2007 Guestbook
Comments and Responses

Comment:

I hope you’ll offer your thoughts on our budding community controversy.

Our United Way has engaged local experts to find ways to help reduce the occurrence of teen pregnancy in our community. We have perennially some of the worst statistics in the state of Michigan regarding teen births. The economic consequences have been calculated as high as $7 million dollars a year.

One of the strategies the group has advocated is providing community education to parents in areas of high teen birth rates. Four area organizations have been selected to provide the education. One of the providers selected is the local Planned Parenthood chapter.

This association with Planned Parenthood to provide parent education has created a firestorm of criticism from our Right to Life Chapter and a nearby Christian university. Both groups have advocated total withdrawal from our United Way for their supporters, students and staff.

We’ve asked both organizations for the opportunity to present the facts of the situation to them (the need to address the problem, the strategy developed by the expert team, the qualification and selection of parent educators, and the commitment to separate education funding from other aspects of the Planned Parenthood organization). We are meeting with the Right to Life president next Monday. We haven’t yet had a response from the university president to our request.

We are being painted as a funder of Planned Parenthood and promoter of abortion. We are responsibly addressing a desperate situation in our community that has far-ranging impact on many critical social issues, including poverty, income disparity, overall child well-being, and education, too name a few.

Peter responds:

It seems to me that you don’t have a prayer of getting right-to-lifers to feel sympathy for your position until you start feeling some sympathy for theirs.

Imagine that a local charity was planning to give a neo-Nazi organization in your community a grant to help educate parents on ways of getting teenagers more politically involved in community issues. I am guessing that you disapprove of neo-Nazis in a way that you (and I) don’t disapprove of Planned Parenthood – but in precisely the way many right-to-lifers disapprove of Planned Parenthood: You think neo-Nazi values are evil.

Okay, Question 1: Are you convinced, really convinced, that the neo-Nazis won’t somehow smuggle their reprehensible values into their political involvement education program? Even if they have promised not to do so, even if the grant isn’t a grant to advance the neo-Nazi agenda but purely to talk generically about ways teenagers can get politically involved, do you really believe they can wall off their values from their educational efforts?

If I were Planned Parenthood, I would certainly want to include abortion on my list of ways teenagers could avoid having babies, in case they somehow failed to avoid getting pregnant. I’d feel incredibly hypocritical not doing so.

But let’s make the assumption that that’s a done deal: Planned Parenthood is going to stick to other ways for teenagers to stay childless, and the neo-Nazis are going to stick to other causes on behalf of which teenagers can get politically involved.

Which brings us to Question 2: Is that good enough for you, even if you believe it? Or do you think it’s wrong to do business with neo-Nazis, period? Doesn’t it give them legitimacy? Doesn’t it give them a chance to make friends they can later talk to about their political values?

Some communities have experienced bitter controversies over whether widely hated groups should even be permitted to join “adopt a highway” programs, where they are paid nothing, but merely volunteer their labor to remove litter. Are you copasetic about this sign on a local highway: “This mile is kept clean by Smith County Neo-Nazis, Inc.” If you’re not, you’d presumably be even more disturbed if the neo-Nazis were getting money for their efforts – money collected by the funder charity with no mention of the fact that neo-Nazi organizations would be among its partner/contractors.

If you keep the neo-Nazis in mind, then you’ll see that when you meet with a protesting right-to-life organization (whether it’s a political chapter or a religious or educational institution), your main task isn’t to “present the facts of the situation.” Rather, your main task is to acknowledge that, given their values, their protest is justified. Think about saying something like this:

Yes, we have decided to work with people that you consider evil. We decided that because they are really, really qualified to help us accomplish the task at hand, and because we think the task at hand – reducing teenage pregnancy – is really, really important. We think we can convince you that we’re right on those two points – that it’s important to reduce teenage pregnancies and that Planned Parenthood can help.

But it was an easy decision for us, because we don’t share your view that Planned Parenthood’s support for abortion rights and its willingness to perform actual abortions make it evil. We probably wouldn’t pick a service provider that we thought was evil. So when we picked a contractor that you think is evil, we should have realized you would have deeply felt, principled objections.

The question for us, now, is whether we are willing to abandon any relationship with Planned Parenthood in deference to your objections. The answer to that question, regretfully, is no. The battle over abortion is not part of our mission. Reducing teenage pregnancies is. We are going to do that the best way we can – and we have decided that that includes being willing to work with Planned Parenthood.

The question for you, now, is what you want to do about that. It goes almost without saying that you will want to protest our decision. We accept that. But there are two other questions you need to answer.

First, are you willing to work with us in our program against teen pregnancies? If you are, we will gladly construct a role for you in the program – even though there may well be people who disapprove of your involvement, just as you disapprove of Planned Parenthood’s involvement. Opponents of abortion have special reasons to want to help teenagers avoid getting pregnant. If Planned Parenthood can participate without advocating abortion, and if you can participate without opposing abortion, you are both welcome. And we will find a way to deal with the awkwardness at planning meetings!

The second question is very important for us all. You approve of much that the United Way does in our communities. But you disapprove of our decision to work with Planned Parenthood. Can you find a way to say both – to urge your members and followers to join you in opposing one United Way decision while continuing to support United Way as a whole?

This isn’t splitting hairs. We imagine you sometimes disapprove of particular United States Government policies, for example, and yet you remain loyal and patriotic Americans, and you don’t refuse to pay your share of taxes. We’re not the United States Government. We’re just the United Way. But we hope you will find a way to oppose the things we do that you oppose without opposing everything we stand for.

You may or may not be able to keep right-to-lifers under your United Way umbrella while funding an organization they despise. It won’t be easy. But your best chance is to make it clear that you respect the moral dilemma you have created for them by choosing a contractor/partner they consider reprehensible.

Jim responds:

I’ve shared your comments with our staff and volunteer leadership.

I don’t think we adequately understood and appreciated the point of view and value system of our anti-abortion community. They should have been included (or at least invited) to participate in our Teen Pregnancy Prevention discussion from the onset. I hope we can all be rational and empathetic enough in our discussion to move forward.

I’ll keep you posted on our progress. Thank you again for your thoughts.

jim adds:

Well, things have taken an interesting turn. What’s the ancient curse? May you live in interesting times?

Our Board of Directors has rescinded its decision to fund the Planned Parenthood proposal from the Teen Pregnancy Prevention workgroup.

The Board supported the recommendation at last Tuesday’s meeting, albeit with less than a full contingent of Board members. However on Friday, they asked all board members to weigh in on the issue, given the considerable controversy and lack of community support for United Way the decision appears to have created. This was done in person, over the phone, and via email, until all Board members were heard from. I don’t know the precise vote, but was told it was approximately 90% opposed.

I’ve tried to frame this as an example of listening to the community and making adjustments along the way.

Our executive director and I did meet with the local Right to Life group today (Monday). We heard their concerns about Planned Parenthood, and admitted we did not appreciate their point of view and the depth of their concern when we were looking at the recommendations to fund the teen pregnancy prevention programs. We invited them to join the workgroup so their point of view could be considered earlier on in the process. They are taking that into consideration, and mentioned some individuals they would consider approaching.

They had already heard about the Board’s decision to back off funding the Planned Parenthood program, and offered whatever assistance they could provide in helping us deal with the issue of teen pregnancy and the fallout from this association with Planned Parenthood.

Is this a new game? Or are we still trying to put two diametrically opposed groups together at the table? I’m concerned that we have seriously weakened our support in the community – from both sides.

Peter responds:

It seems to me that you made two errors, both of which ought to be acknowledged:

• Since preventing teenagers from becoming parents is inextricably tied to issues that arouse strong emotions and involve strongly felt values (teenage sex and abortion are the main two), and since United Way seeks to be a consensus organization, you should have involved a wide range of community groups from the outset in your thinking on how to address the problem. (Either that or you should have avoided addressing the problem at all – which would be a shame, since it’s an urgent problem.)
• For the same reasons, you should have done a better job of apprising your Board of the possible repercussions, and made sure the entire Board was involved in a thorough discussion of how to proceed before you took any action.

Instead, a decision to work with Planned Parenthood was made without sufficient involvement of other community perspectives and without sufficient consideration by the full Board.

This led to controversy – controversy that you consider justified, and for which you blame yourself (United Way staff), not your Board, not Planned Parenthood, and not right-to-life groups. (I think it’s very important to keep saying that both Planned Parenthood and the right-to-life groups have acted in good faith in their responses to the situation.)

In response to the controversy, the Board then voted to rescind the Planned Parenthood involvement.

I would say explicitly that you’re worried that this maladroit handling of a sensitive issue could damage United Way’s reputation among its many and varied supporters – among whom you include both abortion rights proponents and right-to-life proponents. (Saying this – saying anything! – may require Board approval at this point.)

Ideally, United Way would describe a path forward as follows:

• We need to convene a diverse group to help us plan and administer this particular program, reconsidering its structure and activities from scratch.
• We need to rethink our procedure for making program decisions, to make sure we have a process that identifies controversial issues and addresses them transparently and respectfully, drawing on the wisdom of the full range of community perspectives.
• We need to rethink our procedure for securing Board approval of potentially controversial programs, to make sure the full Board has a chance to consider how best to address the possible controversy before any decisions are made.
• We need to apologize to right-to-life groups in our community for being insensitive to their perspectives, and to Planned Parenthood for first extending it a premature offer without sufficient consideration and then withdrawing the offer.
• We need to reaffirm our commitment to finding ways of reducing the number of teenage parents in Jackson County.

Something like that….

Good luck!

Comment:

I first became familiar with risk communication when I worked with the Western Governor’s Association on issues of transporting high-level nuclear waste. Now I am working with a community around the issue of the release from prison of a serial rapist.

Are you familiar with any work that applies the principles of risk communication – or modifies those principles – for working with the public about crime? We do have risk assessment instruments, by the way.

Peter responds:

The principles of risk communication are obviously directly applicable here.

In my terms, the release of a serial rapist back into the community is obviously high-outrage. I’d judge that it is moderate-hazard (the probability of any particular individual getting raped by this person is very low, but the magnitude of that outcome is very high). So the risk communication task falls somewhere between my “outrage management” and “crisis communication” paradigms.

Among the points I would stress to a client in this situation:

• Transparency. I would tell the public everything the law permitted me to tell about the rapist’s release. And I would be especially careful to be transparent about what I’m not permitted to be transparent about. “The law says there are three pieces of information I can’t give you….” Or: “The policy decision has been made to release everything we know except X. The reason we decided not to release X is….”
• Empathy. I would explicitly make the point that people’s anxiety about the prospect of a convicted rapist in their midst is both understandable and reasonable. Make this point without actually accusing anyone of being anxious. NOT: “I know you’re anxious about ….” INSTEAD: “A lot of people in this situation would probably feel ….” or “I think if I were in this situation I would feel ….” Validate not just the “rational concern” aspects of people’s feelings, but also the dread, disgust, and related emotions.
• Context. Give people the information they need to put the risk into context. This presumably includes whatever data you have about the probability of recidivism, the steps you’re taking to monitor the rapist, the number of other rapists already loose in the community (going from N to N+1 is a lot smaller outrage than going from 0 to 1), etc. This information needs to be presented in a way that subordinates it to your acknowledgment that it’s legitimate to be worried: “Even though we’ll be watching this guy in a way we can’t watch the dozens of unidentified rapists who already live somewhere in the Portland area, it’s still upsetting to learn that yet another convicted rapist is being intentionally released back into the community.”
• Dilemma-sharing. Clarify your dilemma and invite the public to help you resolve it. “This is a problem we face all the time, and it’s very tough to come up with an answer. On the one hand, Americans believe in the rule of law, and in the possibility of redemption. When criminals have served their time, they’re supposed to go free. We hope they will make different life decisions this time. We don’t put scarlet letters on people’s foreheads anymore. On the other hand, we know that serial rapists are statistically likely to rape again, so it seems wrong to release them without even warning the neighborhood they end up in. It’s very hard to figure out how to balance the rights of ex-criminals against the rights of potential future victims. And of course once the courts and the legislature have decided what balance they want, police departments don’t have much of a choice. They follow the policy. People who think it’s the wrong policy, or who think we’re following it wrong, should let us know where they think the balance should be.”

The literature on risk communication about crime is extensive, but most of it focuses on precaution advocacy (high hazard, low outrage) – how to warn insufficiently concerned people about the possibility of becoming crime victims and the steps they can take to improve their odds. Given the hot debate in recent years over what the public should be told about the whereabouts of released criminals (especially child molesters), I would guess that there has probably been some writing about this issue from a risk communication perspective, but I can’t give you any citations.

I’d love to hear the end of the story – what you decide to say and how it works out.

Comment:

When a public drinking water system violates a regulatory requirement (whether health based or not), the system is required to notify the public. As regulators, we assist public water systems in fulfilling this requirement by providing written templates.

We also receive phone calls from consumers who have received a notification from their water system. Sometimes, the consumers are upset because the water system has exceeded a health-based standard. But sometimes they are upset when the water system forgot to take one sample.

So the risk perception has a lot to do with the situation and what was presented in the public notification.

We want to support the water systems and at the same time communicate risk accurately. What resources would you recommend to help us become better risk communicators when partnering with the regulated community? Are there workshops specifically on drinking water issues?

Peter responds:

The specific problem you’re raising strikes me as easily solved – though I don’t know whether you have the authority to solve it or you need to ask the legislature.

It ought to be simple enough to discriminate categories of violations: health, environmental, testing, administrative, etc. You might also want to discriminate levels of seriousness, using labels something like “minor,” “moderate,” “serious,” and “unforgivable.” (Okay, you’re unlikely to approve a label like “unforgivable.” How about “critical”?)

Once these distinctions are in place, the next step is to link the notification requirements to them. Perhaps water systems could be required to notify all customers of serious or unforgivable/critical violations, regardless of category, and all health and environmental violations, regardless of level. For the rest, it might be enough to make them post the violations on their websites and send customers an annual report on the number of violations of each sort that year. Or you could continue to make the systems report every violation, but they’d get to put the less important ones into context: “The regulator categorized this as a minor administrative violation.”

It would also be useful to permit water systems to give their own categorization as well as yours. A system that wanted to could say: “The regulator said this was a serious health violation, but we think it’s really just administrative because….” And of course a system that really understood risk communication might do just the opposite: “The regulator said this was a minor administrative violation, but we take it very seriously; if it had continued it could have led to significant environmental problems down the road.”

I should add that I have reservations about your reference to “partnering with the regulated community.” I agree that too hostile a relationship can make it harder to achieve your goal – a safe, efficient, compliant drinking water provider. But too cordial a relationship can also interfere with this goal. The public doesn’t much like the idea of regulators partnering with the industries they regulate, any more than it likes the idea of cops partnering with criminals or prison guards partnering with convicts.

In the long run, moreover, it’s bad for water systems for the public to get the idea that they are regulated by government agencies that think of them as partners. It leads to public demands for harsher, less industry-friendly regulations – which is presumably not what the industry is hoping to achieve.

A lot of my industrial clients, for example, have paid a heavy price for the public’s impression (all too often an accurate impression) that federal regulators are regulating too little and partnering too much. Some companies have even approached activist groups asking them to take on the role of quasi-regulator. “We need somebody to keep us honest and certify to the public that we’re minding our p’s and q’s,” they tell the activists. “Since we can no longer credibly claim that EPA [or OSHA, FDA, etc.] is holding our feet to the fire, can you do the job instead?”

Like the oil, chemical, mining, and pharmaceutical industry, the drinking water industry needs to be able to make a credible case that it is well regulated. You do the industry you regulate no favors when you talk about it as your partner.

As for whether there are risk communication workshops focused specifically on drinking water issues, I don’t know. EPA may offer some, and so may water industry trade associations. But I don’t think you especially need tailored workshops. Most risk communication trainers work for a very wide range of clients facing a very wide range of substantive issues. The riskcomm principles don’t vary much. Trainers have very little trouble adjusting to the specifics of the situation at hand. Mostly, in fact, we don’t have to. The trainer brings his or her risk communication expertise, the group brings its specific problems and issues, and the adjustments are made collaboratively.

I’m not at all certain I’m most effective when working with an industry or regulator I know well. Arguably I do my best work when I’m forced to figure out in real time how riskcomm principles apply to the case at hand. Other risk communication trainers and consultants I’ve talked with have said the same thing.

Comment:

I am working on a model that could help the decision-making process in locating and building infrastructure facilities unwanted by the public, like waste facilities.

In order to get data for the model, the idea was to divide the methodology in three phases: Define technical risk perception about a waste facility; define the risk perception of a group of key actors about the same facility; and finally, measure the general public perception.

For the first and second phases I used a matrix of Impact versus Probability, with a scale of 1 to 5 for each. So the lowest probability-times-impact corresponds to 1 and the highest probability-times-impact corresponds to 25. By comparing the results for the two groups I hope to have a lower level for the technical group – that would be expected, right? I wanted to ask you, even if it is a technical group, the result I’ll have should still be considered as a perception, right? It is a level of perception different from the perception of the key actors group – but it can’t be considered as a risk evaluation?!

Finally I tried to measure the public perception in general using the outrage components you have defined. The idea was to find a question or two for each component, which could be translated into a numerical scale. By the end it would be possible to compare the results and understand which outrage components are most responsible for the existing outrage. That is why I wanted to know more about your software.

If I can structure all this maybe I’ll be able to write a thesis.

Peter responds:

I think I understand what you’re trying to do. A few quick reactions:

Comment:

I am researching a paper for my capstone project. I work at a refinery in the Great Lakes area and I am also the union safety rep. I would like to know as much about the effects of morale on safety as possible. Do you have any suggestions?

I would like to do a survey of the hourly workers. Do you have any suggestions for questions?

Peter responds:

The question you’re raising is on the periphery of my field, and you’re going to learn a lot I don’t know when you start reviewing the literature. But here are a few thoughts to get you started.

It is well established that individuals work safer when they’re happy with their job and like their boss. In one typical study, employee drivers who disliked the company and planned to quit were less likely to follow road safety rules than their more satisfied coworkers. Another study found that one of the strongest predictors of on-the-job back pain was job dissatisfaction.

The effect seems to be greatest for unhappy workers, whose safety records are much worse than average; the records of happy workers aren’t as clearly better than average. The extreme case is the employee so unhappy that he or she is (at least temporarily) reckless or even suicidal. It’s impossible to know how many workplace accidents have an element of “I don’t care anymore” in them – but the number isn’t tiny.

It’s worth noting that unhappy employees don’t just endanger themselves; they also endanger their coworkers and sometimes their customers. Healthcare studies, for example, find that employee morale is a good predictor of the quality of care received by patients. Very unhappy (and very unbalanced) employees may even “go postal.” The worst industrial “accident” in modern history, the 1984 Union Carbide methyl isocyanate disaster in Bhopal, India, is thought by many to have been the intentional act of an angry employee.

At the same time, it is also well established that unhappy employees are likelier to complain about unsafe working conditions. For example, employees who are experiencing the double-bind of both disliking their jobs and being afraid of losing their jobs are especially likely to turn up in a supervisor’s office complaining that workplace chemicals are nauseating them or giving them headaches. I doubt that this results from unhappy employees being more health- and safety-conscious. Rather, it seems to be a case of unhappy employees being more symptomatic – and, of course, more inclined to complain. (One unhappy employee complains about unsafe working conditions, another about burdensome safety rules.)

Strictly speaking, morale isn’t just whether an individual employee likes or dislikes the job. Morale is a group phenomenon; it means the same thing as esprit de corps. I like Alexander Leighton’s definition of morale, quoted by Wikipedia: “the capacity of a group of people to pull together persistently and consistently in pursuit of a common purpose.”

Using this narrower definition of morale, the question is whether employees in organizations with high morale are likelier to take care of themselves and especially of each other, leading to an improved safety record. This is obviously the case if safety is part of the common purpose that defines the group’s morale. There’s a huge literature on how to build a “safety culture” in which everyone is proud of the organization’s safety record and determined to help sustain it, not just by working safe but also by making sure others work safe.

Part of building a safety culture is pointing out to employees that safety is a shared value (which helps to make it one). That’s the difference between praising a safe act because it’s safe and praising it because it reflects the group’s shared safety norm. The latter does more to build a safety culture, because it makes safety the heart of group morale.

But if morale is built around common purposes other than safety, does the group cohesion still lead to improved safety performance? I think it should. If we’re pulling together in other ways, you’d expect us to pay more attention to keeping each other safe. Even in the military, where morale is sometimes defined in terms of a soldier’s willingness to die for his or her comrades in arms, high morale is nonetheless thought to contribute not just to victory but also to survival. But I don’t know if there is research that shows this (or refutes it).

Most of the studies of the morale/safety relationship are correlational. They’re usually interpreted as meaning that when the workforce is happier and more cohesive it will therefore act more safely: morale → safety. But of course it’s just as credible that a workforce with fewer accidents will therefore feel happier and more cohesive: safety → morale. Certainly when management seems to care not just about productivity and profitability but also about employees’ safety, that ought to contribute something to morale (and thus, perhaps, to productivity and profitability). It will take more than a survey to disentangle this causal web.

Speaking of surveys, I don’t have any questions to suggest. First you need to figure out what aspect of the morale/safety relationship you want to study.

Comment:

In light of a new Hollywood movie called “Awake,” which supposedly exposes (in a horrifying way) a rare condition called “anesthetic awareness,” I have been asked by a local surgeon to collaborate with him on an article for our local paper to inform the public of the “facts” about this condition vs. the Hollywood myth. (See http://www.slate.com/id/2178716 for more about the movie.)

How do you suggest we approach this issue? Also, I’m aware of our own “outrage” with Hollywood’s irresponsibility. We are afraid the hype could scare some people to the point that they may refuse a needed surgery. How should we deal with this outrage in our communications?

Peter responds:

The basic principle of outrage management here is this: Acknowledge the “other side’s” good arguments.

Let’s start by assuming you have an audience that either already takes the issue of anesthetic awareness seriously or is likely to start taking it seriously sometime soon – presumably because of seeing “Awake” or hearing or reading about it. Your main worry is that some in this audience may decide against surgery they would otherwise have because they’re afraid they might have an anesthetic awareness experience. Your secondary worry is that they might go through with the surgery, but with more anxiety than they would otherwise have felt. Your goal is to persuade them that anesthetic awareness isn’t a major concern – that it’s worth shrugging off.

(I know nothing about anesthetic awareness, but based on the “Slate” article you referenced, this is an honorable goal.)

Okay, here’s what you need to acknowledge – not reluctantly or defensively, but as empathically as you can:

• Anesthetic awareness apparently exists. There is debate over how rare it is – the movie cites the most alarming statistics out there, ignoring other sources that think it’s much rarer. And there’s debate over whether “awareness” means actually feeling the pain of surgery without being able to say or do anything about it, or whether it means being vaguely semi-aware of some things going on in the operating room, or even whether it means having “recollections” of the surgery that might actually be drug-induced dreams or transposed memories from things you were told afterwards. But whatever it means, a small percentage of surgical patients do report later that they weren’t completely out – and at least a few claim they were completely there and felt everything.
• The idea of anesthetic awareness is terrifying. It’s the stuff that nightmares are made of: watching the surgeon’s scalpel descend, feeling the incision … and being completely paralyzed, unable to move or scream. It’s a creepy thought. That’s why they based a creepy movie on it.
• The medical profession hasn’t been in any hurry to take this issue seriously. At least doctors haven’t been in a hurry to be candid with patients about it. (It’s not part of the standard informed consent protocol, for example.) When people learn that anesthetic awareness exists – however rare or partial it might be – they are likely to feel understandable outrage about never having been told.

