2005 Guestbook
Comments and Responses

Comment:

I don’t want to read long surveys, so to build my own estimate I’m looking for experts to give their probability estimates that the pandemic will come and how bad it will be. Who will give such estimates? Will you give yours?

The precise question could be: What’s your (subjective) expectation value of the number of deaths due to H5N1 (the current bird flu) in the next five years? Or: What’s your probability estimate that there will be more than 10 million H5N1 deaths in the next five years?

One number says more than 1000 words! (A graph showing how this estimate developed over time would be even better.)

Peter responds:

I have followed with interest your search for a quantitative estimate of how likely a severe flu pandemic is in the next few years. The Flu Wiki dialogue you provoked has been enlightening in many ways. But as you know all too well, it didn’t yield the number you sought.

It is incredibly frustrating not to have such a number. (I’m not going to have one for you either. I’m just a communication expert, not a flu expert.) We can calculate the odds that a severe hurricane will hit any particular location within any specified period of time. Why can’t we do the same thing for a pandemic?

In a very limited sense, we can. Over the past 300 years there have been roughly three influenza pandemics per century (not evenly spaced), so in any randomly chosen year the odds of a pandemic are about one-in-30. The most severe influenza pandemic known to history was the 1918 Spanish Flu pandemic. We have pretty decent history back around 500 years. So based on this extremely limited data set, I suppose the odds of a pandemic at least as bad as 1918 are about one-in-500 per year.

The problem is that this ignores what we know about the influenza virus of the moment, H5N1. How does what we know about H5N1 change the odds? We don’t know. Some virologists say H5N1 looks alarmingly like the Spanish Flu; they think the current odds of a severe pandemic are a lot higher than one-in-500 per year, maybe even higher than one-in-30. Other virologists say H5N1 has been around since 1997 without learning the trick of efficient human-to-human transmission, so it probably never will – suggesting that the probability of a severe pandemic today is no greater than it was before 1997, roughly one-in-500.

Both groups are guessing. For nearly all of the past 500 years, we lacked the ability to monitor a novel flu virus before it did or didn’t go pandemic. In recent decades, scientists have monitored a handful of novel flu viruses in other species. Other than H5N1, only H7N7 and H1N1 (the 1976 swine flu virus) caused any human deaths. Neither one caused a pandemic. H5N1 is the only flu virus so far that we have watched become widely endemic in birds and jump species to humans scores of times. If it starts a pandemic, that will be the first time ever that we have seen a flu virus follow this pattern and then start a pandemic; we’ll be one for one. If it doesn’t start a pandemic, that will be the first time ever that we have seen a flu virus follow this pattern and then not start a pandemic; we’ll be zero for one.

There have been pandemics before, but we didn’t know about them until they were well launched. There have been false alarms before, too, but we didn’t know about them either until people started (and then stopped) dying. How many times has an influenza virus followed a course like that of H5N1 (high infectiousness and high virulence among some bird species, low infectiousness and high virulence among humans) and then mutated into a human pandemic? We don’t know. How many times has an influenza virus followed that course and then not mutated into a human pandemic? We don’t know that either. This is the first time we’ve been able to watch.

In the absence of data, then, what you’re asking for is a collection of expert guesses. This isn’t a foolish thing to ask for. There is a lot of research, and even more argument, on the value of expert guesses as a stand-in for actual evidence. There are even formal procedures (the best known is called Delphi) for gathering and tabulating the guesses. Most such procedures seek a compromise between isolated individual judgments (too little opportunity to learn from each other) and roundtable discussions (too much pressure to conform). Their results are reported not as a single numerical estimate but as a distribution of estimates. The variance of the distribution – how much consensus the experts ended up reaching – is at least as important as its mean or median.

Also of interest is the shape of the distribution. For the question you’re asking, I would predict two humps. (Warning: I am now guessing about what flu experts might guess.) The larger of the two humps, I think, would be those who go with precedent and stick to the view that severe pandemics are very rare; the smaller hump would be those whose guts are telling them H5N1 is different. If you could get the experts to guess, and if the expert guesses turned out the way I’m guessing, what would that say about the real risk? I don’t know. It would probably say more about the psychology of risk estimation in the midst of uncertainty, the sort of thing Daniel Kahneman and Amos Tversky studied so effectively. And of course it would say something about the common tendency to get more confident and more extreme in your judgment when you’re immersed in a public controversy.

To their credit, most experts know they’re guessing – which is why they work hard not to get nailed to a specific number. And I suspect most experts would agree that the “true” probability distribution has three humps. There’s a good chance that nothing will happen in the next five years; there’s presumably a good chance that H5N1, if it does go pandemic, will be fairly mild, killing fewer than ten million; and there’s also a non-trivial chance (given its current virulence and other factors) of a real catastrophe similar to or even worse than 1918.

It’s hard for an expert to address all three humps at once – especially when talking to the media. So most experts tend to focus their public remarks on just one of the three humps. There are worst case scenario experts, mild (“typical”) scenario experts, and it-might-not-happen-for-many-years experts. And too often, at least as they’re quoted in the media, the experts end up less than clear that they’re talking about only one of three possible futures. The early media coverage of H5N1 (that is, up until the fall of 2005) tended to emphasize the mild scenario, often without saying it could be a lot more severe than that. The current media coverage tends to emphasize the severe scenario, often without saying it could be a lot milder than that.

By the way, the experts’ public guesses (if you could get them to guess publicly) are probably not as good a predictor as their private behavior. I’d like to know how many virologists now have antiviral stockpiles for themselves and their families.

Another hotly debated question is the relative accuracy of global guesses about big questions versus narrower guesses about sub-questions. It’s not hard to divide your pandemic question into components: What is the probability that H5N1 will develop the capacity for efficient human-to-human transmission? If it does, what change in its virulence would be expected to accompany the increase in transmissibility? How likely are antivirals to work against the mutated virus? How long will it take to develop how much vaccine? You can compile the answers to these sub-questions into an answer to the big question. What we don’t know is whether it’s better to ask the experts the big question or to ask them the little questions and then do the math. The two procedures typically yield very different answers. Opinions differ on which sort of answer is likelier to be on target.

Perhaps the hardest thing for us all to come to terms with – harder even than realizing nobody can give us a number – is realizing we don’t need a number. Regardless of the probability of a severe pandemic in the next five years, pandemic preparedness is a good investment. This is true for three reasons.

First, just about everybody agrees that there will be more pandemics in the future. There may or may not ever be one as bad as 1918 was. But milder pandemics are inevitable, sooner or later. Getting ready for a mild pandemic is a no-brainer.

Second, except for vaccines and antivirals, much of what we should do to get ready for a severe pandemic will also prepare us for other sorts of catastrophes – terrorist attacks, earthquakes, etc. Psychologically as well as logistically, disaster preparedness is largely generic.

Third and most important, the cost of preparedness is a very tiny fraction of the cost of being unprepared. Nobody (well, almost nobody) is urging governments, businesses, or households to turn their priorities upside down getting ready for a severe pandemic that may never come. Most are urging moderate, commonsense precautions, easily integrated into normal living. Figure it this way. Forgetting everything we know about H5N1, there has been one severe influenza pandemic in the past 500 years. Estimate how much damage a severe pandemic could do. Then plan on spending one-500th as much each year on preparedness.

Guenter Stertenbrink has written a point-by-point response, which is available on this site.

Note also that the Flu Wiki is planning to establish a statistical predictions page to compile any actual estimates Guenter is able to collect.

Comment:

I would like to know your opinion about influenza pandemic risk communication by the main scientific journals.

In my opinion until a few weeks ago, as you repeatedly stated, the main problem was to raise alarm in the public and in indolent institutions. But now the problem is shifting to the other aspect of the communication dilemma you outlined: to make it very clear that we are facing a risk whose size and timing are highly uncertain, in order to avoid a backlash if nothing happens in the next few months.

Maybe this is the reason why, for example, Science, which had always emphasized the alarms of WHO and other experts, in recent weeks has kept a relatively low profile and has given more room to skeptics (e.g., 18 November, p. 1112). On the other hand, it seems to me that other magazines such as Nature – and even more New Scientist, which last February came up with the record estimate of 1.5 billion deaths – are still maintaining a more alarming mood, maybe less appropriate to the new situation.

What is your opinion?

Peter responds:

Whenever a severe pandemic strikes, whether that’s days from now or decades from now, it will of course dominate everyone’s attention: the public’s, the government’s, the media’s, and the scientific journals’. Until then, the threat of a severe pandemic is simply an issue. And issues routinely go through what Anthony Downs dubbed in 1972 the “issue-attention cycle.” Interest rises, peaks, and then declines to a new floor that is somewhat higher than the old one was. Although Downs didn’t say so, for many issues the cycle repeats itself periodically, yielding a two-steps-forward one-step-back sort of long-term progress.

For advocates of action (such as increased pandemic preparedness), the lesson of the issue-attention cycle is to strike while the iron is hot. When people are paying attention, it is important to seize the teachable moment and use it wisely: inculcating good hand hygiene habits; persuading governments to make systemic improvements in vaccine manufacturing capability; urging communities and businesses and households to think through their emergency plans with a pandemic in mind; stockpiling essential supplies that are likely to become unavailable; etc. When people aren’t paying so much attention, a smaller group of pandemic fanatics should use the downtime to consolidate their gains and figure out how to take maximum advantage of the next attention spurt.

Inevitably, interest subsides (as it rose) unevenly. Some publications, scientific and otherwise, lose interest more quickly than others, or rebalance their coverage in the direction of greater skepticism.

I am not convinced yet that the current pandemic issue-attention cycle is on the wane. Google News did show a lot fewer daily hits for “bird flu” in late November than in late October, but that rough measure of attention has risen and fallen before; there are baby “cycles” inside the real cycles, often provoked by a single piece of news. Every country still experiences a huge increase in attention the first time a high-path H5N1-positive bird is discovered in that country – and there are a lot of countries, including the U.S. (and Italy), still awaiting that experience. Time will tell whether we’re in a momentary lull or on the down stroke of the 2004–2006 cycle. I think it’s a momentary lull.

I’m also not sure you are right that there is increasing coverage of the skeptical position, in the science journals or elsewhere. I have a casual impression that there is; my wife and colleague Dr. Jody Lanard (who reads even more bird flu coverage than I do) has the opposite impression. Periodically, a pandemic skeptic (Marc Siegel, Wendy Orent, Michael Fumento) publishes a book, article, or op-ed that generates a new flurry of coverage. Are there more such flurries now than there were a few months ago? I can’t tell.

It is important to distinguish some of the varieties of opinion that get lumped together as skepticism. It isn’t skepticism per se to point out that so far very few people have been infected with H5N1, that the virus may never learn efficient human-to-human transmission, and that all our worries and preparations may be for naught. That’s just the truthful acknowledgment of actual uncertainty; it is half of a balanced position.

Skepticism is that half denying or minimizing the other half. The skeptical view is that if H5N1 were ever going to launch a pandemic it would have probably done so already; that a severe pandemic is always possible but highly unlikely, and no likelier today than before H5N1 came on the scene. This is a legitimate position that deserves coverage – as is the alarmist position, of course. (I think the alarmist position deserves somewhat more coverage, not because it's necessarily closer to the truth but because it’s more dangerous to ignore. Paying more attention to scary news than to reassuring news is a kind of conservativeness.)

Beyond skepticism is reactance. The reactant position is that since a severe pandemic is (skeptics think) highly unlikely, anyone who urges or takes pandemic precautions is being hysterical. This is a non sequitur. People who have listened to the skeptical position can nonetheless rationally advocate precautionary action either because they think the skeptics are wrong on the probabilities or because they think a severe pandemic would constitute such a catastrophe that precautions are justified even though the odds favor the skeptics. The most extreme reactant positions express steadfast disapproval of any emotional or precautionary response to any risk until that risk is guaranteed and imminent. Reactance is beautifully captured in a 2003 New York Times headline: “Fear Is Spreading Faster than SARS” – as if it were somehow a mistake to worry about a disease before you actually catch it.

If coverage of the uncertain position is increasing, that’s good. If coverage of the skeptical position is increasing, that’s okay, as long as the alarming position is also holding its own. If coverage of the reactant position is increasing, that’s too bad.

I don’t agree with your implication that the best way to tell people about pandemic risks is first to arouse their concern with one-sided warnings, and only later to counter the possible backlash by acknowledging that Armageddon may not be right around the corner after all. The last thing I want is a communications universe divided into an alarmist camp (that pretends or imagines it is confident a severe pandemic is imminent) and a reactant camp (that insists the pandemic risk is minimal and precautions are a sign of panic).

What we need is publications – and individual articles, and even individual paragraphs – that acknowledge skepticism and integrate uncertainty and alarm. Something like this:

Nobody knows when the next severe pandemic will come. Nobody knows whether or not H5N1 will start spreading efficiently through the human population. Some experts believe this is very unlikely. But many experts believe the probability of such a spread is high enough, and the magnitude of the possible calamity is high enough, to justify taking precautions now. There is reason to hope these precautions won’t be needed soon, just as there is reason to fear they will come too late or won’t be nearly enough. But there is no good reason to postpone taking precautions.

I’d also like to see some more discriminating skepticism. Skepticism about whether there’s going to be a pandemic should be part of the media mix. But I continue to see pandemic news coverage in which certain specific claims are made without any skeptical rejoinder at all. High on my “where are the skeptics when we need them” list:

• Local health departments that proudly announce they are ready to handle mass vaccine inoculations or mass distribution of antiviral medications if a pandemic reaches their community. I don’t doubt that they’re ready, or at least readier than they were. What isn’t ready is a vaccine for them to fill those syringes with, or an adequate supply of Tamiflu or Relenza for them to distribute.
• “Experts” who offer false, unlikely, or inconsistent arguments against individual stockpiling of Tamiflu.
  • “If you need it the government will have enough for you.” (That one’s false.)
  • “If you stockpile it you’ll probably use it indiscriminately” – that is, when there isn’t actually a flu pandemic. (That one’s unlikely.)
  • “If you use it before the pandemic comes, you’ll contribute to making H5N1 more resistant to the drug when we need it; and anyway we should save our Tamiflu for the annual flu that’s on its way.” (That one’s inconsistent. If we’re worried about the resistance problem, we should avoid using Tamiflu against the annual flu too; and people who use Tamiflu when they don’t have any flu will waste the medicine, but they can hardly create a drug-resistant flu virus in the absence of any flu virus.)
• Poultry industry spokespeople who say their country is safe from a flu pandemic because their birds are carefully checked for H5N1. This is the ultimate non sequitur. Every contact between an H5N1-positive bird and a human being is a new opportunity for the virus to learn how to spread through the human population. Once the virus has learned this trick, anywhere in the world, we’re all vulnerable. If a pandemic starts, odds are it will start on a family farm in Asia (or Africa, when H5N1 makes it to Africa) – where poultry and humans commingle routinely; where hygiene is rudimentary; where there is virtually no way to monitor for H5N1. Your pandemic risk doesn’t go up much when your country finds its first H5N1-positive bird. And your pandemic risk doesn’t go down much if your country manages to keep H5N1 out of its poultry flocks.
• National governments that claim it is irrational to be nervous about eating chicken. It is true (as far as we know) that eating well-cooked chicken is safe whether or not the chicken might have had the flu. But not all chicken is well-cooked. And handling a raw chicken (not to mention killing and plucking a chicken) isn’t necessarily safe. So it is sensible – and emotionally inevitable – for chicken sales to decline when H5N1 is found in local flocks. In much of the world, moreover, it is also sensible for chicken sales to decline when H5N1 has not been found in local flocks. Is surveillance really good enough that they’ll know if a flock has H5N1? Are farmers likely to hide, and sell, the sick chickens they do know about? Is the government guaranteed to be candid if it suspects some local flocks might have an H5N1 problem? If countries all around yours have found H5N1, but officials insist your country is H5N1-free, it is credulous bordering on irrational to take their word for it.

Panflu skeptics: Keep right on debunking exaggerated claims that a pandemic is sure to happen soon and sure to be catastrophic. But please find time to debunk some of these other claims too.

Comment:

I love to use analogies when I am teaching a concept. I might say something like: “Adding to the budget each year is like overeating at each meal. In time you must deal with being overweight and all of the difficulty in losing the unwanted weight.” What are your thoughts about the use of analogies? Do you encourage them or have any cautionary thoughts?

Peter responds:

All great teachers make use of analogies. They are especially useful when what you have to say is abstruse, which explains why analogies to the everyday – from simple metaphors to extended parables – have played a key role in the rhetoric of the great teachers of science and religion.

I know of two exceptions, one comparatively minor and the other, for risk communication, quite major.

The minor one is that analogies are never precise. They help your audience understand what you’re getting at, but at the expense of changing it at least a little. When precision is your goal, analogies are not a useful tool.

The major exception stems from the minor one. Analogies are always vulnerable, both to misunderstanding and to attack. They’re invaluable when your audience is on your side, trying to get your meaning. But when the audience is hostile, resistant, or very upset, I would steer away from analogies; in those cases, it is better to say what you mean, not compare it to something like what you mean. I’d be especially wary of analogies to everyday situations when trying to explain a risk your organization is imposing or excusing. Outraged people are pretty much guaranteed to react badly when told that living next door to your dimethylmeatloaf emissions for a year is like white-water canoeing for a minute, or that a part per million of dimethylmeatloaf is like one crouton in a salad the size of an Olympic swimming pool.

Comment:

After multiple emails that were tactfully deflected, the mayor of my township emailed me and requested that I meet with her soon to discuss avian flu/pandemic flu. Since this could be the only meeting I may have with township officials, what do you suggest in the way of specifics to discuss, duration of the meeting, and written materials I’d like to leave with her? I don’t want to put her to sleep nor to panic her.

Peter responds:

Obviously you know your mayor and the mood in your township a lot better than I could. But here are some thoughts.

Good luck with your meeting!

Comment:

I have searched your website and find that most of your risk communication information is intended for use with the general public. I would appreciate information on risk communication for healthcare workers who may be asked to provide care for patients hospitalized with influenza H5N1.

Although using recommended infection control precautions will minimize the risk of infection, the risk can never be entirely eliminated (as evidenced during the SARS outbreak). Also, if a pandemic occurs personal protective equipment such as respirators, etc. may be limited.

I am concerned about the oft-repeated comment that HCWs will not come to work in such a scenario. In 30 years of working in healthcare, I have observed many instances of heroism and few of cowardice, although both are likely to occur in a pandemic. Just a generation ago, HCWs regularly took risks working with TB and other infectious patients, etc. More recently HCWs took risks caring for HIV patients when the mode of transmission was unclear. And of course there is the SARS experience.

What lessons can be learned from past experiences and from the SARS outbreak that can be applied if a pandemic occurs?

Peter responds:

This response was written jointly with my wife and colleague Jody Lanard, M.D.

As you point out, healthcare workers (HCWs) are usually responsible, sometimes heroic, and only occasionally too frightened to do their jobs. On the other hand, a severe infectious disease outbreak is about as frightening as a healthcare crisis can get. We don’t think anybody can predict with confidence how HCWs will respond if and when a pandemic hits your community.

What we can say with confidence is this: What HCWs do during a pandemic will depend in large measure on how they were talked to, and listened to, in the run-up to the pandemic.

At a recent Yale University symposium on “Ethical Aspects of Avian Influenza Pandemic Preparedness,” a hospital infection control officer told Jody that she had real reservations about passing on to her staff the CDC’s recommendations about masks and other personal protective equipment (PPE) – recommendations she saw as grounded more in speculation than in actual knowledge. Even after a pandemic began, she said, there would still be enormous uncertainty about which precautions were essential. She feared spending lots of hospital money on expensive N95 masks, and then being told later that they were unnecessary. She also feared skimping on N95 masks and running out, only to learn that they were medically essential but no longer available, forcing her staff to make do with less protective surgical masks.

Best risk communication practice in such a situation, Jody told her, is to acknowledge the uncertainty, share the dilemma, and solicit the opinions of everyone who is (or will be) affected. This can be done now, while the hospital is deciding what PPE purchases to make. It is even more important to do later, after the pandemic has begun … and still later, as it starts to become clear how wise or unwise those uncertain early decisions have turned out to be.

Candor and consultation may or may not improve the quality of a hospital’s decisions. They are virtually guaranteed to improve the likelihood that HCWs will understand the risks and the uncertainties, will accept the difficulty of making so many uncertain decisions and the inevitability of making some wrong decisions, and will therefore feel both more able and more willing to cope with the outcomes.

The bottom line: Whether healthcare workers accept the risks of working through a pandemic – that is, whether they decide to come to work – depends only partly on how serious they believe the risks are. It depends also on how candid and consultative they believe hospital administrators have been. Infection control officers should predict candidly that the CDC may learn things that lead to changes in official recommendations as the pandemic evolves. And they should acknowledge that the CDC-recommended precautions may not always be available during a prolonged and severe pandemic.

Here are some other risk communication measures that make important contributions to healthcare workers’ willingness to take patient-care risks:

• Strong demonstrations of hospital support for infection control measures.
• Validation of staff fears rather than expressions of contempt or over-reassurance.
• Non-intrusive emotional and social support for HCWs under stress.
• Appropriate provision for the care of HCWs’ families. (Some pandemic plans specify that antiviral medications are to be provided to HCWs’ family members as well as to the HCWs themselves. Presumably, the rationale is partly that family members may be more exposed than other people, and partly that HCWs are likelier to accept dangerous work if they know their loved ones are being protected.)
• Evidence that top hospital officials are themselves also willing to tend to patients at the bedside.

All of this is supported not just by risk communication theory but also by experience with SARS, HIV, and other potentially very frightening infectious diseases. Only some of it has been tested in formal empirical studies, however.

One very interesting study conducted during the SARS outbreaks surveyed Japanese healthcare workers. Although there were no SARS cases in Japan, SARS fear among Japanese HCWs was high. The study correlated healthcare workers’ knowledge of recommended infection control procedures, their perception of their hospitals’ support for infection control, and their perception of personal risk – measured by their intent to care for or avoid prospective SARS patients.

HCWs’ knowledge of officially recommended infection control precautions did not correlate with whether they were willing to care for SARS patients. What mattered was the workers’ perception that their hospitals had “clear policies and protocols, specialists available, and adequate training.” The unsurprising risk communication message is that knowledge alone – “educating people” – is not always the key to precaution-taking. Demonstrating that leaders take the issue seriously can have a bigger impact than making sure doctors, nurses, and other hospital workers can pass a quiz on infection control measures.

(That is one reason we keep urging health departments to supplement their hand-washing education programs with a clear demonstration of institutional commitment: Change all the faucets and doorknobs in public washrooms to be more like those in surgical suites, which can be operated with your elbow.)

Another study analyzed the safety opinions of Canadian healthcare workers after the SARS outbreaks. Among the authors’ conclusions:

Workplace attitudes towards safety were … important. Paramount to this were the attitudes and actions of management and the perceived importance of occupational health and safety, both of which were important determinants of the safety climate within hospitals.…

Communication about safety within healthcare organizations was seen as having a key role in protecting HCWs, especially during the SARS outbreaks. Face-to-face “town-hall” meetings were seen as necessary in order to build worker confidence in hospital infection control policies during SARS.

[U]sers as well as infection control and occupational health experts need to be consulted before required workplace practices are established and PPE is selected.

Your comment addressed the needs of healthcare workers only, but everything in our answer applies also to healthcare volunteers. Anyone who spends time in a hospital, whether as an employee or as a patient, knows how essential volunteers have become. In a pandemic, of course, volunteers have less reason to keep coming to “work” than HCWs – no financial incentive, no professional duty of care, no (or much less) moral obligation. And yet volunteers will be all the more essential when some HCWs simply can’t come to work because they are sick or dead.

In a pandemic there will also be a natural cohort of such volunteers: survivors. People who get the flu and survive are presumably immune, at least until the virus mutates substantially. They can be doing all sorts of work that either would be very dangerous or would require continual antiviral doses for someone who has so far gone unscathed.

Will volunteers be willing to work in a hospital in the middle of a pandemic? The answer depends largely on risk communication.

What I would add to this site:

A discussion addressing state and county plans for mass triage and immunization, pros and cons.

Comment:

I am involved with a Mass Triage and Immunization planning process in my county. It’s along the lines of the mass smallpox plan a few years ago.

The plan is to have the people in the towns around the county go to a central location in their town, be checked for symptoms, then loaded onto a bus for transport to the county fairgrounds.

At the fairgrounds, the people on the buses will again be checked for symptoms and the well ones reloaded onto the buses for transport to a Mass Dispensing Site in the next county south of us, which will be receiving people from a few other surrounding counties. At that point the people on the buses will be lined up to receive a vaccination.

In my mind, massing people is the worst thing to do if we are in fact dealing with a respiratory virus. To me, it would be the fastest way to spread the disease. However, I have been told by the county EMS Director that she just has to have blind faith in the higher powers that be that they know what they are doing.

I have a masters in Urban Studies. I know how urban planning began with the Sanitarians and the public health movement. I understand enough about medicine and public heath and epidemiology to know that what is planned is a disaster in the making, not only logistically, but humanistically. And I could not agree with you more about the need for non-medical responses, which is ultimately about rebuilding community.

Given the reality of not having any vaccine for maybe up to six months or more after the flu makes the h2h [human-to-human] jump and makes it to the U.S., what is the point of having a mass triage and immunization program anyway during the very time when people will be sick and perhaps dropping like flies?

If the objective is to vaccinate as many people as possible, whenever the vaccine is available and your community hasn’t been hit yet, and yet prevent the spread of the disease as effectively as possible, wouldn’t the best way to accomplish this be to have teams go out to the various towns (our whole county only has about 11,600 people) and just go door-to-door? Or give people appointments to go to the clinic or a school for the vaccination?

Peter responds:

Being a risk communication expert doesn’t qualify me to judge whether or not you’re right. On first hearing, it certainly sounds nonsensical to bus everybody to one place in the middle of a pandemic to vaccinate them against a disease some of them may already have. People can spread the flu before they’re symptomatic, so checking as they get onto the buses won’t solve the problem. And of course they’ll have already been mingling in the parking lot. Public gatherings of all sorts are usually the last thing you want during an infectious disease outbreak.

On the other hand, flu pandemics tend to come in waves. It may be feasible (and efficient) to carry out a mass immunization program in a centralized location while your area is between waves.

