Peter Sandman
Comments and Questions
(and Some Answers)
2005

The precise question could be: What’s your (subjective) expectation value of the number of deaths due to H5N1 (the current bird flu) in the next five years? Or: What’s your probability estimate that there will be more than 10 million H5N1 deaths in the next five years?

One number says more than 1000 words! (A graph showing how this estimate developed over time would be even better.)

It is incredibly frustrating not to have such a number. (I’m not going to have one for you either. I’m just a communication expert, not a flu expert.) We can calculate the odds that a severe hurricane will hit any particular location within any specified period of time. Why can’t we do the same thing for a pandemic?

In a very limited sense, we can. Over the past 300 years there have been roughly three influenza pandemics per century (not evenly spaced), so in any randomly chosen year the odds of a pandemic are about one-in-30. The most severe influenza pandemic known to history was the 1918 Spanish Flu pandemic. We have pretty decent history back around 500 years. So based on this extremely limited data set, I suppose the odds of a pandemic at least as bad as 1918 are about one-in-500 per year.

The problem is that this ignores what we know about the influenza virus of the moment, H5N1. How does what we know about H5N1 change the odds? We don’t know. Some virologists say H5N1 looks alarmingly like the Spanish Flu; they think the current odds of a severe pandemic are a lot higher than one-in-500 per year, maybe even higher than one-in-30. Other virologists say H5N1 has been around since 1997 without learning the trick of efficient human-to-human transmission, so it probably never will — suggesting that the probability of a severe pandemic today is no greater than it was before 1997, roughly one-in-500.

Both groups are guessing. For nearly all of the past 500 years, we lacked the ability to monitor a novel flu virus before it did or didn’t go pandemic. In recent decades, scientists have monitored a handful of novel flu viruses in other species. Other than H5N1, only H7N7 and H1N1 (the 1976 swine flu virus) caused any human deaths. Neither one caused a pandemic. H5N1 is the only flu virus so far that we have watched become widely endemic in birds and jump species to humans scores of times. If it starts a pandemic, that will be the first time ever that we have seen a flu virus follow this pattern and then start a pandemic; we’ll be one for one. If it doesn’t start a pandemic, that will be the first time ever that we have seen a flu virus follow this pattern and then not start a pandemic; we’ll be zero for one.

There have been pandemics before, but we didn’t know about them until they were well launched. There have been false alarms before, too, but we didn’t know about them either until people started (and then stopped) dying. How many times has an influenza virus followed a course like that of H5N1 (high infectiousness and high virulence among some bird species, low infectiousness and high virulence among humans) and then mutated into a human pandemic? We don’t know. How many times has an influenza virus followed that course and then not mutated into a human pandemic? We don’t know that either. This is the first time we’ve been able to watch.

In the absence of data, then, what you’re asking for is a collection of expert guesses. This isn’t a foolish thing to ask for. There is a lot of research, and even more argument, on the value of expert guesses as a stand-in for actual evidence. There are even formal procedures (the best known is called Delphi) for gathering and tabulating the guesses. Most such procedures seek a compromise between isolated individual judgments (too little opportunity to learn from each other) and roundtable discussions (too much pressure to conform). Their results are reported not as a single numerical estimate but as a distribution of estimates. The variance of the distribution — how much consensus the experts ended up reaching — is at least as important as its mean or median.

Also of interest is the shape of the distribution. For the question you’re asking, I would predict two humps. (Warning: I am now guessing about what flu experts might guess.) The larger of the two humps, I think, would be those who go with precedent and stick to the view that severe pandemics are very rare; the smaller hump would be those whose guts are telling them H5N1 is different. If you could get the experts to guess, and if the expert guesses turned out the way I’m guessing, what would that say about the real risk? I don’t know. It would probably say more about the psychology of risk estimation in the midst of uncertainty, the sort of thing Daniel Kahneman and Amos Tversky studied so effectively. And of course it would say something about the common tendency to get more confident and more extreme in your judgment when you’re immersed in a public controversy.

To their credit, most experts know they’re guessing — which is why they work hard not to get nailed to a specific number. And I suspect most experts would agree that the “true” probability distribution has three humps. There’s a good chance that nothing will happen in the next five years; there’s presumably a good chance that H5N1, if it does go pandemic, will be fairly mild, killing fewer than ten million; and there’s also a non-trivial chance (given its current virulence and other factors) of a real catastrophe similar to or even worse than 1918.

It’s hard for an expert to address all three humps at once — especially when talking to the media. So most experts tend to focus their public remarks on just one of the three humps. There are worst case scenario experts, mild (“typical”) scenario experts, and it-might-not-happen-for-many-years experts. And too often, at least as they’re quoted in the media, the experts end up less than clear that they’re talking about only one of three possible futures. The early media coverage of H5N1 (that is, up until the fall of 2005) tended to emphasize the mild scenario, often without saying it could be a lot more severe than that. The current media coverage tends to emphasize the severe scenario, often without saying it could be a lot milder than that.

By the way, the experts’ public guesses (if you could get them to guess publicly) are probably not as good a predictor as their private behavior. I’d like to know how many virologists now have antiviral stockpiles for themselves and their families.

Another hotly debated question is the relative accuracy of global guesses about big questions versus narrower guesses about sub-questions. It’s not hard to divide your pandemic question into components: What is the probability that H5N1 will develop the capacity for efficient human-to-human transmission? If it does, what change in its virulence would be expected to accompany the increase in transmissibility? How likely are antivirals to work against the mutated virus? How long will it take to develop how much vaccine? You can compile the answers to these sub-questions into an answer to the big question. What we don’t know is whether it’s better to ask the experts the big question or to ask them the little questions and then do the math. The two procedures typically yield very different answers. Opinions differ on which sort of answer is likelier to be on target.

Perhaps the hardest thing for us all to come to terms with — harder even than realizing nobody can give us a number — is realizing we don’t need a number. Regardless of the probability of a severe pandemic in the next five years, pandemic preparedness is a good investment. This is true for three reasons.

First, just about everybody agrees that there will be more pandemics in the future. There may or may not ever be one as bad as 1918 was. But milder pandemics are inevitable, sooner or later. Getting ready for a mild pandemic is a no-brainer.

Second, except for vaccines and antivirals, much of what we should do to get ready for a severe pandemic will also prepare us for other sorts of catastrophes — terrorist attacks, earthquakes, etc. Psychologically as well as logistically, disaster preparedness is largely generic.

Third and most important, the cost of preparedness is a very tiny fraction of the cost of being unprepared. Nobody (well, almost nobody) is urging governments, businesses, or households to turn their priorities upside down getting ready for a severe pandemic that may never come. Most are urging moderate, commonsense precautions, easily integrated into normal living. Figure it this way. Forgetting everything we know about H5N1, there has been one severe influenza pandemic in the past 500 years. Estimate how much damage a severe pandemic could do. Then plan on spending one-500th as much each year on preparedness.

Note also that the Flu Wiki is planning to establish a statistical predictions page to compile any actual estimates Guenter is able to collect.

In my opinion until a few weeks ago, as you repeatedly stated, the main problem was to raise alarm in the public and in indolent institutions. But now the problem is shifting to the other aspect of the communication dilemma you outlined: to make it very clear that we are facing a risk whose size and timing are highly uncertain, in order to avoid a backlash if nothing happens in the next few months.

