Posted: December 30, 2002
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Article SummaryIn December 2002, I was asked to help plan and run a meeting on risk communication recommendations for the U.S. program to vaccinate healthcare workers and emergency responders against smallpox. The first column is an edited version of my introductory remarks. It addresses some familiar “risk communication linchpins” – paying attention to outrage, doing anticipatory guidance, expressing wishes and feelings, tolerating uncertainty, sharing dilemmas, riding the seesaw, etc. – all customized for the controversies I thought likeliest to emerge over smallpox vaccination. What I learned from the meeting was that most of the public health professionals implementing the smallpox vaccination program were themselves outraged that it even existed. So I wrote an “afterthought” on the sources of that outrage, and the need to deal with it lest it undermine the program … which, in my judgment, it later did.

Smallpox Vaccination: Some Risk Communication Linchpins

On December 17–18, 2002, the National Immunization Program of the Centers for Disease Control and Prevention (CDC) hosted a meeting in Atlanta to consider how best to communicate about smallpox vaccination. In addition to the CDC, the Department of Defense (DoD), the Food and Drug Administration, the Association of State and Territorial Health Officers, and a number of other government agencies and professional associations sent representatives. President Bush had just announced the U.S. program. Military vaccinations had already begun; civilian vaccinations (starting with emergency room personnel and other medical responders to any future smallpox attack) were scheduled to begin within a couple of months.

I was one of two risk communication experts asked to help plan and run the meeting; the other was Vincent Covello. The announced purpose of the meeting was to listen to Vincent and me, react to our comments, and emerge with a sense of what changes (if any) were needed in smallpox vaccination communication planning.

Vincent and I each gave an initial 40-minute presentation on “key points” we wanted the group to bear in mind throughout the two-day meeting. The following closely follows my presentation notes, but it isn’t exactly what I said. It has been revised based in part on what I learned in the ensuing two days.

I want to focus this morning on nine pieces of advice I hope you will keep in mind as we go through these next two days together. Here they are in a sentence apiece:

I chose these nine points to emphasize because they all raise issues where I think current smallpox vaccination planning is deficient, and where I think there may be pushback and a need for discussion. In other words, I have skipped the things you seem poised to do well and the things you seem likely to accept easily.

It follows that my comments do not add up to a fair assessment of your communication planning and actual communication activities to date. Much of what you have done and plan to do is excellent. My focus will be elsewhere. It also follows that you are unlikely to be able to “adopt” my nine recommendations before you leave this meeting. You may not want to adopt them at all! But if you do, you will probably need to bring them back to your agencies and organizations for further discussion first. I do ask that you put aside for now the question of how far you think you can persuade your management to move in the directions I recommend. Focus instead on how far you think it would be wise to move in those directions. If I can’t sell you on my thinking, you won’t need to sell your boss. If you’re sold, then we can work together on an organizational change strategy.

1. Embrace the “Risk = Hazard + Outrage” formula.

If “hazard” is the technical seriousness of a risk, “outrage” is its cultural seriousness, a compound of voluntariness, familiarity, dread, control, trust, responsiveness, etc. The correlation between hazard and outrage is an absurdly low 0.2. Moreover, outrage has a far greater impact on hazard perception than actual hazard does. It follows that managing the vaccination controversy means managing hazard perception by managing outrage.

link up to indexI have written extensively elsewhere on my “Risk = Hazard + Outrage” formula for risk communication, and I am not going to take your time here for a detailed presentation on it. But I do want to give you the quick version.

Everyone agrees that there is an absurdly low correlation between the technical seriousness of a risk (how many people it kills, for example) and its cultural seriousness (how many people it upsets, for example, and how badly it upsets them). In research studies that correlation hovers around 0.2, accounting for a tiny four percent of the variance. This is two problems, not one: the problem of risks that are likely to kill people but do not upset them (so they fail to take appropriate precautions), and the problem of risks that upset people but are not likely to kill them (so they take unnecessary precautions).

I have given the label “outrage” to the cultural half of risk. I call the technical half “hazard.” When I argue that “Risk = Hazard + Outrage,” I am claiming that both technical seriousness and cultural seriousness are part of what we mean by risk. What matters most here is that outrage pretty much determines perceived hazard. When people are upset, they will think the risk is deadly, even if it isn’t. And when people are not upset, they will think it isn’t deadly, even if it is. High-hazard low-outrage risks thus provoke insufficient concern and insufficient precaution, while low-hazard high-outrage risks provoke excessive concern and excessive precaution. So the job of risk communicators is in large measure to get people’s outrage where you think it belongs, to manage the outrage so it is commensurate with your assessment of the hazard.

Outrage is not random. Nor is it the result of media sensationalism or activist organizing; media and activists certainly capitalize on outrage and in the process they amplify it, but they do not create it. Outrage is a predictable, measurable, and controllable outcome of known factors. Here are twelve of the most important ones, with the low-outrage side of the continuum listed first:

  • Voluntary versus coerced
  • Natural versus industrial
  • Familiar versus exotic
  • Not memorable versus memorable
  • Not dreaded versus dreaded
  • Chronic versus catastrophic
  • Knowable versus unknowable
  • Individually controlled versus controlled by others
  • Fair versus unfair
  • Morally irrelevant versus morally relevant
  • Trustworthy sources versus untrustworthy sources
  • Responsive process versus unresponsive process

If you use this list to do a quick “outrage assessment” of the risk of a terrorist smallpox attack on the United States, it becomes immediately apparent that such an attack is an extremely high-outrage risk. It is on the high-outrage side of all twelve factors listed. The risk of smallpox vaccination is also pretty high-outrage, but not as high. Of course most public health experts currently judge that the attack is lower in hazard than the vaccination (because they think its probability is low); that’s why they recommend against mass civilian vaccinations.

This raises all sorts of complexities for management of the two issues. Smallpox vaccination outrage will almost certainly focus on the vaccine’s occasional horrific side effects. Smallpox attack outrage may or may not focus on the current unavailability of the vaccine to the general public – but if it does, there will then be a greater furor over vaccine access than over vaccine safety. Certainly an outrage management approach suggests emphasizing each outrage as a counter to the other. “If the threat of attack weren’t so awful, we would never use this dangerous vaccine on anyone. If the side effects of the vaccine weren’t so awful, we would immediately vaccinate the country to preclude an attack.”

Looking at vaccination outrage alone, several of the twelve factors immediately stand out as candidates for attention in any outrage-reduction or outrage-prevention effort:

  • Voluntariness – There will be more outrage on behalf of military victims of side effects than civilian victims, since military vaccinations are mandatory.
  • Familiarity – The smallpox vaccine used to be familiar, but for most Americans it no longer is. Making it more familiar will reduce the outrage.
  • Dread – The outrage provoked by dread is reduced if the dread is acknowledged and legitimated. This is why dramatic photographs of what the vaccine can do to people are good risk communication, and why “horrific side effects” is a better phrase than “adverse events.”
  • Knowability – As a knowability factor, uncertainty provokes less outrage than expert disagreement. It follows that it will help keep vaccination outrage low to acknowledge the unknowns, rather than being accused of hiding them or missing them.
  • Trust – Misinforming people, blindsiding them, and over-reassuring them are risk communication strategies that are likely to damage trust and thus exacerbate outrage.
  • Responsiveness – Both prospective vaccinees and vaccination opponents must be listened to. Their objections must be treated respectfully. Changes in the vaccination program in response to their concerns and criticisms are not signs of weakness; they are signs of responsiveness, and they will diminish vaccination outrage.

