For those who will bear the responsibility of communicating to journalists during an outbreak of pandemic flu, the preparation comes in the daily exchanges they are having already with reporters and in working internally to establish guidelines for how best to get information out to the public in ways that are trustworthy and timely. Speaking out of their experiences at two leading health organizations — the Centers for Disease Control and Prevention and the World Health Organization, respectively — communications specialists Glen Nowak and Dick Thompson shared insights from their work.

Glen Nowak, Chief of Media Relations, Centers for Disease Control and Prevention

It’s not as easy as it sounds: The challenges of risk communication in real life, real time.

One challenge we face is that the news media are often viewed by scientists and physicians as if journalists should have the same standard as they do for what you allow into your stories, and you should primarily rely on views that have been established or accepted by most scientists. There is also a belief that you should be providing all the nuances and caveats that would be found in a journal article, and you should use as much space and time as it takes to get the information out there properly. As we all know, at least those of us in communications, that isn’t a realistic expectation.

It is often assumed — and we do this at our level — that the news media should primarily serve as an educator of the public and of policymakers. That means you should be doing more to give us high visibility and provide frequent replays of the same messages. Every year at the Centers for Disease Control (CDC) I’m often told, “You know, we could use about three months of steady, ‘get-your-flu-shot’ stories.” And we often have to say, “Well, perhaps at the beginning of the season we can hold a press release and announce the kickoff of the season.” You can get some play for that, but it won’t continue unless there’s some new developments and some new angle, some new idea, some new research, something new. At the end of the day, the first three letters of news are n-e-w. At CDC our consistent advice is that if they want to do those other things, they need to think about purchasing the time and space or using other venues. So we spend some time educating some scientists and physicians that the news media are not the only way to get the message out, and it’s a challenge but one of the things we deal with.

Another challenge arises out of a strong belief among scientists and physicians and probably policymakers that we can at some level “FYI” the news media. People will come to me and say, “I’ve got a really important piece of information, and I think we should get it out there,” and then we will ask, “So what should people do with that information? How should they change their behavior? What’s our health recommendation as a result of the information?,” and they will say, “I don’t know. But it’s really important to get this out there. We need to call a press conference.” The act of calling a press conference elevates the information — it may be the most efficient way for us to get this information out to multiple numbers of reporters — but that act is incongruous with the moment when the first thing out of your mouth is, “This really isn’t that important.” Journalists rightly call us into question, “If it wasn’t important, why did you call the press conference?” So we often struggle with this at the CDC when we have information to share, but we may not be ready in terms of understanding it completely.

Another challenge emerges when we deal with political leaders. A lot of appointments at Health and Human Services, and sometimes the CDC, are political ones. These people come in with a backload of experience in political communications; often what you’d do in political communications is the opposite of what you would do in health and risk communications. Good health and risk communications means sharing dilemmas, disclosing information, and being transparent. When people come in from political campaigns, this approach is the antithesis of what they typically do in a campaign. It is very scary for them when we say, “Let’s be transparent.” It’s the exact opposite of what they’ve been doing during the campaign.

The other thing I’ve been struck by is that the public and our medical experts have ways of viewing the world, and that can be a communications challenge. Sometimes we recognize those differences and struggle with how to incorporate them into our message strategies; other times the differences can be very subtle, yet important, and we don’t recognize them. The other day I was involved in a discussion at a meeting about antivirals. When we spoke about the use of antivirals as a “treatment,” the public had a mental model that a person got antivirals and stopped the progression of the disease and, therefore, was not going to get really severe complications. The physicians’ mental model was different; they saw antivirals as an effective way to treat some of the symptoms, but they were not a cure. So there was a lot of confusion as the physicians were trying to say, “Look, it’s not a cure,” and people in the audience were saying, “But you said it’s a treatment. Treatments are cures.” Sometimes we don’t recognize these differences and, as a result, they can cause us problems in communications.

It’s not easy to base decisions, actions, communications or even recommendations on science since the science is often lacking and often changing. With the avian influenza, it’s a rapid and dynamic environment in which we are working, and sometimes I think we don’t fully appreciate how dynamic it really is.

Dick Thompson, Team Leader, WHO Pandemic and Outbreak Communication

The toughest audience: reporters.

