On May 21, 2009, Nature published a major abridgment and minor updating of this column under the title “Pandemics: good hygiene is not enough.” An Adobe Acrobat file (707-kB .pdf) of the complete article 
is available. (Note: The Nature links require payment. Free access to a copy is available.) A French translation of the Nature article is also available online.
New viruses move fast. What I'm writing on April 29 may be hopelessly antiquated by the time you read it.
By the time you read this:
- The outbreak of H1N1 “swine flu” (or “swine-origin flu,” as some are urging it be called) we’re all tracking may already have launched a worldwide catastrophe.
- It may have proved itself too mild (except at its start in Mexico) to cause serious health problems in significant numbers.
- It may be a lot worse than mild but still a lot milder than catastrophic.
- Its spread may have slowed or stopped instead of snowballing – because we’re successfully isolating cases and inhibiting transmission, or because it doesn’t like the increasingly hot weather in the northern hemisphere, or for other reasons that scientists won’t figure out for months.
- It may still be hanging in the balance – in which case public health experts will still be watching with bated breath, but the media and the public may well have moved on to something else, muttering about fear-mongering.
And whatever the situation is like by the time you read this, that won’t be the end of the story either. A mutated virus (more virulent or more transmissible or resistant to antivirals) could come roaring back a few months later.
As a risk communication professional, I have been watching the U.S. government walk a tightrope between over-reassurance and over-alarm about a swine flu outbreak that could easily turn out devastating, minor (except in Mexico), or anywhere in between.
I will focus my comments here on the U.S. government, because I have been watching it most closely. Most governments in places with fewer cases, or none so far, have been much more reassuring in their public communications than the U.S. government has been. The U.S. hasn’t faced the temptation to issue false reassurances that the authorities will keep the pandemic from “our” shores – a temptation to which dozens of governments have succumbed. I doubt any government is doing better swine flu risk communication than the U.S. government. So let’s talk about what the U.S. government is doing, especially what I believe it is doing wrong.
If you want to know more about how the rest of the world’s governments – and some U.S. state governments – have been mishandling the crisis, check out a posting on the Flu Wiki Forum with the wonderful title “Ministers in Wonderland / Beyond Indefensible Over-reassurance.” “Path Forward” (the poster) is the nom de flu of my wife and colleague Jody Lanard, currently working with WHO in Asia.
Failure to Warn
The U.S. CDC is doing a superb job of explaining the current situation and how uncertain it is. Anyone who’s paying attention gets it that we just don’t know if this thing is going to fizzle, hang in abeyance for months, disappear and then reappear, spread but stay mild, replicate or exceed the 1918 catastrophe, or what. The reiteration of uncertainty and the insistence on what that means – e.g. advice may change; local strategies may differ; inconsistencies may be common – has been almost unprecedentedly good.
In fact, the CDC has done three things superbly, the last two of them rare:
- It has told the public exactly what it knows so far.
- It has done “responsible speculation” about likely and possible future scenarios, including the scary ones.
- It has been willing to make predictions where the probabilities were clear (e.g. future U.S. deaths are likely) and has insisted on uncertainty where the probabilities weren’t clear (e.g. the eventual extent and severity of the outbreak).
The CDC’s biggest failure: not doing nearly enough to help people visualize what a really bad pandemic might be like – while helping them also to hold in mind that it’s only one of many possibilities – so they can feel the knot in their stomachs that everyone on the inside is feeling, get past this adjustment reaction, gird up their loins, and start preparing.
It is especially important to get this message to business and community leaders, who have prep work to do ASAP in case things get worse.
But individuals also have prep work to do – logistical as well as emotional prep work. All that preparing will stand us in good stead even if The Big One isn’t right around the corner yet … and it’ll be essential if it is!
For the ordinary citizen, the U.S. government has so far recommended only hygiene, not preparedness. It has told people to stay home if they’re sick, cover their coughs, and wash their hands a lot. It hasn’t told people to stock up on food, water, prescription medicines, and other key supplies. Two years ago HHS Secretary Mike Leavitt was crisscrossing the country with that advice. These past few days Acting CDC Director Richard Besser kept evading questions from journalists about whether it’s still good advice.