In the context of admitting these things, you can urge patients not to let fear of anesthetic awareness deter them from surgery they would otherwise have. But you have to do that empathically too. “It’s natural to feel creeped out by the idea of anesthetic awareness. For some people that can become the symbol of all their other worries and reservations about going under the knife. It may help a little, but only a little, to know that it’s rare – that of all the people you know who have been through surgery, not one has ever told you: ‘I felt it.’ But people often find it hard not to imagine that they could be the one, the rare one, who feels it. Deciding about surgery is always about playing the odds – and playing the odds is never easy when there are vivid emotional images in the way.”

Your own outrage at Hollywood for irresponsibly exploiting the anesthetic awareness issue probably needs to be moderated, if you can manage it, into the mildly patronizing amusement that characterizes the “Slate” article. After all, Hollywood at least raised the issue. In choosing between Hollywood’s exaggeration and the medical profession’s silence, I think most people would see Hollywood’s sin as the lesser of the two evils. Try to write with that in mind.

That’s how you should talk to people who are upset about anesthetic awareness, or who are likely to become upset about it in the coming weeks.

But here’s the problem. Many of the people who will read your article neither saw “Awake” nor plan to see it; or they saw it and thought it was foolish. Many have never even heard of anesthetic awareness. In the process of managing the outrage (the fear and possibly anger) of those who are taking the issue seriously, you will inevitably introduce the issue to people who know nothing so far, and you will raise its salience for people who have shrugged it off so far.

I’m okay with that. I tend to see people who have never heard of anesthetic awareness as people who will one day find out and get outraged. I tend to see people who think just it’s a movie fantasy as people who will one day learn different and get outraged. So I’m happy to see you “inoculating” them against future outrage by leveling with them now. But some communication experts – and a lot of doctors – might advise you to leave it alone. Let doctors deal one-on-one with distressed patients, they would say, and don’t dignify the movie with a response.

Let me add something from my own surgical experience, a minor procedure a couple of years ago. My anesthesiologist told me the drug he wanted to use caused amnesia; I would be awake during the procedure and able to help the surgeons by answering questions, but I would remember nothing about it. I spent a few minutes pondering the if-a-bird-sings-in-the-forest conundrum of whether pain I would feel while I was under but wouldn’t remember afterwards was really pain. Then I said okay. But I pondered your anesthetic awareness question through the lens of that experience.

Comment:

We are writing in reference to your September 2007 article: “Indoor Air Quality Risk Communication: Before You Fix Anything, Talk!” We are currently working on a story slated to run in February that focuses on landlord responsibility as it relates to leasing and indoor air quality problems.

Our question: What are the three most important Indoor Air Quality concerns that landlords need to be aware of when consulting with their attorneys about drafting lease provisions?

Peter responds:

I don’t have a lot of on-the-ground experience with advising landlords on how to draft leases with IAQ in mind.

Obviously, landlord and tenant share three interests.

• They share an interest in preventing IAQ problems by maintaining the building well.
• If there are genuine IAQ problems that are making people sick, they share an interest in identifying and correcting those problems as quickly as possible.
• If there are no IAQ problems making people sick, they share an interest in preventing the tenant’s employees from overreacting to minor problems (which always exist) and ending up symptomatic as a result of their worry and outrage, rather than as a result of the problems themselves.

In order to accomplish the third objective, landlord and tenant need to communicate well with each other about the tenant’s employees’ concerns. And they need to communicate well with the tenants’ employees in ways that show their respect for those concerns – their determination to identify and correct any IAQ problems as quickly as possible, their willingness to do so transparently rather than secretly, and their willingness to listen to the employees’ views on what the problem might be and how to approach it.

My client in IAQ controversies has usually been a corporate tenant. The landlord has sometimes been allied with the tenant in trying to ameliorate the tenant’s employees’ concerns. Other times the landlord has become intransigent – either about addressing the IAQ problems themselves or about being candid with the tenant (and especially with the tenant’s employees) about what is being done.

Legal fears are often behind the landlord’s intransigence.

But in my judgment the intransigence worsens the landlord’s legal risk; upset employees sue their employer, which then sues the landlord. The paradox here is that the tenant ends up claiming the IAQ problems are physical rather than psychogenic in order to bolster its case against the landlord. The landlord ends up defending by arguing that the problems are psychogenic and therefore not the landlord’s responsibility – even though the landlord’s intransigence may have greatly increased the frequency and seriousness of psychogenic symptoms.

If the building has serious IAQ problems, it seems to me, landlord and tenant may have genuinely conflicting interests. But if the health complaints of the tenant’s employees are mostly psychogenic, then landlord and tenant have a shared interest in doing a good risk communication job with the tenant’s employees in order to resolve those complaints and end the controversy without litigation (and without the tenant deciding to vacate the building).

I don’t know how all this should translate into lease provisions.

Comment:

In many European countries, there is considerable concern that exposure of troops to depleted uranium used in bombs causes cancer, although in at least some of the countries where this has been of concern, detailed studies have shown no association.

What is it about depleted uranium that appears to cause such continued and inordinate fear as a putative cause of cancer even in the absence of evidence and/or presence of other more likely etiologic agents?

Peter responds:

Let’s start with three basic principles of risk perception and risk communication:

• The correlation between whether a risk is dangerous (“hazard”) and whether it’s upsetting (“outrage”) is very low. The two are essentially unrelated.
• Hazard perception, whether people think a risk is dangerous, is much more highly correlated with outrage than with hazard itself.
• In the strong relationship between hazard perception and outrage, outrage is mostly the cause, hazard perception the result. For the most part, it’s not true that people get upset because they think a risk is dangerous. It’s much more true that people think a risk is dangerous because they’re upset.

So here’s how I would rephrase your question: What’s upsetting about depleted uranium, leading people to think it’s a serious hazard whether it is or not?

Look at some of the outrage components that apply:

Dreaded versus not dreaded

Radioactivity is more highly dreaded than most sorts of risks. The idea that a piece of radioactive shrapnel from a depleted uranium weapon might lodge in my body, emit deadly radiation day and night, and ultimately give me cancer is profoundly unsettling. So is the thought that children in Bosnia who live near the “impact site” of an early 1990s NATO air strike might be breathing radioactive dust containing depleted uranium. Radioactivity weighs on the mind in a way that the threat of an automobile accident, for example, does not.

Some of the dread of depleted uranium probably comes from the association in our minds with nuclear weapons. Actually, depleted uranium is used in munitions, tanks, and armor not because it’s radioactive but because it’s dense, and thus helps penetrate or prevent penetration. It’s natural uranium (or occasionally spent uranium fuel from nuclear reactors) that has been “depleted” – made about 40 percent less radioactive – by removing most of the U²³⁴ and U²³⁵, leaving behind mostly U²³⁸. I suspect many of the people (including veterans) who worry about depleted uranium imagine either that it’s used in nuclear weapons or that it’s made from nuclear weapons. (This isn’t entirely mistaken; it’s conceivable that a nuclear weapon could have been reprocessed into reactor fuel, used in a reactor, then reprocessed again into depleted uranium.)

I also doubt most people who worry about depleted uranium understand that “depleted” means it’s been made less dangerous than it was when it was dug out of the ground. And how many of them know that U²³⁸ has a very long half-life, and is therefore less radioactive than elements that decay more quickly? (Some sources describe it as “barely radioactive.”)

But of course even people who know these things still know uranium is radioactive and radioactivity is scary.

Memorable versus not memorable

The memorability of depleted uranium, too, comes mostly from the association with nuclear bombs, mushroom clouds, glow-in-the-dark monsters, etc. We all have vivid images in our minds of the horrific things radioactivity (and thus uranium, we assume) can do to us.

Untrustworthy sources versus trustworthy sources

This important outrage component isn’t about depleted uranium itself; it’s about the people and institutions who assure us that depleted uranium is safe.

Most of the studies on the health effects of depleted uranium were funded (and in many cases undertaken) by governments that would be in considerable moral, political, and economic hot water if depleted uranium turned out to be a significant risk. They would have daunting obligations to both veterans and civilians who might have been exposed in the Balkans, Iraq, Afghanistan, and elsewhere since depleted uranium started being used in the 1991 Gulf War. They would have even more daunting cleanup obligations in the places where depleted uranium has been used. And they would need to figure out how to do without depleted uranium in the future.

It isn’t unreasonable to mistrust the assurances of governments that have such pressing reasons to want depleted uranium to turn out to be a non-problem. This is especially the case when the assurances come from governments that have already lost trust on other issues, and from arms of those governments (such as the military) that seem especially unlikely to be candid about the risks. These same objections, of course, apply to research sponsored by NATO or the United Nations.

Imagine how much more trust people would feel if a radical veterans rights group were to announce that it isn’t worried about depleted uranium – that it has a long list of grievances against the military, but having examined the evidence carefully it is convinced that depleted uranium isn’t a significant health problem for veterans and doesn’t belong on the list. Of course it’s hard to imagine a radical veterans rights group reaching that conclusion – just as it’s hard to imagine a military hierarchy reaching the opposite conclusion. That’s my point. Neither side can be trusted when it concludes what’s in its interests to conclude.

The best solution to the trust problem isn’t figuring out how to be trusted; it’s figuring out how not to demand trust. For example, government researchers studying the health effects of depleted uranium would do well to invite their critics to collaborate in the research – making it harder for the government to cheat and harder for opponents to claim it’s cheating. For more on diminishing the need for trust, see my column on “Accountability.”

Unknowable versus knowable

Part of the untrustworthiness of depleted uranium assurances is their one-sidedness. This connects closely to another outrage factor: knowability.

As far as I can tell, the weight of the evidence suggests that depleted uranium is not a serious health risk for veterans whose exposures were typical. Most of the experts seem to agree that this is the case. But surfing the Web, it isn’t hard to find a minority of experts who disagree, and who have found evidence to cite on their side of the argument. This isn’t rare; most controversies have at least some evidence and experts on both sides. But expert disagreement – dueling Ph.D.s – leads to a lot of outrage.

By contrast, garden-variety uncertainty leads to less outrage (some, but less). To convert expert disagreement into mere uncertainty, all that’s necessary is to discuss the other side respectfully. “We think the risk is X. But we know they think it’s Y. Here’s our evidence. Here’s theirs. It’s hard to be certain where between X and Y the truth actually falls.”

Those on the reassuring side of the depleted uranium controversy would be wise to concede the existence and arguments of the other side. This is true even if the other side is only two percent right – perhaps especially if the other side is only two percent right. You can’t put that discrepant two percent of the evidence and those dissenting two percent of the experts into context without talking about them. And if you don’t talk about them, they loom all the larger in the minds of worried and mistrustful people who know about them already, or who learn about them later. As I wrote very recently in a Guestbook comment on the controversy over thimerosal in vaccines, “overconfident, one-sided ‘reassurance’ forfeits credibility.”

I don’t know the literature well enough to say what the best arguments are on behalf of the view that depleted uranium is a serious risk. Some of them, certainly, are non-technical facts, like the European Parliament’s call a few years ago for suspension of all use of depleted uranium. Some of them are non-technical allegations, like the claim that depleted uranium violates environmental treaties and even the Geneva Convention. Some of them are rhetorical flourishes, like the inarguable assertion that deploying depleted uranium constitutes, if only incidentally, the use of “radioactive weapons.” And some of them are research findings and scientific claims. The fact that the weight of the evidence is on the other side does not justify ignoring the evidence on this side.

There’s another knowability problem worth mentioning with regard to depleted uranium: detectability. When I was at the 1979 Three Mile Island nuclear power plant accident, many normally unflappable journalists were visibly anxious about the risks of radiation. Asked why, they often mentioned detectability. “At least in a war you know you haven’t been hit yet,” one reporter told me. “I’d be a lot happier if radiation was purple instead of invisible,” another said. Those who carried dosimeters they could read on the spot checked them often, and were less anxious than those who had no way to tell what their exposure had been so far.

Testing the uranium content of veterans’ urine is an established way to help assess whether they have a depleted uranium problem worth worrying about. In hazard terms, the test is only occasionally valuable. In outrage terms, it might be worth doing more often.

The knowability problem of depleted uranium is complicated by the mysterious diseases afflicting veterans of recent wars in which depleted uranium was used. There’s a lot that isn’t known about Gulf War Syndrome and Balkans War Syndrome. The claim that there’s no evidence these illnesses are linked to depleted uranium isn’t terribly reassuring when it comes from authorities who haven’t a clue what they are linked to.

Other outrage factors

Depleted uranium has a familiarity problem. Even veterans of extensive battlefield experience with depleted uranium weaponry are typically unfamiliar with radiation, dose-response curves, and the rest.

It has a voluntariness problem. Many soldiers were drafted; others volunteered – but not to be exposed to depleted uranium. Civilians victims, of course, were all coerced.

And it has a responsiveness problem – though that’s improving. I don’t know about Italy or the rest of Europe. In the U.S., military risk communication has progressed from secrecy to something closer to transparency. The Defense Department and the Department of Veterans Affairs are trying (pretty hard, even) to acknowledge that soldiers and veterans are worried; there’s even an effort to persuade VA doctors to raise the issue proactively with veterans who served where depleted uranium was used.

But they’re finding it hard to listen empathically to people’s concerns about depleted uranium, harder to acknowledge that those concerns are understandable, even harder to concede that the evidence is mixed (albeit mostly on their side), and hardest of all to admit that they’re not to be trusted on the matter. And of course the risk communications aimed at U.S. soldiers and veterans are enormously superior to what civilians who live on former or current battlefields are told.

Comment:

I have for some years enjoyed reading your articles and columns, tried to learn, and made numerous references to you and your site when talking about risk communication and crisis communication.

I find the seesaw principle very useful and applicable to a wide range of situations and communication challenges. My intuition and experiences tell me it makes sense.

On the other hand, where do I find references to more surveys backing the principle?

Peter responds:

The essence of the seesaw principle is that ambivalent people tend to stress the half of their ambivalence that is insufficiently represented elsewhere in the communication environment. Assume that I’m torn between X and Y. If you keep insisting on X, I’ll usually end up claiming Y; if you focus instead on Y, I’ll probably shift to X. And if you are expressing a balance of X and Y, sharing your own ambivalence (and the genuine complexity of the situation), I may be able to find my way to a similarly balanced view.

I believe this principle is central to effective risk communication, especially crisis communication (high hazard, high outrage) and outrage management (low hazard, high outrage). For examples of some of the uses I have made of the seesaw principle, see almost any article on this website, including:

• Advice for President Bartlet: Riding the Seesaw
• Riding the many pandemic seesaws
• Games Risk Communicators Play: Follow-the-Leader, Echo, Donkey, and Seesaw
• The “Ride the Seesaw” section of “Smallpox Vaccination: Some Risk Communication Linchpins”
• The Boss’s Outrage (Part I): Talking with Top Management about Safety
• The Boss’s Outrage (Part II): Talking with Top Management about Risk Communication
• The Seesaw of Risk Communication

That said, I haven’t been able to find any risk communication research studies devoted to the seesaw principle, at least not under that name. Not a one.

This isn’t definitive. The risk communication research literature has burgeoned, and I haven’t kept up. (I wasn’t a particularly good bibliographer to begin with.) Still, a Google search for “risk communication seesaw” yielded almost entirely references to my own writing. And searching for “seesaw” in back issues of the single most important risk communication research journal, Risk Analysis, revealed nothing relevant. (Note: You have to be a member of the Society for Risk Analysis to use the searchable online repository of Risk Analysis back issues.)

If a reader of this site knows about any research relevant to the seesaw, please email me and I’ll be happy to post the link or citation (and to read the study!).

But if you go beyond risk communication, back to the origins of the seesaw concept, there is a huge relevant literature, much of it theoretical and/or empirical.

Start by looking for references to “reverse psychology.” Most of these, of course, aren’t research; they’re likelier to cite popular culture examples than empirical studies. Two literary examples of reverse psychology that I remember vividly from my own early years:

• In one of Joel Chandler Harris’s “Uncle Remus” stories, Br’er Rabbit escapes from Br’er Fox by pleading, “Please, Br’er Fox, don’t throw me in that briar patch!” Determined to torture Br’er Rabbit as effectively as possible, the fox responds to Br’er Rabbit’s entreaties by throwing him in the briar patch, and thus he escapes.
• In high school I was enchanted by “The Fantasticks,” a 1960 musical based loosely on Edmond Rostand’s play, “Les Romanesques.” Both tell the story of two fathers who put up a wall between their houses and fake a feud in order to ensure that their children will fall in love, since teenagers reliably do the opposite of what their parents want. (This had the ring of truth to me then, and it still does.) In one of the songs from the show, the two fathers sing: “Why did the kids put beans in their ears? … They did it ’cause we said no!”

There’s a slight difference in emphasis between the “reverse psychology” concept and the seesaw. Reverse psychology is about oppositionality, whereas the seesaw is about ambivalence (with some oppositionality thrown in – people don’t like being told what to do or believe). Both are psychologically sound. Oppositional people say or do the opposite of what they’re told; ambivalent people go to the neglected side of their ambivalence. (Since teenagers are oppositional and ambivalent, they’re endlessly riding seesaws.) Others can capitalize on your oppositionality or ambivalence by taking the side they don’t want you to take. They say/do X in order to get you to say/do Y.

The seesaw concept is also a lot more nuanced than reverse psychology. It goes way beyond getting people onto the seat on the seesaw that you left conveniently vacant, tricking them into saying/doing the opposite of what you’re saying/doing. It suggests the far more respectful and humane possibility of helping people move toward the fulcrum of the seesaw – that is, helping them cope with their ambivalence; helping them tolerate being torn between incompatible beliefs, desires, or feelings instead of settling for the distorted simplification of picking one or the other.

My long fascination with reverse psychology started morphing into the more nuanced “seesaw” concept after I met my wife and colleague Jody Lanard. A psychiatrist trained in family systems theory, Jody was a champion of a set of therapeutic strategies known as “paradoxical intervention.”

In a paradoxical intervention, the therapist tries to induce change by discouraging it. For example, the therapist may prescribe the symptom the patient has said is the problem he or she wants cured. Someone who has sought help for never getting things done might typically be urged to “take time to procrastinate.”

Among the authors whose theoretical writing about paradoxical intervention influenced Jody – and thus me too – are Viktor Frankl, Chloe Madanes, Jay Haley, and Milton H. Erickson. (Jody particularly recommends Haley’s 1993 book on Erickson, entitled Uncommon Therapy.)

A Google search for “paradoxical intervention” yields endless research studies as well as some pretty turgid theoretical writing. It’s in a therapeutic context rather than a risk communication context, but it’s about the seesaw.

One related concept that’s shared by psychotherapy and risk communication is “reactance.” The term was coined by James Brehm, who argued that when people feel their freedom threatened by the actions or statements of others, they react against those actions or statements. You’ll find plenty of research (and plenty more turgid theoretical writing) on reactance in both the therapy and the riskcomm literatures. A lot of this work is about how to overcome reactance – that is, how to avoid saying the sorts of things that make your audience turn against your recommendations. (For example, reactance is one of the reasons why it’s hard to persuade teenagers not to smoke.) But some of it, in both fields, addresses ways of making use of reactance – that is, making a paradoxical intervention, using reverse psychology, riding the seesaw.

A book that’s probably worth reading is Motivational Interviewing: Preparing People for Change, by William Ross Miller and Stephen Rollnick. I confess I haven’t read it yet – just some wonderful excerpts from the chapter on “Responding to Resistance” (courtesy of Amazon’s preview service). It gives great, accessible, risk-communication-relevant examples of seesaw paradoxical interventions.

Another useful reference is “Converting Ineffective Behaviors Motivated by Unconscious Psychological Defense Mechanisms into Consciously Determined Effective Coping Behaviors.” It’s Appendix C of a National Highway Traffic Safety Administration report on Unconscious Motivators and Situational Safety Belt Use. The whole thing, including the appendix, is available online. The appendix is a lovely literature review on the reasons why people resist safety messages and what to do about the various sources of resistance. In my terms, it’s about overcoming unconscious resistance in precaution advocacy. The seesaw/reactance/reverse psychology approach is in there, along with a lot of others.

I had never seen either of these two till I started trying to answer your question. Thanks for asking!

Comment:

You are probably familiar with the controversy about the mercury-containing preservative thimerosal that was used in pediatric vaccines, and its purported risk of autism.

What is the best way for public health professionals to communicate with the public about the perceived (and sometimes real – e.g., smallpox) risk of vaccines, as well as the benefits? Even if the concern about thimerosal fades away, something else will take its place, as has happened during the entire history of the use of vaccines.

I also wonder if you had the opportunity to see the editorial by Dr. Paul Offit in this week’s New England Journal of Medicine. Commenting on a study published in the same issue that examined the risks of thimerosal in pediatric vaccines, he discusses thimerosal risk communication.

The thimerosal issue was widely publicized in July 1999 when the American Academy of Pediatrics (AAP) issued the following statement discussing the intention to remove thimerosal from most pediatric vaccines:

Parents should not worry about the safety of vaccines. The current levels of thimerosal will not hurt children, but reducing those levels will make safe vaccines even safer. While our current immunization strategies are safe, we have an opportunity to increase the margin of safety.

Dr. Offit writes that “Critics wondered how removing something that hadn’t been found to be unsafe could make vaccines safer.” He adds: “Many parents, frightened by a sudden change in policy, reasoned that thimerosal was targeted because it was harmful – and their faith in the vaccine infrastructure was shaken. Doctors were also confused by the recommendation.”

He continues: “Although the precautionary principle assumes that there is no harm in exercising caution, the alarm caused by the removal of thimerosal from vaccines has been quite harmful. For instance, after the July 1999 announcement by the CDC and AAP, about 10 percent of hospitals suspended use of the hepatitis B vaccine for all newborns, regardless of their level of risk. One 3-month-old child born to a Michigan mother infected with hepatitis B virus died of overwhelming infection.”

“During the next few years,” he concludes, “thimerosal will probably be removed from influenza vaccines, and the court cases will probably settle down. But the thimerosal controversy should stand as a cautionary tale of how not to communicate theoretical risks to the public; otherwise, the lesson inherent in the collateral damage caused by its precipitous removal will remain unlearned.”

What can public health professionals do to ensure that a blunder like this doesn’t happen again?

Peter responds:

As you say, vaccines have always been scary to some people, and probably always will be. Maybe it’s the fact that, unlike ordinary medicines, vaccines are a version of the very disease they’re supposed to protect us from. There’s something profoundly counterintuitive about that! And vaccine advocates would do well to say so. When talking to a nervous patient or parent, it’s empathic to find ways to acknowledge that it’s natural to be nervous.

Which is part of why the AAP statement you and Paul Offit quoted is so off-putting. I don’t agree with the AAP that “Parents should not worry about the safety of vaccines.” Worrying about possible risks to one’s children is both natural and desirable, and telling parents not to worry is incredibly unempathic.

Offit is obviously right that it’s incoherent to say thimerosal is safe but getting rid of it will be safer. But while Offit objects to the second half of this self-contradiction, I object to the first half. Calling something “safe” without a qualifying adjective is almost always a mistake. There would be nothing incoherent about offering to reduce or eliminate the small potential risk of thimerosal.

Your comment focuses on the problem of what to do when people are unjustifiably worried about a risk that’s probably tiny and may well be non-existent. Does it make sense to take presumably unnecessary precautions in order to reassure the public? Or will the precautions be too often seen as evidence that the worriers were right in the first place?

This is an important question. But to make sense of the answer as applied to thimerosal, I have to back up and talk about how public health has forfeited much of its credibility on the subject of thimerosal safety.

Overconfident, one-sided “reassurance” forfeits credibility.

I last wrote about the thimerosal controversy in a July 2005 Guestbook comment entitled “Thimerosal, autism, and misleading toward the truth.”

Public health professionals claim that the weight of the scientific evidence shows that thimerosal does not cause autism. Critics claim that the public health profession is covering up the portion of the evidence that shows otherwise. Although I’m not qualified to assess either claim definitively, my strong impression is that both claims are true. (See for example my discussion of the June 2000 Simpsonwood Conference in the Guestbook entry linked above.)