Maybe this is the reason why, for example, Science, which had always emphasized the alarms of WHO and other experts, in recent weeks has kept a relatively low profile and has given more room to skeptics (e.g., 18 November, p. 1112). On the other hand, it seems to me that other magazines such as Nature — and even more New Scientist, which last February came up with the record estimate of 1.5 billion deaths — are still maintaining a more alarming mood, maybe less appropriate to the new situation.

What is your opinion?

For advocates of action (such as increased pandemic preparedness), the lesson of the issue-attention cycle is to strike while the iron is hot. When people are paying attention, it is important to seize the teachable moment and use it wisely: inculcating good hand hygiene habits; persuading governments to make systemic improvements in vaccine manufacturing capability; urging communities and businesses and households to think through their emergency plans with a pandemic in mind; stockpiling essential supplies that are likely to become unavailable; etc. When people aren’t paying so much attention, a smaller group of pandemic fanatics should use the downtime to consolidate their gains and figure out how to take maximum advantage of the next attention spurt.

Inevitably, interest subsides (as it rose) unevenly. Some publications, scientific and otherwise, lose interest more quickly than others, or rebalance their coverage in the direction of greater skepticism.

I am not convinced yet that the current pandemic issue-attention cycle is on the wane. Google News did show a lot fewer daily hits for “bird flu” in late November than in late October, but that rough measure of attention has risen and fallen before; there are baby “cycles” inside the real cycles, often provoked by a single piece of news. Every country still experiences a huge increase in attention the first time a high-path H5N1-positive bird is discovered in that country — and there are a lot of countries, including the U.S. (and Italy), still awaiting that experience. Time will tell whether we’re in a momentary lull or on the down stroke of the 2004–2006 cycle. I think it’s a momentary lull.

I’m also not sure you are right that there is increasing coverage of the skeptical position, in the science journals or elsewhere. I have a casual impression that there is; my wife and colleague Dr. Jody Lanard (who reads even more bird flu coverage than I do) has the opposite impression. Periodically, a pandemic skeptic (Marc Siegel, Wendy Orent, Michael Fumento) publishes a book, article, or op-ed that generates a new flurry of coverage. Are there more such flurries now than there were a few months ago? I can’t tell.

It is important to distinguish some of the varieties of opinion that get lumped together as skepticism. It isn’t skepticism per se to point out that so far very few people have been infected with H5N1, that the virus may never learn efficient human-to-human transmission, and that all our worries and preparations may be for naught. That’s just the truthful acknowledgment of actual uncertainty; it is half of a balanced position.

Skepticism is that half denying or minimizing the other half. The skeptical view is that if H5N1 were ever going to launch a pandemic it would have probably done so already; that a severe pandemic is always possible but highly unlikely, and no likelier today than before H5N1 came on the scene. This is a legitimate position that deserves coverage — as is the alarmist position, of course. (I think the alarmist position deserves somewhat more coverage, not because it's necessarily closer to the truth but because it’s more dangerous to ignore. Paying more attention to scary news than to reassuring news is a kind of conservativeness.)

Beyond skepticism is reactance. The reactant position is that since a severe pandemic is (skeptics think) highly unlikely, anyone who urges or takes pandemic precautions is being hysterical. This is a non sequitur. People who have listened to the skeptical position can nonetheless rationally advocate precautionary action either because they think the skeptics are wrong on the probabilities or because they think a severe pandemic would constitute such a catastrophe that precautions are justified even though the odds favor the skeptics. The most extreme reactant positions express steadfast disapproval of any emotional or precautionary response to any risk until that risk is guaranteed and imminent. Reactance is beautifully captured in a 2003 New York Times headline: “Fear Is Spreading Faster than SARS” — as if it were somehow a mistake to worry about a disease before you actually catch it.

If coverage of the uncertain position is increasing, that’s good. If coverage of the skeptical position is increasing, that’s okay, as long as the alarming position is also holding its own. If coverage of the reactant position is increasing, that’s too bad.

I don’t agree with your implication that the best way to tell people about pandemic risks is first to arouse their concern with one-sided warnings, and only later to counter the possible backlash by acknowledging that Armageddon may not be right around the corner after all. The last thing I want is a communications universe divided into an alarmist camp (that pretends or imagines it is confident a severe pandemic is imminent) and a reactant camp (that insists the pandemic risk is minimal and precautions are a sign of panic).

What we need is publications — and individual articles, and even individual paragraphs — that acknowledge skepticism and integrate uncertainty and alarm. Something like this:

Nobody knows when the next severe pandemic will come. Nobody knows whether or not H5N1 will start spreading efficiently through the human population. Some experts believe this is very unlikely. But many experts believe the probability of such a spread is high enough, and the magnitude of the possible calamity is high enough, to justify taking precautions now. There is reason to hope these precautions won’t be needed soon, just as there is reason to fear they will come too late or won’t be nearly enough. But there is no good reason to postpone taking precautions.

I’d also like to see some more discriminating skepticism. Skepticism about whether there’s going to be a pandemic should be part of the media mix. But I continue to see pandemic news coverage in which certain specific claims are made without any skeptical rejoinder at all. High on my “where are the skeptics when we need them” list:

• Local health departments that proudly announce they are ready to handle mass vaccine inoculations or mass distribution of antiviral medications if a pandemic reaches their community. I don’t doubt that they’re ready, or at least readier than they were. What isn’t ready is a vaccine for them to fill those syringes with, or an adequate supply of Tamiflu or Relenza for them to distribute.
• “Experts” who offer false, unlikely, or inconsistent arguments against individual stockpiling of Tamiflu.
  • “If you need it the government will have enough for you.” (That one’s false.)
  • “If you stockpile it you’ll probably use it indiscriminately” — that is, when there isn’t actually a flu pandemic. (That one’s unlikely.)
  • “If you use it before the pandemic comes, you’ll contribute to making H5N1 more resistant to the drug when we need it; and anyway we should save our Tamiflu for the annual flu that’s on its way.” (That one’s inconsistent. If we’re worried about the resistance problem, we should avoid using Tamiflu against the annual flu too; and people who use Tamiflu when they don’t have any flu will waste the medicine, but they can hardly create a drug-resistant flu virus in the absence of any flu virus.)
• Poultry industry spokespeople who say their country is safe from a flu pandemic because their birds are carefully checked for H5N1. This is the ultimate non sequitur. Every contact between an H5N1-positive bird and a human being is a new opportunity for the virus to learn how to spread through the human population. Once the virus has learned this trick, anywhere in the world, we’re all vulnerable. If a pandemic starts, odds are it will start on a family farm in Asia (or Africa, when H5N1 makes it to Africa) — where poultry and humans commingle routinely; where hygiene is rudimentary; where there is virtually no way to monitor for H5N1. Your pandemic risk doesn’t go up much when your country finds its first H5N1-positive bird. And your pandemic risk doesn’t go down much if your country manages to keep H5N1 out of its poultry flocks.
• National governments that claim it is irrational to be nervous about eating chicken. It is true (as far as we know) that eating well-cooked chicken is safe whether or not the chicken might have had the flu. But not all chicken is well-cooked. And handling a raw chicken (not to mention killing and plucking a chicken) isn’t necessarily safe. So it is sensible — and emotionally inevitable — for chicken sales to decline when H5N1 is found in local flocks. In much of the world, moreover, it is also sensible for chicken sales to decline when H5N1 has not been found in local flocks. Is surveillance really good enough that they’ll know if a flock has H5N1? Are farmers likely to hide, and sell, the sick chickens they do know about? Is the government guaranteed to be candid if it suspects some local flocks might have an H5N1 problem? If countries all around yours have found H5N1, but officials insist your country is H5N1-free, it is credulous bordering on irrational to take their word for it.

