Strike while the iron is cold.
Peter Sandman penned this slogan in one of a series of risk communication fact sheets for managers attending Sandman’s professional seminars. It promotes the wisdom of raising public awareness on the various aspects of hot-button issues before misinformation, half-truths, and official over-reassurances have raised the levels of emotional outrage in the public at large. I think it serves well as a rule of thumb for educational risk communication campaigns, too.
Hysteria - a term (dating from the time of Hippocrates in 400 BC) for excessive and uncontrollable emotion; including anxiety disorders and related conditions. Adj. Hysterical. The term is derived from the Greek word “hystera” meaning womb or uterus. Since the condition seemed to affect mainly women of childbearing years, it was believed to be caused by a wandering uterus. The ASAP Dictionary of Anxiety and Panic Disorders
I’ve seen the words “hysteria” and “hysterical” in print a a lot in recent weeks, precipitated by the host of crises that have swept or threaten to sweep through the nation and region: mosquito-borne EEE, devastating hurricanes followed by breakdowns of both emergency response and civic order, the emergence of a strange flu that jumped from horses to dogs, the threat of pandemic influenza.
I feel queasy when I read, “This is no time for hysteria,” or its close rhetorical relative, “There’s no need for panic,” coming from public officials or experts on the topic at hand.
When I closely examine the context of these injunctions, I usually find a subtle or not-so-subtle form of social control that encourages me (1) to remain passive and leave the situation at hand to experts, (2) to deny my reasonable fear or outrage, and (3) silence my legitimate demands for information (or lack of information) about matters that affect my life. I want to stay in the loop.
When I feel fear, I don’t want vague, patronizing, abstract reassurances. I want my leaders to acknowledge and validate my fears—even the irrational ones. I want to know what they know about the situation and what they don’t know, and most of all, what steps I and my neighbors can take to protect ourselves, our loved ones, and our neighbors.
In cases of imminent threats, I want to know what steps emergency planners and the subject matter experts have taken to protect people more vulnerable than I; if they haven’t taken any steps, or can’t offer any meaningful protection, I want to know that, too.
I want my leaders to acknowledge their errors of omission and commission. Most of all, I want to admit their own fear, and to become exemplars of resoluteness and courage in the face of it.
Well-known risk communications experts support my point of view. For example, see Fear of Fear: The Role of Fear in Preparedness ...and Why It Terrifies Officials.
One evening last week, I spent some time poking around the Extension Disaster Education Network (EDEN) to check its stock of emergency preparedness resources.
EDEN describes its purpose on the hompage: “[To link] Extension educators from across the U.S. and various disciplines, enabling them to use and share resources to reduce the impact of disasters.”
Along the way, I looked for information about H5N1 avian flu, one of the hottest topics on the national and international scene. Its dimensions include human health, agriculture, wildlife (birds), critical infrastructure, international economics, and political preparedness, among others.
Keying “pandemic,” “H5N1,” or “avian flu” into EDEN’s search function takes a reader to this February, 2004 publication entitled Specialist: 'Bird flu' unlikely to cause pandemic, the primary “resource” EDEN seems to offer on this critical and emerging issue.
I say “seem,” because the link doesn't lead to information about the H5N1 avian flu virus, but to a report on an outbreak of another strain of avian flu that emerged in Delaware in 2004. Very confusing to users looking to inform themselves about the H5N1 strain of “bird flu” currently raging in Southeast Asia, which scientists fear might mutuate to trigger the next human flu pandemic.
Even more troubling from a risk communication perspective—the Ag Answers report contains this unqualified statement by a Purdue poultry specialist: “Low pathogenic AI does not affect human health.”
Last week the Center for Infectious Disease Research and Policy at the University of Minnesota ran a bulletin titled: “
Scientific accuracy often improves when writers understand the pedagogical value of uncertainty, and when they use conditional language in statements describing current scientific understanding of a topic.
In the case above, Purdue poultry specialist Applegate might have more accurately reflected the situation with words such as, “To date, we have no evidence that low pathogenic avian flu viruses can infect humans,” or, “Leading virologists say that low pathogenic flu viruses don’t infect humans.”
