2017 Guestbook
Comments and Responses

Flu vaccination dishonesty, 2017 edition – and why am I posting so little these days?

name: Tobi
This guestbook entry
is categorized as:

      link to Pandemic and Other Infectious Diseases index

field:Registered Nurse
date:October 5, 2017
location:Washington, U.S.


It’s been many years since I’ve seen anything new or updated on the flu vaccine on your website. I’m writing to you because every year around this time I experience a mantle of dread surrounding the decision about whether to receive the flu shot under duress or suffer the cultural and professional consequences.

I have been an RN for many years now and have increasingly struggled with the movement towards mandate regarding this vaccine. Luckily I have not yet worked for an organization that could terminate on such grounds, but masking as the alternative has its own challenges. I also struggle with the increasingly caustic and media-amplified rhetoric concerning the flu vaccine and HCWs who choose not to vaccinate.

A friend sent me to your website many years ago and I was so grateful for the exposure to such thoughtful and intelligent perspectives as well as to the research it provided. Every year since I have printed and highlighted sections of your articles and attached them to the form we are required to submit with proof of vaccination or declination, as I have done both. One year the nurse just ripped it right off and I was emphatic that I wanted it to stay attached as it moved into my file. I have not once been engaged or contacted in response to any of the submissions.

So I am wondering if you have any new thoughts or information on the matter – as I continue to utilize the writings available but am more aware of the dates published when I share them with others now.

It was not lost on me that both you and your wife still choose vaccination, and I am not opposed to the science of herd immunity. But I am very opposed to the gross misrepresentation of data and I resent the presentation of such being done under the guise of “evidence-based practice.” It seems that it is presented as a black-and-white issue, with a scarlet letter for anyone who might disagree or want to have real dialogue on the efficacy of the interventions.

If I have missed anything more recent on your website, my apologies, and please do direct me there.

Thank you for your work. It has validated many of my feelings and exposed me to a much richer perspective on the topic and for that I am grateful.

peter responds:

I am delighted to learn that you have found www.psandman.com useful over the years. By taking the time to tell me so, you made my week.

I promise I will get to the topic of flu vaccine risk communication. But first, I want to comment briefly on why I haven’t written much lately.

Why I am writing less (in case anyone wants to know)

You’re quite right that I haven’t posted anything about flu vaccination in some time. As I imagine you’ve noticed, I am posting less and less on the website about any topic. At 72, I’m finding myself drawn to other activities instead – travel, my lifelong stamp collection, grandchildren, etc.

One of the advantages of being self-employed is that retirement doesn’t have to be dichotomous. Though I’m mostly retired now, I’m still willing to say yes to work that looks more-than-routinely interesting, important, or profitable (ideally at least two out of three). But less and less work comes my way that I decide meets these specs.

Originally, I thought cutting way back on paid work would make more time for website writing. And maybe it will, in time. But so far it hasn’t. This is a discovery rather than a decision. I have a list of risk communication topics I’d like to write about, and the list keeps growing. From time to time I look over the list and consider picking one to write about … and then go do something else instead.

My wife and colleague Jody Lanard M.D. – even more of a flu geek than I am – is similarly mostly retired. I’d be extremely reluctant to write about flu (or any other medical or public health topic) without Jody’s coauthorship, or at least her behind-the-scenes correction of technical errors in my drafts. (I’ll wait for her to read and critique this Guestbook entry before I post it.)

Part of my near-retirement, I think, comes from feeling that I have very little left to say that I haven’t already said. I see endless new instances of bad risk communication – but what I want to say about them is pretty much the same as what I said about earlier instances of bad risk communication.

All that notwithstanding, there is one flu vaccination topic right now that tempts me to sit down and write – and if I can inveigle Jody into writing with me, I may just do it.

The flu vax risk communication story of the month

The topic is the recently published study that found (to the investigators’ surprise) that pregnant women in two post-pandemic flu seasons who were vaccinated against the flu the previous year and again in the current year during their first trimester were likelier than other women to miscarry. At least in this particular study of these particular seasons, first-trimester flu vaccination of pregnant women who had also been vaccinated the year before posed a statistically significant danger to their fetuses.

The study wasn’t some piece of anti-vaccination propaganda. It was funded by CDC, which expected it simply to reaffirm the safety of flu vaccination for pregnant women, and was conducted by mainstream members of the vaccine research “Guild” (including Guild superstar Ed Belongia).

The study replicated the methodology of an earlier study, also CDC-funded, which had found (as had many other studies) that flu vaccination posed no threat to pregnancies. Because there were new circulating flu strains and flu vaccine strains since the 2009 H1N1 pandemic, it made sense to redo the study and make sure nothing had changed. When evidence emerged that maybe something had changed, the researchers attempted a post-hoc analysis to shed light on possible causes. The factor that emerged from this analysis was flu vaccination in two successive years. This factor, the sequence of two flu shots, hadn’t been looked at in the earlier study and wasn’t slated to be looked at in this study either, until the researchers found an excess of miscarriages in vaccinated women and started looking for explanations.

The finding needs replication, of course; it’s a signal of a possible problem, not dispositive proof that the problem is real. And even if the problem is real, odds are that pregnant women are still better off getting the flu vaccination than not. Flu is almost certainly a bigger risk than the flu vaccine – to pregnant women, to their fetuses, and to their babies after they’re born.

(I’m obviously not qualified to give medical advice, but if asked I’d advise a pregnant relative to get vaccinated anyway, but to wait till her second trimester, especially if her first trimester didn’t coincide with flu season. Given the evidence of the waning of flu vaccine efficacy, getting your flu shot arguably makes more sense in October than in August or September even if you’re not pregnant! If your first trimester comes in August or September, it surely makes sense to wait till October.)

What I’d love to write about is the over-the-top and sometimes dishonest way the public health profession (“the Guild”) has trashed this study – as it tends to trash any study that it fears might threaten public confidence in the virtues of vaccines. I understand the value of assuring pregnant women that they and their babies face a greater risk from flu than from the flu vaccine – and that one tentative study result is way short of proof that they face any risk at all from the flu vaccine.

But arguing that the study shouldn’t have been published, as Paul Offit (another Guild superstar) wrote, strikes me as bad science and bad risk management if he means it, and as dishonest risk communication if he doesn’t.

I’m frankly not sure if Offit is saying the study shouldn’t have been funded in the first place; or if he’s saying it should have been aborted once it found a suggestion of a possible problem; or if he’s saying the news of the possible problem should have been quietly shared with fellow Guild members but never published in a journal where medical reporters could read it and write articles that ordinary people (some of them pregnant) might see.

In fact, the study results were presented to the CDC’s Advisory Committee on Immunization Practices in 2015. The ACIP meeting was public, but few if any journalists attend most ACIP meetings and nobody picked up on the story two years ago. The study was also rejected by two other journals before the journal Vaccine accepted it. I don’t know why it was rejected. In particular, I don’t know whether the Guild put any pressure on journal editors to reject it – though I’m personally aware of two earlier cases in which pressure was exerted on journals to reject studies that found problems with flu vaccination, even though the studies were authored by highly regarded (and highly pro-vaccination) Guild members. Both of these earlier studies reported then-startling findings that are now accepted by the Guild as fact.

The bottom line is that Offit almost got what he wanted: suppression of this signal of a possible downside of flu vaccination.

Some of the criticisms of the study by Offit and others are valid – and were acknowledged by the authors in the first place. In fact, the study authors were clearly unhappy about what they had found and went out of their way to emphasize the study’s flaws, both in the Vaccine article and in follow-up media interviews.

Other criticisms are not so valid. Two of them particularly offend me:

number 1

The claim that the numbers in the key subsample analysis are too small to be significant.

As I’m sure you understand (and so do the critics), statistical significance is responsive to sample size. It takes a substantial effect to show up as statistically significant in a tiny sample. When one does, complaining that the sample is tiny misses the point. A finding that’s significant at p < .05 has less than a one-in-twenty chance of being a false positive, regardless of the size of the sample.

It’s true that post-hoc analyses of unexpected findings can sometimes be guilty of “data dredging.” If you examine dozens of possible correlations, one-in-twenty of them will turn out “significant” at p < .05 just by chance, even if nothing real is going on in your dataset. Some critics have implied or claimed that this study committed the data dredging sin. They might be right, but I don’t see much evidence of it.

And it’s not like the study authors dredged up something fanciful, like “vaccinated women with red hair have more miscarriages.” There’s a growing body of research that prior years’ flu vaccinations affect how the body responds to a current flu vaccination. Miscarriage would be an effect that hasn’t been seen before – but it’s not as far-fetched a possibility as critics want to pretend.

Most of the articles criticizing the study – and even most of the news stories simply reporting the study – don’t actually tell readers the key numbers. Here they are. The study authors identified 485 women who suffered miscarriages. They matched them with 485 women who didn’t. They found that the women who miscarried were likelier to have had a flu shot, so they looked for clues to why. The clue they found: Out of the 485 women who miscarried, 14 had had a flu vaccination in their first trimester after another flu vaccination the year before. Out of the 485 women with normal births, only four had experienced the double vaccination. These are indeed tiny numbers. Even so, the difference between the two groups was big enough – 14 is 350% of 4 – that the result was statistically significant.

number 2

The claim that the study isn’t worth worrying about because it found only an association between flu vaccination and miscarriage, and failed to prove that vaccination causes miscarriage.