I can’t stress enough that the extent of controversy over smallpox vaccination will depend almost entirely on management of the outrage, not management of the hazard. Of course you need to manage the hazard well anyway, for all sorts of ethical and medical reasons. But you also need to manage the outrage well. A lot of people in this room are deeply committed to doing what is technically wisest, and to providing sound technical information to the public and the decision-makers. But the technical validity of a chosen course of action and the technical accuracy of an information package have very little correlation with the resulting level of public outrage. Give good technical advice. Provide good technical information. And if you want your advice and information to carry the day, do good outrage management as well.

2. Do anticipatory guidance.

People do much better with bad news when they saw it coming – especially when they have had a chance to think through in advance how they might feel (and how they should feel) when it happens. Smallpox vaccine side effects (“adverse events”) are just one smallpox vaccination issue that deserves anticipatory guidance. Others include routine reactions and unsubstantiated (but unfalsifiable) claims of serious harm.

link up to index“Anticipatory guidance” is a fancy term for a simple concept: telling people in advance what to expect – not just what is likely to happen, but also how they are likely to react. This gives them a chance to “rehearse.” They can get ready for what may happen and how they may react, which makes it easier for them to decide to react differently. All bad news benefits from anticipatory guidance.

The most obvious need for anticipatory guidance regarding smallpox vaccination is, of course, the prospect of “adverse events” – the possibility that some may suffer horrible and even fatal side effects from the vaccine. Anticipatory guidance on adverse events needs to be simultaneously blunt and compassionate: “We will probably kill some people with this program. Some may die because of screening errors or other errors; some may die despite our doing everything right. Every death will be a tragedy. In the face of vaccination deaths, some people, maybe even some of us in the program, will be tempted to conclude that it was a mistake to launch the vaccination program at all. After all, these will be actual deaths … compared to a merely possible smallpox attack. So it is important for me to say now that we are going into this with our eyes open, knowing that some deaths are likely and believing that protecting ourselves from a possible smallpox attack is important enough to bear that risk.”

The anticipatory guidance in the previous paragraph focuses on the possibility of deaths – both deaths from “screening errors or other errors” and deaths even without errors. What else do we need anticipatory guidance about:

  • The prospect of non-fatal but extremely serious side-effects.
  • The prospect of serious or even fatal side-effects from “shedding” – affecting people who weren’t even vaccinated themselves.
  • How awful even the less serious side effects will look and feel.
  • How bad the ordinary reactions will be – a week or more of feeling rotten; incredible itching; missed work.
  • The inevitability of unsubstantiated but also unfalsifiable side effects – people with debatable claims (and firm convictions) that the vaccine was responsible for their illnesses.
  • The prospect of a vaccination not “taking,” and vaccinees needing to go through the whole ordeal a second time.

Perhaps the most difficult sort of anticipatory guidance is anticipatory guidance with respect to unanticipated events. You don’t know what will happen. You don’t even have a complete list of what might happen. So warn us to expect the unexpected. “It has been several decades since we stopped giving smallpox vaccinations in the United States. There is much that we have forgotten, much that we never knew, much that may have changed. We are going to learn things in the coming months that we will then wish we had known now.” Anticipatory guidance is not confined to prospective vaccinees. The entire society, and most particularly the media, will respond more mildly to vaccine side effects and vaccine controversies if we have been properly prepared.

There is ample precedent for all this, from the swine flu vaccinations in the mid-1970s to the Gulf War Syndrome twenty years later. A recent 2002 article in the Journal of the American Medical Association (M.C. Danovaro-Holliday, A.L. Wood, and C.W. LeBaron, “Rotavirus Vaccine and the News Media, 1987-2001,” JAMA 287:1455-1461) discusses the media reaction to the “discovery” that the rotavirus vaccine could cause such side effects as intussusception. Coverage of the vaccine went from very positive to very negative (and much more extensive), a pattern described by the authors as “early idealization, sudden condemnation.” Anticipatory guidance aims to avoid this pattern. More coverage of the side effects early on helps inoculate against an over-reaction later.

So far, anticipatory guidance about smallpox vaccination adverse events has been excellent. Many public health officials are more worried about the risks of vaccination than the risks of attack; they supported a more limited vaccination program in the first place, and they have worked hard to make sure the public and prospective vaccinees understand vaccination risks. But I sense the beginning of a counter-movement now, as concern rises that the program may fail to find sufficient volunteers. The solution, I think, is not to downplay the warnings about vaccination risks. Instead, put more emphasis on warnings about the risk of facing a possible smallpox attack without a cadre of vaccinated medical responders. Understandably, health care people tend to be more alert to medical risks (such as vaccination adverse events) than to terrorism risks; they know more about the medical issues and feel more comfortable addressing them. Nonetheless, good anticipatory guidance means warning people about vaccination … and warning people about the possible attack vaccination aims to mitigate. A good first step: Stop calling it a smallpox “outbreak.”

It almost goes without saying that the organizations represented in this room should be ready for various smallpox vaccination crises and smallpox attack crises. You should have a plan in place – a communication plan as well as a medical plan – for responding to these crises if and when they happen.

I am arguing something more controversial than that: Virtually any crisis that deserves a contingency communication plan also deserves an immediate communication effort – so the crisis, if and when it comes, will not take the media, stakeholders, and the public by surprise. That is true of the possibility of a smallpox attack. It is true of the possibility of a smallpox “false alarm” that precipitates an emergency response and then turns out to be merely an idiosyncratic case of chicken pox. It is true of the possibility of fatal vaccine side effects. And it is true of a wide range of other possible vaccination crises, from a bad batch of vaccine to a large number of soldiers refusing to get vaccinated (or a large number of hospitals refusing to participate in the vaccination program).

I understand the reasons why my clients prefer to keep their possible crises to themselves, unless and until the crisis actually happens. But consider the benefits of anticipatory guidance, and the damage done by blindsiding your publics and stakeholders. You are preparing for the possibility that X or Y may happen. Give the rest of us a chance to prepare as well.

3. Express wishes and feelings.

Communicators too often confine themselves to explaining facts, leaving the audience alone with its wishes and feelings. If only we had a safer vaccine! If only we knew more about how to treat those horrible side effects! If only Marie hadn’t died! If only we knew for sure what the terrorists were planning! If only we didn’t have to live with bioterrorism risk! If you feel these things, say so. Show that you, and we, can bear them.

link up to indexAfter thirty years of working with technical people on crises and controversies of all sorts, I can report with confidence that technical people are human. They have wishes and feelings. In a crisis they have very powerful wishes and feelings – quite often the same wishes and feelings the rest of us are going through. But they worry that expressing these wishes and feelings, and thus letting their humanity show, will somehow cost them their professionalism. So they confine themselves to the technical facts … and wonder why the public so often sees them as unfeeling, inhuman technocrats.

