Note from Peter Sandman: This panel discussion transcript was very lightly edited by the Nieman Foundation for Journalism. I did a little additional editing of my parts, but it’s still very much a transcript, not a polished presentation. I did not try to clean up anybody else’s words. Please do not quote from the presentations or comments of people other than me!
An abridged version of my portion of the panel discussion was published in the Spring 2007 issue of Nieman Reports.
Tini Tran: Hi, welcome back. My name is Tini Tran. I’m a Nieman Fellow this year, but I have been the bureau chief for the Associated Press in Vietnam for the last four years and as such have had the opportunity to see things from a ground zero perspective on a number of the major issues that we’ve been talking about: SARS and Avian Influenza in particular. This morning we’ll be continuing, segueing from our great discussion this morning to talking about messages: What we know and what we don’t know about how disaster communication affects the public, and as a journalist, that’s a subject near and dear to my heart, in particular in being able to understand how the stories that I write about and report on ultimately impact the public as well as the leadership in countries and communities where these major issues are playing out.
To start us off this morning, I’d like to introduce Howard Koh, who is currently the Harvey Feinberg Professor of the Practice of Public Health here at Harvard School of Public Health. He is the director of the Division of Public Health at the Center for Public Health Preparedness and he served as State Commissioner here in Massachusetts between 1997 and 2003, so he’s going to talk a little bit about his experiences from the leadership point of view and the messages that he was involved in shaping and sending to the public.
Howard Koh: Thank you so much and welcome to Harvard. I’ve had nothing to do with organizing this conference, but I’ll take full credit anyway. [Laughter] It’s really great to see you all and I’m just delighted to welcome you here. I’m going to add about a 10-minute perspective to this really fantastic conference by telling you my thoughts as a former health commissioner, what it’s like to be on the front line through a crisis such as Anthrax, which is what I experienced when I served as commissioner in this state in the fall of 2001 and what it’s like for current health officials to be serving in this time of continued crisis, particularly the threat of pandemic flu.
I’m a physician; I am a professor and associate dean of the Harvard School of Public Health. I direct the Center for Emergency Preparedness there. I also co-instruct a course there, now, on health communication, because I believe that health communication is so critical for all public health students and for public health leaders, but my major reason for being here today is to talk about my perspective as a former Massachusetts health commissioner from 1997 to 2003 under multiple governors, if I can say.
When I went into public service in 1997 I never found myself thinking that I would be embracing these unpredictable crises, but they come all the time. Anybody who is in public service faces unpredictable crises, they come all the time, and one of the messages to my students now is that instead of being surprised, we should be prepared and ready because they’re going to come regularly and instead of viewing them as giant obstacles… there’s a wonderful saying from my wonderful friend, the late Reverend William Sloan Coffin. He used to say, “Giant obstacles are brilliant opportunities, brilliantly disguised as giant obstacles.” [Laughter]
It’s only with the passage of time that I can say that now regarding the fall of 2001. So let me just tell you what it was like back then and this is not theory for me, it’s practice, and I head the Division of Public Health Practice also at the Harvard School of Public Health. This was the time, as you remember, where we had between October 3rd and early December of 2001, 22 cases of Anthrax, five tragic deaths, thousands of samples of white powder circulating around the country. No one knew which of those powders were really Anthrax and which of them were false alarms. There was tremendous uncertainty, emotional chaos, lots of menacing images on TV, and we health commissioners, state health directors, everybody on the front line were asked to lead the public health response at that time, which came out of nowhere. In fact you all know that we still don’t know who the perpetrators are of that incredible chapter of public health history.
I have so many memories of that time. One memory is that we had all 50 state health commissioners on a conference call with the CDC director, the Secretary of Health and Human Services. A number of months later, we had a second conference call with all 50 state health directors, the CDC director, the Secretary of Health and then the Secretary of Homeland Security, and that was about smallpox. And I was told later on that that was the first time in U.S. public health history that we had that level of intense communication. And I will always remember and actually cherish that sense of being called to duty. I mean this was a real phenomenal sense of mission and we felt a responsibility and a duty to protect the people in our states, to protect the people in our society and to lead the public health response in our respective communities.
But within a matter of days it became clear that my major job in my state and the major job of each director was risk communication and at first I was surprised and then quickly became acclimated to that because within days we would have multiple interviews to the point that we had daily press conferences. All the press were asking for and deserved updated information. It was important to share the information as soon as it became current and it was important to deliver that information in one voice so that people were not confused. And it was my goal here in this state to provide that information accurately and in a timely fashion and to offer my perspective on all of this, to try to keep it in perspective the best I possibly could.
So how do health officials do this and what should they keep in mind? And now I teach this and I look at that experience as a great teacher for me. The first message I tell my students is that every public health official has their own unique strengths. So people can teach you various principles, people can offer their academic lessons from their ivory tower, but we all have our unique strengths as communicators. So you have to understand what those unique strengths are ahead of time so that when you’re called into service you can tap into them right away. For me, I’m a physician; I’m trained in multiple areas, especially and including cancer. I still see patients on a regular basis, so I’ve spent my career delivering difficult news to people and I tapped into that experience, if I can say.
I am obviously Asian-American, the first Asian-American commissioner in the history of the state, and I’ve been told there have been something like under 10 health directors in the history of the country who are Asian-American. And being Korean-American is even better, if you’re Korean-American you’re always No. 1 in those categories. [Laughter] So I tried to tap into that through my tenure as commissioner and say, “I am the son of immigrants. I am a minority in this society, and in my role as a health commissioner, my role is to protect the health of all people, regardless of where you were born or regardless of whether you speak English as a first language or not.” That was something I believe very strongly and try to communicate in all my interviews, particularly in the fall of 2001.
It was an opportunity, if I can say, to talk about a sense of mission and what does public health do, because public health is usually very invisible to people. Most people didn’t know there was a state lab processing white powders. Most people didn’t realize there was a public health work force at the state and local level. We made that very visible during that time. It was important for me as a health director, communicating to the press, to convey a sense not only of passion, but compassion and I was very attuned to acknowledging the fear and trying to convey that compassion right away in any interview I did, and to acknowledge that it was an evolving situation without clear answers.
And then also, despite the fact that it was a time of tremendous uncertainty, that over time that we made progress, that we were able to process these white samples, that there was not and still has not been, now, any defined or definitive Anthrax in our state, in Massachusetts. Although we had one death in northern Connecticut that came very, very close.
When I look back at this episode what I’m proudest of is that we were able to show and demonstrate to people that public health has a tremendous mission of prevention, but also a tremendous mission of protection and the public health system works for people 24/7 whether they realize it or not. And in crises like this, it’s an opportunity to tell people what the public health system is, that there is usually an invisible system protecting people and that is a very noble and sacred mission and call to duty that we lived during that time.
So now we’re in a time where we’re facing pandemic flu. Our center at Harvard is very involved in that education. We work with health professionals and increasingly the public in several states and across the country. I am hoping that, if we continue to stress the importance of collaboration and public health mission, prevention and protection, we can advance public health in this country and indeed around the world in collaboration with leaders from the media like yourself. So those are my opening comments and thank you very much.
[Applause]
Tini Tran: Next up, I’d like to introduce Peter Sandman, who if you have been here needs no introduction as a risk communicator par excellence. He will be talking with us a little bit about what we’ve talked about in our earlier session and expand on that, which is to talk a little bit about the fear of fear and panic itself. Is it okay to scare people about pandemics?
Peter Sandman: I think so. [Laughter] I want to make three points if I can this afternoon.
The first point I want to make is that we need to overcome our fear of fear and be willing to frighten people. If we want to warn people, we’ve got to be willing to frighten them. When bad things happen, the bad things will frighten them. Once we have a pandemic we won’t have to frighten them, the pandemic will take care of that. But, if we want precautions, rather than people muddling through as best they can, not having taken precautions, then we have to frighten them before events do. That’s the first point I want to make.
