Peter Sandman
Comments and Questions
(and Some Answers)
2007

Our United Way has engaged local experts to find ways to help reduce the occurrence of teen pregnancy in our community. We have perennially some of the worst statistics in the state of Michigan regarding teen births. The economic consequences have been calculated as high as $7 million dollars a year.

One of the strategies the group has advocated is providing community education to parents in areas of high teen birth rates. Four area organizations have been selected to provide the education. One of the providers selected is the local Planned Parenthood chapter.

This association with Planned Parenthood to provide parent education has created a firestorm of criticism from our Right to Life Chapter and a nearby Christian university. Both groups have advocated total withdrawal from our United Way for their supporters, students and staff.

We’ve asked both organizations for the opportunity to present the facts of the situation to them (the need to address the problem, the strategy developed by the expert team, the qualification and selection of parent educators, and the commitment to separate education funding from other aspects of the Planned Parenthood organization). We are meeting with the Right to Life president next Monday. We haven’t yet had a response from the university president to our request.

We are being painted as a funder of Planned Parenthood and promoter of abortion. We are responsibly addressing a desperate situation in our community that has far-ranging impact on many critical social issues, including poverty, income disparity, overall child well-being, and education, too name a few.

Imagine that a local charity was planning to give a neo-Nazi organization in your community a grant to help educate parents on ways of getting teenagers more politically involved in community issues. I am guessing that you disapprove of neo-Nazis in a way that you (and I) don’t disapprove of Planned Parenthood – but in precisely the way many right-to-lifers disapprove of Planned Parenthood: You think neo-Nazi values are evil.

Okay, Question 1: Are you convinced, really convinced, that the neo-Nazis won’t somehow smuggle their reprehensible values into their political involvement education program? Even if they have promised not to do so, even if the grant isn’t a grant to advance the neo-Nazi agenda but purely to talk generically about ways teenagers can get politically involved, do you really believe they can wall off their values from their educational efforts?

If I were Planned Parenthood, I would certainly want to include abortion on my list of ways teenagers could avoid having babies, in case they somehow failed to avoid getting pregnant. I’d feel incredibly hypocritical not doing so.

But let’s make the assumption that that’s a done deal: Planned Parenthood is going to stick to other ways for teenagers to stay childless, and the neo-Nazis are going to stick to other causes on behalf of which teenagers can get politically involved.

Which brings us to Question 2: Is that good enough for you, even if you believe it? Or do you think it’s wrong to do business with neo-Nazis, period? Doesn’t it give them legitimacy? Doesn’t it give them a chance to make friends they can later talk to about their political values?

Some communities have experienced bitter controversies over whether widely hated groups should even be permitted to join “adopt a highway” programs, where they are paid nothing, but merely volunteer their labor to remove litter. Are you copasetic about this sign on a local highway: “This mile is kept clean by Smith County Neo-Nazis, Inc.” If you’re not, you’d presumably be even more disturbed if the neo-Nazis were getting money for their efforts – money collected by the funder charity with no mention of the fact that neo-Nazi organizations would be among its partner/contractors.

If you keep the neo-Nazis in mind, then you’ll see that when you meet with a protesting right-to-life organization (whether it’s a political chapter or a religious or educational institution), your main task isn’t to “present the facts of the situation.” Rather, your main task is to acknowledge that, given their values, their protest is justified. Think about saying something like this:

Yes, we have decided to work with people that you consider evil. We decided that because they are really, really qualified to help us accomplish the task at hand, and because we think the task at hand – reducing teenage pregnancy – is really, really important. We think we can convince you that we’re right on those two points – that it’s important to reduce teenage pregnancies and that Planned Parenthood can help.

But it was an easy decision for us, because we don’t share your view that Planned Parenthood’s support for abortion rights and its willingness to perform actual abortions make it evil. We probably wouldn’t pick a service provider that we thought was evil. So when we picked a contractor that you think is evil, we should have realized you would have deeply felt, principled objections.

The question for us, now, is whether we are willing to abandon any relationship with Planned Parenthood in deference to your objections. The answer to that question, regretfully, is no. The battle over abortion is not part of our mission. Reducing teenage pregnancies is. We are going to do that the best way we can – and we have decided that that includes being willing to work with Planned Parenthood.

The question for you, now, is what you want to do about that. It goes almost without saying that you will want to protest our decision. We accept that. But there are two other questions you need to answer.

First, are you willing to work with us in our program against teen pregnancies? If you are, we will gladly construct a role for you in the program – even though there may well be people who disapprove of your involvement, just as you disapprove of Planned Parenthood’s involvement. Opponents of abortion have special reasons to want to help teenagers avoid getting pregnant. If Planned Parenthood can participate without advocating abortion, and if you can participate without opposing abortion, you are both welcome. And we will find a way to deal with the awkwardness at planning meetings!

The second question is very important for us all. You approve of much that the United Way does in our communities. But you disapprove of our decision to work with Planned Parenthood. Can you find a way to say both – to urge your members and followers to join you in opposing one United Way decision while continuing to support United Way as a whole?

This isn’t splitting hairs. We imagine you sometimes disapprove of particular United States Government policies, for example, and yet you remain loyal and patriotic Americans, and you don’t refuse to pay your share of taxes. We’re not the United States Government. We’re just the United Way. But we hope you will find a way to oppose the things we do that you oppose without opposing everything we stand for.

You may or may not be able to keep right-to-lifers under your United Way umbrella while funding an organization they despise. It won’t be easy. But your best chance is to make it clear that you respect the moral dilemma you have created for them by choosing a contractor/partner they consider reprehensible.

I don’t think we adequately understood and appreciated the point of view and value system of our anti-abortion community. They should have been included (or at least invited) to participate in our Teen Pregnancy Prevention discussion from the onset. I hope we can all be rational and empathetic enough in our discussion to move forward.

I’ll keep you posted on our progress. Thank you again for your thoughts.

Our Board of Directors has rescinded its decision to fund the Planned Parenthood proposal from the Teen Pregnancy Prevention workgroup.

The Board supported the recommendation at last Tuesday’s meeting, albeit with less than a full contingent of Board members. However on Friday, they asked all board members to weigh in on the issue, given the considerable controversy and lack of community support for United Way the decision appears to have created. This was done in person, over the phone, and via email, until all Board members were heard from. I don’t know the precise vote, but was told it was approximately 90% opposed.

I’ve tried to frame this as an example of listening to the community and making adjustments along the way.

Our executive director and I did meet with the local Right to Life group today (Monday). We heard their concerns about Planned Parenthood, and admitted we did not appreciate their point of view and the depth of their concern when we were looking at the recommendations to fund the teen pregnancy prevention programs. We invited them to join the workgroup so their point of view could be considered earlier on in the process. They are taking that into consideration, and mentioned some individuals they would consider approaching.

They had already heard about the Board’s decision to back off funding the Planned Parenthood program, and offered whatever assistance they could provide in helping us deal with the issue of teen pregnancy and the fallout from this association with Planned Parenthood.

Is this a new game? Or are we still trying to put two diametrically opposed groups together at the table? I’m concerned that we have seriously weakened our support in the community – from both sides.

• Since preventing teenagers from becoming parents is inextricably tied to issues that arouse strong emotions and involve strongly felt values (teenage sex and abortion are the main two), and since United Way seeks to be a consensus organization, you should have involved a wide range of community groups from the outset in your thinking on how to address the problem. (Either that or you should have avoided addressing the problem at all – which would be a shame, since it’s an urgent problem.)
• For the same reasons, you should have done a better job of apprising your Board of the possible repercussions, and made sure the entire Board was involved in a thorough discussion of how to proceed before you took any action.

Instead, a decision to work with Planned Parenthood was made without sufficient involvement of other community perspectives and without sufficient consideration by the full Board.

This led to controversy – controversy that you consider justified, and for which you blame yourself (United Way staff), not your Board, not Planned Parenthood, and not right-to-life groups. (I think it’s very important to keep saying that both Planned Parenthood and the right-to-life groups have acted in good faith in their responses to the situation.)

In response to the controversy, the Board then voted to rescind the Planned Parenthood involvement.

I would say explicitly that you’re worried that this maladroit handling of a sensitive issue could damage United Way’s reputation among its many and varied supporters – among whom you include both abortion rights proponents and right-to-life proponents. (Saying this – saying anything! – may require Board approval at this point.)

Ideally, United Way would describe a path forward as follows:

1. We need to convene a diverse group to help us plan and administer this particular program, reconsidering its structure and activities from scratch.
2. We need to rethink our procedure for making program decisions, to make sure we have a process that identifies controversial issues and addresses them transparently and respectfully, drawing on the wisdom of the full range of community perspectives.
3. We need to rethink our procedure for securing Board approval of potentially controversial programs, to make sure the full Board has a chance to consider how best to address the possible controversy before any decisions are made.
4. We need to apologize to right-to-life groups in our community for being insensitive to their perspectives, and to Planned Parenthood for first extending it a premature offer without sufficient consideration and then withdrawing the offer.
5. We need to reaffirm our commitment to finding ways of reducing the number of teenage parents in Jackson County.

