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Bird Flu:
Communicating the Risk

Before we introduce some of the fundamentals of risk communication, here is a primer on avian influenza-and why sounding the alarm isn't easy.

Flu again? Who cares?

Influenza has long been the neglected child in the infectious disease family. Every winter, tens of millions of people get the flu. Most are home, sick and miserable, for about a week. Some—mostly the elderly—die. We know the worldwide death toll exceeds a few hundred thousand people a year, but even in developed countries the numbers are uncertain, because medical authorities don't usually verify who actually died of influenza and who died of a "flu-like illness." People think of the flu as a minor nuisance. Even a major controversy like last year's contamination of half the U.S. vaccine supply provokes only a temporary blip in flu anxiety. For a few weeks people stood in line to get vaccinated (and were inaccurately seen as panicking by many harassed officials). By January there was vaccine left over, rationing was abandoned, and the authorities were back to urging everyone to go get a shot, please!

The factors that make a risk upsetting and the factors that make it dangerous are completely different. Actual mortality and morbidity often have little impact on how worried, frightened, or angry people are.

When some other disease like SARS or West Nile virus captures the headlines, authorities and columnists contemptuous of the "hype" often compare the new disease to influenza. Whatever we're "overly" worried about kills fewer people every year than the flu, they tell us. We're not worried about the flu. So why worry about this other thing?

There are good risk communication answers to this question. Compared with flu, SARS and West Nile virus are unfamiliar; there is more reason to wonder if the experts really know what they're doing and if they're telling all they know. A fundamental risk communication truth is that the factors that make a risk upsetting and the factors that make it dangerous are completely different. Mortality and morbidity statistics determine the technical seriousness of the risk. But they often have little impact on how worried, frightened, or angry people are. Think of that as "cultural seriousness," determined by factors like these: Is the risk voluntary or coerced? Familiar or exotic? Controlled by the people at risk or by others? (See Risk = Hazard + Outrage, at the end of this article)

The annual flu is a perfect paradigm of a risk that is serious technically but not so serious culturally-the sort of risk that kills people but doesn't much upset them. It is familiar rather than exotic, and anything but memorable (especially since it has been so long since the last pandemic).

It isn't voluntary, but in developed countries getting vaccinated against it usually is. It is chronic rather than catastrophic, reappearing every year like clockwork. It's not especially dreaded. Except for striking too many old people, it is undiscriminatingly fair. And there aren't very many flu controversies in a typical year-no battles over control or fairness, no issues of morality or trust or responsiveness. It is very, very difficult to get people really worried about influenza.

Not your ordinary flu!
 Mother holds portrait of her deceased son
A Vietnamese mother cradles a portrait of her 4-year-old son who died of avian influenza in 2004. The family, from a village near Hanoi, had killed and eaten chickens that had the disease. (FAO photo)

In 1997, a child in Hong Kong died not of human flu but of bird flu, an avian influenza strain known to virologists as H5N1. Since then H5N1 has spread inexorably throughout Southeast Asia's bird population. It is a big problem for the poultry industry. So far it is only a small problem for human health. As of late June, around a hundred people were believed to have caught H5N1 directly from birds. A couple of people are thought to have caught it from other people. But more than half of the confirmed cases have died. And a high percentage of the dead were young and otherwise healthy.

Because H5N1 has never infected humans before, people have no natural immunity to it, and there is not yet an H5N1 vaccine developed and approved for human use. The only thing protecting us from H5N1 is that so far bird flu is a hard disease for people to catch. But influenza viruses keep changing. They mutate. And they exchange genetic material with other flu viruses, a process called reassortment. All that's needed to launch a human health crisis is a mutation or reassortment that produces a new variant of H5N1 that transmits easily between people the way "regular" flu does. If that happens, we face a worldwide epidemic: a pandemic.

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