Hey Mike!

Here's some stuff you might choose to read (or not {wink}) to see why I am “on the other side” about the oncoming pandemic (of whatever sort it turns out to be) and advisable preparations.

On this page: one whole guestbook discussion on risk communication controversies (how much to tell, what to tell and not tell, and etc.), plus one excerpt from “Risk Communication Lessons from Germany’s Deadly E. coli Outbreak” and here are some specific links if you want to read more. Some of this is the stuff they DON’T tell you about “what's coming” – cause the CDC, WHO, Fed, state and local govt idiots don’t get it!

I’ve been doing Peter’s website since 2000. My notes, for Boeing, back in 1997? 1999? when I took Peter’s class and had an absolute epiphany! (Peter and his “wife and colleague” Dr. Jody Lanard, are dear friends. She’s spent several months (some years ago) is Switzerland, advising the WHO. They both did a lot of consultig for CDC, till CDC got pissy about them pointing out when the CDC was really screwing up!)

  • Pandemic Influenza Risk Communication: The Teachable Moment
  • The Flu Pandemic Preparedness Snowball
  • Fear of Fear: The Role of Fear in Preparedness
  • Tsunami Risk Communication: Warnings and the Myth of Panic
  • Bird Flu, Pandemic Flu, and Poultry Markets: Playing Ostrich or Talking Turkey?
  • Practicing for The Big One: Pennsylvania's Hepatitis A Outbreak and Risk Communication
  • It’s Not a Fake Pandemic – but WHO’s Defense Lacks Candor
  • Superb Flu Pandemic Risk Communication: A Role Model from Australia
  • What to Say When a Pandemic Looks Imminent: Messaging for WHO Phases Four and Five

    • Surgical masks: Another pandemic risk communication controversy

      name: Kay
      This guestbook entry
      is categorized as:

            link to Pandemic and Other Infectious Diseases index

      Field:State health agency risk communicator
      Date:February 9, 2006


      I just finished reading your Tamiflu stockpiling column and I couldn’t agree with you more. It’s a relatively clear dilemma – should you stockpile Tamiflu in case of a pandemic, or should you be a “good citizen” and do what’s best for society? I personally have not stockpiled Tamiflu. But months ago I advised my daughter and her family (in fact, all my family members) to run – not walk – to their doctor for a Tamiflu prescription. I know the government won’t be able to protect them in a pandemic. But as a mother, that’s my job. If another mother fails to do her job, it’s a shame. But I’ll do what I can for MY kids.

      Having said that, I also am concerned about the message being sent about masks. Our scientists are saying we absolutely should not advise people to stockpile surgical masks in case of a pandemic. Why? Because there’s “no evidence they work to prevent transmission of influenza in non-medical surroundings.” Several questions arise.

      (1) If surgical masks don’t work to prevent transmission of influenza when worn by the general public, why do pandemic plans advise health care workers to wear them in any interaction with patients with flu-like symptoms? Isn’t that a much higher-risk setting than just being out in public? If mask use is indicated for a high-risk setting, why wouldn’t it be helpful in a lower-risk situation?

      (2) Is there really evidence that masks don’t help prevent influenza transmission, or it is just a case of no studies having been done? (Bet it’s the latter.)

      (3) If masks aren’t indicated for prevention (e.g., for you and me to wear when we’re healthy but have to ride the subway shoulder-to-shoulder with people who are coughing and sneezing), why are they indicated for the people who are coughing or sneezing? To simplify – if a mask keep their germs IN, why won’t it keep their germs OUT?

      (4) If the concern is that people who wear masks will later self-inoculate their mucus membranes after they touch contaminated items or surfaces, or while taking off their own mask, isn’t that a matter that can be addressed by hygiene education? What does it have to do with whether wearing a mask is a good idea in a pandemic?

      (5) The experts are saying that we will run out of masks in a pandemic and that there likely will not even be enough for health care workers. If that is anticipated, doesn’t it make sense to conclude that people WILL want masks (and will make their own ad hoc versions, if necessary)? So why not advise people to stockpile them now, explaining honestly about their benefits and limitations and educating people about how to optimize their use? If we start to run short, manufacturers will make more. That’s supply and demand. But if we keep downplaying mask use, and run out when we most need them, will we again “scold” people for putting their individual needs ahead of society’s?

      (6) If there’s no evidence that masks help prevent influenza transmission when used by the general public, why haven’t studies been done to find out one way or another? Does anyone remember SARS? People wore masks! It’s been a while – what’s everyone waiting for?