That is, I think that the experts have solid grounds for concluding that thimerosal in pediatric vaccines is very unlikely to be responsible for the surge in autism diagnoses. And I think that once they reached that conclusion the experts have too often sought to reassure the public by overstating their degree of certainty, and have tried to ignore or discredit the evidence (a lot of anecdotal evidence plus a few studies) that suggested there might be something to the relationship after all. That’s what I mean by “misleading toward the truth.”

Overstating a mostly valid conclusion and hiding the small amount of contrary evidence is an incredibly common (and tempting) mistake. It is most common (and tempting) when people are upset, when you want to calm them down, and when all you have to work with is a pile of studies that didn’t find the effect they were looking for, plus a handful that might have found something. The evidence is maybe 85% on your side, but you’re afraid that acknowledging the other 15% might prolong the debate you’re trying to quell. So you suppress the 15%.

Sooner or later the strategy backfires. Even before the other 15% of the story comes out, people may sense that you are giving them one-sided information and are not to be trusted. When it does come out, you look like a liar. Your belated efforts to explain why you didn’t mention the discrepant 15% lack credibility, and the 15% therefore looms far larger in people’s minds than it deserves. Your one-sided messaging may win the day with people who are barely paying attention, but you forfeit any chance of influencing those who have become immersed in the controversy.

I can’t tell you how many clients I have worked for over the years who were 85% right, claimed to be 100% right, got caught being dishonest about the remaining 15%, and lost the debate. Arguably this is the Erin Brockovich/PG&E story, the W.R. Grace Woburn story, the breast implant story, the perchlorate story.… (Note: PG&E and Grace were not clients.)

If you’re 98% right instead of 85% right, the same principle applies. When scientists let themselves sound certain instead of nearly certain, and when they ignore or trash discrepant evidence instead of addressing it respectfully, their behavior is neither sound science nor sound risk communication.

There is another vaccine story unfolding as I write this that illustrates almost the same point: an unusually large outbreak of vaccine-derived polio virus (VDPV) in Nigeria.

The oral polio vaccine is a live, weakened vaccine. It is significantly less safe than the injected (dead) vaccine – but it’s a lot cheaper, and has other advantages that make it the vaccine of choice for developing countries. But about one vaccinee in a million gets polio from the vaccine itself, and from time to time there’s an outbreak of vaccine-derived polio cases. (Vaccine virus sheds in the stools of vaccinated children, and very occasionally reverts to a more virulent form that starts circulating in the community. Unvaccinated people are then at risk of catching vaccine-derived polio.)

Nigeria is currently experiencing the largest such outbreak on record. It started in 2005 and was reported to the World Health Organization and the U.S. Centers for Disease Control in September 2006. But health authorities have been reluctant to acknowledge it. Last week the CDC finally said something in its Morbidity and Mortality Weekly Review, and the Canadian Press and Science covered the story.

Why were the authorities reluctant to say anything? Religious leaders in parts of some Muslim countries, including Nigeria, have opposed the polio eradication program as a western genocidal plot. The polio risk from the oral vaccine is the germ of truth in that false belief, although of course the vaccine prevents orders of magnitude more polio than it causes. Authorities feared that acknowledging the Nigerian VDPV outbreak would give credence to the claims of anti-vaccine imams. Instead, of course, suppressing news of the VDPV outbreak has given credence to those claims.

The decision to take the thimerosal out of as many pediatric vaccines as possible has been keeping company with the tendency to deny that thimerosal could conceivably be dangerous. The two add up to a bad mixed message.

How to make precautions reassuring, not alarming.

I very much doubt Paul Offit’s claim that parents’ “faith in the vaccine infrastructure was shaken” simply by the decision to take the thimerosal out of pediatric vaccines. I don’t have any evidence, and he doesn’t cite any either. But I’ll bet that the parents most affected by this decision were the ones who were following the controversy and already resented the one-sidedness of the official stance. Those parents noted the incongruity of intransigent rhetoric accompanied by responsive policy change. They deduced that the public health profession’s acts were a better guide to truth than its words – that thimerosal must be dangerous and that the authorities must have decided to correct the problem without ever admitting the problem.

In other words, it was mostly the absence of candor and the appearance of hypocrisy that shook some people’s faith in the vaccine infrastructure.

That said, Offit has a point: Unnecessary precautions are not usually a good strategy for reassuring people who are mistakenly worried.

I explored this question in laborious detail in a 2004 essay on the risks of mobile telephones and telephone towers (masts). Entitled “Because People Are Concerned: How Should Public ‘Outrage’ Affect Application of the Precautionary Principle,” the essay was initially commissioned by Vodafone. I concluded:

Governments can best help reassure their publics … by telling them what they can do if they’re concerned: offering people a range of voluntary individual precautions to match their varying levels of concern. People who are concerned, alarmed, frightened, or outraged feel better if there are things they can do – things they can decide to do – to exert control over perceived hazards. This is true whether the hazard is sizable or not, and whether the precaution is effective or not.…

In addition, … research, education, and labeling are all appropriate responses to public concern.…

By contrast, in the face of existing public concern government precautions (“here’s how we are protecting you”) and government warnings (“here’s how we urge you to protect yourself”) seem likelier to backfire, to be alarming rather than reassuring – even if accompanied by a rhetorical disclaimer (“because people are concerned” or “just to be on the safe side”).

Policy-makers, practitioners, or researchers may eventually find ways of taking precautions or issuing warnings that reliably reduce people’s concern, that help resolve risk controversies instead of reinvigorating them at a higher level of protectiveness. If such reliably reassuring precautionary approaches materialize, then a PP [Precautionary Principle] response to public concern may begin to make sense. Until then, the PP should be seen as a strategy for protecting people from uncertain risks, not as a strategy for reassuring them about those risks.

Since then, several empirical studies by Peter Wiedemann and colleagues have documented that government precautions against mobile telephone risks tend to exacerbate people’s concern about those risks.

So what would it take to make a government precaution – such as taking the thimerosal out of vaccines – reassuring rather than alarming? In the absence of any relevant research, here’s my best guess:

• Keep your rhetoric as conciliatory as your actions. That is, acknowledge that while the weight of the evidence suggests the risk is probably low or non-existent, there is some evidence to the contrary. If you haven’t been one-sided, recalcitrant, and defensive from the outset, taking a new precaution doesn’t make you look like a liar – just a cautious decision-maker.
• Acknowledge the role of common sense in the decision. Whatever the evidence says, we know mercury is a poison. Even though you believe the small amount of thimerosal in vaccines has no measurable effect on health, you have found a way to accomplish the desired antibacterial effect without a known poison. So much the better.
• Attribute the change to the power of opposition groups. By far the easiest way to establish that a new precaution isn’t hypocritical is to concede that it’s a response to pressure. “If you’re so sure thimerosal is safe, why are you removing it?” “Because our critics won that fight!”
• Explain the practicality of the decision. Whether it’s a genuine risk or not, a vaccine that significant numbers of people fear to take (or to let their children take) isn’t an effective vaccine. You’re not just deferring to your critics; you’re deferring to reality.
• Try to offer choices, so the control is in the hands of the individual patient or parent. It would make good risk communication sense to offer alternative vaccine formulations. The thimerosal-free vaccine is for people who are worried about the possible autism connection. The “traditional” vaccine is for people who prefer the tried-and-true version, which is likely to be less expensive because it doesn’t have to be packaged in single-dose vials. People who can choose which vaccine to take are less likely to choose neither.

Comment:

I have attended one of your seminars (Alice Springs, Australia, November 2005) and often browse your website. My colleagues are sick of my Sandman stories.

I have a question I do not have a ready outrage management case for – but I am convinced the theory can be applied in this instance.

The individuals from the environmental regulator that I have to deal with are usually inexperienced, with no practical or field experience. This fact is not going to change in the foreseeable future, due to the state of the resources industry worldwide and the relative salary of the regulator versus the industry. I regard this challenge as the highest priority the industry has at present.

To deal with this issue, my company’s practice to date has been to meet quarterly with the regulator, together with other companies’ environmental staff. The agency approached the industry with this request to meet. At these meetings, there are planned presentations, and discussion in general terms of typical industry mitigation measures for the usual environmental impacts such as air or water.

When dealing with matters of licencing, individuals within the regulatory agency often “put up the shutters” – they do not ask questions of understanding and become very defensive. There is then the circle of requesting more information, deferral to others, and long delays.

How would you manage this situation?

Peter responds:

It’s not unusual for experienced and knowledgeable industry professionals to find themselves working with regulators who know much less than they do. As you point out, the salary differential between regulatory agencies and companies is part of the explanation. Also, many agencies move their people around, and then (if they don’t lose them) promote them into management, leaving individual projects, facilities, and controversies in the hands of comparative newcomers.

It’s tough enough to manage a subordinate who still has a lot to learn. It’s much tougher to manage an inexperienced boss. And it’s toughest of all to manage a regulator who’s rightly feeling inadequate.

There’s likely to be outrage on both sides of such a relationship.

Company people get understandably frustrated at being sent a regulator who doesn’t really know the job yet. It must be infuriating to be subject to the judgment (or what may feel like a whim) of an enforcement officer whose power exceeds his or her technical knowledge and procedural wisdom.

But it’s also extremely painful to be in the novice regulator's shoes – to be expected to know what to do, to realize that there’s a lot you don’t know yet, and to try to figure out how to learn on the job without screwing up. Beginning regulators often feel their only choices are to fake it and hope for the best or to confess their inadequacies and thereby put themselves at the mercy of the very companies they’re supposed to be riding herd on. It’s not surprising that regulators so often choose to hide their self-doubts in what looks like arrogance and arbitrariness.

The situation is a setup for conflict. Some of the following suggestions may help.

• Remember that it’s not the regulator’s fault that he or she has been thrown into the deep water and ordered to learn to swim. Nor is it your fault. You both have a grievance, but it’s not with each other.
• Manage your own outrage (and the outrage of your colleagues). Otherwise it will be next-to-impossible to do a good job of managing the regulator’s outrage.
• Resolve now that complaining to the regulator’s boss is not likely to be a good strategy, no matter how tempted you may be. Odds are a complaint will make the regulator feel all the more precarious and therefore act all the more peremptory. Odds are it will also force the boss to rally behind his or her subordinate. Appealing the regulators’ decisions up the agency hierarchy is similarly likely to do more harm than good. So is asking for a different project manager.
• Find empathic ways to acknowledge the regulator’s dilemma. This can’t be done too overtly. (“It must be hard to be so incompetent” isn’t empathic!) For specific suggestions, see my column on “Empathy in Risk Communication,” especially Section 3.
• Make it clear to the regulator and to agency management that your company would like to help find a way to get valuable training to financially strapped regulatory bodies. Show you know this is a sensitive issue. Share the dilemma by saying something like this:

  Well-run companies have a stake in fostering state-of-the-art regulatory oversight. So it’s in our interests to help. But of course you can’t afford to take your guidance from us. Can you think of a way we can support agency training without biasing it or appearing to bias it?

• Companies and government agencies sometimes give Technical Assistance Grants (TAGs) to community groups, so they can hire the technical advisor of their choice to help them deal with complex ongoing issues. I have never heard of a company giving an agency a TAG – but maybe it's a possibility.
• Think about offering to pay for the regulator to get some training from trusted third parties, such as academic institutions. Better yet, pay for your people to go get the same training at the same time. (Along these lines, I have occasionally had corporate clients pay for me to do an outrage management seminar for regulators, and often had corporate clients invite the regulators to my outrage management seminar for them.)
• To take away most of the odor of bias or patronization, consider your regulator’s need for training the next time you’re about to be assessed a fine. Ask whether there’s a way to convert part of the fine into an agency continuing education budget. If they’re making you pay to get them the training they need, they’re a lot less likely to feel manipulated or demeaned.

Comment:

I am working on a freelance magazine story about two University of Oregon graduates who both hold risk communication positions. I wanted to ask you two questions.

1. What different strategies or approaches are called for in communicating during a pandemic, as opposed to an episode such as a flood or an earthquake?

2. What do people in the risk communication field know now that they weren’t aware of five years ago?

Peter responds:

What’s unique about pandemic communication?

In most ways pandemic communication is like any emergency communication. As in most emergencies, for example:

• The situation is fluid and uncertain.
• People are upset and rightly so.
• A core communication task is to help them bear their feelings and act wisely.
• The most usual communication errors are over-reassurance, over-confidence, and disparagement of the public’s emotions.

But pandemics are also different in a few important ways:

• Infectious diseases provoke more dread than most emergencies.
• Pandemics last much longer than most emergencies – months and years rather than minutes or days.
• Pandemics happen everywhere (that’s what the “pan-” means), so people can’t come in from the “outside” to help.
• The available precautions and responses probably can help only a little, at least until a vaccine becomes available.
• It’s hard to arouse people before the pandemic starts to take the risk seriously enough, since it’s just “the flu.”

For the most part, these differences don’t really indicate a need for a different sort of crisis communication. Mostly they tell us that it will be both harder and more important to do pandemic crisis communication properly than in the case of most other crisis situations.

What’s new in risk communication?

I’d say the two biggest changes within the risk communication field in the past five years are these.

First, the field is much bigger. Five years ago there probably wouldn’t have been two Oregon riskcomm grads for you to write about. This is good news in many ways – but not in all ways. As the label “risk communication” has become trendy, lots of communication professionals have rebranded themselves as risk communicators without altering their skills and inclinations.

Former science educators who thought the job was to “teach the public what we know” still think so; former PR people who thought the job was to put a good face on bad facts and control the spin still thing so. These people may now call themselves risk communication experts.

Meanwhile, the real risk communication experts are discovering that their core problem isn’t really figuring out how to communicate with stakeholders about risk. Rather, it is figuring out how to persuade our clients (and employers) to do what we advise. That’s the second major change.

Although there are still plenty of unknowns and disagreements within the risk communication field, these pale to insignificance compared to the huge gaps between what we know already and what practitioners in government and industry tend to do. So more and more effort has started to focus on identifying and overcoming the organizational, cognitive, and emotional barriers to adoption of risk communication best practices.

Of course we still need to keep delineating what those best practices ought to be. But today’s cutting-edge risk communicators are at least as preoccupied with how they can get through to the client as with how the client can get through to the public and the stakeholders. This is altering the nature of risk communication research, consultation, and above all training.

Comment:

How do you gauge information security risk appetite before conducting a security risk analysis?

My financial advisor recently sent my wife and me a questionnaire entitled, “Investor Risk Tolerance Indicator.” Its apparent purpose is to gauge our (financial) risk appetite.

This inspired an idea: What if we (the community of infosec professionals) were to create a questionnaire for our clients/employers along the same lines: an “Information Security Risk Tolerance survey.” Have you ever seen or heard of such a thing?

It seems to me that Business Impact Analyses and risk analyses are related, but not quite the same thing as a risk tolerance analysis. The BIA determines the business impact of different types of events, but it does not determine the organization’s appetite for information security risk. Likewise, depending upon how one defines “risk analysis,” a risk analysis may or may not include a step that determines risk appetite. Some definitions/methodologies, including ISO Guide 73 (which really just defines risk analysis terminology), presuppose that the risk appetite of the decision-maker has been determined prior to conducting the risk analysis.

The more I think about it, the more I like my financial advisor’s approach / the ISO Guide 73 approach, whereby the risk analyst first attempts to get the decision-maker to define his/her risk appetite, and only after that input is provided does the analyst offer risk recommendations. I have to confess that when I have done formal security risk analyses in the past, I have attempted to gauge the client’s risk appetite during the risk analysis activity itself. In retrospect, I’m now beginning to think that was a mistake, and I should have determined the risk appetite first. That enables the security risk analyst to attempt to tailor mitigation strategies based on the client’s expressed risk appetite. There is still a chance that the client may reject the risk analyst’s recommendations, but the approach of first defining the risk appetite should make the prospect of rejection by the client less likely.

Your thoughts?

Peter responds:

I’ve done too little thinking about risk tolerance and risk appetite – but now you’ve got me started!

First of all, you use these terms interchangeably. That makes sense if you work in an area (like information security) where risk ranges from intolerable to tolerable but couldn’t possibly be attractive. But some risks for some people are better than tolerable; they’re sought out. The thrill of risk-taking is the essence of many recreational activities, from bungee-jumping to mountain-climbing. And it’s part of the appeal of some occupations (think about fighter pilots), which makes it a lot harder to enforce safety rules.

So we should envision a risk variable that stretches from attractive at one end to intolerable at the other, with tolerable in the middle. Better yet, we should probably envision two different variables. The risk appetite question is about the risk itself: How appealing or unappealing is this particular risk to this particular group or individual? The risk tolerance question looks not just at the risk but also at the various downsides of reducing the risk, of which cost is usually the biggest. When we ask about risk tolerance, we’re assuming that the risk is unappealing rather than appealing, and we’re proceeding to a more complicated question: Given what it would take to reduce this risk, how much of the risk do you prefer to bear instead?

Think about your financial advisor, for example. Let’s assume that you’re not a recreational investor who actually enjoys financial risk; investing isn’t your alternative to bungee-jumping. Can you meaningfully answer questions about how much risk you consider tolerable without first knowing the relationship between risk and return? You can probably say something generic about your ability to sleep well during a stock market rollercoaster ride. But whatever your personal financial risk tolerance algorithm, you will surely tolerate more risk for an investment with huge potential profitability than for one with only a modest upside. In order to evaluate a financial strategy that reduces your risk – switching from penny stocks to index funds, say, or from index funds to your mattress – you will want to estimate not just how much risk reduction you’re buying, but also how much profit reduction you’re paying.

If this makes sense, it follows that risk appetite can be assessed on its own, but a risk tolerance assessment needs to wait until you have analyzed the costs and benefits of various risk management options.

In fact, one of the advantages of asking people how risk-tolerant they are is that it forces them to consider the costs of a precaution, as well as its benefits. Over the Labor Day weekend I read about a recent salmonella outbreak in spinach. It was fairly well-contained by a new program of voluntary testing, under which the grower found and recalled the contaminated batch before much of it had been consumed. So far, no illnesses have been reported. But in the news story I read, a Consumers Union spokesperson was expatiating on the inadequacy of this program. “Eight thousand cartons left the plant for distribution in the U.S. That’s 8,000 too many,” CU’s Jean Halloran told the Associated Press. I wanted to ask Halloran a few risk tolerance questions:

• Does she really think that growers should distribute no produce at all until after testing is complete, as her “8,000 too many” quote claims? Is zero really the only salmonella risk level she considers tolerable?
• Does CU have a salmonella risk management plan that will accomplish this?
• What is the cost of the plan – not just in dollars, but also in diet? Suppose the only way to get the salmonella risk from fresh produce down to zero is to abandon fresh produce altogether. If everything is canned or frozen, it will be easier to sit on it all till the testing is over. Does Halloran consider that preferable to tolerating a non-zero risk of salmonella?
• Fresh spinach consumption still hasn’t recovered from the September 2006 E. coli outbreak. I don’t know what has replaced the spinach. Other fresh produce? Canned or frozen vegetables? Meat? Doritos? Does it matter, in Halloran’s judgment?
• How much further decline in fresh spinach consumption is likely to result from this new salmonella controversy? How much further improvement in grower safety precautions is likely to result from the controversy? Does Halloran care whether the controversy might do more harm than good? Should she care?

As a risk communicator, I’m especially interested in distinguishing the hazard component of risk tolerance from its outrage component. Years ago, I worked with an environmental advocacy group that was engaged in a campaign against industrial dioxin emissions. Scientists had just found detectable levels of dioxin in human breast milk – an irresistible message point for the campaign. The communicators wanted to blame industry for making it unsafe for mothers to nurse their babies. One of the group’s scientists objected. Despite the dioxin, she said, nursing is still better for babies than bottle-feeding – and an honest and socially responsible campaign should say so. We came up with messages that did say so, while still bemoaning the contaminated purity of the nursing experience.

Similarly, I would have loved to read something like this from Halloran:

Fresh produce and especially fresh spinach is a wonderful, healthy food. If the only choices were eating fresh spinach with a small probability of salmonella or not eating fresh spinach at all, I would keep eating fresh spinach. In fact, I do keep eating fresh spinach. But I am angry that the spinach industry still isn’t doing everything it should to get the salmonella risk as close to zero as possible.

When it comes to communicating about risk tolerance, nobody has clean hands. Too often, activists and government regulators pretend the risk should be zero, while industry pretends it is zero. What we desperately need is a candid debate over the core risk tolerance question: Given the cost and other downsides of the available ways to reduce this risk, how safe is safe enough?

Comment:

I recently attended a national workshop on risk communications and homeland security.

Of what I saw, the most focused program appears to be from the folks at the Centers for Disease Control and Prevention. Their “Crisis and Emergency Risk Communication: By Leaders, For Leaders” training packet is at least interesting in that it emphasizes leadership above all other factors.

In other words: No one really remembers what Rudy Giuliani said or did in the 9/11 aftermath. They just remember that he led.

What do you think?

Peter responds:

It’s interesting that you thought the CDC approach was the most “focused” at the conference you attended. I have seen the CERC materials, and like most of the CDC riskcomm stuff I’ve seen, CERC is a mix. The people who put it together intentionally included advice from a range of perspectives, sometimes incompatible ones. (Respond to “what-if” questions. Don’t speculate or address hypotheticals.)

Considering how strongly CDC believes in speaking with one voice, a view I don’t share, it certainly puts out materials that speak with a whole bunch of voices, without trying to reconcile the contradictions or even acknowledging them. That this potpourri approach to risk communication strategy was more coherent than anything else at the conference says a lot!

On the notion of Leadership Über Alles, I have mixed feelings. It is true that a good leader has to do more than worry out loud and wring his or her hands. It’s true that people either feel they’re in good hands or feel they’re not. And it’s true that in fearsome situations feeling well led contributes to cooperation and sustains morale; paradoxically, feeling well led also helps people exercise their own autonomy.

But it’s also true that good leaders need to share what their publics are feeling, including uncertainty, confusion, and even fear. They need to be role models of how to function well while feeling those things, not “role models” of finding it easy to function well because they’re feeling nothing.

The problem is that most would-be crisis leaders think leadership is about projecting strength without doubt, a John Wayne / General Patton kind of thing. But that’s only one kind of leadership – and one that backfires badly most of the time it’s attempted. Rudy Giuliani thinks what he did right after 9/11 was to demonstrate that he was a take-charge guy who wasn’t cowed by a terrorist attack. But what he really did right, as evidenced by his iconic “more than any of us can bear” quotation, was to voice what the public was feeling. (He started, minutes after the attacks, by validating what the public was seeing on TV.) He provided the kind of leadership we desperately needed – notwithstanding some errors such as not requiring rescue workers to wear PPE. But he doesn’t know what he did right, and his advice will lead others to lead badly.

rusty replies:

About an hour after I wrote to you, I found your most recent online column, “Empathy in Risk Communication.”

I read and reread the paragraph where you examine what Rudy did right in the 9/11 aftermath. And you’re dead on. It’s the empathy that resonates, though that’s likely a hard sell on the campaign trail. And given Rudy’s background as a “tough on crime” prosecutor, he’d probably rather be known as a tough leader than an empathetic one.

Perhaps we should define “effective crisis leadership” as some blend of strategy and empathy. The strategy says, “Here’s where we are, here’s where we’re going and here’s how we’re going to get there.” The empathy says, “Here are the fears and the sorrows we share as a community, and it is valid for us to feel these emotions.” (Of course, this only works if the speaker is actually a part of the community. If it’s an outrage situation, as you point out in your column, taking this approach can lead to fireworks.)