To remain credible, an organization that promotes itself as research-based should consider setting up internal committees that scrutinize existing documents, prune old information from its Web site, or update documents to reflect current research.
Communication is about shared meaning. Successful communication requires that the words you choose mean the same thing to you as they mean to the people you’re talking to. Peter M. Sandman, Risk Words You Can’t Use
Scientific accuracy and research-based information alone won’t guarantee effective written communication with your stakeholders.
Once again, I refer to the advice of risk communications expert, Peter Sandman. His paper, Risk Words You Can’t Use, though directed at corporate and public risk professionals, should resonate with CE professionals who may have come from a science or policy background, but who often must communicate various kinds of risk diverse stakeholder populations.
“Here are some risk words that are likely not to communicate,” Sandman begins. His list includes conservative, significant/insignificant, positive/negative, bias/anecdotal, risk, safe, prepared, confident, regret, compassion/empathy.
Of the unavoidable use of the word “risk” itself, Sandman advises caution:
What risk assessors mean by risk is the magnitude of a bad outcome times its frequency. The rest of the world focuses on the frequency half of the definition; when people ask how big a risk is, they usually mean how likely, not how bad. People also use risk to mean uncertainty; a course of action may be called “risky” either because the probability of a bad outcome is high or because the probability is unknown. Not to mention that what most people really mean by risk is what I call outrage—is it unfamiliar, memorable, involuntary, controlled by others, morally wrong, imposed by people you can’t trust, etc. [italics mine, except for really]
Sandman notes key differences between how scientists use the words “bias” and “anecdotal,” and the common, everyday meanings of those words:
All “bias” means in statistics is non-randomness; a biased study is one that can’t be relied on because the sample might not be representative. But to normal people “bias” implies cheating. So when [industrial] plant neighbors collect information about family members’ diseases, don’t say their study is biased.“Anecdotal” has a slightly different problem. Again, all you mean is that the neighbors’ study is nonrandom; it sounds like you think it’s chock-full of amusing little stories about those sick family members.
As writers, we need to speak in the common tongue when we communicate with our general publics. If you haven’t already, please look at Jody Lanard’s (Sandman’s physician wife) and Sandman’s Scientists and the Public: Barriers to Cross-Species Risk Communication. I consider it the best treatment of this topic I’ve seen, and I think it ought to sit on every Extension professional’s desktop as a reference work.
Besides serving as the subject of daily press accounts, what do Eastern Equine Encephalomyelitis (EEE), West Nile Virus (WNV) and H5N1 avian influenza have in common?
Birds. Wild and domestic birds play key roles in transmitting all three viral diseases to humans and other mammals. Humans get EEE and WNV from the bites of infected mosquitoes, who have picked it up from infected birds. People get avian flu directly from close contact with infected birds, although public health officials worry that the virulent H5N1 virus may mutate to enable human-to-human transmission.
Symptoms. A quick review of official information about the three viral illnesses on CDC Web sites features medical experts describing symptoms of the mosquito-borne illnesses as flu-like:
CDC’s EEE site
CDC’s West Nile site
CDC’s Avian Flu site
The combination of birds and use of the the adjective flu-like to describe symptoms of all three illnesses can lead to dangerous confusion among readers, viewers and listeners in times like these, when stories of all three illnesses appear daily in state and national press.
Even the press gets confused. In recent weeks, I’ve seen several headlines that demonstrate the confusion, such as this one: Lawmakers get briefing on triple-E and avian flu, which precedes an article in which the reporter never mentions avian flu at all, apparently having confused the news of the threatened flu pandemic with the current outbreak of mosquito-borne EEE in New Hampshire.
Two years of working the phones at Extension’s Family, Home & Garden Center Info Line taught me that busy people read headlines, hear sound bites on the fly, and fit what they read or hear into their existing frames of reference. When people take in information about simultaneous outbreaks of different insects, plant diseases, or human illnesses in the same day, not to mention the same article, information bleeds from one issue to another in their minds.