It is possible, I admit, to go too far in the direction I am recommending, to come across as too vulnerable, too emotional, unable to cope. But you are unlikely to go too far. You are quite likely not to go far enough. Take comfort and inspiration from such role models as Secretary of Defense Donald Rumsfeld, whose personhood is almost always on public display, and CDC head Julie Gerberding, who recently told the public all about her husband’s brush with West Nile Virus.

The purpose of expressing wishes and feelings isn’t just to demonstrate that you are human (though that would be purpose enough). It is to help your stakeholders and publics cope with their own wishes and feelings. If I am frightened, or angry, or bereaved, for example, a purely technical communication leaves me alone with these feelings – and if the feelings are hard to bear, I may sink into depression or flip into denial. That doesn’t mean you should pretend to share my feelings if you don’t. But if you do, let it show!

In an actual attack, expressing wishes and feelings is crucial. Remember New York Mayor Rudy Giuliani’s wonderful answer when asked how many died at Ground Zero: “More than we can bear.” He was clearly feeling the weight of the catastrophe, and he was clearly bearing it – and that helped the rest of us feel it (instead of going into denial) and helped us bear it (instead of falling apart). The stakes may be lower when you’re just talking about a vaccination program. But the principle is the same.

What wishes should you express (assuming you feel them)?

  • We wish that we had a safer vaccine – that we weren’t stuck using one grounded in 50-year-old technology.
  • We wish that we knew more – about screening, about treatment of side effects, etc.
  • We wish that we were sure one way or the other about the risk of a smallpox attack. How awful that we are doing all this, maybe even killing some people with the vaccine, and it might turn out there was never an actual attack threat. How much more awful that there might be an attack and we’ll wish we had vaccinated everybody. The vaccination program is a compromise, an insurance policy, a halfway measure to address an uncertain situation. Like many compromises, it feels profoundly unsatisfying.
  • Above all, we wish that we didn’t have enemies capable of unleashing such horrific weapons, that we could somehow win them over, or reason with them, or destroy them all … that we didn’t have to play defense.

As for feelings:

  • Sorrow for awful things that happen: “We lost Brenda this morning.”
  • Guilt that they might have been prevented: “If only we’d known she had an immune disorder.”
  • Exhaustion, tension, frustration.
  • Even anger – it’s not the most attractive of feelings, but it is preferable to no feeling at all.

Notice how tempting it is to avoid expressing wishes and feelings. In fact, it is tempting to avoid even noticing them. Sometimes my technical clients are so deeply (emotionally) committed to being emotionless that they feel threatened by the legitimate and appropriate emotions of their stakeholders and publics. Instead of helping others bear their wishes and feelings, they put pressure on others to deny them: “There’s no reason to wish that, no reason to feel that.”

On the whole, engineers tend to have more trouble with emotion than health care practitioners. But one emotional issue on which health care practitioners tend to be very vulnerable is uncertainty about whether they are doing the right thing. Avoiding the emotional discomfort of uncertainty can lead to a mistaken effort to persuade everybody that what you are doing – in this case, the U.S. civilian smallpox vaccination program – is obviously the right thing to do. It may well be the right thing to do – but it isn’t obviously the right thing to do. In our hearts, I think, most of the people in this room fear this dangerous vaccination program may be unnecessary … and we fear it may be insufficient. Maybe we should vaccinate nobody … or everybody. Instead of acknowledging both fears and using them to explain how our government came to choose a middle course, we deny both fears – and we adopt as communication goals getting the public to deny both fears as well. Thus some drafts of the CDC’s smallpox vaccination communication plan articulate the twin goals of making sure the audience is not “inappropriately” concerned about a smallpox attack on an unvaccinated population and making sure the audience is not “inappropriately” concerned about the horrific side effects of the vaccine. Actually both fears, especially the former, seem pretty appropriate to me. Our communication goal should be to help our audiences acknowledge these two fears, bear them, put them into perspective, stack them up against each other, decide what actions to take, and understand the actions we have decided to take.

4. Tolerate uncertainty – and help us tolerate it too.

Acknowledge that the vaccination program is grounded in uncertainty. Show that you can bear the uncertainty and expect us to do the same. Pay sufficient attention to worst-case vaccination scenarios and to worst-case attack scenarios. In addressing prospective vaccinees, present pro and con with equal zeal. Give your recommendation and your reasons, but show you respect their autonomy and the reasonableness of other views.

link up to indexThe entire smallpox vaccination program is grounded in uncertainty: about the likelihood of attack (which isn’t your field anyway!), about the efficacy of post-attack ring vaccination, about the frequency of vaccination adverse effects and the best way to treat them, about the way liability and compensation issues will be resolved (again, not your field), about the likely public reaction to the whole business (my field – and just as uncertain as the rest of the list). The result of all these individual uncertainties is the global uncertainty I ended the last section with: uncertainty about whether the compromise vaccination program the President has chosen will turn out to have been the right one for the country.

Endlessly acknowledge this global uncertainty and all these individual uncertainties. Keep saying that you’re not sure, and that you wish you were and you know we also wish you were. Explain matter-of-factly that it is essential to act even in the face of all this uncertainty – that doctors and governments have to do that all the time, that you can bear it and you believe the public can bear it too. Of course you should also tell us what you do know; uncertainty isn’t the same thing as total ignorance, and you don’t want to leave people thinking it is. But even when explaining things you know, allow room for the possibility that you may be wrong. Predict (sadly) that you will be wrong sometimes, that you will learn things during the vaccination program that we will all end up wishing you’d known when you started.

The worst thing you can do with uncertainty is to sound sure and turn out wrong. It’s not being wrong that kills you. Its being wrong after sounding sure. That doesn’t mean you ought to sound indecisive. Confidently explain that you are not sure, but are prepared to take action nonetheless.

Actually, what really kills you is having things turn out worse than you said you were sure they would. If things turn out better than you said, our relief tends to make us want to forgive your error. In talking about your uncertain knowledge, therefore, bend over backwards not to be over-optimistic … even at the cost of turning out over-pessimistic instead. Explain what outcome you think is likeliest, but explain also what the worst-case scenario looks like. For vaccination adverse events, for example, the worst case is the largest number of deaths and serious illnesses you can imagine resulting from the vaccine. State this number prominently, along with your lower best estimate.

Rather than underplaying the smallpox vaccination worst case, balance it with the smallpox attack worst case. In essence, the vaccination program represents an unattractive compromise between two even more unattractive extremes: vaccinating the entire country and enduring a correspondingly large number of horrific side effects, versus going “naked” against the unmeasurable but non-zero possibility of a smallpox terrorist attack on the United States. There is much uncertainty about vaccination risks, and almost complete uncertainty about attack risks. The vaccination worst case is bad; the attack worst case is almost too horrible to contemplate. The vaccination likeliest case is not so bad, but not great; the attack likeliest case is probably no attack at all. Faced with this dilemma, this choice between uncertain options – one pretty bad but pretty likely, the other dire but we think unlikely – the President chose a compromise.

That’s uncertainty about policy. But there is also an uncertain individual decision some of us must make: whether or not to get vaccinated.