      Bottom line: The experts say masks really aren’t helpful. Hand-washing is overrated. Most of us have no chance to get vaccine or Tamiflu.

      “Don’t hoard Tamiflu in advance,” we are told. “There are people who need it more than you. We will give Tamiflu only to pandemic patients who are admitted to the hospital.” But we don’t want the “worried well” inundating the hospitals, so we have to develop some risk communication messages to convince them to stay home unless they’re really sick. Of course, if we are successful at keeping them away from the hospital until they are really sick, it will be too late for Tamiflu to do any good.

      What’s a risk communicator to do?!!!

      Peter responds:

      This response was written jointly with my wife and colleague Jody Lanard M.D.

      There are three fundamental issues here – and they all apply to a lot more than the surgical mask controversy:

      What does “sound science” tell us, and are health officials consistent in deciding when to rely on intuition and when to stick to the evidence?

      Infectious disease experts often discourage amateurs from taking precautions that are not evidence-based.

      • This is reasonable when the scientists are advising against far-fetched, possibly dangerous precautions, especially if people are prone to take them instead of potentially more useful precautions.
      • It is less reasonable when they’re advising against precautions that common sense (and the little evidence that’s available) says probably do some good and virtually no harm.
      • It is least reasonable when they’re simultaneously endorsing other precautions that are similarly supported more by intuition than by data.

      The same people who insist there’s no convincing evidence that mask-wearing by the public helps reduce the transmission of influenza also urge people to cover their mouths when they cough. Only when pressed do they concede there is not much evidence on behalf of that either. But the “experts” get to decide when they want to recommend things even though there’s no supporting evidence, and when they want to recommend against things because there’s no supporting evidence.

      Not to mention that a mask does cover your mouth, and may keep you from touching your face (also widely recommended) – and it does so a lot more efficiently than a tissue or a sleeve when you’re standing on a bus holding the strap with one hand and your possessions with the other. At least until most people are wearing them, masks also increase social distance (try wearing one in public and watch the distance increase), which is universally agreed to be useful in reducing contagion.

      Yet most health officials say people shouldn’t plan to wear masks in public during a flu pandemic. There must be something about the public wearing of masks that strikes terror into the hearts of officials and experts.

      But this apparent terror is slowly morphing into a degree of acceptance. The CDC’s current “Cover your Cough page starts out advising you to “cover your mouth and nose with a tissue when you cough or sneeze or cough or sneeze into your upper sleeve, not your hands.” But then the instructions add: “You may be asked to put on a surgical mask to protect others.” The CDC is not yet ready to concede that it might make sense to wear a mask to protect yourself as well as others (though that is what doctors and nurses do), nor that you might want to do it without being asked. Still, there’s progress.

      More progress is reflected in a literature review written by the World Health Organization’s “Writing Group” and published in the January 2006 issue of the CDC’s own Journal of Emerging Infectious Diseases. The “Hygiene and Disinfection” section notes:

      Recommendations for “respiratory hygiene/cough etiquette,” such as covering one’s mouth when coughing and avoiding spitting, have been made more on the basis of plausible effectiveness than controlled studies (32). As summarized in part 1 of this article, influenza virus can remain viable on environmental surfaces and is believed transmissible by hands or fomites (3). Most, but not all, controlled studies show a protective effect of handwashing in reducing upper respiratory infections (Appendix 2). Most of the infections studied were likely viral, but only a small percentage were due to influenza (33). No studies appear to address influenza specifically.

      In other words, there is no hard evidence that covering your mouth when you sneeze or coughing into your sleeve reduces influenza transmission. And there is only the slightest hint of hard evidence that hand-washing does so. Nevertheless, these are widely and officially recommended methods of reducing the risk of flu transmission. What the WHO Writing Group calls “plausible effectiveness” translates in plain English into common sense.

      The same article presents an extremely tentative retrospective finding that surgical masks worn in public during the SARS outbreaks in Hong Kong was one of a group of precautions that collectively reduced influenza transmission – though there is no proof it was mask-wearing that did the trick:

      Influenza and other respiratory viral infections apparently declined in Hong Kong during the 2003 SARS epidemic, as determined on the basis of a review of viral diagnostic laboratory records (20). Public health interventions included closing schools, swimming pools, and other public gathering places; canceling sports events; and disinfecting taxis, buses, and public places. A high percentage of people wore masks in public and washed hands frequently, and in general, much less social mixing occurred.

