# 3674
When it comes to Risk Communication, you can’t do much better than the works of Dr. Peter Sandman and Dr. Jody Lanard. Both are well established experts, and together have provided a long and valuable stream of essays and books on the subject.
Dr. Sandman is the creator of Risk= Hazard + Outrage meme. A shorthand way of expressing that risk is more than just the hazard, it is the hazard plus the outrage people feel about it.
There are some hazards that are relatively major, but that we are used to, and so our outrage is small. The annual death toll from influenza - estimated at 36,000 Americans – is a good example.
Since 90% of the deaths occur in the the elderly – often among nursing home patients or others that are weak or infirmed – we tend not to be terribly outraged over that risk.
Pneumonia, for centuries, has been called `The Old Man’s Friend’, because it tends to take the elderly quickly and quietly. This yearly viral `harvesting’ of those close to the end of their life is accepted, or at least largely ignored, by the public.
When children, or young adults die from influenza, it is another matter entirely.
It makes the newspapers, and sometimes the evening news. It jolts the public, because we think it isn’t supposed to happen. And so, when it does, the outrage is high.
In truth, between 50 and 100 children die each year from influenza. A horrible number, but still small in a nation of 300 million people.
Now . . . imagine the outrage if 1,000 children should die this winter from pandemic flu. Or 5,000. Or more . . .
We would rightfully view it as a national tragedy.
The only thing that might temper it, and cause it to have a smaller emotional impact than say – the 9/11 tragedy – would be that it would occur over a period of months, not all at once and on live TV.
In order to meet this challenge the CDC and the HHS have put together numerous guidance documents on everything from ways to keep school open to the best way for HCWs (Health Care Workers) to protect themselves when caring for flu patients.
Most of the guidelines, and recommendations being promoted by the HHS and the CDC are perfectly reasonable given the circumstances. They are based on a combination of the available science, practicality, and the fact that thus far, the novel H1N1 virus has shown a low level of lethality.
And in a perfect world, that would be enough.
People would recognize the limitations that any government or society has in dealing with a pandemic, accept that certain losses cannot be avoided, and acquiesce to the policies promulgated by pandemic planners (sorry, I am unfortunately functionally alliterate).
Of course, we don’t live in a perfect world. And what may seem reasonable from one perspective isn’t always reasonable to another. Following policies that make sense on a macro, or population-wide basis, may not always seem attractive or reasonable to individuals and families.
Some hazards may be statistically small, but nonetheless carry a lot of outrage.
Officials who base their planning decisions solely on the science, and fail to take into account the `outrage factor’ that their plans and guidance may foster, are likely to find an irate and uncooperative public response.
Keeping schools open is a good example.
There is a lot to be said for that. Schools are the ideal place to teach kids good flu hygiene, and probably the best venue to deliver vaccinations to large groups of children.
Closing schools won’t stop the spread of the virus in a community, and it would constitute a burden to a great many families where the parents both work. There are also millions of students who depend upon the school nutrition program.
All valid reasons to keep schools open, and operational if possible.
It is arguably good for kids, it’s good for the community, and it’s good for the economy.
That is . . until a healthy kid - who follows the government’s advice and goes to school - comes home with the virus and ends up in the hospital . . . or worse, dies.
And we know that is almost certainly going to happen. Hundreds, probably thousands of times over the next few months.
And when it does, parents – who instinctively think of schools as a `safe place’ to send their kids – are going to be outraged.
Count on it.
Disinfecting school rooms, fever checks each morning, encouraging hand washing, and sending kids home with flu-like symptoms all make sense, but they won’t prevent kids from catching the virus at school – and bringing it home.
At best, these things may slow down the spread of the virus. But parents aren’t going to want to hear that.
They want their children safe and protected.
I’m already hearing a lot of outrage from parents who can’t believe that the plan is to keep schools open, even if students are falling ill from the virus. No matter how `reasonable’ from a public health standpoint the argument is for keeping schools open, for a parent, the health and wellbeing of their child comes first.
Parents of children with asthma, or where there are at-risk individuals in the home, are particularly concerned over the risks of sending their kids to school, and what they might bring home.
My fear is that officials aren’t taking the inevitable outrage into account. Or perhaps they are, which is why the decision to close schools has been left to local officials.
Closing schools is going to be a damned-if-you-do, damned-if-you-don’t decision. And no, I don’t have a good solution. I suspect there isn’t one.
Just as many people are likely to be outraged if you close the schools as those who will be outraged if you don’t.
But public officials need to understand that for parents there is no trauma greater than the loss of a child, and no instinct stronger than that of protecting their children from harm.
If parents are afraid to send their kids to school in a pandemic – even if, in the eyes of authorities, it is an unreasonable fear - they need to be able to keep their kids home without punitive actions taken against them, or their kids.
If officials try forcing kids to attend school during a pandemic, and those kids start getting sick, or dying, they are just asking for outrage.
Regardless of how reasonable their arguments might be.
* * * * * *
In 1976, the Swine Flu vaccine ended up being blamed for about 25 deaths, and hundreds of cases of paralysis. The outrage over the damage caused by that vaccination program probably cost Gerald Ford the presidential election.
