick relatives, or dead, or mourning dead relatives, or unable to get to work, or too frightened to come to work. We will need to make optimal use of the other 60 percent.

Are there aspects of your job that are essential to keep society going? If there are, get ready to focus on them. And start training some colleagues to help you or replace you if necessary. If what you normally do can safely be put on hold during a pandemic emergency, then ask yourself what else you might be able to do during that emergency. Has your employer given you an emergency assignment, a pandemic crisis duty station? If not, ask for one – or suggest one.

Some organizations have already devoted a lot of effort to what we call “business discontinuity planning” – getting ready to abandon routine work and regroup for essential tasks only. Others haven’t yet. But even the ones that have taken discontinuity planning seriously have tended to do so quietly, without involving much of their workforce. That will need to change fast (if it hasn’t already) when a pandemic looks imminent.

There are three reasons to ask employees what they do that’s essential, and what they know how to do that’s essential:

: The first reason is because we will need their counsel. There are pieces of the answer to this question that employees know a lot better than management.
: The second reason is because we will need their buy-in. Employees need to know that management is reorganizing for business discontinuity. They should already be in the loop when they’re asked to do some urgent cross-training, for example. They’re a lot likelier to show up for work during a severe pandemic if they have a sense of mission about their pandemic crisis duty station than if they picture themselves risking their lives to do their routine jobs.
: The third reason may be the most important: We will need their determination. Crisis managers know (and so does the military) that people cope much better with their fears when they’re busy – when they have things to do and things to decide in order to help themselves and others get through the crisis. The psychology catchphrase for this is: “Action binds anxiety.” (See Peter’s 2001 column on the anthrax attacks.) When a pandemic looks imminent, people will be at great risk of seeing themselves as potential victims – and only that. Part of the answer is offering them ways they can help themselves, and asking them to suggest additional ways. The rest of the answer is offering them ways they can help others, and asking them to suggest additional ways. In crisis situations, officials too often regale the public with long lists of supposedly reassuring official activities – “we’re doing this and this and this and this” – without making an all-out effort to involve the public as well. One key to getting through a severe pandemic (or any crisis) is to encourage an active rather than a passive public.

Imminent Pandemic Standby Message #20

Here’s what the government will be doing….

Getting through this imminent crisis will be mostly the work of households, neighborhoods, civic groups, businesses, and local governments. Influenza pandemics happen everywhere more or less at the same time, and that makes them intensely local events. Help from “outside” will inevitably be sparse.

Local governments can coordinate and facilitate the work of others, noticing where there are problems to solve or gaps to fill. And local governments must sustain their own essential functions – police and fire, water and sewer, in some places hospitals and power plants. Deciding what to do about schooling will also be a key task for local governments. Schoolchildren are very likely to give each other the flu, and then bring it home to their parents. On the other hand, closing the schools will make it much harder for parents to care for their children and still do their work.

What will the national government be doing? Its most important immediate task will be to monitor and disseminate information about the imminent pandemic, and then about the pandemic itself if it happens. Its most important longer-term (but urgent) task will be to foster the development and manufacture of a vaccine against the pandemic influenza strain. It will take months before even a small amount of vaccine becomes available, so there almost certainly won’t be any vaccine during the first wave of the pandemic. But there may be limited amounts ready if a second wave spreads around the world months later.

Other pandemic tasks for the national and state governments include….

This isn’t a terribly important message, which is why we haven’t developed it at any length – and why we put it near the end of the list, in opposition to all the natural tendencies of government officials.

Still, all those other messages about what individuals and households and civic groups and businesses should do will inevitably lead people to wonder whether the government is shouldering its share of the load. It is worthwhile to anticipate this question, validate it, and answer it.

Regardless of this pandemic messaging advice, we do realize that national governments will probably talk first (and at length) about what they are doing. We hope they will get through their “what we are doing” messages as quickly as possible. What matters most is telling people candidly how alarming the situation is, what is likely to happen in the coming weeks, and what they can do for themselves and their communities.

Imminent Pandemic Standby Message #21

Try not to switch off. Try not to overreact.

There are two psychological dangers in this crucial period when we are preparing for a pandemic that looks imminent. They are opposites, and they are both problems.

The first danger is that people may refuse to take the pandemic risk seriously enough.

Some may deny that the threat is real, reflexively scoffing at experts who predict that a disaster could well be approaching. Others may accept the threat intellectually but continue routine activities, refusing to drop anything in order to make time to prepare.