      The real breakthrough comes in the article’s “Discussion” section, where the authors treat mask-wearing with unusual respect:

      WHO has recommended that mask use by the public should be based on risk, including frequency of exposure and closeness of contact with potentially infectious persons; routine mask use in public places should be permitted but not required. This recommendation might be interpreted, for example, as supporting mask use in crowded settings such as public transport.

      If public mask-wearing is going to be recommended (or at least tolerated) during a pandemic, it follows that public mask-stockpiling ought to be recommended (or at least tolerated) beforehand. We aren’t aware of any current surgical mask production bottleneck, nothing analogous to the Tamiflu rationing dilemma. Of course once a pandemic has begun there are likely to be mask shortages, like the ones hospitals in other countries experienced during SARS. As you point out, that’s all the more reason to stockpile masks now, stimulating the demand and thus reducing the likelihood and severity of future shortages.

      Mask-wearing isn’t a panacea, of course. Dr. Alison McGeer, a Canadian infectious disease specialist (and excellent risk communicator) who survived her own case of SARS, said in a recent interview for the CBC-TV show “Black Dawn” that “one of the consequences of wearing a mask – particularly for those of us who don’t usually wear masks – is that it draws your hands to the face. If your hands are not clean, and you keep putting your hands up around your face, you may actually increase the risk that you might get influenza despite the fact that you’re wearing a mask.”

      No precaution is a panacea. As your comment rightly says, the solution is hygiene education – to try not to fiddle with your mask; to cough or sneeze into something that can trap most of the droplets; to wash your hands as soon as you get to your destination after riding on public transport; to remember to turn off the public washroom sink with a paper towel.

      Why are officials and experts so often contemptuous of precautions the public finds appealing?

      Here is one Q&A from the State of Delaware’s official website page on “Avian Flu FAQs”:

      Q. Would you recommend that Delawareans wear breathing masks when in public? Should travelers use breathing masks outside the United States?
      In the case of a pandemic, we would not discourage any activity that limits the spread of the virus no matter how ineffective as long as these activities are safe. At this time, in the absence of a pandemic, there is no need to take … precautions against H5N1.

      Well, at least they said it was okay to wear a mask, “no matter how ineffective.” But the answer positively drips contempt. Compare it to this excerpt from Delaware’s website on “regular” flu:

      How to Prevent the Spread of Influenza

      DPH recommends residents take the following steps to prevent viral illnesses and relieve symptoms should they occur:

      Cover your mouth when coughing or sneezing….

      We cannot fully explain the tone of ridicule and disdain that frequently accompanies health officials’ advice against mask-wearing. One of us (Sandman) thinks it might have something to do with the fact that masks are part of the doctors’ professional equipment, not to be profaned by laypeople’s use. Lanard disagrees. Neither of us has any evidence for or against this hypothesis.

      It’s got to be more fundamental than that, because it’s not just masks. Officials and experts tend to be contemptuous of any precaution the public comes to on its own, without (or especially against) the advice of the professionals. We suspect that there is a lot of ego at stake here – that the people whose job it is to tell us how best to protect ourselves simply do not take kindly to unseemly public displays of autonomy. And we suspect that the less confident they are about the knowledge base behind their precautionary recommendations, the more they feel a kind of projected contempt for people who make up their own minds about precautions.

      Note that our evidentiary support for the previous paragraph is non-existent. We believe that ego, insecurity, and projection are probably behind health officials’ contempt for publicly chosen precautions on the same basis that we believe that covering your mouth and wearing a mask probably help reduce the spread of influenza.

      What’s the risk communication angle – in particular, how does the availability of precautions affect people’s level of concern about a risk?

      Health officials typically offer two contradictory explanations for opposing a precaution the public finds attractive.

      • On the one hand, they say, hearing the precaution recommended or seeing others actually taking the precaution will scare people too much.
      • On the other hand, they also say, hearing the precaution recommended or actually taking the precaution themselves will reassure people too much.

      Both rationales are familiar with respect to surgical masks. They showed up during the SARS outbreaks and they are showing up again in debates over pandemic influenza preparedness.

      • Mask-wearing will leave you too terrified to live your normal life.
      • Mask-wearing will leave you too complacent to take the officially recommended precautions.

      This two-barreled opposition is not unique to mask-wearing. During debates about distributing potassium iodide pills to people living near nuclear power plants, a June 13, 2002 New York Times editorial noted: “Nuclear advocates fret that making the pills available will exaggerate public fears, while nuclear critics worry that the pills will breed complacency about nuclear risks.”