It’s certainly not radical advice. Under Leavitt, the Bush administration put together a website on pandemic preparedness, www.pandemicflu.gov. It has checklists on what individuals, communities, schools, hospitals, local governments, and others should do. The checklist for individuals and families is at www.pandemicflu.gov/plan/individual/checklist.html. There are less cautious checklists available on non-government pandemic prep websites like www.fluwikie.com. But I’d be satisfied if Dr. Besser urged people to check out www.pandemicflu.gov. To the best of my knowledge, he has yet to do so. (In fairness, there is a link to www.pandemicflu.gov on the CDC’s special swine flu web page, www.cdc.gov/swineflu/.)
Dr. Besser isn’t understating the risk. Again and again, he says he is “very concerned” – a notch higher on the emotional arousal scale than President Obama, whose money quote on the crisis so far came when he told the National Academy of Sciences that the outbreak “is obviously a cause for concern … but it is not a cause for alarm.” Dr. Besser expresses his concern with a soothing bedside manner; he doesn’t have that rumpled, exhausted emergency manager look the Nuclear Regulatory Commission’s Harold Denton perfected in the 1979 Three Mile Island crisis. Denton left people feeling simultaneously that the risk was serious and that they were in good hands. Dr. Besser says it’s serious but leaves us feeling that he doesn’t really want us to worry much.
Still, I don’t fault Dr. Besser for looking and sounding reassuring. The gold standard in crisis communication is to say alarming things in a calm tone, and he is doing exactly that.
The problem is that he isn’t giving us anything to do except practice good hygiene. He keeps telling us, accurately, that the CDC is being very aggressive in its response to the outbreak. But he is not asking the public to be aggressive.
The closest he has come so far was several appeals to think about how we’ll cope if there’s an infection in our child’s school and the school is closed for a few days. That’s good. It helps people “imagine the real”; it invites what CDC risk communicator Barbara Reynolds has aptly called “vicarious rehearsal.” Of course there are more dire possibilities we could be vicariously rehearsing. Nobody in U.S. officialdom has asked the public to imagine a replication of Mexico City in our hometowns, much less a full-scale severe pandemic: more corpses than coffins, virtually everything closed, virtually nothing in the stores that are open.
Still, Dr. Besser’s suggestion that we think about what we might do if things got slightly worse has been a high point. The low point came on Saturday, when the CDC’s Anne Schuchat blurted out at a media briefing that “we’re worried and we’re acting on a number of fronts so you don’t have to worry.” I’m sure Dr. Schuchat regretted saying that.
I’m also sure it’s exactly what the U.S. government has in mind. From the start of the swine flu crisis, I believe, there was a decision – probably a very high-level decision – to take the situation extremely seriously but to hold off on asking the public to do the same. The result is almost surreal. The federal government has already released one-quarter of the Strategic National Stockpile of antiviral drugs to the states, so there will be millions of courses of Tamiflu ready to deploy if there are millions of sick Americans requiring medication. But it hasn’t yet asked those millions of Americans to stock up on tuna fish and peanut butter.
Fear of Fear
I have been here before. In 2005, the pandemic influenza threat came from an avian H5N1, instead of the current swine-avian-human hybrid H1N1. (Lest anyone forget, H5N1 is still around too.) The CDC and HHS were similarly convinced then that the risk was serious, similarly committed to aggressive preparatory action – that’s why we have that Strategic National Stockpile of antivirals – and similarly disinclined to alarm the American people. The feeling was that people had been alarmed enough by 9/11 and the ensuing wars in Afghanistan and Iraq, and that the government had pretty much exhausted its quota of scary utterances. There is much the same feeling today about the economic meltdown.
I was in the minority then, as I am now, urging officials to involve the public in its pandemic preparedness efforts. In February 2005, I was invited to give a day-long seminar on my recommendations to a high-level conclave of CDC and HHS infectious disease experts and officials. They heard me out, sent me home, and reaffirmed their policy of quiet preparedness.
Over the summer President Bush read about the 1918 pandemic in John Barry’s The Great Influenza. Then Katrina happened. The two together convinced the White House that Cassandra might be a better role model than Pollyanna. Pretty soon the CDC and HHS were sounding the alarm about a possible pandemic. They aroused some concern, though no panic; they inspired some individual and community preparedness efforts, though not enough. And then the focus shifted to other risks … until this past week.