Something like that....

Good luck!

Are you familiar with any work that applies the principles of risk communication – or modifies those principles – for working with the public about crime? We do have risk assessment instruments, by the way.

In my terms, the release of a serial rapist back into the community is obviously high-outrage. I’d judge that it is moderate-hazard (the probability of any particular individual getting raped by this person is very low, but the magnitude of that outcome is very high). So the risk communication task falls somewhere between my “outrage management” and “crisis communication” paradigms.

Among the points I would stress to a client in this situation:

Transparency. I would tell the public everything the law permitted me to tell about the rapist’s release. And I would be especially careful to be transparent about what I’m not permitted to be transparent about. “The law says there are three pieces of information I can’t give you….” Or: “The policy decision has been made to release everything we know except X. The reason we decided not to release X is….”

Empathy. I would explicitly make the point that people’s anxiety about the prospect of a convicted rapist in their midst is both understandable and reasonable. Make this point without actually accusing anyone of being anxious. NOT: “I know you’re anxious about ….” INSTEAD: “A lot of people in this situation would probably feel ….” or “I think if I were in this situation I would feel ….” Validate not just the “rational concern” aspects of people’s feelings, but also the dread, disgust, and related emotions.

Context. Give people the information they need to put the risk into context. This presumably includes whatever data you have about the probability of recidivism, the steps you’re taking to monitor the rapist, the number of other rapists already loose in the community (going from N to N+1 is a lot smaller outrage than going from 0 to 1), etc. This information needs to be presented in a way that subordinates it to your acknowledgment that it’s legitimate to be worried: “Even though we’ll be watching this guy in a way we can’t watch the dozens of unidentified rapists who already live somewhere in the Portland area, it’s still upsetting to learn that yet another convicted rapist is being intentionally released back into the community.”

Dilemma-sharing. Clarify your dilemma and invite the public to help you resolve it. “This is a problem we face all the time, and it’s very tough to come up with an answer. On the one hand, Americans believe in the rule of law, and in the possibility of redemption. When criminals have served their time, they’re supposed to go free. We hope they will make different life decisions this time. We don’t put scarlet letters on people’s foreheads anymore. On the other hand, we know that serial rapists are statistically likely to rape again, so it seems wrong to release them without even warning the neighborhood they end up in. It’s very hard to figure out how to balance the rights of ex-criminals against the rights of potential future victims. And of course once the courts and the legislature have decided what balance they want, police departments don’t have much of a choice. They follow the policy. People who think it’s the wrong policy, or who think we’re following it wrong, should let us know where they think the balance should be.”

The literature on risk communication about crime is extensive, but most of it focuses on precaution advocacy (high hazard, low outrage) – how to warn insufficiently concerned people about the possibility of becoming crime victims and the steps they can take to improve their odds. Given the hot debate in recent years over what the public should be told about the whereabouts of released criminals (especially child molesters), I would guess that there has probably been some writing about this issue from a risk communication perspective, but I can’t give you any citations.

I’d love to hear the end of the story – what you decide to say and how it works out.

We also receive phone calls from consumers who have received a notification from their water system. Sometimes, the consumers are upset because the water system has exceeded a health-based standard. But sometimes they are upset when the water system forgot to take one sample.

So the risk perception has a lot to do with the situation and what was presented in the public notification.

We want to support the water systems and at the same time communicate risk accurately. What resources would you recommend to help us become better risk communicators when partnering with the regulated community? Are there workshops specifically on drinking water issues?

It ought to be simple enough to discriminate categories of violations: health, environmental, testing, administrative, etc. You might also want to discriminate levels of seriousness, using labels something like “minor,” “moderate,” “serious,” and “unforgivable.” (Okay, you’re unlikely to approve a label like “unforgivable.” How about “critical”?)

Once these distinctions are in place, the next step is to link the notification requirements to them. Perhaps water systems could be required to notify all customers of serious or unforgivable/critical violations, regardless of category, and all health and environmental violations, regardless of level. For the rest, it might be enough to make them post the violations on their websites and send customers an annual report on the number of violations of each sort that year. Or you could continue to make the systems report every violation, but they’d get to put the less important ones into context: “The regulator categorized this as a minor administrative violation.”

It would also be useful to permit water systems to give their own categorization as well as yours. A system that wanted to could say: “The regulator said this was a serious health violation, but we think it’s really just administrative because….” And of course a system that really understood risk communication might do just the opposite: “The regulator said this was a minor administrative violation, but we take it very seriously; if it had continued it could have led to significant environmental problems down the road.”

I should add that I have reservations about your reference to “partnering with the regulated community.” I agree that too hostile a relationship can make it harder to achieve your goal – a safe, efficient, compliant drinking water provider. But too cordial a relationship can also interfere with this goal. The public doesn’t much like the idea of regulators partnering with the industries they regulate, any more than it likes the idea of cops partnering with criminals or prison guards partnering with convicts.

In the long run, moreover, it’s bad for water systems for the public to get the idea that they are regulated by government agencies that think of them as partners. It leads to public demands for harsher, less industry-friendly regulations – which is presumably not what the industry is hoping to achieve.

A lot of my industrial clients, for example, have paid a heavy price for the public’s impression (all too often an accurate impression) that federal regulators are regulating too little and partnering too much. Some companies have even approached activist groups asking them to take on the role of quasi-regulator. “We need somebody to keep us honest and certify to the public that we’re minding our p’s and q’s,” they tell the activists. “Since we can no longer credibly claim that EPA [or OSHA, FDA, etc.] is holding our feet to the fire, can you do the job instead?”

Like the oil, chemical, mining, and pharmaceutical industry, the drinking water industry needs to be able to make a credible case that it is well regulated. You do the industry you regulate no favors when you talk about it as your partner.

As for whether there are risk communication workshops focused specifically on drinking water issues, I don’t know. EPA may offer some, and so may water industry trade associations. But I don’t think you especially need tailored workshops. Most risk communication trainers work for a very wide range of clients facing a very wide range of substantive issues. The riskcomm principles don’t vary much. Trainers have very little trouble adjusting to the specifics of the situation at hand. Mostly, in fact, we don’t have to. The trainer brings his or her risk communication expertise, the group brings its specific problems and issues, and the adjustments are made collaboratively.

I’m not at all certain I’m most effective when working with an industry or regulator I know well. Arguably I do my best work when I’m forced to figure out in real time how riskcomm principles apply to the case at hand. Other risk communication trainers and consultants I’ve talked with have said the same thing.

In order to get data for the model, the idea was to divide the methodology in three phases: Define technical risk perception about a waste facility; define the risk perception of a group of key actors about the same facility; and finally, measure the general public perception.

For the first and second phases I used a matrix of Impact versus Probability, with a scale of 1 to 5 for each. So the lowest probability-times-impact corresponds to 1 and the highest probability-times-impact corresponds to 25. By comparing the results for the two groups I hope to have a lower level for the technical group – that would be expected, right? I wanted to ask you, even if it is a technical group, the result I’ll have should still be considered as a perception, right? It is a level of perception different from the perception of the key actors group – but it can’t be considered as a risk evaluation?!

Finally I tried to measure the public perception in general using the outrage components you have defined. The idea was to find a question or two for each component, which could be translated into a numerical scale. By the end it would be possible to compare the results and understand which outrage components are most responsible for the existing outrage. That is why I wanted to know more about your software.

If I can structure all this maybe I’ll be able to write a thesis.

1. I think everybody’s risk “assessment” is, strictly speaking, just a perception. Nobody can apprehend the Platonic essence of a risk without perceiving it. Experts, like the rest of us, are stuck relying on their perceptual apparatus. Comparing expert risk “assessment” or “evaluation” with public risk “perception” is pulling rank. Compare the public’s judgment with the experts’ judgment, or the public’s perception with the experts’ perception, or the public’s assessment with the experts’ assessment.

Your intuition on this point is exactly right.

2. Furthermore, what I call outrage influences everybody’s perceptions – including the experts’. The public’s perception of the hazard from a waste facility may be distorted by outrage because the company trying to site the facility has been dishonest, contemptuous, unresponsive, etc., and because various aspects of the facility (and the technology itself) are hotly debated, highly dreaded, etc. The experts’ perception of the hazwaste facility hazard gets similarly distorted by outrage at the people who are questioning their competence and integrity, costing their employers millions of dollars, ignoring their assurances, etc.

It is commonplace to hear grossly over-reassuring, overconfident claims made by technical experts speaking on behalf of such a facility – saying very different things to the public than the much more tentative, nuanced things they say to each other in professional papers and technical meetings. So what’s going on when they do this? Do they know they’re being dishonest? Do they somehow consider it honest to oversimplify in a consistently reassuring direction when talking to laypeople? Are they too outraged at the way they and their expertise have been treated to remain dispassionate and objective?