Mostly, I’m interested in the communication aspects of your comment.

Your paraphrase of the county EMS director – that we must have blind faith that those in authority know what they're doing – goes to the heart of the problem. Whether or not the plan you describe makes good medical sense, it doesn’t feel like it does – it doesn’t feel that way to you or the EMS director, and it probably won’t feel that way to the people who are told to make their way to the buses. The odds are good they won’t come.

Check out a New York Academy of Medicine study entitled “Redefining Readiness.” This extremely important study asked Americans what would determine whether or not they followed instructions in the wake of specified terrorist attack scenarios. One of the scenarios involved telling people to gather for smallpox vaccinations after terrorists had released the smallpox virus in one part of town. Lots of people said they wouldn’t do it, for a variety of reasons – including a sensible fear of being intermingled with those who had already been exposed.

The main point of this study is that people make their own sense of emergency situations, and decide how best to cope. They do pay attention to what the government is telling them, but they don’t necessarily follow orders. They are likelier to “follow orders,” of course, if they helped develop the plan, if they knew in advance what it calls for, and if their reservations about it have been identified, acknowledged, and addressed.

You almost certainly do not have a county full of people who will have “blind faith” after a pandemic strikes. So an EMS director who has blind faith now can’t be doing a good pandemic preparedness job. Keep raising your objections. If you’re right, the plan needs to change. If you’re wrong, somebody needs to show you why. Either way, your county’s residents need to be part of the debate.

This isn’t just about your county, of course. Scores of county governments have released public statements that proudly note how quickly they are prepared to implement a mass vaccination or antiviral distribution program if a pandemic comes (and if they have a supply of vaccine or antiviral medication, a qualifier they don’t always mention). Most of the announcements don’t describe the plan. Most of the plans, I’ll bet, didn’t involve much public discussion. Whether or not these plans make good technical sense, if the planners haven’t involved their publics and if they haven’t anticipated and addressed the concerns people are likely to have, they cannot be good plans.

Comment:

I am the publisher of Flu Wiki, and I thank you for the favorable mention. I understand that you recently met one of my wiki partners. He is the person who has turned me on to your and Jody’s work. Since I’m now in the business of “risk communication,” I have been devouring your work on the web.

I’ll be at the big flu conference in the Bay area this week and look forward to talking with the other professionals about it.

Thank you for making your work available to the average citizen activist.

Peter responds:

Thank you for your kind words.

Flu Wiki and kindred websites are filling a crucial need. You help newbies get through their adjustment reaction, and you help veterans stay up-to-the-minute and figure out together how best to respond. If a pandemic strikes, your regulars will be leaders in their communities.

Jody and I are proud that you find our stuff a useful part of the mix.

What I would add to this site:

In regards to the pandemic, I'd like more informed opinion as to the after-effects, should this H5N1 be as severe as the 1918 flu. Will the U.S. resume its long lost manufacturing capabilities? Will the rich still be rich? Depression? I’d like to be a fly on the wall when banks and big business discuss their plans regarding inevitable losses due to business failures, plummeting stocks, mortgage defaults, etc. Pretty grim stuff, I know. Or, could business flourish, wages shoot through the roof, manufacturing and technology rebound on a huge scale as they did even after the Black Plague of the Middle Ages?

Comment:

Thank you for a great read. I found Minister Abbott’s speech completely refreshing. I have been following the avian flu crisis (yes, crisis) with extreme interest after reading John Barry’s recent book on the Spanish Flu Pandemic of 1918–20. I feared I was misinterpreting much of the information I have read online, due to the fact that our local, state and national reporters seem to think and/or convey the “slight and remote” risk this flu pandemic could cause the U.S.

I for one, am instituting a plan for my very small business and family. I have grave doubts that my government will be in a position to offer much assistance to myself, my family or my immediate community should this strain of H5N1 suddenly appear. This is how I will be able to sleep at night. I will do what I can with pre-planning, and then continue to live as normal.

I only wish our government felt as compelled to educate and inform their people as Minister Abbott. My biggest fear is of the unknown. It’s never too early to educate and inform the public. People need to make plans (and yes, this includes updating their wills) now, and they need to instruct and educate their children on how they can help protect themselves (i.e., hand washing, covering a cough, etc.). Get people everywhere involved in the process, and they will not feel so helpless or panicked. Get it done, and move on. I am planning for the worst, but hoping for the best.

History has always told us a lot about our future. I can’t imagine why our highly educated representatives in Washington just don’t seem to get it, even when it stares them in the face.

Peter responds:

Your approach to a possible pandemic seems absolutely right to me: Do what you can to prepare, and then live normally (but watchfully) while you wait to see what happens. I fervently agree that people who are actively preparing themselves and their communities are best able to find the right level of concern, roughly equidistant between apathy and panic.

But I think your criticism of the U.S. government is less on target than it would have been a couple of months ago. President Bush and HHS Secretary Leavitt are sounding a lot like Australia’s Minister Abbott these days – acknowledging that a severe pandemic would be horrific, that we’re not ready, that we’ll never be entirely ready, and that there’s a lot to be done to get us readier than we are right now.

Read the new U.S. pandemic plan or the much shorter National Strategy for Pandemic Influenza. I think you can make a case that these documents – and the funding to implement them – show a greater sense of urgency about government medical preparedness than about individual non-medical preparedness. But individual preparedness is certainly there. And any sense of urgency is welcome.

As for the likely financial effects of a pandemic, it’s anybody's guess. Until a few months ago, I saw no evidence that the financial community was even trying to guess. But Deutsche Bank (and others) sponsored a big September 2005 conference on “Bulls, Bears, and Birds: Preparing the Financial Industry for a Pandemic.” And there is beginning to be published speculation on how a pandemic might affect markets and economies. Probably the leading source in this area is Sherry Cooper of Toronto’s BMO Nesbitt Burns. See for example her “Don't Fear Fear or Panic Panic.”

What I would add to this site:

Links to the CDC causes of death and countermeasures for same. Listing of the all-time Worst Risks in terms of frequency and impacts.

Comment:

Risk is something most of us live with and shrug off every day, and yet we worry. Individually, cardiovascular disease is the number one risk to each of us. This we tend to understand. It’s personal and we've seen others who have died from it.

Collectively, in terms of planet earth as a whole, what is our greatest risk? In terms of almost negligible but horrific probabilities there is the collision of an asteroid or comet with earth that has happened before and will again, or potentially even worse, the possibility of a nearby star going supernova. The first we could survive as a species if we speed out into space to colonize the moon and Mars. The second, we have zero countermeasures at this time.

Peter responds:

As your comment suggests, there are two kinds of “worst” risks: the common, chronic ones that kill a lot of people one at a time (like cardiovascular disease) and the rare, cataclysmic ones that kill a lot of people all at once (like a collision with an asteroid).

Both of these kinds of risks can be high-outrage or low-outrage, depending on other factors. So a third way of categorizing the “worst” risks would be to focus on the high-outrage ones, the ones that arouse the greatest concern and the most interest in taking precautions.

The CDC’s National Center for Health Statistics has a short list of leading causes of death in the U.S. that you might want to look at. The top three are heart disease, cancer, and stroke. A recent World Health Organization report on “Preventing Chronic Diseases” provides some worldwide data.

As for the high-magnitude, low-probability risks, you might want to check out one professor’s list of the “Ten ‘Worst’ Natural Disasters.” His interest, like yours, is focused on earth and space; he doesn’t list any pandemics, for example.

From a risk communication perspective, the big challenge is how to generate sufficient outrage about a serious hazard that isn’t generating much outrage on its own. For a risk communication approach to high-magnitude, low-probability risks, see Worst Case Scenarios. Generating outrage about chronic risks can be a bigger challenge still. That’s what health educators and safety managers try to do day after day – warning apathetic publics that they ought to worry more about diet and exercise, and apathetic employees that they ought to be more careful about slips and falls. For some possible approaches here, see the articles listed in my Precaution Advocacy Index, particularly the ones on employee safety.

Comment:

I read with great interest your article, “The Flu Pandemic Preparedness Snowball.” I’ve used it locally to educate health and government officials as a great summary to key non-medical steps for a local response.

In regards to an avian or pandemic outbreak I am in agreement that for now, at least, we should not rely on medical response strategies in our pre-planning response efforts. Since I work in local public health (i.e., the front line), I see the pre-planning activities as a coordinated campaign of local publicity and education to partners, stakeholders and the public, and synchronizing of response plans among the key agencies.

Therefore, I am troubled somewhat when I see national attention and funding being largely focused on vaccine research and antiviral issues (who will pay for them, how much should each state stockpile?). From a federal message point, I feel we are losing this “teachable moment” to talk about what realistically can be accomplished based on past experiences with large, catastrophic events. What can limited government resources do for you … and what can you do for yourself to decrease the risk of becoming a victim?

In that regard, self-sustainability should be a strong message out in front of the medical solutions that currently do not exist. I feel the current national media attention being paid to medical solutions for an avian or pandemic outbreak is dampening this key message and reinforcing a false sense of security in the general public that a medical solution will be provided.

Would you agree with this assessment of the developing federal medical response message, and if so how would you recommend being inclusive of the obviously now unavoidable medical response message while still trying locally to be convincing about the need for crucial non-medical messages?

Peter responds:

Recent U.S. government pronouncements about a possible flu pandemic are enormously better than those of the past, especially in their acknowledgment that things might get really, really bad. At least for the moment, I can no longer complain about government over-reassurance.

I agree with you that the U.S. federal focus is too much on vaccines and antivirals – and, more broadly, on medical preparedness and medical response. There is also some attention in the new federal pandemic plan (and the speeches that accompanied its unveiling) to what individuals, local communities, and the private sector can do. But not surprisingly, the feds are focusing on what the feds can do.

Three things are true of this medical approach to pandemic preparedness:

• If the next pandemic is mild, as 1957 and 1968 were, our needs will be mostly medical. Medical preparedness will have been the right approach.
• If the next pandemic is years into the future, the medical approach may (or may not) turn out to be the most important approach. A new generation of vaccine manufacturing methods and antiviral drugs may someday enable us to cope medically with a virus that would quickly overcome today’s doctors. I’m not in the least critical of the U.S. government’s determination to pursue these possibilities.
• If the next pandemic is soon and severe, everything we can throw at it medically won’t be nearly enough to make much difference – even in the U.S. and certainly in the developing world. Preparedness for this worst case scenario needs to be about keeping society going so we don’t lose still more people because of starvation, contaminated water, lack of fuel for heating, riots, etc. Preparedness for a worst-case pandemic needs to be about people getting ready to endure bad conditions in a spirit that resembles London during the blitz, not New Orleans after Katrina.

What does this mean for a local public health communicator? I would certainly welcome the new federal focus on medical preparedness. That’s something the feds can do best, and it’s good news that they’ve decided to take the task seriously. In addition, I would aggressively inform my local stakeholders that our task, the local task, is different.

Every local business, public agency, civic group, household, school, and neighborhood needs to prepare itself – emotionally and logistically – for the possibility of a severe pandemic, one that would dwarf our medical capabilities and test our courage, our perseverance, our common sense, and our sense of community. From learning how to wash our hands properly to stockpiling essential supplies to planning how to make best use of volunteer survivors, we have things to do.

There’s a local medical preparedness job to be done too, of course. Hospital surge capacity, for example, is about local medical preparedness. So is figuring out how to isolate flu patients from other patients. So is stockpiling essential medications and supplies needed to treat conditions other than influenza.

Perhaps the biggest local medical preparedness task, paradoxically, is helping our citizens realize that medical preparedness may not do the trick. People need to know that the flu medications we have may not work. They need to know that even if they do work, there still won’t be enough for all (at least not for a very long time). And they need to participate now in debates over who should get top priority for medical help.

It is a sign of the federal government’s focus on the less severe pandemic scenarios that it is still suggesting that scarce antivirals would be allocated to the most vulnerable, for example to those with impaired immune systems. That makes sense if the pandemic is mild, or if it comes after there is an ample antiviral stockpile. If the pandemic is soon and severe, we will need to try to keep the water treatment plant and the power plant staffed, and that will inevitably mean allocating scarce antivirals to the people we most need to keep alive, rather than the people we think are likeliest to die. This is a painful truth. Learning it mid-pandemic could spark “Tamiflu riots.” People need to learn it – indeed, help decide it – now. Forewarning and participation won’t prevent all social disruption, but they will help.

I don’t think the federal focus on medical preparedness is costing us the teachable moment. The feds’ message – it’s a serious risk and here’s what we’re going to do about it – is a very good message as far as it goes. Now the rest of us need to chime in with messages that the feds aren’t emphasizing enough. Don’t start with “But….” Start with “Yes, and ….”

The underlying issue here is the unspoken pressure to “speak with one voice.” One of the toughest questions in crisis communication is what to say about differences of opinion within your agency or among the many agencies trying to manage a crisis together. Should you let the diversity show, letting the public see that the problems you face are difficult and the answers aren’t obvious? Or should you try to cobble together a unitary message and hope the rough edges stay hidden and the dissenters don’t leak?

As you can probably tell from the way I phrased the choice, I favor letting the diversity show. I think it’s really damaging if decision-makers look unaware of each other’s positions or disrespectful of each other’s positions. But pretending that we all have the same position goes too far. The odds of the manufactured consensus sticking are low. It is better to reveal the diversity than to get caught papering it over.

This can be a very tough call. But I don’t think it’s a tough call this time. You can, in fact, lean heavily on the feds themselves in support of your non-medical focus, your focus on pre-pandemic communication, and your focus on involving the individual citizen. Page two of the National Strategy for Pandemic Influenza (released the day before the detailed plan of the Department of Health and Human Services) states:

While a pandemic will not damage power lines, banks or computer networks, it will ultimately threaten all critical infrastructure by removing essential personnel from the workplace for weeks or months. This makes a pandemic a unique circumstance necessitating a strategy that extends well beyond health and medical boundaries, to include the sustainment of critical infrastructure, private-sector activities, the movement of goods and services across the nation and the globe, and economic and security considerations.

Page three lists the three pillars of the National Strategy. The first of these, entitled “Preparedness and Communication,” reads as follows:

Activities that should be undertaken before a pandemic to ensure preparedness, and the communication of roles and responsibilities to all levels of government, segments of society and individuals.

And President George Bush’s introduction to the National Strategy includes these words:

[The plan] also outlines the important roles to be played not only by the Federal government, but also by State and local governments, private industry, our international partners, and most importantly individual citizens, including you and your families.

While your government will do much to prepare for a pandemic, individual action and individual responsibility are necessary for the success of any measures.

The federal government says local governments have an important role to play in pandemic preparedness. So play your important role. Don’t criticize the feds’ medical focus, and don’t feel obliged to copy it.

Comment:

I love your website. I found it doing some theorist research and now read it weekly.

I have decided to do a paper on your research and work and would like to know if you have any web articles to study on children. When 9/11 happened my daughter was in first grade and her school gathered all the children in the auditorium with TV's and the principal was talking about what was going on. They stayed in there all day except for lunch and she came home devastated, as I’m sure many kids did.

So far my paper entails your background; outlines risk, hazard, outrage and the key words to stay away from and why; and the key words that are ok to use and why. But if you have any articles on helping children cope I’d be interested in studying them.

Peter responds:

I haven’t written as much as I should about ways of talking with children about risk. There are several different problems here: (a) How to talk with children about awful things that have happened to others (e.g., 9/11, Katrina); (b) How to talk with children about their fears of awful things than might very well happen (e.g., a flu pandemic); and (c) How to talk with children about their fears of awful things that can’t happen but they are fearful of nonetheless (e.g., goblins in the closet).

In all three cases it is clear that respectful listening to their fears is the key. In the first two cases the big question is how frankly to validate that their fears are realistic. I lean toward candor rather than over-reassurance even for children. I am also a big believer in involving kids in various efforts to take precautions (and to volunteer for others). I’d rather offer them things to do to help them bear their fear and misery than try to talk them out of their fear and misery.

But there are limits. I wouldn’t have let a first grader sit in front of a television all day on September 11, 2001, watching the Twin Towers fall again and again.

Two relevant pieces on the website: (1) “Giving children frightening bird flu information” (a thoughtful question and my attempt at an answer on the Guestbook); and (2) “Teaching about terror” (an article by Robert Taylor that quotes me and others).

What I would add to this site:

You have given much excellent information about dealing with the public. Are there any specific guidelines when dealing with an internal audience that will be required to provide a necessary service? Specifically I am referring to enforcement personnel.

Comment:

I want to express my sincere appreciation for your thought-provoking articles that are written in such an accessible and engaging manner. As the recently appointed communications point person for avian influenza communications planning for my agency, I am very grateful for the information you provide. I am printing off each of your articles to use as reference as I develop our plan.

I do have a quick question that I hope has not been asked already. How do you define or recognize “panic”? I have read many of your articles that discuss it as a rare reaction and therefore not the most likely response. The reason I ask is in the first formal interaction with our on-site health nurse, her words to me (after relating a story where a constable came to her to tell her he was going to buy antivirals over the internet), were “We need to stop this panic!”

I thought about this and asked myself, “Is this really panic?” Personally I thought that this constable may think, in the absence of information, that this might be a rational thing to do to protect his family. So the nurse calls it panic. I think it might be a rational decision in his mind. How do we know who is right?

Peter responds:

There are many definitions of “panic” in the field. But what’s most important in defining the term, I think, is to distinguish panic from panicky feelings. Panic is a behavior. In particular, I define panic as behavior that has two key characteristics: (a) It is destructive, often self-destructive. (b) The person who is panicking knows the behavior is destructive (or would know if he or she were thinking straight), but can’t help doing it because of overwhelming, ungovernable fear. If you feel panicky but behave well, it isn’t panic.

And if what you feel is “alarmed” or even “afraid” rather than panicky, it certainly isn’t panic – even if other people don’t like the precautions you decide to take.

So buying some Tamiflu or Relenza on the Web isn’t panic. Opinions differ as to whether it’s a worthwhile investment to have antivirals in your medicine cabinet, but it’s very hard to build a case that it’s destructive. And there is no case whatever that antiviral customers know they’re doing something destructive but are just too terrified to stop themselves. You can argue that the purchase is over-cautious; you can argue that it’s disobedient (if the government has said people shouldn’t do it); you can even argue that it’s selfish, that the society would be better served by a communal stockpile instead of a lot of individual stockpiles. But as I define the term, you can’t argue that it's panic.

Why is it a serious problem when governments (or physicians, journalists, etc.) describe precautions they disagree with as panic? In an effort to prevent or ameliorate the “panic,” here is what governments do. They withhold alarming information. They interpret the information they can’t withhold in one-sided, over-reassuring ways. They express contempt for the public’s fears, which leaves people alone with those fears. And they mandate some behaviors and forbid others, reducing people’s freedom to choose their own precautions. These efforts to “allay panic” actually increase the likelihood of panic. Even so, people don’t usually panic. But they do become more anxious, more skeptical, and more hostile – not at all the effects the government was seeking.

For more on this topic, see “Fear of Fear: The Role of Fear in Preparedness … and Why It Terrifies Officials.”

The question of risk communication for enforcement personnel and other emergency responders deserves an essay all its own. Some of the points such an essay would need to cover:

• Emergency responders have a right to and an appetite for detailed risk information. Whether it’s a hazmat team boning up on the toxicological details of a spilled chemical or a beat cop learning the protocol for avoiding HIV exposure in a “blood-rich” environment, this is an audience that genuinely needs solid data, not bland generalizations.
• In the heat of an emergency, responders often experience a highly functional sort of denial, putting their normal feelings (fear, empathy, anger, etc.) on hold so they can cope. When the emergency is over, they may need some help recovering those feelings and reintegrating themselves.
• Emergency responders are risk communicators. When the crisis isn’t in an acute phase, they spend a fair amount of time talking to people about what might happen, what to do if it happens, how to prevent it, etc. And when the crisis is acute, they talk to victims. A lot of what went wrong during Hurricane Katrina might have been alleviated if more of the responders had been through a few hours of risk communication training.
• In many ways, emergency responders are like everyone else. Their reaction to a new risk, for example, is likely to follow the predictable pattern of an adjustment reaction. It is just as important to notice the ways in which emergency responders are not different as the ways they are.

Comment:

I’m writing to thank you – I just found your October 10 Snowball article, which is such a fine discussion of the communications around the flu pandemic.

I have this little blog – http://www.twentyfirstcenturyart.com/dakota/mt/ – (thus I understand your craving for comments) in which I have been trying intermittently to talk about pandemic possibilities. I referenced your teachable moment piece awhile ago and then lost track of you – I think I thought it was a single article. I am delighted to discover that you have such an informative, thoughtful, living, breathing site.

I am seeing a bunch of adjustment reactions around me. I think that’s quite an improvement, actually, from the pervasive denial that preceded it. It has been so hard to get people to simply face this possibility – too horrible to integrate psychologically. The good news is that since the snowball started to roll, my friends want to have lunch with me again, and best of all, my husband has stopped rolling his eyes and has agreed to look at material on inverters, which I am incapable of reading. Clearly I wasn’t hitting the right note.

I plan to read everything on your website, in between carrying cases of this and that into the basement.

You can use any part of this in your comments, I was just shy. Thank you for your valuable work. You should be consulting to Health and Human Services, but this administration is not famous for using expertise, is it?

Peter responds:

Reading everything on my website sounds a bit like a penance to me – but if you get very far I hope you'll let me know what you think.

In response to your last comment, I should note that I have in fact done a fair bit of consulting for the U.S. Department of Health and Human Services over the years, much of it through its Centers for Disease Control and Prevention. Nor can I complain that HHS and CDC have ignored my views on pandemic communication. They haven’t. Despite some strong criticism in “Pandemic Influenza Risk Communication: The Teachable Moment” of the HHS draft pandemic communication plan, I was invited to do two days of pandemic communication training and consulting at HHS. My recommendations were received with thoughtful, respectful attention. And then a decision was made to move in a different direction – less high-profile and a lot less alarming than I thought best.

As you know, this decision has recently been reversed. HHS, CDC, President Bush, and the rest of the U.S. government are now as alarming and as high-profile as one could reasonably ask on the risks of a flu pandemic. This could be attributable to the President’s holiday reading of a pandemic history book, or to the lessons of Hurricane Katrina, or to the alarming communications emanating from other governments and non-government organizations. It might even have had something to do with me. (I like to imagine it did.)

And here’s another possibility. Maybe this is the government version of the adjustment reaction. When individuals start focusing on a risk that’s new to them, they over-react for a while before integrating an appropriate level of precaution-taking into their New Normal. Governments may have a different sort of adjustment reaction – over-reassuring (or going silent) for a while.

Both are “knee-jerk” reactions. While you and I are “automatically” putting our ordinary preoccupations on pause, searching for news of the approaching threat, and practicing the precautions we may soon need, governments are just as automatically churning out statements that “the situation is under control.” As we get the new risk into context our concern becomes calmer and more deliberate; as governments get it into context they start conceding that there is good reason to worry. Just as some people get stuck in over-wrought mode, some governments get stuck in over-reassuring mode. It looks like the U.S. government is finally unstuck.

As you point out, even individuals often shrug off a new risk for a while before they take it on board. Whether you call this denial or complacency, it is common – a sort of “pre-adjustment reaction.” So let’s forgive the government its period of over-reassurance and help it fine-tune its pandemic messages: less about vaccines, more about local preparedness, more about non-medical preparedness, etc.

Comment:

I am a physician in a rural community in SW Colorado. I have been following the news and am quite concerned. Your recent piece was quite perceptive and I too admit falling into the false sense of security of purchasing dose packs of Tamiflu and Relenza for family and friends. I agree this is a false sense of security. My question is how I should approach informing my colleagues and local community about preparing for a pandemic. I think the issues regarding maintaining essential services and local preparedness are salient. I look forward to your reply.

Peter responds:

Buying Tamiflu or Relenza for family and friends – and recommending it to acquaintances and patients – is a very good place to start. As you know, it’s a crapshoot whether either medication will work against the strain of flu that eventually launches a pandemic. Even if it’s H5N1, currently the top contender, it’s going to take a mutation or reassortment to make H5N1 capable of spreading efficiently from human to human; there’s no telling how that change might affect its susceptibility to Tamiflu or Relenza. Still, lots of precautions are less than perfect and nonetheless worth taking. I think this is one of them. (But see The ethics of Tamiflu (below) for a Guestbook comment from a doctor who disagrees.)

Beyond that, I think doctors have a special opportunity to tell their patients about pandemic influenza in the context of the annual flu season that is just beginning. Check out the CDC and WHO websites, and the dozen or so flu-focused blogs and discussion boards and wikis; find an introductory FAQ you like; download it; and give a copy to every patient, especially every patient who comes in for a flu shot.

There has been a lot of debate among pandemic communicators over how to address the relationship between the annual flu and pandemic flu. The bottom line, in my judgment, is this. The two are completely different – they are different strains of influenza, with different magnitudes and probabilities of risk and different sets of appropriate precautions. But that doesn’t mean you shouldn’t talk about both at the same time. In fact, the only way to explain how different they are is by talking about both at the same time! And one of the best opportunities is when people are getting their annual flu shot. “Now let me tell you about a completely different kind of flu,” your message should begin, “a kind of flu that the shot you just got does absolutely nothing to protect you from.”

As a doctor, you have more standing and more access than the rest of us to raise the alarm about local medical preparedness – hospital surge capacity, for example, and local stockpiles of essential medical supplies. (With shipping slowed to a trickle, how long will it take every doctor, clinic, and hospital in town to run out of surgical masks?)

You also have higher credibility than non-doctors to point out that pandemic preparedness isn’t entirely medical – and that preparedness for a severe pandemic is mostly non-medical. Try to persuade your medical colleagues to join you in insisting, publicly and aggressively, that there is little doctors can do to prepare for a severe pandemic, and little they will be able to do to ameliorate one if it comes. When we talk about preparedness for a severe pandemic, we’re talking about food, water, energy, and security; about infrastructure, inventory, and the allocation of survivor volunteers. Nobody can say it’s not mostly about doctors with half as much credibility as a group of doctors!

If you can’t attract any allies at the start, go it alone. The tools are familiar to you already – letters to the editor, comments from the audience at town council meetings, etc. But don’t neglect the single most potent tool at your disposal: conversations with your patients.