In order to avoid frightening the public, this past week, the U.S. government has avoided clueing in the public that we should all be preparing for a possible pandemic – not just the feds.
Why are officials so leery of describing the worst case vividly and urging people to prepare for that possibility? Here’s why:
Fear of fear and “panic panic.”
There is a virtual terror of frightening people excessively (as if that were easy). Although crisis management experts have known for decades that panic is rare, officials routinely go into “panic panic” – either predicting that the public will panic if told alarming things or misdiagnosing orderly efforts to prepare as panic. A Google News search this morning for “swine flu panic” netted over 8,000 hits. Some of them were urging people not to panic (unnecessary and condescending advice); a few were pointing out that people weren’t in fact panicking, not even in Mexico City. But the vast majority were interpreting precaution-taking as evidence of panic. No wonder, then, that officials are reluctant to urge precaution-taking! For more on this phenomenon, see Fear of Fear: The Role of Fear in Preparedness … and Why It Terrifies Officials, which I wrote with Jody Lanard in 2003.The paradox of “panic panic” is that it backfires so routinely. Officials who imagine that the public is panicking or may soon panic often feel impelled to make over-reassuring statements, to suppress alarming information, and to belittle those who are frightened as “irrational” or “hysterical” (or “panicky”). These official preemptive strikes leave frightened people alone with their fears, and persuade them that their government has betrayed them and cannot be trusted. The result is an increase in public anxiety, which officials cannot properly channel into effective action because they have already delegitimized the fear and because they are unwilling to involve the public. During the 2003 SARS outbreaks, for example, the Chinese government denied that Beijing was seeing SARS cases and SARS deaths. These false denials led to actual panic in Beijing. Why did the Chinese government hide the truth? To allay panic.
To its credit, the CDC has not made over-reassuring statements, suppressed alarming information, or belittled people’s fears. For several days before the first U.S. swine flu death this morning, Dr. Besser continually predicted that there would soon be U.S. deaths. That’s excellent risk communication. He’s not understating how bad things are or how bad things could get. His failure (of skill? of nerve? of policy?) is subtler than that: He is creating the sense that the CDC will do whatever needs doing to protect us, and that we need do little or nothing to protect ourselves. I think this is intentional, aimed at avoiding what he or his superiors consider excessive public alarm.
Reputational worries.
Underlying the fear of frightening people is the fear of being accused of frightening people, especially in the current economic environment. This is a realistic fear, I have to concede. Every novel risk brings out a cadre of commentators, poised to accuse officials of “fear-mongering” for issuing excessively dire warnings about a phenomenon that has hardly killed anybody yet … as if the proper time for preparedness were after the disaster has struck. Already the same officials that I am criticizing for under-warning the public are being accused by others of over-warning the public. And of course if the virus recedes and this pandemic never materializes, these critics will consider themselves vindicated … as if the fact that your house didn’t burn down this year proved the foolishness of last year’s decision to buy fire insurance. It is dangerous nonsense to imagine that warnings are justified only if they are followed quickly enough by disasters. People who don’t take precautions often escape injury. That makes them lucky, not wise.
The only consolation I can offer officials is this one: Over the years, many more bureaucrats and politicians have lost their jobs for failing to take a disaster seriously enough than for being excessively alarmist about a possible disaster that never materialized. Yes, there will be critical comments about “overreaction” if swine flu goes away – but think about the Congressional investigations into preparedness failures that will follow a full-scale swine flu pandemic.
Still, the costs of overreacting – that is, of being seen in hindsight as having overreacted – are high. A new administration with an ambitious agenda can’t afford to squander credibility on pandemic precautions that may look foolishly excessive in hindsight.
The risk communication solution to this quandary is to issue warnings that are simultaneously scary and tentative. Public health officials need to learn how to say “This could get very bad, and it’s time to prepare in case it does” and “This could fizzle out, and we’ll probably feel a bit foolish if it does” – to say them both at the same time, in the same sound bite.
Once they master that, then officials need to learn how to explain the relative probability of the two outcomes, as well as various outcomes in the middle. Hurricane forecasters, for example, distinguish a hurricane watch (pay attention) from a hurricane warning (take precautions). Tornado risk communication gets more specific still, right down to “If you live here or here, go to your cellar NOW!”