A guy like Rudy is more likely to acknowledge the strategy half of the prescription; a guy like Bill Clinton is more likely to acknowledge the empathy half. But you gotta have both to be effective.

At least that’s how it appears for the moment, in the aftermath of reading your column, studying the CDC manuals, and thinking over the DHS workshop. I’m not at all settled on this notion.

Odd that you should mention Patton. Over the weekend, I stumbled upon the actual text of the speech he gave many times to U.S. troops just before the Normandy landing. A version of that speech opens the George C. Scott movie. One paragraph struck me as especially relevant:

Some of you men are wondering whether or not you’ll chicken out under fire. Don’t worry about it. I can assure you that you’ll all do your duty. The Nazis are the enemy. Wade into them. Spill their blood. Shoot them in the belly. When you put your hand in a bunch of goo that a moment before was your best friend’s face … you’ll know what to do.

Brutal? Yes. But highly effective because it’s also empathetic. What soldier doesn’t worry about chickening out under fire?

In that speech, Patton combines his strategic approach to war (“We’re advancing constantly and we’re not interested in holding onto anything except the enemy”) with astounding empathy for his audience: “Thirty years from now, when you’re sitting by your fireside, with your grandson on your knee, and he asks: ‘What did you do in the great World War Two?’, you won’t have to shift him to the other knee, cough, and say, ‘Well, I shoveled shit in Louisiana.’”

And he did it in preparation for what any leader would consider a crisis of astronomical proportions: D-Day.

Patton was a brutal bastard, no doubt. But there’s a reason he resonates 60 years after his death. It’s his empathy, not his gung-ho attitude.

But I agree with you. When most CEOs and other leaders emulate Patton, they obsess over the “gung ho” and completely miss his ability to empathize with the fears of the common soldier.

Peter responds:

I like your formulation that crisis leaders need to provide both direction and empathy.

This isn’t a new thought, of course. (What is?) I remember reading about “effective” (task-oriented) and “affective” (relationship-oriented) leadership more than 40 years ago in an undergrad social psych course. And I remember thinking then that the terminology was unfortunate, since the key finding was that genuinely effective leaders needed not just the practical “effective” skills but also the emotional “affective” ones. (Not to mention the inevitable bewilderment of people who tend to confuse “effect” and “affect” to start with and are unfamiliar with the noun “affect” meaning emotion.)

I don’t follow the leadership literature closely – neither the research literature nor the hortatory literature nor the (auto)biographical literature – but my impression is that many business leadership gurus have focused big-time on the affective (emotional) side. That is, a lot of business leadership theory puts a premium on empathy, at least for the moment.

Yet homeland security officials imagine that in a crisis there’s no time for empathy – that crisis leaders need to lead from their “effective,” John Wayne side. I’d suggest the opposite; people in crisis situations need leaders who are more empathic than in normal times, not less. (See “Are empathy and compassion really what matters in mid-emergency?”)

What’s most interesting is why so many officials who have actually done the job – led their publics through a difficult crisis – look back and see only the gung-ho aspects of their success, not its empathic aspects. It’s not just Giuliani (or Patton). The CDC’s “By Leaders For Leaders” materials have the focus they have because that’s what the crisis leaders who were interviewed said. How can a mere consultant contradict the officials who actually led the way through 9/11, anthrax, SARS, etc.? Yet I am very sure their recollections are one-sided.

When crisis veterans look back at their own performance, why do they consistently emphasize their task leadership so much more than their emotional leadership? It may be political posturing in the case of Giuliani, but surely not for all the others too.

My best guess: some kind of amnesia/denial, plus a limiting preconception about what leadership means. I believe they were good leaders precisely because they were finding it emotionally difficult to cope, coped anyway, and let both the difficulty and the coping show (not just the coping). That’s what made them role models, what enabled them to inspire and hearten their publics. But in hindsight they have made their memories conform to their opinions about the nature of leadership. I think they must genuinely remember themselves as having been much calmer (inwardly) and less emotionally available (outwardly) than they actually were.

elenor (peter’s webmaster) chimes in: (with peter’s approval)

My best guess would add to your best guess the split between public persona and private emotional self.

The leaders who can empathetically present information during a crisis probably don’t see exposing their own emotional state as “leading” – they may see it as their own emotional selves “slipping out from their control.” It’s not seen as good leadership to let the people you’re leading see that you’re not all-knowing, all-seeing, and completely able to protect them. (I expect that’s more a personal and unconsidered belief on the leader’s part than the actual view of most of the people looking to the leader.)

When these leaders look back and try to report “dispassionately and accurately” on how they decided what to do or chose what to say, they don’t see value in their own emotions (and the empathetic actions/words that resulted). All they see is a failure on their part to repress or control their own emotional responses.

Comment:

I am concerned about communicating with newly arrived, foreign-born populations (refugees) and the accompanying cultural and language concerns. Are there any observations you would make about risk communication, education, motivation, etc., in that arena?

Refugee resettlement (and health) programs are struggling to be “at the table” in panflu planning, and any advice you might have would be appreciated.

Peter responds:

Although you frame your question in terms of refugees, most of the foreign-born are simply immigrants, not necessarily refugees. The risk communication issues are pretty much the same. On the other hand communicating with illegal immigrants raises special concerns, since they have reason to fear contact with officialdom, including health officials. I’ll leave those problems aside, and focus on panflu communication with recent (legal) immigrants.

Let me start by acknowledging something that’s difficult and painful to acknowledge. Experts agree that cultural and linguistic barriers pose a very tough challenge when trying to communicate with foreign-born populations, especially those who are newly arrived. Experts also agree that communicating about pandemic flu is a very tough challenge under the best of conditions, especially now when the level of interest is low. And experts agree that many immigrant communities face more urgent threats to their wellbeing than the prospect of an influenza pandemic one day.

When you put these facts together, you can make a good case that addressing recent immigrants should not be a priority for panflu precaution advocacy – that is, for talking to people now about a possible future pandemic. With limited resources, it makes sense to focus on audiences that are both easier to reach and, once reached, likelier to judge that pandemic preparedness deserves some of their time.

But writing off some of our country’s most vulnerable people feels profoundly wrong. So here are some suggestions.

Whether or not recent immigrants are targeted for pandemic precaution advocacy now, there needs to be planning and preparation now to reach them if and when the need becomes urgent. This is an important distinction. Establishing relationships now with the leadership of immigrant communities (and other demographically isolated communities) is essential. Those leaders should be offered a role in pandemic planning, including pandemic communication planning, to ensure that their communities are not neglected when a pandemic looks imminent.

There also needs to be some pre-crisis communication now aimed at the immigrant rank-and-file. At the very least, they should be told what might happen, what it might be like, and where they can go for more information (in their language) when the time comes. On the tougher question of how aggressively to urge them to fully inform themselves now, stockpile food and medicine, etc., I would tend to defer to the judgment of their leaders.

Robert Littlefield and colleagues at North Dakota State University have been studying ways of doing risk communication and crisis communication with cultural and linguistic minorities. One of their findings: Such communities tend to mistrust governmental authorities on grounds that they don’t understand the community’s values and needs, but they also lack confidence in their own leaders on the grounds that they don’t have access to the levers of power and confidential information. Communication is most effective when the source is a team: an outsider who has the credibility of establishment power paired with an insider who has the credibility of community membership. For more on his important work, write Dr. Littlefield at r.littlefield@ndsu.edu.

Perhaps the most important thing I can say is this: Pandemic preparedness planning should be mostly a neighborhood activity anyway. Federal, state, and even city government agencies are too big; they should be planning how to keep the hospitals and power plants running, but they’re not going to have much impact on individual preparations. But the household is too small a planning unit. It is neither logistically efficient nor emotionally sustaining to plan for catastrophe one family at a time. We need to start seeing neighborhood churches, neighborhood civic organizations, and neighborhood schools taking a leadership role in pandemic preparedness.

Once that happens, some of the disadvantage of immigrant communities disappears. Linguistic and cultural minorities have their own places of worship and their own civic organizations – in many cases stronger and more vibrant ones than the mainstream. They are already well-integrated into neighborhood schools. It’s genuinely difficult for the Department of Homeland Security to communicate with, say, a Hmong enclave in Minneapolis – which is why DHS is funding Dr. Littlefield’s work. But the Hmong have no special difficulty communicating with each other. It’s only when we see pandemic preparedness as a governmental task that cultural and linguistic minorities pose a uniquely challenging problem.

Comment:

Now that there is no shortage of Tamiflu, is it ethical to begin stockpiling it?

Peter responds:

In our January 2006 column “The Dilemma of Personal Tamiflu Stockpiling,” Jody Lanard and I argued that it might be best overall if a country’s Tamiflu supply were centralized, but it was best for the individual to have his or her own stockpile. That’s what made it a dilemma. We supported personal stockpiling, albeit with some reservations. I revisited the Tamiflu stockpiling dilemma in a March 2006 Guestbook entry entitled “More on Tamiflu ethics and psychology.”

In February 2007, when someone wrote to ask “Why do I want the government to control all the Tamiflu?” I pointed out that I don’t. I added that the dilemma had eased significantly by then, at least in the U.S., since so many state governments had decided not to buy all the Tamiflu the feds had allocated for them. I can’t see how any government can pass up the chance to add to its stockpile and still plausibly argue that individuals are ethically obligated to leave all the Tamiflu for the government’s stockpiles.

I considered the matter one more time in an April 2007 Guestbook entry on “Corporate Tamiflu stockpiling.” Since there was no longer a Tamiflu shortage – and in fact Roche had announced production cutbacks because of a surplus – I asserted that the dilemma “has pretty much disappeared.” I added:

It will no doubt arise again if a pandemic materializes and if Tamiflu is useful against the pandemic strain of influenza. But for the moment there is apparently enough Tamiflu being manufactured to meet all existing demand.

What has changed since then? Nothing, really.

But there is one development worth reporting. The overriding assumption of most countries’ Tamiflu policy (and their policy for all antiviral medications that might work against a pandemic flu strain) has been that Tamiflu should be used to treat people who already have the flu. The hope is that it will reduce the severity and length of their illness, thus reducing the case fatality rate, the burden on hospitals, and the job absenteeism problem. The evidence supporting this strategy is mixed. Tamiflu apparently won’t do much good unless it’s taken very soon after the onset of symptoms – and some experts say it probably won’t do much good even then.

It was always clear that Tamiflu (and other antivirals) could be used preventively instead. The case against prophylactic (preventive) use of Tamiflu was simply that there couldn’t possibly be enough for ordinary people to just keep taking it whenever the pandemic was in town … or even whenever a close contact was sick. Tamiflu is used now to prophylax people who have had intimate contact with bird flu victims (human or avian). But the conventional wisdom is that once a pandemic arrives there won’t be nearly enough of any antiviral to use it that way.

At least one government, Australia’s, disagrees. Australia has decided that it makes better medical sense to plan to use antivirals for prophylaxis than for treatment. It has therefore accumulated a bigger pandemic stockpile (proportional to population) than other countries, including the U.S., that plan to use their antivirals for treatment.

Obviously, a prophylactic stockpile needs to be hugely bigger than a treatment stockpile – whether it’s for your family or your country (or anything in between). If the experts start to think Australia has the right idea, we may be looking at Tamiflu shortages and stockpiling ethical dilemmas again.

Comment:

Wow! “Empathy in Risk Communication” is wonderfully insightful, illuminating, reasoned, relevant, and entertaining. I greatly admire you for expanding an essential tenet of risk communication with a rationale and foundation that so effectively reveals the mechanism of its power. I believe part of what I just said is a performative. I really do want you to know how much I gained by carrying your words with me as I fly tonight from Atlanta to Seattle to start my holiday. Time flies when you get a good read. I can’t imagine how long it took to distill and organize these concepts but sense it was a labor of love. And I’m not making fun using some of the empathic principles in this praise. I really mean it, Peter, you done good.

I’m also feeling a bit cocky because I recognize how I’ve used many of these tools in my discussions without realizing (or analyzing) it. That, I believe, is essential to convincing, sincere communication. I assume you believe that as well, through your assertion that your essay is “not a cookbook,” but rather a guide. I hope all who read it will find guidance for any necessary course correction in their discourse, a few new arrows in their quiver when they are communicating through challenging situations, but mostly confidence that “what comes naturally” (assuming it does) is apt to agree with the experts. Manna from Havens it is! (Pun intended.)

In Part 1 you describe empathy, at a minimum, as attitude: “You are genuinely trying to get how your stakeholders feel.” I would suggest the point of that pursuit is to somehow demonstrate (communicate) that understanding. So empathic communication is very bilateral in that we discover by ear, eye, and intuition; and affirm by body, eye, word, and heart. It occurs to me that empathic communication employs the brain to engage the soul. That’s what makes it so impossible to fake or mistake. If it’s real, people on both sides of a controversy know it in their core. You’ve helped explain why that’s so.

I like the idea of expressing anger selectively and appreciate your admonition to gauge communication strategy by the motivation behind it. This requires the gift of honest introspection. Communicators can’t kid themselves about this. If we want to be truly empathetic we pretty much have to deny self in favor of stakeholder. Of course, in achieving successful risk communication we have something to feel good about, so there is probably a subliminal paradox buried in there, i.e., we get what we want by rejecting instant gratification. Am I getting this right? This approach, it seems to me, requires abundant patience, but more than that, a respect for our stakeholders based on a confident understanding of human nature – including our own.

To “try to feel your way back into their shoes” is, I agree, not to empower bad behavior, but to respect a perspective born of diverse life experience. In this discussion you help us take on a sufficiently thick skin without allowing it to block our ear canals.

You suggest that the cold fish official who showed no emotion in hearing the crying mother talk about her child’s leukemia might be seen as more professional than the second example. I would not be as generous. While her reaction may epitomize a stereotype of professionalism, I would argue that such behavior is now known to be so damaging as to be highly unprofessional.…

Regarding deflection, to my mind, “it” is slightly more intrusive than “some people.” The thought occurred to me in thinking through the property values example. The whole notion of deflection, I believe, helps assure that risk communication principles remain applicable to diverse cultures and traditions. You are describing strategies for broaching potentially sensitive subjects, and that sensitivity is apt to be modulated by gender, age, religion, etc. The tools you offer provide a safe way of bringing issues “into the room,” as you put it, thereby testing the waters before daring to make the attempt at greater specificity.…

I’m concerned about how we can admit error in an era where sound bites are so deliberately lifted out of context for the sake of sensationalism. In a regrettably litigious society, I’m afraid there are good reasons to tread lightly with this one. Help us, if you can, figure out new ways to acknowledge shortcomings without falling prey to opportunistic legal opponents.…

I was almost afraid to read element #8, but after the skillfully deflected disclaimer I felt bold enough to plow ahead. And God knows it was worth it. My take-home is the Havens quote, “Projective statements are free offerings meant to be taken, amended or set aside.” I can identify with the notion of using these as “a gentle probe.” This stuff works in risk communication and in managing staff. And there are a lot of applications in day-to-day life.

Some people may be startled by the drilling-company-in-an-African-village anecdote. Do you really think you would ever want “to admit a painful truth: If we could do it to you again, there’s a good chance we would”? I would never go that far because to do so would, I think, leave a perpetual impression that the only way we can keep ourselves from exploiting the hell out of you is if you have the power to hold us in check. I’d soften this by simply acknowledging that “even if we wanted to exploit you – which we don’t – we couldn’t because….” The latter approach acknowledges our previous sin, and the theoretical temptation to repeat it, but defuses the risk by reminding the audience of its power to prevent. The point is made without unnecessarily aggravating or perpetuating distrust.

I agree with Jody that it does feel like an oxymoron to operationalize empathy. But you have succeeded in helping us understand the power of creating intimacy with our audiences without laying a hand on them.

Thank you so much for advancing the field in this way. I believe your work saves lives. It really does.

Peter responds:

Thank you for your lovely response to my Empathy column. (And thank you for plowing through it at the start of your holiday!)

I want to comment on two of the matters you raised: (a) empathy as something we do intuitively, a skill set that the column reaffirms rather than introduces; and (b) the risk of admitting wrongdoing, and especially of admitting that one might continue to do wrong if one could still get away with it.

Intuitive versus analytic empathy

You wrote that you have used many of the empathic approaches in the column “without realizing (or analyzing) it,” and suggested that the main contribution of the column may be to reassure people that “what comes naturally” is likely to be the right thing to do.

I am certain that is true for you. As Jody wrote in an offline email, you’re “like a kid with an innately great sense of direction who is thrilled when he learns that the outside world actually has words for ‘left,’ ‘right,‘ north,’ and ‘south.’ He already had the concepts, but didn’t know there was this language to systematically describe and apply them.”

But that’s not true for everybody. There are intuitive empaths and analytic empaths. I actually did some research on this as a psych undergrad in the 1960s. I found that intuitive empaths scored worse when they were asked to use analytic skills to understand other people than when they just made intuitive, global guesses; while analytic empaths had comparatively poor intuition and did better when they used an analytic approach.

Similarly, I used to teach technical writing courses to engineering students, most of whom lacked much intuition for what makes a good sentence. They tended to feel resentful when writing instructors told them they needed to develop an “ear” for language and sentence structure, pointing out that their engineering instructors never expected them to intuit whether the physical structure they were designing would stand or fall. So I tried to offer them guidelines – not a cookbook, but not just a suggestion that they use their intuition either.

That’s what I was trying to do in the Empathy column.

I really enjoyed your self-conscious, intentional use of the various empathic elements in your comment. That’s fun to do. But more than that – it’s genuinely useful. For people whose empathic skills are mostly intuitive, using these elements consciously makes us temporarily self-conscious. (During the time I was writing this column, Jody and I found ourselves using the elements constantly, seeing them in everything we were reading, hearing them in conversations.) But they quickly fade back into the background – maybe, as you say, with a few new arrows in our quivers.

For people who don’t find the elements of empathy so intuitively comfortable, using them consciously may be an essential first step. Of course it can feel incredibly awkward at first. But in time it becomes more fluid – maybe even intuitive. Practice (in both listening and speaking) leads to habit. One of the points of Jody’s “Afterword” was to acknowledge the self-consciousness that can accompany analyzing one’s own utterances – and to support the effort to continue despite the self-consciousness and get past it.

Empathic stakeholder relations doesn’t come naturally to a lot of people, including a lot of corporate and government officials. Aside from being, perhaps, more analytic than intuitive in their personal styles, they may be derailed by defensiveness, anger, and other feelings that come a good deal more naturally than empathy. I am delighted that you felt heartened and validated by the column. I believe some other readers may have felt challenged or even out of their depth. I hope some felt guided toward new skills.

By the way, I love your phrase, “Empathic communication employs the brain to engage the soul.” Wonderfully said! And a wonderful merger of the analytic and the intuitive.

Admitting wrongdoing

I take your point about the danger of admitting error and opening oneself up to litigation. But if the error has been committed and is known to have been committed and can be proved to have been committed, I would argue that admitting it reduces people’s inclination to sue more than it improves their ammunition for the suit. So even in the legal arena it ought to do more good than harm.

I tell my clients that the pros and cons of keeping secrets are debatable, but that there are only cons to refusing to admit a negative that isn’t secret anyway. Certainly it is more empathic to concede the bad things stakeholders already know about you than to ignore them or deny them.

Nonetheless, I rarely find a client willing to concede, for example, that the company might continue to act like a colonial oppressor if it could still get away with doing so. That’s a bigger proactive acknowledgment than I expect to be able to sell, though I do keep trying.

I often hear the argument you made on this point: that admitting low motives dooms the company and its stakeholders to an untrusting relationship forevermore. I don’t think so. I think that if stakeholders are already convinced you harbor low motives, admitting them clears the air and improves the relationship. And I think that if stakeholders are ambivalent about your mix of motives, admitting the less admirable ones helps them stay aware of the more admirable ones, in keeping with the seesaw principle. I see only one situation where the admission does harm, at least in the short term: if it has never occurred to your stakeholders that your motives might be anything but pure. I doubt this is likely when a multinational corporation is interacting with an African village.

Despite all of the above, I would happily settle for a client that took your more moderate advice: to point out that whether or not the company might want to act like a colonial oppressor, it no longer can.

Comment:

Semrad often said, “I love to kibitz and to learn. That’s why I spend my career around psych residents.” So there is no doubt in my mind that he would have loved your development and application of his work.

This article is profound and compelling for all humanistic therapists.

You may be interested to know that in my research over the last 12 years, reviewing the complete Semrad audio tapes of case conferences he chaired (over 200), there is a very compelling case in which a woman gone psychotic after moving from East Africa to Boston remembers the warmth and attachment shown her by her local witch doctor and contrasts it with the lack of understanding she has felt from her physician. While the residents are defensive, Semrad emphasizes, “People know when their deepest feelings are being heard and warmly regarded, and sometimes we don’t do it as well as others.”

Peter responds:

My wife and colleague Jody Lanard M.D. was a psychiatrist before she was a risk communication consultant. She introduced me to Elvin Semrad’s work, and particularly his advice that therapists should help patients acknowledge intolerable emotion, then help them bear it, and then help them put it into perspective.

I really appreciate the Semrad story and quotation in your comment – and of course I’m very flattered that you approve of the way I have used Semrad’s work. It’s a little scary for me to venture so far outside my own field; I couldn’t do it without Jody.

I have referenced Semrad’s “acknowledge/bear/put into perspective” formulation three times on this website. I think the article you read is probably “Talking about Dead Bodies” – so that’s the one I linked your comment to. There are briefer references to the same Semrad formulation in “Anthrax, Bioterrorism and Risk Communication” and “Beyond Panic Prevention.”

In a more recent piece on “Empathy in Risk Communication,” I leaned very heavily on the work of Leston Havens, who did his psychiatry residency under Semrad at Massachusetts Mental Health Center. Jody did hers under Havens at Cambridge Hospital. So my empathy article relies indirectly on Semrad … though it never mentions his name.

None of this is meant to suggest that risk communicators should see themselves as therapists, or their stakeholders as patients. We have neither the expertise nor the authorization to tinker with our stakeholders’ psyches. Nonetheless, the effort to be understanding and compassionate when people are upset (whether rightly or mistakenly) goes to the heart of risk communication. Semrad, Havens, and other psychiatrists have much to teach us about that effort.

Comment:

I have been researching risk and I am so confused about B. Fischhoff’s seven stages of risk communication. Why are they so confusing? I read V. Covello’s – they make so much sense.

Did Covello interpret Fischhoff’s or did Covello create his own? Do you know where I can find an explanation of Fischhoff’s stages in normal English?

P.S. Bravo to your site.

Peter responds:

One of the most frequently cited articles in the entire risk communication literature is Baruch Fischhoff’s 1995 Risk Analysis article, “Risk Perception and Communication Unplugged: Twenty Years of Process.” (The abstract is available online; so is the full text, but it’s not free.)

In this article, Fischhoff identifies seven “developmental stages” of risk communication:

• All we have to do is get the numbers right
• All we have to do is tell them the numbers
• All we have to do is explain what we mean by the numbers
• All we have to do is show them that they’ve accepted similar risks
• All we have to do is show them that it’s a good deal for them
• All we have to do is treat them nice
• All we have to do is make them partners
• All of the above

Fischhoff starts his narrative history by pointing out that in biology “ontogeny recapitulates phylogeny” and it’s the same thing in risk communication. This may be what threw you. What he means is that each individual risk communicator tends to go through the same stages that the field as a whole has gone through. He wrote the article hoping to short-circuit the process a little – that is, hoping that reading about the early stages might help newcomers skip them or at least get through them more quickly.

Vincent Covello and I have a somewhat different list. In two back-to-back presentations in the 1980s and later a 2001 book chapter called “Risk Communication: Evolution and Revolution,” we specified just four stages. They’re summarized in my handout entitled “The Four Stages of Risk Communication” as:

• Stonewall Stage: no communication – ignore the public.
• Missionary Stage: one-way communication – show the public why you’re right and they’re wrong.
• Dialogue Stage: two-way communication – learn from the public the ways in which they’re right and you’re wrong.
• Organizational Stage: internal communication – become the sort of organization that finds dialogue possible, even natural.

