Posted: June 15, 2009
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Article SummaryOn June 11, the World Health Organization finally let the other shoe drop, formally declaring H1N1 a pandemic. CIDRAP’s Robert Roos sent me an email asking for my comments. I responded that the delay itself had been pretty sensible – which turned into Bob’s lead angle. But I had mixed feelings about some of what Director-General Margaret Chan and Interim Assistant Director-General Keiji Fukuda said in making the announcement. What had motivated WHO to delay in the first place had been its twin concerns that the declaration might frighten people unduly (“Oh my God a pandemic!”) and that the declaration might reinforce people’s complacency (“This is a pandemic? What’s the big deal?”). Yet the announcement did relatively little to address either concern. My original response to Bob’s inquiry came in several emails, which I have compiled into one document here.

Reactions to the WHO’s Phase 6 Declaration

Robert Roos’s CIDRAP News article is also online.

Robert Roos to Peter M. Sandman
June 10, 2009

It seems likely that the WHO will declare a pandemic tomorrow, so we’ve been trying to gather some expert assessments of the possible effects and implications of this step, for use in a news story. I’m wondering if you’d like to comment.

In particular:

number 1
Do you still think that the pandemic declaration won’t cause undue fear or panic?
number 2
Do you think some governments will overreact with things like trade embargoes and travel restrictions?
number 3
Are you still concerned that a pandemic declaration in the current context will cause many people to conclude that a pandemic is not a serious concern? Or do you think that the WHO can avoid this outcome if it comes up with a severity scale, so that it will still have some formal descriptive language left to use if the pandemic gets worse later?
number 4
Do you think the WHO has hurt its credibility by postponing the pandemic declaration as long as it has? Or has the agency been able to use the time to prepare the world psychologically for this step?
number 5
Do you think the pandemic declaration will do some good in the way of boosting preparations in some countries? Or do you think most countries are already doing about as much as they’re likely to do?

I’d really appreciate getting your thoughts.

Peter M. Sandman to Robert Roos
June 11, 2009, 11:56 a.m.

Do you still think that the pandemic declaration won’t cause undue fear or panic?

Panic: no.  Unless you dumb down the word to mean worrying a bit and taking some precautions that are probably ineffective, there will be no panic.  No one will go running through the streets, hands waving over their heads, howling.

Undue fear: sure.  Whenever people encounter a new and scary risk, they go through what risk communication experts call an “adjustment reaction” – they become temporarily overanxious and hypervigilant.  During the adjustment reaction, they often take precautions that are unnecessary or at least premature.  This is natural.  It is temporary – soon enough we settle back into the New Normal, more concerned than previously but less concerned than at the height of our adjustment reaction.  And it is useful: It’s a cognitive, logistical, and emotional rehearsal for what may be coming.  People who go through an adjustment reaction before a crisis are better prepared to cope with the crisis.  People who go through an adjustment reaction before a false alarm are better prepared to notice that it is a false alarm and stand down.

The key task of leaders is to guide the adjustment reaction instead of ridiculing it.  That helps get people through it more quickly.  And it helps people come out in a better place.  The goal is for people to emerge from the adjustment reaction aware that they are not currently at great risk (so they don’t need to continue the precautions they may have begun) but also aware that the situation may deteriorate (so they should prepare and remain vigilant for signs of changing conditions).  You don’t want people to get stuck in a permanent adjustment reaction (that’s called an adjustment disorder) – that’s bad but rare.  The more common problem: You don’t want the pendulum to swing too far back the other way, so people end up feeling foolish for having been concerned, angry at those who warned them, and resistant to later evidence that the situation is worsening (a virulent pandemic second wave, for example).  Leaders who guide the adjustment reaction instead of ridiculing it are best positioned to help their people avoid these two extremes.

So here’s some of what I would be saying if I were WHO:

We realize that no matter how well we prepare countries, there may still be some initial overreactions.  We hope countries will not blame their people, will not call them irrational or hysterical. We hope the media will not label the possible initial overreactions as “panic.”  At WHO, we are learning to use the term “adjustment reaction” to describe this stage of temporary overreaction to a risk that’s new to people.

We fully understand that no matter how well we prepare countries, a pandemic declaration may still sound scary to many people at first. A pandemic is unfamiliar; many people have been visualizing bird flu when they think of flu pandemics. It is completely understandable and not irrational that some people may overreact.