In situations like that of the impending flu pandemic, where public health officials want people to get scared enough to educate themselves about the prevention measures they can take, come up a learning curve, and stay alert for many months, even years, in the face of incredible uncertainty, officials will have a difficult time trying to help the public separate the recurrent seasonal problems from something new and far more lethal.
“Regular flu” season will come along shortly after cold weather has ended the threat of mosquito bites which transmit EEE and WNV to humans. Then people and the press will have to learn to distinguish between regular flu and pandemic flu, for which we will likely have no vaccine, and against which we have no acquired antibodies:
I offer a snippet from a February, 22, 2005, Washington Times interview with Dr. Julie Gerberding, head of the federal Centers for Disease Copntrol & Prevention:
At the same time, the agency is helping to produce the 180 million or so doses of vaccine for regular flu that are needed annually. Dr. Gerberding said the timeline for producing the regular vaccine yearly is tight, with little room for problems. To produce a vaccine in response to the sudden emergence of an [H5N1 pandemic] flu bug would require an extraordinary effort, she said.”We don't now have the capacity to do both,” she said.
“There is no wiggle room here,” she said. Making an avian flu vaccine in case of an outbreak would be faster than starting from scratch, “but we just don't have the surge capacity to produce both.”
So avian flu vaccine would be rationed.
People transmit the flu virus before they show symptoms of illness, so it would be almost impossible to stop its spread by watching or isolating sick people, Dr. Gerberding said.
Depending on the situation, Extension specialists, field staff, and volunteers at the Family, Home & Garden Center Info Line may serve as primary, secondary, or third-line risk communicators for many stakeholder groups. Risk communicators need to understand people’s common habit of mixing the facts of two or more health threats. We need to make sure we get our facts straight ourselves. Should a flu pandemic erupt, we can’t assume quick shifts of understanding within the general public distinguish between regular flu (no big deal) and pandemic flu.
We can’t assume pandemic flu’s arrival in New Hampshire wouldn’t coincide with an outbreak of regular flu or some natural disaster: a blizzard, an ice storm, a flood. What if the pandemic arrived just as another Hurricane Katrina blew through the Gulf Coast, with the same levels of National Guard troops still deployed in Afghanistan and Iraq?
I’ve begun scrutinizing New Hampshire’s official pandemic preparation documents—both state and local, along with significant press accounts, and have plans to organize and link to the important ones here at this blog in future weeks. You can form your own opinions, and maybe ask questions of state and local authorities about the details of how the important stakeholder groups you serve will receive information before and if a pandemic occurs.
If you want to plunge right in, begin here:
NH DHHS fact sheet on avian flu
State of New Hampshire Interim Influenza Pandemic Epidemiologic and Surveillance Plan (Warning: 47-page pdf file)
Family & Consumer Resources educator Thom Linehan, who has an office down the hall from me, rose early this morning, switched on the local TV news, and heard this message (which I later confirmed by getting a transcription from the Channel 9 newsroom):
Manchester officials are warning city businesses to be prepared for a possible flu pandemic. They say there is no cause for concern, but a pandemic is overdue and a particular strain of the avian flu is something health officials are concentrating on. Projections from the CDC say a serious outbreak of influenza could infect thousands of Granite Staters who have no antibodies against it.
A call to Richard DiPentima, Manchester’s Deputy Public Health Director, who said he’d seen, but hadn’t hadn’t talked to the WMUR reporter himself, told me the health department had organized the meeting with local business leaders to distribute information about ways to keep essential services—food supply, banking, etc.—during a pandemic.
DiPentima said not many business representatives showed up for the meeting, at which he urged attendees to think about how to keep operating if they had a 40 percent absentee rate. He said he’d stressed “no need for panic, but we certainly have cause for concern. That’s why we organized the meeting.”
We can’t blame Channel 9 reporters for underwhelming viewers with their brief reporting on this event, or the Manchester business community for not turning out in greater numbers.
Words like pandemic and antibodies haven't made their way into our daily lexicon, especially in conjunction with the term “influenza.” We speak casually of having “a touch of the flu,” or “getting a flu shot.” Like black flies, black-legged ticks, mosquitoes, colds and stomach bugs, the flu comes through town every year. Nasty, but no big deal, really.