Let’s divide the public into four groups:

  • The “can’t” group -- those you refuse to vaccinate. That’s most of us, so far. Even among first responders and soldiers, this group includes people with contraindications such as eczema and autoimmune disorders.
  • The “shouldn’t” group – those you advise not to get vaccinated, but you’ll do it if they insist. It’s not clear if anyone is in this group yet. The Defense Department is considering treating families of some service members this way. This may also end up applying to first responders with “gray area” contraindications, such as those with a family member with a history of eczema. And of course the bulk of the population may wind up in this group if the vaccine is ultimately made publicly available.
  • The “should” group – those you advise to get vaccinated, but they don’t have to – medical responders, and soon other emergency responders. Actually, “advise” is the wrong word here; you are requesting them to get vaccinated, conceding that they would be doing so more for society’s benefit than for their own. (This has major implications for how you present the choice, and for what you do about compensation for adverse events.)
  • The “must” group – those you require to get vaccinated. So far, this group is confined to some members of the military. It could get vastly bigger if there were an actual attack, or even if one seemed imminent. (Fringe groups are already issuing Internet warnings that universal smallpox vaccination is the government’s secret goal.)

Some of the communication materials I have seen are systematically vague about the distinctions among these four groups. In particular, there is a tendency to say vaccination is “not recommended” for people you are flatly unwilling to vaccinate. It is essential to be clear and explicit about which choices the government is making for us, and which choices the government is allowing us to make for ourselves, although it may have a recommendation or even a strong preference. Do not blur the line between “shouldn’t” and “can’t,” or between “should” and “must.”

Outrage will of course be greatest for the first (“can’t”) and the last (“must”) of the four groups, the people whose decisions have been preempted, whose non-vaccination or vaccination is coerced. It will be all the greater if the coercion is accompanied by misleading language that implies the choice is ours.

But it is the two middle groups that really do face the choice, that in the face of considerable uncertainty must decide to get or not to get the vaccine. In informing these two groups, brief the case for saying yes. Brief the case for saying no. Offer your recommendation, and your reasons for your recommendation. And make it clear that you will respect their decision whichever way it goes.

The alternative is to brief the case only for what you want people to do. That diminishes the uncertainty for those who are prepared to be led like sheep; they don’t have to know there’s a tough decision to be made here. It leaves the rest of us alone with our uncertainty, with you busy pretending it’s a no-brainer. The downside of not leveling about the uncertainty is threefold: (1) Overdependency without real buy-in for some. (2) Resentment and resistance for others. (3) Belated feelings of betrayal for the first group when things go wrong … or even if things don’t go wrong, when controversies arise and they belatedly realize they were conned into a decision they didn’t really think through. In short, people whose choice was hurried or incompletely informed tend to end up almost as outraged as people whose choice was preempted entirely.

Let me practice what I preach. There is also a downside to leveling about the uncertainty: (1) More confusion, more indecisiveness, perhaps even some resentment that you’re not just telling us what to do. (2) Probably more time required per interaction, since it takes longer to nurture a thoughtful decision than to urge a biased one. (3) Possibly fewer people actually doing what you recommend (though those who do will experience fewer regrets).

Note that I am not advising you to offer people the vaccination choice without any recommendation (unless you really have no opinion what they ought to do). You are entitled – perhaps even morally obligated – to explain why you think first responders should accept the vaccine, and why you think the general public should not want the vaccine. But show that you respect alternative views. Tell us the case for and against, tell us why you are on the side you are on, and tell us that we are free to be on the opposite side without your thinking any less of us. Tell us stories about people you know – in your department, in your local rescue squad – who have decided to, and decided not to, get vaccinated. This is not the path of least resistance. But it is the path of greatest integrity, and of lowest eventual outrage.

One postscript on uncertainty: The various agencies and organizations involved in planning the vaccination program have gone to considerable effort to eliminate “discrepancies” in their descriptions of vaccination risks. A variety of overlapping estimates of adverse event frequencies were in circulation, for example, prompting negotiations aimed at choosing a consensus estimate. I understand the appeal of speaking with one voice. And I am all in favor of exploring differences of opinion and reconciling them when they are reconcilable. But it is dangerous to take this reconciliation effort too far.

Consider two scenarios with respect to estimating the frequency of adverse events. If there are half a dozen different estimates in circulation, and if everybody respectfully acknowledges everybody else’s estimates, then the media and the public will quickly deduce that all specific estimates are only uncertain approximations and the best estimate is a range, even a fairly wide range. As long as the “truth” ends up somewhere in that range, nobody was lying; nobody was even mistaken. By contrast, if the relevant experts and authorities all agree on a single estimate, journalists will soon dig up their prior estimates and begin asking why these discrepant numbers have been “suppressed” and what kind of pressure was applied to achieve an apparent consensus. And when the “truth” eventually emerges, your shared estimate will almost certainly have been wrong; if the final answer turns out worse than your negotiated consensus, charges of dishonesty will flourish. On balance, I think you’d do better with all those discrepant estimates still in circulation, and with the emerging “consensus estimate” a confession of uncertainty and a range that embraces them all.

5. Practice dilemma-sharing.

Dilemma-sharing is explicitly claiming that a decision is difficult, and the right answer isn’t obvious. Before deciding, you can share the dilemma and ask for help. After deciding, you can still share the dilemma by stressing that it was a tough call, with strong champions and solid arguments on all sides. Instead of pretending that the smallpox vaccination decision was a no-brainer, point proudly to the government’s months of open debate.

link up to indexDilemma-sharing is closely related to uncertainty. In a nutshell, it is acknowleding uncertainty about decisions you face, and most importantly about decisions you have already made. My clients hate it. But it is well worth adding to your repertoire. In fact, I think dilemma-sharing is absolutely crucial to the success of the smallpox vaccination program.

Dilemma-sharing has five huge benefits:

  • It is usually the truth – and has the ring of truth, the credibility of truth, the trust-building of truth.
  • It disarms critics – it’s hard for me to claim you’re obviously wrong when you’re not claiming you’re obviously right; everyone winds up agreeing that it’s a tough call, then disagreeing on which way to go. The debate moves toward the center, where it belongs.
  • It makes the things you say are obvious sound obvious. If you share dilemmas routinely, we take you seriously when you say something really is a no-brainer.
  • It buys you considerable protection when you turn out wrong. You always said you might be wrong.
  • It sets a standard of respect for the other side and the merits of the other side’s case. If critics are not similarly respectful of you and your case, they will pay a high price among the undecideds.

You can do dilemma-sharing about things you haven’t decided yet, and invite audiences to help you decide. You can also do dilemma-sharing about things that are up to your audiences, not up to you – which explains why your recommendations are less than firm, maybe even why you chose to leave the decision up to them in the first place.

Most important is dilemma sharing about things you have already decided. One of the most common errors my clients make is to suppose they must pretend a tough decision was easy once they have made it. This means pretending that nobody in the organization ever even considered, much less advocated, a different decision. It also means pretending that everyone in the organization now agrees that the decision management ultimately made wasn’t just a reasonable decision, wasn’t just the right decision; it was obviously the right decision. You can be loyal to a decision without these pretenses.