The second one I want to make is that the problem isn’t panic, the problem is denial, and I want to talk some about how to prevent denial, which is essentially a communication task in which the media can be very helpful.
And the third point I want to make is that when you frighten people, it’s temporary. You can’t sustain fear. There is an adjustment reaction phenomenon and then people revert to the new normal. Because I never finish, I thought I would make the third point first and I will at least get through that one. [Laughter]
The concept of adjustment reaction is one that is widespread in psychiatry and my colleague, Dr. Jody Lanard and I borrowed it: we haven’t returned it. [Laughter] We borrowed it from the field of psychiatry in order to describe what happens when people first become aware of a risk that they were not previously aware of. And what people do when they are initially aware of a risk is they over-react. They have a temporary short term over-reaction. You pause in what you were doing before. You become hyper-vigilant, you check out the environment more carefully than you normally would. And this is perhaps the most important characteristic of the adjustment reaction: you take precautions that may be excessive, may be inappropriate and are certainly premature.
So you may go get Tamiflu, even though the government thinks that you shouldn’t. If it’s BSE, you may stop eating meat; if it’s SARS, you may stop going to Chinese restaurants and then you hear about hepatitis in a Mexican restaurant, and say, “All right. I’ll go to Chinese restaurants.” If it’s 9/11, you may go through a long period where you don’t want to go into tall buildings and you don’t want to go on airplanes. If that lasts a long time, it’s no longer an adjustment reaction, it’s an adjustment disorder and you need clinical help. If it lasts a short time, you’re perfectly normal (which doesn’t mean psychiatrists won’t take you as a patient to make money from you). [Laughter] But you’re perfectly normal and you’re going through a reaction.
Now, the adjustment reaction is often termed knee-jerk and it is, in the sense that it’s not entirely under your voluntary control. But knee-jerk has had a bad press. Bear in mind that when your doctor checks you for reflexes your doctor is hoping you have them. [Laughter] And the knee-jerk reaction of over-reacting early to a potential crisis is extremely useful. Like other knee-jerk reflexes, it protects us and perhaps the most important thing to say about the adjustment reaction is people who have gone through it come out the other side calmer and better able to cope. If you want people able to cope with a crisis, recognize that the way people become able to cope with a crisis is by going through an adjustment reaction. They either do that in mid-crisis, in which case they’re late in coping, or they do that in advance of the crisis, in which case they are ready to cope. Does this make sense to everybody?
I think it is inevitable that people will have an adjustment reaction to a pandemic or any other crisis. We want them to have it early rather than late. And the way to accomplish that is to guide the adjustment reaction rather than trashing the adjustment reaction, as it seems to me officials often do and journalists also sometimes do.
The second point I want to make is that the problem is not panic, the problem is denial. I am not going to say any more about panic than has already been said [yesterday], but I want to say something about denial. Denial is why panic is rare. We are equipped with a circuit breaker and when we’re about to panic, we go into denial instead. Denial is not useful in that people in denial don’t take precautions, but it’s preferable to panic. People who are panicking do themselves harm; people who are in denial don’t accomplish much, but at least they don’t make things any worse. So denial is God’s way or nature’s way of protecting us from the horrible effects of panic, and whereas panic is rare, denial is extremely common and we need conscious effort on the part of the sources and, insofar as journalists are willing to make conscious efforts, a conscious effort on the part of journalists to protect people from denial and to seduce people out of denial.
I want to identify what the research literature suggests are the five principal bulwarks against denial. The first of those five is to legitimize fear. People go into denial because they don’t feel entitled to be afraid and the more entitled people feel to be afraid the less likely they are to go into denial. This is why the message, “Don’t be afraid,” is a very destructive message in serious circumstances, a very harmful message. And much superior is the message, “Well, of course, you’re afraid, I’m afraid too. We’re all afraid. We’ll get through this together.” So the legitimation of fear is a bulwark against denial.
The second bulwark against denial is “things to do.” Efficacy and self-efficacy were mentioned in the earlier panel and the research there is extremely strong. It’s not that if you have things to do you are less afraid, it’s that if you have things to do you are better able to bear your fear. So, you can tolerate higher levels of fear if you’re busy. The military understands this very well and it tries to keep soldiers busy so that they can tolerate their fear.
A third bulwark against denial is things to decide. This is even better than things to do: instead of only enlisting our ability to act, you enlist our ability to choose. So rather than offering people things to do, wherever possible I urge my clients to offer people menus of things to do so they have opportunities to decide what they want to do and what they don’t want to do. That makes them less likely to go into denial because it makes them more able to bear their fear.
Bulwark number 4 is love. Anyone who has had the experience of loving knows that we are much better able to bear fear on behalf of those we love than on our own behalf. The military understands this very well; they don’t call it love because they’re a little homophobic, they call it – [Laughter], they call it esprit de corps. But it’s love. They know very well that soldiers don’t fight for their country, soldiers fight for their buddies, so that’s a bulwark against denial. Again it’s not that loving makes you less afraid, it’s that loving makes you more able to bear your fear and less likely to trip that circuit breaker into denial.
And the fifth bulwark and one that’s much more controversial is hate: the military understands that one, too. Having somebody you hate or maybe even a virus you hate can enable you to bear your fear and hang in there without tripping the circuit breaker into denial.
The last point I want to make – I have what, a minute? – is just to say one or two more things about the fear of fear. Officials it seems to me are dominated by panic-panic. They are panicking that the public is going to panic. Or at least they feel panicky. The problem is the difference between feeling panicky and acting panicky. I suspect what’s going on, frankly, with officials is they are feeling a variety of performance anxiety. [Laughter] When officials feel panicky during a crisis they’re not afraid they’re going to die, they’re afraid they’re going to screw up. They’re thinking this is my “Rudy Giuliani moment” and I wasn’t trained for it.
Because those feelings are unacceptable, officials tend to project their panicky feelings onto the public. This is my hypothesis, I have not got data on this – most of what I’ve said today I have data on, but this one, I don’t. My hypothesis is that the main reason why officials resist the data that panic is rare is because officials are projecting their own panicky feelings. The more panicky the official feels the more the official is likely to deduce that the public is panicking. I can’t prove that, but I suspect it strongly.
Anyway, the point that I need to make and that I need to end with is this. We have to overcome our fear of fear. We have to understand that fear is the solution, not the problem. It simply makes no sense to say, “I want you to take precautions, but I don’t want you to be afraid.”
Perhaps the single most important thing to tell you in order to help overcome the fear of fear is to remind you that fear is a competition. When you make people afraid, you don’t make them more fearful people, except very momentarily during the adjustment reaction. What you do is you get a larger slice of their fearfulness pie. Jerry Falwell wants everybody to be afraid of gay marriage. Greenpeace wants everybody to be afraid of genetically modified food. And I want everybody to be afraid of a possible pandemic. When I try to scare people about a pandemic I’m not trying to turn them into more frightened people, I’m trying to tap the fear that will otherwise be allocated to Falwell and Greenpeace. [Laughter] This is the law of conservation of outrage. The level of fear you have is the level of fear you have, it changes glacially. We are all of us most fearful than we were as teenagers, thank God. [Laughter] Yes, it does change a little bit, but it’s mostly stable and what we’re going to do is not produce more frightened people, but get more of their fear for our issues. My sense is that that understanding makes people feel a little bit less fearful of frightening people. Let me stop there.
[Applause]
Tini Tran: Next let me introduce Glen Nowak, who is the chief of media relations for the Centers for Disease Control. Glen will be talking a little bit about the challenges of risk communication in real time in a globalized world. Thanks.
Glen Nowak: I guess Dick and I have been practicing real risk communication in a couple of ways, one probably [going after Peter] …. [Laughter] That’s always risky, and two I think both of us have sort of that same general theme, which is kind of letting you take a look behind the curtain in terms of what we do as part of our job dealing with the people that are the policymakers, are the people who appear in the press, are the people who appear on television. So I’d like to take you a little bit behind the scenes as part of my talk because of some of the challenges that people like Dick and I face when we’re providing communications advice and media advice to the people that we deal with on a regular basis.