And don’t neglect the rest of the healthcare profession. In many cases nurses do a lot more communicating with patients than doctors do. Make sure everyone on your staff knows about pandemic flu and feels encouraged to talk about it. And persuade your colleagues to involve their staffs as well.

Comment:

I use your risk formula to demonstrate how fire mitigation treatments can be applied.

With the greatest respect and acknowledging your work, and after reading about the application of risk communication, I have added the Awareness and Effort elements (as part of my understanding of your work on risk communication) to the formula to demonstrate how Hazard and Outrage can be minimised through applying Effort (time & energy) to deliver greater public awareness (education of fire and wildfire risk on public land).

Based on your work and my understanding of it, the formula is expanded: Risk equals Hazard plus Outrage, divided by Awareness, multiplied by Effort:

Thank you for your work on risk communication.

Peter responds:

I can see where effort to increase people’s awareness about fire risks could reduce the hazard by making them more cautious. But mightn’t it also increase the outrage, by making them more concerned? Doesn’t the impact of effort depend on whose – industry’s effort versus activists’ effort, for example? And can’t awareness, also, cut in either direction? Don’t industry and activists both claim to be aiming to make people more aware (of their side)?

But no matter. People sometimes ask me why I’m not multiplying H and O instead of adding them. I tell them I’m not an engineer, and I mean my formula to be a metaphor. I talk about it; I don’t do calculations with it. And certainly effort and awareness matter.

Comment:

I have a concern about your suggestion to individuals to get a prescription for Tamiflu or Relenza now before supplies run out.

If everyone does so, there will be no medicine for those who may need to be treated this fall/winter for the run-of-the-mill flu, even if there is no pandemic. There may be thousands of doses sitting in people’s medicine cabinets just in case of a pandemic, but none for vulnerable people who may need it for treatment or prophylaxis within the next few months during the normal flu season which will definitely occur.

While the prospect of a pandemic is very frightening, and I can understand why people and physicians would want to stockpile some Tamiflu to protect themselves and their families, I would also want it to be available to sick or exposed vulnerable people this flu season and to critical service providers in case of a pandemic.

If I cannot support everyone taking this approach because of its negative impact on the health of individuals and groups, I cannot in good conscience prescribe Tamiflu for myself and my family.

I agree with you that the focus on antivirals and vaccines, which are unlikely to be available if a pandemic occurs soon, is detracting from other important planning efforts at the local level.

Thank you for your many useful and stimulating comments on pandemic influenza.

Peter responds:

I think you’re right. Any treatment course of Tamiflu (or Relenza) that’s sitting on someone’s shelf waiting to be needed isn’t going to be available to someone else who needs it already. Of course this is also true of a can of soup; there are hungry people right now who would have use for what I’ve stockpiled in my kitchen. But there’s no sign that the supermarkets are running out of soup, whereas the drugstores are very likely to start running out of Tamiflu soon. So many of my friends share your view that we should let the available Tamiflu remain unallocated, so it will be there for the first people who get sick and need it.

On the other hand, there hasn’t traditionally been much Tamiflu use for the annual flu. It needs to be taken within 48 hours of the onset of symptoms, which isn’t much time to get in to see your doctor – and many people with the flu don’t see the doctor for it at all. And most doctors (and patients) haven’t been all that interested in a drug that cuts the duration and severity of a disease most regard as an inconvenience, not a threat.

Moreover, Tamiflu for the annual flu is a little like the morning-after pill. People worried about the annual flu are supposed to get themselves vaccinated. Their ethical claim on Tamiflu if they neglected to get vaccinated seem less compelling to me than the claim of someone worried about a potentially pandemic flu strain for which there is no available vaccine. (Of course there are also people who couldn’t get vaccinated, or whose vaccinations didn’t take.)

The more common argument against personal stockpiles is that they diminish the supply available for a communal stockpile. Wouldn’t it be best for the government to centralize all the Tamiflu and, in the event of a pandemic, distribute it to those who need it most? Or, as is likelier, to those we most need to keep healthy?

There is truth in that one too, even though Roche claims its supply chain for individual prescriptions and its supply chain for government bulk orders are independent. (I don’t know if I believe that.) Of course the federal government has had at least as much forewarning as the rest of us; it ordered as much Tamiflu as it decided to order, presumably leaving the rest for you and me. And if state and local governments decide to commandeer the remaining Tamiflu supply (as they commandeered the flu vaccine supply last summer), they will. They haven’t yet.

Six months ago I argued that individual orders of Tamiflu were a double good: Not only did you get your Tamiflu, you also built the demand and thus the incentive for Roche to increase production capacity. By now I guess Roche has all the incentive it needs. So the question is straightforward. If you get your own Tamiflu now, your chances are better of having it available if you or someone you love gets the flu – whether it’s the annual flu or a pandemic flu. If you don’t get your own Tamiflu now, there will be that much more available for someone else to stockpile, or for the government to nationalize and allocate, or (your hope) for someone who already has the annual flu to start taking.

I respect, even admire, those who choose to forgo the chance to protect themselves now in the hope that someone else will be able to meet an imminent need instead. I nonetheless urge my family and friends to protect themselves now.

There’s also an interesting middle ground to consider. Small groups of friends and neighbors might be able to develop a shared stockpile. This would lessen the chances of a dose sitting unused on a shelf, while still freeing the participants from dependence on a very chancy government supply. Of course the issues of trust and equity could get hairy!

The ethical issue for the prescribing physician is a little different. Assume you believe that public health is best served by denying your patient a Tamiflu prescription, leaving one more treatment course in the communal pool, available for people who are already sick or whose health is especially important to protect. But you also know your patient’s health – the patient sitting in your office right now – is best served by providing the prescription, so your patient can be prepared if he or she gets the flu after there is no Tamiflu to be had. To whom does the doctor owe a higher duty: the doctor’s vision of what’s best for the general public or the doctor’s knowledge of what’s best for the individual patient? I’d have thought it was the latter, but I’m neither a physician nor a medical ethicist.

Despite all of this, the most important bottom line is personal morality. If getting (or prescribing) Tamiflu seems unethical to you, don’t do it.

What I would add to this site:

When the dust settles I would like to get your considered view on the breakdown of preparedness and response in relation to the New Orleans flooding – how such a studied textbook scenario could get through to the keeper and really demean the U.S.’s reputation in fields that most outsiders felt they held pre-eminence.

Comment:

Excellent article looking at the Abbott speech in relation to sound crisis communication – at the time of the speech I recognised it was powerful and different to much “pollie speak ” but your analysis aided my understanding. I work with Kelly Parkinson whom I believe you know and maybe we can catch up when you are in Oz. All the best and keep up the good work.

Peter responds:

Thank you for your kind words about the Abbott column. He really is a fine role model for appropriately alarming pandemic communication. Many other government officials around the world are now also sounding the alarm about bird flu. It is possible, I think, that Australia’s Abbott helped give them the courage to speak candidly.

As for Katrina, if you haven’t seen it, you might want to look at “Katrina: Hurricanes, Catastrophes, and Risk Communication,” my Hurricane Katrina column from a month ago. It’s not the after-the-dust-settles assessment you rightly say is needed, just a heat-of-the-moment set of early reactions.

A month later, I continue to be of two minds about the nearly universal view that the U.S. federal response was poor. Clearly it was inadequate – but we should expect the response to an unprecedentedly severe catastrophe to be inadequate. (What would it mean to have standby capacity to cope adequately with something unprecedently severe?)

I am struck by the reality that no hurricane response could have saved New Orleans, which was doomed by virtue of its location and the condition of its levees. And no response could have saved the people who were drowned almost immediately when the flooding began, though a more complete evacuation obviously could have saved those lives. As contrasted with preparedness, in other words, a better response would have alleviated only the death and suffering that occurred between the time a terrific response might have got things under control and the time the actual response did get things under control.

So there is damage attributable to the failure to have levees that could withstand the storm, and there is damage attributable to the failure to evacuate everyone before the storm, and there is damage attributable to the failure to respond quickly and efficiently enough after the storm. Sometimes we seem to be attributing all the damage to the third of these factors, which makes the inadequacy of that response look far more harmful than it was.

Comment:

Excellent and thorough article on Katrina. The only thing I might have added was a section about the excellent response of many companies to the crisis (e.g., Wal-Mart – of which I am not a fan) and perhaps exploring the differences in how corporate leaders and associates respond to a crisis as opposed to bureaucratic leaders and associates. There is something to be learned by our governments at every level and they need to figure out how to incorporate the business world in responding to crises of this nature.

Peter responds:

I agree. There is considerable evidence that companies are able to respond more speedily and flexibly to emergencies than governments are. And certainly many companies responded well to Katrina.

In fairness, we want governments to be rigid and bureaucratic. When I was working for the government commission that investigated the accident at Three Mile Island, all my expenses were paid for my workdays in central Pennsylvania. When the weekend came, my trip home and back again was also paid. But the government refused to pay for me to stay on at my hotel over the weekend. It was cheaper to stay – but I had a right to go home on my days off at government expense; I didn’t have a right to eat and sleep at government expense. Any agency that let me save the government money by staying in town would have risked serious legal troubles.

Companies try to choose the sensible option, rules notwithstanding. Governments follow the rules, sense notwithstanding.

A government employee who breaks the rules in an emergency may be a hero if everything works out well. But if problems arise, that government employee will be pilloried for taking the law into his or her own hands. “That’s exactly why we have rules!” we will all intone.

I think your recommendation for governments to involve the private sector more in emergency response makes sense. I have mixed feelings about the recommendation – so commonly voiced in the wake of Katrina – that governments should act more like the private sector, more flexible, less bureaucratic.

When disaster strikes, companies are often remarkably generous, and their help is usually focused and effective. Given how well the private sector copes with emergency response, I wish it would get more involved in emergency preparedness as well. Most big companies have “business continuity” departments that prepare seriously for company-specific disasters (what to do if the building floods). Many prepare also for community disasters (what to do if the city floods). But their planning tends to focus on keeping the business going rather than on helping their neighbors. And they rarely contribute much to community planning efforts. (Did any New Orleans company play a significant role in municipal emergency planning? I doubt it. The plans would have been better if they had.)

Industry is just beginning to pay attention to the threat of an avian influenza pandemic – potentially a worldwide “flood.” Companies need to start figuring out how to keep their business going if a pandemic devastates staffing, transport, and production. And they also need to help the communities in which they operate figure out how to keep the soup kitchen, water treatment facility, and fire department going too.

Comment:

In an employee risk communication meeting where the organization (and individuals) have clearly made mistakes leading to potential chemical exposures and caused outrage, should one of your messages be “we are sorry that this has happened”? This assumes the Sandman/Covello approach is understood and risk communication skills have been developed and practiced. I distinguish this environment from a community meeting.

Peter responds:

I’m not sure what you’re getting at when you distinguish a meeting of employees from a public meeting. I don’t think employees’ outrage differs much from neighbors’ outrage. (For more on the similarities, and a few differences, see “What’s Different about Employees?.”

In particular, I think apologizing is very much the right thing to do when mistakes have led to unintended chemical exposures. This might be debatable if employees were unaware of the exposures and if you were confident the exposures didn’t endanger their health. Even then I’d recommend telling them you’d messed up … and got lucky. But in the scenario you describe, someone “clearly” made mistakes and there is outrage already. So the question isn’t whether to tell the truth or not; they know the truth. The question is whether to acknowledge it apologetically or stonewall. That’s a no-brainer, I think.

Even your lawyer’s objections to apologizing should disappear given that employees are already aware and outraged. Lawyers have a point when they advise against admitting something that isn’t already known. If you’re going to deny it in court, or if you have reason to hope that the plaintiffs can’t prove it in court, it’s legally important not to confess at an employee meeting. But in the situation you’re describing, there is no legal downside to balance against the outrage management upside of acknowledging and apologizing for an error.

The single biggest component of the upside, by the way, is this: The sorrier you are about the mistake you made, the less likely employees are to imagine your mistake was deadly. Outrage at a company’s unapologetic intransigence converts easily to the conviction that the accidental exposure must have had serious health implications. That’s why apologizing is just as necessary for benign mistakes as for genuinely harmful ones.

All this is about apologizing for the company’s role in what went wrong. Attributing what went wrong to specific individuals is a tougher issue. It’s likely to sound like scapegoating, lessening the value of the organizational apology. And it can certainly raise complicated legal issues vis-à-vis the people you’re accusing. On the other hand, “mistakes were made” is a lot less credible than “George Smith should have done X and Y.” If you do decide to name names, try to make it clear that the company knows it is responsible for everything that goes wrong. By definition, the individual’s mistake is a failure of company policy or training or supervision. Focus on the systemic problem that the individual mistake has revealed.

For more on apologizing, see “Saying You’re Sorry.”

Comment:

Thank you for your article on “Bird Flu.” The article gives me good perspectives to look at a desease that can separate across the world’s borders. Actually it is not directly related to my job. But, I feel I am responsible to take part in protection activities. But I didn’t know “how”? Your paper told me how I could take a role in this case. I will give some lectures on it to my students who usually come and discuss about their businesses and studies. Thank again Drs.

Peter responds:

Thank you for your comment – from a part of the world that is very much at the center of the bird flu epizootic (for those who don’t know this word, it’s an animal epidemic – in this case, birds), and from a country that has had very little to say publicly about its own bird flu problems and policies. If you have more to add, it would be most welcome!

Comment:

I have just finished reading your book Responding to Community Outrage, which was loaned to me by a friend with a management background, not medical. He thought, rightly, it might be relevant to some of my work.

I am involved in clinical risk management (I should say hazard management because we don’t really deal with outrage) for my organisation. Much of my work might be characterised as “crash investigation.”

As I read your work I was struck by the relevance it has to an area we are very cautiously exploring – communication with the patients and families who are harmed by healthcare, and more widely with the community on whose behalf we think we are working to improve the safety of healthcare.

I was particularly struck by your approach to reducing outrage. It is almost an article of faith in healthcare circles that when people say, “I just want to make sure this doesn’t happen to anyone else,” they are really saying “show me the money.” Personal experience had led me to doubt this. As I understand your argument, you would contend that this is probably a starting point for many people – and it is in fact our response (fuelled by our organisational outrage) that may ultimately escalate their outrage to a point where what we fear, perhaps litigation or pillory in the media, is inevitable.

I hope to use my understanding of your work as we tackle the issue of communication with our public and inclusion of that public in our work.

Peter responds:

Thank you for your very thoughtful comment – thoughtful not just in your kindness in bothering to send it, but also in the way you are applying my thinking about outrage to iatrogenic health problems.

This isn’t an issue I’ve worked much on directly. But I certainly agree that outrage plays a key role in how people react when professional healthcare efforts boomerang. I agree also that what defensive doctors (and their attorneys) see as greed is often outrage instead, and that seeing it as greed is likely to exacerbate the outrage. (For one thing, if you mistake outrage for greed you tend to neglect the need to apologize.)

And I agree with the example you mention. People genuinely want to give their suffering meaning by insisting on improvements that will protect others from what they endured. This will be true in the wake of Hurricane Katrina. It is true when doctors and nurses make mistakes. And it is true in much more minor situations. I remember when a client of mine was sued by a passenger who ripped his pants on a nail sticking out of a railway station bench. As he pursued his grievance, he kept checking the bench to see if anyone had hammered in the nail yet; the fact that it continued to protrude contributed enormously to his outrage.

Comment:

There is a book out. I haven’t read it, but it looks like it comments on the fears of the public in a world less “safe” than it used to be. The link is to a summary of a Today Show interview with the author.

“In ‘False Alarm,’ author Marc Siegel writes about how to look behind the hysteria and take back our lives from fear mongers. Read an excerpt – http://msnbc.msn.com/id/9075655/.”

If you read it, your comments would be of interest.

Peter responds:

I haven’t read Marc Siegel’s book, False Alarm. So my comments are based solely on the August 27 MSNBC excerpt. Siegel’s argument that we are undergoing an “epidemic of fear” induced by media sensationalism is common. I think it’s mistaken.

I agree with Siegel that people are less endangered today than ever before. Even this is debatable, since so many more of our risks today are of the high-magnitude low-probability variety; we are certainly capable of creating man-made disasters of unprecedented size. Still, at least in the West, a higher proportion of the population than ever before is comparatively safe from infectious diseases (H5N1 notwithstanding), hunger, enslavement, war (Iraq notwithstanding), etc.

But I very much doubt Siegel’s contention that people are more frightened than ever before. No doubt they think they are. People have always imagined that “now” is a scarier time than the past.

It may be that our fears today are more labile than in times past. This could result partly from the real biggies, the Four Horsemen, having gone into semi-eclipse. It could result from the difficulty of coping with high-magnitude low-probability risks. It could result from the related reality that more and more of the risks we face are high-tech and hard to comprehend (though there are exceptions; we understand disease, for example, as never before). It could result from our increased ability to see and worry about approaching risks and potential risks that haven’t yet materialized. I’m open to the possibility that people’s attention now oscillates more quickly from risk to risk.

But I see no evidence whatever of an “epidemic of fear.” Most of our great-grandparents lived far more frightened lives than we live. My own great-grandparents probably most feared famines, pogroms, epidemics, and the wrath of God – and undoubtedly feared each of these more than I fear anything.

Yes, our worries about GMOs and cell phone cancers may be a little effete. Perhaps our fearfulness has remained pretty constant as our safety has improved, so we end up fearing silly things sometimes. But an epidemic of fear? I don’t see it.

Similarly, Siegel is right that the media over-cover trivial risks. The media also under-cover serious risks, especially boring ones like smoking. This is mostly because the media cover a story in proportion to how interesting it is, not in proportion to how significant it is. For risk stories, that means high-outrage risks get a lot of coverage whether or not they are also high-hazard, and low-outrage risks get very little coverage whether or not they are also low-hazard.

There’s another phenomenon here that Siegel doesn’t mention, at least not in this excerpt: The media under-cover the most serious hazards whether or not they are also high-outrage. From Three Mile Island to avian influenza, journalistic sensationalism goes into remission when facing a story that is legitimately terrifying rather than just titillating; reporters and editors instead find themselves allied with official sources in over-reassuring the public. Is Hurricane Katrina an exception? It might be now; tragedies make for more engrossing journalism than risks. Certainly the media didn’t focus much before Katrina on New Orleans’s vulnerability to hurricanes, nor did reporters dedicate themselves to frightening people into evacuating as Katrina approached. Even in Katrina’s aftermath, it is too soon to tell if the coverage has been overly sensational or overly mild, though it would be hard to claim there hasn’t been enough of it.

Siegel notes with approval that countries like Israel have gotten used to terrorism, and respond more stoically than the U.S. But the U.S., too, has become more stoic about terrorism, and more attacks will inevitably lead to still more stoicism. This is normal, even inevitable. The “adjustment reaction” to any new risk is a temporary overreaction, and a useful one; it contributes to emotional readiness and logistical readiness. And then it gives way to the New Normal.

Siegel is exquisitely sensitive to the detrimental health effects of fear, and thoroughly insensitive to its safety benefits (at least in this excerpt). Some of the studies he mentions are new to me, but nobody is surprised to learn that extended fearfulness can be injurious to health; nor that excessive fearfulness can paralyze. It is equally obvious that insufficient fearfulness, too, can kill. (Think about the people who decided to ride out Katrina in their New Orleans homes.) I can’t tell whether Siegel really thinks our society is too frightened, as he seems to be claiming, or if he thinks it’s frightened of too many silly things. The second charge is a lot more supportable than the first. That’s not an epidemic of fear. It’s a competition for people’s fearfulness, a competition that is too often won by the wrong risks.

Some of the specific issues mentioned in the excerpt make me wonder if Siegel has been seduced by his “epidemic of fear” hypothesis into ignoring the seriousness of some risks, and greatly overstating the seriousness of fearing those risks. During the 2001 anthrax attacks, for example, the CDC had complex goals, among them: to protect people from a possible wider attack to come (terrorists sometimes start with pilot projects); to reassure people that there was a very low likelihood so far that any specific individual would encounter anthrax; and still to respect people’s natural tendency to overreact at first. The CDC people I worked with during this period would be amazed to hear that they were trying to make people afraid of opening their mail in order to distract them from the mishandling of criminal evidence. Note also that virtually all Americans did manage to open their mail.

Similarly, SARS was a pandemic-in-the-making until it proved itself relatively poor at community transmission. It endangered Singaporeans and Torontonians at least as much as it “petrified” them. I would say there is a better case to be made that media, officials, and public all under-reacted than that they over-reacted. (See “Fear Is Spreading Faster than SARS” – And So It Should! for more on this example.)

As for last summer’s flu kerfuffle in the U.S., there was little if any “panic” when it looked like there wouldn’t be enough vaccine. Many people who had opted out of prior vaccination opportunities were motivated by the shortage to decide that this time they wanted to get vaccinated – an irritating phenomenon, perhaps, but normal, and as good an opportunity as any to recruit new vaccination regulars. Some of these people stood in line for hours. That may have been unwise, maybe even unhealthy. But if Siegel believes that standing in line qualifies as panic, no wonder he thinks he sees an epidemic of fear.

For more on the underlying issues here, see Fear of Fear: The Role of Fear in Preparedness … and Why It Terrifies Officials.

Comment:

I have just read your (and Jody Lanard’s) article “Communication: Risky Business,” as published in “Perspectives in Health.” I came across it at the web site of the Center for Infectious Disease Research and Policy. I am still absorbing some of the ramifications, but already I am finding it quite useful … for adults as the target audience. I need to know about minors.

I am a retired (one year ago) high school history teacher. At the end of June, I read “Preparing for the Next Pandemic” by Dr. Michael T. Osterholm. He was kind enough to set up a phone call with me. At the end of our conversation, I inquired about what should be happening in our schools. Dr. Osterholm encouraged me to use my contact with local schools to promote education on this topic.

Here’s the rub. You article states that it is within bounds to scare adults, at least to some degree. However, with the combination of potentially scary topics and minors in the public education system, a great deal of care must be taken. I don’t need to tell you: Parental complaints of fear-mongering produce backlashes which lead to more harm than good. Likewise, public school administrators are chary of touchy topics – witness what is happening in evolution and sex education.

Some might say the following concerning H5N1. With juniors and seniors, with reasonable presentation, one might well be able to communicate the full story. For freshman and sophomores, one needs to pare it back and proceed more gingerly. For seventh- and eighth-graders, one needs to consider seriously whether this is an appropriate topic or not. And for elementary, one is probably best off not bringing up the topic at all.

My rough approximation does not in any practical way tell me where to draw the line with regard to content about H5N1. Nor am I well armed in knowing how to approach school administrators about volunteering to go into school(s) in order to make a presentation. Further, in addition to convincing administrators about content, those administrators would also only feel comfortable if they knew in advance how to be prepared for parental response of a negative nature. Another complication is that top administrators already do not have enough time to fulfill all their duties, let alone to read up on topics such as this.

I believe this matter of public school students is a refinement of the above-mentioned article which is worthy of its own follow-up article. Getting such an article into publications that public school teachers are most likely to read could be a real service. There could be guidelines which would also act as a carry-over into other troubling topics.

I agree with Dr. Osterholm: Students do need to become politically aware and politically active. On the other hand, we can’t send our students home to have nightmares. The differentiation among different age groups within the public school population is, I believe, a matter of justified concern. I would appreciate very much any assistance that you can give me regarding my concerns.

Peter responds:

The relationship between age and fear-tolerance isn’t something I’ve studied. I don’t know the literature, or even if there is a literature (is there a “Piaget of fear”?). So I’m not qualified to write the definitive article you rightly say is needed on age-appropriate bird flu warnings.

But I do think children are far more resilient than educators sometimes imagine. Many kids like scary stuff, from Maurice Sendak and the Brothers Grimm to roller coasters and fantasy play to hurricanes and tornados on the Weather Channel. Many kids are veterans of lots of end-of-the-world threats, courtesy of comic books, television, science fiction, and Hollywood. I’ll wager most classrooms will perk up when the teacher devotes the day’s science or history or even arithmetic lesson to pandemics.

I note also that educators are quite willing to frighten children when they want to – and to use children as a medium to frighten their parents. Among the school-based fear campaigns that come immediately to mind are those devoted to smoking, home fires, and seat belts. Health ed and drivers’ ed have always had a heavy dose of fear appeals. Not to mention sex ed and drug ed: Very few commentators have worried that kids might have nightmares about STDs or marijuana. Or think about the discussions of war and genocide in our classrooms. Why aren’t we worried about Holocaust nightmares?

Most parents are similarly copasetic about provoking fear in their children. We try to terrify toddlers about the dangers of playing with matches, riding their trikes into traffic, or taking candy from strangers; we try to terrify teenagers about the dangers of just about everything they want to do. A substantial percentage of us send our children to church so they can learn about the wages of sin and the approaching End Times.

So why not bird flu?

I’m not suggesting that no child ever had a nightmare as a result of a frightening classroom experience. And I’m not suggesting that nightmares are good for children. It wouldn’t surprise me, however, to learn that normally treated children have the number of nightmares their diet and disposition foreordain, and that only the content varies with experience. I’m only guessing – but this is certainly true of most normal adult fear. Except for a short-term adjustment reaction, scary information doesn’t usually make us into people who are more scared; it just reallocates our fearfulness to new topics.

Back in the 1980s I worked as an activist against nuclear weapons development. I was also the parent of two young children, and I worried some that my preoccupation with Mutually Assured Destruction might be hard on them. I was reassured by research showing that the children of activists tended to have more confidence in the future and fewer nuclear nightmares than most children. This makes sense. If mommy and daddy are working to prevent a nuclear war, the kids can rest that much easier.

Nor did the children of non-activists suffer inordinately. Like their parents, they coped with terrifying information about a possible nuclear Armageddon by going into denial.

There are two lessons here. First, the real danger of teaching children frightening information about bird flu isn’t that they’ll become permanently obsessed; those who can’t settle into the New Normal (after an appropriate and useful adjustment reaction) will instead trip an emotional circuit breaker and go into denial – which is bad for pandemic preparedness but not a serious threat to pediatric mental health. Second, the key to helping children bear frightening information about bird flu is to pay a lot of attention to preparedness – to what is being done already and what else can be done, not just by governments but by all of us, children included. A child who goes home with a pandemic preparedness family checklist is likelier to feel empowered than terrified. Ditto for a child who does a report on how the local supermarket, the water treatment facility, or the school itself can start getting ready for a pandemic.