Few Americans alive today remember the pandemic influenza of 1918-1919, before the era of global travel. That influenza outbreak killed as many as 50 million people worldwide, half of them healthy adults.
For some straight talk on the subject from one high-ranking public figure, read the August 3 speech by U.S. Senate Majority Leader and medical doctor Bill Frist, calling for a 21st-century Manhattan project to research and combat potential epidemics/pandemics. A snippet:
But we will not be able to sleep through what is likely coming soon -- a front of unchecked and virulent epidemics, the potential of which should rise above your every other concern. For what the world now faces, it has not seen even in the most harrowing episodes of the Middle Ages or the great wars of the last century. We are unprepared for rampant epidemics. And even worse, we haven’t taken sufficient note of the fact that though individually each might be devastating, they are susceptible of either purposeful or accidental combination, in which case they could be devastating almost beyond imagination...In 1918 - 1919 the mortality rate was 3 percent, which seems merciful in comparison to the 50 percent mortality rate of today’s highly pathogenic H5N1 avian flu. In just the last 18 months, avian flu has caused the death or destruction of over 140 million birds in 11 Asian nations. And, most alarmingly, in 4 of those nations, H5N1 has taken the worried jump from birds to infect humans.
Should the virus shift and human-to-human transmission become sustained, imagine how many human lives avian flu will take. How then would a nation greatly moved and touched by three thousand dead, react to 5 or 50 million dead?
Even though it appears in a paper aimed at business communicators who manage both public relations and risk communications for their firms, I like Peter Sandman’s distinction between publics and stakeholders:
Publics are people who don’t care much. There are a lot of them, and one of PR’s two key skills is figuring out how to grab their attention, which usually requires grabbing the media’s attention first. The other essential PR skill is figuring out what to do with the infinitesimal amount of attention you’re likely to get: What to say in that precious eight-second sound bite. The essence of PR is overcoming apathy.Stakeholders, on the other hand, are just what the word suggests: people who have a stake in the issue, and who know it. (You probably deserve to be called a stakeholder if you have a stake but don’t know it, or if you think you have a stake but really don’t — but let’s stick to the easy cases for now.) At a minimum, stakeholders are interested, so getting their attention isn’t a problem. Typically they are concerned. Sometimes they are really upset, skeptical, hostile, or outraged: You have more attention than you want, and it’s unfriendly attention. They may even be terrified.
Both public relations and stakeholder relations are important tasks. One of the problems in risk communication is that they call for radically different skills and strategies, yet they must often be done simultaneously… —from Stakeholders
Later in the same paper, Sandman writes, “Once in a while, the distinction between stakeholder relations and public relations disappears, and everyone becomes a stakeholder. This is what happens in a crisis, of course…”
UNH Cooperative Extension programs target dozens, perhaps hundreds, of both loosely constructed and well defined “publics.” For the most part, we tend to think of and describe them all as stakeholders, although we do invest time and worry envisioning ways to reach out and get more of the “don’t care much” public to understand and benefit from all we do.
But in the case of a major health or other crisis, all our publics would become stakeholders in need of massive amounts of information. We ourselves would become stakeholders.
The empirical data on the situation would change from day to day, perhaps hour by hour. Many aspects of the situation might lack a research base on which to ground decisions.
Major crises have many dimensions, which may include economic, political, moral, cultural, geographic, and environmental. They have age and gender aspects. Major crises ruthlessly ignore our carefully constructed boundaries academic disciplines, socio-economic classes and geographic boundaries.
Each of us stakeholders would approach and pass through the crisis with somewhat different interests and concerns, levels of preparation and understanding, needs, and expectations of ourselves and our public institutions. Each of us would also possess strengths, such as knowledge, coping skills and access to other knowledge.
Coming up the learning curve as I’ve explored available information about the threatened pandemic of avian flu has forced me to think about and seek out the kinds of risk communication I need for myself and my loved ones. It’s forced me to consider the kinds of self-talk (interior risk communication) I know I need to practice to avoid dangerous emotional states: denial, magical thinking, terror, over-reaction, helplessness.