Of course it’s perfectly true that observational studies can’t prove (or “fail” to prove) causality. That’s a drawback of virtually all of epidemiology – and of most of the studies that are said to “prove” that vaccines are effective at reducing vaccine-preventable illness. Much of what we know about the value of vaccination we know from observational studies. The Guild rightly trusts well-designed observational research right up until it runs into a study with findings it doesn’t like, and then it suddenly decides that “merely” observational findings can safely be shrugged off.

The gold standard for proving causality is the randomized control trial – the true experiment. If you randomly assign people to groups, the randomization assures you (within known parameters depending on your sample size) that the groups are equivalent in every way. So if you treat the groups differently and get a different result, you really know the treatment you’re studying caused the result you found.

But if you can’t randomize (often for ethical or economic reasons), you’re pretty much stuck inferring causation, tentatively, from your correlational data. People who decide to get vaccinated start out different from people who decide not to, so any later difference you find between the two groups (a difference in whether they get the flu, a difference in whether they have miscarriages, etc.) might be because of vaccination but it might be because of those other preexisting differences. The study authors tried to minimize this problem by matching statistically for some preexisting differences. But you can’t match for everything; you certainly can’t match for differences you’re not even aware of. So you can’t turn a study that’s observational and correlational into a study that proves causality.

The critics are on firm ground when they suggest ways the miscarriage study’s matching might have been improved. But when they proclaim that the study didn’t prove causality, they’re intentionally and dishonestly making this feature of all observational studies sound like a defect of this particular study.

Sorry. I’m sure that’s more than you want to read about the flu vaccine / miscarriage study.

Flu vax risk communication more generally

Jody and I still get our flu shots every October – and another a half-year later if we’re going to spend much time in the Southern Hemisphere. Even though the flu vaccine is one of the least effective vaccines in current use, especially for people our age and older, we still think it’s a lot better than nothing. The upside of the flu vaccine isn’t anywhere near as impressive as the upside of all those incredibly wonderful childhood vaccines, but it’s real, whereas the downside is almost nonexistent. In our judgment, getting a flu shot is easy, cheap, and safe, so why not?

We still think the Guild oversells the flu vaccine. The widespread attacks on the miscarriage study are only the most recent of many examples.

Every year as flu season approaches, Jody and I collect examples of flu vaccine hype and dishonesty. One perennial example: Somewhere in the Southern Hemisphere just had a really bad flu season, so ours will probably be really bad too. This year the meme is that Australia’s season was bad so ours will be bad. Australia’s flu season really was a lot worse than the previous five years of mild Australian flu seasons (though it wasn’t as unprecedentedly bad as some stories report). But why do we never, ever see a news story that quotes a public health official to the effect that Australia just had a mild flu season so ours will probably be mild too? The answer is obvious. Every year flu vaccination proponents choose what to say this year that isn’t actually false to encourage people to get vaccinated.

Selectively deciding which parts of your data to share isn’t exactly dishonest, but it isn’t exactly evidence-based medicine either. It’s what PR people and lawyers do, not what scientists are supposed to do.

Jody and I are flu vaccination proponents too, but we oppose public health dishonesty and even public health hype. For years we have warned our public health clients that the chickens will eventually come home to roost – that hype and dishonesty threaten their credibility. This is demonstrably true of corporate hype and dishonesty. We don’t have much evidence that it’s also true of public health hype and dishonesty. For my entire career, my public health clients have been gilding the lily – overstating the upsides and understating the downsides of genuinely worthwhile health interventions. So far, at least, their evidence that their risk communication misbehaviors have saved lives is stronger than my evidence that these misbehaviors have undermined credibility.

The example of flu vaccination hype that’s most familiar to you, I assume, is the Guild’s overstatement of the case that vaccinating healthcare workers against the flu protects patients. I think “easy, cheap, and safe” is a good enough reason for me to get a shot that might or might not protect me from the flu. But it’s obviously not a good enough reason for your employer to force you (or any healthcare worker) to get a shot you don’t want to get. Protecting patients, on the other hand, probably would be a good enough reason.

There is some evidence that flu vaccination of healthcare workers protects patients in nursing homes and similar facilities. There is virtually no convincing evidence that the same thing is true in other healthcare settings. I am comfortable with the employers of healthcare workers in these other settings urging them to get the flu shot for their own sakes, and to reduce absenteeism. I am comfortable with employers suggesting that it’s plausible that there might be a benefit to patients, even though the benefit hasn’t been shown. Going beyond that is going beyond the evidence.

I do not favor mandatory flu vaccination for healthcare workers; I think it’s likely to boomerang in terms of the vaccination attitudes of the coerced practitioners. But I prefer frank coercion to dishonest persuasion. If nothing else, it’s easier for healthcare workers (and their union if they have one) to grieve a new coercive rule than to challenge a dishonest evidentiary claim.

By the way, in the last year or two, as the evidence that flu shots don’t work all that well has become undeniable, vaccination proponents have put new emphasis on the claim that even when it doesn’t prevent the flu, vaccination leads to milder cases. I don’t know how valid this claim is. But insofar as vaccinating healthcare workers means their flu cases are milder, it should follow that vaccinated healthcare workers are likelier than their unvaccinated colleagues to have flu cases mild enough to tempt them to go to work anyway. So presenteeism would presumably be a bigger problem for vaccinated healthcare workers than for unvaccinated healthcare workers – which makes me wonder whether it’s still plausible to postulate that vaccinating healthcare workers against the flu reduces flu incidence among their patients.

As for masking, public health officials can make a plausible claim that wearing a mask probably helps prevent flu transmission – at least if you wear it consistently and correctly, change it frequently, dispose of it properly, etc. But it’s wearying to wear a mask all day, or even just when you’re in contact with a patient.

It is worth noting that hospitals that require unvaccinated healthcare workers to wear masks don’t ask unvaccinated visitors or unvaccinated patients to wear masks. And even though flu vaccination works only about half the time (at best – on healthy young adults in a year with a good match), hospitals never require vaccinated healthcare workers to wear masks unless they have titers to prove that their flu vaccinations actually produced antibodies. In a year with 50% flu vaccine efficacy, half of all vaccinated healthcare workers are just as susceptible as their unvaccinated colleagues to catching a case of the flu that’s bad enough to see a doctor. Why aren’t they masked too?

I can’t help thinking the mask requirement is more an “incentive” to get vaccinated and a punishment for those who refuse than a measure to protect patient health. Is masking merely masquerading as a patient health measure? I suspect it is. In fact, the whole battle over healthcare worker flu vaccination strikes me as more about management control than patient health.

Well, enough of that. More than enough, probably. Again, thank you for your kind words about my website. Maybe you’ll inspire me to write more often. You certainly inspired me to write this Guestbook entry, my first one in six months!

How good and bad regulations affect stakeholder outrage

name:Eelco de Groot
This guestbook entry
is categorized as:

      link to Outrage Management index

field:Public acceptance expert
date:March 28, 2017
location:The Netherlands


In the Netherlands, we are currently finalizing legislation on spatial planning. In this new law, public participation is now legally required. (It wasn't before.) But what public participation entails, like the definition of participation stages or project phases, is not defined or standardized. According to the new law, it is up to the local authorities to decide whether a stakeholder engagement plan is needed, and if yes, if it is appropriate. When affected communities do not agree with this decision there is not much they can do. When they go to court, the court will refer to the mandate of the authorities.

Many experts think that this will lead to legal inequalities for both the private sector and affected communities. Local authorities may judge differently on public participation for similar cases, like wind farms. This may lead to a cumbersome process of case law, leading to high costs for the private sector (impact on the project and on reputation) and for society (on both the community and the governance level).

In your 1998 “Outrage Prediction and Management” software, at chapter 8C on government control, you say this:

Companies often oppose all government regulation, in a knee-jerk response compounded of habit, ideology, and ego. I can see why you might oppose a necessary regulation, one that makes you spend money to do something you'd prefer not to have to do. And I can certainly see why you should oppose a stupid regulation, one that makes you spend money to do something that won't protect the public anyhow. But you need some sort of regulation to keep outrage under control, to stand between you and your potential victims. For any worthwhile thing that you are already doing or plan to do, a regulation that requires you to do it is gravy. Fight for such regulations. Offer them in exchange for the stupid ones. Support them publicly.

I have three questions:

  1. Do you still subscribe to this point of view?
  2. What has been the reaction of your industry clients?
  3. Is there any evidence that such regulation helps to bring costs (project, reputation, transaction, societal, etc.) down?

I also have a broader question: Although your theory has been widely acknowledged, there are still barriers for the industry to apply it. In your writing you often refer to internal alignment problems, corporate culture, individual psychological characteristics, etc. It's not so easy to have an open discussion on these things. Perhaps it is better to focus on the costs of not applying your approach: delays, cancelations, liabilities, reputational damage, etc. After all, it is the ultimate responsibility of the CEO to act in the best interests of the company, and not to be unduly influenced by his or her career interests or worldview.