Of course we don’t know anything yet about the relative probabilities of different swine flu outcomes. Flu experts say the way things look right now is the way a disastrous pandemic could look at this early stage – and it’s also the way a false alarm could look at this early stage.
Warnings about swine flu are particularly difficult in another way as well: bad precedent. The problem is partly grounded in the 1976 swine flu fiasco, when the U.S. prematurely launched a vaccination program that caused more illness than that no-show pandemic did. But the bigger source of official hesitation, I suspect, is the 2005–2006 bird flu scare. Public health authorities then seemed to be implying that the bird flu virus was expected to mutate and launch a human pandemic by next Tuesday. But the virus remained (and so far remains) confined to countless millions of birds and a few hundred profoundly unlucky people.
(There are some key differences between the two pandemic threats, other than the fact that one is still theoretical and the other looks imminent. The H5N1 bird flu still hasn’t learned how to spread easily from person to person, a skill the H1N1 swine flu has amply demonstrated already. On the other hand, H5N1 has killed over half the people it has infected, whereas the new H1N1 looks comparatively mild so far … though not as mild as early U.S. reports implied. Another difference: In the U.S. and most of the developed world, we now have a sizable supply of antivirals that are known to work – so far – against the swine flu virus we’re facing.)
Pandemic risk communication about H5N1 a few years back was appropriately scary, given that the risk was (and remains) serious. But officials got the tentative part wrong. They ended up with egg on their faces in the minds of many citizens. And since I was pushing them hard to take a more alarming line, I lost some credibility in the minds of many officials. So now it’s all the harder for officials to decide to sound the alarm about swine flu … and all the harder for me to talk them into doing so. This time they’re at risk of getting the tentative part right and the scary part wrong.
Projection.
Underlying both of the above, I believe, are the sources’ own fears of what a pandemic might be like. They try to suppress the knot in their own stomachs, and it emerges as a psychological projection: “The public is panicking!” What they don’t understand is that the knot is part of a useful “adjustment reaction.” They need to guide themselves through it, and they need to guide the public into it and then through it.Benefits of Precaution-Taking
It might help if officials had a better understanding of the relationship between precaution-taking and fear. Leave aside the practical benefits of precautions. There are two psychological benefits worth describing.
Let’s start with the impact on the people officials are most worried about – those who are excessively alarmed. Here’s the secret of preparedness that fearful government leaders tend to forget: It’s a calming experience to prepare. As psychiatrists sometimes put it, “action binds anxiety.” Having things you can do that seem likely to improve your situation gives people a sense of control; it builds self-efficacy, which leads to determination, calm, and even confidence. It’s not that taking action makes people less fearful; rather, it makes people more able to bear their fear.
Those who have been working hard not to worry about the pandemic that might be looming will feel more in control after they have taken some concrete steps to get themselves and their family ready.
The other psychological effect of precaution-taking may matter less to the CDC right now, but it matters just as much to the country’s prognosis if a pandemic happens. Some people – a lot of people, in fact – are not yet very worried about a possible swine flu pandemic. It was a big story yesterday, but not THE big story; Arlen Specter’s defection to the Democrats was bigger. (And plenty of people ignored both.) Many drug stores have run out of surgical masks and Tamiflu, but they didn’t have much of a supply to start with; as far as I know, supermarkets haven’t run out of anything. The government may be worried about the risk of pandemic anxiety, but I am more worried about the risk of pandemic apathy.
When officials urge people to take precautions, that doesn’t necessarily pierce the apathy – but it helps. Each time officials repeat the advice, more people take it. Some of them take it skeptically, but take it nonetheless. In September 2003, when the U.S. Department of Homeland Security urged Americans to gather supplies against a possible terrorist attack – including duct tape to seal doors and windows – there were endless snarky comments, but duct tape sales skyrocketed. (See “Duct Tape Risk Communication.”)
As social psychologists know well, attitudes follow behavior far more reliably than they determine behavior. Leon Festinger coined the term “cognitive dissonance” to describe the discomfort people feel when they have just done something they don’t especially think makes sense. Cognitive dissonance leads to information-seeking – the (biased) search for information to make sense of the new behavior and thus reduce the dissonance.