And of course the experts’ perceptions of the public itself are hugely distorted by outrage!

Any risk perception study that misses the impact of outrage on the company and the experts, as well as the public, is missing a lot. (Of the main players, it may be the activists whose perception of the hazard is least clouded by outrage – but of course it is significantly clouded by ideology instead.)

3. As for questions that capture the outrage components, you might do well to go back to the early psychometric work of Slovic, Fischhoff, et al. – before they reduced what I call outrage to two factors and stopped measuring its components separately. There are also a few scholars who have done research measuring outrage explicitly. Look at the work of Lars-Erik Warg at the School of Public Health in Örebro, Sweden; Simon Chapman has done some related work using outrage components to track outrage about cell phone towers in Australia. A copy of my Outrage Prediction & Management software wouldn’t help much, because it uses a large number of questions to get at various aspects of each outrage component; you want a question or two for each.

I would like to do a survey of the hourly workers. Do you have any suggestions for questions?

It is well established that individuals work safer when they’re happy with their job and like their boss. In one typical study, employee drivers who disliked the company and planned to quit were less likely to follow road safety rules than their more satisfied coworkers. Another study found that one of the strongest predictors of on-the-job back pain was job dissatisfaction.

The effect seems to be greatest for unhappy workers, whose safety records are much worse than average; the records of happy workers aren’t as clearly better than average. The extreme case is the employee so unhappy that he or she is (at least temporarily) reckless or even suicidal. It’s impossible to know how many workplace accidents have an element of “I don’t care anymore” in them – but the number isn’t tiny.

It’s worth noting that unhappy employees don’t just endanger themselves; they also endanger their coworkers and sometimes their customers. Healthcare studies, for example, find that employee morale is a good predictor of the quality of care received by patients. Very unhappy (and very unbalanced) employees may even “go postal.” The worst industrial “accident” in modern history, the 1984 Union Carbide methyl isocyanate disaster in Bhopal, India, is thought by many to have been the intentional act of an angry employee.

At the same time, it is also well established that unhappy employees are likelier to complain about unsafe working conditions. For example, employees who are experiencing the double-bind of both disliking their jobs and being afraid of losing their jobs are especially likely to turn up in a supervisor’s office complaining that workplace chemicals are nauseating them or giving them headaches. I doubt that this results from unhappy employees being more health- and safety-conscious. Rather, it seems to be a case of unhappy employees being more symptomatic – and, of course, more inclined to complain. (One unhappy employee complains about unsafe working conditions, another about burdensome safety rules.)

Strictly speaking, morale isn’t just whether an individual employee likes or dislikes the job. Morale is a group phenomenon; it means the same thing as esprit de corps. I like Alexander Leighton’s definition of morale, quoted by Wikipedia: “the capacity of a group of people to pull together persistently and consistently in pursuit of a common purpose.”

Using this narrower definition of morale, the question is whether employees in organizations with high morale are likelier to take care of themselves and especially of each other, leading to an improved safety record. This is obviously the case if safety is part of the common purpose that defines the group’s morale. There’s a huge literature on how to build a “safety culture” in which everyone is proud of the organization’s safety record and determined to help sustain it, not just by working safe but also by making sure others work safe.

Part of building a safety culture is pointing out to employees that safety is a shared value (which helps to make it one). That’s the difference between praising a safe act because it’s safe and praising it because it reflects the group’s shared safety norm. The latter does more to build a safety culture, because it makes safety the heart of group morale.

But if morale is built around common purposes other than safety, does the group cohesion still lead to improved safety performance? I think it should. If we’re pulling together in other ways, you’d expect us to pay more attention to keeping each other safe. Even in the military, where morale is sometimes defined in terms of a soldier’s willingness to die for his or her comrades in arms, high morale is nonetheless thought to contribute not just to victory but also to survival. But I don’t know if there is research that shows this (or refutes it).

Most of the studies of the morale/safety relationship are correlational. They’re usually interpreted as meaning that when the workforce is happier and more cohesive it will therefore act more safely: morale → safety. But of course it’s just as credible that a workforce with fewer accidents will therefore feel happier and more cohesive: safety → morale. Certainly when management seems to care not just about productivity and profitability but also about employees’ safety, that ought to contribute something to morale (and thus, perhaps, to productivity and profitability). It will take more than a survey to disentangle this causal web.

Speaking of surveys, I don’t have any questions to suggest. First you need to figure out what aspect of the morale/safety relationship you want to study.

How do you suggest we approach this issue? Also, I’m aware of our own “outrage” with Hollywood’s irresponsibility. We are afraid the hype could scare some people to the point that they may refuse a needed surgery. How should we deal with this outrage in our communications?

Let’s start by assuming you have an audience that either already takes the issue of anesthetic awareness seriously or is likely to start taking it seriously sometime soon – presumably because of seeing “Awake” or hearing or reading about it. Your main worry is that some in this audience may decide against surgery they would otherwise have because they’re afraid they might have an anesthetic awareness experience. Your secondary worry is that they might go through with the surgery, but with more anxiety than they would otherwise have felt. Your goal is to persuade them that anesthetic awareness isn’t a major concern – that it’s worth shrugging off.

(I know nothing about anesthetic awareness, but based on the “Slate” article you referenced, this is an honorable goal.)

Okay, here’s what you need to acknowledge – not reluctantly or defensively, but as empathically as you can:

• Anesthetic awareness apparently exists. There is debate over how rare it is – the movie cites the most alarming statistics out there, ignoring other sources that think it’s much rarer. And there’s debate over whether “awareness” means actually feeling the pain of surgery without being able to say or do anything about it, or whether it means being vaguely semi-aware of some things going on in the operating room, or even whether it means having “recollections” of the surgery that might actually be drug-induced dreams or transposed memories from things you were told afterwards. But whatever it means, a small percentage of surgical patients do report later that they weren’t completely out – and at least a few claim they were completely there and felt everything.
• The idea of anesthetic awareness is terrifying. It’s the stuff that nightmares are made of: watching the surgeon’s scalpel descend, feeling the incision ... and being completely paralyzed, unable to move or scream. It’s a creepy thought. That’s why they based a creepy movie on it.
• The medical profession hasn’t been in any hurry to take this issue seriously. At least doctors haven’t been in a hurry to be candid with patients about it. (It’s not part of the standard informed consent protocol, for example.) When people learn that anesthetic awareness exists – however rare or partial it might be – they are likely to feel understandable outrage about never having been told.

In the context of admitting these things, you can urge patients not to let fear of anesthetic awareness deter them from surgery they would otherwise have. But you have to do that empathically too. “It’s natural to feel creeped out by the idea of anesthetic awareness. For some people that can become the symbol of all their other worries and reservations about going under the knife. It may help a little, but only a little, to know that it’s rare – that of all the people you know who have been through surgery, not one has ever told you: ‘I felt it.’ But people often find it hard not to imagine that they could be the one, the rare one, who feels it. Deciding about surgery is always about playing the odds – and playing the odds is never easy when there are vivid emotional images in the way.”

Your own outrage at Hollywood for irresponsibly exploiting the anesthetic awareness issue probably needs to be moderated, if you can manage it, into the mildly patronizing amusement that characterizes the “Slate” article. After all, Hollywood at least raised the issue. In choosing between Hollywood’s exaggeration and the medical profession’s silence, I think most people would see Hollywood’s sin as the lesser of the two evils. Try to write with that in mind.

That’s how you should talk to people who are upset about anesthetic awareness, or who are likely to become upset about it in the coming weeks.

But here’s the problem. Many of the people who will read your article neither saw “Awake” nor plan to see it; or they saw it and thought it was foolish. Many have never even heard of anesthetic awareness. In the process of managing the outrage (the fear and possibly anger) of those who are taking the issue seriously, you will inevitably introduce the issue to people who know nothing so far, and you will raise its salience for people who have shrugged it off so far.

I’m okay with that. I tend to see people who have never heard of anesthetic awareness as people who will one day find out and get outraged. I tend to see people who think just it’s a movie fantasy as people who will one day learn different and get outraged. So I’m happy to see you “inoculating” them against future outrage by leveling with them now. But some communication experts – and a lot of doctors – might advise you to leave it alone. Let doctors deal one-on-one with distressed patients, they would say, and don’t dignify the movie with a response.

Let me add something from my own surgical experience, a minor procedure a couple of years ago. My anesthesiologist told me the drug he wanted to use caused amnesia; I would be awake during the procedure and able to help the surgeons by answering questions, but I would remember nothing about it. I spent a few minutes pondering the if-a-bird-sings-in-the-forest conundrum of whether pain I would feel while I was under but wouldn’t remember afterwards was really pain. Then I said okay. But I pondered your anesthetic awareness question through the lens of that experience.