These reactions are natural, even inevitable. Fortunately, they compete with a strong, resilient urge to learn more about the problem, to figure out what to do, and to man the battle stations. We want to encourage your resilience, because we need everyone to get ready for the crisis that may be coming. There are actions we can all take to improve our odds of getting ourselves, our loved ones, and our communities through a pandemic.

If the pandemic happens and if it is severe, there will be hard times. But most of us will make it through. A year or two after it starts, the pandemic will be over, and most of us will still be here. By preparing now, by learning how to help ourselves and each other, we can lighten the burden.

The second danger is that people will overreact.

Overreaction is natural too. It too competes with our natural resilience.

Remember, the pandemic isn’t here yet. It may not happen right away, giving us time for last-minute preparations. Despite the indications, it may not happen this time at all. Or it may turn out to be a mild pandemic, like the last one in 1968.

Though it is essential to get ready for the possibility of a severe pandemic, we aren’t living with one yet. Two implications of this important fact:

Resist the temptation to wear a face mask now, or to stop going out in public, or to keep your kids home from school, or to stay home from work yourself.

When people start to imagine a severe pandemic, they sometimes feel as if it were already happening. The feeling is a useful way to rehearse emotionally for the crisis that may be coming. But our task now is to make pandemic preparations. It isn’t time to take pandemic precautions yet.

That time may indeed come. But it hasn’t come yet, and taking precautions prematurely will get in the way of more useful preparations.

Think twice before you take all your money out of the bank or the stock market.

In anticipation of any major crisis, it is prudent to keep more cash on hand than usual, in case there are breakdowns in electronic means of obtaining cash or paying for goods (such as problems with ATMs or credit card verification). But most U.S. banks stayed open throughout the 1918 pandemic. In countries where deposits are insured, trying to empty out your bank accounts is probably unwise and unnecessary – and will make it harder for others to get the short-term cash they need.

The stock market is a tougher call. Economic researchers have models predicting the markets will fall if there is a pandemic. Even now, some markets are already falling on the news that WHO has declared Pandemic Phase 4 [or 5]. [Note to readers: This is one of those places where we feel compelled to remind you that this article is devoted to a hypothetical scenario. There is no “Pandemic Imminent” market collapse as we write in mid-March 2007!]

We apologize that we cannot in good conscience advise you about your investments. No one knows how far the markets will fall. No one knows how quickly they will recover after a severe pandemic … or after a mild pandemic … or after a false alarm. And of course no one knows which of these scenarios we are about to live through. Some large investors tell us they are planning to ride out a pandemic almost fully invested, rather than selling at a huge loss during the inevitable market drop when the pandemic looks imminent. As always in the stock market, there will be a buyer for every seller. We don’t know which of the two will end up being considered the smart one. We do know this: However the pandemic progresses, it will eventually end, the world will try to recover as quickly as it can, and stock markets will climb again.

The first half of this message is essential, we think – warning people about denial and offering them some bulwarks against denial (things to do, things to decide, love, legitimization of fear). Because the word “denial” has such negative connotations to many people, we decided not to use it. But with or without the label, discouraging denial will be a crucial task during Communication Phase 4. (For more on the dynamics of denial in crisis situations, see Peter’s 2003 article, “Beyond Panic Prevention: Addressing Emotion in Emergency Communication.”)

We’re more worried about the second half of the message, warning against overreaction. There is real concern among pandemic planning experts that public overreaction in the run-up to a pandemic may lead to a set of self-fulfilling prophesies. People’s fear of shortages can cause shortages. People’s worries about a stock market collapse can collapse the market. And these things can happen even if the pandemic threat dissipates or the pandemic turns out mild.

But ignoring these concerns won’t reduce the risk. The best option, we think, is to make people aware of the risk – to tell them that overreacting is as much a danger as underreacting when a pandemic looks imminent. We’re not at all confident that will work. But we’re very confident nothing else will. In particular, glib over-reassurance about factors that are beyond anyone’s control (like a market crash) will damage credibility without actually reassuring anybody.

There is also a risk of similar governmental overreactions. Closing borders, for example, won’t stop a pandemic – but it will worsen the problem of supply shortages. Yet many experts predict that national governments will close their borders anyhow, knowing it will do more harm than good, simply to be able to say they tried, they did what they could, they didn’t just stand idly by. It might be worth adding a message urging people to urge the government not to overreact.