Do you have evidence of these costs when doing poor stakeholder engagement, so the CEO may refer to it when s/he needs to convince the Board and senior management?

peter responds:

Your comment raises two issues: what I think about the new public participation law in the Netherlands, and whether I still believe government regulation can help ameliorate stakeholder outrage. The two intertwine in complicated ways. I’ll start with the second one and work my way to the first. In a nutshell: While I remain convinced that well-designed regulations can help ameliorate outrage, a badly designed public participation requirement could easily backfire.

At the end of my response I’ll briefly address your postscript on how best to sell outrage management to senior executives.

Effects of government regulation on outrage

Everyone knows government regulation has bottom-line downsides for a regulated company, most obviously the cost of obeying the regs. So at first glance it might seem that the most profitable industry is always the least regulated industry.

But government regulation also nurtures profit in some not-so-obvious ways. It increases the cost of entry, for example, which helps protect established companies from competition by newcomers. It keeps out corner-cutting shady operators that might otherwise undermine the reputation of the entire industry. It sets and enforces minimum standards, thereby reducing competitive pressures for a “race to the bottom” in which everybody has to cut corners because everybody else does.

One key way government regulation benefits companies is its capacity to prevent or reduce stakeholder outrage. I think most people rightly distrust unregulated capitalism, on the sensible grounds that if companies are free to maximize profit in ways that harm their stakeholders and society as a whole, they will do so (at least sometimes). This is especially the case when the harm companies might profitably do isn’t necessarily apparent to non-experts. Most neighbors of a factory, for example, can’t judge for themselves whether the factory’s emissions might give them cancer. They have to count on the government to outlaw dangerous emissions.

More broadly, we all look for evidence that the companies we rely on are not free to maximize profit in harmful ways. The existence of a strong regulator gives us some assurance that capitalism’s natural rapacity will be kept within reasonable bounds.

In short, companies need cops.

In the course of 40+ years of risk communication consulting, I worked with clients in highly regulated and less highly regulated settings. In some countries where I worked, government regulation was widely known to be lax or corrupt or both. People had good reason to suspect that companies in those countries were cutting corners. Even in developed countries, the regulatory environment waxed and waned. In the U.S., for example, there were times when a company could credibly lean on the credibility of the Environmental Protection Agency (EPA), times when it actually helped reassure stakeholders to point out that “EPA says what we’re doing is safe.” There were other times – and in 2017 I think we’re about to enter such a time again – when the EPA’s credibility was at a low ebb, and stakeholders would laugh bitterly at any company’s assertion that something must be safe because the EPA permits it.

If government regulators are too weak to be credible cops, smart companies look for alternative cops. When the EPA’s credibility was low, my U.S. clients sometimes asked me to facilitate other eco-compliance options, such as “partnership” with environmental groups or membership in green standard-setting organizations. I always argued against the “partnership” frame; cops and crooks aren’t supposed to be partners. But my clients’ sense that they needed to be accountable to somebody was right on target.

I’m not suggesting that government regulation is a cure-all. When things go really awry, the public wants a scapegoat. It’s usually not hard for government agencies to place the blame on the companies whose behavior did harm, rather than on the government officials who failed to forbid or failed to police that behavior. In my view the Global Financial Crisis of 2007–08 was more a result of inadequate regulation than of corporate malfeasance (see “What Did Goldman Sachs Do Wrong?”) – though it’s true that the finance industry lobbied hard to be less regulated. Most Americans, however, blame the crisis on Wall Street, not on Congress or the regulatory agencies.

In ordinary times, as distinct from crises, people can’t tell for themselves whether everything’s okay or something’s wrong. So we’d like to be able to rely on government regulators to make that determination for us. If regulation seems to be strict and effective, we’re less inclined to worry ourselves into a state of outrage about ambiguous signals of possible risk.

Whether on balance a particular regulation is beneficial or detrimental to a particular company depends on many factors. Not least of these factors is the likely bottom-line impact of stakeholder outrage. When outrage is doing a company relatively little damage, outrage management may be costlier than it’s worth. As the cost of outrage goes up, various outrage management strategies become more cost-effective. In this, government regulation is no different from any other outrage management strategy. Looking at government regulation just from the company’s perspective, not society’s as a whole, and just in terms of the outrage management benefit, not other benefits, it’s fair to say that regulation pays for itself if and only if it costs the company less than the outrage it prevents would have cost.

A tough new regulation that makes a company do something it would prefer not to do has a silver lining insofar as it’s a bulwark against stakeholder outrage. But the most cost-effective regulation is a regulation that “makes” a company do something it was planning to do anyhow – thereby reducing stakeholder outrage without increasing operational costs. That’s what I was trying to get at in the passage you quoted from my 1998 software.

But as I pointed out in the passage you quoted, habit, ideology, and ego often lead companies to oppose even regs that have no downside. Here’s the example I gave in the software:

A paper company client had spent hundreds of millions of dollars on a new environmentally friendly mill, way below the industry norm in its use of chlorine and its emissions of dioxins and other suspect chlorinated hydrocarbons. It did this in anticipation that the regulations would get tighter, that a mill already in compliance with the next generation of requirements would end up cheaper than one forced to retrofit its way to compliance. But the regulations didn't tighten as soon as expected, and my client was left with a mill that was “too clean” for the company’s economic good.

Yet when tougher mill effluent standards were proposed, the CEO testified against them. Now maybe he was thinking about his other mills. Or maybe he wanted to keep a competitive advantage in wooing the green market rather than force his competitors to retrofit. But I don’t think so. I think the ideology of unregulated capitalism took precedence in his mind even over profits.

You ask whether there is evidence that strong regulation actually reduces costs by minimizing stakeholder outrage, improving corporate reputations, streamlining project approvals, etc. There is plenty of anecdotal evidence. I wish there were more rigorous evidence. But if studies exist that prove the case, I haven’t seen them.

There are really two steps in the argument:

  1. that effective government regulation fosters better stakeholder relations and lower community outrage; and
  2. that better stakeholder relations and lower community outrage lead to reputational and project approval benefits that improve a company’s bottom line.

My clients used to give me a hard time about both points. These days I think the second point is widely accepted. Nobody really doubts anymore that being well-liked is a corporate asset and being much-hated is a corporate liability (see “Two Kinds of Reputation Management”) – that stakeholder outrage is costly and stakeholder relations is a sound investment. Many companies still don’t walk the walk, though, so maybe better quantitative evidence is needed to clinch the deal.

Much tougher questions are raised about the first step in the argument: whether regulation fosters better stakeholder relations and lower community outrage. I have argued for decades what I am arguing again in this response, that the right sort of regulation helps protect companies from outrage. But I never had much luck convincing clients to welcome what they invariably saw as government interference.

Effects of required window dressing on outrage

A government regulation ameliorates outrage against a company when stakeholders see the regulation as helping prevent the company from doing them harm. A law that requires proponents of a project to jump through prescribed public participation hoops – and then lets them do whatever they want – isn’t likely to have that effect.

As you describe it, the new public participation requirement in the Netherlands sounds like a poorly conceived piece of regulation. Local authorities can devise any stakeholder relations protocol they like, and they’re not required to devise a good one, or maybe even to stick to the one they devised. You’re worried about inequity: the same sort of project getting an easy okay in one community while in another it has to run the gantlet of a tough engagement process. What would worry me more is the likelihood that most local authorities will come up with protocols that will feel more like window dressing than actual engagement – especially in the judgment of stakeholders who opposed a project that was approved despite their opposition.

In my writing and consulting on public participation, I try to distinguish pro forma consultation from meaningful consultation. Here for example is what I said in a 1986 article on siting hazardous waste facilities:

A fatal flaw in most governmental public participation is that it is grafted onto a planning procedure that is essentially complete without public input. Citizens quickly sense that public hearings lack real provisionalism or tentativeness. They often feel that the important decisions have already been made, and that while minor modifications may be possible to placate opponents, the real functions of the hearing are to fulfill a legal mandate and to legitimize the fait accompli. Not surprisingly, citizen opponents meet what seems to be the charade of consultation with a charade of their own, aiming their remarks not at the planners but at the media and the coming court battle.

This scenario is likely even when the agency sees itself as genuinely open to citizen input. For legal and professional reasons, experts feel a powerful need to do their homework before scheduling much public participation. In effect, the resulting presentation says to the citizen: “After monumental effort, summarized in this 300-page document, we have reached the following conclusions…. Now what do you folks think?” At this point it is hard enough for the agency to take the input seriously, and harder still for the public to believe it will be taken seriously….

The solution is obvious, though difficult to implement. Consultations with the community must begin early in the process and must continue throughout. Public participation should not be confined to formal contexts like public hearings, which encourage posturing. Rather, participation should include informal briefings and exchanges of opinion of various sorts, mediated where appropriate. The Commission must be visibly free to adjust in response to these consultations, and must appear visibly interested in doing so. Above all, the proposals presented for consultation must be provisional rather than final – and this too must be visible. A list of options or alternatives is far better than a “draft” decision. “Which shall we do?” is a much better question than “How about this?”

This sort of genuine public participation is the moral right of the citizenry. It is also likely to yield real improvements in the safety and quality of the facilities that are built. As a practical matter, moreover, public participation that is not mere window-dressing is probably a prerequisite to any community’s decision to forgo its veto and accept a facility. This is true in part because the changes instituted as a result of public participation make the facility objectively more acceptable to the community. Public participation has important subjective advantages as well. Research dating back to World War II has shown that people are most likely to accept undesirable innovations, such as rationing, when they have participated in the decision.