Eighteen months ago – and I think I can do this with this audience – I was struck by an ad campaign that I came across and the ad campaign said, “This strikes two million Americans each year and complications from this kill up to 200,000 people a year: more than breast cancer, car crashes and AIDS combined. The good news is in most cases this can be prevented.” So I go out and ask audiences, “So what is that? What did I just describe?” This is a campaign that was undertaken purposely so, to get all of us in America to pay more attention to this cause that I just described, and that was their ad copy. Would anybody care to.…
[Many guesses, including drunk driving[
Glen Nowak: I’ve never had an audience get it right. It’s deep vein thrombosis. [Laughter].
A campaign that ran for six weeks. It had ads in Parade magazine, there was a handful of articles in the newspaper and as far as I can tell it was a six- to eight-week-long campaign and I think it’s very illustrative on a number of levels. Oftentimes people like myself and Dick are told, if we just get the numbers out there people will take this issue to heart. Here’s a campaign that did, I think, a marvelous job of just getting the numbers there, trying to frame the numbers of things that we’re all familiar with: car crashes, breast cancer, things of that nature, and it still doesn’t resonate. I think what the first challenge is, I’m going to talk about, is one of the challenges that we’re faced with are the beliefs, the expectations of those outside the realm of risk communications and the media. And they include political leaders, scientists, and the general public that each of them [inaudible] into events.
As you sort of experienced the last couple days, scientists and physicians often have some interesting beliefs about the media and we struggle with those at CDC and I’m sure Dick struggles with those at the World Health Organization. One of the challenges that we face is that the news media are often viewed by scientists and physicians that they should be operating like journeymen journalists, that we should have the same standard in terms of your criteria for what you allow into your stories, that you should primarily rely on views that have been established or accepted by most scientists. You should be providing all the nuances and caveats that you receive in your journal article. You should use as much space and time as it takes to get the information out there properly. And, as we all know, those of us in communications, that isn’t a realistic expectation.
I think you’ve often assumed (and we do do that at our level) that the news media should primarily serve as an educator of the public and of policymakers and how that translates is that you should be doing more to give us high visibility, frequent playings of the same messages. And so we face this every year at CDC. I’m often told, “You know, we could use about three months of steady, ‘Get your flu shot’ stories.” And we often have to say, “Well, perhaps at the beginning of the season we can hold a press release and announce the kickoff of the season.” You can get some play for that, but unless there’s some new developments and some new angle, some new idea, some new research, some new [money], something new, news is at the end of the day; the first three letters are N-E-W. If you want to do those other things, and our advice has been probably pretty consistent at CDC, you need to think about purchasing the time and space or using other venues. And so we spend some time educating [some] scientists and physicians that the news media are not the only way to get [at access], but it is a challenge and it is one of the things that we deal with.
I think another challenge is there is a strong belief among scientists and physicians and probably policymakers that we can at some level FYI the media. This really is a challenge. It comes in the form that people will come to me and say, “I’ve got a really important piece of information and I think we should get it out there,” and then we will ask, “So what should people do with that information? How should they change their behavior? What’s our health recommendation as a result of the information?” And they will say, “I don’t know.” But it’s really important to get this out there. We need to call a press conference and [inaudible] to this. And the very act of calling a press conference elevates the information, it may be the most efficient way for us to get this information out to multiple numbers of reporters, but that act is kind of incongruous with – you can’t call a press conference and then the first thing out of your mouth is to say, “This really isn’t that important.” [Laughter] Because as those of you who are journalists would rightly call us into question, “If it wasn’t important, why did you call the press conference?” So we often struggle with that… at the CDC and at the World Health Organization as well, is that “We have information, but we may not be ready in terms of understanding it completely.”
I think any other challenge we face is oftentimes, as you know, we deal with political leaders. A lot of the appointments at HHS and sometimes the CDC are political appointments. I think one of the challenges there is these people come in with a backload of political communications and often what you would do in political communications is the opposite of what you would do in health and risk communications. And so good health and risk communications means sharing dilemmas, disclosing information, being transparent.
People who come in from a political [background], political campaigns, that is the antithesis of what they typically do in a political campaign, so this is very scary for them when we say, “Let’s be transparent.” It’s the exact opposite of what they’ve been doing for the past six or seven months as far as their campaign.
I had the – I guess it was the pleasure the last couple of months to observe a lot of public communications media or public and [inaudible] meetings on pandemic flu, and that’s been enlightening. We’ve been trying to engage the public in terms of giving us input and among the things that the public has been asked – I’m not sure that I would have asked them but I think it’s been asked and I think it’s been instructive is, “How should we communicate, what communications principles would you provide?”
What’s interesting is in many cases the public is dead on. The things I’ve heard in the last few weeks on the communication front is that many people in the public have told us that we should take a multi [inaudible] -orial approach, involve lots of different organizations, including business. Involve lots of different partnerships, engage the communities, engage faith-based organizations, provide frank messages and work to make sure your messages are visible.
I think the other thing I’ve been struck by is that, as people have probably noted earlier, the public in our medical expert societies have different mental models, ways of viewing the world and that can be a communications challenge because sometimes we recognize those differences and we struggle in terms of how to incorporate them into our message strategies, other times they’re very subtle and important, but we don’t recognize them. The one that came to the forefront the other day was a discussion around antivirals and there were people in this meeting from the public who… their mental model was that when we talked about using antivirals as a treatment they thought that this was a [cure], that you got antivirals and you stopped the progression of the disease and therefore you were not going to get these really severe complications.
The physicians, on the other hand, had a different mental model. Their mental model was this is an effective way to treat some of the symptoms, but it wasn’t a cure. So there was a lot of confusion in this meeting as the physicians were trying to say, “Look, it’s not a cure,” and the people in the audience, the public, was saying, “But you said it’s a treatment. Treatments are cures.” So sometimes you capture those things, but sometimes you don’t recognize them and, as a result, they can cause us problems in communications.
Just a couple of things I also would highlight – we are in a rapid world here with Avian Influenza. It’s not easy to base decisions, actions, and communications, recommendations, or even recommendations in general on science. The science is often lacking and the science is often changing. A good example was earlier this year, March 21st, there was a story in the Wall Street Journal. The headline was “CDC Reports H5N1 has split into two different forms.” The article went on to say, “the H5N1 virus responsible for global bird flu outbreak has evolved into two genetically different strains, U.S. scientists reported, raising concerns of an increased risk to humans. Now that they have split into two genetically distinct forms scientists are even more concerned that it will evolve into a form more easily transmissible between humans which can [spark] a pandemic.”
Three days later, different study, University of Wisconsin, Madison, headline is “Bird Flu [thought] to spread.” It said, “An international team of researchers at the University of Wisconsin, Madison reported that they have identified the biological roadblock that prevents the [inaudible] of the virus from transmitting easily between people. There was only three days between the reports of those studies and so you can see – we recognize where the dynamic environment – sometimes I think we under appreciate how dynamic [inaudible] really is.
A couple of other things: Peter has said that the key fundament of risk communications is acknowledging uncertainty, but I think if you’ve listened to the last couple of days, if we really did that visibly, repeatedly, it probably would have [inaudible] our credibility adversely because we’d be saying, “We don’t know how influenza is transmitted. We don’t know how effective influenza vaccine is. We don’t know how effective or useful anti viral medications are or will be. We don’t know if closing schools will have any effect and we don’t know how severe the pandemic will be.”
We do have to acknowledge that certainly, but the thing I call to your attention is it’s sometimes easier said than done and if you’ve been in [inaudible] like I just did, people would walk away with, “I should trust you why?” [Laughter.]
