In October 2005, a North Dakota public information officer sent one of us (Peter) an email, noting that she had searched this website without finding “any suggested messages for the public at the start of and through the height of” an influenza pandemic. We had written about pre-pandemic messaging – what to say now about a possible future flu pandemic. But her department was about to do a tabletop drill for an actual pandemic. What messages did we recommend?
Over a year later, we finally found the nerve to work on the first part of her query: some messages for when it looks like a pandemic is about to start.
The list of 25 “pandemic imminent” messages contained in this long article is not intended to be comprehensive or definitive. Some of the more situation-specific messages (how the initial outbreaks arose, where to get more information, etc.) have been omitted. And some of what’s here may turn out not to be technically accurate.
Our main goal is to suggest, in considerable detail, the sorts of messages we think people will need to hear when a pandemic looks imminent – focusing especially on the ones that are counterintuitive, that government and corporate sources are likeliest to neglect. We have tried to explain the rationale for each message in terms of crisis communication theory.
We have looked at a lot of pre-pandemic messaging – messaging designed for use now, as opposed to when a pandemic looks imminent. Many international organizations, non-government organizations, national governments, state and local governments, and corporations are trying to tell their publics what might be coming someday. An organization just starting to work on pre-pandemic communications can borrow freely from this existing messaging. In the U.S., the Department of Health and Human Services brought in risk communication expert Vincent Covello to help recast its pre-pandemic messages into 74 pages of “message maps,” now posted on its website. Other sources of pre-pandemic information are using or adapting some of these messages.
Our own short list of pre-pandemic messages is contained in our December 2004 column, “Pandemic Influenza Risk Communication: The Teachable Moment.” More than two years later, it strikes us as too preoccupied with vaccines. (The flu vaccine shortfall of 2004 had provided that particular pre-pandemic teachable moment.) And it doesn’t empathically acknowledge and correct some misimpressions that have since become common. (Some version of “It’s not about the birds!” definitely needs to be a message.) But much of it still looks useful. Peter’s October 2005 column on “The Flu Pandemic Preparedness Snowball” has some additional suggestions for pre-pandemic messaging.
But we can find very few posted or published standby messages for use when a pandemic is about to start.
It’s possible that collections of standby messages have been developed and are being held until they’re needed. And some officials have told us they are working on pandemic messages, which they plan to publish soon. But when conference speakers present lists of their organizations’ pandemic preparedness activities, the lists rarely include “develop standby messages.”
In any case, standby messages are not readily available now. At the pandemic tabletop exercises we have attended, participants invariably develop their own messages on the spot. No one ever suggests using existing standby messages. If such message repositories exist, even in draft, it would be useful for their sources to post them (as HHS has done with its pre-pandemic messages), so others can comment on them and borrow from them.
We think this is a shocking gap. A novel influenza virus could launch a pandemic at any moment. The most worrisome animal flu virus right now, H5N1, has been around since 1997; it has been a focus of worldwide attention at least since late 2003. If H5N1 (or some other new flu virus) starts transmitting easily from human to human, a pandemic will be imminent. Nobody knows how quickly it will spread once that happens.
The moment that happens, pandemic risk communication will change radically. And as things stand right now, it looks like most pandemic risk communicators will be writing their messages nearly from scratch.
Not quite from scratch. Many organizations have developed guidance documents of risk communication principles and strategies. If they’re taken seriously, and operationalized effectively, these guidance documents can help a lot. See particularly the World Health Organization’s “WHO Outbreak Communication Guidelines” (2005) and the pandemic influenza risk communication training course developed by the U.S. Centers for Disease Control and Prevention.
Also worth examining are the communication objectives for each phase in the “WHO Global Influenza Preparedness Plan.” Among the national communication objectives listed for Pandemic Phase 5 are these two, which require just the sorts of difficult crisis communication approaches we try to exemplify in this column:
Guidance documents like these are a good start. But they fall far short of a list of standby messages to build on and then quickly deploy when a pandemic looks like it’s starting.
Most of this column will be our first crack at a list of standby messages, annotated in terms of risk communication principles.
As a rule, we like to pepper our columns with examples – good ones and bad ones. This overlong column will be an exception, because there aren’t many examples.
The crucial distinction between pre-pandemic messaging and pandemic messaging is obvious. There’s all the difference in the world between warning people about something that might happen (nobody knows when) and guiding people through something that looks like it’s about to happen or already happening.
