The Fear Factor

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The Fear Factor

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Preparing the public for a major disaster like pandemic flu without inciting panic is tricky. But the truth goes a long way
By Nancy Shute
11/21/05

A disease outbreak that could happen 30 years from now isn't at the top of most people's list of worries. But now the deadly avian flu virus has leapt from Asia into Europe, and perhaps the Middle East. President Bush is talking about how the military could help quarantine victims of a flu pandemic. And new United Nations pandemic flu czar David Nabarro cautions that up to 150 million people could die. Influenza is, suddenly, a source of great fear.

That's good news to infectious disease experts in the United States and abroad, who since 1997 have warned that the newly emerged H5N1 strain of bird flu posed a serious threat of sparking a human pandemic, only to have those warnings largely ignored. But it's bad news, too. Their worry is that this spike in public concern will soon wane but the threat will not, leaving nations and families unprepared. Thus the dilemma: How do you tell people to prepare for a risk that may be horrendous, but maybe not? For the first time, figuring out what to tell people, and when, has become a major part of preparing for a disaster, be it a Category 5 hurricane, a bioterrorism attack, or a deadly new strain of flu.

Tricky. "We've really been walking a tightrope on pandemic communications," says Dick Thompson, spokesman for infectious disease with the World Health Organization in Geneva. "We've wanted to motivate countries into action, but we haven't wanted to sacrifice our credibility with scare tactics. We don't know the timing of the next pandemic, how severe it will be. We don't know what drugs will work. We don't have a vaccine. Yet we're telling them to prepare for a pandemic. It's tricky." It's even trickier because some WHO members are not known for their candor--China, which tried to suppress news of the 2003 SARS outbreak, comes to mind. But during last week's meeting in Geneva to map a pandemic strategy, WHO membership backed the new, blunt approach. "This is scary, and we don't know," says Thompson. "That's the message."

The U.S. Department of Health and Human Services, which just four years ago was insisting that a Florida man's anthrax infection couldn't possibly be due to terrorism, is also learning the virtues of uncertainty and trepidation. "If a pandemic hits our shores, it will affect almost every sector of our society, not just healthcare but transportation systems, workplaces, schools, public safety, and more," HHS chief Mike Leavitt said last month. "We are inadequately prepared."

Much of this new willingness to play it straight with the public is due to an evolution in the understanding of how people communicate important but upsetting information--and how easily that communication can go awry. In the past 40 years, the analysis of risk has grown into a science, increasingly relied on by businesses and government in deciding how to spend their billions of dollars more wisely or profitably, be it on new cancer treatments or hurricane-resistant buildings. But where risk assessment is mathematical and quantifiable, risk communication is subtle and often counterintuitive.

Panic. For instance, public officials often presume that people will panic when told of impending disaster. So they overdo their efforts to reassure them, which paradoxically prompts people to panic. During the disastrous 1918 flu pandemic, which killed at least 50 million people worldwide, U.S. officials were obsessed with preserving morale and never publicly acknowledged that the deadly flu outbreaks posed a danger. Near anarchy ensued, with people afraid to go to work or tend to the sick. Dead bodies were left in the streets, and orphans were abandoned. "You will only get panic if people lose faith in their own authorities," says Baruch Fischhoff, a psychologist at Carnegie Mellon University who researches risk communication. "They'll lose faith much quicker if the authorities don't level with them."

That lesson has been hard for nations to learn, even in recent times. In 2003, for example, Chinese officials scrambled to hide reports of a pneumonialike outbreak in Guangdong province. Their secretiveness is widely thought to have given the SARS virus time to spread beyond China, eventually infecting 8,000 people, killing 800, and bringing the Asian economy to a standstill. In October 2001, Tommy Thompson, then secretary of HHS, told an American public still reeling from 9/11 that a Florida man's anthrax infection appeared to be "an isolated case," perhaps contracted by drinking from a stream. Four more people died; the U.S. Capitol was shut down, and people swamped doctors' offices seeking the antibiotic Cipro. Even when no one is harmed, risk-communication failures destroy trust. Tom Ridge, the first secretary of homeland security, will be forever remembered for the department's widely mocked color-coded terror alerts. "The public can generally tolerate much higher levels of alarm than politicians imagine," says Peter Sandman, a Rutgers University professor and risk communications consultant.