Media practices are often a challenge for us, the idea of being balanced. Just to highlight – again this happened this year back in January. It was a UPI story that said 42 in Japan die after taking Tamiflu, that headline caught my attention. The first sentence said, “Health officials in Japan say 42 people have died after taking Tamiflu, but only two deaths resulted from taking the drug.” [Laughter.] So again we’re up against the headline writers who have a different issue.
A more recent example: last week I got a call from a Belgian paper asking about the fact that one of the anti-vaccine groups had posted a posting saying that 17 people died during the trials of the [HPV] vaccine. So we did check into that and it’s true that there are 17 adverse [medical] reports involving deaths in a clinical trial, but they were 17 recorded deaths, 7 were from car accidents, [inaudible] were suicides, 2 were cancer deaths. So again it’s people putting information out there without the full context.
I think probably two points I would make is that I think we need to recognize that our efforts and investments in pandemic influenza preparedness such as vaccines, anti-virals, non-pharmaceutical inventions, planning and preparedness do a couple of things. One, they get media attention and when they get media attention and we make those investments we actually now further our pandemic preparedness, but we also do foster the perception that many people are engaged in preparing and protecting us and that in turn does dampen and lessen media and public urgency interest and concern. So I don’t say we shouldn’t highlight those things, but in highlighting those things we raise the bar in terms of getting further publicity and we raise the bar in terms of trying to get people concerned and interested in what we’re doing.
And then finally I think that there are two phenomena that we desire that really don’t exist and one of them is calm measured heightened and highly visible media attention coverage. I don’t think that exists, nor do I think calm, measured, heightened policymaker attention and response is something that probably exists and I say that because if you think about two things that may be on the horizon and how the world will respond to the media world. One, what would happen if Dick and his group, WHO, convenes its expert panel to consider a change in the threat level for pandemic. If he convened that meeting, there would be just a ramp-up of interest and then secondly if they did change the threat level, what would happen then? I think you’d see a plethora of stories and we would all start treating this as a 100-yard dash when in fact you’re competing in a marathon.
[Applause]
Tini Tran: Let me introduce our final speaker on this panel and he perhaps will be delivering perhaps the single most important message that we will all be waiting for. Dick Thompson is the WHO team leader for pandemic and outbreak communication and ultimately this means that he is the guy we will be hearing from if the shit hits the fan. [Laughter.]
Dick Thompson: We’re going to allow you a peek behind the curtain and I’m not sure it’s going to be all that – will build your confidence in what we’re doing, because the focus is a little bit messy. [Laughter] I, like you, was interested in health and medicine reporting and, after a couple decades, I became more and more interested in public health and its importance and I think anybody who spends a long enough time reporting medicine stories eventually starts to shift to being more interested in public health and its impact on society. And then in 2001 I had an opportunity to make a jump from being a reporter to actually working in public health and so the stars seemed to be aligned and I took that opportunity and shortly after I arrived at WHO and I was installed as a communication chief. Actually I was it for my department, communicable diseases. It’s a mistake that a lot of organizations make. They think that by hiring a reporter they’re hiring somebody who knows about communications: that was completely wrong. [Laughter]
We’ve been used by communicators most of our lives and then you get on the other side of the street and you learn what those tricks were and you say, “Oh, my God!” But shortly after I arrived, SARS broke out – I won’t tell you who named SARS, but it was me and somebody else. What happened right then was that we were overwhelmed with calls and we had to speak constantly about something that was a new disease and that people weren’t responding to antibiotics. The virus was moving all around the world very quickly. It was up to us to decide how we were going to speak about this and so I looked around WHO to see what risk communication resources were there. Actually there were none, which really surprised me, so we were pretty much left on our own and what we did was to rely on our instincts as reporters. If I was a reporter reporting this story, what would I want from me and what I would want first of all is to hear from me. [Laughter] Just to be accessible is really important and hard to do when there are all sorts of calls coming in. But I’d also want to have some kind of faith that what you were telling me was the truth and if I ever detected that you were spinning me or lying in any way, if you were covering up or protecting your organization, you’d just automatically devalue what you hear.
So I applied these rules, this instinctive behavior as a reporter, and somehow we stumbled through it and I think we did okay. There were a few missteps, but after that we were asked to put it on more solid footing. There would certainly be other risk communication challenges in the future and WHO needed to know what to do and what to say.
I should say that it was during the SARS outbreak that I first had contact with Peter who turned out to be enormously helpful, volunteered his time, and gave us all kinds of wisdom that helped us, and it was simply great to find somebody out there that would tell you, “You may be drifting off here and you might want to pay more attention to people who are wearing masks.” Masks actually was my biggest mistake – well, one of my mistakes during SARS and that was we were seeing people wearing lots of masks in Hong Kong and Singapore and we’d get calls from reporters saying, “Is this effective?” So I’d go to the technical team, they’d say, “No. It’s a waste of time. They’re not wearing the mask properly. It’s not a good mask, it’s not doing any benefit at all.” I went out with that message and what I heard from Peter and his wife Jody Lanard is that that was a real mistake, because people were telling us something and I just wasn’t listening. They were telling us that they needed to do something and I needed to give them something to do, but instead I fell back on our technical resources and they told us that something was wrong here with wearing masks and that’s the message that I passed on.
So after it was over we rebuilt or actually we built risk communications at WHO. We called it Outbreak Communication because we’re focusing on a special type of public health event. There are a lot of special things about outbreaks, but most importantly is that they’re unfolding events. Nobody really knows where they’re going. So I was looking at Peter’s graph yesterday and he could play something with high hazard and low outrage. And with outbreaks, especially in the beginning, there’s high outrage, high concern, but you don’t know what the hazard is. Maybe you don’t know the cause, maybe you don’t know the roots of transmission, what treatments might be valuable. So there’s a real unknown there and I still don’t know where to put it. But that’s why we called it Outbreak Communication because it seemed to me that it had special features.
With the help of Dr. Lanard, we spent six months reviewing risk communication literature and there’s actually a lot of very good literature about this because there have been big public health communication disasters that have been extensively studied. So we looked at those. We came up with five principles that we then took to a group of outbreak response managers and there were 85 people in Singapore. Peter was there. These were response managers that had addressed all sorts of outbreaks from Ebola to [inaudible] virus, cholera, everything, and they worked in different cultures, in different economic systems, different levels of development, and they all endorsed these five principles and we came up with this book, which I think is one of the best things that I’ve ever been involved in, even after 23 years in journalism. This is the Singapore Report and it’s online, it’s best practices for communicating with the public during an outbreak.
Two years later we actually were able to get all this information down onto this little card. [Laughter] So you could write long, but it takes you a while to write short. So what are the principles that we use, how will we communicate? As we heard this morning, trust is the most important thing. As a communicator this is the currency I work in. Every time I communicate I’m earning trust or I’m spending it and sometimes we knowingly spend trust. Be as transparent as possible. This is very very difficult, especially for people who are – a culture that’s generally used to working behind closed doors and coming out with peer-reviewed publications, it’s very difficult for them to allow the public in to see what we’re doing. But, once we do that, I think it increases the trust and confidence people have in us. Announce early, even when there’s incomplete information. This is another thing that’s very difficult. A lot of times officials will want to wait and they use the reason that they don’t have all the information they want. They use that to delay and delay and delay. Finally you pick it up, it’s reported and they have to respond that, “Yes they’ve known about it for three weeks” and they lose a lot of trust.
Listen to the public. I talked about that and then plan for the extreme demands of outbreak communication and on the back we’ve got hints for interviews and they’re special hints for outbreak interviews and that is to clearly say what you don’t know. This again is hard, especially for physicians. They’re used to saying well, “This is what it is” and to say what you don’t know is something that doesn’t come naturally to these professionals. To share dilemmas, as we’ve talked about here, to leave room for the unexpected in your comments. In an outbreak, you shouldn’t make definitive statements about anything because even as an outbreak is drawing to a close, that can be the most dangerous time because people relax their guard. Somebody slips through and you have another outbreak.