In 1990 I discussed these four stages in a speech to the Chemical Manufacturers Association on “Addressing Skepticism about Responsible Care.”

If this is what you mean when you refer to Covello’s stages, it was developed independently of Fischhoff’s list.

What I think is wonderful about the Fischhoff stages is how beautifully they capture the succession of excuses corporate and government officials tell themselves to avoid actually listening to their stakeholders and making them “partners.” What’s missing from Fischhoff’s list of stages – but certainly not missing from his work overall! – is our fourth stage, in which risk communicators start to realize that real collaboration with stakeholders is going to require internal organizational change.

Comment:

In her February 4 comment, Karen said she was having trouble searching through your site. She also reported that your search engine sometimes does not work.

There is a simple answer to this problem: Google. The Google search engine offers a site-specific search. To use this functionality, you can either type “site:www.psandman.com” before the search string or simply click “advanced search” from Google’s main page. The latter choice is particularly useful because you can access so many additional options for narrowing the search without knowing any of the commands Google uses to tell its search engine what to do.

Elenor’s suggestion to use Control-F to find the passage of interest is correct. If you install the Google toolbar in your browser, however, you can eliminate the extra typing, because each time you do a search, the toolbar will create buttons for each search term. To find the search term on the page, you only need to click the button. It's wonderful.

You have a fantastic collection here.

Peter responds:

Thanks for your search advice, and for your kind words about the site.

I have to agree that the search engine provided automatically by the company that hosts my website is a lot worse than Google. When I’m searching for something on the site, I too ignore my own search engine and use Google.

Until recently, replacing the site’s free search engine with Google was prohibitively expensive. But in mid-July Google announced a new site search engine that websites like mine can deploy at much less cost. I’m going to wait a few months to let the early adopters find the bugs. Then if it’s still looking good I’ll buy it.

What I would add to this site:

It’s great as is. I always enjoy your columns. Practical information – based on theory – but real-world applications.

Comment:

In preparing for a scenario (such as an anthrax attack) in which it would be essential to get antibiotics, vaccines, or other medicines to many thousands of people within one or two days, is it reasonable to expect that people will be willing to stand patiently in line? We’re being asked for “messages” that will convince them to do that.

My sense is that success will have a lot to do with perception of fairness – for instance if older individuals are moved to the front of the line, or get to wait inside rather than out in the cold. (Or if elected officials have a “VIP” line!) And what if some people have to stand in line at the neighborhood school, while others can get what they need from their employers, or via some other shortcut.

The underlying question is will people “panic” if they have to wait for something we (and the media) are telling them they desperately need in a hurry, or will they accept that this is a shared dilemma?

How can risk communication help?

Peter responds:

During the flu vaccine shortfall of 2004, I was amazed when seniors all over the country stood in line for hours waiting for their shots. I wasn’t amazed that they were willing to wait. I was amazed that the organizations dispensing the vaccine couldn’t think of any other way to organize the demand. Veterans of rock concerts, theme parks, and crowded retail establishments are familiar with a range of alternatives: “Take a number.” “People with blue tickets come back at 2 p.m.” At the very least, folding chairs could have been provided (and in some places they were).

There are additional reasons to avoid lines in planning for infectious disease outbreaks or terrorist attacks. Lines are the antithesis of social distancing – a key strategy to slow the spread of infectious diseases such as pandemic flu, where victims are contagious before they’re symptomatic. And the invaluable “Redefining Readiness” study by Roz Lasker and others at the New York Academy of Medicine found that when people were faced with a smallpox attack scenario, many strongly resisted the idea of lining up for vaccination, especially if those who were probably exposed were going to be in the same lines with those who were probably okay so far.

Bottom line on lines: They’re probably not the best way to deliver crisis medical care. The reliance of so many crisis plans on asking people to line up betrays a lack of imagination, a lack of realism, and a failure to consult with the public.

If you’ve got to ask people to stand in line, don’t expect them to do so “patiently.” In fact, risk communication suggests that explicitly validating people’s impatience (and, more importantly, their fear and anger) will help them bear their feelings better. Anticipatory guidance should also help. Organizations that cope with long lines routinely have found, for example, that people can handle the wait more easily if they are given accurate information on how long it should take from where they are currently located.

You’re certainly right about fairness. Medical historian Judith Leavitt has compared two emergency smallpox vaccination campaigns, one in Milwaukee in 1894 and the other in New York City in 1947. Leavitt tells us that the Milwaukee effort collapsed in a month of riots, allowing the smallpox to spread widely through the city, while New York’s campaign a half-century later vaccinated millions of people in two weeks and successfully controlled the outbreak. There were lots of differences between the two cities, but the biggest was fairness.

In Milwaukee, health authorities relied on home quarantine for the wealthy and the middle class, while poor residents (“the scum of Milwaukee” was the phrase the newspapers used) were taken to hospitals and forcibly vaccinated. In New York, by contrast, the strategy was universal voluntary vaccination at schools and police stations as well as hospitals, promoted with daily news conferences and with signs and buttons reading: “Be safe. Be sure. Get vaccinated.”

The 1947 New York City vaccination campaign is still celebrated as the largest mass vaccination in U.S. history. A contrarian analysis by Kent A. Sepkowitz argues that New York’s accomplishment was more flawed than Leavitt implies. But it’s hard not to be impressed by the photos: long lines snaking through the streets of the city as New Yorkers patiently awaited their smallpox vaccinations. (See this one , for example.)

Fairness is a hard concept to pin down. It’s obviously unfair to treat the rich differently than the poor (though Milwaukee’s Health Commissioner Walter Kempster thought he had good medical reasons for the distinction). But is it really unfair to let the elderly sit inside while younger people are left to stand in line outside? Is it really unfair that people whose employers have stockpiled Tamiflu (or who have stockpiled some themselves) won’t have to wait in line for the government’s supply at the start of a pandemic? For that matter, do we really want our leaders to stand in the same lines as the rest of us, or is it wiser – and maybe even fairer – to take care of them first so they can manage the emergency?

These aren’t easy questions to answer. Nor does risk communication have any particular ethical wisdom to impart. What risk communication offers is the obvious (but often ignored) advice to get the fairness issues onto the table. This is essential before the crisis, so the public can advise planners on what feels ethically acceptable and what doesn’t. It is also essential during the crisis, so people’s resentment of unfairness isn’t exacerbated by the pretense that there’s nothing there to resent. Whether or not you think it’s fair to move the elderly to the head of the line, once you decide to do so it is certainly good risk communication to point out that “some people are really angry that we decided to move the elderly to the head of the line.”

One final point about panic. As you know, actual panic is much rarer than most officials imagine. (See “Fear of Fear: The Role of Fear in Preparedness … and Why It Terrifies Officials.”) But it is sometimes hard for people to hold onto their self-control when they feel simultaneously frightened and unfairly treated. People can usually bear their fear if they feel we’re all in the same boat. People can usually bear their anger about unfairness if only their self-esteem, not their survival, is at stake. But from Milwaukee in 1894 to New Orleans in 2005, the combination of fear and anger is potent. I don’t think “panic” is the right label – it’s more the anger than the fear that gets acted out. Still, there’s a crucial lesson here. Trying to treat people fairly is always important, but it’s especially important in a frighteningly deadly emergency, when it is one of the keys to sustaining order.

Comment:

I am working (voluntarily) with a task force on antibiotic resistance. We have focused on educational efforts on Methicillin-Resistant Staphylococcus Aureus (MRSA), and have survey data to suggest that we have had no impact whatsoever on providers, population, etc.

I would like to get info on effective risk communication strategies for education on control of MRSA (e.g., wash your hands and other “radical” approaches).

I like your split out of the technical versus the “outrage” portion. We have been successful on the technical side (with both the community and providers) but are just starting to suffer from the “outrage” stuff (fear, politics, etc.).

The output of our task force is on the health department web site – lots of “tool kits” for offices, nursing homes, schools, etc. I think we are on the cutting (often bloody) edge of this topic since our task force has been in place nearly ten years now. Web site: www.tpchd.org under MRSA.

Peter responds:

My wife and colleague Jody Lanard collaborated on this response.

Readers who are unfamiliar with MRSA are unfortunately all too likely to become familiar with it in the coming decades. It is one of the key fronts in the war against antibiotic resistance. As staph infections that are virtually immune to antibiotics become more and more common, MRSA and other so-called “superbugs” threaten to help turn hospitals and nursing homes into places patients fear to go. (MRSA got its name in the 1950s when methicillin was the antibiotic of choice against staph; the name stuck while new antibiotics arose and staph developed resistance to them too.) Apart from its huge and growing impact on healthcare outcomes, MRSA also afflicts a wide range of occupational categories, from farmers (who get it from animals dosed with antibiotics, whether for medical or non-medical reasons) to athletes (who get it from sharing equipment in an abrasion-rich environment). MRSA infections are also increasingly common in schools. Reducing the spread of MRSA is a high-priority medical goal.

We’re not sure what you mean when you say your educational efforts “have had no impact whatsoever” although you have been “successful on the technical side.” But we need to start with an obvious point: Persuading people to worry about a new risk and adopt a new set of precautions is a long, tedious process. From seat belts to smoke alarms, new precautions typically take a generation or more to become standard operating procedure. Sometimes the desired behavioral shift doesn’t happen at all – but it almost never happens quickly. Precaution advocacy is a slog, not a sprint – and that’s just as true when the audience is doctors as when it’s the rest of us.

Fighting MRSA has two additional communication disadvantages.

First of all, the key individual behavior you’re recommending, more frequent and more thorough hand-washing, is extremely familiar. It’s hard to mobilize people to do something they’ve been urged to do for decades already. (Think about flossing.)

Second, the fight against MRSA (and against antibiotic resistance generally) is unwinnable. It is the nature of microbes to mutate, and mutations that resist antibiotics have an obvious evolutionary advantage. We can slow the spread of MRSA – and doing so can save many lives, and buy time to find new antibiotics. But we cannot “eradicate” MRSA the way we can eradicate smallpox. Like poverty, hunger, terrorism, and disease itself, MRSA is probably here to stay. Research by Daniel Kahneman and others shows that it is very hard to mobilize people to slow the inexorable spread of a problem that can’t be stopped.

Part of the MRSA risk communication job is to acknowledge these two drawbacks so they will get in the way less. We need to get people past the fact that hand-washing isn’t a very sexy remedy, and we need to help people bear the fact that the war against MRSA is a war we know we can’t win (with our existing weapons) but are struggling to lose as slowly as possible.

While hand-washing is the key individual weapon against MRSA, the key institutional weapon is screening and cleaning, a strategy often called “search and destroy.” Here, too, there is a lot of room for improvement. In the U.S., nearly 60 percent of the Staphylococcus aureus infections in intensive care units are methicillin-resistant (and thus much more dangerous). The comparable number in Canada is less than ten percent; in some Scandinavian countries it is less than two percent. In countries whose hospitals have very low MRSA incidence (such as the Netherlands, Finland, and Denmark), every patient is tested for MRSA on admission and again prior to discharge. Most U.S. hospitals, by contrast, rely on “passive” measures, catching MRSA if it happens to show up in cultures taken for other purposes; they actively screen for MRSA only in identified high-risk areas of the hospital. U.S. hospitals that have ramped up their MRSA screen-and-clean protocols have seen significant improvements – and in the process they have saved money as well as lives. See for example the website of Evanston Northwest Healthcare.

So how do you get hospital administrators, physicians, and nurses in “backward” countries (the U.S., the U.K., Japan, etc.) to do more about MRSA, about antibiotic resistance and superbugs generally, and even more generally about iatrogenic medicine? There are three basic choices:

• You can appeal to your audience’s altruism, professionalism, and rationalism, urging hospitals and healthcare professionals to do better simply because it is possible to do better. That’s the slowest route.
• Or you can add a threat – pointing out that sooner or later the public is going to find out about MRSA; people will conclude that the healthcare establishment has been dragging its feet and then all hell will break loose. That’s the middle course.
• Or you can supercharge the change by actually implementing the threat, mobilizing hospital patients, school parents, the media, and others to demand state-of-the-art programs to control MRSA.

Mobilizing public outrage (and patient outrage) is almost certainly the quickest route to improved MRSA control. As every activist knows, arousing people’s outrage is a lot more effective as a strategy of precaution advocacy than merely “educating” them or increasing their “awareness.”

For an example of what anti-MRSA activism might look like, see Consumers Union’s “stophospitalinfections.org” website. Consumers Union has publicized the MRSA-screening successes of specific hospital systems; it has fought for state laws requiring hospitals to publish their MRSA infection rates; it has organized a letter-writing campaign to get people to push politicians to make hospitals shape up.

But arousing people’s outrage has three collateral costs.

First, becoming more outraged necessarily means getting more upset for a while. (We call this the “adjustment reaction.”) It is upsetting that germs are learning how to survive antibiotics. It is upsetting to imagine a future with MRSA, and drug-resistant TB, and hospitals that are dangerous the way hospitals were in the pre-antibiotic era. When a MRSA infection hits the local media, with revolting photos of boils and pus-filled wounds, people are right to be upset.

Second, when people are outraged and upset, they look for targets to attack. They’ll want to attack the MRSA, of course – that’s the goal you share. But they may also want to attack the people and institutions that they decide haven’t done enough to warn them about the problem and manage the problem – hospitals, school systems, doctors, politicians…. And maybe you.

And third, people whose outrage exceeds their technical knowledge don’t always demand the right solutions. The focus on making hospitals publish their iatrogenic infection data, for example, has certainly upped the pressure to improve performance. But the statistics hospitals in various states are required to submit vary in their reliability, validity, and value; some pieces of data are hard to interpret, and some are arguably misleading.

In your comment, you note that you’re “just starting to suffer from the ‘outrage’ stuff (fear, politics, etc.).” That sentence suggests you’re fully aware of the costs of mobilizing outrage. Don’t lose track of its benefits. The fastest route to progress is to mobilize and manage the outrage, instead of regretting, resenting, or resisting it.

Pretty often, it seems to us, doctors, hospitals, and health departments forgo the benefits of public outrage because they are unwilling to endure its costs. So they try to improve the healthcare system without alerting the public, the media, or the patient population. Or they try to alert the public, the media, and the patient population to the dangers of MRSA without alerting them to the proven MRSA-screening strategies that most hospitals have failed to adopt. Their communications to fellow professionals may bemoan how far behind U.S. hospitals are compared to those in the Netherlands, while their communications to laypeople focus on the (genuinely important) recommendation to wash their hands more.

When a public school has a case (or several cases) of MRSA, the information machine goes into action. Most of the time, accurate and thorough information is sent out to parents and staff. Hygiene and cleaning protocols are ramped up. Everyone takes the local problem very seriously. Parents get anxious; they get information; they get lots of things to do to reduce their families’ risk. And they also get a fair amount of reassurance that appropriate institutional action is being taken. The school gets cleaner. The students wash their hands more. The sports teams do more to sanitize their equipment. The parents calm down and the media coverage stops.

All this is appropriate. But there’s something missing. Rarely does anyone seize on the teachable moment to raise people’s alarm about the overall MRSA problem. Rarely does anyone try to convert parental anxiety into citizen advocacy to put pressure on politicians and health departments and local hospitals to “search and destroy” MRSA. Even MRSA experts who routinely argue for a more aggressive fight against the superbug often join in the effort to keep everybody calm. And so what could have been framed as a warning signal, a shot across society’s bow, and a chance to mobilize into action, is all too often seen instead as an isolated problem in one school.

The quality of risk communication during these school MRSA outbreaks varies substantially. One school district quickly sends home an information letter and responds to rumors with compassion. Another school district delays reporting the incident and then downplays its health significance. These are both real, recent cases. The good example was in Tacoma, Washington (your area) in early June; the not-so-good example was in State College, Pennsylvania in late June. Not surprisingly, parents of children in the State College school were angrier and therefore more worried, for longer, than parents of children in the Tacoma school.

In other words, Tacoma did better outrage management than State College – a better job of acknowledging the problem, validating parents’ concerns, and ultimately restoring parents’ confidence in the school’s ability to keep their children safe. But in neither case did we see much evidence of any effort to arouse concern and action about the larger problem – except for one letter to the editor in Tacoma, several weeks later.

Under the headline “All must do more to help prevent infection spread,” Kayleen Faraca wrote:

It is no news to myself and my co-workers that the MRSA … infection rate is so high. We who work in the health care industry are very frustrated at the lack of public knowledge about MRSA…. We are also frustrated at how some staff are noncompliant with the protocol for treating isolation patients with MRSA…. Patients and their families can help…. Be proactive and insist that local hospitals get a better handle on lowering infection rates.

[Tacoma News Tribune, June 27, 2007]

This is a good example of seizing the teachable moment.

Paradoxically, a school MRSA case that’s poorly communicated can sometimes lead to more community activism about MRSA in hospitals and nursing homes than a well-communicated one. Bad outrage management can stumble accidentally into some much-needed precaution advocacy.

Not that we’re recommending mishandling school outbreaks in order to mobilize public demand for hospital improvement. An optimal response would convince parents that the school is managing the outbreak well, teach parents the importance of hand-washing to reduce their children’s MRSA risk, and mobilize parents to advocate for better MRSA screening in healthcare settings.

Comment:

What is the role of risk communications in achieving homeland security for the United States?

Since Hurricane Katrina, the scope of homeland security has widened from its initial definition of protecting Americans from terrorist attack to what is known as the “all-hazards approach.” The DHS now concerns itself with identifying, preparing for, detecting, responding to, and recovering from every conceivable catastrophe, whether intentional, accidental or natural.

This includes everything from critical infrastructure to public health to port security to emergency response. Indeed, today, “homeland security” is all about the hazard side of the risk equation.

DHS has also defined “risk communications” as a crucial element to its long-term success. Yet the ever-growing body of literature seems to wander across the landscape without a sense of where it is going or what it intends to do. What is needed is a “true north” to guide the overall strategic thinking.

I’ve been wrestling with this for more than a year, and I’ve come to this conclusion: If Risk = Hazard + Outrage, and “homeland security” is all about hazard, then the role of risk communications in homeland security is to:

• Assess each hazard’s actual threat (high or low) to the public.
• Compare that to the public’s level of outrage (high or low).
• Use that comparison to determine the appropriate communications strategy – precaution advocacy, crisis communication, or outrage management.
• Respond with the tactics that are appropriate to the strategy.

Now, as I examine that answer, I wonder if that isn’t simply the role of risk communications in ANY situation that involves hazard and outrage. I may be just stating the obvious.

Can you help me refine my thinking on this, to make the answer more specific to “homeland security”? Or is stating the obvious enough?

Peter responds:

I am flattered and delighted that you think my “Risk = Hazard + Outrage” formulation and my distinction among precaution advocacy (high hazard, low outrage), outrage management (low hazard, high outrage) and crisis communication (high hazard, high outrage) might constitute a “true north” for homeland security risk communication.

Without going quite that far, I agree that risk communication should aim for a level of outrage – concern, fear, anger, whatever – that is commensurate with the actual hazard (whether current or potential). So when people’s outrage is too low you try to raise it (precaution advocacy), and when it’s too high you try to reduce it (outrage management). And when people’s outrage is rightly high already, so you don’t need to raise it and shouldn’t want to reduce it, then you try to help them bear it and help them choose wisely how to respond (crisis communication).

All this is certainly germane to homeland security risk communication.

What’s special about homeland security? There’s an obvious answer, I think: the concept of terror. Terror is high outrage of a very particular kind – high outrage that isn’t conducive to fruitful protective action. People who are terrified may be too paralyzed by their fear to do anything; or they may trip a psychological circuit-breaker and go into denial; or (less often) they may be panicked into taking extremely unwise actions. Some people who have been terrified in the past have trouble recovering; they can remain depressed or experience bouts of post-traumatic stress disorder.

There are many definitions of terror. Terrified people experience extremely high outrage; it is outrage dominated by the fear family of emotions; it is usually more outrage than the hazard justifies. (Though horrific, terrifying events are not often widespread; for terrorism to succeed, they have to feel more widespread than they are.) All of that is true, but I don’t think it’s the essence of terror. The essence of terror is that it is demoralizing rather than empowering.

Terrorists practice a unique form of risk communication aimed at arousing and sustaining terror. Of course terrorists also work to create hazardous situations. But for terrorists, hurting and killing victims is mostly a means to an end. The end, the goal, is terrifying – and thus demoralizing – bystanders.

A core mission for homeland security professionals is to prevent terror and, when that fails, to manage and diminish terror. Foiling terrorists’ plans is clearly the best way to accomplish this mission. But there are also crisis communication strategies that help prevent and manage terror: giving people things to do and things to decide; acknowledging, validating, and sharing their fears; telling them what to expect; helping them live with high levels of uncertainty; appealing to other emotions such as anger and love; etc. (Since natural disasters, infectious disease outbreaks, and other events can also provoke terror, preparing for these events and coping with them are properly part of the homeland security mission too.)

Being honest with the public is a major part of a sound strategy for managing terror. While this cannot always mean revealing every last detail about an attack or a potential threat, it does mean withholding information only for security reasons, not because the information is alarming or embarrassing. Honesty requires acknowledging how unpredictable terrorism risks can be. It requires admitting and apologizing for mistakes. It requires trusting in the public’s ability to bear upsetting news. These are some of the hardest elements of risk communication, and they have almost nothing to do with assessing and explaining the hazard right.

So where do terrorism and counterterrorism fit in my “Risk = Hazard + Outrage” equation and my precaution advocacy/outrage management/crisis communication framework?

Terrorism is like precaution advocacy in that it aims at increasing people’s outrage. But practitioners of precaution advocacy want to increase people’s outrage in order to motivate them to take effective precautionary action. Terrorists want to increase people’s outrage in order to demoralize them; terrorists want people to act unwisely or not at all. The level of outrage terrorists want to arouse is higher. More importantly, the sort of outrage terrorists want to arouse is different. They’re aiming for outrage that is disorganized rather than organized, thoughtless rather than thoughtful, atomistic rather than collective, etc. Terrorism really doesn’t fit into the framework very well.

Counterterrorism communication fits, but not neatly. During and immediately after a terrorist attack, “counterterror risk communication” is best thought of as a subset of crisis communication. But it’s also a special kind of outrage management, aimed at converting dysfunctional outrage (terror) into functional outrage (manageable fear and anger). Between attacks, and especially when an attack may be imminent, counterterror risk communication is largely a variety of precaution advocacy. Then its goal is to replace complacency with vigilance, to arouse and sustain people’s concern and involvement.

Comment:

I saw the news about Christine Todd Whitman’s testimony [concerning U.S. EPA reassurances about air quality after the 9/11 attacks] and thought it a very relevant example of what you likely describe as not using the “seesaw” approach.

I was curious to hear what you thought.

Peter responds:

I agree that former EPA head Whitman did a poor job of acknowledging her critics’ concerns or the strong points of their criticism. It’s hard not to be defensive when you’re answering hostile questions from a Congressional committee in front of a booing audience. Still, Whitman knew what to expect when she came to testify on June 25. She chose to argue her case without conceding her critics’ case. As you say, she didn’t make use of the seesaw of risk communication.

It seems to me that there are three important truths about EPA’s handling of post-9/11 risk communication:

Andrew responds:

The situation seemed to me to be a case of good intentions (a spokesperson wanting to be reassuring in an unsure time) which then painted them into a corner. She was then perhaps unable or unwilling to contradict her earlier statement that the air is safe, perhaps fearing that she would come across as flip-flopping or unsure of what she knew.