I recommend these exercises. They've brought me comfort and have deeply influenced how I now think about communicating risk to other stakeholders.
Government communication about pandemic influenza continues to be generally disappointing….too many national and local governments have had little to say, and too much of that little has been over-reassuring bordering on misleading.So we have been keeping an eye out for good examples. We’ve found a few, most of them local. But by far the best example comes from Australia’s national government, in an early May speech by Health Minister Tony Abbott. —from Superb Flu Pandemic Risk Communication: A role Model from Australia, by Jody Lanard and Peter M. Sandman
Examples of best practices help guide writers faced with important communications projects and educators reviewing communications produced by others.
In this extraordinary paper, the authors annotate, paragraph by paragraph, a speech delivered by Australian Health Minister Tony Abbott in May, in which he warns his nation about the risk of N5H1 avian flu and details the official Australian planning efforts.
I encourage you to read it, not only as an exemplary instance of an “official” risk communication, but also as a first-rate example of how to conduct a close, critical textual review.
Also valuable in this paper: a list of 25 recommendations for risk communicators, which the authors (a medical doctor and a risk communication specialist) reference by number throughout their lengthy annotation of Abbott's speech. I’ll repeat the list here: 1. Don’t over-reassure.
2. Put reassuring information in subordinate clauses.
3. Err on the alarming side.
4. Acknowledge uncertainty.
5. Share dilemmas.
6. Acknowledge opinion diversity.
7. Be willing to speculate.
8. Don’t overdiagnose or overplan for panic.
9. Don’t aim for zero fear.
10. Don’t forget emotions other than fear.
11. Don’t ridicule the public’s emotions.
12. Legitimize people’s fears.
13. Tolerate early over-reactions.
14. Establish your own humanity.
15. Tell people what to expect.
16. Offer people things to do.
17. Let people choose their own actions.
18. Ask more of people.
19. Acknowledge errors, deficiencies, and misbehaviors.
20. Apologize often for errors, deficiencies, and misbehaviors.
21. Be explicit about “anchoring frames.”
22. Be explicit about changes in official opinion, prediction, or policy.
23. Don’t lie, and don’t tell half-truths.
24. Aim for total candor and transparency.
25. Be careful with risk comparisons.
Although people have always tried to figure out how to communicate about risks, the field of risk communication dates back only to the 1980s, evolving from health education, public relations, psychology, risk perception, and risk assessment. —Risk communication specialist Peter M. Sandman
As a longtime, serious student of health communication, for the past year I’ve followed intently various international sources of news and information about the virulent H5N1 avian flu virus now endemic in domestic poultry in Southeast Asia despite programs that have exterminated tens of millions of domestic birds in that part of the world.
Humans in close contact with infected birds have fallen prey to this illness. The World Health Organization reports 112 laboratory-confirmed human cases. More than half of those infected have died, including many healthy young people. Scientists fear mutation of the virus to allow human-to-human transmission may trigger the next global pandemic in which millions will die.*
Since I’ve established this blog to support Extension writers, I want to use the extraordinary and extreme example of a possible pandemic of avian flu to post this week on various aspects of risk communication.
In the case of an influenza pandemic, or even discovery in the region of birds infected with the H5N1 strain, UNH Cooperative Extension will almost certainly—willingly or not—play a variety of critical roles in communicating with the general public, both in the preparation and in the coping phases of the crisis.
Consider:
• Hospital networks and medical professionals will likely find themselves overwhelmed with direct caregiving responsibilities.
• State and local authorities will have to focus mainly on maintaining essential services.
• We work with diverse populations in every community in the state. We operate 10 fully-staffed county offices where live people answer the telephone. We maintain a statewide tollfree Info Line and a Web site. People trust Extension as a source of information. Our professional staff have connections to experts throughout the nation’s land grant university system and other academic/research institutions.
• A lot of the risk communication work will fall naturally to us. A few examples: The Ag Resources and Family, Home & Garden Education Center staff will get questions about domestic poultry and pets, the forestry and wildlife folks about wild birds. Families and communities may need preparation for long periods of legally-imposed quarantine. Parents will want information on how and when to prepare and what to tell their children. Families will have questions about the safety of their food and water supplies.