We expect these adjustment reactions to be brief, and they are more likely to be brief if leaders and the media are respectful and understanding of the initial reactions, rather than disdainful and contemptuous.

The longer-term concern – and bigger concern – is exactly the opposite: not panic, but complacency.  Many people understand already, and many more will come to understand in the days ahead, that the novel H1N1 pandemic we are declaring today is not a terrifying public health emergency.  It is a serious event, making demands on every country’s health resources, but it isn’t the severe pandemic the world has been fearing and preparing for since H5N1 bird flu reappeared and began to spread in 2004.

It would be very unfortunate if people responded to this realization by concluding that pandemics are no big deal – that we finally got the pandemic we’ve been worrying about for five years and it’s a paper tiger.  This is not the severe pandemic we have been worrying about for five years.  But it could turn into that severe pandemic.  H1N1 could mutate into a more virulent virus.  H5N1 could mutate into a more transmissible virus.  H1N1 and H5N1 could reassort into a new, combined virus that has the transmissibility of the former and the virulence of the latter.

Or, of course, these things could fail to happen, leaving us with only the less severe pandemic we are coping with now. 

So the world has two pandemic-related tasks today: to cope with the pandemic we face now, and to prepare for the much more severe pandemic we might face in the future.  Overreacting to what we face now would be a mistake, but it’s a short-term, temporary, self-correcting mistake.  Under-preparing for what we might face later would be a much more serous mistake. 

Do you think some governments will overreact with things like trade embargoes and travel restrictions?

Of course a lot depends on what you consider overreaction.  Some governments have a policy of containment, which calls for them to “overreact” to their early cases, in an effort to slow the spread of the disease.  They know this strategy will fail to stop the spread of the disease, but it is useful nonetheless as a delaying tactic, buying time to prepare hospitals for the additional cases, to teach hygiene to the public, to develop a vaccine, etc.

Unfortunately, most countries are failing to explain to their publics that containment is a short-term strategy that becomes inappropriate once it has failed (as it inevitably does) to stop the spread of the disease.  So their people are perplexed and even outraged when they try to abandon the strategy (“Why aren’t you giving my kid Tamiflu?  You gave Tamiflu to all the kids in that other school last week!”).  In many cases, this leads governments to continue the outmoded strategy long after it is no longer sensible.  It would help if WHO explained that today – by saying something like this:

Regarding what we face now, I want to remind the world that influenza pandemics cannot be stopped, but they can be slowed.  Efforts to slow the spread of H1N1 are useful.  They buy time, time for community education in things like hygiene, time for the healthcare system to prepare for the burdens of caring for the sick, time to develop and manufacture an H1N1 vaccine, etc. 

But ultimately, the virus will spread anyway.  And when it does, the things countries are quite rightly doing to slow the spread will no longer be worth doing.  I’m talking about things like checking incoming travelers, tracing and then quarantining the contacts of people who have become ill with the disease, administering antivirals even to people with mild symptoms or no symptoms at all, etc.  Many countries are rightly doing these things when they have only a handful of known cases, and rightly stopping when they have hundreds or even thousands of known cases and evidence of sustained community transmission.

All this is as it should be.  But it has sometimes been confusing, and upsetting, to people who don’t understand why the policies seem to change in the middle of an outbreak.  Unless the reasons for the change are explained – ideally, explained in advance – the policy change can seem inconsistent and incoherent.

I urge governments to let their people in on their plans – that they will do certain things to slow the early spread of the disease in their country; that they know they can slow it but not stop it; and that they are already planning to abandon these delaying strategies after they have done their job and the disease is now spreading locally anyway.

Beyond that, many governments are taking technically unsound precautions in order to reassure their publics.  This is a very complicated risk communication issue.  In my terms, the question is whether it ever makes sense to take hazard management actions for outrage management purposes – to reduce harmless factory emissions, for example, because people wrongly think the emissions are giving them cancer.  Here’s what I wrote about that on my website recently:

Another extremely common phenomenon has been the use of swine flu precautions that most experts consider unnecessary, futile, or unwise, presumably in order to reassure anxious members of the public that “everything possible is being done.” (The most extreme possibilities here – such as border closings and swine culls – have been mercifully rare so far.)

In many places, for example, swine flu school closing policies have been vastly different from the policies in place for seasonal flu outbreaks. This was a wise precaution in the early days, before it was clear how severe swine flu illnesses would be. But schools continue to close in response to significantly lower illness and absenteeism rates than have previously been required for such a measure. While closed, the schools are often disinfected far beyond normal flu season cleaning protocols – even though the flu virus lasts only hours to a few days on most surfaces, and even though recontamination is inevitable if the school reopens while H1N1 is still circulating.