And then, finally, never over-reassure or mislead and I think what this thing says is that our instinct in the beginning to act as a good source was right. We needed to gather this evidence and we need to have the endorsement of the experts. So that we could say be a good source and that’s pretty much what we do here and now we run workshops around the world in outbreak communication, trying to train people from ministries of health in outbreak communications and sometimes it’s very effective. In Egypt, for example, we found that the ministry of health reports transparently, quickly about all human H5N1 cases. We’ve done surveys of trust and confidence and what we see is that there’s a baseline level for information that people trust from the government. It’s a little higher for the ministry of health and it’s higher still when they talk about Avian Influenza, which is very good. But I’ve also worked in countries where after an outbreak communication lecture they’ve gone into a meeting about how to bury bodies in the middle of the night so that they don’t get people concerned about how bad the outbreak is. I think we’re making some progress. The way that it helps shape our message is that we began talking about the “I don’t knows.” We don’t talk about the availability of vaccine because we think that’s misleading. I think that every communication that we’ve made is really a pandemic communication because we’re either building trust or it’s costing us. So I hope it’s working.
Once we’ve finished our work with the outbreak guidelines I finally was able to read The Great Influenza by John Barry and in the last two pages of the book I was really hit hard by what he had to say because he talked about the public terror that existed in 1918 and he said that that terror existed because public officials lied about what was going on and it became apparent to people who were at risk that they were being lied to and it was that broken trust that really led to what he called the terror of 1918. And he concluded his book with a plea that those in authority must retain the public’s trust and the way to do that is to distort nothing, to put the best face on nothing and to try to manipulate no one and I hope that’s what we’re doing with our guidelines. Thank you.
[Applause]
Tini Tran: Thank you all. We’ll start our question and answer period.
Q: John Pope of the Times Picayune. I have two questions for Glen. [inaudible]
Glen Nowak: Yeah. I believe he did. One was Madison and one was [inaudible].
Q: Second question, [inaudible] to develop your communication on Avian flu. One thing I’ve been concerned with throughout this conference is [inaudible] about giving enough information about scaring the hell out of people or risk that it doesn’t quite exist yet.
A: There’s a lot of people who were involved with that. We worked closely with the Department of Health and Human Services and the folks up there. We worked very closely with people from across the CDC and there’s also been a concerted government effort to engage almost every federal government agency who could be touched by Avian influenza, so that there have been, for instance, the development of six different scenarios that could play out, ranging from there’s an infected bird in the United States to there’s an infected person in the United States. And so you actually have these exercises where you go on through with the number of government agencies, both federal and state and local officials that figure out if this was the scenario, who would be responsible for what? What would the communication messages need to be? What kinds of materials and resources would need to be rapidly or instantly available?
We work very closely with the state public health information officers and so a lot of what we do in our program is make sure that we’ve established networks. Because we know that if we have to get information out quickly to a lot of people, and a lot of people are going to probably need a heads up in terms of what’s happening, and so one of the groups that we work very closely with is the state and local public health information officers [so] we can facilitate that happening.
Q: How about what you put out to the public?
A: Well, again a lot of what we put out and what we’ve developed is actually on websites. [inaudible] a tremendous source of a lot of it, CDC website has some additional stuff, but you’re right, we’re always looking at, based on the calls that come into our hot line, based on the questions that reporters are asking, based on things that are in the news, based on research that’s coming up, what kinds of materials do we need to have available? Are there some fact sheets? Are there new pages that need to be on our website? Do we need to update information on our website and so we’re always in a dynamic mode in respect to Avian Influenza information.
Tini Tran: Peter.
Peter Sandman: It’s worth noticing in response to your question that HHS went through a period in which it was terrified of frightening – as you say, the hell out of people. It was taking pandemic risk seriously, but not very aggressively urging the public to take it seriously. That came to an end I think because of two things. One, George Bush read a book. [Laughter] He read Barry’s book about The Great Influenza and the other thing that happened is Katrina, which began to say to people that maybe Pollyanna wasn’t the right role model and Cassandra was.
But what’s important from the perspective of your question is that when HHS reversed course and started being extremely scary, it’s not as if the public fell apart. The public’s response to those very scary messages was to just barely notice them. [Laughter] We have to keep our perspective here. When we think we’re terrifying people, we may be just barely reaching them. Now if a pandemic comes, people will be genuinely terrified, but nobody has ever been genuinely terrified by an HHS news release about possible future events. It doesn’t happen.
Q: Andrew Dworkin of The Oregonian. I’m curious, following on that, though to find out what you guys think about Anthrax and smallpox because the reaction to that, there were buildings closed. We had a run on gas masks in Portland, Oregon. People buying plastic sheeting, our garden writer wouldn’t open her mail without wearing gloves for months. And this was for 22 cases of one disease. So even in U.S. bioterrorism terms [it was] probably a very small historical outbreak, and zero cases of another disease that everybody knew didn’t exist except in two laboratories. Is that good or bad?
A: The media amplify the unusual and look for the unusual and so in that case the vast, vast majority of Americans weren’t taking any actions and so you’re not going to write a story about people who don’t take action, you’re going to write about the person who does do the things that you describe because that is the unusual, that is the difference. The same thing, as you look through this past couple of months, there have been stories, the stories that appear on flu vaccine have highlighted places that don’t have the vaccine. You don’t have these stories about places that are flush with vaccine. So again part of it is a media phenomenon – I’m not blaming the media because it’s real easy to focus on news and the unusual, but in doing that you elevate these things and then other people then interpret them and that’s a broader behavior then it really is.
Q: [inaudible]
Glen Nowak: But it wasn’t CDC so – [Laughter].
Howard Koh: I think one difference is that Anthrax literally came out of nowhere. It came out October 3rd, 2001, but there was no forewarning at all. At least for this current potential threat there is the time to get the public ready, get government ready and I think we have to capitalize on that if we’re concerned about promoting public health. One of the challenges in my view is that – it’s [inaudible] before journalist is that there is obviously a difference between H5N1 Avian Influenza and pandemic influenza. I’ve already noticed this morning that people used them interchangeably and it could well be – if H5N1 does not turn out to be a pandemic influenza, and the signs are pointing that way that when the next version of Avian Influenza comes up, that people will say, “Oh, we’ve been through this already and everybody got us worked up and it didn’t occur.” We don’t want that to happen. We – when I say we, I’m talking as a health professional, I would like to think that we would say, “Oh, this is an opportunity for the world to get ready, to get prepared and understand what public health is and what our responsibilities are.” That’s the outcome that I would like to see as a public health professional.
Peter Sandman: Two quick points about Anthrax. One: people’s suspicion that Anthrax might be a trial run for a much larger Anthrax attack and, therefore, taking precautions against Anthrax even though it was extremely narrowly distributed so far – that wasn’t a crazy suspicion. The U.S. government had exactly the same suspicion and, in fact, the principal suspect had that in mind. So it wasn’t nutty to say it’s only a handful of people and I’m not actually a media heavy, so the likelihood that they’re going to go after me is low, but if this was a test case, maybe now they’d blitz all of the mail. So that wasn’t crazy.
But the more important thing to notice is how quickly we got over it. If you want to say people over-reacted to Anthrax, I think you have a good case that some people over-reacted, but notice how briefly people over-reacted, and then they got used to it. The post office is one of my clients and there were thousands of postal workers reporting white powders for a few months and now their problem is that the postal workers have stopped reporting white powders and it’s now absolutely easy to attack the post office because nobody is going to report the white powder because they don’t want to look stupid. We went through the adjustment reaction. We went back to the new normal and if anything we went back down too low.
Q: Christine Gorman, Time magazine. When you talk about masks and how you were explaining them differently, let’s transfer the situation to Massachusetts or somewhere in the United States. What would you say about masks if people are wearing masks, knowing that your technical people are saying that they’re ineffective.