Panflu skeptics: Keep right on debunking exaggerated claims that a pandemic is sure to happen soon and sure to be catastrophic. But please find time to debunk some of these other claims too.

I know of two exceptions, one comparatively minor and the other, for risk communication, quite major.

The minor one is that analogies are never precise. They help your audience understand what you’re getting at, but at the expense of changing it at least a little. When precision is your goal, analogies are not a useful tool.

The major exception stems from the minor one. Analogies are always vulnerable, both to misunderstanding and to attack. They’re invaluable when your audience is on your side, trying to get your meaning. But when the audience is hostile, resistant, or very upset, I would steer away from analogies; in those cases, it is better to say what you mean, not compare it to something like what you mean. I’d be especially wary of analogies to everyday situations when trying to explain a risk your organization is imposing or excusing. Outraged people are pretty much guaranteed to react badly when told that living next door to your dimethylmeatloaf emissions for a year is like white-water canoeing for a minute, or that a part per million of dimethylmeatloaf is like one crouton in a salad the size of an Olympic swimming pool.

1.   The Flu Wiki has a sample letter to a local city council that you might want to look at. Your own letter already worked, but this one might still give you some good ideas for the meeting itself.

2.   I would keep the meeting short. Or at least I’d plan on keeping it short — and then stay alert for signs that the mayor wants to prolong it.

3.   It’s probably wiser to focus more on what you can do to help the township (and the township government) get ready for a pandemic than on what you think she and her government ought to be doing. Government officials spend an awful lot of time fending off demands from constituents; offers are much less unwelcome. But don’t ask for nothing, either. I think it was Ben Franklin who said that if you want to make a friend of someone, it helps to borrow his pen. Ask for something small.

4.   Be sure to ask for advice! You want to launch a local pandemic education/awareness program (at least I hope you do). What’s the mayor’s advice on how best to do that? And does she want a role — by offering you space on the township’s website or in its newsletter, for example? Does she think it would be a good idea for you to talk with the township health officer?

5.   Have the names of a few other local citizens you’ve met with who also want to get involved. (But unless you’ve asked first, don’t bring them with you — you want a conversation with the mayor, not a demonstration or a show of force.) The point here is that you’re not just one kook with a pandemic bee in her bonnet. It may help to put the kook issue on the table. Mention that “some people” think the pandemic issue is being overemphasized in the media; they think people like you are panicking or at least unduly alarmist. Then explain that you’re concerned, not freaking out; that you’re still living your normal life; and that you believe people who prepare themselves now will be far likelier to stay calm if a pandemic arrives than people who are taken by surprise.

6.   Bring some appropriate quotations with you from President Bush and the recently published “National Strategy for Pandemic Influenza” — quotations about the seriousness of the pandemic risk and the importance of local government preparedness and individual involvement. Maybe bring some quotations from prominent congressional Democrats as well.

7.   Emphasize the vital role volunteers will need to play in a severe pandemic — keeping essential local infrastructure going (the hospital, of course, but also the sewage treatment plant and the soup kitchen). Talk about how people who get involved now can become the nucleus of a volunteer service corps later. Remind the mayor that not much help will be coming from “the outside,” since everyone else will be coping with the same pandemic. And remind the mayor that many people who get the flu in a pandemic will survive; then they'll be immune to the current strain, making them excellent candidates for essential volunteer work.

8.   As a nurse, you have more credibility than most people would to address local healthcare issues — from hospital surge capacity to stockpiling of essential medications to planning for mass inoculations (if and when there is a vaccine). Even so, focus more on non-medical than medical preparedness. You want to start doing the things nobody is doing yet. You don’t want to interfere with ongoing emergency medical planning. There’s a good chance you’ll ultimately be invited to help with ongoing emergency medical planning. But start with the pandemic preparedness turf nobody else is claiming.

9.   Don’t leave too much reading behind — just a couple of short articles plus a list of URLs if the mayor wants to know more. Whatever else you include, I urge you to tell her how to get to the Flu Wiki. Point out that the Flu Wiki is an unofficial source that has excellently organized links to all the mainstream official sources, plus good introductory explanations for people newly interested in the topic.

10.   Whatever else you say or don’t say, I would make it clear that you do plan to try to help your fellow township residents get ready for a possible pandemic. You’re not asking for her permission to do that. Nor are you demanding that she make pandemic preparedness a major focus, just because you’re making it one. You are seeking the mayor’s advice on how she thinks you can be most useful. You especially want to know how she would like to see the linkage develop between your private pandemic preparedness efforts and her government’s official efforts.

Good luck with your meeting!

Although using recommended infection control precautions will minimize the risk of infection, the risk can never be entirely eliminated (as evidenced during the SARS outbreak). Also, if a pandemic occurs personal protective equipment such as respirators, etc. may be limited.

I am concerned about the oft-repeated comment that HCWs will not come to work in such a scenario. In 30 years of working in healthcare, I have observed many instances of heroism and few of cowardice, although both are likely to occur in a pandemic. Just a generation ago, HCWs regularly took risks working with TB and other infectious patients, etc. More recently HCWs took risks caring for HIV patients when the mode of transmission was unclear. And of course there is the SARS experience.

What lessons can be learned from past experiences and from the SARS outbreak that can be applied if a pandemic occurs?

As you point out, healthcare workers (HCWs) are usually responsible, sometimes heroic, and only occasionally too frightened to do their jobs. On the other hand, a severe infectious disease outbreak is about as frightening as a healthcare crisis can get. We don’t think anybody can predict with confidence how HCWs will respond if and when a pandemic hits your community.

What we can say with confidence is this: What HCWs do during a pandemic will depend in large measure on how they were talked to, and listened to, in the run-up to the pandemic.

At a recent Yale University symposium on “Ethical Aspects of Avian Influenza Pandemic Preparedness,” a hospital infection control officer told Jody that she had real reservations about passing on to her staff the CDC’s recommendations about masks and other personal protective equipment (PPE) — recommendations she saw as grounded more in speculation than in actual knowledge. Even after a pandemic began, she said, there would still be enormous uncertainty about which precautions were essential. She feared spending lots of hospital money on expensive N95 masks, and then being told later that they were unnecessary. She also feared skimping on N95 masks and running out, only to learn that they were medically essential but no longer available, forcing her staff to make do with less protective surgical masks.

Best risk communication practice in such a situation, Jody told her, is to acknowledge the uncertainty, share the dilemma, and solicit the opinions of everyone who is (or will be) affected. This can be done now, while the hospital is deciding what PPE purchases to make. It is even more important to do later, after the pandemic has begun ... and still later, as it starts to become clear how wise or unwise those uncertain early decisions have turned out to be.

Candor and consultation may or may not improve the quality of a hospital’s decisions. They are virtually guaranteed to improve the likelihood that HCWs will understand the risks and the uncertainties, will accept the difficulty of making so many uncertain decisions and the inevitability of making some wrong decisions, and will therefore feel both more able and more willing to cope with the outcomes.