Shortly after I arrived at WHO after for many years working as a medical and health reporter at Time, SARS broke out. We were overwhelmed with calls, and we had to speak constantly about something that was a new disease, and the virus was moving all around the world very quickly. It was up to us to decide how we were going to speak about this, and so I looked around WHO to see what risk communication resources were there. There were none, which really surprised me, so we were pretty much left on our own, and what we did was to rely on our instincts as reporters. If I were a reporter covering this story, what would I want from me? What I’d want first was to hear from me. Just to be accessible is really important and hard to do when there are all sorts of calls coming in. But I’d also want to have some kind of faith that what I was hearing was the truth; if I ever detected that you were spinning me or lying in any way — if you were covering up or protecting your organization — I’d automatically devalue what I heard.

So I applied these rules — from my instinctive behavior as a reporter — and somehow we stumbled through it, and I think we did OK. There were a few missteps, but after that, we were asked to put it on more solid footing. There would certainly be other risk communication challenges in the future, and WHO needed to know what to do and what to say. So we built risk communications and called it “outbreak communication,” because we’re focusing on a special type of public health event. There are a lot of special things about outbreaks, but most important is that they’re unfolding events. Nobody really knows where they’re going and, especially in the beginning, there’s high outrage and high concern in the absence of knowing what the hazard is.

WHO Outbreak Communication Best Practices
We came up with five principles, and we took these to a group of outbreak response managers at a meeting in Singapore in September 2004. The 85 response managers at this meeting had addressed all sorts of outbreaks from Ebola to cholera, worked in different cultures and economic systems and levels of development. All of them endorsed our five principles. We published a report called “Outbreak Communication,” a book that is one of the best things I’ve been involved with, even after 23 years in journalism. It speaks to best practices for communicating with the public during an outbreak. By 2006, we were able to get all of the critical information from that report onto a pocket-sized card.

How will we communicate when confronted with an outbreak situation? Here are the principles we use:

  1. Trust is the most important thing. As a communicator, this is the currency I work in. Every communication we make is really a pandemic communication, because we’re either building trust or it’s costing us.
  2. Be as transparent as possible. This is very, very difficult, especially for people who work within a culture that’s generally used to working behind closed doors and coming out with peer review publications. It’s very difficult for them to allow the public in to see what they are doing, but once we do that, it increases the trust and confidence people have in us.
  3. Announce early, even when there’s incomplete information. This is another thing that’s a very difficult aspect of this; a lot of times officials will want to wait and use the reason that they don’t have all the information they want. They use that to delay and delay and delay. Finally, journalists pick up the information and report it, and then they have to respond that, yes, they’ve known about it for three weeks, and they lose a lot of trust.
  4. Listen to the public and then plan for the extreme demands of outbreak communication. On the back of this little card, we’ve got hints for interviews. There are special hints for outbreak interviews, such as to clearly say what you don’t know. This again is hard, especially for physicians. To say what they don’t know is something that doesn’t come naturally to these professionals. Also there is a need to share dilemmas and to leave room for the unexpected in your comments. In an outbreak, we urge people not to make definitive statements about anything because even as an outbreak is drawing to a close that can be the most dangerous time, because people relax their guard, somebody slips through, and you have another outbreak.
  5. Finally, never overreassure or mislead.

What these principles tell us is that our instinct in the beginning — to act as a good source — was right. But we needed to gather this evidence, and we needed to have the endorsement of the experts so that we could say, “Be a good source.” That’s pretty much what we do as we run workshops around the world in outbreak communication, trying to train people from ministries of health in outbreak communications. Sometimes it’s very effective. In Egypt, for example, we found that the Ministry of Health reports transparently and quickly about all human H5N1 cases. We’ve done surveys of trust and confidence, and what we find is that there’s a baseline level for information that people trust from the government. It’s a little higher for the Ministry of Health, and it’s higher still when they talk about avian influenza, which is very good. But I’ve also worked in countries where, after an outbreak communication lecture, the officials have gone into a meeting about how to bury bodies in the middle of the night so they don’t get people concerned about how bad the outbreak is.

We’re making some progress. What helps shape our message is that we began talking about the “I don’t knows.” For example, we don’t talk about the availability of vaccine because we think that’s misleading. So I hope it’s working.
Excerpts from “The Great Influenza”
– John M. Barry

Once we finished our work with the outbreak guidelines, I finally was able to read “The Great Influenza” by John M. Barry. In the last two pages of the book, I was really hit hard by what he had to say, because he talked about the public terror that existed in 1918. He said it existed because public officials lied about what was going on, and it became apparent to people who were at risk that they were being lied to, and it was that broken trust that really led to what he calls the terror of 1918. He concluded his book with a plea that “Those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, and to try to manipulate no one.” And I hope that’s what we’re doing with our guidelines.

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