Our question: What are the three most important Indoor Air Quality concerns that landlords need to be aware of when consulting with their attorneys about drafting lease provisions?

Obviously, landlord and tenant share three interests.

• They share an interest in preventing IAQ problems by maintaining the building well.
• If there are genuine IAQ problems that are making people sick, they share an interest in identifying and correcting those problems as quickly as possible.
• If there are no IAQ problems making people sick, they share an interest in preventing the tenant’s employees from overreacting to minor problems (which always exist) and ending up symptomatic as a result of their worry and outrage, rather than as a result of the problems themselves.

In order to accomplish the third objective, landlord and tenant need to communicate well with each other about the tenant’s employees’ concerns. And they need to communicate well with the tenants’ employees in ways that show their respect for those concerns – their determination to identify and correct any IAQ problems as quickly as possible, their willingness to do so transparently rather than secretly, and their willingness to listen to the employees’ views on what the problem might be and how to approach it.

My client in IAQ controversies has usually been a corporate tenant. The landlord has sometimes been allied with the tenant in trying to ameliorate the tenant’s employees’ concerns. Other times the landlord has become intransigent – either about addressing the IAQ problems themselves or about being candid with the tenant (and especially with the tenant’s employees) about what is being done.

Legal fears are often behind the landlord’s intransigence.

But in my judgment the intransigence worsens the landlord’s legal risk; upset employees sue their employer, which then sues the landlord. The paradox here is that the tenant ends up claiming the IAQ problems are physical rather than psychogenic in order to bolster its case against the landlord. The landlord ends up defending by arguing that the problems are psychogenic and therefore not the landlord’s responsibility – even though the landlord’s intransigence may have greatly increased the frequency and seriousness of psychogenic symptoms.

If the building has serious IAQ problems, it seems to me, landlord and tenant may have genuinely conflicting interests. But if the health complaints of the tenant’s employees are mostly psychogenic, then landlord and tenant have a shared interest in doing a good risk communication job with the tenant’s employees in order to resolve those complaints and end the controversy without litigation (and without the tenant deciding to vacate the building).

I don’t know how all this should translate into lease provisions.

What is it about depleted uranium that appears to cause such continued and inordinate fear as a putative cause of cancer even in the absence of evidence and/or presence of other more likely etiologic agents?

1. The correlation between whether a risk is dangerous (“hazard”) and whether it’s upsetting (“outrage”) is very low. The two are essentially unrelated.

2. Hazard perception, whether people think a risk is dangerous, is much more highly correlated with outrage than with hazard itself.

3. In the strong relationship between hazard perception and outrage, outrage is mostly the cause, hazard perception the result. For the most part, it’s not true that people get upset because they think a risk is dangerous. It’s much more true that people think a risk is dangerous because they’re upset.

So here’s how I would rephrase your question: What’s upsetting about depleted uranium, leading people to think it’s a serious hazard whether it is or not?

Look at some of the outrage components that apply:

Dreaded versus not dreaded

Radioactivity is more highly dreaded than most sorts of risks. The idea that a piece of radioactive shrapnel from a depleted uranium weapon might lodge in my body, emit deadly radiation day and night, and ultimately give me cancer is profoundly unsettling. So is the thought that children in Bosnia who live near the “impact site” of an early 1990s NATO air strike might be breathing radioactive dust containing depleted uranium. Radioactivity weighs on the mind in a way that the threat of an automobile accident, for example, does not.

Some of the dread of depleted uranium probably comes from the association in our minds with nuclear weapons. Actually, depleted uranium is used in munitions, tanks, and armor not because it’s radioactive but because it’s dense, and thus helps penetrate or prevent penetration. It’s natural uranium (or occasionally spent uranium fuel from nuclear reactors) that has been “depleted” – made about 40 percent less radioactive – by removing most of the U²³⁴ and U²³⁵, leaving behind mostly U²³⁸. I suspect many of the people (including veterans) who worry about depleted uranium imagine either that it’s used in nuclear weapons or that it’s made from nuclear weapons. (This isn’t entirely mistaken; it’s conceivable that a nuclear weapon could have been reprocessed into reactor fuel, used in a reactor, then reprocessed again into depleted uranium.)

I also doubt most people who worry about depleted uranium understand that “depleted” means it’s been made less dangerous than it was when it was dug out of the ground. And how many of them know that U²³⁸ has a very long half-life, and is therefore less radioactive than elements that decay more quickly? (Some sources describe it as “barely radioactive.”)

But of course even people who know these things still know uranium is radioactive and radioactivity is scary.

Memorable versus not memorable

The memorability of depleted uranium, too, comes mostly from the association with nuclear bombs, mushroom clouds, glow-in-the-dark monsters, etc. We all have vivid images in our minds of the horrific things radioactivity (and thus uranium, we assume) can do to us.

Untrustworthy sources versus trustworthy sources

This important outrage component isn’t about depleted uranium itself; it’s about the people and institutions who assure us that depleted uranium is safe.

Most of the studies on the health effects of depleted uranium were funded (and in many cases undertaken) by governments that would be in considerable moral, political, and economic hot water if depleted uranium turned out to be a significant risk. They would have daunting obligations to both veterans and civilians who might have been exposed in the Balkans, Iraq, Afghanistan, and elsewhere since depleted uranium started being used in the 1991 Gulf War. They would have even more daunting cleanup obligations in the places where depleted uranium has been used. And they would need to figure out how to do without depleted uranium in the future.

It isn’t unreasonable to mistrust the assurances of governments that have such pressing reasons to want depleted uranium to turn out to be a non-problem. This is especially the case when the assurances come from governments that have already lost trust on other issues, and from arms of those governments (such as the military) that seem especially unlikely to be candid about the risks. These same objections, of course, apply to research sponsored by NATO or the United Nations.

Imagine how much more trust people would feel if a radical veterans rights group were to announce that it isn’t worried about depleted uranium – that it has a long list of grievances against the military, but having examined the evidence carefully it is convinced that depleted uranium isn’t a significant health problem for veterans and doesn’t belong on the list. Of course it’s hard to imagine a radical veterans rights group reaching that conclusion – just as it’s hard to imagine a military hierarchy reaching the opposite conclusion. That’s my point. Neither side can be trusted when it concludes what’s in its interests to conclude.

The best solution to the trust problem isn’t figuring out how to be trusted; it’s figuring out how not to demand trust. For example, government researchers studying the health effects of depleted uranium would do well to invite their critics to collaborate in the research – making it harder for the government to cheat and harder for opponents to claim it’s cheating. For more on diminishing the need for trust, see my column on “Accountability.”

Unknowable versus knowable

Part of the untrustworthiness of depleted uranium assurances is their one-sidedness. This connects closely to another outrage factor: knowability.

As far as I can tell, the weight of the evidence suggests that depleted uranium is not a serious health risk for veterans whose exposures were typical. Most of the experts seem to agree that this is the case. But surfing the Web, it isn’t hard to find a minority of experts who disagree, and who have found evidence to cite on their side of the argument. This isn’t rare; most controversies have at least some evidence and experts on both sides. But expert disagreement – dueling Ph.D.s – leads to a lot of outrage.

By contrast, garden-variety uncertainty leads to less outrage (some, but less). To convert expert disagreement into mere uncertainty, all that’s necessary is to discuss the other side respectfully. “We think the risk is X. But we know they think it’s Y. Here’s our evidence. Here’s theirs. It’s hard to be certain where between X and Y the truth actually falls.”

Those on the reassuring side of the depleted uranium controversy would be wise to concede the existence and arguments of the other side. This is true even if the other side is only two percent right – perhaps especially if the other side is only two percent right. You can’t put that discrepant two percent of the evidence and those dissenting two percent of the experts into context without talking about them. And if you don’t talk about them, they loom all the larger in the minds of worried and mistrustful people who know about them already, or who learn about them later. As I wrote very recently in a Guestbook comment on the controversy over thimerosal in vaccines, “overconfident, one-sided ‘reassurance’ forfeits credibility.”

I don’t know the literature well enough to say what the best arguments are on behalf of the view that depleted uranium is a serious risk. Some of them, certainly, are non-technical facts, like the European Parliament’s call a few years ago for suspension of all use of depleted uranium. Some of them are non-technical allegations, like the claim that depleted uranium violates environmental treaties and even the Geneva Convention. Some of them are rhetorical flourishes, like the inarguable assertion that deploying depleted uranium constitutes, if only incidentally, the use of “radioactive weapons.” And some of them are research findings and scientific claims. The fact that the weight of the evidence is on the other side does not justify ignoring the evidence on this side.

There’s another knowability problem worth mentioning with regard to depleted uranium: detectability. When I was at the 1979 Three Mile Island nuclear power plant accident, many normally unflappable journalists were visibly anxious about the risks of radiation. Asked why, they often mentioned detectability. “At least in a war you know you haven’t been hit yet,” one reporter told me. “I’d be a lot happier if radiation was purple instead of invisible,” another said. Those who carried dosimeters they could read on the spot checked them often, and were less anxious than those who had no way to tell what their exposure had been so far.