Her statements now seem to be focused more on defending herself than on those who are affected, making her appear to be less concerned about their well-being than hers – which, in my opinion, isn’t helping her case in the court of public opinion.

Comment:

I am an energy industry consultant and have recently been asked by an HSE [health, safety, and environment] executive of a Canadian oil company to develop a “training” (I use that term loosely) session for the corporation’s Board of Directors and senior executives in the company that have little to no operational exposure/experience.

The objective is to impart a level of awareness, appreciation and respect for the HSE risks and liabilities associated with the operations of an integrated oil and gas company. As HSE governance ultimately rests with the Board, their ownership and leadership in this area is essential to the success of all endeavors.

My question to you relates to your vast experience in developing programs for and working with Boards and executives. What successful delivery strategies have you employed that not only are effective in imparting the information, but moreover are successful in engaging the participants while respecting individuals that hold positions at these levels?

Peter responds:

My experience talking to Boards of Directors isn’t vast. I’ve done it fewer than a dozen times all told. But for whatever they’re worth, here are a few observations.

All of these points apply also to senior management presentations. Even the conflict-of-interest point applies. If a company’s HSE vice president wangles an hour for you to address the executive committee, he or she will have one set of goals for the session, while the rest of the executive committee may have quite different goals. You have to get clear in your own mind who your client is during that hour. I tend to have a different answer in this case. When top management brings me in to speak to the Board, I usually arrive hoping to help the Board understand the directions in which I’d like to see it push the company. When the VP I’ve been working closely with brings me in to speak to top management, I usually arrive hoping to help top management understand the directions in which the VP and I are already trying to push the company. Maybe that’s why I get to give a lot more top management presentations than Board presentations.

Comment:

I work for a mining company, and one of the environmental regulators appears to be ideologically opposed to mining. This regulator has been trying to tighten the thumb screws on all of the mines in the area, to the point where it is likely to be impossible to achieve what is being asked. Do you have any suggestions on managing outrage in this circumstance?

Peter responds:

Your very brief description of the situation leaves me with four hypotheses. All four should be considered whenever a stakeholder – regulator, neighbor, customer, whatever – seems to be making impossible demands.

What I would add to this site:

Policies, templates, etc.

Comment:

I am looking for some sample “Release of Information” policies. Some of our local health departments within our consortium do not have a policy in writing, and I am looking to create one off of some that already exist. Do you know where I might find this information?

Peter responds:

I don’t know of any repository where health department release-of-information policies are collected. I did what you probably did: a Google search for “health department policy release information.” I didn’t find any comprehensive release-of-information policies, but some of what I did find is revealing. Among the top 20:

• Criticism of the California Department of Health Services for refusing to make public a report on the September 2006 E. coli outbreak in spinach.
• A Rhode Island Department of Health guidance document on how to limit the information released about reportable infectious disease outbreaks so as not to violate legal prohibitions against revealing confidential medical information about individuals.
• A National Institutes of Health website on how to submit Freedom of Information Act requests and how to appeal when the requests are denied.
• A news release from an advocacy group in the U.K. called The Campaign for Freedom of Information, entitled “Health Department challenged over ‘absurd’ hospital consultant secrecy.”
• An Illinois Department of Public Health “Privacy Policy” statement, focusing mostly on a pledge not to release information collected from users of the department’s website.
• A 2003 CDC report entitled “HIPAA Privacy Rule and Public Health,” offering guidance to public health officials on their obligations under the then-new privacy provisions of the Health Insurance Portability and Accountability Act.

These entries, and the ones that followed, lead to two unsurprising conclusions. First, there is a genuine issue of patient confidentiality, and there are strong laws and policies in place to prevent unauthorized release of confidential health information. Second, health departments are often tempted to invoke these laws and policies in order to avoid releasing information they’d rather not release, and are far more often criticized for keeping too many secrets than for keeping too few.

On the positive side of the balance sheet are the World Health Organization’s “Outbreak Communication Guidelines,” which include excellent advice about releasing more information rather than less, sooner rather than later; and about explaining the reasons for withholding information that must be withheld.

With all this in mind, let me suggest some guidelines for developing release-of-information policies.

• Construct your policies around an assumption of openness. That is, list the situations under which certain information must be withheld, not the situations under which it may be released. Knowing that health departments err on the side of secrecy far more often than they blab too much, design your policies to correct the imbalance. Articulate a philosophy that clearly requires good reasons for withholding information, not good reasons for releasing it.
• Patient confidentiality is of course a good reason for withholding information. So is compliance with HIPAA and other laws. But you need a policy that warns officials not to interpret these strictures too broadly (or too narrowly – but too broadly is the common problem). And you need a procedure for journalists and others to appeal if they think they’re being given an excuse rather than a reason.
• Whenever a health department withholds information, policy should require it to say what is being withheld and why. There are several reasons for doing this. First, it will help reduce the frequency with which information is withheld unnecessarily. Second, it will make it much easier for those to want the information released to challenge the decision to withhold it; they’ll know where to start. And third, people are much less outraged at being kept in the dark if they’re told what they’re not being told, and if they’re given a good reason.

  But make sure it is a good reason. During the SARS outbreaks, for example, many cities withheld the names of hospitals that were caring for suspected SARS patients. When asked why this information was kept secret, some officials said it was not relevant – which was a lie. Their real reason, as then-Secretary of Health Tommy Thompson said at the time: “As the World Health Organization has emphasized, SARS seems to be unusually infectious in hospital settings.” Realizing that it was a sensible precaution for a patient with choices to avoid any hospital that was treating someone for SARS, hospitals were afraid of losing business if it became known that that they had a SARS patient. So health departments cooperated by suppressing the hospital names.

• At the very least, be honest with yourselves about what is being withheld and why. I have advised clients to attach a “secrecy ledger” to every draft announcement. As it goes through the revision and approvals process, anyone who edits out an accurate piece of factual information should be required to enter that information onto the secrecy ledger, along with his/her name and an explanation of why it needs to be withheld. The obligation to give a reason, the prospect of others in your organization reading what you wrote, and of course the risk of seeing the ledger made public someday should all help reduce how much information is withheld. (To the best of my knowledge no client has ever taken this advice to heart and implemented a secrecy ledger policy.)
• Uncertainty should not be a reason for withholding information. Uncertain information should be released promptly despite the uncertainty, with clarity that it is in fact uncertain (and just how uncertain). I’d make an exception if you’re going to have a lot more certainty very quickly and if there’s nobody demanding the information now and no good reason to release it before you’re sure. But in general, uncertain information should neither be suppressed nor be released overconfidently. And when previously released information turns out wrong, corrections should be released ASAP, with clarity that the preliminary information was wrong. Don’t just stop saying X and start saying Y. Say: “We thought it was probably X, but it turned out to be Y.” (See “Acknowledging Uncertainty.”)
• Health Departments often take too long to release information. So there is a need for policies that push officials to release early rather than late. Jody Lanard and I wrote an entire column on this. The title says it all: “When to Release Risk Information: Early – But Expect Criticism Anyway.”
• Often what holds up the release of information is a constipated approvals process. Too many officials spend too much time editing the announcement. This leads not only to delay, but also to secrecy; as the announcement climbs the departmental hierarchy, potentially embarrassing facts tend to disappear. So you need a policy that prescribes a schedule and limits the number of people who need to okay the release. A streamlined approvals process is especially crucial in crisis situations. That’s when speed matters most, and when organizational timidity is likeliest to get in the way. One policy that the CDC has found very helpful: Specify that anything top officials have already said publicly may be included in announcements without further vetting.
• You need a policy on behalf of releasing information about ignorance. Like everyone else, health departments tend to focus on what they know. They don’t much want to say what they don’t know. Sometimes they pretend to know it all; more often they just don’t mention the questions they can’t answer. But some of the most useful information to the public is what your health department doesn’t know. Some of what you don’t know you’re working to find out; tell us what you’re doing and when you’ll know more. Some of what you don’t know you will never know; say so and help us learn to make do.
• Try to develop a policy that urges releasing information about disagreements – both inside your health department and between your department and other agencies. “Some of us think X, and some think Y. It’s a tough call.” You can say this before a decision is made, perhaps seeking advice on how to make the difficult choice you face. You can also say this after a decision is made, acknowledging that it wasn’t a no-brainer, that some people favored a different option, and that the one you picked may turn out to be a mistake. Health departments rarely release this sort of information; in fact, there are often explicit policies requiring the department to “speak with one voice.” For a detailed rationale for the opposite policy, see “‘Speak with One Voice’ – Why I Disagree.”

P.S. The preceding policy recommendations are all about releasing information in a new or evolving situation. But a lot of the information actually put out by health departments isn’t new at all. It is “evergreen” information about chronic health risks: smoking is bad for you; exercise is good for you; it’s important to get an annual checkup; etc. The main release-of-information issue in such cases isn’t openness, but wasted effort. Endlessly repeated good advice may do some cumulative good, establishing a culture that disapproves of smoking, admires exercise, and wishes it had time to get a checkup. But it violates two key principles of precaution advocacy and social marketing. The first principle is that health messages aimed at mobilizing apathetic audiences need to arouse some emotion: fear, disgust, anger, whatever. And the second principle is that such health messages are likelier to have impact during those periodic “teachable moments” when the audience is temporarily less apathetic than usual. I wouldn’t object to an informal policy that curtailed the endless release of boring health information, emphasizing emotional arousal and teachable moments instead.

Comment:

What is your feeling about how FDA and USDA are presenting the human health risk of consuming meat and poultry products that have been exposed to melamine-contaminated livestock feed? The dilution factor seems to be difficult for the media to understand, interpret and convey.

Peter responds:

Compared to the furor over pet food contamination, there doesn’t seem to have been much of a public reaction (or media reaction) to the human health risk from melamine in animal feed, and thus in the human food chain. People (and reporters) mostly seem to get it that pets ate melamine itself and some of them died, whereas people ate meat from animals that ate melamine, and none are known to have gotten sick.

I’m not certain people understand that this is about dilution. My guess is that they are reacting more to the distinction between direct and indirect consumption. Suppose there turns out to be melamine in human food too; suppose certain food products on supermarket shelves are found to contain gluten or flour that was dishonestly laced with melamine by Chinese suppliers. (This is far from inconceivable, though it seems less likely as the days go by without such a revelation.) The FDA and USDA might still determine via risk assessment that the human risk is negligible because of dilution. “The public eats a much more varied diet than most dogs and cats,” they would explain, “so even though there was melamine contamination of some human foods, it is very unlikely that any person would ingest anywhere near as much as the pets did.”

This explanation would be a lot tougher to make persuasive, I think. People would have trouble getting beyond the outrageous fact that human food was intentionally contaminated with kidney-threatening melamine. It would help a little for the FDA and USDA to acknowledge that most non-experts are understandably surprised to learn that a contaminant in food can sometimes be harmless if it’s dilute enough (that is, below a certain concentration). And it would help a little for the FDA and USDA to acknowledge that a major reason why this is hard to accept is because we have been taught to expect not to eat contaminated food at all – taught by the implicit promises of industry (when they use such words as “pure” and “wholesome,” for example), and of the FDA and USDA themselves (when they claim that the U.S. has the safest food in the world, for example).

Assuming the contamination remains confined to pet food and animal feed, there are still some acknowledgments that would help if the issue gets hot again (as it well may).

First and foremost, I think, officials should acknowledge the yuck factor more. They should say something like this: “Even though our rapid multi-agency risk assessment suggests there is a vanishingly low risk from this meat, and even though no actual melamine has been found so far in tested meat, many people we know have a sense of revulsion at the thought of eating meat from animals that ate contaminated feed.” I can’t actually imagine the government using the word “revulsion” in this context – but the closer officials can make themselves come to naming the public’s rational, understandable disquiet, the more successful they will be in allaying it.

This is of course the risk communication seesaw. Decades ago, I worked on the problem of used hypodermic syringes washing up on the Atlantic Coast of the United States, apparently flotsam from seaside waste dumps. In New Jersey, government officials accurately insisted that the syringes weren’t really dangerous, and said it would be prohibitively expensive to do anything about them. The New Jersey public recoiled in horrified disgust, and demanded that steps be taken. In Rhode Island, on the other hand, officials got on the other side of the seesaw. “Even though the risk from used syringes is negligible,” one top state health official told the media, “this is a disgusting thing to find on our beaches, and the Health Department will do whatever it takes to put a stop to it.” “Wait a minute,” Rhode Island citizens and editorialists responded. “If it’s not really dangerous, how much taxpayer money are you going to spend trying to prevent it?”

New Jersey ignored or mocked the disgust, which left people stuck in it. Rhode Island validated the disgust, which made it much easier for people to get past it.

Officials should also acknowledge the longer-term significance of the melamine scandal. “At the very least, this problem raises people’s awareness about how easy it can be for unknown or untested substances to end up in our food. That is an upsetting realization for many people. It makes them wonder if their food is safe, and if food regulators are doing a good enough job.” I can’t imagine an FDA or USDA official saying that either. But to the extent that it’s true, saying it is a lot better risk communication than letting it fester unspoken in the backs of people’s minds.

Other acknowledgments worth considering:

• “Understandably, some people find it surprising that such a quick and confident risk assessment can be done on melamine, especially since we have already said that there is virtually no research literature on melamine health effects.”
• “Our early statements downplaying the possibility that animal feed might also turn out to have been melamine-contaminated were over-confident and over-reassuring. We should have been more cautious. In fact, we should have alerted people in advance that feed intended for one animal often winds up getting fed to other animals, and that it wasn’t especially unlikely that an ingredient in pet food might also have been used in animal feed.”
• “We also should have been more cautious about the possibility that melamine might turn out to be in more ingredients, and more pet food products, than were initially identified. A recall that keeps getting bigger and bigger day after day, as this one did, is bad from every viewpoint. It is bad for health (in this case pet health), bad for public confidence, and bad for industry recovery. At the very least, we should have warned people more vigorously, early on, that the initial recall was very likely to widen.”

Along with acknowledging problems and mistakes, officials should also offer the public more “anticipatory guidance” (advance warning) of what may come next. For example:

• “Having learned to be cautious about melamine, we are not willing to rule out the possibility of direct melamine contamination of human food, even though we haven’t found any evidence of such contamination yet.” [One of the FDA’s good communication moments re melamine was when Assistant Commissioner David Acheson was quoted as saying that there was no evidence that melamine-contaminated product ended up as an ingredient in human food, “but it’s prudent to look.”]
• “Even though melamine is mostly excreted via the kidneys in animals fed melamine-spiked feed, we will not be entirely surprised if we find small amounts of melamine in the meat of such animals. But in the ___ batches of meat we have tested so far, we have not found any melamine yet.”
• “If we do find that melamine was added directly to human food ingredients, or that melamine residues are sometimes present in meat from animals that ate melamine-contaminated feed, we expect the health risk to be small. This is counterintuitive for many people. If it can kill dogs and cats, why isn’t it dangerous to people? Here’s why….” [It’s a lot more convincing to explain in advance why X won’t be hazardous even if we find it than to claim we won’t find it, then find it, and then explain why it’s not hazardous.]
• “Because of melamine and other recent contamination episodes, everyone (companies, regulators, the media, etc.) is now on notice that food ingredients can be mislabeled and can be dangerous. We are all particularly aware now of imported ingredients, especially from China where the melamine originated. As a result of this increased sensitivity and increased scrutiny, additional problems along the same lines may well come to light. There have been a number of food scares in recent months – spinach, Taco Bell, melamine, etc. There are likely to be more in the months to come. Although it is upsetting, this is ultimately good for the safety of the food supply. It should lead to improved safety performance on the part of suppliers, importers, manufacturers, growers, retailers, and regulators.”

Acknowledgment and anticipatory guidance are risk communication principles that food safety officials (and government officials generally) have trouble implementing or even wanting to implement. On balance, the U.S. government’s melamine risk communication wasn’t awful, especially with regard to melamine in the human food chain. But it could have been better.

My wife and colleague Jody Lanard also worked on this response.

What I would add to this site:

The differences in countries’ global plans for a pandemic.

Comment:

Congrats on an excellent article on Tamiflu stockpiling.

Question: What about Corporate stockpiling? Is THIS a good thing? Should Corporations stockpile Tamiflu for their staff and perhaps their families?

I’d like to know your informed view on this subject.

I work with Roche in Ireland. I am interested in your views but wanted to be open with you.

Peter responds:

When Jody Lanard and I wrote “The Dilemma of Personal Tamiflu Stockpiling” in January 2006, it really was a dilemma. We supported personal stockpiling, but we readily acknowledged that there was a Tamiflu shortage; personal stockpiling was thus in competition with governmental stockpiling, and with actual use against the seasonal flu.

The dilemma has pretty much disappeared. It will no doubt arise again if a pandemic materializes and if Tamiflu is useful against the pandemic strain of influenza. But for the moment there is apparently enough Tamiflu being manufactured to meet all existing demand.

In that context, it is much easier now to support both individual and corporate stockpiling – and I do.

Obviously stockpiling antivirals (like Tamiflu) isn’t the only thing a company should do to prepare for a pandemic. It probably isn’t even the most important thing. I’d rank it behind at least two other tasks:

• Developing a company “business discontinuity” plan – a plan to focus on essential tasks and cut out peripheral ones in the event of a severe pandemic
• Developing and implementing an employee pre-pandemic communication program – a program to alert employees to the risk, help them prepare at home, and seek their help for preparing in the workplace.

But I certainly agree that a company that hopes to function at all in a severe pandemic would be wise to have its own stock of Tamiflu.

I am even more supportive of companies that distribute their stockpiles now to employees, rather than planning to administer the drug centrally or waiting to distribute it when the pandemic looks imminent. There are several reasons for this, including the risk of bottleneck, the risk of nationalization, and the desirability of taking antivirals as soon as possible after the onset of symptoms.

A number of companies have decided to give each employee his or her own supply of Tamiflu now – normally after teaching the employee how and when to use the drug. This shows a level of trust in employees’ ability to cope wisely that most governments are not yet showing in their citizens’ ability to cope wisely.

Now that the shortage issue has apparently abated, I expect to see governments rethinking their positions. When personal stockpiles were competing with government stockpiles, governments frequently justified their opposition to personal stockpiling by asserting that many citizens weren’t competent enough to manage the drug on their own. Now that there is enough for all, perhaps these governments will discover that their citizens are smarter than they thought.

As you probably know, Roche is one of the companies that are distributing their stockpiles directly to employees. I assume Roche means to set an example for its prospective corporate customers, and I hope it succeeds.

On the other hand, Roche has apparently decided to distribute only enough Tamiflu for employees themselves, not for family members. This strikes me as a strange decision, and one I’d expect to see Roche change pretty quickly. Obviously if an employee’s child gets the flu, we all know where that employee’s treatment course is going to end up. A company that wants its employees to treat themselves (if they get the flu) needs to give them enough Tamiflu to treat their family members (if they get the flu) as well.

Some international agencies, by the way, are ahead of Roche in recommending stockpiling for families as well as employees, but behind Roche in failing to recommend advance distribution to employees for in-home storage. For instance, the “United Nations Medical Services Staff Contingency Plan Guidelines For an Influenza Pandemic” recommends that all UN offices:

• Stockpile Oseltamivir (Tamiflu) to treat 30% or more of staff and dependants.
• In addition, stockpile enough Oseltamivir to provide prophylaxis for 6 weeks for all staff needed and identified to maintain “essential” functions.

By the way, the UN plan also recommends that all UN offices stockpile surgical masks “in numbers sufficient to provide all staff and dependants with 2 masks per day for 6 weeks.”

Comment:

I was reading some of Vincent Covello’s material where he’s stating that in low-trust, high-concern situations, empathy and caring often carry more weight than numbers and technical facts. He presents the Trust Factors Graph, explaining that 50% of trust is based on empathy – listening and caring. He also quotes Will Rodgers, saying that “When people are stressed and upset, they want to know that you care before they care what you know.”

I do agree with that. However, I don’t believe it applies to all audiences. It applies for the audience watching a crisis through their TV set; it applies for a crowd that has been through a crisis but is now out of it; it also applies for the families of the victims. But it does not apply when you’re addressing a distressed crowd going through a crisis situation. All that crowd wants is leadership, someone in control of the situation telling them what’s going on and what they can do, an army-general-like approach, clear instructions, clear respectful orders. Empathy and compassion would have their place after the group is out of the crisis, not during.

Would you agree with that?

Peter responds:

There have got to be moments when people are in extremis, know they’re in extremis, have already come to terms with the situation emotionally, and just want practical help – information about what’s going on and instructions or advice about what to do.

When that’s the situation, “empathy” means noticing that that’s the situation and not wasting precious time trying to show you care.

But I think that’s very much the exception. Even in the middle of an emergency – or perhaps I should say especially in the middle of an emergency – most people need emotional support, not just practical help. And our ability to absorb and respond to practical help often depends (as Vincent Covello says) on our getting the emotional support up-front. Paramedics and EMTs, for example, are often in situations where seconds count; even so, they find time to murmur words of support to the patient and the patient’s family. Ditto for 9-1-1 operators. Even surgeons are learning to find ways to demonstrate their humanity before the patient goes under.

Narratives by survivors of the 9/11 attack on the World Trade Center frequently emphasize the empathy and compassion shown by firefighters, police, and their fellow survivors as they struggled to find their way to safety. They emphasize the practical help too. It’s not either/or.

The most famous quotation to come out of 9/11 was what New York City Mayor Rudy Giuliani told a reporter who asked how many people had died in the Twin Towers. “The number of casualties,” he said, “will be more than any of us can bear.” Why did his words resonate so deeply? Giuliani was saying, in effect, that the attack was unbearable. He was bearing it, but with difficulty – and he let the difficulty show. That’s what helped New Yorkers (and the rest of us) bear it too.

Interestingly, Giuliani’s speeches since then have expressed the view that it was his strong, calm leadership that rallied New Yorkers after the attack. I think it was his empathy and compassion. Of course it was important that he didn’t fall apart. But the unexpected blessing was that we could all watch him struggling, successfully, not to fall apart. Watching Giuliani hold it together helped millions of us to hold it together too.

Despite all this, I agree with you that emergencies are different from less urgent situations. Sometimes people are upset about a risk even though you’re pretty confident they’re not actually endangered. Under those circumstances, the toughest part of the risk communication job is to reassure your audience that the technical risk is low – especially if you’re responsible for causing the risk in the first place and have an economic interest in dissuading them from objecting to it. I call this the “outrage management” paradigm. The core of the outrage management problem is that your audience has good reasons not to believe your reassurances, even when your evidence is strong. In this situation, establishing an emotional connection is incredibly difficult and absolutely essential. Whether you think of it as “showing empathy and compassion” or as “acknowledging people’s grievances, feelings, and concerns,” it’s a prerequisite to progress.

In an emergency, on the other hand, people are upset and endangered. The paradigm is crisis communication, not outrage management. The risk communication job here isn’t to reassure people; it is to help people bear the emergency and cope wisely with it. The need for action is central. The role of empathy and compassion is to help your audience bear the situation and the strong emotions it arouses, so they are able to act wisely.

For a brief summary of the distinction between outrage management (low-hazard, high-outrage) and crisis communication (high-hazard, high-outrage), see “Four Kinds of Risk Communication.”

A leader who relies on outrage management strategies in a crisis will mishandle the crisis badly. The problem isn’t that the leader is putting too much stress on empathy and compassion. The problem is that the leader is trying to use empathy and compassion to reassure the public, rather than to help the public take wise action. Fundamentally, it isn’t even empathic to tell people that the situation is under control and everything is going to be fine when actually the situation is deteriorating and we need to prepare ourselves to cope with what may be a horrific experience.

Is it possible for a leader in an emergency to focus too much on empathy and compassion, neglecting people’s urgent need for information and instruction? I’m sure it’s possible. But there are two more usual problems, I think: emergency leadership that neglects empathy and compassion in its haste to tell people what to do, and emergency leadership that imagines showing empathy and compassion means it’s okay to over-reassure.