Misunderstanding. Risk is a subjective concept. People are usually more worried about risks that are new, unfair, or forced upon them--say, having a toxic-waste dump put next to their home. But people tend to get less upset about risks that are familiar or that they take on of their own volition, like smoking or driving on the interstate. These mundane risks cause far more illness, injury, and death than all toxic-waste sites combined. Armed with data, some risk analysts call those kinds of responses irrational, revealing a yawning gulf of misunderstanding between technocrats and those in harm's way. "The tendency to say the public disagrees because they're ignorant is not fair or correct," says Paul Slovic, a psychologist at the University of Oregon and a pioneer in studying risk perception. "Risk lives in our minds not just as calculations but as feelings. That's how we navigate through life."

Finding out how people feel about a distressing subject like pandemic flu, Slovic says, is critical if you want them to listen. Scientists, unfortunately, are inclined to think of communication as a science lesson: how avian flu could mutate into a form that would easily infect humans, say, or how nuclear power plants are constructed. The intended audience may be thinking something far different. With Hurricane Katrina, for example, many people refused to evacuate not because they didn't think the hurricane could be deadly but because they didn't want to leave their pets behind.

Obsessed.
When people become aware of a threat, they typically seek out information on it and start figuring out what to do. Some might obsess; Internet chat rooms are now awash with people debating the merits of various bird flu treatments or trading tips on how best to heat the house if fuel supplies are interrupted during a pandemic. But in most cases, risk experts say, people soon settle into a "new normal" and get on with life.

Preparing for a pandemic is problematic because even the experts don't know when it will hit or how bad it will be. "The case for taking precautions isn't that you expect the bad outcome," says Sandman, who has advised numerous countries, including the United States, on pandemic communications, "but rather that you can't afford to take the chance, and that it will be too late to protect yourself by the time you know whether the bad outcome is going to happen or not."

Until very recently, the federal government has been loath to scare its citizenry. Its draft pandemic flu plan, unveiled in 2004, talked of only a mild pandemic with 89,000 to 207,000 deaths in the United States, similar to the 1957 and 1968 pandemics. The report included statements that are astonishingly optimistic: "Pandemic influenza can be controlled by rapid, appropriate public-health action that includes surveillance, identification and isolation of influenza cases, infection control, and intense contact tracing. These measures can be a temporary inconvenience to those involved but are essential for containing a pandemic outbreak."

In fact, no pandemic has ever been controlled or contained. Although infectious disease experts are hoping to try to do that using vaccines and antiviral drugs, none of them are sure that those measures will work. A pandemic in which one third of the population falls ill, with waves of outbreaks lasting months, would be far more than a "temporary inconvenience."

But the final flu plan, released earlier this month, is much more dire. It estimates that pandemic deaths in the United States could approach 2 million, more on a par with the 1918 contagion. The plan also talks about the widespread breakdown in municipal services and social order that could occur, including the loss of public transportation and electricity, and food shortages.

Flu experts have criticized the U.S. plan for relying too much on the antiviral drug Tamiflu. No one knows if it would work against a pandemic flu strain, and even in the best-case scenario the United States would have enough for only about 1 in 4 people. A pandemic flu vaccine, another cornerstone of the federal response, wouldn't be widely available until 2010 at the earliest. But the final plan does acknowledge shortcomings: In a pandemic, communities would be on their own, with little or no help from state or federal authorities.

Over the summer, HHS polled 60,000 people and 20,000 doctors and asked them what they knew about avian flu or flu pandemics. The answer: not much. They also asked them what they thought about the department's "priority groups" for handing out a potential pandemic flu vaccine. Respondents were offended by the notion of priorities, even though they agreed that first responders like doctors should be at the head of the line. HHS now calls them "predefined groups."

In the next three months, HHS's Leavitt will travel to communities around the country, urging people to start querying their workplaces or neighborhood schools on how each would handle a pandemic. The risk, Sandman says, is having people turn around five or 10 years from now and say, "Why did you scare us? Why did we spend all this money? This pandemic was no big deal." But, he adds, "it is better to waste time, money, and emotional energy than to risk stumbling into a crisis unwarned and unprepared."

http://www.usnews.com/usnews/health/art ... 21risk.htm
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