Testing the uranium content of veterans’ urine is an established way to help assess whether they have a depleted uranium problem worth worrying about. In hazard terms, the test is only occasionally valuable. In outrage terms, it might be worth doing more often.

The knowability problem of depleted uranium is complicated by the mysterious diseases afflicting veterans of recent wars in which depleted uranium was used. There’s a lot that isn’t known about Gulf War Syndrome and Balkans War Syndrome. The claim that there’s no evidence these illnesses are linked to depleted uranium isn’t terribly reassuring when it comes from authorities who haven’t a clue what they are linked to.

Other outrage factors

Depleted uranium has a familiarity problem. Even veterans of extensive battlefield experience with depleted uranium weaponry are typically unfamiliar with radiation, dose-response curves, and the rest.

It has a voluntariness problem. Many soldiers were drafted; others volunteered – but not to be exposed to depleted uranium. Civilians victims, of course, were all coerced.

And it has a responsiveness problem – though that’s improving. I don’t know about Italy or the rest of Europe. In the U.S., military risk communication has progressed from secrecy to something closer to transparency. The Defense Department and the Department of Veterans Affairs are trying (pretty hard, even) to acknowledge that soldiers and veterans are worried; there’s even an effort to persuade VA doctors to raise the issue proactively with veterans who served where depleted uranium was used.

But they’re finding it hard to listen empathically to people’s concerns about depleted uranium, harder to acknowledge that those concerns are understandable, even harder to concede that the evidence is mixed (albeit mostly on their side), and hardest of all to admit that they’re not to be trusted on the matter. And of course the risk communications aimed at U.S. soldiers and veterans are enormously superior to what civilians who live on former or current battlefields are told.

I find the seesaw principle very useful and applicable to a wide range of situations and communication challenges. My intuition and experiences tell me it makes sense.

On the other hand, where do I find references to more surveys backing the principle?

I believe this principle is central to effective risk communication, especially crisis communication (high hazard, high outrage) and outrage management (low hazard, high outrage). For examples of some of the uses I have made of the seesaw principle, see almost any article on this website, including:

• Advice for President Bartlet: Riding the Seesaw
• Riding the many pandemic seesaws
• Games Risk Communicators Play: Follow-the-Leader, Echo, Donkey, and Seesaw
• The “Ride the Seesaw” section of “Smallpox Vaccination: Some Risk Communication Linchpins”
• The Boss’s Outrage (Part I): Talking with Top Management about Safety
• The Boss’s Outrage (Part II): Talking with Top Management about Risk Communication
• The Seesaw of Risk Communication

That said, I haven’t been able to find any risk communication research studies devoted to the seesaw principle, at least not under that name. Not a one.

This isn’t definitive. The risk communication research literature has burgeoned, and I haven’t kept up. (I wasn’t a particularly good bibliographer to begin with.) Still, a Google search for “risk communication seesaw” yielded almost entirely references to my own writing. And searching for “seesaw” in back issues of the single most important risk communication research journal, Risk Analysis, revealed nothing relevant. (Note: You have to be a member of the Society for Risk Analysis to use the searchable online repository of Risk Analysis back issues.)

If a reader of this site knows about any research relevant to the seesaw, please email me and I’ll be happy to post the link or citation (and to read the study!).

But if you go beyond risk communication, back to the origins of the seesaw concept, there is a huge relevant literature, much of it theoretical and/or empirical.

Start by looking for references to “reverse psychology.” Most of these, of course, aren’t research; they’re likelier to cite popular culture examples than empirical studies. Two literary examples of reverse psychology that I remember vividly from my own early years:

1. In one of Joel Chandler Harris’s “Uncle Remus” stories, Br’er Rabbit escapes from Br’er Fox by pleading, “Please, Br’er Fox, don’t throw me in that briar patch!” Determined to torture Br’er Rabbit as effectively as possible, the fox responds to Br’er Rabbit’s entreaties by throwing him in the briar patch, and thus he escapes.
2. In high school I was enchanted by “The Fantasticks,” a 1960 musical based loosely on Edmond Rostand’s play, “Les Romanesques.” Both tell the story of two fathers who put up a wall between their houses and fake a feud in order to ensure that their children will fall in love, since teenagers reliably do the opposite of what their parents want. (This had the ring of truth to me then, and it still does.) In one of the songs from the show, the two fathers sing: “Why did the kids put beans in their ears? ... They did it ’cause we said no!”

There’s a slight difference in emphasis between the “reverse psychology” concept and the seesaw. Reverse psychology is about oppositionality, whereas the seesaw is about ambivalence (with some oppositionality thrown in – people don’t like being told what to do or believe). Both are psychologically sound. Oppositional people say or do the opposite of what they’re told; ambivalent people go to the neglected side of their ambivalence. (Since teenagers are oppositional and ambivalent, they’re endlessly riding seesaws.) Others can capitalize on your oppositionality or ambivalence by taking the side they don’t want you to take. They say/do X in order to get you to say/do Y.

The seesaw concept is also a lot more nuanced than reverse psychology. It goes way beyond getting people onto the seat on the seesaw that you left conveniently vacant, tricking them into saying/doing the opposite of what you’re saying/doing. It suggests the far more respectful and humane possibility of helping people move toward the fulcrum of the seesaw – that is, helping them cope with their ambivalence; helping them tolerate being torn between incompatible beliefs, desires, or feelings instead of settling for the distorted simplification of picking one or the other.

My long fascination with reverse psychology started morphing into the more nuanced “seesaw” concept after I met my wife and colleague Jody Lanard. A psychiatrist trained in family systems theory, Jody was a champion of a set of therapeutic strategies known as “paradoxical intervention.”

In a paradoxical intervention, the therapist tries to induce change by discouraging it. For example, the therapist may prescribe the symptom the patient has said is the problem he or she wants cured. Someone who has sought help for never getting things done might typically be urged to “take time to procrastinate.”

Among the authors whose theoretical writing about paradoxical intervention influenced Jody – and thus me too – are Viktor Frankl, Chloe Madanes, Jay Haley, and Milton H. Erickson. (Jody particularly recommends Haley’s 1993 book on Erickson, entitled Uncommon Therapy.)

A Google search for “paradoxical intervention” yields endless research studies as well as some pretty turgid theoretical writing. It’s in a therapeutic context rather than a risk communication context, but it’s about the seesaw.

One related concept that’s shared by psychotherapy and risk communication is “reactance.” The term was coined by James Brehm, who argued that when people feel their freedom threatened by the actions or statements of others, they react against those actions or statements. You’ll find plenty of research (and plenty more turgid theoretical writing) on reactance in both the therapy and the riskcomm literatures. A lot of this work is about how to overcome reactance – that is, how to avoid saying the sorts of things that make your audience turn against your recommendations. (For example, reactance is one of the reasons why it’s hard to persuade teenagers not to smoke.) But some of it, in both fields, addresses ways of making use of reactance – that is, making a paradoxical intervention, using reverse psychology, riding the seesaw.

A book that’s probably worth reading is Motivational Interviewing: Preparing People for Change, by William Ross Miller and Stephen Rollnick. I confess I haven’t read it yet – just some wonderful excerpts from the chapter on “Responding to Resistance” (courtesy of Amazon’s preview service). It gives great, accessible, risk-communication-relevant examples of seesaw paradoxical interventions.

Another useful reference is “Converting Ineffective Behaviors Motivated by Unconscious Psychological Defense Mechanisms into Consciously Determined Effective Coping Behaviors.” It’s Appendix C of a National Highway Traffic Safety Administration report on Unconscious Motivators and Situational Safety Belt Use. The whole thing, including the appendix, is available online. The appendix is a lovely literature review on the reasons why people resist safety messages and what to do about the various sources of resistance. In my terms, it’s about overcoming unconscious resistance in precaution advocacy. The seesaw/reactance/reverse psychology approach is in there, along with a lot of others.

I had never seen either of these two till I started trying to answer your question. Thanks for asking!

What is the best way for public health professionals to communicate with the public about the perceived (and sometimes real – e.g., smallpox) risk of vaccines, as well as the benefits? Even if the concern about thimerosal fades away, something else will take its place, as has happened during the entire history of the use of vaccines.

I also wonder if you had the opportunity to see the editorial by Dr. Paul Offit in this week’s New England Journal of Medicine. Commenting on a study published in the same issue that examined the risks of thimerosal in pediatric vaccines, he discusses thimerosal risk communication.

The thimerosal issue was widely publicized in July 1999 when the American Academy of Pediatrics (AAP) issued the following statement discussing the intention to remove thimerosal from most pediatric vaccines:

Parents should not worry about the safety of vaccines. The current levels of thimerosal will not hurt children, but reducing those levels will make safe vaccines even safer. While our current immunization strategies are safe, we have an opportunity to increase the margin of safety.