Imminent Pandemic Standby Message #22

Even though we hope riots, panics, and other sorts of civil disorder will not be common, it is important to be on guard.

Experts in crisis management know that riots are an unusual reaction to emergency situations. But it is important to remember that they do happen on occasion – especially when people feel the authorities are lying to them, withholding information, or behaving unfairly. Despite over 50 years of research showing that emergencies tend to bring out the best in most people, it is important to stay alert for the possibility of civil disorder.

The same is true of panics. People often feel panicky when they are extremely stressed. Although they usually manage to control the feeling and act sensibly, there are exceptions – especially when people are under the influence of alcohol.

Riots and panics did happen from time to time during the most severe pandemic in modern history, in 1918. True, they were relatively minor aspects of that event; there are far more stories of people helping each other through the horrors of the 1918 pandemic than of people making things worse by losing control. Once again, the exceptions were mainly when people felt the authorities were being dishonest, or when the authorities seemed to be playing favorites in the distribution of scarce supplies of food or medical care. In places where the situation was honestly acknowledged and the suffering was evenly shared, order was usually sustained.

But not always. Concern about possible riots and panics is both natural and prudent. Local governments share that concern, and crowd control is a high pandemic priority for local police. Many believe that the rush to stockpile food and other supplies when a pandemic looks imminent – that is, now – carries a real risk of disorder, as people first come to grips with the reality of shortages. There are also plans to guard public stockpiles of pandemic-related medical supplies against the possibility of looting.

If a severe pandemic materializes it will be mostly the virus that runs riot. But there hasn’t been a severe pandemic in almost a century, and no one can predict for certain how people will act. There are many good reasons to avoid crowds during a pandemic – and despite probabilities based on past disasters, concern about riots and panics is one of them.

Why have a Communication Phase 4 message about riots and panics? Partly because civil disorder is a real possibility, and partly because the prospect of civil disorder will inevitably be on people’s minds. (Memories of televised images from Hurricane Katrina will ensure that this is so – but it would be so anyway.) It is always good crisis communication to get unspoken concerns onto the table, where they can be ventilated, shared, addressed, and put into perspective.

Like the public, government officials usually overestimate the probability of civil disorder during crises, and often perceive the public’s rational precautionary behavior as “panic.” In response to these expectations and misperceptions, officials frequently make over-reassuring statements, withhold alarming information, suppress freedom (declaring martial law, for example), and order people – often with ill-disguised contempt – not to panic. Ironically, these responses increase the probability of civil disorder. One reason we want authorities to keep telling the public that riots and panics will probably be rare is to keep reminding the authorities themselves that riots and panics will probably be rare.

Notice that we have written the message in a way that wraps the reassuring news in warnings about the need for vigilance. This is a crisis communication strategy worth mastering. People in crisis situations expect the authorities to try to over-reassure them, and their response to one-sided, reassuring messages is often skeptical; they get on the other side of the seesaw and actually become more alarmed instead. Paradoxically, the reassurances can “get in” better if they are surrounded by expressions of concern. (See “Crisis Communication: How To Reassure Without Over-Reassuring.”)

Imminent Pandemic Standby Message #23

We are going into this pandemic crisis determined to be candid. That means you need to expect bad news, confusing changes in policy, conflicting opinions, and conflicting information.

One of the clearest lessons of the 1918 pandemic is the value of candor. In places where the government was brutally frank, communities rallied, took wiser precautions, and helped each other. Places where the government tried to “keep people calm” by sugarcoating the truth fared worse.

The temptation to sugarcoat is always strong, but we are going to try to overcome it. We may not always succeed, but total candor is our goal.

This has four important implications.

First, expect a pretty steady diet of bad news, at least for a while. We’ll tell you the good news too, when we have any. But in an effort to earn your trust, we will be struggling to tell you all the bad news, even when it’s preliminary and uncertain. People sometimes assume the government is overstating the good news and suppressing the bad, so they correct for that tendency by interpreting what they hear pessimistically. We plan to be pessimists ourselves. We hope you will discover that you don’t have to apply a pessimistic correction factor to what we tell you.