Can a good engagement process actually reconcile participants to a project they opposed? I’ve actually seen it happen: The “losers” in the battle really do sometimes say, “Well, we still think the project should have been stopped, but we had our shot, we got heard, we did have some impact on the outcome, and we see there’s a case for moving forward.” I’ve also seen it fail, of course. Even the best engagement process doesn’t guarantee that people who don’t get the outcome they wanted will nonetheless believe the process was a good one. But the odds are better. On average, a poor engagement process arouses more outrage than a good one.

In fact, a poor engagement process sometimes arouses more outrage than none at all. Making people go through the motions when they can tell it’s all a charade is itself an outrage-arousing thing to do. If you’re determined in advance to coerce people in the end, it’s probably better to skip the window dressing.

A mandatory poor engagement process prescribed by the national government is arguably the worst of all the options. And the new public participation requirement in the Netherlands sounds like it may fit that description.

Throughout my consulting career, quite often my corporate clients were regulated by government agencies that knew next to nothing about outrage management. A regulator would typically take actions that I considered foreordained to exacerbate stakeholder outrage, such as setting up a time-wasting, energy-wasting, frustration-inducing pro forma stakeholder engagement process. My clients were frequently undismayed, sometimes even pleased, by the regulator’s maladroitness. “Well, so the agency will piss off community opponents,” they would say with barely disguised glee. “Not our problem.”

This was very shortsighted. When government regulators arouse community outrage, the outcome is in some ways worse for a regulated company than if the company had aroused the outrage on its own. If people are outraged about something the company has done, the company can at least figure out how best to ameliorate the outrage. But if people are outraged about something the regulator has done, how will the regulator try to ameliorate the outrage? Probably by blaming the company. Or worse: The regulator may wriggle out from under the stakeholder outrage blanket by overregulating the company.

Literally billions of dollars in technically unnecessary hazard regulation is attributable to government agencies trying to reduce outrage by overregulating companies. I hasten to add that I consider underregulation at least as big a problem as overregulation. But when overregulation occurs, the regulator’s goal is often to ameliorate stakeholder outrage – not infrequently outrage the regulator provoked in the first place.

The fundamental basis for my approach to risk controversies is my contention that hazard perception is chiefly a product of outrage – that is, of “outrage factorslink is to a PDF file like trust, control, fairness, dread, etc. And as I have often written, an outrage problem deserves an outrage solution, not a hazard solution. Here’s the way I put it in a seminar handout link is to a PDF file that I have been using since 1994: “The proper response to a serious outrage is neither to ignore the outrage nor to pretend that it is a serious hazard. Just as a serious hazard requires hazard mitigation, a serious outrage requires outrage mitigation.” Or as I sometimes say at the end of presentations:

If the hazard is broke, fix the hazard. If the outrage is broke, fix the outrage. If they’re both broke, fix them both. If your factory needs a vapor recovery system, install one. If your neighbors need an apology, apologize. But don’t expect a vapor recovery system to make people less upset – any more than you’d expect an apology to make them less endangered.

When regulators do something that arouses outrage, the odds are high that they’ll try to ameliorate the outrage by overregulating some company. It’s bad enough if the XYZ Corporation should be apologizing to the community for its offensive behavior, but decides to install a multimillion-dollar vapor recovery system instead. At least the company is wasting its own millions in an ineffective attempt to make up for its own misbehavior. It’s far worse if an agency that regulates the XYZ Corporation has offended community members – and instead of apologizing the agency requires XYZ to spend those millions on an unnecessary vapor recovery system.

How does this apply to the new public participation law in the Netherlands? Here’s the scenario that worries me. Under the new law, a local authority implements a poor engagement process, one that is obviously just window dressing. As community members work their way through the process, their outrage at the local authority gets higher and higher. Eventually, community outrage is so high that the authority sees only one viable option: to cancel the project.

The local authority’s final conclusion is terribly unfair. It punishes project proponents for its own mistakes. But given those mistakes, the authority’s conclusion isn’t unreasonable. Sometimes outrage is so high, and doing so much damage – to reputations, to community cohesion, etc. – that a technically sensible project is no longer culturally/socially viable.

In 1993 I consulted briefly on a local controversy over the siting of a sewerage outfall in a coastal Australia community. Unbeknownst to me, opponents of the outfall had done an analysis of the outfall siting process based on my twelve principal outrage components. link is to a PDF file They concluded that the process had aroused very high community outrage. (They ought to know; it was their own outrage they were analyzing.) They submitted this conclusion to the local authority as part of their case against the project.

A side-controversy resulted over whether a defective public participation process leading to a high level of community outrage constituted an appropriate reason to turn down an otherwise sensible project. People on both sides sent me emails, asking my opinion. Here are some excerpts from my responses, which were duly entered into the record:

I have no idea whether the proposed … outfall is technically wise or technically foolish. But if it is technically wise, it does not become technically foolish simply because proponents have (mis)managed it in a way that has generated a lot of outrage. The proper response to a serious hazard is hazard mitigation. The proper response to a serious outrage is neither hazard mitigation nor ignoring the outrage. It is outrage mitigation. It seems likely that proponents of the outfall owe the neighborhood an apology, increased control over how the outfall is managed, enforceable guarantees that feared outcomes will not happen and compensation and penalties if they do, etc. But it doesn’t necessarily follow that proponents owe the neighborhood abandonment of the project….

If an agency has sited a facility in a way that generated high outrage, it is sometimes wisest (from the perspective of outrage reduction) to retreat from that particular site, which might be technically ideal and still be “contaminated” by the process used. If this is impossible, agencies can sometimes retreat from the process but not the site, apologize, and begin from the beginning – developing a more collaborative, noncoercive process at the same site. If even this is impossible – if an irrevocable decision has been made – there are still outrage reduction strategies that make sense….

Unless high-visibility problems plague a facility after it is built, people tend to make their peace with it; those who cannot tend to move…. But while the facility itself may come to be accepted, this does not mean that the controversy has no long-term social impacts. Social dissension is extremely costly to communities, and many of the costs are very long-term indeed. An unsuccessful fight to stop a controversial facility often leaves behind a cadre of activists whose views about the legitimacy of government range from cynicism to bitterness and rage.... This may be a desired or an undesired outcome, but it is a likely one: more controversy to come. A more clearly negative outcome is the residue of divisiveness within the community. A major controversy divides neighbor from neighbor, family member from family member. Long after most people have come to terms with the facility itself, their relations with those who fought them on the issue may remain strained.

Wise community leaders often decide not to pursue a policy option that will so divide their community, even if they think the option sensible and winnable. If they do pursue the option despite these social costs, they may decide that outrage reduction is critical to help mitigate the costs.

In short, stakeholder outrage is itself a hazard. (See my 1995 article, “When Outrage Is a Hazard.”) The most extreme examples of this truth are terrorism and employee sabotage. Sometimes outraged people kill. Social dissension is a more commonplace example.

If the authorities mismanage outrage badly enough, they may end up with no viable choice but to mismanage hazard to match. A good hazard management plan can become unfeasible because of out-of-control outrage and its costs.

But the goal should always be an outrage solution to an outrage problem and a hazard solution to a hazard problem. You don’t expect an apology to reduce people’s exposure to carcinogens, and you shouldn’t expect a vapor recovery system to calm them down. Of course outraged people presumably think they have a hazard problem. They expect the vapor recovery system to calm them down, and they’re a bit surprised when it doesn’t. But we should know better.

I’m making two conflicting points here:

number 1
Hazard reduction is a very inefficient way to manage outrage. It doesn’t make sense to cancel an otherwise sensible project because defects in your process have aroused a lot of stakeholder outrage. It’s far better to apologize for the defects and redesign the process.
number 2
High outrage is itself a hazard. Sometimes the defects in your process have irremediably undermined the viability of your project.

For more on the complications of hazard solutions to outrage problems, see “Because People Are Concerned: How Should Public Outrage Affect Application of the Precautionary Principle?link is to a PDF file

I do still think good regulations help keep stakeholder outrage under control, though I was never able to convince clients of this point in the face of their ego and ideological reasons to dislike all regulations. But bad regulations can exacerbate outrage instead. Outrage at the regulator gets offloaded onto the company. Outrage at a poor engagement process gets projected onto the substance of an otherwise sensible project. The regulator weasels out of the outrage caused by its own maladroit regulatory activities by blaming and overregulating the company. Some of this sounds like it may apply to the new public participation law in the Netherlands.

Selling outrage management to senior executives

At the end of your comment, you raise a completely different question: how to sell my outrage management approach to senior corporate executives.

You rightly note that I often write about “internal alignment problems, corporate culture, individual psychological characteristics, etc.” You rightly claim that it’s “not so easy to have an open discussion on these things” with corporate officials. So you wonder whether belaboring these internal barriers might be a mistake. Wouldn’t it be wiser, you ask, to focus the outrage management sales pitch on its strengths, especially on its ability to reduce such costs as reputational damage and project delays and cancelations.