The most visible dilemma for smallpox vaccination is the risk assessment. The magnitude of a smallpox attack is almost certainly huge, though opinions differ on how many lives can be saved by post-attack quarantine and ring vaccination. The probability of a smallpox attack isn’t a statistical question at all; it hasn’t happened (that we know of) since Lord Jeffery Amherst did it to the Indians in 1754, and we have no way of knowing, really, whether it might happen tomorrow. So an attack is almost certainly very-high-magnitude; we guess that it is low-probability but we’re just guessing. Vaccination adverse events, on the other hand, are much more predictable. There are unknowns, but for a single vaccinated individual the mortality and morbidity risk is high-magnitude and low-probability; for the vaccinated cohort as a whole, the risk of horrific side effects is a high-probability low-to-moderate-magnitude risk. What to do in such a situation is anyone’s guess. It is a dilemma.

From the very beginning, opinions differed inside and outside the government about how to respond to this dilemma. Many influential and knowledgeable people, including Vice President Cheney, championed vaccinating the entire country. Others just as influential and knowledgeable, including the CDC’s Advisory Committee on Immunization Practices (ACIP), championed extremely limited vaccinations. The question went through extensive government, technical, and public debate, and ultimately was decided by the President himself – who ordered a bigger vaccination program than most health authorities had urged, but a smaller one than most counterterrrorism authorities had urged. Acknowledge this recent history, not abashedly but with justified pride. This is how healthy democracies deal with tough questions: publicly, confident that debate will strengthen the eventual decision and will not erode the public’s confidence in that decision.

Above all, emphasize that the scope of the vaccination program is still a difficult decision. National policy has now been set by the President – but it could still change: if the threat of an attack goes up or down; if the assessment of the frequency, severity, and treatability of side effects goes up or down; if the availability of licensed vaccine or even a new vaccine goes up or down. Meanwhile, people who think a different policy would have been wiser are no more foolish or disloyal today than they were before the decision got made. Your message in a nutshell:

The President has decided what we’re going to do. Here is the case for the option he chose. Here is the case for some of the rejected alternatives – alternatives on both sides of the one the President chose. It was a tough call. There are still many in and out of government who would have preferred a different option.

Many factors, from cognitive dissonance to bureaucratic self-justification, make it tempting to pretend or imagine that a tough call, once it has been made, was an easy call. But if you want the public to respect the decision the President has made, do not claim it was an easy or obvious decision, and do not express contempt for those who continue to disagree.

The Bush administration has been more open about dilemma-sharing and internal dissent than any in my memory. And the public’s response has shown that united fronts are greatly overrated – or, rather, that a country can be united and still nurture robust debate. Most people are glad that Donald Rumsfeld and Colin Powell are both exercising substantial influence on the war against terrorism and the decision whether to go to war in Iraq. They model respectful disagreement, the merger of loyalty with integrity, and above all the acknowledgment that important decisions are almost always dilemmas. Let’s try to do as well with smallpox vaccination.

6. Ride the seesaw.

Whenever people are ambivalent, they tend toward the side of the ambivalence that others are neglecting. So don’t preempt the seat on the seesaw that you should be reserving for your publics. If you don’t want us to blame you for adverse events, blame yourself some. If you don’t want us to be excessively fearful, don’t be excessively reassuring. And if you want us to learn to tolerate ambiguity and uncertainty, meet us at the fulcrum.

link up to indexWhat I have sometimes called “the seesaw of risk communication” stipulates that as long as an audience is ambivalent – that is, as long as people see merit on both sides of an issue – they will emphasize whichever side of the ambivalence the communicator fails to emphasize.

The geometry of the seesaw is exquisite; people will do what they need to do to keep the seesaw in balance. If you are way out on one edge, your ambivalent publics will end up way out on the other. If you go over to their edge, they will come over to yours. If you inch your way toward the middle, they will too. And if you move all the way to the fulcrum, articulating both sides with equal fervor and struggling to tolerate the ambivalence, so will they.

In the short, term, then, sit where you don’t want us (the public) to sit; leave our seat open for us. Communicators who misread the situation may act as if they were playing “follow the leader” instead of seesaw. In their effort to lead people toward the preferred position, they may preempt the seat they wish the public were sitting on.

In the longer term, invite the public to join you at the fulcrum, to bear the uncertainty and ambiguity with you, to see both sides at once and still cope. Acknowledging uncertainty and dilemma-sharing are all about getting us all to the fulcrum of the seesaw.

One important venue for using the seesaw is blame. When things go wrong, there is typically a good case for blaming those in charge and a good case for forgiving or even exculpating them. The more you blame yourself – for adverse events, for example – the less we will tend to blame you. The CDC learned this lesson very painfully during the anthrax attacks of 2001. The agency had not realized that weaponized anthrax spores could get through a sealed envelope during the mail-sorting process. Two postal workers died. It was exceedingly difficult for the CDC to accept some blame for this “mistake” (exceedingly difficult even to call it a mistake, which is why I put the word in quotation marks). But it was essential for the CDC to do so if the rest of us, and especially the postal workers’ unions, were to stop blaming the CDC and move on.

The most fundamental smallpox vaccination seesaw is about riskiness. When people are ambivalent about a particular risk, their response to what the authorities say about that risk will be governed by the seesaw. If you take the risk very seriously, we can relax; we can even criticize you for overreacting. But if you seem to blow it off, if you overreassure, if you leave the worried seat on the seesaw vacant, we are bound to occupy it.

For the prospective vaccinee, an adverse event is a high-magnitude low-probability risk. If you emphasize its low probability, I will emphasize its high magnitude. If you emphasize its high magnitude, I will emphasize its low probability. If you emphasize both, I will emphasize both. Assume your communication goal is to make me aware of the risks and cautious about the risks (for example, careful not to scratch), but nonetheless willing to accept the vaccination. In terms of the seesaw, you want me somewhere between the unworried seat and the fulcrum. Then your communications should be somewhere between the worried seat and the fulcrum. Give me the evidence that shows the probability of an adverse event is very low, but dwell on how horrific some of the side effects can be. Let me think your warnings are excessive … and take the inoculation.

The draft materials for prospective vaccinees are pretty good on this dimension. They do emphasize the high magnitude of adverse events (with spectacularly gory photographs); they state clearly but do not overemphasize the low probability. Early focus group results suggest that these materials work well. Screening and compensation are the major adverse event stumbling blocks, not the mere fact that something awful could happen. People get that it’s horrible but unlikely. Most are willing to take the risk, but they want assurances that they’ll be properly screened, and that if the worst happens they and their families will be taken care of.

Where the materials I have seen are not so good is on the dual nature of the broader smallpox vaccination story. There are two risks here, not one:

  • The risk of a smallpox terrorist attack.
  • The risk of horrific vaccination side effects.

I want to stress over and over that these two risks should be discussed in tandem. Each is the lion’s share of the answer to the other. We have a vaccination program that vaccinates fewer people than we would if the first risk were bigger and the second smaller, and more people than we would if the first risk were smaller and the second bigger.