The second implication is that there will be frequent changes in policy. Nobody knows what the approaching pandemic will actually be like. There hasn’t been an influenza pandemic since 1968; there hasn’t been a severe one since 1918; every flu pandemic is different anyway. As the situation evolves, and changes, and clarifies, we will learn a lot more than we know now. Almost certainly, some of what we learn will be very different from some of what we think we know now. So some of our policies and recommendations will change. Obviously we can’t predict what’s going to change – whether it will be policies about school closings, or masks and respirators, or quarantines…. But we can confidently predict that much of what we learn in the coming months we will wish we had known when we started. This is part of what it means to be candid. We will tell you when we are sure. We will tell you what we think, even though we’re not sure – and we’ll tell you we’re not sure. And then we will tell you when it looks like we turned out wrong and have to reverse course.

The third implication: You’re going to hear a lot of differences of opinion. Governments usually try to speak with one voice, to keep their policy disagreements to themselves. It rarely works, even in normal times – and it doesn’t have a chance of working when pandemic news dominates the media 24/7. So we’re not going to try. When our policy is different from some other agency’s policy (or some expert’s recommendation), we’ll tell you so, and we’ll tell you why we decided the way we did. We’ll do the same thing when there are important policy disagreements inside our own agency. So who should you believe when opinions differ? Ultimately, of course, that’s up to you. Listen to a range of sources, so you can tell where there’s an emerging consensus and where there’s a wide-open debate.

The fourth implication is this: Just as you will hear a lot of conflicting opinion, you’re going to hear a lot of conflicting information too. Everything about an emerging pandemic sets the stage for rumors: The stakes are very high; so is the level of uncertainty, and the level of people’s anxiety; the media are ravenous for more information, and so is the public. Inevitably, a lot of the pandemic information you hear in the coming days and weeks will be misinformation. We will not ignore the rumor mill. Instead, we will track and report the rumors we hear. We’ll confirm the ones we know are true; we’ll rebut the ones we know are false; we’ll stay skeptically, publicly attentive to the ones in the middle.

Yeah, okay, maybe it’s a pipedream to expect any official source to articulate these principles. But we believe they are all solid crisis communication principles:

aim for total candor;
err on the alarming side;
acknowledge uncertainty;
share dilemmas;
warn people about changes in policy;
let opinion diversity show; and
acknowledge people’s existing beliefs (including the rumors they may have heard already).

Many of the messages in this column embed these principles already. What’s different about #23 is that it articulates the principles explicitly. There are two good reasons for doing this.

The first reason is to help officials stay true to the principles. Telling the public that you’re going to be candid and acknowledge uncertainty doesn’t guarantee that you really will – but it helps.

The second reason is to alert the public to what’s coming. This is a crisis communication principle too; the term-of-art is “anticipatory guidance,” but we usually call it telling people what to expect. Being candid means sounding more pessimistic and more uncertain than the public is used to hearing from official sources; it means pointing out uncertainties and disagreements and course changes instead of trying to hide them. If you’re going to behave so uncharacteristically, you should warn the public to expect it.

Anticipatory guidance (telling people what to expect) is one of the core tasks during Communication Phase 4. The goal of most of the messages on this list is to help people know what to expect in the pandemic that may be starting. The goal of this particular message is to help them know what to expect from your communications.

They really do need to know that. They need to know that you’re not sugarcoating the message. They need to know that everything you’re telling them about the pandemic is subject to change as you learn more. They need to know that there will be disagreements within your agency and between agencies. They need to know that there will be rumors and conflicting information. The sooner they figure these things out, the better you will be able to help guide them through the hard times to come.

Imminent Pandemic Standby Message #24

Listen to stories about what 1918 was like, and to guesses about what the coming pandemic may be like.

Preparedness experts know that being prepared isn’t just a matter of what you have done and what you have learned. It’s also about what you have imagined. Military training, for example, devotes a lot of effort to helping recruits imagine what battle will be like. Sports coaches ask their athletes to imagine, again and again, what the crucial moment of the crucial game will be like.

Of course nobody really knows what the next pandemic will be like. All we have are historical accounts from previous pandemics and fictional accounts of the next one. To get ready for the pandemic that looks imminent, therefore, feel your way into these diaries and scenarios….

This really shouldn’t be a separate message. It should be sprinkled through all the messages. What’s it like to be told to stay home with the flu because there’s no room at the hospital? What’s it like to take over a crucial job because the person who knows it best is too sick to work? What’s it like to bury a child or a spouse without a funeral because public gatherings are banned?