Howard Koh: One way you could answer that is there are no formal recommendations. Let me get back to the Anthrax – during those times we had the problem, I got asked all the time about how to open your mail. It was unbelievable the detail that people were having, “How do I open my mail and what precautions do I follow to open the mail?” So oftentimes I would say – this is my own personal answer would be: “Well, there are certain guidelines offered by the postal service and if people want to do more for their own peace of mind, they are obviously welcome to do so,” or something like that. So I don’t know if that’s a principle that would apply to the mask use.
Dick Thompson: In Europe there’s a large developed country that has a very large stockpile of masks and they plan on distributing these in the event of a pandemic. They’re to be used in a household, not for street wear, but I imagine that people would use it for – they have masks for everyone in the country. The bordering country has decided that masks are completely worthless and they have not invested in masks, so come the pandemic there will be one country providing masks and the next country over saying, “These are worthless.” What we’re trying to do now is to develop some discussion, how are we going to talk about this in public. I’m not sure that we’re clear about how influenza is transmitted from person to person. So there’s some room to say that these may be effective if it’s given to the person who is sick if you have to be in a household caring for somebody. But what we saw in Singapore when people were wearing these masks, the message there was that this was something people were doing for the community, that this was a socially responsible thing to do. And I thought that was a very good message about masks. Now, whether or not it was personally protected was one thing, but was it protecting people around you?
Q: Just maybe a question and a point of clarification, be very careful to distinguish between masks and respirators. They virtually look almost the same, they both just attach to the face. A mask is like a surgical mask tied behind your head, a respirator, an N-95, is basically one that fits tight on the face and there’s a big difference between [inaudible] . I guess I’d come back to Dick and ask you this and then Peter to a certain degree, because one of the things asked more from the technical side I worry about is not that we don’t acknowledge this idea of if you’re wearing masks, this is important, but then when we see breakthrough, we see problems, we basically are going to then on the flip side be accused of, “Wait a minute. You didn’t give people the accurate science information.”
And I guess I’d like to challenge the notion that you should have supported wearing masks, what you should have possibly done or we should do is just put the data out that we have and tell the truth and just say, “This is what we know. If aerosols play a role in those particles, the respirators can be required because otherwise they’ll float right in through the mask cracks. If it’s large particle droplets which it could be some of that too, then masks will work and then I think you have to let the public decide for themselves.” You don’t tell them no, but you also [don’t] just reinforce their behavior they’re doing because you’re afraid if you don’t you’re not acknowledging their outrage.
Peter Sandman: I think it’s very, very complicated. The general principle certainly stands that you don’t distort hazard data in order to address outrage. You address outrage by addressing outrage, not by lying about hazards. You should never ignore outrage, but it’s not an excuse for misrepresenting the hazards.
That said, and particularly since this is an audience of journalists, we sources are very inconsistent in when we insist on good science and when we advance crappy science, pretending it’s good science. To summarize a lot of research in three sentences, surgical masks work against droplets, but they become fomites, potentially dangerous themselves. N-95 masks work against aerosols, but they’re going to be in incredibly short supply and they’re uncomfortable and they’re hard to fit. Washing your hands works against fomites and that’s all it works against. All of the people who say we shouldn’t oversell masks don’t ever seem to mind overselling washing your hands. The science that masks work against droplets is every bit as good as the science that washing your hands works against fomites. So you’ve got a double standard here. Journalists are not doing all they could do to catch the bullshit that some sources are giving them.
Glen Nowak: I think the other problem leading up with the people getting data. We saw this with Anthrax, the antibiotics is that when we did that, people interpreted it as ambivalence. “You’re the expert and you’re telling me you go make the call,” that really put them in a bind and oftentimes what they did was they changed the question. They said, “So what would you do as a person in my situation?” It’s really hard for us to be able to say here’s the data, this says do and this says don’t. Good luck with your decision, let us know how it plays out.
Q: Jennifer Boen from the News-Sentinel in Fort Wayne. This summer the state health commissioner in Indiana [inaudible] a conference for the media throughout the state. One message that we were given was depending on where or how H5N1 entered the United States, let’s say through a bird. The messages they made initially comes through the USDA and would you talk just a little bit about it and the state commissioner told us they have some different protocols than CDC, so I’d like to know what those are and how this message might be communicated through USDA.
Glen Nowak: You’re absolutely right in the case of Avian Influenza. The CDC deals with people and so the domain of birds actually is the U.S. Department of Agriculture. Actually one of the things that’s happened in the past couple of years is figuring out whose turf that really is. Because there’s Interior, there’s a whole bunch of places that until a lot of conversations happen there was some uncertainty as to how it will play out. So, for cases involving birds, it is going to be the domain of the Department of Agriculture. They’ll be working very closely with the different state organizations that are involved in poultry and wildlife and those vary by different states.
The U.S. Department of Agriculture, I think, a while back, decided that one of the things that they were going to do to foster transparency was they were going to announce any time that they got a bird to test to see whether it was low path or high path and they did that. They embarked on that journey for three or four months and then got a lot of attention for the first time they did it. They said we’re testing a bird. The second time they tested a bird, got a little bit less attention, and by the fourth time they realized they had no attention. So I think they rethought that policy. So it is challenging because I mean you’d argue from a risk communication perspective: be transparent. And if you keep being transparent it’s sometimes misinterpreted as [inaudible] or you’re calling attention to things. There’s also lags in testing, say you send the bird off to the lab and then it’s [two] weeks later before you get the test results back and so there is this time lag and in that time period often the advice is there’s not much – there’s no action we’re recommending that you take as a result of us testing these ducks. You can still go to that park, you can still do whatever you’re going to do, so it’s kind of a short message. But, yeah, if it involves birds, if it’s out of the realm mostly of the CDC [inaudible] early on [inaudible] . When it comes to communication, we’ll be rapidly involved.
Peter Sandman: Does everybody in the room understand – I think everybody does – but does everybody in the room understand that when H5N1-positive birds come to North America, that will have absolutely zero impact on the risk of a pandemic? There’s a reason why that’s widely misunderstood. It’s widely misunderstood because we have successfully told the public two things. We have told the public that H5N1 is transported by birds. Okay? And it’s coming here sooner or later. And second, we’ve told the public that H5N1 could produce a pandemic that would kill millions. What we haven’t emphasized nearly enough is that the H5N1 in those two sentences or the bird flu in those two sentences is a different disease, a different virus. The one that’s going to come here in birds is not the one that’s going to kill millions of people. The one that kills millions of people you’re going to get from your neighbor or your subway. You’re not going to get it from a bird.
I look forward to H5N1 reaching our shores in birds because it will be a teachable moment. And the first thing we’re going to have to teach people is, “No this isn’t the start of the crisis, this is just a reminder of the crisis we’ve been looking at all along.” It’s still likely to hit us from the developing world, not from a bird in this country. By the time it gets to this country, it will have already made that transition and it will be transported in people. We’re going to have to teach people that. We’ve taught people the wrong stuff and now we’ll have to un-teach them and teach them the right stuff. We can do it, we’re going to have to do it.
Howard Koh: The analogy here is the West Nile Virus story. When those first birds were infected and that hit the press and the public in ’99 I believe. It was an extraordinary time and now seven years later that extraordinary has become an ordinary part of public health. So this time will come and I [tend] to say we’ll go through sort of the same chapter again.
Peter Sandman: People will be scared of eating chicken for a few months and then they’ll get over it. And you can help them get over it by teaching them that it’s not about the birds, it’s about people.
____: Just one thing, this happens in every country.
____: That’s it. Except the UK where for some reason it didn’t happen.
____: Well, [inaudible] there was quite a media frenzy about – until it was discovered to be a German swine. [Laughter]
Peter Sandman: The UK is the only place I know where they found H5N1 in birds and the poultry markets didn’t decline. I think maybe people thought, “We went through this with BSE, we don’t want to stop eating some other food.” Everywhere else it has happened. But only for a little while; people got used to it and poultry markets recovered.