Do schools have to be able to cope with an occasional exception, a child who has a traumatic response to the classroom pandemic lesson and needs help recovering? I guess they do. But this suggests only that there are fragile children in the world who need special care – not that we shouldn’t include our children in our efforts to prepare for a possible crisis.

Of course even sturdy children can be unsettled by unduly vivid disaster imagery. I share the widespread view that it wasn’t a good idea for children (or adults) to watch the Twin Towers collapse over and over again. If the pandemic comes, I won’t be urging educators to show kids photos of makeshift morgues filled with flu victims. But for now, the pandemic threat is if anything too abstract, not vivid enough to provoke a decent preparedness effort – much less an epidemic of children’s nightmares.

None of the above means that there won’t be parents who disagree. Many U.S. government officials currently believe pandemic risks are too scary to explain candidly to the American public; they are sacrificing the opportunity to forewarn people in order to avoid the possibility of panic. I think they’re wrong, but that seems to be their genuine opinion. Inevitably, some parents will think the pandemic risk is nonsense, and some who think the risk is real will nonetheless resist the school’s efforts to teach their children about it. I have no expertise whatever on how schools ought to cope with parental dissent, except the obvious: Teachers should not blindside the principal, and schools should not blindside the parents. Let parents know what you’re going to do, and why, before you do it. And defer cheerfully to those parents who want their children to do something else (watch a nice venereal disease movie, maybe) during the pandemic lesson.

Comment:

Having just read your article on Telstra towers, I live on Bilgola Plateau in Sydney and have Telstra, Optus and Vodafone towers all within 40 metres of our house. These towers have been there for 20 years or so, and my wife and 2 children seem to have suffered no ill effects.We have decided to sell our property as children have now left and are shocked at the amount of concern being shown by purchasers as to the towers. Do you have any advice?

Peter responds:

Of course it would be unethical (as well as unfeasible) to pretend the towers aren’t there. And it’s very bad risk communication to pretend they aren’t alarming to some people. So I would be candid – disarmingly so. Early in conversations with potential buyers, before being asked, I’d make the following points:

• You may have noticed that there are several mobile telephone towers near the house.
• They were put in about twenty years ago, well after we moved in. They have never bothered me or my family, and as far as I know there haven’t been any problems with the neighbors either.
• But some people worry about the possible risks of living near mobile telephone towers. If it bothers you, obviously, you shouldn’t even think about buying my house. Nobody should live in a house that makes them nervous!
• I’m not an expert, but I’ve looked into the tower issue a little. There has been a lot of research, and nearly all of it has found no health effects from living near towers. But some experts say there are still unanswered questions. It’s like so much of modern technology. They don’t have evidence that it’s dangerous, but they can’t absolutely prove that it’s safe.
• The other thing you might be worried about is whether the towers could affect the price if you ever want to sell the house. Of course I knew about the towers when I set my own selling price. So the odds are whatever effect they’ll have when you sell is balanced by the effect they’re having right now. Frankly, I don’t think that’s much of an effect. There are plenty of people who aren’t the least bit worried by mobile telephone towers. Some are glad to know they’ll get good reception.

None of this will scare away a customer who wasn’t going to be scared away anyhow. Some customers will be impressed with your honesty, and that much more confident that other aspects of the house have also been fairly represented. Some will be bored by your focus on the towers and change the subject, thus assuring themselves that the towers don’t worry them. And when your house sells, you’ll have the good feeling of knowing you didn’t mislead anybody.

You might even want to make some of these points in your ads or your real estate listings. After all, why waste time on a prospective purchaser who’s going to bolt as soon as he or she sees the towers? But if you want to maximize the number of people who come look at the house, wait till they’re there. Don’t wait too long, however. Buyers are least likely to be deterred if you raise the issue, likelier to be deterred if they have to raise it, and likeliest to be deterred if nobody raises it and it just rattles around in the back of their minds as a reason to look elsewhere.

Here’s the underlying risk communication principle. When talking to an uninterested audience, it makes sense to mention a negative briefly and then bridge to happier topics. But when talking to an attentive, skeptical (or hostile) audience, glossing over a negative is sure to backfire. Your only options are to keep it secret or to wallow in it. So if secrecy isn’t possible or isn’t ethical, then wallowing is the way to go. Homebuyers are invariably attentive and skeptical. Your towers aren’t secret. Prepare to wallow.

Comment:

Thank you and Dr Lanard for giving us the opportunity to learn on line about risk and crisis communications! It’s been a true pleasure reading your columns, as well as the comments/questions section.

I’ve been taking part in international discussions about what would be the best strategy to prepare the public to face a possible influenza pandemic. It’s been disappointing for me to see how the general tendency seems to be wanting to reassure the public and completely avoid sounding the alarm. A reference is often made to the Homeland Security color coding as the example of a system that is not taken seriously by the public and is only perceived as a hassle. I was wondering what’s your take on the color coding system? Are people really desensitized because of false or perceived false alarms? Do you think a similar system can be used to warn people about the pandemic influenza that we’re hearing more and more about?

How come there aren’t more speeches like Australian Health Minister Tony Abbott’s?

Peter responds:

Why are so many officials reluctant to sound the alarm about the risk of pandemic influenza? Why are there so few speeches like Minister Abbott’s?

Like you, I have participated in meetings in which my view that people need to be warned was a minority opinion. On the whole, I hear three main arguments against aggressively warning the public about bird flu:

• That people might panic, or at least become “unduly” alarmed.
• That people will be apathetic no matter what we tell them.
• That there’s nothing for people to do anyhow.

The first two arguments don’t exactly cancel each other out, but they are the two tails of a distribution. A few people do freak out and more than a few do remain steadfastly oblivious – but most people slowly become aware, then go through an adjustment reaction, then regain their equilibrium and start getting themselves ready. As for the third argument, it would be a good reason not to warn people if it were true. But it’s not (see “What can individuals do to prepare for a bird flu pandemic?”).

I suspect there is often a fourth rationale, though I have never heard it articulated. It is hard for a government to warn its population aggressively about a risk when the government itself hasn’t got a very good record of preparing for that risk. On the whole, the governments that are issuing the sternest flu pandemic warnings are the ones, like Australia, with the best flu pandemic preparedness programs. Maybe if the U.S. government (for example) had stockpiled more Tamiflu it would feel less vulnerable about urging its citizens to gird up their loins.

I too have heard the U.S. terrorism color coding system used as a counter-example, especially by those advancing the #2 argument above. “People don’t take the color coding seriously,” it is said. “Instead they just ridicule the Department of Homeland Security. The same thing would probably happen to warnings about bird flu.”

The irony is that I’m not at all convinced the Homeland Security color coding is working badly. Its main flaw is that it asks too little of people; fear-provoking warnings are effective risk communication only if there are efficacious precautions to be taken and people feel capable of taking them. Despite that flaw, the evidence I’ve seen suggests that most Americans have adjusted fairly well to the threat of terrorism. We are generally supportive of the precautions that require our support (we tolerate security inconveniences at airports and public buildings; we accept civil liberties threats in the name of security; we agree to spending allocations for improved security). I see no grounds for thinking Americans are dangerously rebellious against their government’s homeland security policies; if anything we are too compliant. Yet we are surely not too frightened. We have settled well into the New Normal; we are appropriately concerned and saddened by a post-9/11 world, but few of us have hobbled our normal lives in response.

Whatever criteria you use to judge the preparedness of the U.S. population – getting on with normal life, cooperating with security requirements, accepting that there will be more attacks anyway, being willing to help more (though we’re seldom asked) – the data suggest the outcome so far is pretty good. I see many more flaws in other aspects of U.S. terrorism preparedness than in the attitudes of the American public.

The black humor surrounding the color coding is more embarrassing to officials than it is harmful to the security effort. I do sometimes worry that the humor might be a sign of denial, which would indicate excessive fear. But humor is also part of a healthy adjustment reaction; think of the traditional humor, much of it aimed at the brass, that soldiers use to come to terms with the horrors of war.

On balance, I think, Homeland Security has done a far better job of preparing Americans to cope with a terrorist attack than the job Health and Human Services has done of preparing Americans to cope with a pandemic. In that context, it’s remarkable to see the “failure” (what failure?) of the Homeland Security color coding used as an excuse for not warning people about pandemic risks.

Comment:

I read with great interest your column about misleading towards the truth and agreed with many of the arguments made in it, but I think it overlooked a problem. This is a problem contained in one of your more recent columns, “A Blind Spot for Bad Guys.”

Sometimes there is a battle going on with respect to the truth and that battle is important. Those arrayed on one or both sides may have a vested interest in a particular outcome without regard to the actual truth. In the case of vaccine, that is potential lawsuits or government compensation. The problem is that acknowledging your opponent in this kind of war can be dangerous. Even allowing for the possibility that there may be some validity to their claim allows them to wage a sort of asymmetric warfare. I have to look no farther than the Terri Schiavo story to see an example of that. What if one of the experts on one side had acknowledged even a 1% (or 0.1% or even 0.001%) chance that Schiavo was not in a PVS. How would that have played?

Another objection I have is word count. It is impossible in many cases to acknowledge the other side of the argument without giving it too much attention. Let’s say that there is a 10% chance that you are wrong. Given a vocal opposition, you will spend much more than 10% dealing with objections. That’s just the nature of things, but the problem is drawing the line. At 10% I think that addressing the objections is worthwhile. At 5%, perhaps, but below that spending time on the opposition’s arguments especially if they are motivated by an economic or political agenda divorced from a respect for the truth will lead to analysis paralysis.

Peter responds:

Thank you for a very thoughtful comment. I think you are partly right (more than five percent right, so even by your standard I should have acknowledged your part of the truth).

The key question, I think, is which audience you’re most interested in. Think of the public in a controversy as divided into fanatics, attentives, browsers, and inattentives. (See my column on “Stakeholders” for more on this distinction.) You’re not going to convince the fanatics or inattentives of anything; one group has firmly made up its mind and the other isn’t paying attention. So you’re down to attentives and browsers.

For me, the important audience is usually the attentives. They are watching you do battle with the fanatics (that is, with the fanatics on the other side; you and your allies are equally fanatics in their view). They’re listening hard to both sides’ arguments. But their listening isn’t symmetrical. For the side that is trying to arouse outrage against the established view, the attentives’ standard of judgment is whether that side’s arguments carry emotional and intellectual weight: Do they score points? But for the side that is trying to defend the established view and damp down the outrage, the standard of judgment is whether you are giving the opposition their due: Do you fight fair?

This asymmetry is built into most people’s assessments of most controversies between a company or a government agency on one side and an activist group on the other. We see the activists as David and the company or agency as Goliath. We expect David to exaggerate and we don’t really mind; that’s the nature of activists. But we want Goliath to be scrupulously transparent. Even if we figure David probably has only a small piece of the truth, we still want Goliath to be forced to acknowledge and address that piece. And if Goliath refuses to do so, we are much likelier to end up on David’s side.

So if you’re an establishment arguing with an activist in front of a bunch of attentives, proving that you’re listening is more important than proving that you’re right. Proving that you’re listening is virtually a prerequisite to getting the attentives to see that you’re (mostly) right. Under these circumstances, even if you’re 99 percent right you need to concede the validity of the other side’s one percent. Don’t give the false impression that you think it’s more than one percent, but don’t ignore it or belittle it either. Even if you’re 100 percent right, in fact, under these circumstances it is wise to find something to concede your critics are right about. Perhaps they’re right that you were slow to share your data, or arrogant in the way you explained how right you were.

It’s different for the browsers. They’re not paying nearly as much attention. They’re following the issue in the media, but not carefully; they’re getting impressions but not keeping score. Here I think you have a good case. If people are going to absorb a couple of TV news sound bites and that’s about all, you probably don’t want to use up one of your sound bites conceding that some minor critique of your position has validity. If the issue is hot and the other side is visible, you still need to come across as respectful and compassionate rather than contemptuous of your critics’ concerns. But for persuading browsers, nailing your own strongest arguments matters more than acknowledging those of your opponents. And of course if the issue isn’t hot – if the other side isn’t getting much traction – it would be silly to draw the browsers’ attention to them. Why give your critics or their concerns more legitimacy than they could earn on their own?

The problem is that often you’re talking to attentives and browsers at the same time, and have to decide which audience matters more to you. (There are more browsers than attentives, but the attentives play a bigger role in shaping public policy.) And people don’t necessarily stay in the same category forever. Suppose you see your audience as browsers who may someday become attentives. If you ignore your critics’ best arguments now, you leave your audience far more vulnerable to those arguments later on. “Here’s what they didn’t tell you” is a better launch pad for critics than “As the company [or agency] admits….” So even with browsers, it might be wise to give the other side its due. You can think of this as an insurance policy – or an inoculation.

Three bottom-line recommendations for defenders of the status quo:

• If the other side has substantial merit – even if less merit than your side – then you should acknowledge it consistently, no matter whether you’re talking to browsers or to attentives. Your credibility and your integrity are at stake.
• If you’re talking to people who are paying a fair amount of attention to the controversy, you should acknowledge the other side’s arguments even if they capture only a small piece of the truth. Attentives judge your side by how well you listen to your critics.
• If you’re talking to people who are paying only a little attention to the controversy, and the other side is nearly entirely wrong, you should focus on the truth as you see it. Why introduce unimportant complexities to browsers who otherwise would probably never encounter them? But think again if you’re worried that your audience may get more interested and more attentive later on.

It’s simpler for critics of the status quo. They should push their strongest arguments and arouse as much outrage as they can, period.

I think the battle over thimerosal, autism, and vaccine safety illustrates all this very well. The critics of vaccination are appropriately one-sided. Since the public is becoming more and more attentive to the controversy, the defenders of vaccination are unwisely one-sided. They need to be much more transparent about acknowledging the critics’ case. While continuing to assert that the weight of the evidence strongly suggests that thimerosal in vaccines does not cause autism, they should not ignore (and should not hide!) the minority of the evidence that weakly suggests the opposite. More important still, they should be respectful and compassionate, not contemptuous, toward those who suspect a thimerosal-autism link

The Terri Schiavo case is tougher. (Note to non-American readers: Schiavo suffered cardiac arrest in 1990, and went into a coma. Her husband believed her to be in a persistent vegetative state (PVS) and wanted to let her die; her parents thought she might recover, fought the husband’s decision, and ultimately lost. The controversy dominated U.S. politics and the U.S. media in March 2005.) Certainly public attention at the end was high; browsers turned into attentives whether they wanted to or not. Normally this should mean the establishment side ought to give the activists their due. But in this case it wasn’t clear which side was the establishment and which was the activists. Both sides were trying to arouse outrage at the other; neither side was trying to damp it down. And the issue got very polarized along ideological lines; attentives and even browsers were mutating into fanatics on both sides. Even so, my intuition is that those who supported the husband would have done better to treat the parents’ supporters and their arguments with more respect.

What I would add to this site:

What is very necessary is an explanation to the two largest overlapping groups: the small businesspeople and those workers who will be stuck at home. The experience of shock & dismay, the powerlessness and directionlessness of billions can be explored a priori by you. And a list of ways that are legitimate to cope … again offering alternatives … during the long, long, long pandemic.

Comment:

Extraordinarily fair and balanced analysis of announcement – very rare to see. It’s very worthwhile and will be forwarded to some who are willing to slog through the entirety.

There are few voices who understand the reality of the issue, in the run-up to the pandemic. Yours and Abbott’s are three.

Peter responds:

This reply was drafted by Jody Lanard.

Thank you for your comments about our article, “Superb Flu Pandemic Risk Communication: A Role Model from Australia.”

We agree with you on two points, and disagree on one.

Obviously we agree that Australia Health Minister Tony Abbott’s candid pre-pandemic speech conveys “the reality of the issue” – not just the reality of what he calls the “scary prospect,” but also the reality that his citizens will not fall apart if he tells them about it.

We also agree with you that “shock and dismay” will be an inevitable reaction to a moderate or severe flu pandemic. This will be especially the case for people who are taken by surprise, but it will be a difficult time even for those who have intellectually and emotionally rehearsed for it. Living through a flu pandemic will be different from imagining one.

We disagree with your prediction that billions of people will be powerless and directionless when a pandemic occurs. We have read your contributions to online avian influenza discussions; we know about your participation in the clinical trials of a candidate H5N1 vaccine. Your own sturdy involvement in pandemic preparedness is our best argument that most people will cope when the time comes, even if they haven’t been forewarned as aggressively as we'd like them to be.

You and the many other citizens contributing to online preparedness discussions got through your initial shock and dismay – what another participant in the H5N1 vaccine trials recently called his “avian influenza epiphany” – pretty quickly. Then you moved into the self-organizing resilient response phase. That is what human beings tend to do! It is what people did after September 11 and after the tsunami; it is what people do after (and during) most catastrophes – not all of us, but very large numbers of us.

The more people who become informed and involved in advance, of course, the more efficacious these “self-organizing systems” will be when they’re needed. That is one of the main arguments for raising the alarm. (We realize that many government officials prefer to talk about “raising concern” – and raising it very gently at that. But Paul Revere did not gallop around to every Middlesex village and farm calling out quietly, “The British are coming. This is very concerning.”)

We would like to direct our readers to three of the remarkable self-organizing systems that have sprung up online to cope with the “scary prospect” of a pandemic – to learn, to spread the word, to plan, to raise troubling questions, to try to correct misperceptions, to get used to the idea. Whether or not readers agree with all the ways members of this online community are coping, we hope you will notice that they are not panicking.

A note to those in the PanFlu club (and if you find yourself using expressions like “PanFlu,” and “H2H [human-to-human] transmission,” you are probably in the club): Even the scientists and public health officials who are most heavily involved in this issue need to take time off – time for their gardens, for long bike rides, for their families, even for other issues! That is part of what it means to integrate pandemic planning into your “New Normal.” As we help each other get ready, we must also help each other stay grounded.

Comment:

Do you remember your keynote at the ASTHO annual meeting at Vail in the late ’80s? I will never forget it, having “plagiarized” some of your stuff in talks.

Thanks for your article with Lanard last December re: pandemic communications.

An article on autism this week had the following quote from you:

Sandman says advocates on both sides have fallen prey to a tactic he calls “misleading toward the truth.” It happens when “you believe you know the truth” but don’t trust others to grasp it. “It becomes very tempting to leave out the facts that might mislead the public” toward a different conclusion.

When critics say someone is lying, Sandman says, “you have to say, ‘yeah, but are they lying on behalf of the truth or are they lying on behalf of a lie?’”

I honestly don’t see how that is applicable to the efforts that have been made to get at any association of thimerosal and autism. Perhaps you would write a piece on what you would have done differently.

Peter responds:

I certainly remember our work together two decades ago for the Association of State and Territorial Health Officers. And thank you for your kind words about the pandemic flu column.

The article you refer to is “Mistrust rises with autism rate,” by Anita Manning (USA Today, July 7, 2005). The article reviews the unending controversy between vaccination opponents, who charge that there has been a cover-up of evidence suggesting a link between thimerosal and autism, and vaccination proponents, who claim that the evidence of any such link is extremely weak and almost certainly false. (Thimerosal is a form of mercury that has been widely used to keep vaccines sterile.)

The latest wrinkle in this controversy came with an article by Robert F. Kennedy Jr. focusing on a June 2000 meeting of scientists and public health officials at the Simpsonwood Conference Center near Atlanta. Kennedy wrote that transcripts of the Simpsonwood meeting show the cover-up in action; vaccination supporters retort that the evidence discussed at the meeting was nowhere near persuasive enough to justify serious concern.

My key point is that both sides are right.

Jody Lanard and I first used the phrase “misleading toward the truth” to describe USDA risk communications about mad cow disease. People (including scientists) who believe they are right on the merits tend to withhold information that they fear might lead others to an erroneous conclusion. On vaccination safety, maybe proponents are 85% right. That’s not good enough for them, and too often they are less than candid about the other 15%. (Some of this is the sort of “conspiracy” the recent Kennedy/Simpsonwood kerfuffle is all about; some of it is more basic, like not bothering to mention that mercury is a poison in a disquisition the main thrust of which is the safety of thimerosal.) Leave aside whether or not this is dishonorable; it is demonstrably unwise. In a porous democracy like the U.S., the other 15% inevitably comes out – and the reluctance of proponents to acknowledge it makes it look much more compelling than it deserves.

Suppose the vaccination case isn’t 85% right but 99% right. All the more reason to be candid about that other one percent. The stronger your case actually is, the more foolish you are to try to make it look even stronger than it is.

Another analytic frame that helps is my concept of “yellow flags.” Yellow flags are anecdotal or otherwise inconclusive evidence of possible risk. Once again, they tend to look like red flags when they belatedly emerge after proponents have first tried to suppress them, then later tried to discount or disparage them.

From BSE to Vioxx to thimerosal, yellow flags and misleading toward the truth account for a lot of what goes on in risk controversies. Of course vaccination also has some intrinsically outrage-provoking characteristics, most notably coercion. Even if proponents handled the controversy well, it would be a controversy. But they don’t handle it well.

The core problem for vaccination proponents, in short, isn’t that your critics exaggerate and distort. That’s true, but it’s not your core problem. Your core problem is that you also exaggerate and distort – and feel justified in doing so because you are (mostly) in the right, and don’t notice that it keeps backfiring on you. Or to put it a bit differently, your core problem isn’t that the public doesn’t trust you. That’s increasingly true too, but it’s not your core problem. Your problem is that you don’t trust the public.

As I said to Anita Manning, the public’s task is to see past the unwise exaggerations and distortions of vaccination proponents, see past their mistrust for the public, and make wise decisions anyway. The public needs to distinguish between proponents of truly dangerous technologies, who are misleading them about the weight of the evidence, and proponents of technologies that are probably pretty safe, who are misleading them about a minority of the evidence. When vaccination opponents point out that the proponents are “lying,” in other words, the public needs to say, “Well, yes, people in controversies always distort and withhold contrary information, though we wish they’d stop and level with us for a change. But are they lying on behalf of the truth, or are they lying on behalf of a lie?”

My best guess is that vaccination proponents are “lying” (exaggerating and distorting) on behalf of the truth. That’s why I wish they’d stop.

Why don’t they stop? Vaccination proponents are themselves outraged – outraged that the public doesn’t trust them; outraged that vaccination critics keep impugning their competence and integrity; outraged that nonscientists are daring to make their own scientific judgments; outraged that a major public health achievement may be undermined as a result. Just as the opponents’ outrage makes them unable to interpret the data on vaccination safety appropriately, the proponents’ outrage makes them unable to interpret the data on the sources of opponents’ outrage appropriately. This isn’t a fight between hysterical vaccination opponents and calm, rational vaccination proponents. Both sides, at their worst, behave like children – one side shrill, the other patronizing, and neither entirely honest.

Comment:

“Pandemic Influenza Risk Communication: The Teachable Moment” – the best thing I've read on the pandemic anywhere. The piece is highly intelligent, fascinating and so well written! I have one question:

The article says:

“In February 2004, CDC Director Julie Gerberding testified at a congressional hearing on influenza preparedness that ‘this season CDC acquired, with the strong support of Secretary Thompson, several hundred thousand treatment courses of one antiviral drug as part of the Strategic National Stockpile.’ In September 2004, Ben Schwartz of the CDC’s National Vaccine Program Office presented data estimating that 16 million health care workers and public safety officers would need 93 million courses of antivirals – 8 weeks’ worth for each of them – as protection against flu during the start of a pandemic.”

According to your source, health care workers would need to be protected for eight weeks. That’s 8 x 16 million, which is 128 million courses of treatment. I’m wondering what the 93 million of courses is based upon. What am I missing here?

Peter responds:

This reply was written by my wife, colleague, and coauthor Jody Lanard.

Thank you so much for both your compliment and your close reading. I apologize for the confusing numbers in our article, which you are the first person to note.

Bottom line: You are right that the numbers don’t seem to make sense as written. But as you will see below, the numbers are probably close to correct. If I had been more careful with terminology, the numbers would have made more sense.

So how did we use the CDC’s Ben Schwartz’s numbers to calculate the need for 93 million courses of Tamiflu for prophylaxis, after positing 16.5 million crucial workers taking the drug for eight weeks each? Why isn’t the correct answer 16+ million times 8? Here is an explanation:

The words “course of Tamiflu” actually have three meanings. In our article citing Schwartz’s numbers, we did not clarify this – but we should have, since we were addressing nonmedical as well as medical readers.

The numbers come out right when you use the “correct” meanings of the word “courses.” But this cannot be understood without knowing the difference between a “treatment course,” a “prophylaxis course,” and “a course of Tamiflu” as packaged by Roche!

“Treatment course” – for after you are sick – means 10 pills of Tamiflu (one pill twice a day for five days).

“Prophylaxis course” – to prevent you from getting sick during a predicted 8-week wave of a pandemic – means 56 pills (one pill once a day for eight weeks).

But the way Tamiflu is typically sold is as a pre-packaged pack of 10 pills. This is a “treatment course,” often just referred to as “a course” – as in “a course of treatment.”

When Ben Schwartz calculated the number of “courses” needed for prophylaxis of 16.5 million people for eight weeks, he seems to have been using “courses” to mean “packages of ten pills,” used one pill a day for 56 days. So each “prophylaxis course” would require 5.6 packages of pre-packed Tamiflu.

Thus, he was multiplying 16.5 million times 5.6, to get about 93 million “courses” – 93 million packages of 10 pills each.

(And I think we can assume the folks giving out the pills would open the packs, and re-package them in batches of 56!)

I had fun sorting this out and seeing where the ambiguity came from. I am so familiar with the terminology – and yet I have to struggle so hard with numbers – that I completely missed the ambiguity while doing the calculations.

What I would add to this site:

I liked your site and found it helpful – but I think the problem I’m working with is unique by definition. Everyone ages – everyone is driven to cope with and suppress their outrage over aging. Large structures of society are in place to support tempering of this outrage, because nothing could be done for thousands of years. The same was true of flying. Humans couldn’t fly for all previous history – then, one day – they could. For aging, the same thing is true – for all human history – you age, slow down, get sick, and get ugly – no choice. But now this is changing. Perversely, the coping mechanisms of society to this travesty called aging are so powerful that even the idea of slowing aging down or reversing it is controversial. It reminds me of Patty Hearst and the so-called Stockholm syndrome.

For background on our efforts in addition to the www.mprize.org website you can google “Dr. Aubrey de Grey” (my co-founder) and SENS (strategies for engineered negligible senescence).