The bottom line: Whether healthcare workers accept the risks of working through a pandemic — that is, whether they decide to come to work — depends only partly on how serious they believe the risks are. It depends also on how candid and consultative they believe hospital administrators have been. Infection control officers should predict candidly that the CDC may learn things that lead to changes in official recommendations as the pandemic evolves. And they should acknowledge that the CDC-recommended precautions may not always be available during a prolonged and severe pandemic.

Here are some other risk communication measures that make important contributions to healthcare workers’ willingness to take patient-care risks:

• Strong demonstrations of hospital support for infection control measures.
• Validation of staff fears rather than expressions of contempt or over-reassurance.
• Non-intrusive emotional and social support for HCWs under stress.
• Appropriate provision for the care of HCWs’ families. (Some pandemic plans specify that antiviral medications are to be provided to HCWs’ family members as well as to the HCWs themselves. Presumably, the rationale is partly that family members may be more exposed than other people, and partly that HCWs are likelier to accept dangerous work if they know their loved ones are being protected.)
• Evidence that top hospital officials are themselves also willing to tend to patients at the bedside.

One very interesting study conducted during the SARS outbreaks surveyed Japanese healthcare workers. Although there were no SARS cases in Japan, SARS fear among Japanese HCWs was high. The study correlated healthcare workers’ knowledge of recommended infection control procedures, their perception of their hospitals’ support for infection control, and their perception of personal risk — measured by their intent to care for or avoid prospective SARS patients.

HCWs’ knowledge of officially recommended infection control precautions did not correlate with whether they were willing to care for SARS patients. What mattered was the workers’ perception that their hospitals had “clear policies and protocols, specialists available, and adequate training.” The unsurprising risk communication message is that knowledge alone — “educating people” — is not always the key to precaution-taking. Demonstrating that leaders take the issue seriously can have a bigger impact than making sure doctors, nurses, and other hospital workers can pass a quiz on infection control measures.

(That is one reason we keep urging health departments to supplement their hand-washing education programs with a clear demonstration of institutional commitment: Change all the faucets and doorknobs in public washrooms to be more like those in surgical suites, which can be operated with your elbow.)

Another study analyzed the safety opinions of Canadian healthcare workers after the SARS outbreaks. Among the authors’ conclusions:

Workplace attitudes towards safety were ... important. Paramount to this were the attitudes and actions of management and the perceived importance of occupational health and safety, both of which were important determinants of the safety climate within hospitals....

Communication about safety within healthcare organizations was seen as having a key role in protecting HCWs, especially during the SARS outbreaks. Face-to-face “town-hall” meetings were seen as necessary in order to build worker confidence in hospital infection control policies during SARS.

[U]sers as well as infection control and occupational health experts need to be consulted before required workplace practices are established and PPE is selected.

Your comment addressed the needs of healthcare workers only, but everything in our answer applies also to healthcare volunteers. Anyone who spends time in a hospital, whether as an employee or as a patient, knows how essential volunteers have become. In a pandemic, of course, volunteers have less reason to keep coming to “work” than HCWs — no financial incentive, no professional duty of care, no (or much less) moral obligation. And yet volunteers will be all the more essential when some HCWs simply can’t come to work because they are sick or dead.

In a pandemic there will also be a natural cohort of such volunteers: survivors. People who get the flu and survive are presumably immune, at least until the virus mutates substantially. They can be doing all sorts of work that either would be very dangerous or would require continual antiviral doses for someone who has so far gone unscathed.

Will volunteers be willing to work in a hospital in the middle of a pandemic? The answer depends largely on risk communication.

The plan is to have the people in the towns around the county go to a central location in their town, be checked for symptoms, then loaded onto a bus for transport to the county fairgrounds.

At the fairgrounds, the people on the buses will again be checked for symptoms and the well ones reloaded onto the buses for transport to a Mass Dispensing Site in the next county south of us, which will be receiving people from a few other surrounding counties. At that point the people on the buses will be lined up to receive a vaccination.

In my mind, massing people is the worst thing to do if we are in fact dealing with a respiratory virus. To me, it would be the fastest way to spread the disease. However, I have been told by the county EMS Director that she just has to have blind faith in the higher powers that be that they know what they are doing.

I have a masters in Urban Studies. I know how urban planning began with the Sanitarians and the public health movement. I understand enough about medicine and public heath and epidemiology to know that what is planned is a disaster in the making, not only logistically, but humanistically. And I could not agree with you more about the need for non-medical responses, which is ultimately about rebuilding community.

Given the reality of not having any vaccine for maybe up to six months or more after the flu makes the h2h [human-to-human] jump and makes it to the U.S., what is the point of having a mass triage and immunization program anyway during the very time when people will be sick and perhaps dropping like flies?

If the objective is to vaccinate as many people as possible, whenever the vaccine is available and your community hasn’t been hit yet, and yet prevent the spread of the disease as effectively as possible, wouldn’t the best way to accomplish this be to have teams go out to the various towns (our whole county only has about 11,600 people) and just go door-to-door? Or give people appointments to go to the clinic or a school for the vaccination?

On the other hand, flu pandemics tend to come in waves. It may be feasible (and efficient) to carry out a mass immunization program in a centralized location while your area is between waves.

Mostly, I’m interested in the communication aspects of your comment.

Your paraphrase of the county EMS director — that we must have blind faith that those in authority know what they're doing — goes to the heart of the problem. Whether or not the plan you describe makes good medical sense, it doesn’t feel like it does — it doesn’t feel that way to you or the EMS director, and it probably won’t feel that way to the people who are told to make their way to the buses. The odds are good they won’t come.

Check out a New York Academy of Medicine study entitled “Redefining Readiness.” This extremely important study asked Americans what would determine whether or not they followed instructions in the wake of specified terrorist attack scenarios. One of the scenarios involved telling people to gather for smallpox vaccinations after terrorists had released the smallpox virus in one part of town. Lots of people said they wouldn’t do it, for a variety of reasons — including a sensible fear of being intermingled with those who had already been exposed.

The main point of this study is that people make their own sense of emergency situations, and decide how best to cope. They do pay attention to what the government is telling them, but they don’t necessarily follow orders. They are likelier to “follow orders,” of course, if they helped develop the plan, if they knew in advance what it calls for, and if their reservations about it have been identified, acknowledged, and addressed.

You almost certainly do not have a county full of people who will have “blind faith” after a pandemic strikes. So an EMS director who has blind faith now can’t be doing a good pandemic preparedness job. Keep raising your objections. If you’re right, the plan needs to change. If you’re wrong, somebody needs to show you why. Either way, your county’s residents need to be part of the debate.

This isn’t just about your county, of course. Scores of county governments have released public statements that proudly note how quickly they are prepared to implement a mass vaccination or antiviral distribution program if a pandemic comes (and if they have a supply of vaccine or antiviral medication, a qualifier they don’t always mention). Most of the announcements don’t describe the plan. Most of the plans, I’ll bet, didn’t involve much public discussion. Whether or not these plans make good technical sense, if the planners haven’t involved their publics and if they haven’t anticipated and addressed the concerns people are likely to have, they cannot be good plans.

I’ll be at the big flu conference in the Bay area this week and look forward to talking with the other professionals about it.

Thank you for making your work available to the average citizen activist.

Flu Wiki and kindred websites are filling a crucial need. You help newbies get through their adjustment reaction, and you help veterans stay up-to-the-minute and figure out together how best to respond. If a pandemic strikes, your regulars will be leaders in their communities.