      Experts on both sides concede that the rapid use of potassium iodide could help to prevent thyroid cancer in people (especially children) exposed to certain kinds of radiation that might be released during a nuclear power plant accident or attack. And experts on both sides concede that the drug has to be taken quickly, too quickly to make after-the-fact distribution a practical option. Nonetheless, many experts oppose public distribution beforehand. People might get overanxious and take the pills prematurely. Or people might get overconfident and take the pills belatedly. Or, sometimes, both arguments from the same expert, who is certain only that there must be some good reason why control shouldn’t be handed over to mere patients.…

      What does risk communication theory and research tell us about how the availability of precautions affects risk perception? In a nutshell, you would expect two effects, both of them desirable:

      • People who are unaware of a risk or unconcerned about it become more aware and more concerned when they hear about precautions against that risk that others are recommending, considering, or taking. If you’re not into pandemic preparedness, hearing people talk about stockpiling surgical masks may pique your interest; seeing people walking around in surgical masks is likely to arouse some concern. Whether or not you end up a mask-stockpiler or a mask-wearer yourself, you probably end up more sensitized to the pandemic risk than you were.
      • People who are very concerned about a risk become less afraid – or more able to bear their fear – when they hear about precautions they can consider taking. This effect is amplified if and when they decide to act. If you’re preoccupied with the risk of a pandemic, it helps you cope better emotionally if you know there are things you can do to protect yourself. Thinking about masks; choosing what sort of mask you need and how many to buy; actually buying your mask supply; learning how to use the mask properly – these are all activities that can help you stay calm … even as they help rouse your apathetic neighbor.

      So if you think people ought to be really apathetic about a risk, you don’t want them hearing about precautions, deciding about precautions, or taking precautions. And if you think people ought to be really terrified, you don’t want them doing those things either. But if you want people to be concerned, maybe even fearful, but coping well and getting on with life, then precautions are invaluable.

      In short, whether or not surgical masks help people protect themselves during a flu pandemic, surgical masks can help people establish and sustain the right frame of mind to confront a pandemic.

      The communication “signal” sent by increasing public interest in stockpiling masks may also provoke local hospitals and other institutions (prisons, police, even retailers and taxi companies) to work on their own mask stockpiles. A predictable sign that these institutions are late to the game will be if they start to protest that public stockpiling is interfering with their ability to get the supplies they need.

      This is all common sense (though there is research to support it). Though a memorable car crash may propel you to start wearing a seatbelt, most people put their seatbelts on without vividly imagining the crash. Though you may install smoke detectors after hearing about a horrific house fire, most people change the batteries in their smoke detectors, when the darn things start to beep, without vividly picturing their houses burning down. Precaution-taking becomes integrated into normal life. It reminds people that the risk is real, and simultaneously reminds them that they are addressing the risk sensibly – that they are neither apathetic nor powerless.

      The self-efficacy that people feel when choosing which precautions to take and which to eschew helps them cope with their fears, and is thus a bulwark against panic or (more commonly) denial. That’s why offering people a menu of precautions is better risk communication than offering just one, and it’s why the precautions people come up with themselves are worth encouraging if at all possible. But none of that means that people who stockpile surgical masks (or Tamiflu) are less likely than non-stockpilers to wash their hands a lot. People who take one kind of precaution tend to take others as well. This is predictable from studies of cognitive dissonance, and demonstrable from studies of precaution-taking during the SARS outbreaks in Hong Kong and Singapore.

      During the SARS outbreaks, four British public health doctors traveling in Thailand went through their own initially skeptical adjustment reaction to the sight of so many people using (and misusing) masks in public. Eventually, they reached this tentative conclusion: “The mask became a highly visible symbol of individual and collective determination to achieve control even though its value in community settings is questionable…. Perhaps it is this perception of the importance of personal and collective responsibility by members of the public that the mask symbolises best and the public health contribution of this symbolism should be remembered for future emerging infections.”

      What’s a risk communicator to do? Keep pushing, internally as well as publicly, for straight thinking and straight talking. Especially straight thinking! There was a time when we imagined that companies and governments self-awarely misled their publics. We came to realize that mostly they mislead themselves first. That’s the main problem, we think, with Tamiflu policy and communication … and with mask policy and communication … and with lots of other areas of pandemic policy and communication. Risk communicators often need to help health officials and experts think straight before it’s possible to help them talk straight.

      Kay responds:

      So often I feel like I am shouting, “But the Emperor is not wearing any clothes!” and people (smart people!) just stare at me blindly. I start to wonder if maybe I’m the one who “just doesn’t get it.”