Comment:

Everyone ages – slowly and one at a time – so there’s no outrage. Until a loved parent passes away. Society/culture offers up nursing homes to warehouse the advanced aged so they are out of sight/mind… at death, gatherings of family and friends serve to bleed off the outrage.

Bioscience is beginning to be able to control and reverse aspects of – and eventually – aging in general.

My question – how do you generate outrage that results in support/funding for research into cures/treatments for the decay associated with aging? (See www.mprize.org for our main website.)

Peter responds:

I’m not sure I agree that people are apathetic about aging. Sometimes it seems to me that we’re obsessed with aging – or, rather, with the futile effort not to age. Our preoccupation surely fuels a lot of good things, from geriatric medical research to exercise, and of course it fuels a lot of more debatable things too (like cosmetic surgery).

Still, you’re obviously right that even more preoccupation with aging could fuel even more of the good things (and the debatable ones too). That seems to be happening naturally as the baby boomers age. But it’s entirely appropriate for activists like yourself to try to push it along. See my Precaution Advocacy Index for articles that may help.

Trying to arouse more outrage about aging differs from trying to arouse more outrage about, say, Hodgkin’s Disease in one important way: The main barrier probably isn’t apathy. It’s denial. Maybe people in their twenties who don’t worry sufficiently about aging – don’t take care of themselves, don’t support decent care for seniors or expenditures on geriatric research, etc. – are apathetic. But people in their fifties and sixties who are still “uninterested” in the problems of aging are almost undoubtedly running away from their own mortality. Persuading them to take aging more seriously thus has less to do with piercing their apathy than with helping them bear their suppressed feelings about growing old. I have written about denial often in a variety of different contexts. See especially:

• Beyond Panic Prevention: Addressing Emotion in Emergency Communication
• Scared stiff – or scared into action
• Risk Communication and the War Against Terrorism
• Peter Sandman on Safety, Part 2
• Fear of Fear: The Role of Fear in Preparedness
• Duct Tape Risk Communication

Regardless of whether the key strategy is to pierce the apathy or assuage the denial, trying to arouse outrage is a competitive enterprise. There appears to be something like a Law of Conservation of Outrage. If you succeed in your efforts to arouse outrage about aging, people may momentarily become more outraged in general – but they quickly settle into the New Normal: the same people they were before, with the same level of outrage, but with more of it focused on your issue and less on other issues. Outrage is fungible; we reallocate it. So if you manage to generate more outrage about aging, people will have less outrage available for global warming, bioterrorism, moral decay, deteriorating schools, American imperialism, the resurgent right, the libertine left, whatever….

Comment:

I found your article on the timing of risk communication fascinating. I have been studying risk communication and never really stopped to think about the “when” in the equation. Are there other sites that would have more information on the impact of the timing of the risk communication? I have signed up to do a research paper on that very topic as a result of reading your article. Thank you for writing it.

Peter responds:

Thank you for your kind words about “When to Release Risk Information: Early – But Expect Criticism Anyway.”

There are plenty of case examples of the price of not informing early: China and SARS; China and HIV-contaminated blood; Thailand and avian influenza; the U.K. and mad cow disease; Belgium and dioxin-contaminated animal feed; etc.

Scholarly writing on risk communication consistently makes the same point. Renn and Levine’s article on “Credibility and trust in risk communication,” for example, lists “timely disclosure” as one of the factors that build credibility, and “stalled or delayed reporting” as one of the factors that erode it. You can find the article in Kasperson R, and Stallen P, eds., Communicating Risks to the Public (Dordrecht: Kluwer Academic Publishers, 1991), pp.175–218.

A detailed study of the Belgian dioxin scandal – the hallmark of which was delayed reporting to the public – can be found online: Lok C, and Powell D., “The Belgian dioxin crisis of the summer of 1999: A case study in crisis communications and management,” Food Safety Network Technical Report #13, 2000.

You might also want to look at Hance BJ, Chess C., and Sandman PM., Improving Dialogue with Communities: A Risk Communication Manual for Government (Trenton, NJ: New Jersey Department of Environmental Protection, 1988). Chapter Three is entitled “Deciding When to Release Information.” We quoted it in the article you read, but there’s more there you may find of interest. This short book was reprinted in Covello VT, McCallum DB, and Pavlova M, eds., Effective risk communication: The role and responsibility of government and non-government organizations (New York: Plenum Press, 1989), pp.195–295.

Comment:

I’d like to ask what you think should have been done when in order to protect public health of miners and their families in Libby, Montana.

Peter responds:

For readers who don’t know about the Libby tragedy, W.R. Grace purchased a vermiculate mine in Libby, Montana in 1963 and operated it until 1990. Some vermiculite (not all) contains asbestos; the vermiculite mined in Libby was contaminated with a particularly dangerous form of asbestos called tremolite. Hundreds of deaths and over a thousand illnesses have been attributed to the Libby mining. Lawsuits against Grace for endangering miners and their families have been thrown into limbo by the company’s bankruptcy (caused in part by 150,000 asbestos-related lawsuits across the country). Suits against the state for failure to warn are also pending. The mine itself was designated a Superfund site in 2002.

The most interesting aspect of the case from a risk communication perspective is the criminal indictments handed down in February 2005 by a federal grand jury in Montana. The indictments charge that Grace and seven of its executives knew the Libby mine was releasing asbestos into the air and tried to hide the danger from workers and residents.

I can’t judge the merits of the case. The main legal question is going to be whether Grace executives withheld information they were legally obligated to reveal. If they did – and if the information was alarming, solid, and new – it shouldn’t be hard to make a case that the decision to withhold it was criminally culpable.

The more frequent and more complicated situation is when company officials withhold information that is uncertain and preliminary, or duplicative of other information already public, or both. I’ll bet that’s what Grace will be arguing. In the early years, executives will say, they didn’t know anything for sure; all the studies had methodological flaws and might have aroused needless anxiety. And in the later years their studies simply confirmed known facts readily available already to anyone who bothered to do some basic library research. I don’t know about Libby in particular, but to solve the overall problem we need companies that don’t think these are good enough reasons to withhold risk information.

So what should have been done? Grace executives should have told employees, townspeople, and regulators everything they knew about the risks (including unconfirmed possible risks) from the Libby mine. They should have included “anecdotal” information (local doctors pointing out that a lot of people seemed to be getting sick), preliminary studies with sampling or measurement problems, and all sorts of other “yellow flags.” They should have included summaries of research that had nothing to do with Libby but might apply there – any research on the vermiculite-asbestos connection and the special health risks of tremolite, for example. They should have felt entitled to explain why they believed the mine did not pose an unacceptable risk, but they should also have felt duty-bound to explain why others believed otherwise. And they should have told the story – the complete story – not just once or twice, but incessantly.

This is more than any company I know actually does. But I think it is the direction we need to move.

If everything that was known about the Libby mine risks had been known to the Libby miners (and to all the other stakeholders) in real time, would lives have been saved? Would management have instituted more effective protective measures? Would the mine have been shut down earlier? I don’t know. The answer depends partly on how convincing the early information would have been. And it depends partly on how cautious, how risk-averse, the miners and other stakeholders would have been. (People often knowingly take big risks for smaller reasons than a good job. And regulators sometimes permit potentially serious risks rather than hobble a flourishing industry.)

I can’t say total transparency would undoubtedly have saved lives – though the odds are good. I think the odds are good total transparency could also have saved W.R. Grace. And without doubt, total transparency would have enabled the people of Libby to reach their own informed judgments about the seriousness of the risk they were facing.

Comment:

I have heard several news items recently about predictions of a flu pandemic in the next year or so killing several hundred million people world wide. The items often comment that this appears to be due to a mutation of a virus started among fowl in China which is now (following the mutation) in the human population in China and other south east Asian areas and is now contagious. It is also said that the Chinese have tried to cover the problem up. Does any one know anything about this subject and the source of these rumors??? I also have heard that some authors from the Netherlands are about to publish a paper on this subject. Is there real danger here or just rumor of danger?????

Peter responds:

Many of the issues you raise are about bird flu itself, rather than bird flu risk communication. My wife and colleague Jody Lanard and I will answer these in a separate email.

But we want to respond here to one aspect of your comment: bird flu cover-ups.

You say you have heard that China tried to cover up the problem. It is indeed established that China has covered up previous disease outbreaks. And recently, the Chinese government seems to have delayed and downplayed initial reports of an outbreak of avian influenza in geese. But the country most notorious for covering up and denying its early bird flu outbreaks was Thailand, in early 2004. Since then, Thailand seems to have turned around, diligently and vigilantly seeking and reporting outbreaks, doing better risk communication, and using huge numbers of volunteers to inform its public in the most remote villages.

Cambodia has either covered up or failed to identify its bird flu problems. Viet Nam has prematurely declared its bird flu outbreaks under control and then turned out wrong. Indonesia minimized its outbreaks. A Japanese farmer hid his poultry flock’s bird flu deaths from local authorities, and subsequently committed suicide out of shame for harming his country. Covering up disease outbreaks is very tempting, very common, and very destructive.

At present, we are not aware of any western countries covering up bird flu outbreaks. Nor are we aware of any H5N1 outbreaks in western countries. The U.S. and Canada have had poultry outbreaks of non-H5N1 bird flu in the past two years; we are not aware of any efforts to cover them up.

For more information on bird flu generally, here is a link to our lengthy article on bird flu risk communication, plus links to authoritative sources of information about bird flu and its pandemic potential:

• “Pandemic Influenza Risk Communication: The Teachable Moment” by Peter M. Sandman and Jody Lanard (December 2004)
• “WHO Inter-country Consultation. Influenza A/H5N1 in Humans in Asia”
• U.S. Centers for Disease Control and Prevention, “Key Facts About Avian Influenza”

What I would add to this site:

Suggestions about how to persuade/convince leadership that efforts to engage stakeholders (e.g., through interviews, focus groups, etc.) about their communication/dialogue needs early in a project are well worth the time/effort/money.

Comment:

I’m finishing up a rather lengthy project where I need to reference literature regarding the relationship between stakeholder involvement and the level of concern about specific health risks. My initial thought is that the more involvement, the less concern about the risk. Any thoughts, suggestions about references, and in general about this relationship? Thanks in advance for your time and thoughts!

Peter responds:

I’m afraid I can’t help with references. I am a notoriously bad bibliographer, integrating what I read but forgetting where I read it.

For what it’s worth, I think the relationship between involvement and concern is more complex than the “involvement reduces concern” formula would suggest. A few points (without supporting citations):

How to persuade management that early public involvement is worth the effort? Here are a few quick thoughts:

Comment:

I came across your web site while doing research for a class on Project Risk Management and would like to say that I find it interesting.

I am a structural engineer who designs the structures for buildings and as such a common problem I encounter is how to communicate potential risks and tradeoffs to our clients. Part of the problem is that our clients are often not interested in discussing these issues but all too often the problem has to do with our lack of knowledge how to talk about these issues.

Thus I would appreciate it if you have any references to articles or other sources that deal with communication of risk in a professional environment. Unlike doctors that have no difficulty in telling you that the operation might kill you structural engineers seem to have difficulty in discussing risks with clients.

Peter responds:

A lot of my website is devoted to the distinction between “hazard” (technical risk) and “outrage” (cultural risk – made up of factors like trust, responsiveness, control, etc.). People with technical expertise, whether they’re doctors or structural engineers, have great trouble understanding this distinction. They want to talk only about the hazard, and they see people who are reacting appropriately (or at least predictably) to the outrage as stupid or irrational or misinformed. In recent years I have worked a lot on public health threats (SARS, pandemic flu, etc.). But I spent much of my career advising engineers and engineer-dominated corporations on how to address their stakeholders’ outrage about low-hazard high-outrage risks.

For more on this topic, look first at the articles listed in my outrage management index (http://www.psandman.com/index-OM.htm). You'll find a lot on how to manage other people’s outrage about low-hazard high-outrage risks. And you’ll find a fair amount on why technical people screw this up when they imagine that all they need to do is communicate “the data.”

The issues that come up in crisis communication (high-hazard high-outrage) are somewhat different. But even when the technical risk is serious, technical people mishandle the communication when they respond unwisely to other people’s fear, anger, concern, etc. My crisis communication index (http://www.psandman.com/index-CC.htm) will lead you to the key articles here.

But if I am reading your comment correctly, none of this is what you’re writing about. I think you’re not thinking about outrage at all. You’re thinking about the problem of how to tell people bad news about the hazard – how to warn people, especially your clients, that there are serious risks (technically serious risks) that they are ignoring. In my jargon, this is “precaution advocacy”; the paradigm is the high-hazard low-outrage risk. See http://www.psandman.com/index-PA.htm for my precaution advocacy index.

A lot of precaution advocacy makes the assumption that the audience is apathetic, and that the job is therefore to arouse concern/fear – in my jargon, “outrage” – about the risk, and thus to motivate precaution-taking. Of course lots of people imagine that the job is simply to inform people about the risk, and resist arousing outrage even about serious hazards. They thus hamstring themselves with what as I see as their emotional resistance to paying attention to emotion.

Moreover, the diagnosis of “insufficient outrage” isn’t always the best explanation for failure to take precautions. Sometimes the problem isn’t insufficient outrage about the risk; it is excessive outrage about the remedy. I sense that this may be what was on your mind when you wrote your email. When doctors hesitate to warn patients they’re likely to get cancer if they don’t quit smoking (and doctors do quite often hesitate to give bad news to patients), what’s holding them back isn’t the difficulty of overcoming the patient’s apathy; it’s concern that the patient will resent the intrusion, resist the remedy, get excessively alarmed about cancer and/or angry at the doctor, etc. Similar motives may account for the reluctance civil engineers have to warn their clients about serious hazards.

I do speak on this topic, but I have written on it only a little. See particularly two interviews on employee safety issues:

• Part One: Persuading Management to Take Safety Seriously
• Part Two: Persuading Employees to Take Safety Seriously

Also of interest (though not really self-explanatory) are two related handouts from my precaution advocacy seminar:

• Attitude Dimensions of Safety: 16 Reasons Why Employees Sometimes Ignore Safety Procedures
• Attitude Dimensions of Safety: 24 Reasons Why Employers Sometimes Ignore Safety Procedures

I hope somewhere in here I’ve responded to what was on your mind.

mark replies:

While I believe your writings are helpful in understanding the dimensions of the problem, the vocabulary and examples seem focused on adversarial relationships that you are trying to repair. When discussing risk issues with our client we are dealing with a relationship we wish to maintain and improve. Thus we want our client to appreciate the value that we are giving him while at the same time minimizing our risk by either reducing our client’s risk or by having him make an informed decision.

Yes a key part of this is “precaution advocacy” – but the nature of, and importance of the relationship creates unique challenges. Thus I suggest that the strategies for dealing with this problem are influenced by the context.

Talking with our clients about risk is difficult because:

• Our client does not typically have the background to evaluate the issues. This means that we must try to educate him without having him go off the deep end.
• We do not have clean solutions.
• We end up making our clients feel uncomfortable, which has a negative impact on our relationship.
• Clients may perceive that we are trying to increase our fees (sometimes justified).
• Client may say that they thought the better performance was to be expected for the same fee.
• The client may be uncomfortable formally accepting a risk while at the same time having no good option.

The strategies that you suggest do not appear to be directly applicable in this context. There may be no simple solutions but I do believe that the useful strategies will be a function of the relationships between the key players.

Comment:

A friend of mine who had heard you speak vaguely remembered a quotation he attributed to you along the following lines: Professor Peter Sandman is well known for his theory of risk communication: Risk = Hazard + Outrage. During his lectures he would make a statement about the science of toxicology and how we understand the actions of chemicals on human beings and communicate that risk to others by saying something like this:

“The science of toxicology is where we take a high concentration of one chemical and apply it to a small animal over a short period of time, in order to determine the effects of low concentrations of mixtures of chemicals on a large person over a very long period of time.”

I would be grateful if you could provide me with the original.

Peter responds:

I don’t believe I have written this anywhere, though it may appear in some third-party articles summarizing a presentation, since I say it often. Here’s what I typically say:

“ You all know what toxicology is? That’s where you collect evidence about what happens to small numbers of rodents, exposed to large quantities of one substance at a time over a short period of time – and then you try to decide what might hypothetically happen to large numbers of human beings, exposed to small quantities of lots of substances at once over a long period of time.”

I go on to say similarly exaggerated, dismissive things about the assessment of acute risks, focusing on fault tree analysis. I conclude: “In other words, we all know what part of their bodies risk assessors pull those numbers out of….”

I use this riff to make the point that the risk assessor’s definition of risk – magnitude (or consequence) times probability (or frequency) – is really better thought of as a guess at magnitude times a guess at probability – not even a best guess but an intentionally (and wisely) biased conservative guess. Later I relabel this as “hazard” instead of risk, and introduce a different definition of risk that incorporates what I call “outrage” as well as hazard. I then note that it is a mistake to imagine that outrage is merely perception while hazard is empirical reality, reminding people that, in fact, we usually have better quantitative data on outrage (such factors as control, dread, familiarity, and trust) than we do on hazard. So “if we’re going to get into a fight over which of the two is science, I am in grave danger of winning.”

There is no authoritative version of this. It’s just something I say a lot.

peter from australia replies::

Thank you for your prompt reply. By way of explanation, I am an 82-year-old retired consulting engineer with a long-term interest in liability issues. I write a monthly column for the engineers’ professional body in Australia.

The reference to your words came in discussion, after I had addressed a group of engineers in Melbourne last week, about the stupidity of the numbers game flowing from the application of statistical analysis to sets of data which are not measurements of the same thing – most acutely felt by the medical profession in this country, who must routinely tell patients that a procedure has a 1 in x risk of an adverse outcome because a court found a doctor negligent for failing to warn of a 1-in-48,000 risk. What the patient is supposed to do with that information is far from clear.

I also say things like “not enough engineers understand that a 1-in-200-year flood can happen tomorrow, nor that if it did, then happened again next month, we would not change the probability.”

Comment:

I just fully grasped and internalized the magnitude of what we face. There would be a time during an influenza pandemic (or other national level disaster) when information would be the dearest commodity. And having it readily available to the public could reduce panic.

Here is what happened in Ontario Canada during SARS (from a University of Louisville study for CDC ):

“During the height of the (SARS)outbreak (Ontario) the Hotline had 46 staff on the day shift and 34 staff on the evening shift, including individuals with special language skills. The Hotline received over 300,000 calls between March 15 and June 24, 2003, with a peak of 47,567 calls in a single day. Most calls were complex, with three or more issues identified per call, including self reports of illness or SARS contact, needed access to emergency supplies of food, masks, and other supplies, and concerns about loss of income, loss of housing, and business failure. In addition, the agency convened local community meetings and conducted other community outreach to address specific concerns in schools, workplaces, and among community groups. Toronto Public Health translated updated SARS information into 14 languages and posted this information on the City of Toronto’s official web site. Both Health Canada and the Ontario Ministry of Health also set up and maintained web sites for the dissemination of SARS-related information for members of the public and health professionals.”

I wonder how many are considering these kinds of levels of response and preparing for them? What happens if our systems crash and burn and people cannot get information due to overload? It never occurred to me that people would ask questions like some of those asked.

In Ontario there appeared to be a bell-curve on the response/need that had a very sharp uptake and then a relatively slow decline. I think it is amazing that they had roughly 16% of their calls in one day. Nothing could handle that (except systems like those used to take votes on national TV shows).

We need to be aware that this might happen so WE in public health don’t panic for NOT being able to handle something and potentially incorporate this kind of understanding into what we do and communicate to try to spread the “questions” out to other sources such as websites or possible pre-positioning of materials.

We will also want to know things like what the carrying capacity of our servers are for web-pages. If we overload them and they freeze up then what??? No hotlines, no web-pages. Perhaps pre-taped information shows for television or radio??? And we may want to consider having a plan for a dedicated “intranet” – duplicate sites that have stored web pages, documents so our hotline people themselves don’t get frozen out of any web resources they might need while answering phones… Can we have roll-overs on our lines so a menu of the most commonly asked questions with pre-canned answers can be accessed with a button push?

We in public health need to consider these kinds of things. We do have object lessons staring us in the face. Ontario had roughly 12 million people and only a few hundred SARS cases. What will happen when 10% to 15% of a given (perhaps localized but ever shifting) population is infected at any given point in time for weeks at a time during a pandemic???

I think we better ramp up our thought processes… I know we will be called on the carpet (and probably be rolled up in it and be thrown in the river) if we are not prepared. Is this a national level area of concern?    planning? Should contingency plans, contracts be let (at national?    state? levels) to handle the potentials? And this is just one area. I wonder if we are thinking big enough?

Peter responds:

I agree with everything you say. I’d add that illness and fear-of-illness among health department communication staff (and their contractors) will further complicate the problem.

Preparing now to communicate during a pandemic is, as you say, essential. Your comment focuses largely on logistical preparedness. Message preparedness and meta-message preparedness – figuring out what we will want to say and how we will want to frame our messages so people respond the way we hope – are obviously crucial as well. Most of us have little practice talking to people who are rightly very frightened, in a situation where we have comparatively little help to offer but only compassion, some commonsense advice, and a message of shared endurance. Studying the speeches of Winston Churchill in the dark early days of World War II wouldn’t be a bad way to prepare.

The communication task during a pandemic will be made a little easier if we have done more and better communicating before the pandemic – so the public is better prepared to hear what we are preparing to say. For more on this, see “Pandemic Influenza Risk Communication: The Teachable Moment.”

Comment:

Do you have any advice or materials regarding the pros and cons of pro-active broad-based media communications regarding pending class action litigation when plaintiffs have not yet chosen to go to the media?

Peter responds:

First and foremost, please note that I am not an attorney. When litigation is threatened or pending, you need to think through both the legal and the reputational impacts of everything you say. Too often companies rely excessively on their lawyers without thinking about outrage management. But it would be at least as bad a mistake (though a less common one!) to rely on me and fail to consult your attorneys.

Much of my advice for handling risk communication about issues that are subject to litigation can be found in a column I wrote on “Lawyers and Outrage Management.” I will focus here on class actions in particular.

I think risk communication has at least three goals with respect to a controversy that has led (or seems bound to lead) to a class action lawsuit. The first goal is often neglected, even though it may have a huge impact on the bottom line: You want to reduce the reputational costs of the controversy, independent of litigation costs. Risk communication suggests that you do this by acknowledging what happened; apologizing for anything you have mishandled; addressing people’s fears and grievances sympathetically; demonstrating a willingness to make it right; etc. All of this can best be done through direct interaction with stakeholders. But in a major controversy, it needs to be done indirectly through the media as well.

The other two goals are specifically legal, conceptualizing the media audience as prospective plaintiffs and prospective jurors, respectively. In their role as prospective plaintiffs, you want to reduce people’s incentive to join the class. We know that people become plaintiffs more often out of outrage than out of greed; they sue to get even, not to get rich. So good risk communication can reduce their motive to sue. (And of course reducing the size of the class reduces the appeal of the lawsuit to a plaintiff’s attorney contemplating a contingency fee.) And in their role as prospective jurors, you want to reduce people’s incentive to want to punish your company – most specifically by imposing punitive damages. Punitives are usually the big money in class action lawsuits, and punitives are explicitly about outrage. Good risk communication can help reduce the threat of punitive damages.

Of course the other side is that good risk communication usually means admitting things that reflect badly on your company. Even as they help prospective jurors, prospective plaintiffs, and society in general forgive you, they may help establish that you did something that needs to be forgiven. That often looks to your lawyer like a persuasive reason to say nothing.

But if you’re going to talk, the best time to talk is before the plaintiffs have launched their aggressive media assault. During this “honeymoon” period it is tempting to leave well enough alone – that is, to keep as low a profile as possible. I think that wastes the opportunity to strike while the iron is cold. Instead, I urge clients to use this time to familiarize the public with the case against the company. No, that’s not a misprint. If there’s going to be a big controversy in the media, but it’s not big yet, your strategy should be to dampen the plaintiffs’ ammunition by telling the public everything true (provably true) that the plaintiffs will soon be telling the public. If you don’t plan to try to hide damaging information, in other words, your best bet is to wallow in it apologetically. (Along the way, of course, you can also put it into context, providing mitigating details while continuing to emphasize your own self-criticism of your misdeeds.)

Done right – which means it has to be sincere, not just skillful – this approach leaves the plaintiffs very little to say except things you have already said and things that are flat-out lies. It leaves the public and the media responding to the plaintiffs’ campaign as old news about which the company has already come clean. It leaves the plaintiffs looking more like scavengers and less like whistle-blowers.

Once the plaintiffs have become vocal, your choices are very limited: defend (which makes you look defensive); counter-attack (which makes you look nasty); or concede (which makes you look defeated). The third is usually preferable to the other two – to the extent that it’s compatible with the truth; you don’t apologize for things you didn’t do. But I’d rather see my clients preempt the plaintiffs by announcing what they’re ashamed of, rather than belatedly admitting that the plaintiffs’ much-publicized claims are largely correct.

For a good example, study BP’s recent announcement about its Texas City explosion. See for example the Associated Press’s May 17 story.

Comment:

I am a volunteer for an organisation and was called out to a crisis involving domestic violence.Unbeknown to the police, the offender was hiding in one of the rooms in the house. While talking to the partner he appeared in the lounge in fear of my own safety, I ran out of the house and left the partner there. I ran to my car got in and left. Do you have any sugestions and what would you have done in these circustances.

Peter responds:

I wish I could help you. This is outside my experience and outside my expertise. I admire what you do, and I don't feel qualified to advise you on how to cope with a situation like the one you faced.

I imagine you may be feeling that you should have stayed and tried to defuse the situation and protect the partner, instead of protecting yourself by running. Maybe so. But I’m pretty sure I would have left too. Volunteering to counsel domestic violence victims is a lot different from volunteering to confront their abusers – alone and unprotected. Police are paid, trained, and equipped to face down violent people. Heroes, I suppose, may do it just because the need is there and so are they. The rest of us would do what you did: Get out. Then call the police from a safe place.

I hope things turned out okay for the partner. And I hope you're not giving yourself too hard a time for being prudent instead of heroic.

Comment:

It seems that every week I read a new article about the likelihood of a bird flu pandemic. Newsweek, the newspaper, the internet all carry articles that practically guarantee that a pandemic is coming.