Should outrage management proponents sell its strengths or acknowledge its weaknesses? Both.

Of course proponents should explain the strengths of outrage management. And like you, I wish there were better evidence of those strengths. The stakeholder relations head of a worldwide mining company used to have a PowerPoint deck that I thought came close. It was built on examples from his own company – nothing like a random sample – but it did include actual numbers: “Here’s what it cost us when we angered people at this mine; here’s what it saved us when we listened to people at that smelter.” I thought he made a pretty decent empirical case to his company’s top management on the profitability of stakeholder relations. (On the other hand, that didn’t stop a new CEO a few years later from eliminating the company’s global stakeholder relations department altogether.)

At best, outrage management works the way insurance works. The cheapest outcome for a company is very little outrage and very little outrage management. The most expensive outcome is a lot of unmanaged outrage. Good outrage management is in the middle. Since it’s much more cost-effective to anticipate outrage than to chase it, a wise company invests in outrage management before the need is obvious and desperate. But how much outrage management? Too much wastes resources – like an insurance policy you didn’t need and didn’t use. But too little does far more damage than too much – like huge uninsured losses. So the goal, for the company as a whole and for each individual project, is as much outrage management as the people in charge think may be needed.

Explaining why outrage management is a worthwhile investment is a no-brainer.

But the downsides of outrage management are the elephant in the room – especially the biggest downside of all, internal outrage. Talking to outraged people as if they weren’t outraged invariably exacerbates their outrage. That’s just as true when a senior corporate manager is outraged about your outrage management proposals as it is when external stakeholders are outraged about a proposed project.

Senior managers are likely to be outraged at the specifics of a typical outrage management plan: apologizing for prior misbehaviors, acknowledging current problems, sharing control, setting up accountability mechanisms, staking out the middle, sharing credit, etc. They’re also likely to be outraged at your endorsement of outrage management in general, your suggestion that outrage management might be good or even necessary for the company, your insistence that there are in fact stakeholders who are outraged and ought not to be ignored. So you have to do outrage management on behalf of outrage management – that is, you have to manage management outrage at outrage management.

That absolutely requires acknowledging the reasons why top executives hate your outrage management proposal, no matter how difficult those reasons may be to talk about. Other factors cut the same way – among them ego and corporate culture. But management outrage at outrage management is by far the biggest elephant in the room.

One crucial tool for managing management’s outrage is the risk communication seesaw. Here’s how I put it in “Talking with Top Management about Risk Communication”:

There is an elegant symmetry at work here. Your stakeholders are too outraged at your management to take note of the data that the hazard isn’t all that serious. Similarly, management is too outraged at your stakeholders to take note of the data that stakeholder outrage is quite serious. Your stakeholders are more deeply committed to being proved right than to believing they are safe. Similarly, management is more deeply committed to being proved right than to doing a good job of managing stakeholder outrage….

Figure your boss is probably ambivalent about whether to manage her stakeholders’ outrage or give in to her own. As ambivalent people always do, she will emphasize the side of her ambivalence that everyone else seems to be neglecting. If you’re the voice of reason, apparently unruffled, calmly recommending concessions and compromises, you’re leaving your boss alone with her outrage – and she’s likely to act that much more offended and intransigent. So express some outrage yourself, and let her be the voice of reason.

Just as pure selling backfires vis-à-vis your project because you’re not acknowledging and addressing the concerns, objections, and grievances of your outraged stakeholders, in exactly the same way pure selling of outrage management inside the company backfires because senior management’s outrage isn’t being acknowledged and addressed. As a consultant I always told my clients how repellant my solutions were. If they wanted to get on the seesaw’s other seat and tell me my solutions weren’t really as repellant as I imagined, that was fine with me.

Why do outrage management when you can coerce or deceive people instead?

name: “Northern Thunder!”
This guestbook entry
is categorized as:

      link to Outrage Management index

field:Economist, former disaster communications guy
date:March 12, 2017


In light of recent revelations about CIA hacking and use of malware, how should the CIA manage the crisis about its use of malware of Russian and/or Ukrainian origin and the damage done to its messaging with respect to Russia?

It seems to me that the strategy you typically outline, and say may not appeal to Trump, is slightly different from what the CIA “should” do.

To “tell the truth” in proudly acknowledging the Agency’s use of many kinds of informational weapons would help the CIA’s case. But it can hardly do that while admitting wrongdoing, can it? So why not just continue the public witch hunt against leakers and other “internal enemies and traitors”? Is this not a case where, whatever the damage to the nation as a whole, the CIA’s interests (to the extent it has any separate from the interests of the presidency) would be better served, not by admitting fault, not by telling the truth, not by acknowledging other parties’ merits, but merely by promoting McCarthyite public hatred of whatever fall guy the CIA chooses?

I ask this not because of any political preference, but because I am led to wonder if the excellent – amazing – approach you normally advocate is one that works better for organizations that do not have control over the means of coercion in society. If you are at the top of the food chain, does it not make more sense to lie and bully? I mean, Kremlin propaganda is very effective at that. And CIA messaging normally is too. Why should it change tack?

peter responds:

Decades ago I was hired to give an outrage management seminar to an audience of South Carolina business leaders. I was approached at lunch by the owner of a small town textile mill. He told me he was aware of substantial community outrage aimed at his company and him personally. But he was the town’s only big employer, and nobody dared offend him. Since people nearly always swallowed their outrage anyway, he asked me, “Why should I follow your advice about ways to reduce outrage?”

The same question arose, in roughly the same time period, when I did a couple of days’ work for PDVSA (Petróleos de Venezuela), the government-owned Venezuelan oil company. Management had flown me to Caracas based on some notion that it might be worthwhile to try to reduce very high levels of citizen and employee outrage at the company (and by extension at the government itself). But executives responded to my every suggestion by pointing out that they didn’t really have to compete in a market economy or a free marketplace of ideas. Citizens and employees had no safe ways to express their outrage, they said (or at least implied). So wouldn’t it be easier to just keep on outraging their stakeholders?

I don’t entirely understand your comment, but I think you’re raising the same question with regard to the U.S. Central Intelligence Agency. You believe the CIA has considerable ability and willingness to coerce and deceive. As long as it can “lie and bully,” as you put it, doesn’t that mean the CIA has very little use for outrage management?

I’m not going to take a stand on any of the substantive issues you seem to be basing your comment on:

  • I don’t know to what extent the CIA routinely coerces or deceives Americans.
  • I don’t know whether the CIA might be responsible for the election hacking into Democratic Party secrets, which the U.S. intelligence community has attributed to Russian spies, not American spies. I get it that the CIA knows how to mount that sort of false-flag operation. I don’t quite see why it would seek to undermine first the Clinton candidacy and then the Trump presidency – but spy-versus-spy scenario-building isn’t my métier. If the CIA did want to do that, would ethics or law deter it? I have no professional opinion on that either.
  • I don’t know whether the Obama administration might have wire-tapped the Trump campaign, nor whether the Trump campaign might have conspired with the Russian government.

All that is way beyond my risk communication expertise.

But I certainly agree with you that coercion, deception, and outrage management are alternative ways to keep stakeholders from interfering with an organization’s activities. To the extent that a government agency or corporation finds coercion and/or deception a successful and acceptable modus operandi, it would have that much less use for outrage management. More broadly, an organization has little or no use for outrage management to the extent that any of the following three conditions is met:

number 1
Stakeholders aren’t outraged, and aren’t likely to get outraged, about what the organization is doing. Either the organization’s actions are reliably anodyne or its stakeholders are reliably inattentive or apathetic.
number 2
Stakeholders would be outraged if they knew what the organization is doing. But the organization is successfully deceiving them, expects the deception to remain successful, and is comfortable with that approach.
number 3
Stakeholders are or soon will be outraged. But they’re pretty powerless. Coercion is working, is expected to continue working, and is an approach the organization finds congenial. For the organization, therefore, the cost of outrage is lower than the cost of outrage management would be.

I must add a fourth criterion as well. Outrage has societal value because it motivates action to reduce hazard. For society at large, therefore, outrage management is unarguably appropriate only when the outrage is too high, higher than the hazard justifies. That is, people are more outraged than they ought to be; what the organization is doing deserves less outrage than it is provoking or likely to provoke. (Of course those outraged stakeholders undoubtedly disagree, and some experts may disagree too.) I think there’s also a case for what I called in a 2008 column “Managing Justified Outrage: Outrage Management When Your Opponents Are Substantively Right.” But when the outrage is justified, managing it down is a lot more debatable – especially when organizations decide to manage the outrage down instead of mitigating the hazard.

I think it’s pretty obvious that outrage management is more a more ethical way to minimize stakeholder interference than coercion or deception (though there are ethical objections to outrage management too). And I think it’s pretty obvious that outrage management is better for the society as a whole than coercion or deception. Calming down people who are more outraged than a situation justifies is preferable to coercing people or deceiving them. But I am not an ethicist. And my clients have typically been more preoccupied with their own interests than the interests of society as a whole. So the operative question for them is whether outrage management will serve their interests better than coercion and/or deception.

The main problem is that even when the question is framed in terms of their own interests, most organizations don’t do a good job of figuring out the answer.