Similarly, Tamiflu has often been distributed to healthy young people with mild or even no symptoms – also a defensible measure early on, but much less so as knowledge has increased about H1N1’s relative mildness and which specific groups are at elevated risk. Continuing untargeted use of Tamiflu is a waste of a potentially scarce resource, a risk factor for the development of drug-resistant strains, and a far cry from standard medical practice with regard to the seasonal flu.

These examples of “precaution as reassurance” raise very difficult risk communication issues. Assuming some people are genuinely overanxious and in need of reassurance – a big assumption – is it helpful to respond to their anxiety with precautions that are technically marginal or even potentially harmful? The right answer for potentially harmful precautions is virtually always no. The answer for marginal precautions, I think, depends on whether such precautions will actually be experienced as reassuring. Often they are experienced instead as evidence that the risk is huge, and later (when these marginal precautions are abandoned) as evidence that the authorities are irresolute, inconsistent, and uncaring: “Why aren’t you giving my kid Tamiflu? All the kids in the other school got Tamiflu.” Marginal precautions are probably likelier to be experienced as reassuring if they are explained as responses to public anxiety, rather than simply being deployed as if the authorities thought they were technically sound.

Perhaps most important is to remember that the initial assumption is questionable. Is it really necessary for officials to reassure parents and others about swine flu, or should they be sounding the alarm instead – stressing the seriousness of influenza and the possibility of an increase in H1N1’s severity?

The dilemma of whether to use marginal precautions to reassure people who are overanxious about swine flu is a short-term dilemma. Soon enough the public progresses from anxiety to calm to complacency, and the rationale for precautions as reassurance disappears. But trust in the competence and credibility of officials may have been damaged along the way.

Assume WHO declares Phase 6 and many people experience an over-anxious adjustment reaction.  Will governments overreact by taking steps they know to be economically harmful and technically unsound, such as closing borders?  I don’t know.  But I do know this: Overreacting to a small risk is not a good strategy for helping your public stop overreacting to that risk.  Governments that cater to the adjustment reaction by taking foolish “precautions” are showing a failure of understanding and a failure of courage.  They need to realize that the adjustment reaction will be short-lived; they need to guide people through it respectfully in order to help make sure it is short-lived; and they need to have the courage (and trust in their people) not to overreact to the public’s overreaction – not to disparage it and not to kowtow to it.

Are you still concerned that a pandemic declaration in the current context will cause many people to conclude that a pandemic is not a serious concern? Or do you think that the WHO can avoid this outcome if it comes up with a severity scale, so that it will still have some formal descriptive language left to use if the pandemic gets worse later?

As noted above, I continue to believe that complacency is the main problem, not excessive fear and certainly not panic.  SARS never went pandemic.  H5N1 hasn’t gone pandemic yet.  H1N1 looked bad at first and then turned out mild (so far), so mild that WHO hesitated for weeks to call it a pandemic at all.  Instead of learning from swine flu that influenza is a more serious disease than they thought and that a severe pandemic is an ever-present threat that deserves more preparedness that it has received, what millions of people “learned” (mislearned) is that pandemics are a paper tiger and health officials are fear-mongers.

Insofar as the Phase 6 declaration has an effect, I think confirming complacency will be a more important and more long-lasting effect than provoking a fearful adjustment reaction. 

But I do think WHO has taken several steps that will ameliorate both effects.  The wait has helped lessen the likelihood, magnitude, and duration of any overreaction.  Governments and companies have had a chance to scour their pandemic plans for any automatic triggers yoked to the WHO phases but inappropriate for a mild pandemic, and ordinary people (those who are following the issue) have had a chance to get used to the idea that WHO is about to declare a pandemic and it won’t mean the situation is disastrous.  And the creation of a severity scale will help alleviate both effects.  People who are inclined to overreact to the Phase 6 declaration may find solace in the declaration that it’s only “Phase 6a” (or however it’s phrased), not the dreaded “6c.”  And people who are inclined to dismiss the whole question of pandemic preparedness may find reason to withhold judgment since there may be more severe sorts of pandemics yet to come.  Ideally, the term “pandemic” will ultimately trigger a response something like our response to the word “snowstorm”: “How bad this time?”