The seesaw I urge you to ride most aggressively is not the adverse event seesaw, with high magnitude on one seat and low probability on the other. You’re riding that one pretty well already. It is the big-picture vaccination seesaw, with the vaccine’s horrific side effects on one seat and the need to protect ourselves from a smallpox attack on the other. What best balances alarm about adverse events isn’t reassurance about adverse events; it’s alarm about an attack. What best balances alarm about an attack isn’t reassurance about an attack; it’s alarm about adverse events.

Of course you should also provide appropriate reassuring information. For most vaccinees the side effects will be unpleasant but not dangerous; we think a smallpox attack is probably unlikely; we have Vaccinia Immune Globulin (VIG) for coping with the bad side effects if they happen, and ring vaccination and quarantine plans for coping with an attack if it happens; we don’t even know if any terrorists have the smallpox virus; we absolutely know the vaccine cannot give you smallpox. All of this deserves to be said. But the reassuring information should be distinctly subordinate to a two-horned warning: warning about attack risks and warning about vaccination risks. The dilemma to be shared, the seesaw to be ridden, is all about striking a balance between these two risks. Be sure to treat them – both of them – as serious.

As a start, it’s a smallpox attack, not a smallpox outbreak. (You eradicated smallpox outbreaks from the planet. You’ve never had to deal with smallpox attacks before.) And it’s horrific side effects, not adverse events.

If these two risks were not both serious, our country’s vaccination policy wouldn’t make sense. If the side-effect risk were serious and the attack risk were not, smallpox vaccinations would be illegal. If the attack risk were serious and the side-effect risk were not, smallpox vaccinations would be mandatory. If neither risk were serious, we wouldn’t have a program at all; smallpox vaccinations would be an unimportant individual choice. It is precisely because both risks are serious that everybody in this room is in this room. Say so.

7. Think about four key audiences and their different concerns.

There are at least four audiences whose different concerns should dominate our communication planning:

  • People who are most concerned about bioterrorist attack;
  • People who are required to get vaccinated;
  • People faced with the yes/no decision for themselves; and
  • People angry that they are denied access to the vaccine.

What is uppermost in the minds of each group, and how should their concerns be addressed?

People who are most concerned about bioterrorist attack

link up to indexThe most important thing for me to say about this audience is: Don’t forget them. Most of the people in this room come from a public health background, and most public health people are more sensitive to vaccination risks than to attack risks. Some are inclined to think the risk of a smallpox attack has been exaggerated by their colleagues in homeland security and intelligence. Some are resentful that the spectre of a smallpox attack has vitiated what had been one of the crowning glories of the public health professions: the eradication of smallpox. Some will find it difficult, at least as a matter of disposition and perhaps even as a matter of conscience, to speak warningly rather than reassuringly about the risk of attack, as I am urging you all to do.

Whatever the merits of the argument, and however you decide to resolve the discrepancies that may exist between your government’s policy and your private opinion, the fact remains: Many people are far more concerned about bioterrorist attack risks than about vaccination risks. Some of these people are fearful about a possible attack. Some are terrorized. Some are in danger of escalating into panic or tripping an emotional circuit breaker into denial. A crucial part of the smallpox vaccination communication job is to validate the appropriateness of being fearful about a possible smallpox attack. (If you doubt the appropriateness of this fear, you face a genuine ethical problem.) The way to prevent the overreactions of panic and denial is not by urging people not to be afraid; it is by acknowledging that their fear is justified, and then helping them bear it.

Overreassurance about the risk of a smallpox attack isn’t just bad risk communication; it also threatens your hard-earned reputation for following the data wherever the data may lead. Whenever I hear a health professional asserting that the risk of a smallpox attack is low, I wonder what data he or she is relying on in making this assertion. Intelligence professionals do have relevant data, of course, but they are quite properly reluctant to share all their data. We know, in fact, that intelligence agencies tend to see a smallpox attack as a more serious risk than health agencies do. We also know that intelligence agencies tend to tell the public what they think the public should be told. They do not have, and do not want, the reputation for candor that is essential to public health organizations.

In short, the CDC and the CIA have, and should have, different missions. So there is a dangerous paradox at work when the CDC finds itself repeating and implicitly endorsing the reassurances of the CIA that a smallpox attack is exceedingly unlikely. These reassurances aren’t just outside your field; they aren’t just based on information that hasn’t been peer-reviewed. They come from intelligence organizations that may not particularly believe them, and they are being passed along by health organizations that are desperate to believe them.

Two more specific questions are likely to arise:

First, does the speeded-up and beefed-up vaccination program reflect increased government concern about a possible smallpox attack? The only credible answer to this question, in my view, is yes. Though the probability of such an attack is still seen as fairly low, it seems higher than it once did. I have no objection to your pointing out some of the other reasons for expanding the vaccination program beyond the ACIP’s recommendations and the government’s original inclinations; we have more vaccine doses available than we thought, for example. But it is worse than futile to deny that the government’s assessment of the attack risk has increased, that war with Iraq seems likelier and access to the smallpox virus seems more widespread than previously thought. Remember, your job is to help this audience bear their fear of a smallpox attack … not tell them they’re wrong to be afraid.

Second, how prepared are we to cope with a smallpox attack? This is a key theme, inextricably tied to the vaccination program. The decision to vaccinate only first responders is grounded not just in the low probability of a smallpox attack, but also in the judgment that a small cadre of vaccinated responders will be enough to cope with such an attack if one occurs – enough to get the rest of us vaccinated fast, even in the face of an infrastructure that might not be working so well as the rest of us cower in our homes or line up (or riot) for our inoculations instead of going to work. This judgment seems intuitively far-fetched. You need to explain it and defend it much more explicitly than the government has done so far. To start with, you need to acknowledge that to many it seems intuitively far-fetched.

People who are required to get vaccinated

I have very little I want to say today about this second audience, since for the present only DoD will have to deal with people for whom vaccination is mandatory. But we should all remember that in keeping with the dynamics of risk communication, this is going to be the audience most outraged about adverse events, since for them the risk will be coerced rather than voluntary.

There is also a need, so far not very well met, to explain the rationale for making soldiers get the vaccine while forbidding civilians to get it. Do we believe America’s enemies are likelier to unleash the smallpox virus on an overseas battlefield than in U.S. population centers? (Soldiers were vaccinated against anthrax, but only civilians were attacked.) Do we plan to use soldiers to help respond to an attack on the civilian population? Is it just that soldiers are subject to military discipline and can more easily be required to take the vaccine?

People faced with the yes/no decision for themselves

I have already discussed my most important recommendations for communicating with this audience: Guide their decision rather than preempting it; explain the case pro and con, as well as your recommendation; show respect for their autonomous risk management judgment, whatever it may be.

A few additional points:

First, note that this audience may end up including both people you are urging to take the vaccine (though they are entitled to refuse) and people you are urging not to do so (though they are entitled to insist). You will need to explain to each group not just why you have the recommendation you have, but also why you have a different recommendation for the other group.