For one thing, my clients have typically underestimated how outraged their stakeholders are, and how outraged they’re likely to become. Virtually every time a client has commissioned actual research on stakeholder attitudes, the data turned out more negative than the client expected.

That’s probably inevitable. Outraged stakeholders often avoid contact with the source of their outrage, so the people my clients had contact with were systematically less hostile than the people they never saw. And when they can’t avoid contact, outraged stakeholders often hide their outrage right up until they’re ready to do battle – especially in a company town (or in the Washington bubble, perhaps). And of course it’s normal for humans and human organizations to think they’re more liked or less disliked than they actually are.

Although I can’t know for sure, I suspect my clients have also typically overestimated their ability to deceive their stakeholders. For decades I have routinely advised clients that they would be wise to reveal their own guilty (or merely embarrassing) secrets, on the grounds that bad news does roughly twenty times as much reputational damage when it’s revealed by opponents or whistleblowers as when it’s acknowledged proactively by the organization itself. This advice seldom made much headway. I don’t think my clients doubted the 20x factor. I think they imagined they had better than a 19-in-20 shot at keeping their secrets secret.

Most importantly, my clients have almost invariably underestimated the power of stakeholder outrage to do them harm.

One reason why my clients underestimated the power of stakeholder outrage was motivated self-deception: They were looking for reasons to avoid having to embrace outrage management. The core strategies of outrage management link is to a PDF file – acknowledging prior misbehavior and current problems, admitting the things your opponents are right about, sharing control and sharing credit, etc. – are antithetical to organizational culture and management egos. (See “The Boss’s Outrage (Part III): Managing Management’s Outrage at Outrage Management.”) My clients were strongly motivated to find reasons why my advice was mistaken. The more I told them about how best to ameliorate stakeholder outrage, the more tempted they were to decide that their stakeholders weren’t all that outraged after all.

Another reason is historical. Many developments in recent decades – from social media to socially responsible investment – have ramped up the power of stakeholder outrage. Critics and victims who used to suffer in lonely silence have new tools to find each other and recruit newcomers, mobilizing a movement or a lawsuit or even a rebellion. A senior executive who came up through the ranks when stakeholder outrage was close to impotent might understandably fail to adjust to its increased power today.

But even in olden days when today’s senior executives were learning the ropes, coercion and deception were risky strategies. Perhaps a better way to put it is that coercion and deception have always been “leaky” strategies. As Abraham Lincoln is supposed to have said about deception, “You can fool all the people some of the time, and some of the people all the time, but you cannot fool all the people all the time.” I assume the CIA knows that.

As for coercion, obviously it too can fail. The long list of deposed dictators is testimony to that. And even before it fails, coercion is costly. Suppressed outrage leaks in a variety of passive aggressive manifestations. The impact on morale, for example, is substantial; it’s not fun to be hated, even if the people who hate you keep their lips buttoned. I’d give odds the CIA tracks its reputation and looks for ways to be more loved and less hated.

It’s worth noting that every dictatorial regime lives in fear that its populace might rebel, and therefore looks for ways to diminish its public’s outrage. As I conceded at the start of this response, outrage management is an alternative – a preferable alternative, in my judgment – to coercion and deception. But because coercion and deception are leaky, even the most coercive and deceptive organizations also have use for outrage management.

That’s not quite what I answered the South Carolina mill owner who asked me why he should bother with outrage management when his outraged neighbors were too dependent on him to voice their outrage. I answered that at least in the short term he might be right in eschewing outrage management. But his town and his factory were ripe for an activist organizer, I said – and for a controversy that would convert latent outrage that wasn’t doing much damage to his bottom line into manifest outrage that was. Since he wasn’t yet interested in nipping the problem in the bud with outrage management, I would be happy to work with a union or an environmental group to bring it to flower instead. Or someone else would. And when that campaign succeeded in raising the outrage level to the point where, at last, outrage was costlier to his business than outrage management would be, then maybe he would belatedly give outrage management a try.

Possible kratom ban: what kind of risk communication?

name: Leah Staub
This guestbook entry
is categorized as:

      link to Outrage Management index      link to Precaution Advocacy index      link to Crisis Communication index

field:Volunteer activist
date:February 12, 2017
location:Washington, U.S.


I’m writing you to seek advice on outrage management and risk assessment regarding the plant kratom, which is often used as a supplement in the United States and which is under direct attack by the DEA and the overarching Drug War mentality.

I’m compelled to write anyone and everyone due to the sheer potential impact this plant can have in the lives of those suffering from chronic pain, addiction/alcoholism, PTSD, and other anxiety disorders. I am a human being – flesh and blood and cells and DNA – who has used this plant as an addition to my therapies in treating my PTSD and alcoholism.

Unfortunately, there is a stigma associated with my journey. The American Kratom Association (YES! There is an association!), spearheaded by the ferocious Susan Ash, has been trying to point out the many communities of individuals who use this plant in conjunction with their daily regimen of prescription medications, other supplements, and other therapies. Surprising even to me, there is a large community of veterans who use kratom as a replacement for the opiates they have been prescribed by the VA for years. In using kratom for their pain, they came to find out the many benefits this plant has on another debilitating ailment that many veterans suffer from, PTSD.

The kratom plant is grown in Thailand and other areas of Southeast Asia. It is usually ground and used as a tea. Kratom is indeed illegal in Thailand and has been for decades. Quite honestly, this is because people began using kratom instead of going to opium dens. The only reason kratom was made illegal there was because the government could not profit from it through taxes.

A few months ago I got a group of five kratom users, including myself, to have a successful meeting in our Senator Patty Murray’s office. Although we were unable to garner the outward support of the senator herself, the woman we spoke to said that she was enthralled by our stories and that she would, herself, spread awareness as best she could. There was also a “Dear Colleague” letter that was successfully passed along through Congress and signed by many congressmen across the country.

The DEA is compelled to schedule kratom as a Schedule I drug. Unfortunately, this is in large part due to its unregulated nature and the fact that it has been marketed in head shops in a similar fashion as other synthetic “legal highs” such as spice. Honestly, kratom is a lousy high. At best, it feels as if you drank the best cup of coffee on the block, just without the jitters. In fact, the kratom plant is in the coffee family.

The DEA has also cited a little over a dozen deaths “associated” with kratom. This is misleading, as it only takes a couple of minutes of taking a closer look at these cases to see that there were other substances being taken alongside kratom. In fact, many heroin users often take kratom to wean themselves off of their doses and hopefully maintain complete sobriety. I wouldn’t be at all surprised if some of these cases involved stories like that – stories that unfortunately led to an overdose and death.

The kratom community and many other well-informed citizens shot back and we successfully got the DEA to drop their letter of intent to schedule kratom in order to allow for public comment (which they originally denied us). This unusual move by the DEA resulted, in part, from the overwhelming response they received. The main motivator (I hope) is the blatant tragedies that plague our country on a daily basis.

I don’t have to list off the statistics regarding opioid-related deaths in this country. I don’t have to list off the statistics regarding alcoholism and the damage it causes to families, businesses, and lives in general. I don’t have to list off the statistics regarding mental illness and how it is often associated with the above afflictions.

You know that if kratom is scheduled in the way the DEA and FDA want it scheduled, it will not be studied in the manner that it needs to be studied. We, as a community and as desperate people, are reaching out with arms wide open for anyone who wants to learn more about kratom and its many benefits. We wouldn’t be asking for it to be studied if we believed it to be anything other than what it is.

I’m wondering what we can do as a community to allow for the public to get the entire picture without their preconceived notions impeding their understanding.

peter responds:

I have to start with a disclaimer. Your comment mentions kratom “risk assessment” – something I’m not qualified to do. There’s a lot of hot argument and not much data about how risky it is to self-medicate with kratom, versus its possible benefits, which are also hotly disputed. Nobody should rely on a risk communication expert for guidance on kratom safety or efficacy!

That said, in preparing to respond to your comment I spent a couple of hours reading readily available online sources on kratom. Risk communication aside, I emerged with the following tentative impressions about the technical pros and cons:

  • The evidence on kratom benefits is both scanty and mixed. An awful lot of people testify, as you do, that they have found it a useful self-prescribed treatment for pain, PTSD, and/or addiction – often more useful than anything else they’ve tried. Plenty of others say it didn’t help them at all. Even allowing for a placebo effect, it seems pretty clear that kratom does help some people cope with some very debilitating conditions. And it’s completely clear that some people without debilitating conditions consider kratom a pleasant addition to their lives.
  • The evidence on kratom risks is also scanty and mixed. As you say, most or maybe even all the deaths “associated” with kratom could be due to other drugs, either contaminants in the kratom itself or simply taken more or less at the same time. We’re not talking about a lot of deaths; kratom use has skyrocketed in recent years while reports of kratom deaths really haven’t. But reports of lesser kratom downsides are widespread. Wikipedia lists nausea, constipation, elevated heart rate and blood pressure, liver toxicity, trouble sleeping, seizure, psychosis, and possibly respiratory suppression.
  • The most documented risk of kratom is addiction. Super-effective pain relievers usually turn out to be addictive, which is why we have an opioid epidemic in the first place. And despite what you say in your comment, the evidence that kratom is addictive or something like addictive for many users seems pretty strong to me. Plenty of people, including some who rhapsodize about kratom’s benefits, say it’s hard to do without once you’re used to it. Much depends, of course, on whether it’s addictive like opioids or “addictive” like its botanical cousin coffee. Much depends on whether its benefits include helping people get off other, potentially worse addictions. And much depends on whether it does serious harm aside from its addictiveness; a harmless addiction (if that’s what kratom turns out to be) is arguably not such an awful thing.
  • Nobody is trustworthy on these issues. It is typical for enthusiasts to overestimate the benefits and underestimate the risks of a new drug craze (whether herbal or pharmaceutical). It is also typical for regulatory agencies to want to regulate anything new, especially if it’s psychoactive and feels good, and therefore to overstate its risks and understate its benefits. The DEA in particular has earned its reputation for kneejerk overreaction since President Nixon established it in 1973 to conduct “an all-out global war on the drug menace.”
    • In the absence of good data, the main questions about kratom are values questions, not technical questions. Which side should bear the burden of proof, and which should get the benefit of the doubt? Should we assume kratom is useless until its effectiveness is proven, or deem it effective until it’s proven useless? Is it safe until proven dangerous or dangerous until proven safe? And should the government leave individuals free to answer these questions for themselves, or should it impose societal answers as a matter of public policy?