You probably know all this…my question is: how should an ordinary person react/respond to this threat to try to protect themselves and their family? All the articles I read seem targeted to the public health system (vaccines, treating victims) or government/law enforcement (maintaining the economy, keeping the peace). I’ve not read anything that says: “Here’s what Joe and Jane Doe should do in case of an outbreak to minimize their risk.”

I read your article from 2004 about preparing ourselves psychologically for a pandemic when it comes. I have moved past denial and I’m scared. Now I’d like for someone who’s thought it through to help me come up with a list of things I could do, questions I should ask myself, ways I can protect myself. Then I can start preparing and start talking to friends and loved ones so they can be aware.

Peter responds:

This is very much the right question to ask. And you’re right that it’s not being addressed very well. Even those experts and government officials who are sounding the alarm about the risk of pandemic flu often give the impression that there’s not much for ordinary folks to do except watch and worry. If that were true, why bother to pay attention at all?

I'm not sure I’m the right person to answer your question – I’m just a risk communication expert. But here’s my best shot, with the help of my wife/colleague Jody Lanard (she’s also a risk communication expert, but at least she has an M.D.).

Jody and I urge readers to notice that Amanda says she’s scared – not panic-stricken, hysterical, or irrational. Along with her fear, and largely because of it, she is engaged and thoughtful – forethoughtful, even – about the next pandemic. And she would like to be planful as well. This is one of the main goals of informing and involving (and, yes, scaring) the public. As people take steps to get ready for a pandemic, their fear naturally abates. When a pandemic comes, of course, we’ll all be scared again, more scared than ever – but having thought it through, imagined it, and planned for it, we’ll be able to cope that much better.

Comment:

Thank you for your response regarding my question on a detailed communications plan. Since I sent it, I see the World Health Organization has changed the phases for an influenza pandemic. See: WHO Response Checklist. Any comments on these changes? Your links were very helpful.

Peter responds:

My wife and colleague Jody Lanard wrote this response with me.

One new factor that led to WHO’s revised pandemic phases is the apparently unprecedented spread and persistence of novel influenza viruses capable of infecting humans – especially, of course, H5N1.

We don’t actually know this is unprecedented. In the years before 1918, 1957, and even 1968, very few scientists knew what was happening to bird populations in isolated regions of Asia. The human pandemics of those years seemed to emerge out of the blue. If there were harbingers, they were missed.

But ever since the first known human death from H5N1 in Hong Kong in 1997, experts have been worrying that it could launch the next pandemic. This unprecedented foreshadowing is far from certain; a completely unknown or unsuspected virus may cause the next pandemic. Still, this time, for the first time, we have a chance to prepare.

The new pandemic phases take this simultaneously hopeful and terrifying new reality into account. When potential pandemic viruses are found, WHO now recommends increases in surveillance, information-sharing, and other forms of preparedness – with further increases as the risk grows. In the previous system, for example, the “inter-pandemic period” was one undifferentiated whole: no novel virus yet identified in a human. Now it is divided into two distinct phases. In the new Phase 1, the influenza viruses circulating in animals are considered of low risk to humans. But in Phase 2, the viruses circulating in animals “pose a substantial risk of human disease,” even though they have not yet been found in humans. Later phases trace the growing risk as the viruses spread from animal to human and from human to human, even though they are not (yet) spreading easily from human to human. Thus new knowledge, new surveillance capacity, and new communication capacity have led to new ways of parsing a pandemic threat.

At the most basic level, the new phases are much more clearly divided and labeled than the old ones were. They are identified with crisp integers – 1, 2, 3, 4, 5, and 6 – rather than the former phase/level structure, which started with a counterintuitive “Phase 0, Level 0.” The added precision and clarity of the new system more than justifies whatever inconvenience was produced when various government agencies had to adapt their pandemic plans to match the new WHO phases. It helped that WHO did a good job of explaining its rationale for the changes, so the revision does not seem like “change for the sake of change.” The clear rationale also leaves the door open for future changes as knowledge continues to evolve.

What is most notable to us as risk communicators is WHO’s emphatic insistence on the importance of transparency and the sharing of information among disciplines and among nations. This is in the service of giving the world the earliest possible early warning system for possible pandemics – even possible pandemics that smolder and stutter for years, and perhaps fade away entirely. We would very much like to hear public health officials’ early reactions to the new phases, so we’ll turn the question back on you, Karl, and on other readers as well. How do the new phases help – or not help – your thinking about a pandemic that hasn’t happened yet, and your efforts to mobilize and prepare?

Comment:

Like many, I have been following with dismay the consequences of the publication of the recent article in JAMA “Excess Deaths Associated With Underweight, Overweight, and Obesity” (JAMA. 2005;2931861–1867). It seems to me that there was a MAJOR communication failure on the part of CDC about this study. They (CDC public information folks) have completely missed the boat. No comments about the impact of obesity beyond mortality, no link with the companion article in the same issue that describes the sharp increase in the use of anti-hypertensive and cholesterol-lowering drugs among obese people, no mentioning of the fact that based on the same data used to describe mortality the US population has considerably shifted weight to the right (in other words, we are all a bit more heavy), and so on. In fact, they have tried to keep a very low profile (at least from my view angle), and that has left others the space to exploit the study results to support the argument that the obesity epidemic is not as bad as it has been described, after all. Did they think that ignoring this new publication would just make it go away? Well, that did not happen. Did you see the full-page ad this week on major national media sponsored by fast food chains and food industry that claims that the American Public has been fed lies all along about how bad the problem of obesity is?

This could go in the classroom material for future courses on effective public (mis)communication….

I'd love your opinion on this. How would you have handled this?

Thanks.
Gianfranco Pezzino, MD, MPH
Director of Public Health Studies
Kansas Health Institute
212 SW Eighth Av, Suite 300
Topeka, Kansas 66603-3936
Phone (785) 233-5443 Fax (785) 233-1168
gpezzino@khi.org

(The comments above reflect only the opinion of the author, and not the official position of the organization with which the author is affiliated.)

Peter responds:

I haven’t really followed the weight-and-health research, the media coverage, or the CDC’s stance in that coverage. What little I have read recently, I’ve read with the same gleeful satisfaction as most other middle-aged people worried about their waistlines – though the news hasn’t kept me from continuing to worry about my waistline. So the comments below are tentative. Perhaps others will want to weigh in.

A few quick reactions:

First, the news that being overweight is less deadly than previously thought, and especially the news that being underweight is more deadly than previously thought, is inevitably a source of widespread pleasure and Schadenfreude. Anyone who wants to put the news into context should acknowledge this, and should do so good-humoredly. In the culture war between skinny and chubby, chubby finally won a battle. It would be ungracious not to say so.

Second, I very much doubt that the mortality numbers are a major factor in people’s internal wars over their weight. Even without knowing the literature, I’d bet that morbidity matters more to dieters than mortality, and that appearance matters more than both put together. And I suspect you’d be hard-pressed to find many people who are naturally thin but now plan to force themselves to eat more in order to live longer. The new information about mortality provides reinforcement and ammunition – not really motivation – to those who have trouble controlling their weight. It lets us tell ourselves that our insufficient self-control at mealtimes isn’t as damaging as it might be. Those who want to encourage weight control don’t need to be too distracted by the side issue of mortality statistics. Focus instead on our real reasons for wanting to lose weight and our real reasons for finding it difficult.

Third, the CDC in particular needs to own what has happened in the past year. Its claim that obesity causes 400,000 American deaths a year was under severe attack even before the new study – from a different CDC team – suggested that 112,000 is a more accurate estimate. The CDC should certainly point out that it still views obesity as a top-priority public health problem, and that less-than-obese overweight people do have some genuine health disadvantages (even if a shorter lifespan doesn’t turn out to be one of them). But I think it also needs to concede that it has sometimes been a bit overzealous in making its case.

Finally, it may help to distinguish two different persuasion goals. Strident advocacy is apparently a pretty effective way to persuade institutions (school cafeterias, fast food restaurants, etc.) to change their policies and practices. But I'm not convinced that it’s a good way to persuade individuals to change their eating habits. Headlines about an “epidemic of obesity” tell the average overeater that s/he’s not alone; in fact, that s/he’s handling temptation rather better than a lot of people. Changing people’s eating habits is incredibly difficult, of course; nothing works very well. But risk communication ought to be able to come up with more effective messages than that!

What I would add to this site:

Your site is very useful and user friendly!

Comment:

I have heard when one applies, ‘Critical Mass Theory’ to the number of risk perception factors, one can estimate an over all level of stress/concern. However, I have not been able to find any papers reporting empirical evidence to support this theory. Is Critical Mass Theory an accepted theory? If so, please can you recommend some references that detail this further. Thank you for your time.

Peter responds:

The truth is, I never heard of Critical Mass Theory. That doesn’t necessarily reflect badly on Critical Mass Theory. Since leaving academia 15 years ago I have tried to keep up with the risk communication research literature, but I haven’t always picked up on collateral theoretical developments.

A Google search found me three completely different Critical Mass Theories.

The first comes out of sociology, and apparently flourished in the 1980s and early 1990s. It is/was “a theory of public goods provision in groups.” I’m not sure what that means, or how it bears on risk perception. But the key authors appear to be P.E. Oliver and G. Maxwell. They published a 2001 paper entitled “Whatever Happened to Critical Mass Theory?”

The second use of the term is much more widespread. It refers to what Malcolm Gladwell popularized as “the tipping point” – that is, the observable truth that a variety of social phenomena are likelier to keep happening if they are already happening a sufficient number of times. This has been applied to everything from graffiti to suicide, from racial segregation to charitable giving. (It also applies to many biological phenomena, such as epidemics; a critical mass of cases is needed to turn an infectious disease outbreak into an epidemic. And of course it applies to nuclear explosions, which require a critical mass of fissile materials.) What the critical mass concept adds to our everyday notion of bandwagon effects is the claim that there’s a dichotomy – below the critical mass the bandwagon fizzles; above it the explosion is inevitable. The literature here is huge. There’s probably a good literature review I should send you to, but I haven’t found it.

The bandwagon concept certainly applies to risk perception. In the 1980s, Roger Kasperson coined the term “social amplification of risk” to refer to the reality that people are likelier to take a particular risk seriously when their neighbors take it seriously – or when the media coverage suggests to them that their neighbors take it seriously. Of course the opposite effect, “social attenuation of risk,” is also important; it’s hard for most people to sustain their concern about a risk nobody else seems to be worried about. The same is true within interest groups. If most of your crowd thinks pesticide residues are a serious risk and herbal remedies are not – or vice-versa – that’s likely to be your opinion too. I’m less convinced that there’s an actual critical mass – that is, a certain number of opinionated friends or column inches of newsprint required before the contagion is sure to spread. But I’m open to the possibility.

I’m not sure how this version of Critical Mass Theory might enable you to estimate an overall level of concern. But it certainly is true that a very strong predictor of people’s opinions is other people’s opinions. And it is certainly true that the toughest part of influencing public opinion is getting the ball rolling – that is, influencing the opinions of a critical mass of early adopters.

The third use I found for Critical Mass Theory is directly relevant to risk communication, but very narrow. It is a fundamental truth of risk perception and risk communication that concern about a risk (“outrage” in my terminology) is a product of factors like trust, control, familiarity, dread, responsiveness, etc. Everyone in the field agrees that these factors collectively determine how upset people are likely to be about a risk. Vincent Covello, one of the world’s leading risk communication experts, sometimes goes further. In a recent PowerPoint presentation on “Risk Communication: Applications to Non-Emergencies” , Covello presents a more or less typical list of 20 factors that influence risk perception. Then he has a slide entitled “Critical Mass Theory” which says: “3–7 factors from right-hand side of risk perception chart must be present to create moderate stress.”

I doubt this is literally true. Some of the factors on Covello’s list (and all our lists) are routinely more impactful than others. Some factors are more impactful in specific situations than others. And none of the factors is dichotomous. Risks aren’t “controllable” or “uncontrollable”; sources aren’t “trustworthy” or “untrustworthy” – they vary between these two extremes.

Covello is certainly right that the higher a risk is on the various “outrage factors” (my term; don’t blame it on Covello), the more upset people are likely to be about it. And he is certainly right that there’s a happy medium he calls “moderate stress” where people are interested but not freaking out. Below that happy medium people are going to be too apathetic to listen well; above it they’re going to be too upset to listen well. Is the happy medium “3–7 factors” from Covello’s list of 20? Not always, not exactly – but yeah, okay, sure.

So does “3–7 factors” constitute a critical mass? Not literally. The critical mass concept requires a dichotomy. Below critical mass nothing happens; once you’re above critical mass, getting even higher accomplishes little or nothing. Outrage is much more continuous than that. The more factors you see trending toward the high-outrage side of the continuum, the higher the public’s outrage is going to be. It’s like weight. The more calories you eat, the fatter you’re likely to get. We can identify a calorie range for low, moderate, and high consumption, associated roughly with a low, moderate, and high probability of ending up overweight. But there is no critical mass of calorie intake for obesity.

I’m pretty sure Covello would agree with all this – but you can always ask him.

Comment:

I am completing a research paper where I need to apply your risk communication theory to educating the public on outdoor exercising during “spare the air” days here in the San Joaquin Valley of CA. I was thinking of using the Moderate Hazard-Moderate Outrage stakeholder relationship. Any suggestions would be most welcome.

Peter responds:

I would guess that people who are deeply committed to their exercise regime – dedicated joggers or cyclists, for example, not to mention gardeners – would be more than a little outraged at the news that pollution is so high they really should wait for a clearer day. And I’d guess that they’d be very likely to deal with their own outrage by ignoring (even disparaging) the advice and going ahead with their normal routine.

If I’m right, a risk communication campaign aimed at persuading athletes not to exercise outdoors on bad days would probably benefit from some outrage management. Among the approaches that come immediately to mind: (1) acknowledging the unfairness of the situation; (2) acknowledging their likely outrage, both at those responsible for the pollution and at those urging them to skip their exercise (perhaps instead of doing more about the pollution); (3) acknowledging that they are doubtless tempted to ignore the advice before explaining why they’d be unwise to do so; (4) acknowledging that exercise is good for health, and that skipping it because of air pollution involves risk-risk tradeoffs that are debatable; (5) suggesting ways to do substitute exercise indoors (how about bad-air-day reduced-fee passes to indoor tracks and health clubs?); (6) expressing openness to dialogue (especially about how bad the air should be before issuing these warnings, also about ways to get the air cleaner sooner and ways to do indoor exercise in the meantime)….

These are just off-the-cuff reactions, not to be relied upon too heavily.

For most of the rest of the population, I think you’re right. If exercise is an occasional chore rather than a daily pleasure or daily obsession, the outrage at having to postpone the chore should be modest, as is the hazard. In that case the task is mostly informational. “It’s probably better to wait till tomorrow.”

I’d love to see your paper when it’s done.

What I would add to this site:

Easy to get to Links to best examples of what is available out there surrounding various elements of preparedness planning.

Comment:

We are updating our Pandemic Influenza Plan and I do appreciate your article on risk communications. Very helpful. We want to “go to school” on others instead of re-inventing the wheel. In doing my research, first I have noticed a great deal of what we should do, from a strategic standpoint but then getting to the nitty gritty of “operationalizing” it is more difficult but not impossible. But, I am not finding a “nuts and bolts” comprehensive example (tactical)of a point by point communications plan related to the “phases” of an outbreak. Just parts and pieces which we will use. I have also noted that because of SARS, this planning is less of an academic excercise for Canada than for the US…

Peter responds:

Like you, I have yet to see a detailed pandemic influenza communication plan that is explicitly geared to the World Health Organization phases.

So far, in fact, most of the flu pandemic communication plans I’ve seen are awfully general. The usual pattern: A pandemic plan that’s pretty alarming and pretty detailed, accompanied by a communication “annex” that’s much vaguer and over-reassuring. As your comment suggests, a lot of countries, states, and communities are working now on pandemic communication plans, or revising and expanding the ones they have; the next generation should be a lot more specific.

Of course the most fundamental distinction is pre-crisis communication versus crisis communication. (In the WHO’s parlance, pre-crisis communication has to do with the “inter-pandemic” phase.) The appropriate messages right now are about what might happen, and especially about what needs to be done – and what can and can’t be done – in the way of preparedness and planning. (See “Pre-Crisis Flu Pandemic Talking Points” for a list of messaging suggestions.) Once a pandemic is imminent, the key messages will change. Advice on personal hygiene and ways to increase social distance will become a lot more important; so will help bearing the high level of fear an imminent pandemic will induce. There may be a need to explain what the authorities are doing with their stockpiles of antiviral medications – and perhaps a need to explain why the stockpiles are so scanty. After the pandemic arrives, still other messages will come to the fore: on where the infection rate is waxing and waning; on tasks that need doing to keep society’s infrastructure going; on progress toward manufacturing a vaccine; etc.

Such phase-related communications could be guided in part by my article on “Obvious or Suspected, Here or Elsewhere, Now or Then: Paradigms of Emergency Events.” Also worth looking at are the new “WHO Outbreak Communication Guidelines.”

Comment:

I have just finished reading your article in relation to the risk associated with bodies. Very interesting indeed. My comments/questions relates to that article and also to the “four kinds of risk communication” article.

I would be interested to hear your opinion on these two issues. My apologies for a constant barrage of theoretical questions – but I am slowly finding my theoretical footing in this minefield.

Peter responds:

That said, lots of qualifiers:

• You still need to know what apathetic people are thinking; what they know and believe (even though their opinions are very weakly held) – their mental models. So saying this is a monologue doesn’t mean you don’t do audience research and address your monologue to real people, not to stick figures.
• Experiential learning is obviously more powerful than listening to a monologue. If you can get an apathetic audience involved, you’ll increase their interest and their learning. One-on-one, this is feasible and therefore crucial. Even in mass communications, it’s sometimes worth trying – hence “games” of various sorts in communications aimed at teaching health messages. Efforts to arouse interest through activity do make the communication two-way in a sense – but not in the sense of listening to their opinions when they haven’t got any to speak of.
• People who are apathetic about what you want to talk about may nonetheless be anxious to talk to you about other topics entirely. If there’s a multi-topic agenda, it’s always appropriate and sometimes essential to listen to your audience on Topic X as well as hectoring your audience about Topic Y.

All these qualifiers notwithstanding, outraged people want to yell at you; mildly interested people want to chat with you; completely uninterested people don’t especially want to listen and have nothing they want to say.

Comment:

How do you think that cloning beef cattle will affect the beef cattle market? and why.

Peter responds:

I know absolutely nothing about beef cattle cloning. Apparently it has been going on for some years. I don't know of any impact on the market – but I wouldn't know unless there had been a public controversy.

Some kind of boomerang effect is always a possibility, if cattle cloning leads to an unexpected problem, or if cloning in another species leads to a suspicion about cloned meat generally. It would be interesting to develop a risk communication program for the cattle industry that lets people know beef cattle are sometimes cloned, why they’re cloned, the pros and cons, etc. The goal would be to get this background knowledge into people’s heads as a hedge against possible future controversy – so if an issue did arise, people would react: “This isn’t new. I’ve known about it for years.”

This sort of preventive outrage management makes sense if you sense there may be controversy on the horizon. It’s a kind of inoculation. Understandably, industries tend to resist “inoculating” their publics with potentially controversial information. They’re afraid of the welt the inoculation itself may raise. It’s hard to talk yourself into a self-inflicted wound, even one that will probably be small; it’s easier to do nothing and hope the disease will pass you by.

Though it’s a tough sell internally, any industry can productively draw up a list of things people don’t know that might be grist for future controversies, and then devise a strategy for getting all the relevant information out in a way least likely to provoke outrage – rather than waiting for a critic to get the information out in a way most likely to provoke outrage. If the beef cattle industry had such a preventive outrage management issues list, cloning would probably be on it.

What I would add to this site:

Links to websites set up by individuals or organizations in other countries.

Comment:

First of all, I would very much like to compliment you on your EXCELLENT website (and the articles I have been able to read there, or access through it). It is reassuring to know that the Internet has such a truly informative website.

I found it while looking for information on how to better, or more clearly, explain to my high school students (grades 7–12) the concept that very, very low concentrations (ppm, ppb, even ppt(?)) of chemicals and other biologically active “agents” may be/are harmful (very toxic, even lethal) to humans and other organisms. For some unknown reason(s), the relationship between toxicity/potency and the possibility, and in some well-known cases, the established fact, that ultra-low concentrations can be harmful, escapes them. The various science course curricula prescribed by my province’s (Alberta’s) education ministry requires that biomagnification, LD50, toxicity, benefit-risk analysis, etc. be introduced and taught to students in several different grades.

I’d like to think that many students have difficulty comprehending the concept primarily because many of them are (still) making the transition from concrete to abstract thinking; or, that they are not yet capable of critically thinking about the concept. However, when I encounter adults (parents of my students, and others) who also cannot grasp the concept, I wonder whether it’s what I’m doing or not doing that is part of the problem.

I’m writing to ask if you can refer me to some (teaching or information) resource or resources which address(es) the problem of making this concept more easily understood, not only (but especially) by children, as well as by adults. It may be that I need to employ or provide a concrete or hands-on experience or model, in addition to using the visual presentations I already utilize with my students.

I suspect that you’ve probably encountered this problem when giving your seminars, speaking engagements and workshops to various (age) groups. I’d greatly appreciate hearing from you if you could refer me to even one useful resource (in printed format, or in media format, or a person I could contact, or another excellent website I could access).

Peter responds:

The short answer is that I don’t know the answer. There is a huge literature on chemical and toxicological education, some of it produced by advocates (by the chemical industry or its activist opponents) and some by educators. I suspect you know this literature better than I do – but if you haven’t seen it, check out http://www.liv.ac.uk/Chemistry/Links/refeduc.html for a long list of links to “Chemical Education Resources” on the Web.

I share your conviction that experiential education works best. Teaching kids (or adults) about toxicity has got to work better with lab experiments and demonstrations than with textbook abstractions. But you knew that already. I do want to suggest a piece of the answer that may not have occurred to you, but to do that I have to back up and reanalyze the problem.

There are really two opposite problems.

The problem that industry usually complains about is the one you don’t mention: People often have trouble understanding that “the dose makes the poison” (to use the famous formulation of Paracelsus). We refer easily to this or that chemical as “highly toxic” or “carcinogenic” without considering what dose is required to do the harm we’re worrying about. Of course, different chemicals have different dose-response relationships. In some cases, low doses are beneficial or even essential while high doses are harmful (a phenomenon called hormesis). In some cases, there is no observable effect at all below some threshold dose. In some cases, there is no threshold and any non-zero dose does some harm. The shape of the dose-response curve can also vary. Sometimes it’s linear; sometimes it’s an S-curve (flat at the bottom, then rising sharply, then flat again at the top); occasionally it even seems to turn around, creating a harmful “window” surrounded by less harmful lower and higher doses. Most often, we don’t know as much as we wish we knew about the dose-response relationship for the chemical of concern. Measuring impact at low doses is a huge methodological challenge; measuring impact at high doses is a huge ethical challenge.

Despite the complexities, the generalization is still valid, and still tough to communicate: The dose makes the poison. As we learn how to measure parts-per-billion, parts-per-trillion, and even parts-per-quadrillion, it gets more and more important for people to realize that measurable amounts of toxic substances can be nonetheless harmless.

The second problem is the one you’re focusing on: The poison also makes the poison. That is, some chemicals are hazardous even at minute doses. Some chemicals in some situations, in fact, do demonstrable harm at the lowest dose we’re able to measure, so even a “too low to measure” finding doesn’t necessarily mean there’s nothing to worry about. People who intuitively grasp that the dose makes the poison may neglect to notice that some poisons are still poisonous at very low doses indeed. This is why industry sources are so attracted to concentration comparisons – “one part per billion is a drop of vermouth in 500 barrels of gin” and the like. They figure such a comparison will help them convince their neighbors there’s nothing to worry about.

So sometimes a low dose is pretty safe but people are mistakenly upset anyway. And sometimes a low dose is pretty dangerous but people are mistakenly unconcerned anyway. And, of course, sometimes people are rightly upset about a low dose that’s dangerous or rightly unconcerned about a low dose that’s safe. This is where risk communication comes in. We know that the correlation between how serious a risk is technically and how worried people are about that risk is very, very low. And we know why. It’s what I call outrage. (This website has lots of writing on the dynamics of outrage; for a very short introduction, see my 1987 article “Risk Communication: Facing Public Outrage.”)

When a situation is high in such “outrage factors” as dread, coercion, memorability, unresponsiveness, and distrust, people are likely to find the risk upsetting and intolerable, regardless of what the data say about how serious it is technically. And trying to explain about that one drop of vermouth won’t help and may well backfire. But when a situation is low in these outrage factors, people are likely to shrug off the risk, again regardless of the data. And the drop-of-vermouth comparison goes down smoothly.

So if you’re trying to reassure people about a risk you think is minimal, explaining the data is far less important than reducing the outrage. And if you’re trying to arouse people about a risk you think is serious, explaining the data is far less important than increasing and mobilizing the outrage. This goes far toward clarifying what advocates on both sides should be doing.

What it means for educators is a much tougher question. I’d suggest teaching toxicity by means of matched sets of examples – some where people tend to shrug off a serious risk because the dose is low; some where people tend to worry about a minuscule risk even though the dose is low; some where people are rightly unconcerned or rightly alarmed. Discussing these disparate cases with your students should help teach them that some poisons are poisonous even at very low doses, and some are not. Just as important in my view, it will help teach them to notice their own outrage, where it comes from, and how it affects their responses to risk.

Comment:

I attended your presentation to the CPE yesterday (3/2/05), and it was brilliant. I’m the guy who asked for examples of “High Outrage High Hazard.” Thank you for a lucid and thorough treatment of communications risk. It was illuminating for me in my business and potentially valuable for me in my life. Despite your last name, it’s a credit to you that you put nobody to sleep. Quite the contrary; I believe that if you had the opportunity to speak another hour, you would have lost none of your audience.

In 1992, I wrote a book entitled “Knowledge at Risk” in which I asserted that risk is a function of impact and probability; R=f(i,p) or r=i*p. The way to reduce risk, then is to reduce either of these two factors. Reducing probability is a matter of prevention; reducing impact is a matter of planning. Whereas my formula is practical in operational recovery, yours focuses on communications. Both make sense and serve practical objectives! I was so impressed with your formula and the value you demonstrated, that I am committed to further study in this area, particularly to build it into my own framework of thought on the subject of risk.