Dr. Offit writes that “Critics wondered how removing something that hadn’t been found to be unsafe could make vaccines safer.” He adds: “Many parents, frightened by a sudden change in policy, reasoned that thimerosal was targeted because it was harmful – and their faith in the vaccine infrastructure was shaken. Doctors were also confused by the recommendation.”

He continues: “Although the precautionary principle assumes that there is no harm in exercising caution, the alarm caused by the removal of thimerosal from vaccines has been quite harmful. For instance, after the July 1999 announcement by the CDC and AAP, about 10 percent of hospitals suspended use of the hepatitis B vaccine for all newborns, regardless of their level of risk. One 3-month-old child born to a Michigan mother infected with hepatitis B virus died of overwhelming infection.”

“During the next few years,” he concludes, “thimerosal will probably be removed from influenza vaccines, and the court cases will probably settle down. But the thimerosal controversy should stand as a cautionary tale of how not to communicate theoretical risks to the public; otherwise, the lesson inherent in the collateral damage caused by its precipitous removal will remain unlearned.”

What can public health professionals do to ensure that a blunder like this doesn’t happen again?

Which is part of why the AAP statement you and Paul Offit quoted is so off-putting. I don’t agree with the AAP that “Parents should not worry about the safety of vaccines.” Worrying about possible risks to one’s children is both natural and desirable, and telling parents not to worry is incredibly unempathic.

Offit is obviously right that it’s incoherent to say thimerosal is safe but getting rid of it will be safer. But while Offit objects to the second half of this self-contradiction, I object to the first half. Calling something “safe” without a qualifying adjective is almost always a mistake. There would be nothing incoherent about offering to reduce or eliminate the small potential risk of thimerosal.

Your comment focuses on the problem of what to do when people are unjustifiably worried about a risk that’s probably tiny and may well be non-existent. Does it make sense to take presumably unnecessary precautions in order to reassure the public? Or will the precautions be too often seen as evidence that the worriers were right in the first place?

This is an important question. But to make sense of the answer as applied to thimerosal, I have to back up and talk about how public health has forfeited much of its credibility on the subject of thimerosal safety.

Overconfident, one-sided “reassurance” forfeits credibility.

I last wrote about the thimerosal controversy in a July 2005 Guestbook comment entitled “Thimerosal, autism, and misleading toward the truth.”

Public health professionals claim that the weight of the scientific evidence shows that thimerosal does not cause autism. Critics claim that the public health profession is covering up the portion of the evidence that shows otherwise. Although I’m not qualified to assess either claim definitively, my strong impression is that both claims are true. (See for example my discussion of the June 2000 Simpsonwood Conference in the Guestbook entry linked above.)

That is, I think that the experts have solid grounds for concluding that thimerosal in pediatric vaccines is very unlikely to be responsible for the surge in autism diagnoses. And I think that once they reached that conclusion the experts have too often sought to reassure the public by overstating their degree of certainty, and have tried to ignore or discredit the evidence (a lot of anecdotal evidence plus a few studies) that suggested there might be something to the relationship after all. That’s what I mean by “misleading toward the truth.”

Overstating a mostly valid conclusion and hiding the small amount of contrary evidence is an incredibly common (and tempting) mistake. It is most common (and tempting) when people are upset, when you want to calm them down, and when all you have to work with is a pile of studies that didn’t find the effect they were looking for, plus a handful that might have found something. The evidence is maybe 85% on your side, but you’re afraid that acknowledging the other 15% might prolong the debate you’re trying to quell. So you suppress the 15%.

Sooner or later the strategy backfires. Even before the other 15% of the story comes out, people may sense that you are giving them one-sided information and are not to be trusted. When it does come out, you look like a liar. Your belated efforts to explain why you didn’t mention the discrepant 15% lack credibility, and the 15% therefore looms far larger in people’s minds than it deserves. Your one-sided messaging may win the day with people who are barely paying attention, but you forfeit any chance of influencing those who have become immersed in the controversy.

I can’t tell you how many clients I have worked for over the years who were 85% right, claimed to be 100% right, got caught being dishonest about the remaining 15%, and lost the debate. Arguably this is the Erin Brockovich/PG&E story, the W.R. Grace Woburn story, the breast implant story, the perchlorate story.… (Note: PG&E and Grace were not clients.)

If you’re 98% right instead of 85% right, the same principle applies. When scientists let themselves sound certain instead of nearly certain, and when they ignore or trash discrepant evidence instead of addressing it respectfully, their behavior is neither sound science nor sound risk communication.

There is another vaccine story unfolding as I write this that illustrates almost the same point: an unusually large outbreak of vaccine-derived polio virus (VDPV) in Nigeria.

The oral polio vaccine is a live, weakened vaccine. It is significantly less safe than the injected (dead) vaccine – but it’s a lot cheaper, and has other advantages that make it the vaccine of choice for developing countries. But about one vaccinee in a million gets polio from the vaccine itself, and from time to time there’s an outbreak of vaccine-derived polio cases. (Vaccine virus sheds in the stools of vaccinated children, and very occasionally reverts to a more virulent form that starts circulating in the community. Unvaccinated people are then at risk of catching vaccine-derived polio.)

Nigeria is currently experiencing the largest such outbreak on record. It started in 2005 and was reported to the World Health Organization and the U.S. Centers for Disease Control in September 2006. But health authorities have been reluctant to acknowledge it. Last week the CDC finally said something in its Morbidity and Mortality Weekly Review, and the Canadian Press and Science covered the story.

Why were the authorities reluctant to say anything? Religious leaders in parts of some Muslim countries, including Nigeria, have opposed the polio eradication program as a western genocidal plot. The polio risk from the oral vaccine is the germ of truth in that false belief, although of course the vaccine prevents orders of magnitude more polio than it causes. Authorities feared that acknowledging the Nigerian VDPV outbreak would give credence to the claims of anti-vaccine imams. Instead, of course, suppressing news of the VDPV outbreak has given credence to those claims.

The decision to take the thimerosal out of as many pediatric vaccines as possible has been keeping company with the tendency to deny that thimerosal could conceivably be dangerous. The two add up to a bad mixed message.

How to make precautions reassuring, not alarming.

I very much doubt Paul Offit’s claim that parents’ “faith in the vaccine infrastructure was shaken” simply by the decision to take the thimerosal out of pediatric vaccines. I don’t have any evidence, and he doesn’t cite any either. But I’ll bet that the parents most affected by this decision were the ones who were following the controversy and already resented the one-sidedness of the official stance. Those parents noted the incongruity of intransigent rhetoric accompanied by responsive policy change. They deduced that the public health profession’s acts were a better guide to truth than its words – that thimerosal must be dangerous and that the authorities must have decided to correct the problem without ever admitting the problem.

In other words, it was mostly the absence of candor and the appearance of hypocrisy that shook some people’s faith in the vaccine infrastructure.

That said, Offit has a point: Unnecessary precautions are not usually a good strategy for reassuring people who are mistakenly worried.

I explored this question in laborious detail in a 2004 essay on the risks of mobile telephones and telephone towers (masts). Entitled “Because People Are Concerned: How Should Public ‘Outrage’ Affect Application of the Precautionary Principle,” the essay was initially commissioned by Vodafone. I concluded:

Governments can best help reassure their publics … by telling them what they can do if they’re concerned: offering people a range of voluntary individual precautions to match their varying levels of concern. People who are concerned, alarmed, frightened, or outraged feel better if there are things they can do – things they can decide to do – to exert control over perceived hazards. This is true whether the hazard is sizable or not, and whether the precaution is effective or not.…

In addition, … research, education, and labeling are all appropriate responses to public concern.…

By contrast, in the face of existing public concern government precautions (“here’s how we are protecting you”) and government warnings (“here’s how we urge you to protect yourself”) seem likelier to backfire, to be alarming rather than reassuring – even if accompanied by a rhetorical disclaimer (“because people are concerned” or “just to be on the safe side”).

Policy-makers, practitioners, or researchers may eventually find ways of taking precautions or issuing warnings that reliably reduce people’s concern, that help resolve risk controversies instead of reinvigorating them at a higher level of protectiveness. If such reliably reassuring precautionary approaches materialize, then a PP [Precautionary Principle] response to public concern may begin to make sense. Until then, the PP should be seen as a strategy for protecting people from uncertain risks, not as a strategy for reassuring them about those risks.

Since then, several empirical studies by Peter Wiedemann and colleagues have documented that government precautions against mobile telephone risks tend to exacerbate people’s concern about those risks.

