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Bird Flu:
Communicating the Risk

The recommendations listed below are grounded in two convictions: that motivating people to start taking bird flu seriously should be a top priority for government health departments, and that risk communication principles provide the best guidance on how to do so. The world's governments will inevitably vary in the extent to which they agree. How aggressively will these recommendations be followed? How well will they work? Nobody knows yet.

1. Start where your audience starts

Telling people who believe X that they ought to believe Y naturally provokes resistance. You can't ignore X and just say YY-Y-Y-Y. You can't simply tell people they're wrong. You've got to start where they are, with X, and empathetically explain why X seems logical, why it's widely believed, why you used to believe it too ... and why, surprisingly, Y turns out to be closer to the truth.

Overconfident overreassurance is terrible risk communication. Paradoxically, people usually find it alarming.

The biggest barrier to sounding the alarm about bird flu is that it's flu-usually seen as a ho-hum disease. It would help if people stopped calling every minor respiratory infection "a touch of the flu," but that's not going to happen. Empathy is the only answer. Instead of ignoring the fact that people think flu is minor, or berating people for thinking that flu is minor, acknowledge that even some public health authorities use the term "flu" in ways that minimize its seriousness. (A senior U.S. health official recently apologized for his wife's absence at an event by saying she was home with "a stomach flu"—a misnomer.) After making common cause with the public—"we have all ignored influenza for too long"—talk about how horrific the next flu pandemic may be compared with the annual flu.

2. Don't be afraid to frighten people

Fear appeals have had a bad press, but the research evidence that they work is overwhelming. Although people don't usually stay very frightened very long, getting them a little frightened for a little while motivates precautionary thinking and precautionary action (assuming some precautions are available).

There is one key exception. When people are already terrified, scaring them even more can push them into denial. For example, women sometimes avoid breast self-examination, not because breast cancer scares them too little but because it scares them too much. In places where bird flu is endemic, magical thinking and denial are already a problem. "I am not afraid of bird flu.... I would have been the first who died when the disease struck last year. But look, I am still healthy," a Thai chicken butcher from Roi Et province told the Bangkok Post in February 2005. The Post noted that the butcher wore "no protective gear except nylon gloves." For most of the world right now, though, apathy is the problem—not denial. We can't scare people enough about H5N1. WHO has been trying for over a year, with evermore-dramatic appeals to the media, the public, and Member States. Until a pandemic begins, there's little chance we'll scare people too much.

 Photo from a press conference
Shigeru Omi, regional director for WHO's Western Pacific Region, and spokesman Peter Cordingley brief reporters during a regional health ministers' conference on avian influenza in Bangkok, Thailand, in 2004. (WPRO/WHO photo)

Research evidence won't protect you from criticism, of course. Fear appeals often provoke angry pushback from people questioning your motives or your competence, accusing you of "crying wolf" or provoking "warning fatigue" or panicking the public. That happened after WHO Western Pacific Regional Director Shigeru Omi said that, in a worst case, a bird flu pandemic could kill up to 100 million people (a well-justified estimate). Of course, there is a genuine downside to issuing warnings that turn out to be unnecessary. Although panic is unlikely and warning fatigue is temporary, there is some credibility loss, especially if the warnings were exaggerated or overconfident. But consider the alternative. Which is worse, being criticized for "unduly" frightening people or being criticized for failing to warn people?

3. Acknowledge uncertainty

When the first Thai bird flu outbreaks subsided in 2004, a senior public official said: "The first wave of bird flu outbreak has passed ... but we don't know when the second wave will come, and we don't trust the situation.... So the Public Health Ministry is being as careful as possible." This exemplifies two risk communication principles: acknowledge uncertainty and don't overreassure. (Thailand was initially too reassuring about bird flu, but not in this example.) During Malaysia's first outbreak, tests were pending regarding what strain of flu was killing the chickens. Senior veterinary official Hawari Hussein said, "We know it is H5, but we're hoping it won't be H5N1." This very brief comment not only acknowledges uncertainty; it also expresses wishes, another good crisis communication practice. Everyone shared Hussein's hope, but feared the worst.

Overconfident overreassurance ("the situation is under control, everything is going to be fine") is terrible risk communication. Paradoxically, people usually find it alarming. They sense its insincerity and become mistrustful even before they know the outcome. But overconfident warnings are also unwise. There is so much we don't know about H5N1. Will it ever achieve efficient human-to-human transmission and ignite a pandemic? If that happens, will it become less lethal in the process, or perhaps not lethal at all? How many people will it infect? How quickly will it spread? How long will it last? How much antiviral medication will be available in different parts of the world, and how well will it work? How long will it take for an effective vaccine to be available? Which countries and which people in those countries will get the vaccine first? How well will health care systems cope? How well will national and international economies cope? And how well will civil society cope?

Bird flu experts and risk communicators cannot answer these questions. But we can and should raise them, acknowledging our uncertainty at every turn.

4. Share dilemmas

Sharing dilemmas is a lot like acknowledging uncertainty. Not only are we unsure about what will happen; we're also unsure about what to do. Everyone finds this hard to admit. But dilemma-sharing has huge advantages:

  • It humanizes the organization by letting the pain of difficult decisions show.
  • It gives people a chance to make suggestions and be part of the process.
  • It moderates the conflict between opposing recommendations.
  • It reduces the outrage if you turn out to be wrong.

Officials who make difficult, debatable decisions look easy and obvious are colluding with people's passive desire to be taken care of by an all-knowing government. They then feel entitled to blame the government if things go badly. Dilemma-sharing does raise some anxiety at first, but it allies with the public's resilient, resourceful, mature side. This leads to better buy-in and better coping down the road.

The most important bird flu dilemma at the moment is stockpiling. If we stockpile H5 antigen or an H5N1 vaccine (once it exists), that may save millions of lives if a pandemic materializes. But a vaccine is no magic solution. We probably can't make and distribute enough vaccine for most of the world. And what if there is no pandemic? Or what if the virus mutates or drifts a lot, and the vaccine proves minimally useful? Is this really a good use of scarce health dollars, especially in developing countries? Maybe we should stockpile antiviral drugs. But they're expensive, and who knows how well they will work against the actual pandemic strain that arises? The worst response to the stockpiling dilemma is also the most tempting: Stockpile only a little vaccine and some antivirals and imply that you have enough. Some officials are already engaging in this kind of overreassurance. The risk communication answer: Share the dilemma and let the public help you decide.

5. Give people things to do

One reason sometimes given for not alarming the public is that there's nothing for people to do anyway. A Jan. 13, 2005, Wall Street Journal article quoted Canadian infectious disease expert Richard Schabas as saying: "Scaring people about avian influenza accomplishes nothing, because we're not asking people to do anything about it." But the error isn't scaring people. The error is failing to realize-and say-how much they can do to prepare.

Helping resolve government policy dilemmas is just the beginning. Thailand, for example, has trained almost a million volunteers to reach out to every village in the country to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks. Many companies, hospitals, schools, and local governments around the world are starting to plan for "business continuity" in the event of a pandemic. Even cognitive and emotional rehearsal-learning about H5N1 and thinking about what a pandemic might be like and how you'd cope-is a kind of preparedness and a kind of involvement. The WHO outbreak guidelines say: "If possible, representatives of the public should be brought into the decision-making process.... Risk communication messages should include information about what the public can do to make themselves safer."

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