Jody and I are proud that you find our stuff a useful part of the mix.

I for one, am instituting a plan for my very small business and family. I have grave doubts that my government will be in a position to offer much assistance to myself, my family or my immediate community should this strain of H5N1 suddenly appear. This is how I will be able to sleep at night. I will do what I can with pre-planning, and then continue to live as normal.

I only wish our government felt as compelled to educate and inform their people as Minister Abbott. My biggest fear is of the unknown. It’s never too early to educate and inform the public. People need to make plans (and yes, this includes updating their wills) now, and they need to instruct and educate their children on how they can help protect themselves (i.e., hand washing, covering a cough, etc.). Get people everywhere involved in the process, and they will not feel so helpless or panicked. Get it done, and move on. I am planning for the worst, but hoping for the best.

History has always told us a lot about our future. I can’t imagine why our highly educated representatives in Washington just don’t seem to get it, even when it stares them in the face.

But I think your criticism of the U.S. government is less on target than it would have been a couple of months ago. President Bush and HHS Secretary Leavitt are sounding a lot like Australia’s Minister Abbott these days — acknowledging that a severe pandemic would be horrific, that we’re not ready, that we’ll never be entirely ready, and that there’s a lot to be done to get us readier than we are right now.

Read the new U.S. pandemic plan or the much shorter National Strategy for Pandemic Influenza. I think you can make a case that these documents — and the funding to implement them — show a greater sense of urgency about government medical preparedness than about individual non-medical preparedness. But individual preparedness is certainly there. And any sense of urgency is welcome.

As for the likely financial effects of a pandemic, it’s anybody's guess. Until a few months ago, I saw no evidence that the financial community was even trying to guess. But Deutsche Bank (and others) sponsored a big September 2005 conference on “Bulls, Bears, and Birds: Preparing the Financial Industry for a Pandemic.” And there is beginning to be published speculation on how a pandemic might affect markets and economies. Probably the leading source in this area is Sherry Cooper of Toronto’s BMO Nesbitt Burns. See for example her “Don't Fear Fear or Panic Panic.”

Collectively, in terms of planet earth as a whole, what is our greatest risk? In terms of almost negligible but horrific probabilities there is the collision of an asteroid or comet with earth that has happened before and will again, or potentially even worse, the possibility of a nearby star going supernova. The first we could survive as a species if we speed out into space to colonize the moon and Mars. The second, we have zero countermeasures at this time.

Both of these kinds of risks can be high-outrage or low-outrage, depending on other factors. So a third way of categorizing the “worst” risks would be to focus on the high-outrage ones, the ones that arouse the greatest concern and the most interest in taking precautions.

The CDC’s National Center for Health Statistics has a short list of leading causes of death in the U.S. that you might want to look at. The top three are heart disease, cancer, and stroke. A recent World Health Organization report on “Preventing Chronic Diseases” provides some worldwide data.

As for the high-magnitude, low-probability risks, you might want to check out one professor’s list of the “Ten ‘Worst’ Natural Disasters.” His interest, like yours, is focused on earth and space; he doesn’t list any pandemics, for example.

From a risk communication perspective, the big challenge is how to generate sufficient outrage about a serious hazard that isn’t generating much outrage on its own. For a risk communication approach to high-magnitude, low-probability risks, see Worst Case Scenarios. Generating outrage about chronic risks can be a bigger challenge still. That’s what health educators and safety managers try to do day after day — warning apathetic publics that they ought to worry more about diet and exercise, and apathetic employees that they ought to be more careful about slips and falls. For some possible approaches here, see the articles listed in my Precaution Advocacy Index, particularly the ones on employee safety.

In regards to an avian or pandemic outbreak I am in agreement that for now, at least, we should not rely on medical response strategies in our pre-planning response efforts. Since I work in local public health (i.e., the front line), I see the pre-planning activities as a coordinated campaign of local publicity and education to partners, stakeholders and the public, and synchronizing of response plans among the key agencies.

Therefore, I am troubled somewhat when I see national attention and funding being largely focused on vaccine research and antiviral issues (who will pay for them, how much should each state stockpile?). From a federal message point, I feel we are losing this “teachable moment” to talk about what realistically can be accomplished based on past experiences with large, catastrophic events. What can limited government resources do for you ... and what can you do for yourself to decrease the risk of becoming a victim?

In that regard, self-sustainability should be a strong message out in front of the medical solutions that currently do not exist. I feel the current national media attention being paid to medical solutions for an avian or pandemic outbreak is dampening this key message and reinforcing a false sense of security in the general public that a medical solution will be provided.

Would you agree with this assessment of the developing federal medical response message, and if so how would you recommend being inclusive of the obviously now unavoidable medical response message while still trying locally to be convincing about the need for crucial non-medical messages?

I agree with you that the U.S. federal focus is too much on vaccines and antivirals — and, more broadly, on medical preparedness and medical response. There is also some attention in the new federal pandemic plan (and the speeches that accompanied its unveiling) to what individuals, local communities, and the private sector can do. But not surprisingly, the feds are focusing on what the feds can do.

Three things are true of this medical approach to pandemic preparedness:

• If the next pandemic is mild, as 1957 and 1968 were, our needs will be mostly medical. Medical preparedness will have been the right approach.
• If the next pandemic is years into the future, the medical approach may (or may not) turn out to be the most important approach. A new generation of vaccine manufacturing methods and antiviral drugs may someday enable us to cope medically with a virus that would quickly overcome today’s doctors. I’m not in the least critical of the U.S. government’s determination to pursue these possibilities.
• If the next pandemic is soon and severe, everything we can throw at it medically won’t be nearly enough to make much difference — even in the U.S. and certainly in the developing world. Preparedness for this worst case scenario needs to be about keeping society going so we don’t lose still more people because of starvation, contaminated water, lack of fuel for heating, riots, etc. Preparedness for a worst-case pandemic needs to be about people getting ready to endure bad conditions in a spirit that resembles London during the blitz, not New Orleans after Katrina.

What does this mean for a local public health communicator? I would certainly welcome the new federal focus on medical preparedness. That’s something the feds can do best, and it’s good news that they’ve decided to take the task seriously. In addition, I would aggressively inform my local stakeholders that our task, the local task, is different.

Every local business, public agency, civic group, household, school, and neighborhood needs to prepare itself — emotionally and logistically — for the possibility of a severe pandemic, one that would dwarf our medical capabilities and test our courage, our perseverance, our common sense, and our sense of community. From learning how to wash our hands properly to stockpiling essential supplies to planning how to make best use of volunteer survivors, we have things to do.

There’s a local medical preparedness job to be done too, of course. Hospital surge capacity, for example, is about local medical preparedness. So is figuring out how to isolate flu patients from other patients. So is stockpiling essential medications and supplies needed to treat conditions other than influenza.

Perhaps the biggest local medical preparedness task, paradoxically, is helping our citizens realize that medical preparedness may not do the trick. People need to know that the flu medications we have may not work. They need to know that even if they do work, there still won’t be enough for all (at least not for a very long time). And they need to participate now in debates over who should get top priority for medical help.