In terms of the four kinds of risk communication, pre-pandemic messaging is a kind of precaution advocacy. Hazard is potentially high but outrage is low, and as in traditional public relations, the main problem is grabbing and holding people’s attention. But once the experts have said a pandemic looks imminent, getting people’s attention won’t be much of a problem. The task will shift from precaution advocacy to crisis communication. Hazard and outrage will both be high, and the main problem will be coping with rightly anxious, riveted attention.
Here are some of the major crisis communication challenges when a pandemic looks imminent:
Governments, businesses, and other institutions are paying increased but quiet attention. The media have mostly moved on for the moment. The public, for the most part, has yet to be properly engaged.
With attention as spotty as it is, inspiring preparedness is difficult. Correcting misimpressions – both the misimpression that pandemics are spread by birds and the misimpression that H5N1 somehow “went away” – is even harder.
There is still news coverage of far-away bird flu outbreaks and human bird flu deaths. And there is still some low-level coverage of local pandemic preparedness meetings. But as we write in mid-March 2007, you have to search to find media content on these topics.
Some of the coverage that remains, moreover, is hostile to preparedness: scoffing accusations of official fear-mongering. Endless end-of-the-year news roundups mentioned 2006 as the year the pandemic didn’t arrive. Commentators stressed that there were only 80 human bird flu deaths in 2006, with most of those in the first half of the year – as if that meant a pandemic was now unlikely. In February 2007, John Stossel of ABC News hosted a two-hour documentary on “Scared Stiff: Worry in America.” “Bird flu” came up in passing several times, as an example of a foolish fear too obvious to belabor. The distinction between bird flu and pandemic flu was never raised.
All this will change if a novel flu virus starts transmitting more and more efficiently among humans, leading official health agencies to announce that a pandemic is probably imminent. There will be more coverage than we know what to do with.
It will be mostly responsible coverage, too. A little-recognized truth about media sensationalism is that it almost disappears when a crisis is obviously serious. (See Peter’s September 2006 column on “Media Sensationalism and Risk.”) An emerging pandemic will be dramatic enough on its own. Reporters will cover it heavily, but they won’t have to spice it up.
Of course once a pandemic reaches here – wherever “here” is – it will dominate local coverage. There will be few if any unrelated stories of importance. Still, sensationalism will be rare in the mainstream media. To the contrary: If the pandemic is severe, overly reassuring coverage may be a problem, as it was in the 1918 pandemic.
If the next pandemic turns out mild, if the case fatality rate is low and societal effects are hard to see, the media will soon turn their attention elsewhere. The mop-up coverage will have to choose between two storylines: “This is more serious than it looks on the surface” or “What an anticlimax! How did the experts get it so wrong?” Bet on the latter.
But between the moment when it looks like a severe pandemic might be about to start and the moment when it looks like it didn’t happen, or it has turned out mild, or it’s over, pandemic communication will thrive. There will be a lot of attention.
Which is a good thing, because there will be a lot to say.
The suggested messages in this column are factually nonspecific, since nobody knows yet how the next pandemic will unfold. Specific information will become the focus of additional messages, not included here, such as: Where did the human cluster emerge first? Where has the disease spread to so far? What is being done to try to halt or slow its spread? What symptoms seem to be most common?
Instead of factual specifics, we are focusing mostly on thrust and tone, on what we often call “metamessaging” as opposed to messaging. Especially in a crisis, how you frame information is often as important as the actual facts. Yet communication planners seldom pay much attention to metamessaging issues. Readers who like the metamessaging that follows can use it as a model, even though the actual facts will be different. Readers who disagree with our metamessaging recommendations can start thinking more explicitly about what sort of metamessaging they plan to do instead.
The suggested messages in this column are also long-winded. That’s partly because everything we write together tends to be long-winded. But there’s a better reason. Right now the media and the public have a limited appetite for pandemic information; sources need to talk in sound bites. But by the time a pandemic is on its way, the appetite for pandemic information will be insatiable. Sources won’t always need to cut to the chase; they will need to fill the information vacuum.