Do you think the WHO has hurt its credibility by postponing the pandemic declaration as long as it has? Or has the agency been able to use the time to prepare the world psychologically for this step?

Scientists often like to pretend that all scientific terms have fixed meanings.  And some nonscientists are taken in by the pretense.  So they may think less of WHO for taking political concerns and risk communication concerns into consideration in deciding whether to declare H1N1 a pandemic.

But all definitions are stipulative, arbitrary – and many scientific definitions are quite casual.  In the U.S., for example, the number of cases required for a flu season to be termed “epidemic” is statistically defined in terms of excess cases over the average for prior years – so it takes millions of flu cases to constitute a flu epidemic.  By that standard, H1N1 is not yet epidemic in the U.S.  On the other hand, cholera is rare in the U.S., and a very small outbreak would therefore qualify as an epidemic.  Whether you judge H1N1 (a flu, but one previously unknown) by cholera standards (so it’s epidemic) or by seasonal flu standards (so it’s not) is not a scientific decision.  It depends on what truth about H1N1 you want to showcase.  (The question would be tougher still if H1N1 had arisen in the middle of flu season; we’d be in the awkward position of having an epidemic of the novel H1N1 that involved fewer flu cases than we had simultaneously of the non-epidemic seasonal H1N1.  Try explaining that as a scientific judgment!)  “Epidemic,” in short, means “more than we usually see” – not exactly a rigid definition.

Moreover, WHO is supposed to be a political agency; it responds to the will of the member states.  Once in a great while, when many lives are at stake, a WHO Director-General with courage should ignore the wishes of the member states and do what needs doing for the sake of the world’s health.  A wise Director-General doesn’t do that too often when the stakes are low. 

I think WHO was wise to wait to declare H1N1 a pandemic, while clearly signaling that it would do so soon:

  • partly to give everyone a chance to get used to the idea;
  • partly to give governments and companies a chance to scour their plans for automatic triggers that needed to be adjusted;
  • partly to give itself a chance to develop a severity scale;
  • partly to allow time to reduce the risk of excessively alarming some people and confirming the complacency of others;
  • partly to show due deference to a huge number of governments that wanted it to wait;
  • partly to give the virus time to make it inescapably true that there was widespread community transmission in many parts of the world.

Those are all good objectives.  An urgent health necessity would have trumped all of them, but I have trouble seeing what urgent health necessity would have been served by an earlier declaration.  (It is worth remembering that the WHO’s recommended action steps for Phase 5 and Phase 6 are identical.)

I do think WHO could have reduced any negative impact on its reputation with two additional measures:

number 1
Instead of claiming that its actions were solely based on the science, WHO should have acknowledged, candidly and even proudly, that it is both a scientific and a political entity, that the member states are its constituents and it listens to them, and ignores their requests only when it has compelling reasons to do so.  Its scientific credibility would have been better preserved if it hadn’t tried to represent the delay as a purely scientific decision … which it patently was not.
number 2
WHO should have been – and should still be – more candid about conceding that the definition of a pandemic is a moving target, that it is learning as it goes, and that it is willing to accept the confusion caused by changing definitions in midstream in preference to the resistance caused by adhering rigidly to a definition that has come to feel suboptimal.  I would have urged WHO to acknowledge that it has already changed its definition of a Phase 6 pandemic several times, that by the two prior definitions H1N1 was pretty clearly a pandemic some weeks ago, and that many experts think that even by the newest definition it has been a pandemic for some time.  And I would have urged WHO to point out that it isn’t tinkering with some ancient, time-tested scientific standard.  As far as I know, there was no consensus definition of a pandemic in 1968, and no worldwide debate over when the 1968 flu outbreak first met the standard.  If WHO declares a pandemic today, I believe, that will be the first time any international agency has applied a definition to a data set and declared a pandemic. 

I know Mike Osterholm gave an AP interview yesterday in which he blasted WHO for grounding the pandemic declaration more in politics and risk communication than in science.  I think he’s right that it has been grounded more in politics and risk communication than in science – but I don’t share his sense that that’s an awful thing to do.  Science doesn’t have a consensus definition of “pandemic.”  The earlier WHO definitions, the ones WHO then changed or ignored, were also grounded in politics and risk communication.  And when they seemed unwise from a political and a risk communication perspective, it made sense to adjust them.   

Do you think the pandemic declaration will do some good in the way of boosting preparations in some countries? Or do you think most countries are already doing about as much as they’re likely to do?