Second, many who face this yes/no decision will have a choice of altruistic and selfish reasons for saying yes. Certainly this is true of first responders. The altruistic case for their deciding to get vaccinated is primarily that they will be ready to deal with a smallpox attack if one occurs. (A secondary altruistic argument is the guinea pig argument, that we will learn much of value from the first wave of vaccinations.) The selfish case for their deciding to get vaccinated is that they will be protected in the event of an attack – an important matter since their jobs significantly increase their probability of exposure and, if not vaccinated, their probability of infecting their families. It is important to stress both sorts of arguments. Altruism is a strong motivator for voluntary behavior. People don’t like “being volunteered” for the benefit of others, but many – and first responders are likely to be among them – take seriously the opportunity to serve, even when it puts them at some risk. But the evidence suggests that people are likelier to act altruistically when there is also a self-interest rationale for the behavior. Some will tell themselves they’re being altruistic when their real motives are selfish; some, interestingly, will tell themselves they’re being selfish when their real motives are altruistic; some will simply have mixed motives. All will be likelier to follow the recommendation if both sorts of rationales are presented.

Third, be candid about the compensation issue. I think nearly everybody here today would agree that there needs to be a better Congressional response to prospective vaccinees’ compensation concerns. It would be unconscionable to ask first responders to volunteer to take a dangerous vaccine because we need them – and then abandon them if they suffer a serious side effect. If the vaccination program is launched before the compensation problem has been solved, it will nonetheless be necessary to address it head-on. “Congress still hasn’t dealt properly with the issue, and I have to tell you that the way the law stands today, it might be possible to get vaccinated, be one of the unlucky few to suffer a really bad side effect, and not be properly covered for it – not by your own insurance and not by the government. But nobody thinks things will stay that way. Congress will address the issue soon, and whatever they decide will apply retroactively. Still, the legal protection isn’t in place yet. People who get vaccinated today are trusting that if their number comes up and something awful happens, their government will do the right thing.” This isn’t a wonderful message to have to present, but it beats ignoring the issue altogether.

Fourth and finally, you need to reassure first responders that their vaccination decision is genuinely voluntary. Will there be any employment repercussions if they decline? Can they still be responders without getting vaccinated, or will they be reassigned? If they stay in their jobs without getting vaccinated, how quickly will you vaccinate them if there is an attack? The possibility of stigma and peer disapproval should also be addressed, and you should do what you can to make sure that those who choose to be vaccinated and those who choose not to be vaccinated do not divide into warring camps.

People angry that they are denied access to the vaccine

Not everyone who is denied access to the vaccine will be angry. Much of the public doesn’t want to get vaccinated in the first place; many who do want to get vaccinated – or at least want the choice – are willing to wait a year or two until the government is ready to release the vaccine for general use; most people with contraindicated conditions will be glad they got screened out in time. But some will be angry. Vaccine access will be a big issue for people who think a smallpox attack is more likely than the government says; for people who think post-attack remedies are less effective than the government says; and for people who have fervent overarching values about freedom, the right to choose, libertarianism, government coercion, medical arrogance, etc.

It may also be a big issue for some who think you are being too conservative about contraindications. Consider the plight of first responders who are urged to get vaccinated, ponder the problem, finally give their assent, and then discover they are ineligible because of a contraindicated condition. Members of this subgroup are likely to feel the outrage of anticlimax. To the extent possible, those with contraindicated conditions shouldn’t have to go through the decision-making process. Consider the possibility of doing at least preliminary screening before you ask people to think seriously about their decision. And consider creating a “gray area” of contraindicated conditions dangerous enough for you to urge prospective vaccinees to think again, but not so dangerous that you refuse to vaccinate them.

For all who want the vaccine and can’t get it, or can’t get it yet, there are two key questions. The first question is: Why can’t they get vaccinated now? Note that this is a different question from why you think they shouldn’t get vaccinated now. You can answer the latter question too, but in a country that leaves us free to make many unwise personal risk management decisions, from smoking to hang-gliding, refusing to allow us access to smallpox vaccine requires more than a government judgment that, on balance, we’re better off unvaccinated. The second question is really a complex of questions. When will they be able to get vaccinated? Why then? Is there any way to get it sooner if they really really want to?

The draft materials I have seen so far almost ignore this fourth audience. Yet this audience may ultimately be the most problematic – the most outraged, the most aggressive, the hardest to answer. There are good explanations for why you are offering to vaccinate responders in spite of the adverse event risk. It is much harder to explain why you are refusing to vaccinate the rest of us in spite of the attack risk.

Note that many who would decide not to get the vaccine if the choice were theirs won’t have to reach that judgment when the choice isn’t theirs. They can just be outraged at the coercive government preemption of their decision. The access battle probably won’t shape up as a battle over the wisdom of vaccination. It will be a battle over the right to choose. Vaccine shortage is apparently no longer available as a reason for triaging who gets vaccinated and who doesn’t; the government has said that in an emergency there is enough for all. We are left with explanations grounded in unresolved liability and licensing questions, in concerns about the inadvertent inoculation of contacts, and similar matters – genuine, but complicated and not all that compelling as a rationale for preempting a life-or-death decision. As these issues get laid to rest too, the case for choice will get stronger and stronger.

I hear considerable ambiguity in recent government statements about how soon the vaccine will be made generally available. The President sounds like he is in a greater hurry to accomplish this than the health care establishment; in fact, the health care establishment has been exceedingly reluctant to make the vaccine generally available ever. At a minimum, I think it would be wise to establish and publicize a “pressure relief valve” for those who are desperate to get themselves and their families vaccinated. There are a number of possibilities. Clinical trials might do the trick, if the definition of the trial cohort can be widened and its size multiplied. Commercial efforts to build a stockpile of VIG might provide a quid-pro-quo for those determined to get access to the vaccine. My wife Dr. Jody Lanard has proposed three-week “vaccination camps” where volunteers learn emergency response and paramedical skills while their scabs heal. These three are not the only options. Some way should be found to let people who really want the vaccine now, and who don’t have any obviously contraindicated condition, get what they want.

There is a seesaw at work here, of course. If the vaccine is available to all who want it badly enough to jump through the right hoops (and who have been properly screened, of course), many who would otherwise be fighting for access will decide not to bother. Much of the success of the vaccination program may depend on how well this vaccine access seesaw is managed.

8. Decide carefully when to merge these four sets of concerns, and when to address them separately.

It is often wise to deal with stakeholders separately early in a controversy, then bring them together. It is usually wise to focus more on stakeholders than on the media and the less involved “public.” For smallpox vaccination, adverse events will probably be the most newsworthy issue, but access to the vaccine may well be the issue that provokes the most stakeholder outrage. The two issues will tend to draw the ire of different stakeholders.

link up to indexOne of the most interesting tactical questions in risk controversies is when to segregate your audiences and when to mix them. Of course sometimes you have no choice. But when you do have a choice, my usual advice to clients is to deal separately with stakeholders at the outset, making significant concessions to each group. Then bring them into contact with each other, so they can see you coping with pressure coming from the other side. Ideally, this two-step approach ends up with each stakeholder group investing more and more in supporting you against pressure from the other side … thus moderating (somewhat) their own pressure.