It is a sign of the federal government’s focus on the less severe pandemic scenarios that it is still suggesting that scarce antivirals would be allocated to the most vulnerable, for example to those with impaired immune systems. That makes sense if the pandemic is mild, or if it comes after there is an ample antiviral stockpile. If the pandemic is soon and severe, we will need to try to keep the water treatment plant and the power plant staffed, and that will inevitably mean allocating scarce antivirals to the people we most need to keep alive, rather than the people we think are likeliest to die. This is a painful truth. Learning it mid-pandemic could spark “Tamiflu riots.” People need to learn it — indeed, help decide it — now. Forewarning and participation won’t prevent all social disruption, but they will help.

I don’t think the federal focus on medical preparedness is costing us the teachable moment. The feds’ message — it’s a serious risk and here’s what we’re going to do about it — is a very good message as far as it goes. Now the rest of us need to chime in with messages that the feds aren’t emphasizing enough. Don’t start with “But....” Start with “Yes, and....”

The underlying issue here is the unspoken pressure to “speak with one voice.” One of the toughest questions in crisis communication is what to say about differences of opinion within your agency or among the many agencies trying to manage a crisis together. Should you let the diversity show, letting the public see that the problems you face are difficult and the answers aren’t obvious? Or should you try to cobble together a unitary message and hope the rough edges stay hidden and the dissenters don’t leak?

As you can probably tell from the way I phrased the choice, I favor letting the diversity show. I think it’s really damaging if decision-makers look unaware of each other’s positions or disrespectful of each other’s positions. But pretending that we all have the same position goes too far. The odds of the manufactured consensus sticking are low. It is better to reveal the diversity than to get caught papering it over.

This can be a very tough call. But I don’t think it’s a tough call this time. You can, in fact, lean heavily on the feds themselves in support of your non-medical focus, your focus on pre-pandemic communication, and your focus on involving the individual citizen. Page two of the National Strategy for Pandemic Influenza (released the day before the detailed plan of the Department of Health and Human Services) states:

While a pandemic will not damage power lines, banks or computer networks, it will ultimately threaten all critical infrastructure by removing essential personnel from the workplace for weeks or months. This makes a pandemic a unique circumstance necessitating a strategy that extends well beyond health and medical boundaries, to include the sustainment of critical infrastructure, private-sector activities, the movement of goods and services across the nation and the globe, and economic and security considerations.

Page three lists the three pillars of the National Strategy. The first of these, entitled “Preparedness and Communication,” reads as follows:

Activities that should be undertaken before a pandemic to ensure preparedness, and the communication of roles and responsibilities to all levels of government, segments of society and individuals.

And President George Bush’s introduction to the National Strategy includes these words:

[The plan] also outlines the important roles to be played not only by the Federal government, but also by State and local governments, private industry, our international partners, and most importantly individual citizens, including you and your families.

While your government will do much to prepare for a pandemic, individual action and individual responsibility are necessary for the success of any measures.

The federal government says local governments have an important role to play in pandemic preparedness. So play your important role. Don’t criticize the feds’ medical focus, and don’t feel obliged to copy it.

I have decided to do a paper on your research and work and would like to know if you have any web articles to study on children. When 9/11 happened my daughter was in first grade and her school gathered all the children in the auditorium with TV's and the principal was talking about what was going on. They stayed in there all day except for lunch and she came home devastated, as I’m sure many kids did.

So far my paper entails your background; outlines risk, hazard, outrage and the key words to stay away from and why; and the key words that are ok to use and why. But if you have any articles on helping children cope I’d be interested in studying them.

In all three cases it is clear that respectful listening to their fears is the key. In the first two cases the big question is how frankly to validate that their fears are realistic. I lean toward candor rather than over-reassurance even for children. I am also a big believer in involving kids in various efforts to take precautions (and to volunteer for others). I’d rather offer them things to do to help them bear their fear and misery than try to talk them out of their fear and misery.

But there are limits. I wouldn’t have let a first grader sit in front of a television all day on September 11, 2001, watching the Twin Towers fall again and again.

Two relevant pieces on the website: (1) “Giving children frightening bird flu information” (a thoughtful question and my attempt at an answer on the Guestbook); and (2) “Teaching about terror” (an article by Robert Taylor that quotes me and others).

I do have a quick question that I hope has not been asked already. How do you define or recognize “panic”? I have read many of your articles that discuss it as a rare reaction and therefore not the most likely response. The reason I ask is in the first formal interaction with our on-site health nurse, her words to me (after relating a story where a constable came to her to tell her he was going to buy antivirals over the internet), were “We need to stop this panic!”

I thought about this and asked myself, “Is this really panic?” Personally I thought that this constable may think, in the absence of information, that this might be a rational thing to do to protect his family. So the nurse calls it panic. I think it might be a rational decision in his mind. How do we know who is right?

And if what you feel is “alarmed” or even “afraid” rather than panicky, it certainly isn’t panic — even if other people don’t like the precautions you decide to take.

So buying some Tamiflu or Relenza on the Web isn’t panic. Opinions differ as to whether it’s a worthwhile investment to have antivirals in your medicine cabinet, but it’s very hard to build a case that it’s destructive. And there is no case whatever that antiviral customers know they’re doing something destructive but are just too terrified to stop themselves. You can argue that the purchase is over-cautious; you can argue that it’s disobedient (if the government has said people shouldn’t do it); you can even argue that it’s selfish, that the society would be better served by a communal stockpile instead of a lot of individual stockpiles. But as I define the term, you can’t argue that it's panic.

Why is it a serious problem when governments (or physicians, journalists, etc.) describe precautions they disagree with as panic? In an effort to prevent or ameliorate the “panic,” here is what governments do. They withhold alarming information. They interpret the information they can’t withhold in one-sided, over-reassuring ways. They express contempt for the public’s fears, which leaves people alone with those fears. And they mandate some behaviors and forbid others, reducing people’s freedom to choose their own precautions. These efforts to “allay panic” actually increase the likelihood of panic. Even so, people don’t usually panic. But they do become more anxious, more skeptical, and more hostile — not at all the effects the government was seeking.

For more on this topic, see “Fear of Fear: The Role of Fear in Preparedness ... and Why It Terrifies Officials.”

The question of risk communication for enforcement personnel and other emergency responders deserves an essay all its own. Some of the points such an essay would need to cover:

• Emergency responders have a right to and an appetite for detailed risk information. Whether it’s a hazmat team boning up on the toxicological details of a spilled chemical or a beat cop learning the protocol for avoiding HIV exposure in a “blood-rich” environment, this is an audience that genuinely needs solid data, not bland generalizations.
• In the heat of an emergency, responders often experience a highly functional sort of denial, putting their normal feelings (fear, empathy, anger, etc.) on hold so they can cope. When the emergency is over, they may need some help recovering those feelings and reintegrating themselves.
• Emergency responders are risk communicators. When the crisis isn’t in an acute phase, they spend a fair amount of time talking to people about what might happen, what to do if it happens, how to prevent it, etc. And when the crisis is acute, they talk to victims. A lot of what went wrong during Hurricane Katrina might have been alleviated if more of the responders had been through a few hours of risk communication training.
• In many ways, emergency responders are like everyone else. Their reaction to a new risk, for example, is likely to follow the predictable pattern of an adjustment reaction. It is just as important to notice the ways in which emergency responders are not different as the ways they are.

I have this little blog — http://www.twentyfirstcenturyart.com/dakota/mt/ — (thus I understand your craving for comments) in which I have been trying intermittently to talk about pandemic possibilities. I referenced your teachable moment piece awhile ago and then lost track of you — I think I thought it was a single article. I am delighted to discover that you have such an informative, thoughtful, living, breathing site.

