Swine Flu for Grownups

PRINCETON – No one knows how the swine flu (H1N1) pandemic will evolve. Will it keep spreading, or will it fizzle? Will it retreat during the northern hemisphere’s summer and return in the fall? Will it stay mild or turn more severe? Flu experts just don’t know.

What is certain is that health officials risk mishandling how they explain this new and potentially alarming threat to the public. Although they know a lot about virology and public health, they often know next to nothing about how to talk (and listen!) to people about risks.

So here’s a primer on the swine flu pandemic risk communication, framed in terms of what health officials shouldn’t do when they’re telling you about this new disease.

1. Don’t feign confidence. Nobody likes uncertainty; we all wish the experts knew exactly what will happen. But we cope better with candidly acknowledged uncertainty than with false confidence. When health officials tell us confidently that X is going to happen, and then Y happens instead, we lose trust in their leadership. Smart officials are planning for various swine flu pandemic scenarios, and expecting surprises that will force them to change their plans. They should tell us so.

2. Don’t over-reassure. So far, this pandemic is mild. But even a mild influenza virus kills a lot of people, especially those with other medical problems. And experts worry that the novel H1N1 virus could mutate into a more severe strain. Yet officials endlessly insist that there is, as a Scottish health official put it, “absolutely no need for the public to be concerned.” This is false and it could backfire. Even before a situation deteriorates (if it does), people sense when they are being “calmed” rather than informed. Not trusting that officials will be candid about alarming information, we rely more on rumors. Not trusting official over-reassurances, we become even more alarmed.

3. Don’t worry about panic. Panic is rare in emergencies. Although people may feel panicky, they almost always behave well. But “panic panic” – leaders’ fear that they will be unable to stop their people from panicking – is both common and harmful. In the grip of “panic panic,” officials issue over-reassuring statements, suppress or delay alarming news, and speak contemptuously about how the public is “irrational,” “hysterical,” or “panicking.” Such disdainful communication further reduces trust.

4. Don’t obsess over accusations of fear-mongering. Nothing officials say is likely to cause panic, but they may be accused of causing panic no matter what they say. Even when officials over-reassure, they’re often accused of fear-mongering by critics who can’t bear any signs of public concern. That particular criticism is inevitable, and officials should shrug it off. Far more officials have lost their jobs for under-warning the public about risks that turned out to be serious than for over-warning about risks that didn’t.

5. Don’t fight the adjustment reaction. While panic is rare, it is natural for people to need some time to adjust to a new risk – and this swine flu pandemic is new to us all. We cannot skip what risk communicators call the “adjustment reaction” phase, during which we may become temporarily overanxious and hypervigilant, and may even take precautions that are technically unnecessary or premature. Adjustment reactions are brief, but useful – a cognitive, logistical, and emotional rehearsal for possible hard times ahead. Health officials should guide people through their adjustment reactions, not demand that they skip that step.

6. Don’t oversell what the government is doing. If I could ban one phrase from official statements, my first choice would be “Everything is under control.” (“There’s no need to panic” would be a close second.) Experts agree that pandemics can be slowed, but not “contained.” Officials who promise – or imply – that they can keep this pandemic from their borders, or stop it once it has arrived, are setting themselves up for public outrage later.

7. Don’t oversell what the public can do. It is good risk communication to offer people things to do. Action gives us a sense of control, and helps us bear our fear. And if H1N1 becomes more severe, people (and communities) who have prepared for that possibility will probably fare better than those who have not. But hygiene recommendations like hand-washing and cough-covering help only a little. Flu spreads more slowly if we all do our share, but it still spreads. “It’s not much, but it’s all we’ve got” is just as effective a message as “It will prevent the flu” in getting people to adopt these measures – and truth is far more sustainable than exaggeration.

8. Don’t ask the impossible. Recommending measures that the public cannot implement creates a sense of futility, not a sense of control. Officials shouldn’t urge people to wash their hands where clean water isn’t available. They shouldn’t urge urban residents with underlying health conditions to “avoid crowds” without acknowledging empathically that it’s impossible to avoid crowds entirely for the duration of the pandemic.

9. Don’t neglect the teachable moment. In the developing world, swine flu (so far) is much less serious than many endemic health threats, and the main risk-communication goal should be to help people get through their adjustment reaction, take precautions that are feasible, and refocus on other priorities. But in the developed world, swine flu has two long-lasting lessons to teach: (1) Flu is a bigger deal than many people imagine. (2) Eventually, a severe pandemic will strike, whether it’s H1N1 or not, and we should do what we can, now, to prepare. Health officials in North America mostly missed the teachable moment. Instead of these lessons, many people “learned” (or mislearned) that pandemics are paper tigers, and that health officials are fear-mongers. Let us hope that officials elsewhere will do better.