Friday, 22 May 2009

Excellent advice to officials: Treat victims as adults to reduce panic

I have a bad feeling that US officials and doctors are telling lies to
the US public with their conflicting stories. They sound like those
Chinese officials who try to cover up their mistakes, all in the name
of "preventing" panic.

Telling lies that this Swine flu is just like Normal flu is not going
to help control the current pandemic which is 3-4 times more fatal
than normal flu although it targets only pregnant, asthmatic, gout
(those on medications), obese( probably on some high blood pressure or
heart medications) and those with heart problems.

Pandemics: good hygiene is not enough

Peter M. Sandman1

1. Peter M. Sandman is a risk-communication consultant, 59
Ridgeview Road, Princeton, New Jersey 08540-7601, USA.

Top of page

The US government is doing well to communicate uncertainty over swine
flu. It must also help the public to visualize what a bad pandemic
might be like, says Peter M. Sandman.
Pandemics: good hygiene is not enough


Hygiene is useful, but getting ready for a pandemic also requires
stocking up on key supplies.

By the time you read this, the outbreak of H1N1 'swine flu' may no
longer seem to be a worldwide threat and the disease may have receded
from the headlines. As the initial fuss dies down, public-health
experts will remain on high alert, but the media and public will move
on to something else, muttering about fear-mongering.

And whatever the situation is like now, it won't be the end of the
story. A mutated virus (more virulent or transmissible or resistant to
drugs) could appear a few months later.

As a risk-communication professional, I have been watching the US
government walk a tightrope between over-reassurance and over-alarm
about a swine-flu outbreak that could easily turn out to be
devastating, relatively mild or anywhere in between. The United States
hasn't issued false reassurances that they will keep the pandemic from
'our' shores — a temptation to which dozens of governments have
succumbed. Here I will show what else I think the country is doing
right — and wrong.

The US Centers for Disease Control and Prevention (CDC) is doing a
superb job of explaining the current situation and how uncertain it
is. The reiteration of uncertainty and what that means — advice may
change; local strategies may differ — has been unprecedentedly good.

The CDC's biggest failure is in not doing enough to help people
visualize what a bad pandemic might be like so they can understand and
start preparing for the worst.

For the ordinary citizen, the US government has so far recommended
only hygiene. It has told people to stay at home if they are sick and
to wash their hands. It hasn't told people to stock up on food, water,
prescription medicines or other key supplies. Two years ago in
response to 'bird flu' worries, Mike Leavitt, the then US secretary of
health and human services (HHS), was criss-crossing the country with
that advice ( Today, CDC officials won't
say whether it is still good advice. It is.

Why are officials so wary of describing the worst case vividly and
urging people to prepare for that?

Richard Besser, the acting director of the CDC, isn't understating the
risk. He says he is "very concerned", but expresses his concern with a
soothing bedside manner. He doesn't have that rumpled, exhausted
emergency-manager look that the Nuclear Regulatory Commission's Harold
Denton perfected in the 1979 Three Mile Island crisis. Denton left
people feeling that the risk was serious and that they were in good
hands. Besser says it is serious but leaves us feeling that he doesn't
want us to worry much.

Still, I don't fault Besser for looking and sounding reassuring. Good
crisis communication means saying 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 being
hygienic. He keeps telling us, accurately, that the CDC is being
aggressive in its response to the outbreak. But he is not asking the
public to take further action. He needs to urge citizens, schools,
hospitals and local governments to follow Leavitt's advice.

Instead, we have a surreal situation in which the federal government
has released one-quarter of the Strategic National Stockpile of
antiviral drugs, so there will be enough oseltamivir (Tamiflu) to
deploy to millions of sick Americans. But it hasn't yet asked those
Americans to stock up on tinned fruit and peanut butter.

We've been here before. In 2005, the pandemic influenza threat came
from avian H5N1. The CDC and HHS were similarly convinced that the
risk was serious, similarly committed to aggressive preparatory action
— that's why we have that Strategic National Stockpile — and similarly
disinclined to alarm the public. The feeling was that people had been
alarmed enough by the 11 September 2001 terrorist attacks and the wars
in Afghanistan and Iraq, and that the government had 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 pandemic-preparedness efforts. In early 2005 my
recommendations fell largely on deaf ears.
Don't panic!