My other standard advice is to see stakeholders as more important than the general public and the media. Stakeholders are people who care deeply, who listen attentively, and who tend to be skeptical or even hostile. They are reached directly for the most part, not through the media. The public is people who don’t care much, who aren’t paying much attention, and who are likely to swallow uncritically what little they take in at all. They are reached en masse through the media. My clients tend to overvalue media coverage and public opinion, without realizing that it is stakeholders who ultimately determine the outcome of the exercise … and even determine how the media cover the story and what the public ends up thinking.

The distinction falls apart in a bioterrorist attack, when everybody’s a stakeholder and the media are your direct channel to us all. But smallpox vaccination is just another story, and the distinction holds. Address stakeholders separately as much as possible until you have reason to bring them together. And don’t ignore them in favor of the media and the public.

The media and the public will probably be more interested in adverse events than anything else. So will some of the stakeholders – those required to be vaccinated, and those faced with the voluntary vaccination choice. Because of the coercion, soldiers will often be featured in media coverage and stakeholder activism about adverse events. Because of the irony, young, healthy emergency room volunteers will also be featured. Look for a lot of focus on liability and compensation – who will pay for these people’s care, their families’ loss, etc. Look for a comparison to Ground Zero compensation. Look for a determined scavenger hunt for side-effect “victims” you haven’t revealed and haven’t helped.

But the largest and most vociferous group of stakeholders will probably be those angry that they were denied access – and they may well hijack the media coverage in their direction. Don’t neglect these people and their issue! My guess: Access will be the biggest vaccination controversy and adverse events will be number two … until you offer a good access solution. Then adverse events will ascend to the top, especially if no credible evidence of bioattack threat materializes. And of course if smallpox vaccination ever becomes universal or even strongly recommended for all, the seesaw will tilt the other way and anti-vaccination paranoia (already visible on the Web) will become an important factor in the controversy.

Note that the two big controversies for now – denial of access and adverse events – cut opposite ways. They vitiate instead of reinforcing each other. In other words, you will be attacked from two sides, each with its own argument, rather than from one side using two arguments. The people who are angry at you for not letting them get vaccinated will generally be different folks from the people who are angry at you for allowing horrific side effects to occur. The relatively uninvolved middle will see some merit in both arguments, and will stay uninvolved in part because it sees some merit in both arguments. People will tend to feel strongly only about one, or at least only about one at a time. These are reasons to discuss the two issues together, maybe even to bring together the opposing stakeholders. Certainly with the general public, I would use the two issues side by side whenever possible:

If not for the horrific side effects of the smallpox vaccine, we would be making it available to everyone. But because of those horrific side effects, we feel morally justified in offering it only to responders, and in requiring it only of soldiers. We realize some people want the vaccine in spite of the side effects. At least they want the choice. Our American tradition of freedom is so strong that despite the reality that this is the most dangerous vaccine around today, a vaccine that kills even as it protects, there is ongoing consideration of opening it up to the general population (though without recommending that they take it) – once the responders have been vaccinated, there is plenty of licensed vaccine on hand, and we know more about how to treat the side effects. Of course if there is an actual smallpox attack the decision will obvious; we will try to vaccinate everyone who is exposed.

9. Bend over backwards to avoid charges of cover-up conspiracy.

The adverse effects issue is the kind of issue that feeds cover-up conspiracy claims. Plan now to address such claims effectively. Set up an independent accountability mechanism; empower local authorities to go public quickly; avoid withholding information even for good reasons; don’t use uncertainty as an excuse for withholding bad news; develop a protocol for addressing unsubstantiated claims; be apologetic, not hypertechnical; etc.

link up to indexNothing you can do will entirely prevent a controversy over whether you are hiding some cases of serious side effects. Virtually every vaccination program has led to claims of cover-up conspiracy. This one will too.

But there are ways to lessen the controversy, to make the claims less credible. Here is a checklist of strategies worth considering.

  • Set up an independent accountability mechanism so you couldn’t hide an adverse event if you wanted to. Get your critics to help you set it up and help you run it, so even they must concede that (this time) you’re not hiding anything. Publicize it widely. The message isn’t that you wouldn’t cheat. It is that you can’t. (Think of yourself as an oil company making it impossible to hide a spill.)
  • Don’t just track fatalities and the most serious adverse events; track everything more serious than a routine reaction, everything that requires medical attention. Otherwise journalists and activists will find “victims” you’re not counting, and ask whether you missed them or hid them or just don’t care about them. If the medical budget won’t cover this additional tracking, ask for a communication/accountability budget that will.
  • Realize that cover-ups and cover-up claims start locally. Put in place a mechanism so local authorities are empowered, and know they are empowered, to announce adverse events without waiting for higher-level approval. Make sure this effort (and all the efforts on this list) include DoD. Civilian candor and military secrecy won’t mix well; both will suffer.
  • Keep a log of accurate information about adverse events that you decide to withhold, even temporarily. Explain your reason in the log. Then imagine the log on the front page of the New York Times – and if your teeth clench, reconsider your decision. The best antidote to cover-up claims is full disclosure. And the measure of full disclosure isn’t whether you withhold information for no reason at all. It is whether you withhold information for reasons that seem legitimate to you, but will seem flimsy or self-serving to your critics … and to readers of the Times.
  • Talk before you’re sure. At the very least, don’t use uncertainty as an excuse for withholding unpleasant or alarming news, while good news of equal uncertainty is released promptly. Don’t imply that uncertain information is more reliable than it is – but if you’re worried about cover-up claims, don’t wait till it’s certain before you speak at all.
  • When in doubt, err on the alarming side of the seesaw. It is survivable to have to go back to the media or the stakeholders and say, “It’s not as bad as we feared.” It is devastating to have to go back and say, “It’s worse than we told you.”
  • Don’t try too hard to eliminate discrepancies in the technical judgments of various agencies and professional associations involved in the vaccination program. In particular, every organization has a history; it has said what it has said about the advisability of vaccination, the frequency of adverse events, etc. Any revisionist effort to tamper with that history will only feed claims of cover-up conspiracy.
  • Be apologetic about adverse events. On the blame seesaw, you be the one to (unfairly) blame yourself. And be visibly saddened. Don’t let a misguided version of “looking professional” stop you from looking human. Except in communications with your peers, replace the term “adverse event” with something that sounds more personal, less hypertechnical. (My vote is “horrific side effect,” if you can sell that to your management.)

Perhaps most important, draw on the Gulf War Syndrome experience and other, similar experiences to develop a protocol now for addressing claims of adverse events that are neither provable nor disprovable. Which adverse events will you treat as obviously the fault of the vaccine, which as possibly the fault of the vaccine, and which (if any) as simply not your problem? At the very least, track debatable claims as explicitly and transparently as you track the ones you’re confident are really vaccine-related. Talk to the media in advance about the problem of distinguishing vaccine side effects from coincidences, so the issue will be old news when it arises. And even when you think a particular illness is almost certainly not vaccine-related, be compassionate about the illness itself and respectful of those (the patient’s family, for example) who are convinced you’re either wrong or lying.

If you do all this, will you escape unscathed? No. But things are likely to go better.

Copyright © 2002 by Peter M. Sandman

See also:  Public Health Outrage and Smallpox Vaccination:  An Afterthought (January 2003)

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For more on infectious diseases risk communication:    link to Pandemic and Other Infectious Diseases index
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