Of course there will be a market for short, clear, bottom-line messages too. Some people won’t have the time or the language skills to absorb a lot of detailed information. Some will be too stressed. They’ll just want to be told what to do. But most people’s media consumption goes up in crisis situations. Think about 9/11, or the assassination of President Kennedy, or Pearl Harbor. We’ll have hours of riveted attention, not seconds of easily distracted attention. So we will need both simple cut-to-the-chase messages and longer, more complex messages.
Risk communication expert Vincent Covello has rightly pointed out that when people are anxious or upset their ability to absorb information deteriorates, so they can handle fewer messages and require simpler language. But there’s another force working in the opposite direction: When people are anxious or upset their motivation to absorb information increases. They really want to understand what’s going on and figure out how best to handle it.
If you doubt this, look at the information-seeking behavior of people newly diagnosed with a serious cancer. As Covello tells us, the emotional weight of the diagnosis makes it harder to learn. There are moments of denial when the patient simply cannot bear to learn; there are patients who never get past the denial. But a large number of cancer patients learn huge amounts of highly technical information about their condition.
In high-concern situations, it is important to stay focused on the questions people are asking and on the information you really need them to know, rather than going off into long, jargon-filled, hyper-technical explanations. And it’s important to keep your language simple and direct. But the content itself should not be oversimplified.
Some crises are so fast-moving you simply don’t have time to tell people everything they want to know. You have to get them evacuated or sheltered or medically treated instantly. But while ordering people around without much explanation is sometimes a necessity, it isn’t a virtue. When there’s time, most people would much rather know why they should do what you’re telling them to do. And if it’s important for them to exercise initiative, to take care of themselves and their neighbors, not just follow your orders, they really need to understand the reasoning behind your instructions.
After people understand the reasoning, they may find simplified summaries enormously valuable. Many emergency response professionals carry wallet cards to remind them of key steps to take in high-stress situations when memory sometimes falters. Mnemonic devices are similarly valuable. Fire training always includes the mantra: “stop, drop, and roll.” CPR training inculcates the ABCs: “airway, breathing, circulation.” These aren’t replacements for detail; they are reminders of well-learned basics.
We feel the same way about the crisis communication pocket cards distributed by the CDC and WHO, and about our own checklist of 25 crisis communication recommendations. They are useful as reminders, not as primary instructions.
A pandemic is a slower-moving crisis than a fire or a patient who isn’t breathing – or a tsunami or a terrorist attack. Say it all. Say it understandably. Say it empathically. Repeat the crucial bottom-line points – the ones on your message maps, if you have message maps – more often than the supporting points. Organize the available information in layers so people don’t get lost. Just as a good technical report has an executive summary, a body, and a bunch of appendices, so too pandemic information should offer the public choices among levels of complexity.
The World Health Organization distinguishes six pandemic phases. We are currently in Phase 3.
We’re no longer in Phase 1 because “a circulating animal influenza virus subtype [H5N1] poses a substantial risk of human disease.” We’re no longer in Phase 2 because there have actually been some “human infections with a new subtype”: H5N1 has successfully passed from a bird to a human almost three hundred times so far. There have also been a few cases of limited human-to-human transmission, but only among very close contacts. In WHO’s judgment this does not qualify as the “evidence of increased human-to-human transmission” required for Phase 4.
We’ve been in Phase 3 since 1997 (before the current phases were designated), when the highly pathogenic avian influenza strain H5N1 was identified in poultry and 18 humans in Hong Kong.
As the WHO chart shows, the distinctions among the WHO’s Phases 3, 4, 5, and 6 are qualitative, depending on whether human-to-human transmission is “very limited,” “increased,” “significant,” or “efficient and sustained.”
We want to propose a complementary but different set of phases for planning pandemic communications. The WHO pandemic phases are grounded solely in what the virus is doing. Our pandemic communication phases are grounded also in how “hot” the level of public concern is, and in where the disease is located.
| Communication Phase | WHO Pandemic Phase |
| 1. Pre-Pandemic Cold | 1 or 2 |
| 2. Pre-Pandemic Warm (little public attention) | 3 |
| 3. Pre-Pandemic Hot (teachable moment) | 3 or 4 |
| 4. Pandemic Imminent | 4 or |
| 5 | |
| 5. Pandemic Elsewhere | 6 |
| 6. Pandemic Here | 6 |
| 7. Pandemic Elsewhere (again) | 6 |
| 8. Post-Pandemic | 1 or 2 or |
| 3 or even 4 (for a different strain) |