That summer, President George W. Bush read about the 1918 pandemic in
John Barry's The Great Influenza. Then Hurricane Katrina hit New
Orleans. The two together convinced the White House that raising
concerns about worst-case scenarios was more appropriate than
confident over-optimism. Soon the CDC and HHS were sounding the alarm
about a possible pandemic. They aroused some concern, but no panic;
they inspired some individual and community-preparedness efforts. And
then attention shifted elsewhere, until now.

Why are officials so wary of describing the worst case vividly and
urging people to prepare for that possibility? There are two reasons —
first, a fear of fear itself. Although crisis-management experts have
known for decades that panic is rare (,
officials routinely expect the public to panic if told alarming
things, and misdiagnose orderly efforts to prepare as panic.

This approach nearly always backfires. Officials terrified of creating
panic make over-reassuring statements, suppress alarming information
and belittle those who are frightened as 'irrational'. Frightened
people are left alone with their fears, persuaded that their
government has betrayed them. This increases public anxiety, which
officials cannot channel into effective action because they have
already delegitimized it. During the2003 severe acute respiratory
syndrome (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.
Predicting deaths

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 US swine-flu death on 29 April, Besser
predicted that there would be US deaths. That is excellent risk
communication. He has not understated how bad things were or how bad
things could get. His failure has been subtler than that: sending the
message that the CDC will do whatever it takes to protect us, and that
we need do little or nothing to protect ourselves. From the outset,
CDC messaging has aimed to keep us calm.

The second reason for the wariness of officials is a fear of being
seen to overreact. Critics are already accusing officials of over-
warning the public. And if the virus recedes and a pandemic never
materializes, these critics will consider themselves proved right — as
if the fact that your house didn't burn down this year proved the
foolishness of last year's decision to buy insurance against fire. The
only consolation I can offer officials is that many more people have
lost their jobs for failing to take a disaster seriously than for
being excessively alarmist about a possible disaster that never

The risk-communication solution to this quandary is to issue warnings
that are both scary and tentative. Public-health officials need to use
the same sound bite to say, "This could get very bad, and it is time
to prepare in case it does", and "This could fizzle out, and we'll
probably feel a bit foolish if it does".

It might help if officials had a better understanding of the
relationship between taking precautions and fear. Leaving aside the
practical benefits, there are two psychological impacts worth

First, consider the people officials are most worried about — those
who are excessively alarmed. Here is a secret of preparedness that is
easy to forget: it is calming to prepare. Having things to do gives
people a sense of control. It builds confidence, and it makes them
more able to bear their fear.

Second, there are those who are not worried, or who have already
'switched off'. Each time officials repeat practical advice, more
people take it. Some of them take it sceptically, but take it
nonetheless. Whenever someone acts, the scepticism is reduced. So
urging people to prepare can calm those whose concern is excessive and
rouse those whose concern is insufficient. It also offers the
practical benefits of putting key supplies to hand.

As Besser says, we are currently in a "pre-pandemic" phase. The World
Health Organization raised the alert level up from phase 3 to 4 on 27
April; and ratcheted it up again to phase 5 on 29 April. Phase 6 is a
full-blown pandemic.

In announcing phase 5, Margaret Chan, the WHO director-general, echoed
the CDC advice. When asked what individuals could do to protect
themselves and their families, she advised hygiene and social
distancing; wash your hands, stay home when sick, less hugging in
public. But the WHO's own guidance for phase5 emphasizes that a
pandemic is "imminent" and that the time to finalize preparations is
short. That ought to mean more action than reducing hugging.

We may stay at phase 5 for weeks or months. Or we could progress to a
full pandemic that is mild, not catastrophic, or the threat could
recede. So the key issue is what to say to the public when a pandemic
seems imminent, but no one knows how it will turn out.

Two years ago, my wife and colleague Jody Lanard and I tried to answer
that question in an online article. To aid officials we delineated 25
specific messages (see 'Things to say when a pandemic seems imminent')
and the risk-communication rationales behind them.

Fundamentally, officials need to ask themselves whether they see the
public as potential victims to be protected and reassured, like young
children, or as pandemic fighters — grown-ups — who can play an active
part in the crisis that might be ahead. The difference in tone could
save lives.

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