Comment:

Your quote: “Pandemic is on the back burner for the majority of Americans, where it should be, but it’s not on the back burner of governments and companies.” was disturbing for many of us, who are trying to convince relatives and friends about the danger and get them to prepare for it. Please explain and elaborate a bit.

Also, it has been speculated that you could have a conflict of interest because you were paid by pharma companies and public organizations. In your articles and statements, how can we know that you don’t just reflect the opinion of those who pay you for it?

How does it usually go, when you get a job to write/talk? Can you freely say what you think or are there directives? Do you maybe silently, subconsciously adapt your opinion anticipating what your client of the moment will prefer?

Peter responds:

Anita Manning of USA Today interviewed me for a story that appeared on February 1 under the headline, “The great flu pandemic: Despite dire warnings, public interest has waned.” She used two snippets from her conversation with me, as follows:

“The risk of pandemic had its moment in the sun, where the public was interested, and people were talking about it in grocery lines,” risk-communications expert Peter Sandman says. “Then people got used to it, and interest settled into the new normal.” … Pandemic is “on the back burner for the majority of Americans, where it should be,” Sandman says, but “it’s not on the back burner of governments and companies.”

The point I had tried to make in the interview was that convincing people to get serious about a risk that’s new to them is like climbing a whole range of mountains. You make some progress climbing the first mountain in the range. Then people settle into a valley of higher concern than before but lower than that first peak – the New Normal. Then you climb another mountain and make further progress. Then they settle into another valley, higher than the earlier one. Then you climb some more.

Precaution advocacy is a slog – a marathon, not a sprint, to change metaphors. It’s important to focus on teachable moments, when something happens (or you manage to make something happen) that makes people more-than-usually interested in hearing about the risk. In between the teachable moments, it’s important not to get too irritated at yourself or your audience for the periodic lapses in progress. And in between the teachable moments it’s also important to focus on consolidating prior gains – pushing to get them institutionalized in the policies of governments and companies.

That’s what I said, or tried to say. But the snippets came out sounding like I was saying that it’s not a problem that most people aren’t prepared yet for a pandemic. Some of those in the pandemic prep community, who are working so hard to spread the word about preparedness, felt betrayed.

The resulting controversy turned up on two pandemic-related websites. The debate on Flu Wiki is very extensive, with comments from many perspectives. An even longer and more consistently hostile discussion appears on a blog called “Pandemic Flu Information.”

That discussion was cross-posted onto a third flu preparedness site called PlanForPandemic.com. On this third site, by the way, a poster misattributes to me a statement written about me in a 1999 article in a journal called PR Watch. Here’s the statement, with the poster’s parenthetical additions:

“To engage activists (sheeple), soothe them, and ultimately get them to accept whatever it is the giant corporation or institution (FED) has done or intends to do.”

That’s not, as the poster said it was, “what he does for a living from his own description.” But nonetheless, the previous PR Watch criticism of my corporate consulting is worth reading.

One of the issues that keeps appearing on these three threads is the one you raise: whether I have a conflict of interest because I do a lot of work for corporations and for governments.

I earn my living chiefly as a consultant. Every consultant faces endless conflicts between the urge to say what the client wants to hear and the obligation to say what the consultant thinks the client needs to hear. I’m not immune to this problem, but I think I face it less than most consultants, because my reputation is as an idiosyncratic loose cannon who says exactly what he pleases. Most clients come to me knowing that that’s what they’ll get. And when word gets around that a client has fired me because management didn’t like what it was hearing, that’s a kind of advertising. Over time, the organizations that want to be challenged find the consultants who are willing to challenge them, while the organizations that want to be coddled find the consultants who are willing to coddle them. I think I’m known as one of the former.

But even so, you’re certainly right that the better I get to know a client, the more vulnerable I am to starting to think like the client. It’s much more subtle and unconscious than deciding to say what the client wants to hear; it’s starting to see things the way the client does. I think I lose a lot of my value as a consultant when that happens, so I work hard to prevent it. But it does happen. The key signal that it’s happening is when I catch myself saying “we” instead of “you.” My normal frame as a consultant is what you (the client) are saying to us (the public). If I start talking about what we (the client) are saying to them (the public), I know I’ve let myself get coopted.

The conflict of interest problem is much, much tougher for paid spokespeople. I am not a spokesperson. I talk TO my clients, not FOR my clients. Spokespeople do both. When their advice on what the client should say isn’t taken, they have to say what the client decided instead – or quit. I respect people who walk this tightrope, as my clients’ communications professionals inevitably must. But I don’t like doing it, and I don’t think I’m good at it. So I invariably refuse to speak on my clients’ behalf … ever.

The last time I remember working as a spokesperson was in the early 1980s, when I took a sabbatical from my university job to do volunteer communications work for the nuclear weapons freeze campaign. A decision was made to oppose the introduction of cruise missiles into Europe on the grounds that cruise missiles would make a freeze impossible. I thought this was neither true nor wise to say (after all, we weren’t about to stop working for a freeze if we lost the battle over cruise missiles). I said so internally, lost, and ended up publicly voicing an opinion I didn’t share. I haven’t been somebody else’s spokesperson since.

I do speak publicly on risk communication aspects of a wide range of issues. (I didn’t have to talk to Anita Manning; I wanted to.) But I am never speaking on behalf of anybody but myself.

Occasionally one of my clients thinks that is a conflict of interest. How can I take their money to advise them on how to address a controversy, clients sometimes ask, and then go give a speech or talk to a reporter or write a website column about the controversy?

The distinction I make here seems straightforward to me, though sometimes not to the client. People who hire me are buying access to my opinions – but not exclusive access. While of course I keep confidential information confidential, what the client does in public is fair game. I advise the client on what I think the client should say and do. And I reserve the right to tell others what I think of what the client actually said and did.

Thus I have worked for pharmaceutical companies and criticized (and praised) pharmaceutical companies; I have worked for the CDC and criticized (and praised) the CDC; I have worked for activist groups and criticized (and praised) activist groups. I don’t ever want a prospective client to imagine that hiring me is a way of guaranteeing that I won’t bite the hand that feeds. My clients know I will bite the hand that feeds, and often do.

Of course there’s no way for others to know whether I do or not, unless they listen to my speeches or read my writing. A lot of people understandably assume that I don’t bite the hand that feeds – that someone who earns his living as a consultant shouldn’t be trusted as an “independent” commentator. That’s a pretty reasonable starting position. So when I say something that people disagree with, it’s not surprising that they sometimes think I said it because I have a client that wanted me to.

On pandemic preparedness in particular, my clients have mostly been government agencies – HHS and CDC at the federal level; a score or so of states, counties, and cities; the World Health Organization; and health and emergency preparedness agencies in Canada, Singapore, and elsewhere. I’ve also worked for a few companies seeking help on their pandemic plans and their pre-pandemic employee communications. And I’ve worked for a few academic institutions with a focus on the issue, particularly the Center for Infectious Disease Research and Policy at the University of Minnesota. I also write extensively about pandemic preparedness for no client at all; for a list of pandemic articles on this website, see my “Pandemic Flu and Other Infectious Diseases Index.”

The flu blog posters criticizing me now are in the camp that believes most of these organizations (especially HHS, CDC, and WHO) are trying to tamp down public pandemic concern in the service of corporate capitalism. My USA Today blooper was easily interpreted as yet another example of the ways “TPTB” (the powers that be) conspire to keep people apathetic. There is another camp, also well-represented on the Web, that believes HHS, CDC, WHO, and their ilk are conspiring to keep people terrified, also in the service of corporate capitalism. This group has criticized me for helping my clients do that. See for example Sherri Tenpenny’s “Throw Out the Playbook: A New Plan Arrives,” originally published in September 2005.

Two other conflict-of-interest issues are worth mentioning.

The first is the conflict between keeping a client’s secrets and telling the world. I obey confidentiality agreements; I keep my clients’ confidences even without a legal agreement. I have always known that someday a client may tell me something so important that I feel a moral obligation to violate confidentiality and blow the whistle. In my ethical judgment, confidentiality trumps little secrets, and serious risks to public health trump confidentiality. But this is a genuine conflict of interest, because breaking confidentiality would almost inevitably end my career as a consultant. Like doctors and attorneys, consultants have a strong incentive to decide that it’s ethically okay to keep the client’s secret – since the alternative is professional ruin.

One of the client secrets consultants have to keep is what the consultant advised the client. I am free to criticize a client’s public behavior, but I’m not generally free to say “I told them not to do that!” Once in a long while my advice to a client is revealed by others. In late 2005, I was hired by the Australian Wheat Board (AWB) after the company was implicated in the Iraqi oil-for-food scandal. I advised contrition. AWB rejected my advice, and I kept my mouth shut. Ultimately a legal proceeding in Australia compelled the company to reveal the details of what I advised and how management responded. If you’re interested, read a story from The Age of August 16, 2006, headlined “Sorry is the hardest word for AWB.”

Although I had nothing to do with its becoming public knowledge, the fact that my advice to AWB did become public knowledge – to the further embarrassment of the company – decimated my consulting clientele in Australia. Who wants to hire a consultant if you’re liable to get creamed for deciding not to take his advice?

Bottom line: I know things about my clients (including my pandemic preparedness clients) that others would like to know. My judgment that it is ethically okay to keep my clients’ secrets is inevitably influenced by my self-interest in keeping my clients. If I ever hear a client secret that poses an imminent threat to public health, I hope I’ll have the integrity to reveal it (if I can’t persuade the client to reveal it) and retire.

The final conflict-of-interest issue is working for both sides. I don’t work for both sides at the same time in the same place on the same specific controversy. But I do work for organizations that are on opposite sides more generally. For example, I work for environmental groups that are advocating reductions in greenhouse gas emissions and for oil companies and electric utilities that are among the principal emitters. My opinions don’t change depending on who’s asking. The principles of risk communication are the principles of risk communication. But even so, isn’t this a conflict of interest?

My corporate clients rarely think it is. They require me to keep their secrets, and they understand that I won’t reveal the other guy’s secrets to them – but they generally think it adds to my value that I have experience working on all sides of a controversy. Activists are likelier to decide they don’t want advice from someone who’s willing to work for the enemy. I’m not sure they see this as a conflict of interest, exactly. They just prefer getting their advice from dedicated supporters, not paid professionals.

In general, I am a paid professional. Ironically – considering the criticisms from some writers on the flu blogs – pandemic preparedness is a partial exception. It is a personal cause both for me and for my wife and colleague Jody Lanard. Most of our pandemic work is pro bono or very low-budget.

addendum:

There is some additional dialogue on the topics discussed in this Guestbook entry.

Comment:

Over and over again your website talks about how we’re best off if the government controls all of the Tamiflu. That’s bunk. What is the government doing? Allowing private corporations to stockpile Tamiflu. How is this any different than me setting aside a few doses for myself and my family? Oh yes, I see how it’s different. I don’t donate millions of dollars to politicians. Yes, certainly the government will allocate resources in a way that is best for society. We may as well turn over all goods to them, if that’s true. Why should I be trusted to go to the grocery store on my own? Don’t you know that people are starving in Ethiopia?

You seem really sold on the idea that “government knows what’s best for us.” You don’t work for the government by any chance, do you? Employed at a state school? From a taxpayer’s point of view you’re a government employee. It all makes sense now.

Peter responds:

Although I am not as suspicious of government as you may be, I'm certainly not a champion of government control over individual decisions.

This includes the individual decision to stockpile Tamiflu. The column Jody Lanard and I wrote on The Dilemma of Personal Tamiflu Stockpiling argues that people should be allowed to maintain their own stockpiles, even though some may feel that the Tamiflu could be allocated more efficiently (and thus more ethically) if the stockpile were centralized. In a severe pandemic, the government won't be able to take care of us all; we need to prepare to take care of ourselves and each other. I fully approve of personal stockpiles of food, water, and other emergency supplies, including Tamiflu.

The Tamiflu stockpiling issue is a lot less touchy than it was when we wrote the column. The supply of Tamiflu has increased and keeps increasing. When the federal government recently offered some to the states at reduced prices, most states ordered less than their quotas. So the case against personal stockpiling is weaker now than it was a year ago, when we wrote that it was weak.

I no longer work at a state school, by the way, though I taught at Ohio State University, the University of Michigan, and Rutgers University – all state schools – for most of the 1970s and 1980s. But don’t relax your guard. I still take government consulting and speaking gigs, so I have financial reasons not to criticize the government. You’ll have to read the site a little more closely to decide how I cope with this potential conflict of interest. I suggest you start with an earlier column in which Jody and I were extremely critical of the draft U.S. pandemic plan then under review.

Comment:

Since you have an opportunity for people to make comments, I hope you will not take offense at this: I greatly admire your philosophy, your expertise, your articles and other content … but I hate your website! When someone recommends an article from your site to me, it is often difficult to find. Sometimes, such as this evening, the search engine simply isn’t working. Other times, I find that I have to do a lot of "click-throughs" and scrolling down long pages to find what I want, and often I leave without having found it.

The website could benefit from a site-map overhaul and some design changes (such as no more scrolling, adding navigation bars with multi-layered drop-down mouse-over menus, etc.) The look, feel and user-friendliness of the current site feels about 5-7 years out of date – an eternity in web terms – and it doesn’t reflect the stature of your work.

Peter’s webmaster responds:

I’m sorry you find the website difficult to use. I’m concerned that the search engine wasn’t working for you and have referred that problem to our technical contact at our webhost. The website does indeed reflect the “state of the art” of 1999, when Peter first asked me to build his website. I’m a technical editor by trade, who attended his class at the Hanford Nuclear Reservation in the early 1990s and had an epiphany about technical communication from his work.

I made clear to Peter then that my skills were at the low-tech, “no bells and whistles” level. He said that was his preference, as he did not want a slow-loading, complex site – many of his clients and readers are overseas and many do not have access to fast internet service (if you think dial-up is slow in the U.S. – try it from some locations in Indonesia and Africa!). We agreed that low-tech, close-to-text-only, was the best option to provide his information to all-and-sundry at whatever level of connection they had.

As for a site-map overhaul – you bet, very strongly to be desired. However, as I maintain the website for Peter out of friendship and my own love for his work and knowledge (that is: at no charge, and as I can fit it in around my own work with my husband’s manufacturing company), it’s not going to be possible for ME to do the overhaul. You may have read, in his page called “Working toward a ‘Legacy’,” that Peter is looking for some educational institution, NGO, or foundation to take over the site. That would be a blessing for me and, I expect, for Peter.

In the meantime, I hope our technical contact can figure out why the search engine was not working, [2008 Note: there is now a fully functioning search engine called the Zoom search engine by Wrensoft in place on the website.] and I can only offer the … er … 5–7-year-old work-around of Ctrl F (the “find” function on a PC; I don’t know what it would be on a Mac) to search the page for the text you need. There are only three “indexes” of articles:

• Columns by Peter (or Peter and his wife and colleague Dr. Jody Lanard) called, appropriately enough, “Columns”
• Articles by Peter called “Risk Communication Articles on the Web”
• Articles about Peter, or that reference his work, called “Peter Sandman in the News.”

Other than those indexes, there are these resources:

• Several biography pages are linked from the home page (both Peter’s writing for the site and various profile articles) in the section called About Peter Sandman.
• The “Guestbook” is organized into files by year and indexed by title in the Comments and Questions Index.
• The seminar handouts are indexed both alphabetically and topically.
• And Peter has created topical indexes to reflect four “specialty areas” that people might look to for:
  • Crisis Communication (High Hazard, High Outrage)
  • Precaution Advocacy (High Hazard, Low Outrage)
  • Outrage Management (Low Hazard, High Outrage)
  • Pandemic Flu and Other Infectious Diseases.

  These four pages index the stuff already indexed in the three main lists, with a brief introduction of Peter’s philosophy for each area.

I wish I could give you more help – I certainly agree it’s awkward to have to (“manually”) search three index pages to find an article you’ve heard about and wish to see. I hope any problems with the search engine will be worked out to make finding things as easy as possible. Perhaps this explanation of the philosophy of the site layout will help. (And I hope some foundation or university steps up to take over the site. I realize Peter’s expertise is NOT being “displayed” as it ought, but I’m just not able to do more.)

peter adds:

Elenor (my webmaster) is wonderful, but as she points out the website is a labor of love for her, and she wisely sets some limits.

A few other explanations/excuses/apologies:

• I am a hopelessly nonvisual person – a word guy. Once in a while somebody reprints something from this website on another site or in print, and adds art. My reaction is always half “why did they do that?” and half “why didn’t I do that?” – but I never do.
• I’m also hopelessly pre-computer in my sensibility. Drop-down menus and icons don’t come easily to me. Indexes do.
• I think of this website as a library, a repository. My goal is to get everything I know onto the site so I can start to retire … and still be available (in writing) to people who want my help. I pay far too little attention to seducing the interest of people who might benefit from this stuff but aren’t actively seeking it out. (Maybe unconsciously I even like being a little user-unfriendly. I don’t think so, but it has been suggested.)
• I’m longwinded. The website would be a lot easier to use if everything I write were shorter. That’s the repository thing again. My thinking goes something like this: “If I give two examples instead of five, the other three will be gone forever!”

As Elenor points out, the answer to most of this is to find an institutional home for the site, someplace with people who like risk communication and people who know something about 21st-century website design. Anyone out there interested?

peter’s webmaster adds:

As of August 2008, we’re in the process of redoing and upgrading the entire site. A new search engine (Wrensoft’s Zoom) has been put into place and seems to be working out very well.

We’re discussing and refining page layout and design, and any necessary reorganization. First to be posted will be the several-years-worth of guestbooks, followed by the guestbook list, the topical indexes, and the “big three” indexes: Columns, Articles by Peter, and Articles by Others. Then will come the long hard slog through more than 200 files of text to update them into HTML 4.01 and CSS 2.1.

We welcome any comments and suggestions (or complaints) you wish to send. We’ve created an email address just for them: redesign@psandman.com.

Comment:

I’m not sure if this is more a risk communication or more an ethical question.

When trying to motivate the public to understand the risk of an influenza pandemic and to make household preparations in case of shortages, I am concerned about those who have no means to make such preparations – those who have difficulty getting food for the next day, much less being able to stockpile two to twelve weeks of supplies and medicines.

I know that motivating people to take constructive action helps them to cope with their fear, but urging someone to do things that they are incapable of doing may lead to despair.

I realize it creates an ethical responsibility for all who can prepare – individuals, communities, governments, churches – to try make preparations for those who cannot. But between those who cannot prepare and the many who could, but won’t, prepare, I worry that we will see Katrina-like scenarios.

It is very hard to persuade local governments, with urgent problems they face daily and can’t afford to fix, to expend resources for something that “might” happen at some unknown time in the future.

Do you have any suggestions about what to say to people with limited resources about pandemic preparations?

Do you have any suggestions about what to say to community and governmental organizations about preparing for those who cannot prepare themselves?

Peter responds:

You’re absolutely right that it is a disservice to urge people to do more than they’re capable of doing. In fact, it’s a disservice even to alert people to a risk if they’re incapable of doing anything about it. The self-efficacy research shows vividly that fear is a useful goad to action only when people have actions available to them. If people have nothing they can do, fear morphs into despair or denial.

But it is also a disservice to people to conclude too readily – or to let them conclude too readily – that there’s nothing they can do.

In the days before Katrina, New Orleans authorities urged residents to evacuate the city. The “mental model” of those giving the evacuation order was a middle-class mental model: Get in your car; drive to safe ground; find a motel; and live on your credit cards until the situation is resolved. I realize I am exaggerating a bit. Still, it’s clear that far too little attention was paid to the needs of people who didn’t fit this mental model.

Some people literally couldn’t evacuate – people who were bedridden, for example. Others could evacuate, but only with serious difficulties. They might have had to hike or hitchhike out instead of driving; they might have had no money and no plastic with which to buy food and shelter once they reached safe ground.

It is certainly true that the authorities did too little for these people, apparently assuming that they could do it all for themselves. But it is also true that most could have done more for themselves than they did. The way the evacuation recommendation was phrased left many people feeling more powerless than they were. Since they couldn’t just jump into their cars as the authorities apparently imagined, many decided they couldn’t do anything at all. The authorities betrayed them not just by failing to meet all their needs, but also by failing to show them how to meet some of their own needs.

Similarly, not everyone has the money (and storage space) to stockpile three months’ worth of food, water, medicine, and other supplies against a possible pandemic – or flood, terrorist attack, or other catastrophe. As you say, this is a good reason for government, business, and civil society to think about ways to help. We will need neighborhood food stockpiles for those who don’t have their own. But we also need to distribute bare-bones lists of low-cost, low-volume, high-nutrition foods that all but the very poorest can manage to stockpile. After all, there was a time when we were an agrarian society, and nearly everyone routinely put aside enough food to get through the winter.

I believe, as I imagine you do, that Medicare, Medicaid, and private insurance companies should be pressured to pay the one-time cost for everyone to have a three-month rolling stockpile of prescription medicines. And I know there are plenty of people who literally cannot pay for their own stockpiles. But there are also plenty of people who mistakenly feel they can’t (partly because they feel they shouldn’t have to). There are some diabetics with a better supply of cigarettes than of insulin.

I see four risk communication lessons here:

Comment:

A colleague in Colorado has asked me what I have heard about issues of social stigma and pan-flu. She wrote: “I’m thinking about social distancing and population characteristics type of issues that lead to distrust from a lack of information.”

Any thoughts on whether a pandemic will raise social stigma issues, and how risk communication can help?

Peter responds:

This response was written jointly with my wife and colleague Dr. Jody Lanard.

The psychology of stigma isn’t our field – and there are people whose field it is. Still, we can’t resist commenting. We especially want to draw attention to some risk communication guidance for fighting stigma.

Risk communication teaches that showing compassion is one way to build trust with frightened or skeptical stakeholders. Instead, officials often show disdain and contempt for stigmatizers, calling them irrational, hysterical, or even racist. Almost no compassion is ever shown for the stigmatizers’ own fear, uncertainty, distrust of official proclamations, and effort to make sense out of mysterious phenomena.

In dealing with stigma, officials usually clarify the facts, which is of course necessary and appropriate. But they sometimes downplay the knowledge gaps and genuine uncertainty that contribute to the stigma. And they rarely acknowledge the sound reasoning (even if based on incomplete or inaccurate information) that often leads uninformed or distrustful people to come up with stigmatizing hypotheses. In other words, what we call “stigma” often has some basis in rationality.

Sometimes it’s rational self-interest pure and simple. During the 1918 pandemic, for example, there were stories about people refusing to bring food to sick relatives. Staying away from sick people during a pandemic is grounded in knowledge – accurate knowledge – about contagion. This shouldn’t be called stigma at all. (We still have to get food to sick people, of course.)

Similarly, some hospital managers have worried aloud about being stigmatized as “flu hospitals” during a pandemic. We doubt this is going to be a problem, since every hospital is likely to end up a flu hospital. But if there are designated hospitals for flu victims, it isn’t “stigma” for people with other medical problems to avoid those hospitals. It’s good sense. But if people still fear and loathe the former “flu hospitals” after the pandemic is over, that’s stigma.

When people are acting on inaccurate “knowledge,” it is important to correct them without mocking or castigating them. During the SARS outbreaks, for example, many people avoided Chinese restaurants. Those avoiding Chinese restaurants included huge numbers of Chinatown residents, but some officials still called them “racists.” People had learned that SARS had something to do with China and people traveling from China, and hypothesized that it might be safer to eat elsewhere for a while. There’s no evidence that they were right. But during a period of great uncertainty, enormous knowledge gaps, rational fear, and considerable skepticism about official reassurances, it wasn’t a foolish hypothesis.