I am seeing a bunch of adjustment reactions around me. I think that’s quite an improvement, actually, from the pervasive denial that preceded it. It has been so hard to get people to simply face this possibility — too horrible to integrate psychologically. The good news is that since the snowball started to roll, my friends want to have lunch with me again, and best of all, my husband has stopped rolling his eyes and has agreed to look at material on inverters, which I am incapable of reading. Clearly I wasn’t hitting the right note.

I plan to read everything on your website, in between carrying cases of this and that into the basement.

You can use any part of this in your comments, I was just shy. Thank you for your valuable work. You should be consulting to Health and Human Services, but this administration is not famous for using expertise, is it?

In response to your last comment, I should note that I have in fact done a fair bit of consulting for the U.S. Department of Health and Human Services over the years, much of it through its Centers for Disease Control and Prevention. Nor can I complain that HHS and CDC have ignored my views on pandemic communication. They haven’t. Despite some strong criticism in “Pandemic Influenza Risk Communication: The Teachable Moment” of the HHS draft pandemic communication plan, I was invited to do two days of pandemic communication training and consulting at HHS. My recommendations were received with thoughtful, respectful attention. And then a decision was made to move in a different direction — less high-profile and a lot less alarming than I thought best.

As you know, this decision has recently been reversed. HHS, CDC, President Bush, and the rest of the U.S. government are now as alarming and as high-profile as one could reasonably ask on the risks of a flu pandemic. This could be attributable to the President’s holiday reading of a pandemic history book, or to the lessons of Hurricane Katrina, or to the alarming communications emanating from other governments and non-government organizations. It might even have had something to do with me. (I like to imagine it did.)

And here’s another possibility. Maybe this is the government version of the adjustment reaction. When individuals start focusing on a risk that’s new to them, they over-react for a while before integrating an appropriate level of precaution-taking into their New Normal. Governments may have a different sort of adjustment reaction — over-reassuring (or going silent) for a while.

Both are “knee-jerk” reactions. While you and I are “automatically” putting our ordinary preoccupations on pause, searching for news of the approaching threat, and practicing the precautions we may soon need, governments are just as automatically churning out statements that “the situation is under control.” As we get the new risk into context our concern becomes calmer and more deliberate; as governments get it into context they start conceding that there is good reason to worry. Just as some people get stuck in over-wrought mode, some governments get stuck in over-reassuring mode. It looks like the U.S. government is finally unstuck.

As you point out, even individuals often shrug off a new risk for a while before they take it on board. Whether you call this denial or complacency, it is common — a sort of “pre-adjustment reaction.” So let’s forgive the government its period of over-reassurance and help it fine-tune its pandemic messages: less about vaccines, more about local preparedness, more about non-medical preparedness, etc.

Beyond that, I think doctors have a special opportunity to tell their patients about pandemic influenza in the context of the annual flu season that is just beginning. Check out the CDC and WHO websites, and the dozen or so flu-focused blogs and discussion boards and wikis; find an introductory FAQ you like; download it; and give a copy to every patient, especially every patient who comes in for a flu shot.

There has been a lot of debate among pandemic communicators over how to address the relationship between the annual flu and pandemic flu. The bottom line, in my judgment, is this. The two are completely different — they are different strains of influenza, with different magnitudes and probabilities of risk and different sets of appropriate precautions. But that doesn’t mean you shouldn’t talk about both at the same time. In fact, the only way to explain how different they are is by talking about both at the same time! And one of the best opportunities is when people are getting their annual flu shot. “Now let me tell you about a completely different kind of flu,” your message should begin, “a kind of flu that the shot you just got does absolutely nothing to protect you from.”

As a doctor, you have more standing and more access than the rest of us to raise the alarm about local medical preparedness — hospital surge capacity, for example, and local stockpiles of essential medical supplies. (With shipping slowed to a trickle, how long will it take every doctor, clinic, and hospital in town to run out of surgical masks?)

You also have higher credibility than non-doctors to point out that pandemic preparedness isn’t entirely medical — and that preparedness for a severe pandemic is mostly non-medical. Try to persuade your medical colleagues to join you in insisting, publicly and aggressively, that there is little doctors can do to prepare for a severe pandemic, and little they will be able to do to ameliorate one if it comes. When we talk about preparedness for a severe pandemic, we’re talking about food, water, energy, and security; about infrastructure, inventory, and the allocation of survivor volunteers. Nobody can say it’s not mostly about doctors with half as much credibility as a group of doctors!

If you can’t attract any allies at the start, go it alone. The tools are familiar to you already — letters to the editor, comments from the audience at town council meetings, etc. But don’t neglect the single most potent tool at your disposal: conversations with your patients.

And don’t neglect the rest of the healthcare profession. In many cases nurses do a lot more communicating with patients than doctors do. Make sure everyone on your staff knows about pandemic flu and feels encouraged to talk about it. And persuade your colleagues to involve their staffs as well.

With the greatest respect and acknowledging your work, and after reading about the application of risk communication, I have added the Awareness and Effort elements (as part of my understanding of your work on risk communication) to the formula to demonstrate how Hazard and Outrage can be minimised through applying Effort (time & energy) to deliver greater public awareness (education of fire and wildfire risk on public land).

Based on your work and my understanding of it, the formula is expanded: Risk equals Hazard plus Outrage, divided by Awareness, multiplied by Effort:

            H + O 
    R =   ---------    x E
               A

Thank you for your work on risk communication.

But no matter. People sometimes ask me why I’m not multiplying H and O instead of adding them. I tell them I’m not an engineer, and I mean my formula to be a metaphor. I talk about it; I don’t do calculations with it. And certainly effort and awareness matter.

If everyone does so, there will be no medicine for those who may need to be treated this fall/winter for the run-of-the-mill flu, even if there is no pandemic. There may be thousands of doses sitting in people’s medicine cabinets just in case of a pandemic, but none for vulnerable people who may need it for treatment or prophylaxis within the next few months during the normal flu season which will definitely occur.

While the prospect of a pandemic is very frightening, and I can understand why people and physicians would want to stockpile some Tamiflu to protect themselves and their families, I would also want it to be available to sick or exposed vulnerable people this flu season and to critical service providers in case of a pandemic.

If I cannot support everyone taking this approach because of its negative impact on the health of individuals and groups, I cannot in good conscience prescribe Tamiflu for myself and my family.

I agree with you that the focus on antivirals and vaccines, which are unlikely to be available if a pandemic occurs soon, is detracting from other important planning efforts at the local level.

Thank you for your many useful and stimulating comments on pandemic influenza.

On the other hand, there hasn’t traditionally been much Tamiflu use for the annual flu. It needs to be taken within 48 hours of the onset of symptoms, which isn’t much time to get in to see your doctor — and many people with the flu don’t see the doctor for it at all. And most doctors (and patients) haven’t been all that interested in a drug that cuts the duration and severity of a disease most regard as an inconvenience, not a threat.

Moreover, Tamiflu for the annual flu is a little like the morning-after pill. People worried about the annual flu are supposed to get themselves vaccinated. Their ethical claim on Tamiflu if they neglected to get vaccinated seem less compelling to me than the claim of someone worried about a potentially pandemic flu strain for which there is no available vaccine. (Of course there are also people who couldn’t get vaccinated, or whose vaccinations didn’t take.)