Intuitively, I know that our formulae complement one another, but I’m not sure how. I need to do some pacing and think on it. Any ideas?

Peter responds:

Thanks for your kind words about my presentation.

Risk assessors in various fields – from health and safety to insurance to business continuity – always end up with some variation of your “impact times probability” formula. Instead of “impact,” other formulations say “magnitude” or “consequence”; instead of “probability,” they sometimes say “frequency.” But everyone agrees that the technical and financial calculation of risk (as opposed to the cultural or psychological calculation) means multiplying two factors: how bad it is and how likely it is.

As you know, this is easier said than done. Measuring probability is a methodological can of worms, especially for awful things that have never happened. (How do you even list all the awful things that have never happened, much less calculate their probability?) Even for chronic risks, there is often very high uncertainty surrounding a probability estimate – consider, for example, the probability that low-level emissions of dimethylmeatloaf contribute to the incidence of birth defects. But at least we know exactly what we’re trying to measure. Measuring risk magnitude (“impact” in your terms) is a conceptual and moral can of worms. What is the relative magnitude of the death of a human versus the extinction of an animal species? The death of a healthy child versus the death of a virtuoso violinist versus the death of a terrorist versus the death of an Alzheimer’s patient?

Nor is there universal agreement that risk magnitude and risk probability deserve equal weighting, as the formula suggests. Most people intuitively think that really horrific outcomes (the end of life on earth, say) are unacceptable even if they have commensurately low probabilities. We prefer a lower-magnitude higher-probability risk, even though the magnitude-times-probability product is the same. But at the other end of the distribution, we are also profoundly uncomfortable with sacrificial lambs:   If we just let them kill this one person, the odds of a good outcome will improve markedly for the rest of us.

Even when both magnitude and probability are well-established, people have very different responses to mathematically equivalent risks. Some of this is attributable to perceptual heuristics – some risks are more vivid and emotionally resonant than others, for example. But some of it is real judgment that risks deserve to be assessed by more standards than just their magnitude and probability. Most people know that they are likelier to die in a fatal car accident than in a terrorist attack. Most people know that a million dollars spent on highway safety will reduce mortality more than a million dollars spent on homeland security. But compared to highway safety, terrorism isn’t just more vivid, more emotionally resonant, less familiar, more dreaded, and the rest. It is also more important – morally, politically, culturally. We are willing to spend more on it per life saved.

All these complexities, discontinuities, and inconsistencies are the venue of what I usually call outrage. In my “Risk = Hazard + Outrage” formula, my “hazard” is what you mean by “risk” – that is, magnitude times probability. “Outrage” is all the other considerations that make us assess some risks differently than others, including the considerations that make us right to do so. When I first coined the formula, I was working mostly on environmental controversies, and “outrage” nicely captured the mix of anger, righteous indignation, and worry that people felt about industrial pollution. It isn’t really the right word for some other sorts of risks. The same “outrage factors” explain why people are more attentive to West Nile Virus than to flu, notwithstanding the fact that flu is by far the bigger risk technically. But people are more fearful than angry about West Nile Virus. It feels off to call it “outrage.” Years ago, Sheldon Krimsky and Alonzo Plough wrote about “technical rationality” versus “cultural rationality.” That captures the distinction in a more universal way than “hazard” versus “outrage.” I tend to stick to my own formulation; it’s shorter and it’s mine.

Comment:

Regarding information made available to the public for bioterror and conventional public health emergencies, I believe that information is required now to satisfy the needs of those persons who seek information at this time.

The prospects for an avian flu pandemic motivated a search for information describing preventive activities. There is not much out there. References to universal precautions and the aerosol connection to infection are present, but little else. Bioterror information seems to be directed to first responders and to take the form of seemingly confidential, or at least non-publicized, reports and plans originated by government agencies for public health professional surveillance and response activities.

It seems reasonable that all levels of government would make available focused prevention and response information for those who seek it, even if they are now a minority. Many years ago government sources encouraged the construction and furnishing of private and public nuclear bomb shelters and produced extensive information regarding that subject. While it is certainly true that most private households did not install them, some did. In our “information age” similar availability of information and preparedness for contemporary public health threats is reasonable.

With WHO and CDC and many public health officials predicting an influenza pandemic of massive size it seems productive to promulgate the logistical and behavioral requirements for households with differing requirements in rural, suburban and “downtown” locations that will have to exist during such conditions. As a minimum, it seems reasonable to provide advice on the minimization of contact in public places, the use of masks, gloves, etc., requirements for nutritional and other forms of self-sufficiency, and the variety of sources of information that will report the status of any pandemic.

I think this is planning, not alarmism.

Peter responds:

I fervently agree that people need information on health emergencies, whether the emergency is a bioterror attack, a flu pandemic, or something else. I also agree that the information that’s most needed is information on how to prepare and how to respond.

In fairness, there is some relevant information out there, though it's not as easy to find as it should be. But the information tends to be awfully general. For bioterrorism, for example, it tends to be: Pack a Go Kit, listen for instructions, call a physician if you start experiencing symptoms, etc. I do understand that it’s hard to come up with specific information relevant to dozens of conceivable emergencies, and hard to get people to learn it while it’s hypothetical. So the focus is on stockpiling information to be deployed when a specific emergency materializes.

The relative scarcity of specific information on pandemic preparedness and response is especially upsetting, since a flu pandemic is certainly the most ominous threat on the horizon right now. I have read far too many articles telling me that this or that city/county/state government is prepared for a pandemic. Rarely do the articles say what citizens can do to prepare – or to help the government prepare. The implication is that pandemic preparedness means governments manufacturing a vaccine, stockpiling antivirals, and figuring out who will give the shots and where people will be told to line up. As you point out, far too little is said about how civic organizations and individual citizens can plan to minimize their contacts, ramp up their personal hygiene, and increase their self-sufficiency. Our officials’ reluctance to frighten us (or to be accused of frightening us) is getting in the way of their encouraging us to get ready.

As a rule, such articles also grossly overstate the level of official preparedness. We don’t have a vaccine and we aren’t as close to one as the articles often imply; the typical stockpiles of antivirals will be exhausted in no time. The news that “health officials say they are ready” gets in the way of local residents and civic groups doing their own preparedness work, or volunteering to help the government get ready, or even supporting increased preparedness budgets. Ironically, many health officials have spent years crying in the wilderness that our society is inadequately prepared for a public health emergency. Now that one may be approaching, too many act as if under pressure to claim the opposite – yielding to the risk communication seesaw instead of managing it.

Comment:

After years of investigation of the 2001 anthrax attacks, do you still believe guideline 23 of your article has merit? If so, how do you see analytical deliberative process beginning to determine tentative advisory levels for public building reoccupancy, given present uncertainties?

Peter responds:

My December 2001 column on the anthrax attacks was entitled “Anthrax, Bioterrorism, and Risk Communication: Guidelines for Action.” It listed 26 guidelines, including #23, “Find a non-zero standard for anthrax.” I argued that it’s intolerable to leave contaminated spaces unoccupied until you can prove there are no anthrax spores – and there is therefore no anthrax risk – present. “If the agency doesn’t know enough yet to draw the line,” I wrote, “it still has to recommend where to draw the line while it is trying to learn more. Ideally this preliminary standard should be conservative…. And it should be tentative, grounded in dilemma-sharing; even as they specify the preliminary standard, officials should predict that it may change and they may wish in hindsight they’d set it differently. But some preliminary standard has to be there.”

I still agree with all this.

I’m not qualified to have an opinion on whether there’s a biological threshold for anthrax, and if so what it is. When I was following the anthrax story closely a few years ago, experts disagreed about how many anthrax spores were required to induce human illness, but it was clear that many factors affected this calculation – how finely milled the spores were, how virulent a strain of anthrax was involved, what sort of delivery mechanism was employed, etc. The possibility of bioengineering a new sort of anthrax, moreover, made it tough to rely too confidently on what data they had. Given all the uncertainties, most experts declined to pronounce any non-zero number of anthrax spores “safe.” My impression is that this is still the case.

So if we’re going to dichotomize safety at zero risk – that is, if by “safe” we mean there is no risk whatsoever – then apparently even the most minute quantity of anthrax isn’t safe.

But dichotomizing risk at zero is almost always a mistake. The question for policy-makers trying to decide whether to reopen a postal facility, and for individuals trying to decide whether to re-enter the postal facility, isn’t whether the risk is zero. It’s whether the risk is acceptably low. Of course this question is as much about values and risk tolerance as it is about data and risk assessment. But the values half of the decision relies on the risk assessment half. We are all entitled (and obliged) to decide how safe is safe enough. The experts must tell us, as best they can, how safe this situation is.

In saying that we need a non-zero standard for anthrax, what I am saying is that a responsible official should not promise to keep a building closed until there is absolute certainty that no anthrax spores remain in that building. A seaside resort should not be kept closed until there is certainty it has no coliform and no sharks; a child should not be kept home until there is certainty there are no kidnappers, molesters, or speeding vehicles around. Distinguishing acceptable from unacceptable risk is an unavoidable task of policy-making, of parenting, of living.

In most situations, people easily understand that zero risk isn’t achievable. Even when people are actively demanding zero risk, they usually know (though they try to ignore) that their demand isn’t reasonable, and that it’s not what they demand elsewhere in their lives. A persistent insistence on zero risk is often a sign of extremely high levels of anger or fear. Or the demand may be strategic; policy opponents quite reasonably set unachievable standards for actions they don’t want taken. Of course we all have moments when we wish for zero risk – just as we may sometimes wish for zero cost or zero calories. But unless we’re very angry, very frightened, very calculating, or very young we don’t normally expect the wish to be satisfied.

It follows that promising zero risk is neither wise nor honorable. It sets people up to expect what you cannot deliver.

Figuring out what non-zero standard makes sense for anthrax is both a technical and a political (that is, values-laden) task. It would help enormously to have a No Observable Effects Level (NOEL) – if there are this many spores of that diameter, we’re pretty confident nobody or almost nobody will get anthrax. Even a NOEL doesn’t define zero risk, but it’s a pretty good operationalization of negligible risk. Failing a NOEL, you need some other basis for drawing the line. Getting the anthrax level down to the normal non-zero background level (somewhere) makes some intuitive sense. Getting it As Low As Reasonably Achievable (ALARA) makes a different sort of intuitive sense. Getting it low enough that you predict less than one additional case per gazillion people exposed (ten-to-the-minus-whatever) makes yet another sort of intuitive sense. Getting it as low as you can without creating problems worse than the one you’re trying to solve (without letting the terrorists win, for example) makes sense too.

Experts and citizens alike should have standing in the debate over how to set the standard, how conservative a standard to set, and how much more conservative to make it because you’re not sure of your data and your model. But a zero standard should be seen as either a bargaining position or a cri de coeur, not as a useful solution. Next time we’re cleaning up after an anthrax attack, we need to be able to say to people: “If we find X we’ll keep you out of the building; but if we find Y we’ll let you go back in – and if you don’t want to go back in until we find Z, we’ll make arrangements for that too.”

Obviously if there isn’t any scientific basis for asserting that some non-zero number of anthrax spores is probably pretty safe for most people, then there can’t be a non-zero standard … at least not until some more science is accomplished. But “probably pretty safe for most people” is a different and may be a more appropriate criterion than trying to find a NOEL, failing, and giving up on ever using any facility that might have a few anthrax spores left.

It will take some risk communication skill to explain a non-zero standard compassionately, legitimizing and sharing the audience's wish that we could get rid of the anthrax altogether (not to mention the wish that we hadn’t been attacked in the first place). But even with all the risk communication skill in the world, you can’t get to a sensible policy outcome if zero risk is the only standard you have to work with. And the best time to decide what non-zero standard makes sense is before the next building is contaminated.

Comment:

I would to ask, why has there been no information given as to the possible threat on going after the Indian Ocean Tsunami.? ie: What are the projected possibilities of further Tsunami events causing damage to already affected areas.? What Advance Warning Systems have been set up by Governments of affected countries, to give notice to people in danger areas.? Why have the Government officials, responsible for failing to warn their people and condem thousands to horrible deaths, been allowed to remain in office and evade prosecution for Murder by Neglect. Their performance cannot be excused by saying “We did not know who to notify”. They are supposed to know and they are supposed to act in the best interest of the people they represent. Shame on the world leaders for their failure to condem their actions. They traded the Tourist Dollar for thousands of innocent lives. They should be punished.
Tsunami Survivor.

Peter responds:

I can sense your anger and frustration. Although I can’t imagine what you went through, I can understand how such an experience could leave someone wanting punishment for those who failed to issue warnings. A lot of people who didn’t live through the tsunami personally but only via the media feel that way too.

For what it’s worth, there were some people punished. In Thailand, the director general of the Meteorological Department (Suparerk Thantiratanawong) was demoted for not passing along the warning. He was replaced by Smith Thammasaroj, the former department head who had been forced into retirement after proposing seven years ago that Thailand needed a tsunami warning system. I don’t know what happened to meteorologists and emergency responders in the other countries most affected by the tsunami. Most of them never received a warning to pass on.

People who have made big mistakes are sometimes worth keeping in their posts. Their hard-won learning and their personal feelings of guilt can motivate a dedication to change that would be difficult for a newcomer to match. That doesn’t always happen, of course; other times people get dug in, defending their mistakes instead of learning from them. But it can be terribly wasteful to fire someone who has just learned a powerful, visceral lesson in what not to do. I have read several very moving interviews with Pacific Ocean tsunami experts, who clearly feel terrible that they weren’t prepared to respond effectively to a catastrophe in the Indian Ocean, and who clearly wish now that they had done more to get ready for such a possibility. Firing them might be satisfying, but would it be useful?

The real issue, I think, isn’t about meteorologists and tsunami experts. It’s about the perennial conflict between alerting people to possible threats to their lives and protecting tourism revenues. This comes up constantly. Thailand’s Prime Minister Thaksin Shinawatra, who personally punished Suparerk for putting tourism ahead of a tsunami warning, has often been on the other side – hobbling his country’s fight against bird flu, for example, out of a fear of damaging not just tourism but also the poultry industry (and perhaps his reelection prospects). Nor is this just an Asian phenomenon. Much that was flawed in Canada’s response to SARS was similarly attributable to the priority Canadian officials put on not scaring away tourists.

This isn’t as easy an issue as it may seem. Like many other countries, Canada and Thailand rely on tourism for income that supports jobs, the economy, tax revenues, and thus indirectly public health itself. A warning that scares away tourists and ultimately turns out unnecessary comes at a high price. Obviously, failure to issue a warning that turns out necessary can come at an even higher price; the tsunami certainly teaches us that. Ultimately, I think, tourism is damaged more by preventable disasters than by unnecessary warnings. Tourism is best nurtured over the long term by building a reputation for candor and concern for safety – not a reputation for being too worried about tourism and reputation. But it takes courage to issue scary warnings that might or might not be needed.

Your other questions about efforts to make sure the world is better prepared for another Indian Ocean tsunami are beyond my expertise. I have read, as I’m sure you have, that such preparations are ongoing. I’ve also read that this sort of locking the barn door after the horse has escaped may not be cost-effective; Asia has many pressing health and safety problems, and the next catastrophic tsunami there may not come for centuries. Still, the impulse to lock that barn door is profoundly human, grounded not just in fear but also in the need to give meaning to all those deaths.

If nothing else, many millions of people have learned that earthquakes near coastlines can lead to tsunamis, and that heading for high ground is a wise precaution. A few days ago, a strong earthquake rocked eastern Indonesia’s Sulawesi region. Not waiting for an official tsunami warning, many seaside residents immediately headed uphill. This time the earthquake didn’t cause a tsunami. Some officials and journalists have criticized those who fled their homes for “panicking.” It seems to me they simply learned what to do.

Comment:

I am the risk communicator for a county department of health, and have a question on bioterrorism communication campaigns that I hope you can shed some light on. I am also a member of the National Public Health Information Coalition, and noticed that your pandemic influenza article was recently recommended reading on a conference call with the CDC. I had come across your article earlier, but was glad to see the CDC had pointed it out as something communication professionals should start to discuss further.

In that regard, I had a meeting with our state department of health recently in which I asked why we wouldn’t want to similarly talk about bioterrorism subject matter through promotional campaigns to cognitively and logistically prepare the general public. The response I got was that the state, after conducting some research and focus group studies, came to the conclusion that the general public had no immediate interest in or use for hearing about specific bioterrorism issues. If the issue didn’t immediately affect them, the general public had no prior use for information about bioterrorism agents or agent-specific preparedness. As a result, the state directed its communication money and resources toward a more general all-hazards information campaign.

I recently re-read your article, Risk Communication and the War Against Terrorism: High Hazard, High Outrage, and found that you go into great detail about what you see as denial rather than apathy on the part of the general public. I’m wondering, in your opinion, if you feel that the general public is still responding in a state of denial and that, similar to your concerns to address the next influenza pandemic, we should strive to manage their fear with appropriate and ongoing specific communication campaigns?

My concerns in local public health are that we are potentially causing confusion rather than clarity by creating a possible disconnect from reality by promoting the “all-hazards” route in communications. For instance, I don’t live in a flood plain, and hurricanes surely don’t impact my local area, so to receive a heightened communication and education campaign that is generalized so as not to panic me further doesn’t make sense. I don’t feel, as a member of the general public, that I’ve been fully informed on why I need to increase my preparedness…. It’s like the 900 pound gorilla in the room nobody wants to talk about.

I’m more inclined to feel that communication and education campaigns are continuous and persistent in preparation for a potential event, and if the potential for a bioterrorism event has disappeared I’d understand the reluctance among my colleagues and other government officials … but I’m perplexed with the level and specificity of outreach.

I’d be grateful to you for your thoughts on the subject, or any research that has been done in this area that I could review.

Peter responds:

Thanks for your very thoughtful question. I wish I had an easy answer.

The dilemma of specific versus general bedevils every communication effort – and the answer is always a matter of degree. Extremely specific risk messages (what if there were a botulism attack on a rainy Tuesday in a suburban shopping mall?) are obviously too narrow to be worth much except as case studies embedded in a larger context. Extremely general messages (how should we cope with public health emergencies?) are just as obviously too broad.

It sounds like your state health department thinks “bioterrorism” is too narrow, and wants to talk to people about bioterrorism risks only in conjunction with natural hazards, infectious disease epidemics, etc. If so, I disagree. Bioterrorism is distinct from other sorts of risk in people’s minds – distinguished by its very high level of dread, its unfamiliarity, its intentionality, and other factors. The precautions are different; the emotional reactions are different; the reasons for ratcheting up or down the alertness level are different. Bioterrorism, I think, deserves its own risk communication effort on the part of health agencies.

On the other hand, your state officials are probably right that specific bioterrorism agents don’t deserve separate communication efforts until something happens that distinguishes them from bioterrorism in general – for example, an actual anthrax attack or a smallpox vaccination program. Of course a website or a booklet should have a separate page on each of the major agents, but the bulk of the focus in bioterrorism risk communication should be on bioterrorism generically, intermixing examples from various scenarios. I am skeptical that people will learn specific advice for coping with specific agents until there is reason to think a specific attack might be imminent.

As to whether people are interested in learning more about bioterrorism at all, the evidence is mixed. If you ask them, people generally say they want more bioterrorism information. But actually reading and absorbing the information is another matter. There are several implications here. A bioterrorism communication campaign should put a lot of emphasis on getting the information where people can access it quickly when they decide they need to know – and on getting people to know that that’s where it is. (Many telephone directories, for example, already have “emergency” pages, which could easily be expanded to include a few pages on what to do in a bioterrorist attack.) A second appropriate area of emphasis is making more extensive information available to those who seek it out; that’s where websites and booklets come in.

Anything that is aimed at the general public before a crisis arises needs to be very short, or more-than-usually interesting, or designed for a captive audience. An example of “more-than-usually interesting” would be working to embed appropriate information in the scripts of television dramas; they deal periodically with bioterrorism anyway, so why not help make what they say more useful. Examples of “designed for a captive audience” would be everything from school curricula (children have long been a major source of adult education on newly recognized risks, from smoking to radon) to presentations at civic groups.

I think your state health department is right that people have a limited appetite for information they can’t use. But I think they’re wrong that people can’t use information about bioterrorism. There is a lot to be said – including a lot that isn’t agent-specific – about what to look for, how to prepare, and how to respond.

In addition, there is growing evidence that people don’t just want the government to tell them how to take care of themselves, while the government takes care of everybody and everything else. People want to help. They want to help their neighbors prepare and cope, and they want to help the government figure out how best to respond.

In this context, look at a 2004 study by the Center for the Advancement of Collaborative Strategies in Health of the New York Academy of Medicine, entitled “Redefining Readiness: Terrorism Planning Through the Eyes of the Public.” The study looked at people’s reactions to government plans for coping with two scenarios, a smallpox attack and a dirty bomb attack. In both cases, people had reservations about what the government expected them to do – reservations that suggested some quite different societal responses. Respondents (and the study authors) clearly felt the government’s plans suffered from the lack of citizen input. And a high percentage of the citizen participants expressed a personal interest not just in learning more, but in helping with preparedness and response planning.

Would they actually show up for a meeting? We won’t know if we don’t invite them. But if people are apathetic consumers of the government’s bioterrorism information, involving them more seems a better response than informing them less.

And it’s worth asking, as you do, whether people who resist bioterrorism information are actually apathetic – or are they in denial? The short answer, I think, is both. Consider three groups. (1) A lot of people find bioterrorism too frightening to think about, and therefore try not to think about it; they are in denial. (2) Others are simply not interested in thinking about bioterrorism; they have other things on their mind, or they believe an attack isn’t that likely, or they choose to rely on the authorities to deal with the problem. (3) There’s also an important third group: people who find bioterrorism useless to think about because there is nothing they can do about it anyway. It’s not wrong to call this third group apathetic, but it’s a special sort of apathy, learned helplessness rather than absence of interest.

The most important communication focus for the first group is to legitimize fear; if it’s okay to be frightened, it feels less necessary to deny the fear. The most important communication focus for the second group is to make bioterrorism more interesting. Making the message more frightening will help pierce the second group’s apathy, but at the expense of exacerbating the first group’s denial; for a mixed audience, other ways of being interesting are probably safer. The most important communication focus for the third group is to offer them things they can do and a sense of empowerment and self-efficacy to do them. This helps with the other two groups as well – we can tolerate more fear when we’re active than when we’re passive; and as every educator and parent knows, active learning arouses interest. So coming up with things people can do about bioterrorism should be very high on the communication agenda for all three groups.

Comment:

I’m sure “Talking about Dead Bodies” had to be one of the most difficult pieces you’ve ever written. I’m impressed by the extent of your research, especially regarding historical parallels.

I’m afraid this is one we’re just not going to agree on, though, as I believe people’s approach to the dead is one reaction that is so intrinsic to our cultures, traditions, and humanity there is little to be gained trying to argue logically against that reality. Indeed, if ever there were a basis for “common ground” between public health responders and the public it is with this issue.

If burying the dead cannot be a priority (because of the needs of the living) there must, at least, be some accommodation of removing the dead to temporary repositories. In Thailand, religious structures became temporary morgues. That might actually be a very fitting model for all, as it gets bodies off the street, out of view, away from animal predators; and it offers a measure of dignity the living need as they mourn. Anyone who cares to be could be recruited to convey bodies off the street and into these designated locations. The alternative of leaving them to rot amounts to torture for those who must pass by the spot. After all, Peter, especially in developing places, the needs of the living will always trump the needs of the dead, yet we don’t simply allow people to decay where they fall.

As for eating the fish who may have fed off bodies, my ideal quote wouldn’t parrot the concern that the fish might have eaten human flesh. I just wouldn’t go there at all, but would say, instead, that we have no way of ever knowing what fish eat before they are caught, but we do know that throughout time we have included fish in our diet because we know they are a safe and nutritious food. There is no need to think otherwise now.

If I were mourning a relative lost at sea I would find it disturbing to think that a fish might have eaten them. I see no value in creating or reinforcing such an image, especially in a public venue, where words are heard by mass audiences.

Peter responds:

Jody and I absolutely agree that getting the bodies into temporary repositories is essential, for all kinds of reasons (many of which you eloquently describe). I hope there’s nothing in the column that implied otherwise. The question isn’t whether we need to segregate the bodies as quickly and respectfully as possible – of course we do. The question is whether we need to move fast to bury them.

As for mentioning what the fish might have eaten, it’s always a dilemma whether to risk reinforcing an uncomfortable image (by acknowledging it) or to risk leaving people alone with it (by not acknowledging it). I think the latter is the more pernicious of the two effects; certainly it is the one officials forget to include in the calculation when they’re deciding what to say. But you’re right, the former does some harm too. Of course once people are talking about why they won’t eat the fish, and the media are covering what they say, then there’s no longer much of a dilemma. The image is out there; it’s the elephant in the room. At that point you can’t convince people to eat the fish without first acknowledging why they don’t want to.

Comment:

I must admit that I could hardly stop reading the articles at your site. (Actually I am scanning through the seminar handouts and they are really inspiring.)

But as I keep on reading (your site and other sources about risk/crisis communication) more and more questions emerge. I have a question, for which you are the most authentical source to give an answer.

Is it possible to link your theory of risk (hazard + outrage) with the survey of Slovic and Fischhoff, who found that the lay perception of risk is determined by the knowledge and hazard factors? There are some overlapping parts in the two theories, but the two systems are different. (Some components are in different factors, for example.)

Peter responds:

My creation of the hazard-versus-outrage model came well after the landmark Slovic/Fischhoff/Lichtenstein studies of lay perception of risk (and also of experts’ perception of risk – it’s not as if experts could directly apprehend risks without having to perceive them).

I certainly owe a huge debt to that work, which became the basis of the “psychometric paradigm” – one very influential approach to risk perception, and especially to risk perception measurement. Slovic et al. produced some of the earliest lists of factors affecting risk perception, which were the basis for my early lists of “outrage factors.” I eventually settled on a list of 12 major factors (and a supplementary list, seldom used, of another eight); the naming conventions are a bit different, and the lists cover overlapping rather than identical territory – but certainly my “outrage factors” draw heavily on the earlier Slovic et al. lists.