      We’re beginning to get feedback from our local health departments on our draft pandemic plan and so many are saying “risk communication is our only weapon” or something to that effect.

      Whoa, horse! There are some things we can’t risk communicate away. For example, if Tamiflu is the only drug that will improve your chance of surviving pandemic influenza, AND you have to start taking it within 36-48 hours for it to work, AND if the only way you can get Tamiflu is to be admitted to the hospital, I just can’t think of a message that will convince people to keep trying to get through to their doctor’s office rather than go to the emergency room if there’s a pandemic and they have developed flu-like symptoms.

      Moreover, that message shouldn’t be given from an ethical perspective. It takes a day or more (if you’re lucky) to get a call back from a doctor now! So how dare we tell people to wait patiently when that wait might make the difference in whether they survive? Will there be an influx of “worried well” to hospitals? I’m not so sure about that because most people will have the sense to know that emergency rooms are where they’ll be at highest risk of exposure to the virus. But there sure will be a truckload of “worried sick” if policy effectively denies them any other option.

      The strategy I keep pushing is to say right here right now: “We’ll do our best. Our best won’t be good enough. In a pandemic it is realistic to expect that there will be severe limits on availability of vaccine and antiviral medications and most people will not have access to these resources, at least for many months after a pandemic begins. This fact is unlikely to change, and you should consider it seriously in making your own pandemic preparations. These are preparations we think you should make, and here’s why.…”

      Our actual approach is to be less blunt, but I did get the following language included in a letter to the business community: “It cannot be stressed strongly enough that in a severe pandemic, actions of individuals, businesses and community organizations, as much as those of government, will greatly determine the outcome.”

      So I’ll keep pushing back until they get sick of me, and then I’ll push some more.

      LOVE your columns (but then you knew that).


Excerpt from:

Explaining and Proclaiming Uncertainty:
Risk Communication Lessons from Germany’s Deadly E. coli Outbreak
by Peter M. Sandman and Jody Lanard

(Note: Jody is an M.D./psychiatrist, but had been working with Peter in Risk Comm. for 30-some years)

Nobody likes uncertainty. Everybody on the receiving end of risk communications prefers those communications to be definitive, not tentative.

But the painful truth is that the concept of “risk” is intrinsically uncertain, and risk communicators have no choice but to address the uncertainty, whether they do so well or badly.

This column will concentrate on one complicated example of uncertainty communication, the severe outbreak of E. coli food poisoning that preoccupied Germany and much of Europe from late May until early July 2011. We will focus our lens on the most important aspect of uncertainty about this outbreak: uncertainty about what food was contaminated, how it got contaminated, and where.

We’ll ignore a number of other uncertainties that were raised by the outbreak – whether the source might turn out to be bioterrorism; whether this previously rare strain of E. coli is likely to become common now; whether the new strain was really unusually virulent or just looked that way because a lot of milder cases went untested; whether the benefits of eating suspect raw vegetables outweighed the risks even during this serious outbreak; etc.

As we watched the E. coli outbreak, we flagged several other “uncertainty risk communication” stories as potential case studies. Among them:

  • The World Health Organization’s International Agency for Research on Cancer decided to classify mobile telephones as a “possible human carcinogen,” a super-broad category that includes everything from chloroform and DDT to pickled vegetables and sand.
  • The threat of floods in the U.S. Midwest forced officials to decide how much water to release from dams and levees, intentionally flooding low-population farmlands in designated floodways in order to protect more densely populated towns and cities … risking upstream drought if they released too much.
  • An Italian judge announced that seven members of a committee responsible for assessing natural disaster risks would be tried for manslaughter for having made over-reassuring statements about earth tremors in March 2009, failing to anticipate the earthquake that devastated the town of L’Aquila in April.
  • A hotel housekeeper in New York City accused high-ranking French politician Dominique Strauss-Kahn of sexually assaulting her in his suite, but prosecutors’ early overconfidence in the complainant’s credibility gave way to uncertainty as some parts of her story fell apart.
  • The debate over the safety of shale gas extraction continued to heat up, focusing on conflicting claims and uncertain data about the safety of “fracking” – underground high-pressure injection of a mixture of water, sand, and chemicals in order to fracture (“frack”) the shale and release the gas.

We settled on the German E. coli outbreak because it is a particularly rich “bad example” of uncertainty risk communication. But the issues it raises are generic. Before launching into the case study, we want to lay out some of these generic issues – starting with the fact that nobody likes uncertainty.