The more common argument against personal stockpiles is that they diminish the supply available for a communal stockpile. Wouldn’t it be best for the government to centralize all the Tamiflu and, in the event of a pandemic, distribute it to those who need it most? Or, as is likelier, to those we most need to keep healthy?

There is truth in that one too, even though Roche claims its supply chain for individual prescriptions and its supply chain for government bulk orders are independent. (I don’t know if I believe that.) Of course the federal government has had at least as much forewarning as the rest of us; it ordered as much Tamiflu as it decided to order, presumably leaving the rest for you and me. And if state and local governments decide to commandeer the remaining Tamiflu supply (as they commandeered the flu vaccine supply last summer), they will. They haven’t yet.

Six months ago I argued that individual orders of Tamiflu were a double good: Not only did you get your Tamiflu, you also built the demand and thus the incentive for Roche to increase production capacity. By now I guess Roche has all the incentive it needs. So the question is straightforward. If you get your own Tamiflu now, your chances are better of having it available if you or someone you love gets the flu — whether it’s the annual flu or a pandemic flu. If you don’t get your own Tamiflu now, there will be that much more available for someone else to stockpile, or for the government to nationalize and allocate, or (your hope) for someone who already has the annual flu to start taking.

I respect, even admire, those who choose to forgo the chance to protect themselves now in the hope that someone else will be able to meet an imminent need instead. I nonetheless urge my family and friends to protect themselves now.

There’s also an interesting middle ground to consider. Small groups of friends and neighbors might be able to develop a shared stockpile. This would lessen the chances of a dose sitting unused on a shelf, while still freeing the participants from dependence on a very chancy government supply. Of course the issues of trust and equity could get hairy!

The ethical issue for the prescribing physician is a little different. Assume you believe that public health is best served by denying your patient a Tamiflu prescription, leaving one more treatment course in the communal pool, available for people who are already sick or whose health is especially important to protect. But you also know your patient’s health — the patient sitting in your office right now — is best served by providing the prescription, so your patient can be prepared if he or she gets the flu after there is no Tamiflu to be had. To whom does the doctor owe a higher duty: the doctor’s vision of what’s best for the general public or the doctor’s knowledge of what’s best for the individual patient? I’d have thought it was the latter, but I’m neither a physician nor a medical ethicist.

Despite all of this, the most important bottom line is personal morality. If getting (or prescribing) Tamiflu seems unethical to you, don’t do it.

As for Katrina, if you haven’t seen it, you might want to look at “Katrina: Hurricanes, Catastrophes, and Risk Communication,” my Hurricane Katrina column from a month ago. It’s not the after-the-dust-settles assessment you rightly say is needed, just a heat-of-the-moment set of early reactions.

A month later, I continue to be of two minds about the nearly universal view that the U.S. federal response was poor. Clearly it was inadequate — but we should expect the response to an unprecedentedly severe catastrophe to be inadequate. (What would it mean to have standby capacity to cope adequately with something unprecedently severe?)

I am struck by the reality that no hurricane response could have saved New Orleans, which was doomed by virtue of its location and the condition of its levees. And no response could have saved the people who were drowned almost immediately when the flooding began, though a more complete evacuation obviously could have saved those lives. As contrasted with preparedness, in other words, a better response would have alleviated only the death and suffering that occurred between the time a terrific response might have got things under control and the time the actual response did get things under control.

So there is damage attributable to the failure to have levees that could withstand the storm, and there is damage attributable to the failure to evacuate everyone before the storm, and there is damage attributable to the failure to respond quickly and efficiently enough after the storm. Sometimes we seem to be attributing all the damage to the third of these factors, which makes the inadequacy of that response look far more harmful than it was.

In fairness, we want governments to be rigid and bureaucratic. When I was working for the government commission that investigated the accident at Three Mile Island, all my expenses were paid for my workdays in central Pennsylvania. When the weekend came, my trip home and back again was also paid. But the government refused to pay for me to stay on at my hotel over the weekend. It was cheaper to stay — but I had a right to go home on my days off at government expense; I didn’t have a right to eat and sleep at government expense. Any agency that let me save the government money by staying in town would have risked serious legal troubles.

Companies try to choose the sensible option, rules notwithstanding. Governments follow the rules, sense notwithstanding.

A government employee who breaks the rules in an emergency may be a hero if everything works out well. But if problems arise, that government employee will be pilloried for taking the law into his or her own hands. “That’s exactly why we have rules!” we will all intone.

I think your recommendation for governments to involve the private sector more in emergency response makes sense. I have mixed feelings about the recommendation — so commonly voiced in the wake of Katrina — that governments should act more like the private sector, more flexible, less bureaucratic.

When disaster strikes, companies are often remarkably generous, and their help is usually focused and effective. Given how well the private sector copes with emergency response, I wish it would get more involved in emergency preparedness as well. Most big companies have “business continuity” departments that prepare seriously for company-specific disasters (what to do if the building floods). Many prepare also for community disasters (what to do if the city floods). But their planning tends to focus on keeping the business going rather than on helping their neighbors. And they rarely contribute much to community planning efforts. (Did any New Orleans company play a significant role in municipal emergency planning? I doubt it. The plans would have been better if they had.)

Industry is just beginning to pay attention to the threat of an avian influenza pandemic — potentially a worldwide “flood.” Companies need to start figuring out how to keep their business going if a pandemic devastates staffing, transport, and production. And they also need to help the communities in which they operate figure out how to keep the soup kitchen, water treatment facility, and fire department going too.

In particular, I think apologizing is very much the right thing to do when mistakes have led to unintended chemical exposures. This might be debatable if employees were unaware of the exposures and if you were confident the exposures didn’t endanger their health. Even then I’d recommend telling them you’d messed up ... and got lucky. But in the scenario you describe, someone “clearly” made mistakes and there is outrage already. So the question isn’t whether to tell the truth or not; they know the truth. The question is whether to acknowledge it apologetically or stonewall. That’s a no-brainer, I think.

Even your lawyer’s objections to apologizing should disappear given that employees are already aware and outraged. Lawyers have a point when they advise against admitting something that isn’t already known. If you’re going to deny it in court, or if you have reason to hope that the plaintiffs can’t prove it in court, it’s legally important not to confess at an employee meeting. But in the situation you’re describing, there is no legal downside to balance against the outrage management upside of acknowledging and apologizing for an error.

The single biggest component of the upside, by the way, is this: The sorrier you are about the mistake you made, the less likely employees are to imagine your mistake was deadly. Outrage at a company’s unapologetic intransigence converts easily to the conviction that the accidental exposure must have had serious health implications. That’s why apologizing is just as necessary for benign mistakes as for genuinely harmful ones.

All this is about apologizing for the company’s role in what went wrong. Attributing what went wrong to specific individuals is a tougher issue. It’s likely to sound like scapegoating, lessening the value of the organizational apology. And it can certainly raise complicated legal issues vis-à-vis the people you’re accusing. On the other hand, “mistakes were made” is a lot less credible than “George Smith should have done X and Y.” If you do decide to name names, try to make it clear that the company knows it is responsible for everything that goes wrong. By definition, the individual’s mistake is a failure of company policy or training or supervision. Focus on the systemic problem that the individual mistake has revealed.

For more on apologizing, see “Saying You’re Sorry.”

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