Q: We’ve been talking a lot about the message. We’ve had some excellent messengers but let me ask us to think a little bit about what authority you have to get the right messenger on television. My colleague, Steve [Gorelick] wrote a great op-ed piece called “Bring in the Nerds,” and it was after Tommy [Thompson] was the chief spokesperson and then Dr. [Fauci] was and it looked like the nerd was really communicating effectively. Scaring people with a scary message. It was scaring people with the apparent incompetence of a Secretary who was in charge of a response. So what have you been doing to think about who is the authorized messenger on television and also at the local level. Should it be our weatherman who –
Glen Nowak: He’s delivering a point, a lot of things come into play. I think one of the things that come into play – and I’ve alluded to it in my remarks is that political communication comes into play. At the time of Anthrax that was the beginning of a new administration and so again there’s always the learning curve. And I think unfortunately with Anthrax it happened when the learning curve hadn’t been completed and so I think there is a desire in many cases – if you’re a politician, to get behind the cameras and go out in front of them and if you haven’t had experience in health communications or the health area in general: it’s really easy to make missteps.
What CDC has done is we have realized – and we do spend a lot of time thinking about who the spokespeople are and we now coordinate that very carefully with our colleagues at HHS and other places. Dr. [inaudible], I think in many instances would probably be the person who would be out there because unlike Secretary [inaudible] so that is a consideration and it’s really important to have the right credentials behind your name as well as being able to – the statement made.
Another factor that comes into play is that there are – and people in this room know it, they have their Rolodexes and they know who to contact and so they will be calling people like Mike Osterholm or they’ll probably be calling Tony Fauci directly, they do it today. Some of that is not in our scope or our domain. Particularly Mike, even Tony gets a lot of calls and they’re directly – and a lot of it is by virtue of where you are.
We also have to realize that a lot of local politicians and governors will be speaking and so we have developed resources to guide them, we work with the National Governor’s Association and the city and county health official organizations and the state [inaudible] office organizations to get those training materials to those people so that they’re able to respond effectively and avoid some of the missteps that are often made and respond immediately or quickly to the [inaudible] situation.
Peter Sandman: When I do two-day trainings for people in crisis communication, toward the end of the second day I have an exercise which I call the taxi exercise. I say, “Okay. Now you have had two days of training, the governor hasn’t, the mayor hasn’t, but if the crisis is serious the governor and the mayor are going to elbow you out of the room. Maybe they’ll listen to your advice, but there’s no way they’re going to let you be the spokesperson for a big event in their state or city. So all right, you’re in a taxicab on your way to the first of dozens of news conferences with the mayor about this crisis. Jot down the three message points you have for your cab ride, the three things you want to tell the mayor not to screw up, in the cab, on the way to the first news conference.” Because you’re absolutely right, there’s no way that senior political people will not take responsibility for major crises, they have to.
Dick Thompson: Just to tell you about what would happen at WHO should it hit the fan, and fortunately it won’t be me, it will be Dr. Margaret Chan. Dr. Chan was director of health in Hong Kong during SARS. There’s lots of things she can’t do. She can’t cook, she can’t drive, she can’t type [Laughter], if it wasn’t for her Blackberry and thumb exercise we would never hear from her, but she is a great communicator. During the SARS outbreak in which there was real chaos and concern throughout Hong Kong she was on television daily. She was doing Cantonese and Mandarin and in English. I think she’s an exceptional communicator. She has no problem saying that she doesn’t know. I can’t imagine her over-reassuring ever. So she’s just a joy to work with.
Q: Actually [inaudible] piece “Bring on the Nerds” reminds me of another thing I did on [inaudible] for the Washington Post. I have a suggestion; a lot of people are talking about who will do the speaking and who will be the experts. This piece [you] wrote a long time ago had to do with retiring as an expert because I was being asked to pronounce on things I didn’t know anything about. What it suggested to me when I’ve done work in some newsrooms is pre-vetting and pre-preparation of who your experts will be.
____: Yes.
Q: Because you don’t know who will be the report – some of you are qualified Times reporters, you don’t know who will be on the desk when a story comes in and you need to be ready and not just in the area of pandemic influenza, but in every major subject area where they seriously pre-vetted a considered group of experts who you will call if something happens. The Rolodex can be a very dysfunctional and bad tool in a crisis, so if you all don’t know who in your community you will call if the bird flies over the border you need to know that and now’s the time, not when the bird comes.
Q: Alan Sipress with the Washington Post. I do think it’s significant when that first bird or birds makes landfall in North America and not because that’s going to bring the disease here. I had chicken for lunch every day in Jakarta for several years, but my understanding of the science is – it may be wrong, I don’t have a science background – is that as a virus moves through a larger animal population, it spreads geographically and creates more opportunity for [inaudible], more opportunity for mutation and that means we have to re-double our efforts in terms of monitoring and in terms of bio-security and so there are things to be written at that moment, even if it doesn’t mean that the disease isn’t out there, and we all have to live in fear.
____: The move to Delaware is going to increase that risk less – you’re right. It’s going to increase that risk less than the move to Zaire.
____: Oh, of course.
____: Washingtonians are more at risk if it moves into Zaire than if it moves into Delaware.
____: Absolutely, but it doesn’t mean we [inaudible] we need to do and to monitor and to [inaudible] . The other point I would just make very quickly in regards to the USDA putting out these test results until no one was paying any attention any more: I would encourage public officials to keep putting that information out there, let us decide whether we’re interested or not. We’d much rather have the information. Also we can go back and create a data set, that we can then tap into later when we need to take a longer second. So that gives you some [inaudible] even if we’re not [inaudible].
____: [inaudible] the initial press release that said they’re testing the bird got attention and then the release that came out two and a half weeks later that said they found nothing, it didn’t get any attention, a concern that there isn’t closure and so I think that’s one of the challenges.
____: We’d love to be able to look back and say the last nine months they’ve tested and then suddenly when somebody does come up with a positive, we have a whole context to put it in.
____: When you say you’re going to test something you don’t always find something. It doesn’t mean that you didn’t try really hard but it may mean that the virus is just not growable, by the time you had the sample it was dead and so then you put an announcement and say you didn’t find anything or you can’t confirm the initial results. We had a situation like that in [Tiverton], Rhode Island last summer and all the conspiracy theories on the Internet go crazy. They see that as the government hiding the results that they don’t want people to know.
____: The only thing that comes into play is as you start testing more birds, are you going to put out a press release any time you get white powder to test. At a certain point, it becomes impractical. I mean three hours to put out you’re testing one more, you’re testing one more, testing one more, testing one more.
[Simultaneous speaking]
____: When people start testing here, the results are not going to be anywhere near as clean as you expect them to be. You might have co-infected birds. You might have a really hard time, teasing out what virus was actually there or whether there was any virus there. It’s just not going to be nearly as clean as anybody would like.
Q: Thom Schwarz of the American Journal of Nursing. I’d like to ask a different perspective on the mask question. I’m also a practicing infectious disease nurse and so I have to do a little bit of risk stuff with the people that I work with. This is what I’m afraid is going to happen with masks when the pandemic comes, intuitively people think that this is a good idea. It makes sense you wear a mask. When you give people the data about N-95 respirators or surgical masks, people are still going to intuitively want to buy a mask, and people might put out the message – public officials saying well, it won’t hurt, it really doesn’t help. You got to use this kind of mask, the people are going to want to buy masks and there’s not going to be enough masks and people, as you brought up earlier, today people need something to do, to know what action to take and I think people are going to want to take actions that they’re not going to be able to because we’re going to run out of masks, and then what happens? So I’m interested in your comment on where do we go from there? As far as risk communication to the public and how to stem panic?