I want to introduce you to the risk communication approach offered by Dr. Peter Sandman, a renowned risk communication specialist and Rutgers University professor since 1977. Sandman founded the Environmental Communication Research Program (ECRP) at Rutgers in 1986, and served as its director until 1992. Now a full-time consultant, Sandman maintains academic affiliations as Professor of Human Ecology at Rutgers and as Professor of Environmental and Community Medicine at the Robert Wood Johnson Medical School.
The Pan American Health Organization, the regional office of the World Health Organization, offers as its the lead article in the latest issue of its online magazine, Perspectives in Health, to the article entitled Bird Flu: Communicating the Risk, by Sandman and his wife, Jody Lanard, a medical doctor.
I urge you all to read it (click on the pdf version in the right-hand navigation bar to get a printable version). Then open and read Pandemic Influenza Risk Communication:The Teachable Moment, also by Sandman and Lanard.
Even if you believe you’ll never have to develop risk communications materials yourself, you’ll find these documents invaluable for evaluating the communications coming from other sources.
Sandman’s approach to risk communication emphasizes candor, transparency, early and direct involvement of stakeholders, erring on the alarm side rather than taking a zero-fear approach, and paying close attention to emotional needs and reactions (both the communicators’ and those of their audiences). He suggests that risk communicators emphasize scary information over reassuring information, tell people what to expect, acknowledge ignorance and opinion diversity, ‘fess up to errors, and ask more of people.
In short, he asks risk communicators to reach out to the mature and resilient side of their readers or listeners:
In a crisis, the public — which means most of us, most of the time — is in a state of ambivalence. On the one hand, we long for reassurance, for easy and quick answers, for magic bullets. We want to be passive and taken care of; we want to be told everything will be okay. These yearnings are a kind of regression to a less mature coping level than our normal adult selves. This is an understandable and inevitable reaction to a crisis — but it is only half of our reaction.Finally, I hope all of you can find time to read Sandman's and Lanard's potent essay, Scientists and the Public: Barriers to Cross-Species Risk Communication. From the intro:The other half of our ambivalence in a crisis is our resilient desire to take charge, to be involved, to have input, to learn how to help ourselves and others, to be altruistic, to fight the problem. This half of our ambivalence represents our desire to respond on a more mature coping level, as adults.
If they understood normal people better, scientists (and officials) could choose consciously which side of this ambivalence to ally with. Instead, they typically see only one option. They see only the immature half of the public’s ambivalence, and almost automatically they collude with that half, representing themselves as overly confident, overly reassuring, and overly wise. When they turn out wrong, this approach backfires, of course. But even when they turn out right, this approach does not help inspire the public’s optimal mature coping abilities.
With some stunning exceptions, the vast majority of scientists are notoriously poor communicators, except when talking to each other. Since scientists are often the only people around who actually understand technical data, this deficiency makes risk communication more difficult than it would otherwise be. This column will discuss some reasons why scientists typically use poor communication techniques when talking with nonscientists.
*Off topic: Below, I’ve listed links to a few of my sources for those of you who want to learn more about the H5N1 avian flu.
Foreign Affairs: Special on Avian Flu July/August 2005. This offers free access to Michael Osterholm's Preparing for the Next PandemicNature: Warnings of a Flu Pandemic Avian Flu/pandemic issue, May 26, 2005. — A massive collection of articles by top experts—free access.
H5N1: News and Resources about Avian Flu Crawford Kilian’s excellent, up-to-the minute blog of news/information sources around the world.
Flu Wiki Developed and maintained by public health scientists, this wiki http://isp.webopedia.com/TERM/W/wiki.html contains huge amounts of information about H5N1, as well as a lively discussion forum open to all.
Fluwiki’s Basic Science Information page
University of Minnesota’s Center for Infections Disease Research and Policy (CIDRAP): Pandemic Flu Page The best of the land grant university information sources. (Sadly, I haven’t found any good avian flu information on Extension sites, including EDEN resources, most of which I found woefully out of date.)