      The Drug Enforcement Administration is famously keen on imposing societal answers. That’s its mission: to prevent individuals from “abusing” drugs – that is, from using them in ways that the DEA has decided are unwise.

      Kratom was legal in the United States until August 31, 2016, when the DEA suddenly announced that kratom use was such a serious public health emergency that it was bypassing the ordinary slow-moving government decision-making process. Effective September 30, it said, kratom would be banned as a Schedule I drug. The DEA defines Schedule I drugs as those “with no currently accepted medical use and a high potential for abuse,” including heroin, LSD, marijuana, and Ecstasy.

      The result was an outpouring of protest from the public and some members of Congress – an outpouring you were part of. The pushback worked. On September 29, in what was apparently an unprecedented response, the DEA announced that was suspending the ban and would instead open up a public comment period until December 1.

      It received 23,210 comments, all of which it promised to consider (alongside technical guidance from the FDA) before making a decision about kratom.

      As I write in mid-February 2017, no date for that decision has been announced. So everything’s in limbo. The DEA could renew the emergency and institute an outright ban; or prolong its consideration pending more comment and maybe more research; or revert to its routine process (which might end up in the same place); or propose that kratom should be regulated rather than banned (which would put it more in the FDA’s bailiwick).

      Nor is it clear how the 2016 election results might affect the DEA’s decision. Republicans are generally opposed to regulatory overreach and likelier than Democrats to let freedom ring when the evidence is mixed. On the other hand, they’re not generally fans of recreational drugs, which they seem to view as consumed mostly by hippie Democrats. As for President Trump, there’s some speculation that his criticisms of Big Pharma might incline him to support the continued legalization of kratom, a small business herbal competitor – especially if he accepts the narrative that Big Pharma is behind the anti-kratom campaign because it intends to market its own version and wants to clear the way first. The simple fact that the Obama administration tried to ban kratom might be enough to convince Trump to order the DEA to reverse course. But to the best of my knowledge the new President has never taken a position on this issue, and nobody would be truly surprised by any position he chose to take.

      Risk communication diagnosis

      The question of interest to me is what sort of risk communication the kratom ban calls for.

      If you’re on the DEA’s side of the controversy, the answer to that question is perfectly obvious. Your task is precaution advocacy, aimed at diminishing kratom use. At least three kinds of precaution advocacy are called for:

      • Warning kratom users and prospective users that kratom is dangerous and they shouldn’t use it.
      • Warning users and prospective users that they shouldn’t use kratom even if they doubt the danger warning, because it’s about to become illegal (this part of the warning is on hiatus at the moment) and they don’t want to end up addicted to an illegal drug.
      • Warning society at large that kratom use threatens us all, that it’s part of an overall drug menace and we should support its illegalization.

      Of course the DEA and its allies have no business making these arguments unless they believe the arguments to be true. I have zero reason to doubt their sincerity, just as I have zero reason to doubt yours. Either side may turn out right or wrong – or, likelier, both sides will turn out partly right and partly wrong – but I take it as a given that both sides believe what they say.

      That doesn’t mean the DEA is necessarily always completely candid in its attacks on kratom. In my decades of consulting on hundreds of risk controversies, I have never had a client I thought was completely candid. Typically, my clients genuinely believed they were right. So did their opponents. Secure in their “rightness,” both sides told lots of half-truths, cherry-picking facts and framing arguments in ways that were often one-sided and even misleading but rarely outright lies. This website is full of examinations of various sides’ half-truths with regard to all sorts of risk controversies, from e-cigarettes to Zika.

      I’m not knowledgeable enough to catch most of the DEA’s half-truths about kratom … or the American Kratom Association’s. But I assume they’re there. And whenever people are outraged – as the DEA’s side is outraged about kratom risks and your side is outraged about the DEA’s proposed kratom ban – they’re that much likelier to resort to half-truths, and to feel justified in doing so. At least in the short term, one-sided messaging is actually more effective than two-sided messaging when talking to allies. But of course it can be devastating to credibility when the audience is neutral or hostile. One of the toughest tasks I have faced in my consulting is helping clients manage their own outrage so they could do a better job of policing their own half-truths.

      However scrupulously or carelessly the DEA adheres to its vision of the truth, its proper risk communication strategy is obvious: to warn people about kratom risks.

      But you’re on the other side. You’re trying to fight the kratom ban. And your risk communication task is more complicated. Let me break it down.

      number 1

      Kratom outrage management

      In most risk controversies, when one side’s task is precaution advocacy the other side’s task is outrage management. One side is warning people that X is dangerous; the other side is reassuring people that it’s not.

      Your outrage management challenge, then, is to reassure people who are upset about kratom that it’s a safe, pleasant, coffee-like herb. (You’re entitled to say this because you genuinely believe it, just as the DEA genuinely believes you’re mistaken.) Such reassurances might be addressed to kratom users who are worried about its health effects, or to members of the general public who have “learned” that kratom is a threat to the nation’s health, or to potential influencers such as journalists and legislators.

      When I first started paying attention to kratom, after receiving your comment, I assumed that outrage management would be the principal task facing kratom proponents. But as I looked into it – superficially, I hasten to stress – I got the strong impression that there wasn’t a lot of kratom outrage to manage. I couldn’t find a lot of kratom users desperate to free themselves from kratom addiction, or even worried that their fondness for kratom might turn out harmful to their health. I couldn’t find a lot of non-users upset that kratom-crazed neighbors might accost them on dark corners or that kratom-lulled drivers might veer into their highway lane.

      The vast majority of the kratom-related outrage seems to come from your side – from proponents outraged that kratom could be outlawed at any moment. I read through the comments sections of a couple of dozen news stories about kratom. Without exception, the majority of comments and the overwhelming majority of outraged comments came from kratom proponents. The DEA’s September 2016 announcement suspending its scheduled kratom ban was explicitly in response to your side’s outrage … and, I have to think, to the absence of much outrage from the other side. Fifty-one members of Congress, both Republicans and Democrats, sent letters to the DEA urging it to reconsider; the letters I saw cited constituent concern (outrage) about the proposed kratom ban, not about kratom itself.

      DEA spokesman Melvin Patterson commented: “I have been with the DEA for 20 years and have never seen this level of public response…. We have heard from a lot of people who self-medicate with this for pain and opioid addiction…. We just want to make sure it’s safe.”

      DEA spokesman Russ Baer took a somewhat different line: “Based on the response we’ve gotten over the last month or so, we believe it’s [delaying the ban] the prudent and reasonable action to take…. We want to make sure this is a transparent process. We want to have an open dialog with the public.” But Baer warned that “DEA still firmly believes kratom is dangerous and is harmful.”

      Kratom proponents should stay alert to the possibility that the DEA or its supporters might launch a campaign to arouse public outrage about kratom, to counter users’ outrage about banning kratom. If that starts to happen, and especially if it starts to succeed, kratom outrage management could become a priority. But for now, I don’t see much of a kratom risk controversy. The controversy is about the DEA’s proposal to ban kratom.

      Or to put the point differently, so far there’s not much of an audience for kratom risk communication – just stakeholders who already know what they think. There’s the DEA and its allies (perhaps including the pharmaceutical industry), stakeholders committed to banning kratom. And there’s your community of kratom users, stakeholders committed to preventing the ban. So far the general public seems to be sitting this one out.

      number 2

      Kratom crisis communication

      With little need for outrage management aimed at the general public, the risk communication priority for kratom proponents is crisis communication aimed at your community of users. For contented (or dependent) kratom users, the possibility of a kratom ban is indeed a crisis: high-hazard, high-outrage. Your core crisis communication message to these stakeholders is obviously that “Our access to this vital part of our lives is threatened. We must act now to stop the ban. The need is urgent. Here’s what to do….”

      Judging from results, kratom proponents are already highly skilled at crisis communication. You won an unprecedented victory against the DEA last year, mobilizing sufficient pressure to get it to back down from its plan for an immediate ban and instead open up a public comment period. And you kept up the pressure. When the comment period ended on December 1, 2016, the DEA had received more than 23,000 comments. According to an analysis on the American Kratom Association website, 99.1 percent of the comments opposed the ban.