I don’t have much of an answer to this question.  Developing countries may well be doing as much pandemic preparedness as they’re likely to do – and as much as they should do, given their other pressing health priorities.  Developed countries are doing a great deal to prepare; they could certainly do more, and may do more, but I doubt the WHO’s Phase 6 declaration will make much difference.  That leaves two audiences that might – just might – be influenced by the declaration to take preparedness more seriously: companies and individuals.  Much depends on which response predominates:

number 1
“Okay, we have a pandemic now, and it’s no biggie.  Obviously, preparing for a pandemic was a waste of time, and further preparedness would be an idiotic waste of time.”
number 2
“Okay, we have a mild pandemic now.  That was never what we were preparing for.  But a severe second wave sounds possible, and so does a reassortment with H5N1.  Let’s use the summer to improve our preparedness for those possibilities.”

We can hope for the latter, and work for the latter.  The former is what I’m worried about.   

Peter M. Sandman to Robert Roos
June 11, 2009, 1:56 p.m.

Postscript after listening to the news briefing:

The two main things WHO has been worrying about for weeks are these:

number 1
How do we declare a pandemic without unduly frightening people into pushing their governments to adopt precautions that are unwise and economically damaging?
number 2
How do we declare a pandemic without unduly reassuring people that if this is what a pandemic looks like then pandemics are no big deal after all? 

That is, how do we make our Phase 6 declaration simultaneously a reassuring message about what is happening right now and a warning about what might happen in the months ahead.

It is disappointing that today’s actual news briefing contained comparatively little that spoke to either concern.  D-G Chan and Assistant D-G Fukuda said much less than they might have said to validate that people may overreact temporarily but will recover quickly; that their governments should neither ridicule the overreaction nor take inappropriate “precautions” in deference to it; that the pandemic we declared today isn’t the much more virulent pandemic we have lived in fear of since 2004; and that that more virulent pandemic may still be on the horizon (whether from H1N1, or H5N1, or a reassortment of the two), requiring both vigilance and preparedness.

Once again, a teachable moment has been squandered by health officials who shied away from addressing their most deeply felt concerns.

Peter M. Sandman to Robert Roos
June 11, 2009, 3:22 p.m.

A post-postscript, I guess:

In fairness, WHO has given several interviews in the past day in which it has done a somewhat better job of normalizing the temporary adjustment reaction that may result from a Phase 6 declaration.  Thus:

WHO’s Gregory Hartl on the BBC:

We do understand that the natural reaction of people if and when we declare phase six could be very strong.  But we would hope that there would be quite quickly an adjustment reaction, as happened in the US, when people realised they weren't getting seriously ill.

D-G Margaret Chan on PBS:

This is the kind of dilemma, you know, many of my member states or many of my countries are in.  They understand the importance of an early-warning system so that they can prepare, you know, as I said, put in place appropriate measures to reduce sickness and to reduce deaths in their country.  But having said that, when you give people an alert about a new disease, it does cause a level of anxiety, worry in the people's mind.  And it is understandable, because, by definition, a new disease is unpredictable.  A new disease is anxiety-creating.

So you need to appreciate, it is OK for people to get worried.  It is legitimate.  But people can make the transition and the adjustment very quickly.  And oftentimes, I mean, based on my past experience in managing crisis, actually, the general public, the community, their resilience is actually better than we worried.  So do trust your community.  And I'm sure the, you know, discomfort would be – last only a short while.

D-G Chan to Bloomberg News:

Some political leaders worry about some unwarranted overreaction and some are also concerned that, because of the mildness of the disease, people will say “so what’s the big deal about pandemic?” …. The balance between overreaction or complacency is another issue that’s of great concern.

Dr. Chan also said something close to this in her answer to the last question in her briefing…. 

So there were glimmerings of the key messages, at least.  I’ll back off “squandered” in my previous email … though I still wish these messages had been front-and-center in Dr. Chan’s introductory statement.

Peter M. Sandman to Robert Roos
June 11, 2009, 3:58 p.m.

Whatever gets written about the reactions to the Phase 6 declaration, please note that the world’s stock markets are mostly up today, not down.  And they have been rising throughout the past two weeks, as everyone was waiting for the second pandemic shoe to drop.  In other words, investors do not expect an economically damaging response to the Phase 6 declaration; they are betting that few if any governments are going to close borders or take other steps that would materially damage economic prospects.

Copyright © 2009 by Peter M. Sandman

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