So what would it take to make a government precaution – such as taking the thimerosal out of vaccines – reassuring rather than alarming? In the absence of any relevant research, here’s my best guess:

• Keep your rhetoric as conciliatory as your actions. That is, acknowledge that while the weight of the evidence suggests the risk is probably low or non-existent, there is some evidence to the contrary. If you haven’t been one-sided, recalcitrant, and defensive from the outset, taking a new precaution doesn’t make you look like a liar – just a cautious decision-maker.
• Acknowledge the role of common sense in the decision. Whatever the evidence says, we know mercury is a poison. Even though you believe the small amount of thimerosal in vaccines has no measurable effect on health, you have found a way to accomplish the desired antibacterial effect without a known poison. So much the better.
• Attribute the change to the power of opposition groups. By far the easiest way to establish that a new precaution isn’t hypocritical is to concede that it’s a response to pressure. “If you’re so sure thimerosal is safe, why are you removing it?” “Because our critics won that fight!”
• Explain the practicality of the decision. Whether it’s a genuine risk or not, a vaccine that significant numbers of people fear to take (or to let their children take) isn’t an effective vaccine. You’re not just deferring to your critics; you’re deferring to reality.
• Try to offer choices, so the control is in the hands of the individual patient or parent. It would make good risk communication sense to offer alternative vaccine formulations. The thimerosal-free vaccine is for people who are worried about the possible autism connection. The “traditional” vaccine is for people who prefer the tried-and-true version, which is likely to be less expensive because it doesn’t have to be packaged in single-dose vials. People who can choose which vaccine to take are less likely to choose neither.

I have a question I do not have a ready outrage management case for – but I am convinced the theory can be applied in this instance.

The individuals from the environmental regulator that I have to deal with are usually inexperienced, with no practical or field experience. This fact is not going to change in the foreseeable future, due to the state of the resources industry worldwide and the relative salary of the regulator versus the industry. I regard this challenge as the highest priority the industry has at present.

To deal with this issue, my company’s practice to date has been to meet quarterly with the regulator, together with other companies’ environmental staff. The agency approached the industry with this request to meet. At these meetings, there are planned presentations, and discussion in general terms of typical industry mitigation measures for the usual environmental impacts such as air or water.

When dealing with matters of licencing, individuals within the regulatory agency often “put up the shutters” – they do not ask questions of understanding and become very defensive. There is then the circle of requesting more information, deferral to others, and long delays.

How would you manage this situation?

It’s tough enough to manage a subordinate who still has a lot to learn. It’s much tougher to manage an inexperienced boss. And it’s toughest of all to manage a regulator who’s rightly feeling inadequate.

There’s likely to be outrage on both sides of such a relationship.

Company people get understandably frustrated at being sent a regulator who doesn’t really know the job yet. It must be infuriating to be subject to the judgment (or what may feel like a whim) of an enforcement officer whose power exceeds his or her technical knowledge and procedural wisdom.

But it’s also extremely painful to be in the novice regulator's shoes – to be expected to know what to do, to realize that there’s a lot you don’t know yet, and to try to figure out how to learn on the job without screwing up. Beginning regulators often feel their only choices are to fake it and hope for the best or to confess their inadequacies and thereby put themselves at the mercy of the very companies they’re supposed to be riding herd on. It’s not surprising that regulators so often choose to hide their self-doubts in what looks like arrogance and arbitrariness.

The situation is a setup for conflict. Some of the following suggestions may help.

1. Remember that it’s not the regulator’s fault that he or she has been thrown into the deep water and ordered to learn to swim. Nor is it your fault. You both have a grievance, but it’s not with each other.

2. Manage your own outrage (and the outrage of your colleagues). Otherwise it will be next-to-impossible to do a good job of managing the regulator’s outrage.

3. Resolve now that complaining to the regulator’s boss is not likely to be a good strategy, no matter how tempted you may be. Odds are a complaint will make the regulator feel all the more precarious and therefore act all the more peremptory. Odds are it will also force the boss to rally behind his or her subordinate. Appealing the regulators’ decisions up the agency hierarchy is similarly likely to do more harm than good. So is asking for a different project manager.

4. Find empathic ways to acknowledge the regulator’s dilemma. This can’t be done too overtly. (“It must be hard to be so incompetent” isn’t empathic!) For specific suggestions, see my column on “Empathy in Risk Communication,” especially Section 3.

5. Make it clear to the regulator and to agency management that your company would like to help find a way to get valuable training to financially strapped regulatory bodies. Show you know this is a sensitive issue. Share the dilemma by saying something like this:

Well-run companies have a stake in fostering state-of-the-art regulatory oversight. So it’s in our interests to help. But of course you can’t afford to take your guidance from us. Can you think of a way we can support agency training without biasing it or appearing to bias it?

6. Companies and government agencies sometimes give Technical Assistance Grants (TAGs) to community groups, so they can hire the technical advisor of their choice to help them deal with complex ongoing issues. I have never heard of a company giving an agency a TAG – but maybe it's a possibility.

7. Think about offering to pay for the regulator to get some training from trusted third parties, such as academic institutions. Better yet, pay for your people to go get the same training at the same time. (Along these lines, I have occasionally had corporate clients pay for me to do an outrage management seminar for regulators, and often had corporate clients invite the regulators to my outrage management seminar for them.)

8. To take away most of the odor of bias or patronization, consider your regulator’s need for training the next time you’re about to be assessed a fine. Ask whether there’s a way to convert part of the fine into an agency continuing education budget. If they’re making you pay to get them the training they need, they’re a lot less likely to feel manipulated or demeaned.

1. What different strategies or approaches are called for in communicating during a pandemic, as opposed to an episode such as a flood or an earthquake?

2. What do people in the risk communication field know now that they weren’t aware of five years ago?

In most ways pandemic communication is like any emergency communication. As in most emergencies, for example:

• The situation is fluid and uncertain.
• People are upset and rightly so.
• A core communication task is to help them bear their feelings and act wisely.
• The most usual communication errors are over-reassurance, over-confidence, and disparagement of the public’s emotions.

But pandemics are also different in a few important ways:

• Infectious diseases provoke more dread than most emergencies.
• Pandemics last much longer than most emergencies – months and years rather than minutes or days.
• Pandemics happen everywhere (that’s what the “pan-” means), so people can’t come in from the “outside” to help.
• The available precautions and responses probably can help only a little, at least until a vaccine becomes available.
• It’s hard to arouse people before the pandemic starts to take the risk seriously enough, since it’s just “the flu.”

For the most part, these differences don’t really indicate a need for a different sort of crisis communication. Mostly they tell us that it will be both harder and more important to do pandemic crisis communication properly than in the case of most other crisis situations.

What’s new in risk communication?

I’d say the two biggest changes within the risk communication field in the past five years are these.

First, the field is much bigger. Five years ago there probably wouldn’t have been two Oregon riskcomm grads for you to write about. This is good news in many ways – but not in all ways. As the label “risk communication” has become trendy, lots of communication professionals have rebranded themselves as risk communicators without altering their skills and inclinations.

Former science educators who thought the job was to “teach the public what we know” still think so; former PR people who thought the job was to put a good face on bad facts and control the spin still thing so. These people may now call themselves risk communication experts.

Meanwhile, the real risk communication experts are discovering that their core problem isn’t really figuring out how to communicate with stakeholders about risk. Rather, it is figuring out how to persuade our clients (and employers) to do what we advise. That’s the second major change.

Although there are still plenty of unknowns and disagreements within the risk communication field, these pale to insignificance compared to the huge gaps between what we know already and what practitioners in government and industry tend to do. So more and more effort has started to focus on identifying and overcoming the organizational, cognitive, and emotional barriers to adoption of risk communication best practices.

Of course we still need to keep delineating what those best practices ought to be. But today’s cutting-edge risk communicators are at least as preoccupied with how they can get through to the client as with how the client can get through to the public and the stakeholders. This is altering the nature of risk communication research, consultation, and above all training.

My financial advisor recently sent my wife and me a questionnaire entitled, “Investor Risk Tolerance Indicator.” Its apparent purpose is to gauge our (financial) risk appetite.

This inspired an idea: What if we (the community of infosec professionals) were to create a questionnaire for our clients/employers along the same lines: an “Information Security Risk Tolerance survey.” Have you ever seen or heard of such a thing?

It seems to me that Business Impact Analyses and risk analyses are related, but not quite the same thing as a risk tolerance analysis. The BIA determines the business impact of different types of events, but it does not determine the organization’s appetite for information security risk. Likewise, depending upon how one defines “risk analysis,” a risk analysis may or may not include a step that determines risk appetite. Some definitions/methodologies, including ISO Guide 73 (which really just defines risk analysis terminology), presuppose that the risk appetite of the decision-maker has been determined prior to conducting the risk analysis.