      The analysis quotes Katie Lair, research and communications director of the American Coalition of Free Citizens (an organization founded in 2016 after kratom was successfully banned in Alabama “to defend the rights of people to access and choose safe and natural ethnobotanical/herbal alternatives to prescription drugs”):

      The most curious thing about the public comments is that there were so few responses actually supporting the DEA. Only 113 people out of 23,116 commented in support of the DEA proposal to ban kratom. When you have so much anti-kratom propaganda circulating at the state level and misleading talk of a public health crisis, one would expect more public comments in support of what the DEA is trying to do…. There is no public appetite for banning kratom and continued fierce opposition can be expected by anyone who cares to do so.

      Proponents, in short, have done a spectacularly good job of mobilizing user outrage about the crisis of a possible kratom ban, while critics have failed to arouse much public outrage about the risk of a possible kratom epidemic.

      By contrast, a lot of public outrage has been successfully mobilized about the U.S. opioid epidemic – sufficient outrage to make the horrific opioid addiction crisis a significant issue in the 2016 presidential race. This could cut either way vis-à-vis the kratom controversy. People could see kratom as opioid-like and thus as part of the epidemic, or they could see kratom as an opioid substitute and even an opioid cure, and thus as a response to the epidemic that should be nurtured, not foreclosed. At least so far, the latter view has clearly won the day. Users obviously see kratom as a solution to opioid addiction, while the general public seems to have no opinion on kratom one way or the other.

      Bottom line: I don’t think kratom proponents need a lot of crisis communication advice from me.

      number 3

      Kratom precaution advocacy

      I do wonder if there’s a risk that the anti-ban pressure could subside prematurely. In any ongoing controversy, it’s a challenge to sustain supporters’ sense of crisis, especially in the face of victories. Kratom proponents’ September 2016 victory over the DEA was explicitly temporary. The threat of a ban isn’t over, just on hold.

      The public’s interest in kratom, never very high, has certainly subsided. I just looked at a Google Trends graph of U.S. searches for the past 12 months. The baseline was stable until the end of August. It rose precipitously in early September when the DEA announced the ban, then started declining – especially after the ban was put on hold at the end of September. By November the number of kratom searches was stable again, at a significantly higher baseline than before September but way below the September surge.

      If the decline in kratom Google searches signals a decline in kratom users’ outrage about a possible ban, then there may be a need – now or soon – for kratom precaution advocacy: high-hazard, low-outrage risk communication. For a rundown on my basic precaution advocacy recommendations, see “‘Watch Out!’ – How to Warn Apathetic People.”

      This oscillation between crisis communication and precaution advocacy isn’t unusual. Here’s how it works:

      • Before a crisis, the chief risk communication task is typically precaution advocacy: warning insufficiently outraged people (insufficiently worried, angry, or otherwise upset) that the risk is serious.
      • When the risk becomes obviously serious, the problem of provoking outrage is replaced by the problem of helping people bear their outrage and respond wisely to the threat. That is, crisis communication replaces precaution advocacy as the dominant paradigm.
      • When the risk is past, crisis communication typically gives way to outrage management. Since people are no longer endangered, they’re ready to focus on questions of blame: Why did you let this happen? Why didn’t you warn us? Why didn’t you prepare better? Why didn’t you manage the crisis better? Responding to these sorts of accusations calls for outrage management.
      • But sometimes the risk isn’t past, but people’s sense of crisis has subsided, at least for the moment. High outrage is hard to sustain, even if the level of hazard is still high. So you’re back in high-hazard, low-outrage territory, and the reigning risk communication paradigm is once again precaution advocacy.

      That may be where the kratom controversy is headed.

      number 4

      Kratom support mobilization

      I just looked over my list of 25 generic crisis communication recommendations link is to a PDF file – and I’m not convinced that kratom proponents have much need for them. Apart from the fact that proponents have been doing a fine job of crisis communication already, the focus of my recommendations isn’t right for the sort of crisis communication challenges you’re facing.

      My focus is on two main tasks: helping people bear their justified outrage and helping them choose wise rather than unwise precautions. Thus my recommendations are things like: Don’t over-reassure; err on the alarming side; acknowledge uncertainty; don’t aim for zero fear; tolerate early over-reactions; acknowledge errors, deficiencies, and misbehaviors; etc. My crisis communication prototype is a government agency helping community residents cope with a high-hazard, high-outrage event like a natural disaster or an infectious disease outbreak.

      Your sort of crisis communication is a bit different. Your audience, an audience of stakeholders, is kratom users who are outraged that the DEA wants to ban a product (supporters say “herb”; opponents say “drug”) they rely on. You’re not so preoccupied with helping them bear their outrage or avoid responding unwisely. Your main task is to convert them from passive stakeholders to movement activists – to mobilize their outrage into politically effective action.

      Check out my 2016 column on “Three Ways to Manage Controversies.” It compares three alternative strategies for managing controversies (plus a fourth strategy: deciding to let the controversy rage unmanaged). You can focus on arousing your supporters; that’s support mobilization. You can focus on reaching out to neutrals; that’s public relations. Or you can focus on ameliorating the opposition; that’s outrage management. The column champions outrage management, arguing that it is too often neglected – and that for many sorts of controversies calming opponents’ outrage does more good than intensifying supporters’ outrage or appealing to neutrals.

      My prototype for the sort of controversy where outrage management is preferable to support mobilization or public relations is a regulatory battle. A low-outrage climate of opinion is more conducive to regulatory approval than a high-outrage climate. So calming opponents has more payoff than riling up supporters or attracting newbies; the fewer people who bother to come to the hearing, the better the prospects for getting the regulators’ green light.

      But in the case of kratom, there is no neutral regulator. The decision-maker is your principal opponent. So a low-outrage climate isn’t in your interest; it would just leave the DEA free to move forward with its plans for a ban. You need a lot of outrage against the ban. Among my three ways to manage controversies, I think support mobilization is by far the highest priority for kratom proponents.

      Public relations comes second. You don’t need to reach out to neutrals as much as you need to keep kratom users aroused and active. But reaching out to neutrals is still worthwhile. I’d be especially keen to look for potential ideological allies – libertarians, for example, who aren’t necessarily kratom users or kratom supporters or even herbal medicine supporters, but are hostile to regulatory overreach. Supporters of marijuana legalization, among the most successful movements of its sort ever, might be another worthwhile constituency for kratom proponents to appeal to. A third audience of currently neutral potential supporters: people with chronic pain, PTSD, alcoholism, or other medical conditions that kratom might alleviate.

      And I wouldn’t neglect outrage management altogether. I have already mentioned the need to stay alert to the possibility that critics could start arousing widespread public outrage about kratom risks, necessitating an outrage management response from your side. (If the DEA starts doing good public relations and precaution advocacy, in other words, you need to respond with outrage management.)

      Also worth mentioning is the unlikely but enticing prospect of trying to assuage the outrage of the DEA itself. Bear in mind that what looks like anti-kratom outrage on the part of DEA officials may well be rooted in grievances unrelated to kratom. The DEA has fought a decades-long losing battle against marijuana in particular and recreational drugs in general. Society’s attitudes toward drug use have turned decisively against the DEA position – to the point where the agency is widely despised as a villain or, worse yet, mocked as an anachronism. The DEA has reason to be outraged that ordinary folks feel like they ought to be allowed to decide what risks to take with their own bodies; outraged that ordinary folks think they can assess drug risks on their own; outraged that Congress keeps insisting on a distinction between “drugs” and “herbs”; etc. All these blows to organizational ego are probably germane, and may be key, to the DEA’s position on kratom. I wonder if there are ways to disentangle kratom from DEA’s broader outrage and its embattled self-image.

      I also wonder if there are ways to help the DEA back down gracefully from its anti-kratom hard line. One that occurs to me offhand is to let the agency convince kratom proponents that it’s okay to regulate product purity. (As an uninvolved and largely uninformed neutral, I find it perplexing that so many kratom proponents insist simultaneously that the health downsides attributed to kratom are actually caused by contaminants, that it’s not fair to blame these contaminant effects on kratom, and that the government has no business regulating kratom purity.) Find a way – not necessarily this way – to be inside the government’s regulatory regime, so the DEA can declare victory, bless you, and let you go on using and promoting kratom to your heart’s content.

      Insofar as you try to assuage the DEA’s outrage at kratom, you may also need to assuage supporters’ outrage at the DEA – and at you for “backing down” on your vilification of the DEA. One of the common downsides of any outrage management strategy is supporters’ outrage at the strategy. So any time you set out to manage your opponents’ outrage, you typically need to manage your supporters’ outrage about your outrage management strategy. (See my 2007 column on “Managing Management’s Outrage at Outrage Management.”) A similar problem is likely to arise if you succeed in getting the DEA to abandon its quest to ban kratom. Having done a superb job of arousing, sustaining, and mobilizing kratom users’ outrage, you may not find it easy to convince them to win graciously – to let their outrage go when it’s no longer needed.

      Still, all that is secondary. The main risk communication priority for kratom proponents is the special sort of crisis communication I call support mobilization – alternating with precaution advocacy when your constituency’s outrage has subsided and needs to be revived.

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