While the vaccine killed only 1 person out of every 1.6 million who got the shot - and was blamed for neurological problems (GBS) in about 1 in 80,000 - the nation was horrified.
The actual risk was very low, but the outrage was very high.
Why? I suspect because the vaccine was supposed to save lives. And it didn’t. It claimed more lives than the swine flu that year. More people died in auto accidents in one day in the US than were killed by the vaccine, but that didn’t matter.
Deaths in car accidents are expected. Deaths from vaccines are not.
Thirty years later, and millions of people still don’t trust vaccines. While the hazard was apparently fixed decades ago (we’ve not seen a recurrence of the GBS neurological side-effects since then) the outrage, and the damage, remains to this day.
We are now about to embark on another huge vaccination program, and even if this H1N1 vaccine turns out to be among the safest ever devised, we will almost certainly be bombarded by reports and claims of side effects – and perhaps even deaths – linked to the shot.
These may turn out to be coincidental events, unconnected to the vaccine, but that won’t matter. The media has harped on the dangers of a `rushed and untested’ vaccine for months.
People are primed to expect another vaccine debacle.
Already there is outrage about the fast tracking of vaccines, about the possibility of using untested adjuvants, and some people even fear that the vaccine will be forced on them.
While public health officials may find these fears ridiculous, unfounded, or just plain nuts . . . they would do well to take them seriously. These concerns . . . and the outrage they inspire . . . are powerful and potentially destructive forces.
They must be addressed publicly, and often. Otherwise, they have the potential to derail any national vaccination program.
No matter how safe or effective the vaccine might be.
* * * * * *
Another area of outrage, again with the potential for real damage, comes from health care workers who believe that their safety will be compromised during a pandemic, particularly if surgical masks are deemed `good enough’ protection when caring for flu patients.
(See Nursing Survey Shows Hospital Deficiencies)
For decades they’ve been told that surgical masks are not PPE’s (Personal protective equipment). That you needed N95 respirators or better to protect the wearer from an airborne virus.
Surgical masks protect the patient from the doctor or nurse treating them . . . not the other way around.
Now , with a pandemic on our doorstep and a severe shortage of N95 masks likely, surgical masks are suddenly being promoted as being `good enough’. And many HCWs are outraged.
Most HCWs understand that our supply of N95's is very limited. That, for a variety of reasons, hospitals and the government decided they had more pressing priorities than to stockpile PPEs for a pandemic.
They understand it, but they are outraged over it.
And many feel that rather than admitting to a general failure to prepare, the `rules’ are being changed instead.
While it may be reasonable to recommend surgical masks when there are insufficient quantities of N95s available, the root of the problem is the lack of planning that put us in this situation; The failure to stockpile adequate PPEs.
It is only pure luck that we are facing a less lethal swine flu pandemic, and not a highly fatal H5N1 virus. Our PPE stockpile would have been no better had we been struck by the latter. HCWs know that, and also know that this virus could become more virulent over the winter.
And you can bet that just about every nurse or HCW who is issued surgical masks instead of N95s, and ends up getting sick, is going to blame their hospital or workplace for not adequately protecting them.
Count on it.
And it won’t matter whether or not having N95s would have made a difference. HCWs will assume they would have.
Because that’s what they have been told for the past 30 years.
* * * * * *
These were three examples of predictable outrage, but there are dozens more. And public officials, hospital administrators, and others in a position of power need to be cognizant of their likelihood, and their potential for damage.
And it isn’t just the considerable political hit that public officials may take that should worry them. Businesses (including those in health care) could see lawsuits over perceived lapses in employee safety or patient care.
The ultimate success or failure of the national vaccination program will depend, in large part, on how effectively officials communicate the risks and rewards of vaccination to the public.
The percentage of HCWs and first responders that agree to work during a pandemic may well hinge on how well they believe they are being protected on the job.
In other words, there is a lot riding on how well officials handle the public outrage that pandemic policy decisions are almost sure to generate.
To all of those, in the public or private sector, who are either involved in policy making, or in communicating a pandemic policy to employees or the public . . . I urge you to proceed directly to the Peter Sandman Risk Communication website.
From It’s The Outrage, Stupid by Dwight Holing we get the Sandman philosophy in a nutshell.
When it comes to communicating environmental risk, business needs to recognize that outrage is as important as hazard. “When people are outraged, they tend to think the hazard is more serious than it is,” says Dr Peter Sandman, the preeminent expert on risk communication. “Trying to convince them that it’s not is unlikely to do much good until you reduce the outrage.”
Business can accomplish that by being open, honest, accountable and sharing control with the public.
The same could be said about any government agency, as well.
It isn’t going to be enough to formulate `reasonable plans and guidance’ and expect everyone to accept them. The public has to be brought on board, made a part of the discussion (and that’s a 2-way conversation), and told honestly what can, and can’t be done during a pandemic.
Since the Sandman website has so much information, a good place to start is the Crisis Communication (High Hazard, High Outrage) page along with Sandman’s Swine Flu Pandemic Communication Update.
But pack a lunch, there’s a lot to glean from their website.