In other words, we learn from what we do. If the CDC can get insufficiently concerned people to stockpile supplies against a possible pandemic, the mere act of doing so will make them more attentive to swine flu news and more concerned about pandemic preparedness.
So urging people to prepare is a twofer: it calms those whose concern is excessive and arouses those whose concern is insufficient. Not to mention the benefits of having the right stuff on hand if it becomes dangerous to go out in public, or if supply lines are disrupted and the stuff isn’t available anymore.
Pre-Pandemic Messaging
As Dr. Besser rightly keeps repeating, we are currently in a “pre-pandemic” stage. The World Health Organization ratcheted up from Pandemic Phase 3 to Phase 4 on Monday; it considered ratcheting up again to Phase 5 earlier today (Wednesday), then announced that it was “close” but not quite there, then reconsidered later today and declared Phase 5. Phase 6 is a full-blown pandemic.
In announcing this momentous change, WHO Director-General Margaret Chan followed the same script the CDC has been following. She was asked repeatedly what individuals could do or should do to protect themselves and their families. She said that people in Geneva often hug and touch cheeks three times, and suggested maybe it’s time to stop that for awhile. Hygiene and social distancing: wash your hands; stay home when you’re sick. It’s good advice. But the WHO guidance for Phase 5 calls it “a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.” That ought to mean more for individuals and families than voluntary hugging restrictions.
There may turn out to be no real need for individuals and families to start preparing immediately. We could stay at Phase 5 for weeks or months. Or we could progress to a Phase 6 pandemic that was mild enough to be noticeable only to professionals.
Our thinking about pandemics has been conditioned by H5N1, the bird flu virus that has killed more than half the people it infected. We have become accustomed to assuming that any pandemic would be a catastrophic pandemic. 1918 genuinely was catastrophic, even though its case fatality rate was only 2–3 percent – lower than the apparent rate for H1N1 in Mexico so far (not to mention the appalling rate for H5N1). The other two twentieth century pandemics, 1957 and 1968, were mild, not catastrophic; for most non-professionals they were non-events. The Pandemic of 2009 could be just as mild.
Or it could be catastrophic. Or somewhere in the middle.
So the key question is what to say to the public when a pandemic may well be imminent, but may still fizzle or stay poised at the brink or turn out anticlimactically mild.
Two years ago, my wife and colleague Jody Lanard and I tried to answer that question in a l-o-n-g four-part column entitled “What to Say When a Pandemic Looks Imminent: Messaging for WHO Phases Four and Five.” We were writing for right now. But we were also trying to influence messaging when a pandemic wasn’t imminent yet, trying to persuade officials to do good pandemic precaution advocacy then so it would be a bit easier to do good pandemic crisis communication now. We hoped, and said, that “working on your standby messages for WHO Phases 4 and 5 can help you decide to get more aggressive now, during WHO Phase 3.” We got the virus wrong – we anticipated an H5N1 “bird flu” pandemic – but that affects the messages very little.
The column goes into elaborate detail on what it means to alert the public … and on what it means to communicate with a public that is increasingly alert and increasingly fearful. The core of the column comes in Parts 2 and 3, where we delineate 25 specific messages and the risk communication rationales behind them.
Here are the headings of those 25 messages. (The messages themselves are a lot longer.)
1.It looks like a flu pandemic is about to start.
2.It’s no longer about the birds.
3.This is a new warning, more urgent than any warning so far.
4.The experts still aren’t sure.
5.We don’t know how bad it will be.
6.Here’s what we know so far about the severity issue.
7.It may be very bad. Society will survive, but it may be very bad.
9.What matters most is how households, neighborhoods, community groups, and businesses prepare.
11.Social distancing will be important but unpleasant.
12.School closings present a particularly difficult social distancing dilemma.
15.Getting ready for a pandemic is largely about preparing for possible shortages.
16.It’s probably too late to stockpile much now, but do what you can.
17.Now is also the time to think about how you will care for loved ones at home.
20.Here’s what the government will be doing.…
If you like these headings, read the column. If you hate the headings, definitely read the column. You may still decide it’s way off base – plenty of government officials have decided that this week – but see what Jody and I have to say and make up your own mind.
Copyright © 2009 by Peter M. Sandman