This kind of information is essential for emotional rehearsal, so people get through some of the shock – the adjustment reaction – before the pandemic arrives. The two best sources are historical accounts from the 1918 pandemic and well-informed what-if scenarios about the next one.

Even more than policy information, this sort of narrative information may turn out mistaken. So much is impossible to predict! What will be the symptoms of the next pandemic influenza? What will be the typical course of the disease? We know the answers for 1918. We know the answers for those who contracted bird flu from the pre-pandemic H5N1 virus. During Communication Phase 4, we will start to know the answers for the first victims of the emerging pandemic strain.

Of course we should make these what-if narratives as accurate as we can. But even narratives that turn out wrong will help people prepare emotionally in ways that policy abstractions and concrete logistical recommendations simply cannot match. To help people brace for the potential disaster to come, the narratives have to be vivid, they have to be realistic, and they have to be upsetting. They don’t have to turn out right.

Imminent Pandemic Standby Message #25

Here is some more information you may want to know…. Here is how you can get additional information… Here is how you can give us your feedback and suggestions….

There’s no message for #25 – just this commentary. We’re out of steam.

But the public won’t be out of questions.

It is worthwhile – and not especially difficult – to brainstorm lists of questions people are likely to ask when a pandemic is imminent.

At least one such list has been published. In October 2006, the CDC sponsored a one-day workshop entitled “Pandemic Influenza – Past, Present, Future: Communicating Today Based on the Lessons from the 1918-1919 Influenza Pandemic.” The workshop proceedings includes an appendix entitled “Probable Stakeholder Concerns List.” It is in fact a list of questions stakeholders are likely to be asking. Developed by workshop participants, the list is organized by scenarios.

According to the CDC’s Alan Janssen, work is ongoing to develop standby answers to the questions on this list, then to message-test the answers and put them through the government’s clearance process. Janssen wrote Jody in January 2007: “I hope to have all messages ‘in the can’ by late summer.”

This will be an important step forward in standby pandemic messaging. What the metamessaging will be like remains to be seen.

The CDC’s Scenario 3b – “Asian Influenza Outbreak in People – There are now hundreds of current, confirmed cases of a new influenza virus in an Asian country” – is described as corresponding to WHO Phase 6. But the 3b question list is well worth looking at with Phases 4 and 5 in mind. Here it is:

3-1.	Would you describe the situation as under control?
3-2.	How worried should people be?
3-3.	What can we expect next?
3-4.	What should people be doing now to prepare for the worst?
3-5.	Can people travel from the U.S. to Asia?
3.6.	Will you close the borders?
3-7.	What is being done to keep this disease out of the U.S.?
3-8.	What are the symptoms of this disease?
3-9.	What should someone do if they think they have this disease?
3-10.	Is this pandemic influenza?
3-11.	What is being done?
3-12.	What do you plan to do next to address this?
3-13.	Who is in charge?
3-14.	Who else is involved in the response?
3-15.	Do you expect this disease to get to people in the U.S.?
3-16.	What will you do if someone in the U.S. is diagnosed with this disease?
3-17.	What is being done about vaccine development and production for this disease?
3-18.	How are antiviral medicines being used in the U.S. now to address this?
3-19.	Will the U.S. provide antiviral medicines from the U.S. stockpile to the affected countries?
3-20.	Could this have been prevented?

Many of the questions on the list are questions people will be asking about what the government is doing. They deserve answers. But the list is less focused on what the rest of us should do. It does not match the mantra of U.S. HHS Secretary Michael Leavitt, who says:

Any community that fails to prepare, with the expectation that the federal government or, for that matter, even the state government will come to their rescue at the final moment will be tragically wrong.

The messages in this column were chosen with three criteria in mind.

First, they are the messages we think are most important for helping the public through its adjustment reaction so people are ready to cope with a pandemic.
Second, they are the messages we think government and corporate sources are likeliest to neglect.
And third, they are the messages we consider most likely to give rise to controversy over metamessaging – especially over how alarming and how candid it is appropriate to be when a pandemic looks imminent.

But obviously the column isn’t complete. Use our list of messages and the CDC’s list of questions as starting points. Then add messages that are suggested by your thinking, your reading, your colleagues, and above all your stakeholders and publics.

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For more on infectious diseases risk communication:

What to Say When a Pandemic Looks Imminent: Messaging for WHO Phases Four and Five