Peter Sandman: We’re going to need to think and people are going to need to think of things to do. During SARS where there were people running out of masks and there were occasions for running out of masks, people improvised masks. We could take that seriously technically and start trying to figure out a proper procedure for developing a homemade mask.
____: Somebody already did that.
Peter Sandman: It could be disseminated. Even if people are just sort of doing it on their own – when I’m in Cambodia people are wearing masks all the time just because of the pollution and it never occurs to them to get a surgical mask. They make a mask out of a bandana. I’m not a technical person at all, but it has never made any sense to me at all to say, “Keep your hands away from your face. Don’t wear a mask.” Even a bandana keeps your hands away from your face, so the people who say don’t touch your face, don’t wear a mask – I’d like to introduce those two sentences to each other, because one has some meaning for the other. But basically people will think of things to do. We can help guide them by suggesting things to do. What we don’t want to do is systematically say anything you want to do is crap and stop trying to do anything you stupid public, go back to the victim role we want you in.
____: I think the other challenge with masks is that we run campaigns that any time you cough, you cough into your sleeve. Again, it’s that [inaudible] model: if it’s okay to do this, why isn’t it okay to have a piece of cloth in front of my face? That’s kind of hard to explain to somebody in a way that would make any sense.
Peter Sandman: It doesn’t make sense. [Laughter] It’s crap.
Dick Thompson: There were shortages of masks, especially in Hong Kong, but very quickly there were manufacturers who came out with a designer mask in Hong Kong. [Laughter] So you may see that, but I think that this issue of masks really is a reflection of our failure to come up with really sound ways that people can protect themselves. I think that’s something that – at least our technical team haven’t really addressed and that can be probably because we have a tiny technical team really, and they’re pressed to do other issues and I’m not sure that there’s clear information for them to come up with these things.
____: But it’s also not sexy to tell people – “Well, cover your cough,” a campaign which, of course, I think is great. But it’s just not sexy to tell people that, they want to do something with something that seems more medical.
____: Um-hmm. That may be part of why the medical folks don’t like it, you’re stealing my costume. [Laughter]
Tini Tran: Okay. We’ll take two more questions.
Q: I struggle with this all the time. I’ve got five years worth of bird flu information that I have to boil down to 600 words every time I do the story and then tell my editors too why they don’t need to stockpile masks. Is there a role for the health communicators and the risk communicators to boil down this technical information to give to us so that we can give it to the public and use it for our stories. I’ve seen masses of information and I’ve sat through a whole lot of chemical meetings, on why masks don’t actually work and why washing your hands is better [inaudible] bore us to death [Laughter] . There’s a hole there. I’m not saying you guys are responsible for it, but is there a way to have this in a very accessible form for when it inevitably comes up every three or four months.
____: Except the answers aren’t there yet.
____: We have been absolutely trying to do that and we’ve made incremental progress. I guess if you went back over two years ago we’ve made significant progress. But in terms of those types of questions, we ask them ourselves of our experts and we don’t get consensus. We don’t get clarity, and if we can’t get clarity and consensus, we can’t develop materials for the public or for you in terms of answering this. The desirable goal I think it is where we’re all hoping to move to as soon as possible, but I don’t think we’re there yet.
____: Their mask recommendations are based on the fact that there isn’t enough evidence and in the face of the knowledge that there isn’t enough evidence they’re urging people at hospitals to stockpile them because if they don’t do it now they won’t be able to do it later.
Peter Sandman: Maybe we can move this to our faith-based initiative program. [Laughter.] You can all sort of take this homework. In the absence of evidence about masks the recommendation to hospitals is to stockpile. In the absence of evidence about masks the recommendation to individuals is not to stockpile. Why the difference?
____: We have to clarify something; there is lots of evidence. I think this is a mistake here to have this kind of conversation without evidence. There’s clear evidence masks work very well against large particle droplets. I mean we’ve effectively controlled TB, any number of diseases, where that’s been the case. The data are very clear on that. The point is what we don’t know is what part of transmission is large particle droplet, what part of it is aerosol and what part of it is actually [inaudible] . It may be the larger part of it is large particle droplets and that masks could maybe protect 80 percent of the time or 90 percent of the time. That’s the uncertainty part, maybe aerosols are just a small part of it, but they definitely do play a role. There’s no doubt about that.
So I think it’s the idea of if you can’t do anything at all that’s one thing, but you could with a mask likely bring on a higher level of protection, given the exposure. Respirators are our highest level of protection. [inaudible] One of the things we’re working with right now, for example, is the Muslim community to figure out how we can deal with that with [inaudible] with people who cannot shave a beard for religious reasons. I mean there’s whole kinds of things that come into play that our group is working on that piece right now. So I don’t want to leave people here with there are no data, there are lots of data. We have a data from infection control for many years. They work well against large particles. We just don’t know which part of it is large particle versus aerosol.
[Simultaneous speaking]
Howard Koh: There are public health themes being discussed even though definitive answers are lacking in specific areas. So back to the question that’s posed here, if you can translate those questions into how do people protect themselves? How do people protect their families? What’s the role of the social [inaudible], in those sorts of things.
Another analogy I make is in HIV prevention, sometimes there’s a lot of focus on the condom or the [inaudible] instead of the concept of broad prevention and how do people prevent HIV infections, especially if they’re high risk? One of my pleas to reporters, you’ve got a lot of power is to – instead of getting the public to focus in on the one object, which is very difficult sometimes, make definitive statements, focus on the theme and try to get – offer some time so that experts can develop the recommendations that will be helpful. That would really be a great contribution.
____: If you’re never exposed, you don’t have to worry about respiratory protection. If you’re exposed then these are the levels of respiratory protection we have and it’s going to be a continuum, that’s what we’re going to have to lay out and it’s going lay out in a logical way, it’s going to ultimately give people I think the information they need.
Tini Tran: Okay. Our last question.
Q: Howard, you mentioned that during SARS – Steven Smith with the Boston Globe – You mentioned that during SARS you had a credibility in the community to reach out, through Anthrax, to different parts of the community. If, when there is some sort of pandemic event, how do public health authorities reach out to aspects of the community who quite understandably are suspicious of government and who have fears about what government may do intrusively. How do the messages get out to those parts of the community?
Howard Koh: What a great question. I think one opportunity here is [inaudible] is that if we in public health have the opportunity to get out in front now before the pandemic hits and establish those communications channels and establish that trust now, this is the time for us to do it. That’s the opportunity I see, that’s No. 1.
No. 2 is that we’ve had this conversation already. There have been lots of discussions about who should be the communicator? Who should be the spokesperson? A lot of my colleagues here have done that thinking, people like my colleagues at Harvard, Bob Leonard, have done polling about who are the most trusted spokespersons? So you can see those results, but again I think people with a medical background, if I can say people in the core positions, perhaps maybe are more trustworthy in medical crises like that, so those people should be out front and then if you surround yourself with people who are trusted by other parts of the community, who are more trusted by non English speaking populations, by [inaudible] populations, by all parts of society and bring those trusted figures in now so you can become a unified voice when a crisis hits, that would be really ideal. Hard to say, but I think that’s the opportunity and the challenge for right now.
Peter Sandman: There is research here that you may want to look at that suggests that under-served communities do not trust, as we all know, they don’t trust the establishment. They also don’t trust their own leaders because they judge their own leaders to have insufficient connection with the establishment to be able to deliver on what they say. [Laughter] So the research that I’ve seen indicates very strongly that the message needs to come from a collaboration of someone from inside their community who can sort of certify that this isn’t like people getting the crap again and someone from the traditional power elite who can certify that this isn’t us talking to ourselves without any power again. And that combination seems to be able to inculcate new health habits in communities that are low-trust and low-served.
Tini Tran: Okay. Thank you very much.
[Applause]
[End of Recording]
Copyright © 2006 by Howard Koh, Glen Nowak, Peter M. Sandman, and Dick Thompson