Thereafter we went in somewhat different directions. The three key differences as I see them:

Comment:

Re: Talking about dead bodies

Your point about the need to express empathy with people’s misconceptions when trying to correct them is well taken. But it is also perhaps useful to ask people themselves to empathize with the need of survivors to find their loved ones and give them a proper burial. Experienced disaster experts will tell you that families and neighbors DO NOT tend to want victims buried in mass graves. In a way, there are two or even three publics here: the press, the survivors who have lost loved ones, and the larger public who haven’t. One way to explain to people the importance of NOT burying bodies in mass graves would be to ask them to put themselves in the shoes of survivors who have lost someone. How would YOU like it if your daughter or mother or father or son were buried in a mass grave? You wouldn’t like it at all.

An unfortunate undercurrent in some of the media coverage of the tsunami was an implicit sympathy for the needs of surviving foreign tourists to find lost loved ones but an implicit sense that the masses of local bodies needed to be buried as quickly as possible. I even read a report or two that “exposed” the fact that some foreign tourists might have been buried in mass graves (along with all the local bodies).

Of course bodies do need to be buried, and as soon as is possible. But not at the expense of other more pressing actions or at the expense of not ever identifying them. It should be done rationally, not based on unfounded fears. And it should be done systematically so that if not immediately, at least eventually remains can be identified.

Peter responds:

Thank you for your thoughtful comments. They come from a very experienced source!

I especially resonate to your very good point that survivors who are mourning someone they lost (even a neighbor they knew) feel differently than survivors who didn’t know any of the individual dead and are reacting with anxiety about them collectively. I wish we’d said this, and I’m grateful to you for adding it. Certainly inviting the larger community to feel some empathy for the mourners who need time to try to identify their loved ones is a good thing to do – and is in no way inconsistent with expressing empathy for the larger community’s feelings about all those unburied bodies.

I agree with you also that westerners sometimes have an unconscious double standard for “people like us” versus “other kinds of people.” Of course it’s hard to tell if western journalists and embassy officials were actually imagining that mass burials are good enough for “them” but not for “us” – or if they were just focusing a little more on their countrymen’s tragedies than on other people’s tragedies. The ethnocentrism coexisted with a lot of western empathy (and practical help) for Asian suffering. And ethnocentrism does seem to happen in both directions. Foreign media coverage of 9/11, for example, tended to emphasize how many people from the home country perished in the Twin Towers. We will be a different and better species when we learn to respond with the same emotional empathy to the tragedies of all people.

Comment:

Once again I am going to pick on your vast experience if you don’t mind.

A nut that I am trying to crack at the moment is how PR fits into the whole sphere of communications OR vice versa.

Once again I refer to Nohrstedt when he cites Larsson,1997, in relation to Grunig’s two-way symmetrical model. He makes the observation that it is merely a “tacit or latent strategic act rather than a true communicative one in the Habermas’ sense.”

Now, in reading Grunig, 1992 myself, it is my contention that he equates Public Relations as practiced using the two-way symmetrical model with excellence in communication management. I was wondering what your take on this might be.

I read in one of your own articles where you differentiate between public relations and crisis communications for different situations. Surely, crisis communications is one type of public relations??

Peter responds:

The answer to your query depends on whether you pick a descriptive or a normative definition of public relations – is it what PR people usually do or what PR theorists say they ought to do?

Grunig's normative “two-way symmetrical public relations” model obviously requires good listening, not just good talking. It doesn’t quite require but certainly suggests responsiveness and transparency as well – that what you say and do has been influenced by what stakeholders have told you; and that what you say accurately reflects what you’re doing and what you know. This goes a long, long way toward what I would consider a “good” communication posture.

There are plenty of other issues of special relevance to risk communication – whether you lean toward the alarming or the reassuring side of the seesaw, whether you tend to sound confident or tentative, whether you acknowledge your feelings or focus on the facts, etc. But two-way symmetrical communication is clearly the right foundation.

Unfortunately, PR people often lose credibility by being neither responsive nor transparent. And even if they were under orders and trying to do the right thing, they lose credibility not just for their organization or client, but also for themselves and their profession. That’s why the PR role gets renamed every decade or so. “Public relations”was invented because “publicity” had such a bad odor; when that didn’t do the trick, other euphemisms followed: “public affairs,” “stakeholder relations,” “communications,” etc. If the behavior stinks, the new label soon starts stinking too.

Aside from all that, I think it’s worth remembering that a lot of routine public relations isn’t and doesn’t especially need to be two-way or symmetrical. If the boss just got an award from a trade association, the flack is probably going to put out a news release. Nothing wrong with that. The target audience for the release isn’t likely to be very interested; the news in the release is more important to the source than it is to the receiver. There’s not much basis for a dialogue. Even the monologue is going to be short. The PR job in such a situation is twofold:
(1) Choose your key message points wisely – what’s most worth saying in the very brief window of attention you’re going to get (if you’re lucky); and
(2) Make your message points as interesting as you can to your audience (and to the media in the middle), in hopes of enlarging that window of attention.

If you take this as the paradigm of public relations – and I do – then the kind of risk communication that most resembles routine PR is precaution advocacy: communication about high-hazard low-outrage risks. You’ve got 15 seconds to convince these folks that they ought to get their Hepatitis B shot. Keep it short; stick to the point; make it punchy; don’t expect a challenge or a dialogue. When you’re trying to talk an apathetic audience into taking a precaution, risk communication can often be one-way and asymmetrical. It is farthest from Grunig’s normative model of public relations, and closest to my descriptive slur on public relations.

In low-hazard high-outrage situations, by contrast, you’ve got hours (or months!) rather than just 15 seconds. But now dialogue is essential, and so are responsiveness and transparency. If anything, this sort of risk communication is asymmetrical in the opposite direction. People come to a public meeting more to berate you than to hear you; outrage management is done more with the ear than with the mouth. And even when it’s your turn, outrage management is mostly about acknowledging and ameliorating; it’s about addressing your stakeholders’ messages, not insisting on your own.

Of course it is possible to be good at both precaution advocacy and outrage management, just as it’s possible to be good at both carpentry and plumbing. But they are different jobs. And PR people are naturally good at precaution advocacy.

Crisis communication is a third paradigm: high hazard and high outrage combined. People are rightly upset about a genuinely serious risk. The task isn’t to alert them or reassure them; it is to help them bear their feelings and act appropriately. This is the sort of risk communication that comes closest to Grunig’s two-way symmetrical model.

(One further confusion is worth mentioning. When people are upset about a technically small risk, their outrage may constitute a crisis for the company or agency they hold responsible. But in my terminology this is an outrage management problem, not a crisis communication problem. Nobody’s health is endangered.)

Comment:

Can you please define the terms “cause” and “risk” in layperson’s language? I find that people often confuse these two.

Here is an example of how people can be confused by the terms risk, risk factor, and cause. We know from medical literature that smoking during pregnancy is a risk factor for preterm labor. But not every woman who smokes during pregnancy will have preterm labor. Preterm labor is caused by many things, not all of which are well understood. We are trying to help women understand the difference between risk factors for negative pregnancy outcomes and the causes of those outcomes.

We would appreciate your insights.

Peter responds:

A story in today’s news reports that the increased use of pediatric chickenpox vaccinations may be leading to a greater incidence of shingles (a closely related disease) in adults. It certainly isn’t true that the chickenpox vaccine causes shingles. The hypothesis is that exposure to children with chickenpox may help improve adults’ immunity to shingles; the vaccine means that far fewer children get chickenpox, so fewer adults get the benefit of that exposure.

This is a good illustration of the problem you’re raising.

Here’s what I think I’d say to your clients.

Scientists, doctors, and philosophers will argue till the end of time about what causes a health problem. Even a supposedly simple case like a virus infection gets complicated. Certainly it was caused by the virus itself. Was it also caused by the person you got the virus from? By your decision to spend time with that person? By the heredity that made you more susceptible in the first place?

Risk is more straightforward. Anything that increases the probability of a bad outcome is a “risk factor” for that outcome. It may also be a direct cause, or an indirect contributing cause, or not a cause at all.

Here’s a very familiar example. Taking a walk alone in a bad neighborhood late at night is not a cause of getting mugged. But it is certainly a risk factor for getting mugged. You won’t get mugged every time you do it, and you won’t get mugged “because” you did it. But people who don’t want to get mugged don’t do it.

As for preterm labor, I’m not sure what the relevant facts are. But let me take a guess:

Preterm labor can have many causes. Smoking will probably turn out to be one of them. But so far scientists don’t understand exactly how, when, or why smoking leads to preterm labor. What we know for sure is that it sometimes does. That’s what we mean when we say that smoking is a risk factor for preterm labor: Women who smoke are likelier to have their babies before their time than women who don’t smoke. We don’t know why, but we do know that pregnant women shouldn’t smoke.

Obviously, you’re not teaching a philosophy course, so you don’t want to go into much detail on all this. But I think you’re onto something. One reason people neglect recommended precautions may very well be because they don’t see the causal link between the recommendation and the desired outcome. If it doesn’t make sense to me that X causes Y, it’s that much harder for me to make the effort to avoid X in hope of reducing my chances of Y. Proving to me that X really does cause Y would help a lot. But if you can’t do that, your next best bet is to acknowledge that you’re not sure it’s a cause … but you’re very sure it’s a risk factor.

Comment:

I just want to know more on risk communication in chemical engineering field. Maybe about how to communicate with the risk in the chemical equipments. How to make people realize about the risk in their surrounding? Thanx for you cooperation.

Peter responds:

It sounds like your main interest is figuring out how to alert people – employees in particular, probably – to serious risks that arise in the chemical engineering field.

The most relevant materials on my website are listed in the Precaution Advocacy Index. I’d urge you to start there. Two articles of particular interest: (1) When People Are “Under-Reacting” to Risk, a checklist of possibilities to consider; and (2) Part Two of my safety interview with ISHN, which focuses on persuading employees to take safety seriously.

There are also lots of manuals available online on “hazard communication.” These focus on the comparatively straightforward (but not easy) task of informing employees what hazards they are exposed to – for example, providing access to MSDSs. (By contrast, risk communication pays more attention to convincing people to react the way you think they should.) A Google search should lead you quickly to this literature.

Good luck!

Comment:

I have just now finished reading your very encouraging article in the Sun Dec 2003 – a friend gave the magazine to let me read some of the articles. Encouraging – because finally I hear a voice of reason in an area of concern – the environment!

I also have a concern about the Medical Institution. I don’t know the mechanisms at work in the U.S. so I will speak briefly about ours – in Canada. Do you work for any medical institution – to help them change their ways of depending on drug corporations for solutions to health issues?? I am outraged and furious and – bewildered about the the over-dependence on drugs as a panacea to all our health problems. I come from the perspective that there are cures for “most” (I can’t say all) cancers and major diseases already – but they are hard to put across as most people feel dependent on taking pills and hoping to be cured.

I accept that the drug companies have done quite a bit of good – but the opposite is far more true.

I hope to hear back from you as I am not a CEO or in the business world – except perhaps the business of living as consciously and ethically as I am able – but would be excited to hear what you have to say about the medical issue.

I am only sorry that I just heard about you very recently. Thanks for your article.

Peter responds:

Thanks for your compliments about my interview in The Sun.

I agree with you that our society is too inclined to seek medication as the solution to all problems. I feel that way about ADHD and depression, for example; medication has been a godsend for some sufferers of these two disorders, but I think we are too quick to resort to medication for people (especially children) who are normally restless or temporarily unhappy. But I can’t say I’d extend this analysis to cancer, as you do. I do share some of your skepticism about medical responses to cancer – we sometimes oversell as cures treatments that help only a little at great cost in pain as well as money. But I am even more skeptical about dietary supplements and the like as a response to cancer. I wouldn’t want to go without my vitamins, my glucosamine/chondroitin, or my fish oil. But I’d certainly see a doctor for my cancer!

From a risk communication perspective, I believe that virtually all “cures” are oversold, by both the pharmaceutical industry and the supplement industry. I’ve never worked with the supplement industry (though I’d happily do so), but I have done some work with pharmaceutical companies. Unlike you, I believe their products are overwhelmingly more beneficial than harmful. But they consistently and steadfastly understate the ways in which their products are harmful. In keeping with the risk communication seesaw , this makes the rest of us that much more inclined to exaggerate and resent the harmful side of the medication tradeoff.

Similarly, the pharma companies do far less than they should to publicize medication uncertainties, especially the “yellow flags” – that is, the preliminary indications that a drug may or may not have harmful side effects. As the recent experience of Merck with Vioxx bears out, when the yellow flags start looking red, people are angriest that they were blindsided. In years past, pharma companies (usually) kept regulators and doctors informed about the yellow flags, and that was enough. Regulators decided whether to restrict usage, and doctors decided whether to stop prescribing – and the good doctors talked with their patients about the uncertainties. Pharma companies still (usually) keep regulators and doctors up-to-date. But two things have changed. Doctors stopped spending so much time talking with patients. And pharma companies started advertising directly to patients – ads that briefly acknowledge possible side-effects (because they’re required to) but that nonetheless manage to leave an extremely one-sided impression. Candor about the downside of medications hasn’t been reduced so much as ballyhoo about the upside has been hugely augmented. And so when the downside belatedly gets our attention, we rightly feel misled and get angry.

Pharma companies have also set themselves up for outrage over pricing by perpetuating the unsustainable pretense that they’re more interested in public health than in profitability. I believe in capitalism. But drug company communications too often pretend not to believe in capitalism. Every time a drug company claims it is in the business of nurturing health (rather than the business of selling pharmaceuticals), it justifies the public’s unexamined expectation that it will act like a philanthropy or a government – and so we are outraged when it acts like a business instead. In the U.S., outrage about pricing is grounded in lots of other factors as well, most notably the unique decision of the United States Government to leave healthcare to the free market – which gives the U.S. the world’s highest prices for medicines. Still, the industry’s most fundamental pricing communication error is pretending to be a charity.

Bottom line: With occasional exceptions, pharmaceutical companies have a long way to go as risk communicators. The first years of the 21st century seem to be their moment for intense public scrutiny and ever-increasing public outrage. In the 1980s, as the chemical industry was taking its lumps, the closely allied pharmaceutical industry managed to stay out of the controversy. So the pharma companies didn’t learn the hard lessons their chemical industry colleagues learned about how to avoid or respond to outrage. They are starting to learn those lessons now.

Comment:

I am currently in the process of researching information as part of my PhD studies, with Dublin City University in Ireland, in relation to an assessment of the sophistication of the Irish Government’s strategy towards communication during a major emergency.

I have read many of your articles on your website and find them very enlightening. While reading an article by Nohrstedt, Communication Challenges in Connection with Catastrophes and States of Emergency, he cites you as follows: “The cutting-edge risk communication question today is no longer how to communicate with the public about risk; we have moved a long way toward answering that one. The cutting-edge question is how to become the sort of organization that can do it.”

I think that may be the key to my dissertation. My question is, do you have any publications on the web in relation to this subject?

Peter responds:

I asked my wife and colleague Dr. Jody Lanard to look into decent online resources relevant to organizational aspects of risk communication – and particularly organizational preconditions for being able to do the sort of risk communication Jody and I recommend. As I suspected, she didn’t find much. That’s as much good news as bad for you, I’d say. You can research the organizational culture, org comm, and org development literatures for points relevant to risk communication, and research the risk communication literature for points relevant to organizational prerequisites – and even your lit review will be a contribution. I’d surely like to see it!

Much of what Jody and I write is implicitly about organizational culture. But we tend to make our organizational comments en passant – “Here’s what you ought to do, and by the way it’ll be hard if your organization has this or that characteristic….” It might (or might not) help to search the site for words like “organization,” “culture,” and the like. Two articles of particular relevance on the site are “Scientists and the Public: Barriers to Cross-Species Risk Communication” and “Addressing Skepticism about Responsible Care.”

Jody did find one excellent source: Peterson, Specht, and Wight’s The Technical Basis for the (U.S.) Nuclear Regulatory Commission’s Guidelines for External Risk Communication. Published by the NRC in 2004, it is online at http://www.nrc.gov/reading-rm/doc-collections/nuregs/contract/cr6840/. Jody writes: “It’s an especially good document from an agency systematically trying to become more open in its communication – the U.S. Nuclear Regulatory Commission (formerly the infamously secretive Atomic Energy Commission). This lengthy document provides an excellent model for a thorough and detailed internal needs assessment for communication planning, with survey results, focus group results, interviews, questionnaires about communication needs and barriers, and an annotated bibliography. It is an unusual document, portraying with remarkable detail and candor the process of communication planning. Most published documents only offer the end-product. The process of developing communication policy and plans is difficult, and often carried out behind the scenes. This document allows other planners to follow the steps and even the anguish that can accompany communication planning.”

Caron Chess of Rutgers University has written extensively about your topic, but we can’t find any of the most relevant articles online. You might want to contact her directly. You might also send a query to the riskcomm listserv (write risk-com-REQUEST@umich.edu to join), and see what others in the field have to suggest.

Paul responds:

Thank you so much for your speedy reply to my request for assistance. I will pursue those links that you have sent me and I am sure they will be very useful.

Just a little background to my subject matter. The Irish Government has always paid some attention to emergency planning. Following Sept. 11th they decided that it was time to take the issue even more seriously. Consequently, they established a central Office of Emergency Planning in order to coordinate this function. Many significant advances have taken place in that time. However, each Department is more or less following its own initiatives. In regard to communication, there seems to be absolutely no coordination, apart from a request that each Department should “have a communication plan.”

Having spoken to one of the chief Civil Servants responsible for the overall communication functions, her message was quite clear – “We can’t make the public unnecessarily worried” or else “if we tell the public what we are doing there will be so much opposition from so many quarters that we will not be able to proceed with anything.” What is the pity is that there is so much good work being done by respective departments, but the general public have the perception (this is my personal opinion) that nothing positive is happening.

That is where I am starting from. I feel that my eventual dissertation might help to make the responsible authorities aware that there may be another route towards communications other than their chosen route.

Once again Prof. Sandman, many thanks for your assistance. If you don’t mind too much, I will make contact again with you in the near future.

Peter responds:

I would be happy to stay in touch as you work on ways of getting the Irish Government to see communicating candidly with the public as “best practice” in emergency planning – and on your dissertation about why the Irish Government has trouble seeing this pretty obvious truth and what organizational changes would facilitate a breakthrough. (I may be reframing your dissertation a little here. I trust you can resist if you don’t like the reframe.)

Something you should definitely read: The 2004 New York Academy of Medicine report on “Redefining Readiness.” It’s online at http://www.cacsh.org/eptpp.html. Its focus is on flaws in U.S. smallpox and dirty bomb plans that result from the failure to plan collaboratively with the public. It doesn’t really address the organizational barriers to collaborative planning, but I am on the advisory committee for follow-up work and am pushing in that direction.

I should add that there is sometimes a benefit to addressing the organizational issues sideways rather than frontally. Clients (including terrorism preparedness planners) typically bring me in as a consultant with a one-way definition of their communication problem: How do we get this stupid public to agree to do things our way? I often propose public consultation as an output strategy; that is, I argue that there will be better buy-in from the public if my client communicates more openly, more receptively, and more respectfully. I mention but don’t usually stress that public consultation also serves an input function – that my client will learn things from the public that will change its plans for the better. This is a tougher sell until it happens, so I don’t usually make it the main basis for my advice. As a matter of integrity, I also mention that public consultation is likely to provoke huge, unexpected changes in organizational culture – changes for the better. (For example, external candor leads to greater internal candor.) But again I don’t put much stress on this; I mention it more as a warning than as an incentive.

The point is that just as organizational barriers make it tough for agencies and companies to embark on a program of two-way symmetrical communication, the very act of initiating that kind of communication changes the organization and thus helps undermine the barriers. So I often look for ways to circumvent the barriers temporarily and get communication improvements even if they are for the “wrong” reasons, in the justified hope that the improvements themselves will help launch the organizational change. If a client wants my help designing a PR strategy, I can usually make a pretty persuasive case that spin will accomplish less than candor and responsiveness. I don’t try to change the client’s goals at the start; I try to convince management that their goals are better served by my approach than by the one they had in mind. And I warn them that some of their goals, values, and culture are likely to change in the process.

I think this is important. It’s tempting to give up on screwed-up organizations, to see organizational change as a prerequisite to decent communications. I wrote that way, I think, in my earlier answer to you. But as a consultant I more often use decent communications as an entrée to organizational change.

It’s important to keep your focus on the organizational issues. Don’t get seduced into proving once again that people cope pretty well (and almost never panic) when the Government tells them difficult truths; stay with why it’s so hard for those in Government to notice that this is so. But when working with the Government itself, consider the possibility that it’s sometimes effective to encourage new communication behaviors that will ultimately yield organizational change, instead of requiring the organizational change first.

Comment:

I am teaching an introductory health communication course to undergraduate students in the Department of Health and Nutrition Sciences at Brooklyn College. What readings (from your website or elsewhere) would you recommend to introduce students to the basic concepts and practical implications of health risk communication?

I am grateful for your very fine website.

Peter responds:

I need to start by defining terms. As modern fields of study and practice, “health communication” and “risk communication” have very different histories. Health communication emerged out of health education, and focuses on figuring out how to alert people to serious health hazards – how to get them to quit smoking, exercise, eat right, get vaccinations, comply with their doctors’ advice, etc. The classic health communication effort aims to teach people what the experts already know about how best to handle a significant health problem.

Risk communication, by contrast, evolved in the context of intractable, hotly emotional and hotly debated environmental controversies. The focus is likelier to be on how to resolve the controversy. That should mean (and sometimes really does mean) serious attention to process, to consultation, to listening to people as well as talking to them. There is no overriding assumption that the hazard is necessarily serious. It may well be serious. But quite often the outraged public believes it is serious but the experts believe otherwise; or the experts may be divided on the issue.

Obviously not everyone uses these terms the way I’m describing. Health communication remains focused on serious health risks. But since its creation in the 1980s, risk communication has expanded beyond its original low-hazard high-outrage paradigm (calming people down about trivial risks). I like to talk about “Four Kinds of Risk Communication” – including high-hazard low-outrage (alerting people to serious risks) and high-hazard high-outrage (helping people cope with crises). Still, the unique contribution of risk communication is its historical emphasis on how to talk to angry or frightened stakeholders.

So what is “health risk communication”? It depends how you say it. If you’re doing “health risk” communication – that is, communication about a health risk – you’re almost certainly trying to shed light on a serious health hazard. But if you’re doing health “risk communication” – that is, risk communication about health – then you are just as likely to be trying to persuade people not to take a precaution you consider unnecessary or not to worry about a risk you consider inconsequential.

I assume your course comes out of the health communication tradition. When you turn to the issue of risk, then, there are two things you will probably want to do.

The first is to introduce your students to the thinking of health communicators about how to discuss risk. The cancer communication literature is especially rich here – see for example the many studies on how to explain to cancer patients the risk associated with their various options. Neil Weinstein and colleagues have produced a risk communication bibliography for the National Cancer Institute that is excellent in this area.

I have done some relevant work in this area, most of it listed in my Precaution Advocacy (High Hazard, Low Outrage) topical index. But I think you can find better sources in the Weinstein bibliography and elsewhere.

The second thing you might want to do is to introduce your students to the thinking of risk communicators about how to discuss health. Here I think some of my work can help. I especially recommend Covello and Sandman, Risk Communication: Evolution and Revolution (2001). Then choose some (not all!) of the following:

• Sandman and Lanard, Pandemic Influenza Risk Communication: The Teachable Moment (2004)
• Sandman and Lanard, Flu Vaccine Shortage: Segmenting the Audience (2004)
• Sandman and Lanard, Risk Communication Recommendations for Infectious Disease Outbreaks (2003)
• Lanard and Sandman, Practicing for The Big One: Pennsylvania’s Hepatitis A Outbreak and Risk Communication (2003)
• Sandman, Smallpox Vaccination: Some Risk Communication Linchpins (2002)
• Sandman, Review: The Mad Cow Crisis: Health and the Public Good (2000)
• Sandman, Two-Way Environmental Education (1991)

And on the distinction itself, see these two as well:

• Sandman, Four Kinds of Risk Communication (2003)
• Sandman, Risk Communication (1994)

I hope this helps. Let me know how the course goes.

Comment:

Discuss the validity/otherwise of the view that you cannot control what you have not planned neither can you organise/direct or co-ordinate what have not been planned

Peter responds:

What a nice conundrum to start the year with!

I don’t know that you can “control” much in risk management and risk communication – especially in crisis situations. Even organizing, directing, and coordinating sound awfully ambitious. At best you organize/direct/coordinate your organization’s response to the situation.

Mostly what you do is cope. You try to predict how people will react, notice how they are actually reacting, and figure out what you can do and say that may help. And you make lots of midcourse corrections. If you do this well, you affect the outcome, but you certainly don’t control it.

As for planning, I have mixed feelings. The written plans that organizations produce in advance describing what they will do if X or Y happens are usually close to useless. Reality moves in directions the plan didn’t contemplate, and everybody is too busy to sit back and study the plan anyway.

But while plans are seldom of much value, the planning process is incredibly valuable. It forces you to get to know some of the people you’ll need to work with when the time comes. And it forces you to think about tough issues beforehand, rehearsing how you’ll feel, what pressures you’ll be under, and how you intend to respond. Organizations that have planned cope a lot better than organizations that haven’t, even though the plans themselves seldom help much.

And some standard parts of a good crisis plan are incredibly useful – telephone lists, for example. A lot of Pacific Rim seismologists right now are wishing they’d spent a day or two planning what they would do if a tsunami-producing earthquake struck in the Indian Ocean (or the Atlantic). A student intern could have compiled a list of emergency phone numbers of South Asian officials, saving thousands of lives.

But even as a process, planning has drawbacks. One that was often stressed by the late Aaron Wildavsky is the tendency of planners to devote too many resources to preparing for the contingencies they expect, with too little left over to cope with the unexpected. Wildavsky argued that resilience was a better predictor of good outcomes than preparedness. It’s possible to plan for the unexpected, I suppose. But most planning understandably focuses on getting ready for things you imagine may happen – which can actually leave you less ready for things you couldn’t have imagined. Again, the recent disaster in the Indian Ocean is instructive.

Planning is still worth doing. But it pays to think explicitly about how to be more resilient (and how to nurture everyone’s resilience) in the face of the unexpected. And it pays to remember that it’s the planning, not the plan, that will help most. And even at best, you’re not going to control reality – just nudge it in the directions you think will help.