So what should officials do when stigma rears its head? It doesn’t help to ignore the fact that people are stigmatizing this or that group. And it certainly doesn’t help to stigmatize the stigmatizers. A good risk communication approach to stigma would start by acknowledging that it exists and validating the feelings behind it. While gently correcting any factual errors, officials should acknowledge also the rationality of the stigmatizers’ reasoning. Only after showing compassion for the stigmatizers can officials usefully ask them to have more compassion for those they are stigmatizing.

Even though it has not launched a pandemic, the H5N1 strain of bird flu is already producing some interesting examples of stigma.

In the U.S., there is a concerted effort among poultry interests to call H5N1 “the Asian bird flu.” (The 1918 pandemic got called “the Spanish flu,” though the first recognized cases were in Kansas.) The U.S. Department of Agriculture uses the term “Asian bird flu” 654 times on its website; the U.S. Centers for Disease Control website doesn’t use the term at all. If an H5N1 pandemic starts in Asia, which does seem likelier than other locations, many people may initially try to avoid others who look Asian. But once the pandemic gets here and is spreading freely, the stigma attached to people of Asian ancestry should dissipate. It will dissipate more quickly if some compassionate understanding is shown for the stigmatizers.

Whether it arises from realistic fears of contagion, from fearfulness and prejudice, from denial, or from some of each, stigma isn’t cured by changes in vocabulary. The word “leprosy” became so pejorative that the disease was renamed “Hansen's Disease” – and now there are articles on the stigma of Hansen’s Disease.

In parts of Asia, meanwhile, some farmers complain that efforts to control bird flu outbreaks are themselves examples of stigma. Their governments, they say, are stigmatizing small backyard farms by labeling them as breeding grounds of bird flu. They charge that this works to the economic advantage of the larger, corporate “factory farms” – and greatly damages the reputations of family farmers, even the ones whose birds are perfectly healthy and well cared for. Is that stigma? Or is it just data? If backyard farms have poorer biosecurity and biosurveillance than factory farms, is it stigmatization to say so?

In fact, a lot of bird flu communication has aimed at passing the blame. We don’t know if it can be called stigmatization or not, but backyard and free-range farmers have blamed high-density factory farms as much as factory farmers have blamed backyard and free-range farms. Farmers in one country blame farmers in neighboring countries, stigmatizing that famous source of contagion, Someplace Else. Farmers everywhere blame cockfighters – who join them in blaming migratory birds – whose wild bird advocacy organizations try to focus the blame on farming. And everyone’s happy to put the blame on bird smugglers.

Should we expect a lot of stigma associated with an influenza pandemic? Probably not if it is a mild pandemic, like the last two. But even a mild pandemic may provoke some temporary blame and stigma at the outset – especially since it will inevitably be heralded by an outpouring of official warnings and public anxiety before we know whether it’s going to be mild or severe. (There was no such furor at the start of previous pandemics, because no one knew a pandemic was starting.)

There is far more potential for stigma during a severe pandemic.

This is true in all countries. But we’re guessing that the stigmatization will be most extreme in parts of the world where many people don’t understand the germ theory of disease. There the public will have a harder time making sense of the new calamity posed by a pandemic. Lacking a virus to blame, people may look for ways to blame their traditional enemies instead.

When people don’t understand the source of a disease, even medical responders are likely to be stigmatized. During a Marburg fever outbreak in Angola two years ago, WHO medical vehicles were stoned by villagers who thought the emergency responders were spreading the disease. Last August, angry Indonesian villagers tried to tear off the protective masks worn by senior government health officials who were investigating a family cluster of avian influenza. This episode occurred in the same district where a large family cluster had been confirmed three months earlier. During the first cluster, villagers denied that there was bird flu in the area, and protested at the provincial capital. A protest leader told the Asia News Network that “the people were hurt by what they considered stigmatisation.”

A lot of the stigma about infectious diseases takes the form of anger at people who violate quarantine orders and thus spread (or are thought to have spread) the disease. This was certainly an issue during SARS. It may be an issue at the start of a flu pandemic. But the experts pretty much agree that except at the very beginning, quarantine will play a very minor role in a flu pandemic. Influenza is extremely contagious, and it is contagious before it is symptomatic. There will be no way to quarantine people who have been “exposed.”

Isolating sick people may be more of an issue. Those who are very sick won’t be tempted to go out and spread the disease. But it will be important to persuade people with mild cases of flu-like illnesses to stay home.

And there we have a potentially beneficial use of “stigma” – shaming mildly symptomatic people into social-distancing themselves. There’s bound to be plenty of glaring at people who cough on the bus, or who come to work looking flu-ish. Respiratory hygiene etiquette and social distancing strategies will become strong societal norms, and violators will pay a price. Is that stigma, or wisdom? Can it be stigma if it’s wise? Of course there should be no tolerance whatsoever for violence against people who cough or sneeze in public. But glaring at such people, we think, will do more good than harm – even though the glarers will also catch some innocents who really have asthma or allergies.

Another frequent source of stigma is the existence of “carriers” – people who feel well and appear well but are nonetheless shedding the virus and can infect others with whom they come into contact. Immunocompromised people who recover from the “regular” flu sometimes continue to shed the virus for weeks. We don’t know yet if this will be true of the pandemic strain. It has the potential to add to the stigma associated with HIV/AIDS, and may also create stigma with regard to other categories of survivors.

Since most pandemic survivors will thereafter be immune (at least for the first wave), they will be immensely valuable as volunteers who can perform essential tasks that would be dangerous for anyone else. Good risk communication, and good data about the duration of viral shedding, can help officials “brand” flu survivors as heroes, not disease carriers. It will help, of course, if people’s natural hesitation to get too close to a recently recovered flu victim is treated with compassion rather than derision.

We hope nobody takes these random observations and guesses too much to heart. Officials can’t predict for certain what aspects of the next flu pandemic will lead to what kinds of stigma problems. What officials can do is decide now to be candid about stigma, to treat it as natural and often rational even when it’s mistaken and harmful, and to show compassion and understanding not just for its victims but also for its perpetrators.

introduction:

This dialogue started with a short article in the December 23, 2006 Bangkok Post. The article provoked my wife and colleague Jody Lanard to comment via email – which in turn provoked Dan Rutz to respond.

the article:

Students are at high risk of bird flu

Students in five provinces have high risk of bird flu because of their eating habit, said Public Health Ministry official.

The Ministry of Public Health said that more than 1,800 students aged between 13 and 15 in Bangkok, Kamphaeng Phet, Ayutthaya, Saraburi, and Suphan Buri stand a high chance of contracting bird flu because many of them are fond of eating parboiled eggs and runny eggs.

The chance is also high because more than half of these students, who usually do not wash their hands before eating, raise poultry in their residences. One third of those students regularly throw the remains of poultry into ponds and gardens, causing high possibility of bird flu outbreak.

Suphan Sithamma, spokesman of the Public Health Ministry, said the bird flu virus is becoming active in lower temperature, which is now. Even though the virus has been inactive for over three months, people still have to take care of their health and hygiene to prevent the virus from spreading.

(Bangkok Post, December 23, 2006)

the discussion begins:

Jody’s emailed comment: Seriously incorrect messaging by Thai public health officials (unless the reporter got it wrong)?

Isn’t it well-established that AI [avian influenza] is “not a foodborne disease,” and that there is virtually no evidence of AI transmission from eating infected poultry, even if undercooked? (There is one well-known exception, the Viet “duck blood pudding” brothers.)

We’ve all worked so hard to communicate that the risk of AI from eating poultry is so low!

Dan responds: The Thai Health Ministry message (and the subsequent newspaper item) is actually quite good; it is appropriately transparent and pre-emptive in drawing attention to an important risk that is well founded in science. That these students maintain poultry, prefer it undercooked or raw, and apparently don’t practice optimal hand hygiene to boot is, indeed, cause for concern. If there were infected birds among their flocks, the students certainly would be at elevated risk of infection.

The confusion, I think, stems from our earlier correspondence about the adjustment reaction following the discovery of H5N1 in new places.

Invariably we’ve seen sharp drops in poultry consumption in these circumstances, even when no poultry have been implicated (wild bird outbreaks only) or when the outbreak has been well characterized and controlled. The momentary loss of public confidence in poultry (including commercially produced product) has caused severe hardship and even desperate acts among poultry producers.

We have discussed strategies for reducing the severe consequences of this adjustment reaction, but have not proposed to do so by dismissing public concerns out of hand. Instead, we’ve considered how to apply outbreak (risk) communication principles to the problem. I believe we’ve determined that it is unrealistic to expect people to simply go on eating poultry as they normally would, but we can probably help them adjust to the outbreak more quickly by both respecting their concerns and steering them toward actions that provide them the security they seek without having to abandon a favorite food source.

We’ve also acknowledged that the media itself goes through an adjustment reaction, and that the media’s major emphasis on the story is based more on that reaction than any tangible public health risk. By acknowledging that point both before an outbreak and during one, we can skip the temptation to blame the media for doing its job, and simultaneously help dampen the shocking effect of the glaring headlines.

This is a complicated message strategy, but is actually quite consistent:

• Yes, infected poultry tissues carry virus, but in most situations the infected stock has been well localized.
• Commercial poultry operations ordinarily involve biosecurity measures to further protect product from viral contamination.
• H5N1 joins several other potential foodborne pathogens in poultry products that are ALL neutralized through proper cooking. This provides consumers one additional and very controllable safeguard and places the threat in a more familiar context (e.g., avoiding illness from salmonella and campylobacter).
• The risk of contracting H5N1 from poultry is low for most but higher for others, e.g., people like the students described in the article. Drawing attention to this elevated risk is important for the students’ sake as well as others who may be engaging in similar practices.

To dismiss the risk of human infection through consumption of infected meat, eggs, or byproducts would be scientifically inaccurate, so the Thai officials are correct in voicing their concerns, especially before there is an established outbreak. Our job as communicators is to provide proper context to these threats. I believe we have sufficient scientific evidence to walk that fine line comfortably, as the Thais appear to have done in this example.

three-way discussion:

Peter responds, then Dan annotates the response, then Jody adds some reactions:

1.  Peter: The technical seriousness of a risk is the product of its probability and its magnitude. The magnitude of the risk to humans of zoonotic infection with H5N1 is extraordinarily high; some 60% of those who have caught the virus have died. The probability of the risk is quite low. Bird-to-human transmission is difficult; the vast majority of those who are exposed don’t get sick. It’s like snorkeling around barracudas. If a barracuda decides to attack you, you’re going to get hurt (at least). But barracudas rarely attack humans. The risk of barracuda attack when snorkeling is high-magnitude but low-probability. So is the risk of H5N1 for a student who lives with poultry and eats runny eggs and undercooked chicken without washing first.

Dan: The Ministry’s issue here, I suspect, was the possibility that those barracudas were riled; i.e., that the students’ flocks might include ill birds or those obtained from questionable sources. Students everywhere live on tight budgets.

2.  Peter: The low probability of catching H5N1 if you live with poultry and eat runny eggs and undercooked chicken without washing first is low because most poultry don’t have H5N1 (even in Thailand) and because H5N1 doesn’t pass easily from birds to humans (barring an unfortunate mutation that hasn’t been found yet). The low probability of the students getting bird flu could be made lower still if the students stopped living with poultry. (This precaution would also help reduce the probability of a pandemic, since it would reduce the number of intimate bird/human contacts.) The low probability of the students getting bird flu could also be made lower still if the students washed their hands more often. Since bird-to-human transmission is thought to be mostly through inhalation, not through food, eating more thoroughly cooked eggs and meat presumably adds the least value.

Dan: NOT SO; there are cases attributed to meat (though not runny eggs). Virus is found on eggshells, likely due to fecal contamination.

Peter: But it adds a little, since food is also a potential transmission route and proper cooking will kill the virus if it’s there.

Dan: Remember, too, the adjustment reaction has been most apparent in people’s refusal to eat poultry when an outbreak occurs, and we’ve agreed we should not disparage that choice. Proper food preparation is a fundamental message in getting past the adjustment reaction. I would suggest it is useful to reinforce that message (that cooking/handling matters) through citation of good and (especially) bad examples.

Jody: Yes, there have been initial “temporary over-reaction” fear adjustment reactions in both rich and poor countries with poultry outbreaks. And there have been initial “temporary over-reaction” outrage adjustment reactions, on the part of farmers and poultry sellers. But the “new normal” in the poor countries (after the initial adjustment reaction has passed) is unfortunately mostly in the direction of denial, apathy, and/or hopelessness, if I am reading the knowledge/attitude/practices surveys correctly. Consumers got over their initial fears, farmers learned that they can’t afford some of the recommended precautions, and everyone noticed that very few people got sick.

3.  Peter: The risk communication issue here is this: When talking about a risk, it is important to be clear about what aspects of the risk are high and what aspects are low. For a low-probability high-magnitude risk, both halves of the truth deserve emphasis: “This is really, really bad if it happens to you. This is really, really unlikely to happen to you.”

4.  Peter: Jody and I have focused a lot of our writing on the importance of not over-reassuring – of acknowledging that serious risks are serious and of acknowledging that small but non-zero risks are non-zero, albeit small. We have also focused on the importance of being understanding and empathic about people’s natural tendency to overreact to small risks of which they are newly aware; we have argued that this adjustment reaction needs to be assisted to its conclusion, not derided. When people are excessively wary of eating poultry, in other words, authorities should be empathic rather than contemptuous.

Dan: See above.

5.   Peter: We haven’t put similar emphasis on the importance of conceding that small risks are small. But that is important too. Representing a small risk as bigger than it really is has two paramount dangers: (1) If you persuade your audience, you are over-alarming people about the risk in question, and thus sapping energy/concern/time/budget that could have been focused on more serious risks. (2) If you don’t persuade your audience (or it later learns you were exaggerating), you damage your credibility and your ability to deliver effective warnings about more serious risks. So while the authorities should not be contemptuous of excessive poultry fears, neither should they be spreading those fears with exaggerated warnings.

Dan: This one really involves walking a fine line. The temptation would be to violate #4 (above) in order to comply with #5. And in any event, if there is question about the safety of food (especially if bad chicken makes it to market – already slaughtered) there could be a substantial risk of spreading the virus through the food supply. Again, proper handling/cooking will be especially important, even if the rate of infection via this route is low.

Jody: I agree completely that there are very good reasons to push proper handling and cooking. And the students should be told those good reasons – but they shouldn’t be told that they are “at high risk of bird flu.” That was the statement that caused me to start this correspondence.

6.  Peter: This issue has come up in the efforts of NGOs and Asian governments to persuade poultry farmers to report possible H5N1 outbreaks and cooperate with culling. The reason why reporting and culling are important is to prevent the spread of the disease; reporting and culling benefit poultry farmers elsewhere (by reducing the epizootic risk), and benefit the rest of the world (by reducing the pandemic risk). For the individual farmer, however, reporting and culling are a disaster. The farmer is better off hiding the outbreak and quietly destroying (or selling) the affected birds – especially where compensation policies are inadequate or unreliable.

In an effort to persuade farmers to do what is good for others rather than what is good for themselves and their families, it has been tempting to exaggerate the personal health risk of being near H5N1-positive birds. That risk is not trivial (its magnitude is huge; its probability is fairly small) – but it is exceeded by the high-magnitude high-probability risk of losing one’s only source of livelihood. Ideally, we would change the contingencies by developing a better compensation program; absent that, we should tell the farmer the truth and base the reporting/culling program on some mix of altruism and coercion.

Instead, it is tempting to exaggerate the risk. This is extremely unlikely to work. Farmers know that the number of human bird flu cases is low (although the case fatality rate is high); they rightly judge that they are being misled and conclude that they should neither cooperate with bird flu control programs nor trust those who are running these programs.

Dan: I have not seen data as to the human disease rate among farmers who have diseased flocks. True, a main objective is to keep the disease from reaching other birds, but the farmer and his/her family are also at personal risk. Remember, too, many human cases have been in children, so if a farmer has infected birds the farmer SHOULD be concerned about personal health issues. I don’t think we need to confuse farmers further by ranking the reasons for making them cull the birds. Most societies value human health and safety sufficiently to tolerate less risk regarding it; so it is quite consistent to push culling under these circumstances by focusing chiefly on the risk that a child or young adult (or even us oldsters) could be stricken if the birds remain.

7.    Peter: The Bangkok Post news story looks like a piece of that ongoing strategy of exaggeration. It claims that Thai children are at high risk of getting bird flu because they live with poultry, don’t wash their hands, and eat undercooked meat and eggs.

Dan: I would argue this is reasonable and true.

Peter: This high-magnitude, low-probability risk is lower than the story implies. I have no problem with government efforts to persuade children to wash their hands between hugging their chickens and eating their dinners, and no problem with government efforts to persuade them to eat more thoroughly cooked eggs and meat. These recommendations are certainly sound hygiene, though only marginally related to the bird flu risk.

Dan: Peter, it is DIRECTLY related to the bird flu risk.

Peter: But exaggerating the risk in order to justify the recommendations is not itself justified.

Dan: They didn’t.

Peter: This is especially the case since the underlying purpose of the exaggeration is probably to reinforce the message that bird flu represents a serious health risk to poultry farmers and their families – serious enough that they should cooperate with H5N1 control programs at the cost of their livelihoods. I share Jody’s judgment that this is neither good science nor good risk communication.

Dan: I think we’re just going to have to disagree on #7. Remember, too, the government is made up of people who demonstrate high outrage and respond accordingly. I would much rather have them take this stand than throw up their hands and say, “The risk is low, so don’t sweat it at all.”

Jody: As a risk communication analyst, what I object to most strongly in the article is the statement that the students are at high risk.

This jumbles probability and magnitude in a very misleading way, despite the health official’s excellent intentions. It violates the risk communication standard of “aiming for complete candor and transparency” (which contribute to trustworthiness) – because it greatly exaggerates a risk to try to change behavior. It contradicts what students see with their own eyes: Almost no one is getting sick, despite eating runny eggs.

The Health Minister makes it sound like it is easy to catch bird flu if you are exposed and do not take proper precautions. But students, farmers, poultry handlers, restaurant workers and household cooks in all the bird flu countries notice that vanishingly few of them catch bird flu, even when there are outbreaks in poultry.

A recent avian flu knowledge and practice survey from Cambodia included an observation that risk communicators should try to understand before designing “eggs are dangerous” messages:

Anecdotally, we also reported that family members of H5N1-infected patients, who knew about AI risks, still prepared dead or sick poultry for household consumption during massive die-offs, because they observed that neighbors with the same behavior did not become sick (Institute Pasteur in Cambodia, unpub. data).

[J.Emerging Infectious Diseases, Vol 13, Number 1, Jan 2007]

The “students are at high risk” message conflicts with the experience of the students and farmers, who rationally conclude that the risk to most people is quite low. Better-designed risk communication would acknowledge that the individual risk of catching bird flu is low, but that it is good to try to lower it even more – since it is like Russian roulette, with three bullets in a six-shooter, if you are one of the unlucky ones who catches it. Since you can’t credibly lean on the (low) probability to make your case, lean on the (high) magnitude instead.

During my last three trips to Thailand, most of the eggs I saw served at food stalls and restaurants were soft or runny. Lots of people – tourists and locals – were eating them with no apparent concern. So imagine the same Bangkok Post article aimed at tourists in Thailand, but sourced by WHO instead of the Ministry: “Tourists are at high risk of bird flu because many of them are fond of eating parboiled eggs and runny eggs.” There would be an enormous outpouring of rage from Thai officials claiming that this warning is horribly misleading, because the risk of catching bird flu from infected food is thought to be very low, however it is cooked.

Comment:

I’m finishing my M.S. at present and conducting a thesis into how teachers of Outdoor Education in Australia are currently communicating about the risks involved, in order for parents to provide informed consent.

My theory is that if parents are more involved and have more knowledge of what their child will be doing on these programs, the outcome is likely to be better, especially in the event of an incident. The frequency of such incidents is very low in outdoor education; however, they attract major media attention and public “outrage.” There have been many coronial and lawsuit findings here in Australia and overseas that stated that parents were not “adequately” informed. I am also aware of a number of cases where, when an incident has occurred, the comment has come from the parents that “if I had known this could have happened I wouldn’t have sent my child.”

Much of my reading in risk communication is about new technologies, new hazardous waste sites, etc. Outdoor education is a bit different in that it “intentionally” uses risk/uncertainty as a valuable educational tool. My own belief is that we need to better involve parents but emphasize the costs and benefits of an extended remote wilderness program.

Outdoor education in Australia is a sanctioned school program and as such, I think trust has a major part to play. Parents trust teachers to do the right thing. That’s very different to some commercial rafting company, for example.

What I have generally found is that parents are really not a major part of the risk communication process. In fact, not many risks are being communicated, and teachers generally say they are "surprised" that parents trust them so much with their children!

Have you any views on this? Do you know of any other research in this area that might be relevant? I was planning on comparing theories of risk perception and risk communication with what is currently occurring in Australian schools. I’m a bit worried, though, that a lot of my reading is in technology-based risk communication. In your view, is the message – the “golden rules of effective risk communication” – generally similar?

Peter responds:

I think you are on the right track here. I do feel that the risk communication principles that govern how to tell parents about the risks of an outdoor education program are very much the same principles as the ones governing how to tell (for example) neighbors about the risks of an industrial facility.

Only more so.… As you point out, one key difference is that people have very low trust in the companies running an industrial facility, and much higher trust in the school systems educating their children. That means they’re likelier to believe what you tell them. They’re also likelier to go along even if you tell them very little – and likelier to feel betrayed if something goes wrong and they feel blindsided. In other words, the costs of being candid are lower for a school than for an industrial facility, and the costs of not being candid are higher. So candor ought to be a no-brainer.

What would I want to tell parents? I haven’t thought this through, but see how the following list compares to your findings:

• Here’s what we want to do with your child.…
• This sort of outdoor education program has huge benefits. But it also has some risks. We want you to know about both, so you can make an informed decision. In fact, the law says we have to tell you about the risks. You have a right to know.
• Here’s what can go wrong.… These outcomes are very unlikely – a lot less likely than other risks that confront your child daily, such as riding in a car. But unlike riding in a car, outdoor education is optional. It’s an unnecessary risk. On those rare occasions when something goes wrong during a wilderness experience, parents understandably feel terrible that they let their child go.
• Here are some of the things we do to minimize the risks….
• But even a small risk would be wrong if there weren’t substantial benefits. Here’s what outdoor education can do for your child.…
• As a parent, you’re used to this problem. Everything we let our kids do – from riding their tricycle at age 3 to going away to University at age 17 – has risks attached. We’re always torn between a desire to keep our children protected and a desire to see them spread their wings and develop confidence. It’s always a judgment call.
• Experts on outdoor education judge that it is well worth the risk. But it’s not up to them. It’s up to you. If you want to reach us to talk further about this decision, here’s how….

I’d expect three main outcomes:

I hope this helps. Please email me your thesis when it’s completed.

Claire responds:

I think one of the most interesting parts of this whole area is the feeling from the risk communicators (the teachers in this case); they are genuinely afraid that if they tell parents the risks of outdoor education, then parents will not let their children participate. They believe the truth is bad for marketing. In other words, if I say your child might drown, there’s no way you're going to let your child come.

The word “safe” is still used a lot in risk communication. “To ensure your child’s safety, we do x and y….” It is absolutely impossible to ensure safety. In my view, it is misleading to state that you can.

From bitter personal experience, I know that the number one need for the family following a serious incident is information. If the discussion is just beginning then about what the students were doing, and most importantly why (the benefits), it’s usually too late. That’s where the unnecessary anger and bitterness begin. Once that starts, it’s like a steam train and no-one wins.

As a profession, we need to be better communicators about both the benefits and the risks of outdoor education. We need to ensure that it is really the parents, armed with information, who are able to make that final decision.