The more I think about it, the more I like my financial advisor’s approach / the ISO Guide 73 approach, whereby the risk analyst first attempts to get the decision-maker to define his/her risk appetite, and only after that input is provided does the analyst offer risk recommendations. I have to confess that when I have done formal security risk analyses in the past, I have attempted to gauge the client’s risk appetite during the risk analysis activity itself. In retrospect, I’m now beginning to think that was a mistake, and I should have determined the risk appetite first. That enables the security risk analyst to attempt to tailor mitigation strategies based on the client’s expressed risk appetite. There is still a chance that the client may reject the risk analyst’s recommendations, but the approach of first defining the risk appetite should make the prospect of rejection by the client less likely.

Your thoughts?

First of all, you use these terms interchangeably. That makes sense if you work in an area (like information security) where risk ranges from intolerable to tolerable but couldn’t possibly be attractive. But some risks for some people are better than tolerable; they’re sought out. The thrill of risk-taking is the essence of many recreational activities, from bungee-jumping to mountain-climbing. And it’s part of the appeal of some occupations (think about fighter pilots), which makes it a lot harder to enforce safety rules.

So we should envision a risk variable that stretches from attractive at one end to intolerable at the other, with tolerable in the middle. Better yet, we should probably envision two different variables. The risk appetite question is about the risk itself: How appealing or unappealing is this particular risk to this particular group or individual? The risk tolerance question looks not just at the risk but also at the various downsides of reducing the risk, of which cost is usually the biggest. When we ask about risk tolerance, we’re assuming that the risk is unappealing rather than appealing, and we’re proceeding to a more complicated question: Given what it would take to reduce this risk, how much of the risk do you prefer to bear instead?

Think about your financial advisor, for example. Let’s assume that you’re not a recreational investor who actually enjoys financial risk; investing isn’t your alternative to bungee-jumping. Can you meaningfully answer questions about how much risk you consider tolerable without first knowing the relationship between risk and return? You can probably say something generic about your ability to sleep well during a stock market rollercoaster ride. But whatever your personal financial risk tolerance algorithm, you will surely tolerate more risk for an investment with huge potential profitability than for one with only a modest upside. In order to evaluate a financial strategy that reduces your risk – switching from penny stocks to index funds, say, or from index funds to your mattress – you will want to estimate not just how much risk reduction you’re buying, but also how much profit reduction you’re paying.

If this makes sense, it follows that risk appetite can be assessed on its own, but a risk tolerance assessment needs to wait until you have analyzed the costs and benefits of various risk management options.

In fact, one of the advantages of asking people how risk-tolerant they are is that it forces them to consider the costs of a precaution, as well as its benefits. Over the Labor Day weekend I read about a recent salmonella outbreak in spinach. It was fairly well-contained by a new program of voluntary testing, under which the grower found and recalled the contaminated batch before much of it had been consumed. So far, no illnesses have been reported. But in the news story I read, a Consumers Union spokesperson was expatiating on the inadequacy of this program. “Eight thousand cartons left the plant for distribution in the U.S. That’s 8,000 too many,” CU’s Jean Halloran told the Associated Press. I wanted to ask Halloran a few risk tolerance questions:

• Does she really think that growers should distribute no produce at all until after testing is complete, as her “8,000 too many” quote claims? Is zero really the only salmonella risk level she considers tolerable?
• Does CU have a salmonella risk management plan that will accomplish this?
• What is the cost of the plan – not just in dollars, but also in diet? Suppose the only way to get the salmonella risk from fresh produce down to zero is to abandon fresh produce altogether. If everything is canned or frozen, it will be easier to sit on it all till the testing is over. Does Halloran consider that preferable to tolerating a non-zero risk of salmonella?
• Fresh spinach consumption still hasn’t recovered from the September 2006 E. coli outbreak. I don’t know what has replaced the spinach. Other fresh produce? Canned or frozen vegetables? Meat? Doritos? Does it matter, in Halloran’s judgment?
• How much further decline in fresh spinach consumption is likely to result from this new salmonella controversy? How much further improvement in grower safety precautions is likely to result from the controversy? Does Halloran care whether the controversy might do more harm than good? Should she care?

As a risk communicator, I’m especially interested in distinguishing the hazard component of risk tolerance from its outrage component. Years ago, I worked with an environmental advocacy group that was engaged in a campaign against industrial dioxin emissions. Scientists had just found detectable levels of dioxin in human breast milk – an irresistible message point for the campaign. The communicators wanted to blame industry for making it unsafe for mothers to nurse their babies. One of the group’s scientists objected. Despite the dioxin, she said, nursing is still better for babies than bottle-feeding – and an honest and socially responsible campaign should say so. We came up with messages that did say so, while still bemoaning the contaminated purity of the nursing experience.

Similarly, I would have loved to read something like this from Halloran:

Fresh produce and especially fresh spinach is a wonderful, healthy food. If the only choices were eating fresh spinach with a small probability of salmonella or not eating fresh spinach at all, I would keep eating fresh spinach. In fact, I do keep eating fresh spinach. But I am angry that the spinach industry still isn’t doing everything it should to get the salmonella risk as close to zero as possible.

When it comes to communicating about risk tolerance, nobody has clean hands. Too often, activists and government regulators pretend the risk should be zero, while industry pretends it is zero. What we desperately need is a candid debate over the core risk tolerance question: Given the cost and other downsides of the available ways to reduce this risk, how safe is safe enough?

Of what I saw, the most focused program appears to be from the folks at the Centers for Disease Control and Prevention. Their “Crisis and Emergency Risk Communication: By Leaders, For Leaders” training packet is at least interesting in that it emphasizes leadership above all other factors.

In other words: No one really remembers what Rudy Giuliani said or did in the 9/11 aftermath. They just remember that he led.

What do you think?

Considering how strongly CDC believes in speaking with one voice, a view I don’t share, it certainly puts out materials that speak with a whole bunch of voices, without trying to reconcile the contradictions or even acknowledging them. That this potpourri approach to risk communication strategy was more coherent than anything else at the conference says a lot!

On the notion of Leadership Über Alles, I have mixed feelings. It is true that a good leader has to do more than worry out loud and wring his or her hands. It’s true that people either feel they’re in good hands or feel they’re not. And it’s true that in fearsome situations feeling well led contributes to cooperation and sustains morale; paradoxically, feeling well led also helps people exercise their own autonomy.

But it’s also true that good leaders need to share what their publics are feeling, including uncertainty, confusion, and even fear. They need to be role models of how to function well while feeling those things, not “role models” of finding it easy to function well because they’re feeling nothing.

The problem is that most would-be crisis leaders think leadership is about projecting strength without doubt, a John Wayne / General Patton kind of thing. But that’s only one kind of leadership – and one that backfires badly most of the time it’s attempted. Rudy Giuliani thinks what he did right after 9/11 was to demonstrate that he was a take-charge guy who wasn’t cowed by a terrorist attack. But what he really did right, as evidenced by his iconic “more than any of us can bear” quotation, was to voice what the public was feeling. (He started, minutes after the attacks, by validating what the public was seeing on TV.) He provided the kind of leadership we desperately needed – notwithstanding some errors such as not requiring rescue workers to wear PPE. But he doesn’t know what he did right, and his advice will lead others to lead badly.

I read and reread the paragraph where you examine what Rudy did right in the 9/11 aftermath. And you’re dead on. It’s the empathy that resonates, though that’s likely a hard sell on the campaign trail. And given Rudy’s background as a “tough on crime” prosecutor, he’d probably rather be known as a tough leader than an empathetic one.

Perhaps we should define “effective crisis leadership” as some blend of strategy and empathy. The strategy says, “Here’s where we are, here’s where we’re going and here’s how we’re going to get there.” The empathy says, “Here are the fears and the sorrows we share as a community, and it is valid for us to feel these emotions.” (Of course, this only works if the speaker is actually a part of the community. If it’s an outrage situation, as you point out in your column, taking this approach can lead to fireworks.)

A guy like Rudy is more likely to acknowledge the strategy half of the prescription; a guy like Bill Clinton is more likely to acknowledge the empathy half. But you gotta have both to be effective.

At least that’s how it appears for the moment, in the aftermath of reading your column, studying the CDC manuals, and thinking over the DHS workshop. I’m not at all settled on this notion.

Odd that you should mention Patton. Over the weekend, I stumbled upon the actual text of the speech he gave many times to U.S. troops just before the Normandy landing. A version of that speech opens the George C. Scott movie.

One paragraph struck me as especially relevant:

Some of you men are wondering whether or not you’ll chicken out under fire. Don’t worry about it. I can assure you that you’ll all do your duty. The Nazis are the enemy. Wade into them. Spill their blood. Shoot them in the belly. When you put your hand in a bunch of goo that a moment before was your best friend’s face ... you’ll know what to do.

Brutal? Yes. But highly effective because it’s also empathetic. What soldier doesn’t worry about chickening out under fire?

In that speech, Patton combines his strategic approach to war (“We’re advancing constantly and we’re not interested in holding onto anything except the enemy”) with astounding empathy for his audience: “Thirty years from now, when you’re sitting by your fireside, with your grandson on your knee, and he asks: ‘What did you