COCA Conference Call –Crisis and Emergency Risk Communication: Pandemic Influenza
(January 23, 2007)

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COCA Conference Call
Crisis and Emergency Risk Communication: Pandemic Influenza
Barbara Reynolds
January 23, 2007

Coordinator: This is the conference operator. Please continue to stand by. We will begin this call of CERC momentarily. Thank you again. Please continue to stand by for CERC. Good afternoon and thank you for joining today’s conference. I would like to remind all parties that you will be listening only until the question and answer portion of today’s call. I would also like to remind you that this call is being recorded. If anyone has any objections, you may disconnect at this time. And now, I’d like to turn the call over to Dr. Hadzibegovic. You may begin, ma’am.

Diana Hadzibegovic:  Thank you, Deb. Good afternoon to everyone. This is our first COCA conference call this year. And I am pleased to introduce our speaker, Barbara Reynolds, who was so kind to do another conference call for us. Today’s topic is Crisis and Emergency Risk Communication for Pandemic Influenza. And the objectives for today’s COCA conference call are the psychology of severe influenza pandemic and what kinds of messages the public will need from their public health professionals; why stigmatization occurs and how officials can respond and discourage it; the importance of strengthening community hardiness and personal resilience to provide the optimal opportunity for recovery from the crisis; how to incorporate loss, grief, and mourning rituals in communication to the community while respecting cultural differences.

Barbara Reynolds, the speaker for today’s COCA conference call, has been with the CDC since 1991. Her communication expertise has been used in the planning of response to pandemic influenza, vaccine safety, emergency disease outbreaks, and bioterrorism. Internationally, she has acted as a crisis communication consultant on health issues for France, Hong Kong, Australia, Canada, former Soviet Union nations, NATO, and the World Health Organization.

Barbara is the author of many books and she also wrote Crisis and Emergency Risk Communication Pandemic Influenza which was the basis of an HHS training course taught nationwide this fall.

PowerPoint slides for today’s COCA conference call, you can find if you go on www.bt.cdc.gov/coca. Barbara, we are glad to have you today. You may begin.

Barbara Reynolds: Thank you, Diana. I’m going to start with a little background on Crisis and Emergency Risk Communication, which we have shared in a COCA call in the past. But I think it’s important to reinforce that everything in Crisis and Emergency Risk Communication principles, that we talk about generally, apply to the issue of pandemic influenza. So, we don’t want to lose sight of those principles so I’m going to review them in this context.

And then, with the support of the Department of Health and Human Services, as Diana mentioned last year, we developed a course book specifically for pandemic influenza that went deeper into some issues that might be explored more completely for the context about severe pandemic influenza. And then, we did take this training course on the road this last fall for the ten Health and Human Services regions and taught the courses. And we hope that perhaps some of you had the opportunity to attend that training while we were out on the road; but if not, this is perfect way to get a short introduction. That course was a day-and-half training and so this is going to be a challenge to see how much of that I can share within a short hour and also give you an opportunity to do some Qs and As, which I promise I will make sure we have time for that. So I’m just going to briefly, again, give you an overview of Crisis and Emergency Risk Communication principles and then go into some highlights of some of the training materials that we had developed last year. And I hope I can remember to tell you when to switch slides; but if not, it’ll probably be kind of obvious along the way.

Basically, the reason we developed the concept of Crisis and Emergency Risk Communication as a new area of communication study is because we understand that in a crisis situation the way people take in information actually changes. In fact, the research tells us that people use a different part of their brain; they actually use the more primitive part of their brain, that part that does fight or flight, and that the way we take in information processes and act on it actually changes, and if that changes, then I think that the way we approach our communication with people in a crisis situation have to change also.

Now, the part that changes when people are feeling threatened so when an individual feels that their well-being; the well-being of their family; the well-being of their pets, actually; or their economic well-being, if you’re in a developed country; is feeling threatened, then the way we process information changes.

And so, therefore, the way we communicate to people in a crisis situation has to change too. And that - it could be a mass crisis or it could be an individual feeling threatened in some way. So these principles work in big disasters, they also work in individual situations, but the principles work nonetheless.

One thing I do want to stress is that for those of you who have to run to another situation or little crisis of your own and can’t stay for the whole hour; I want you to know that there are three concepts that are most important for you to take away from this, that when you’re talking to people who are in a crisis situation, that the best things that you can do for them in a crisis communication setting is to have an empathetic message, meaning that you’d let them know that you understand how they feel. It’s not necessary for you to feel what they feel, but it is important that you have an empathetic tone in the way that you talk to them.

It’s also important, whenever you can, to give them something to do. The research finds that when people are feeling uncertain and anxious, giving them something to do makes them feel better. And it’s also important that all of your communication with people is respectful. So there are three words. If you have to write down anything out of this, you write down three words: action, empathy, and respect. You’ll have the gist of what I’m going to talk about in the short hour. So I got that upfront and then I don’t have to worry if you have to go away at some point along the way.

Next slide.

It’s important to understand what people want from its response officials in a crisis situation, including in a pandemic situation or a pre-pandemic situation. They want the facts. They want to know what we know. They also want to have their decision making empowered and that is obviously the facts. The more facts that they could get from us, facts that they understand, the better they feel about it. They don’t necessarily want us making the decisions for them -- at some point, they may -- but the more that they are given the information so that they feel that they are making their own decisions, the better they feel in the situation. They want to be involved as participants not spectators. That’s why it’s important to give people things to do. They want to make sure that when they’re watching, they want to make sure that we’re using their resources, their tax dollars well. So they want us to be accountable for how we use their resources. And then, they want, of course, to get back to normal as fast as possible.

Next slide.

What do we want in terms of our communication? What do we want to achieve in a crisis situation? Well basically, what we typically want to do is we want to be able to get our job done. And for the most part, when I approached this concept of crisis communication, I was looking at this from a “them and us” situation and it was like “How do get them out of the way so we can get our job done?” And there’s still that element of this in here.

But what I found out is if we give them what they need so that they can achieve what they want, we can achieve what we want which is to go about doing our job and instead of it being “them and us” if we could partner with the public and our stakeholders in a crisis situation, we can do our job and they can do their job and ultimately, we’re all doing the same job which is getting the community back to normal as quickly as possible and, by the way, maybe reducing the number of people who become ill or die in that crisis situation.

And you can see especially in a severe pandemic situation that there are some things that we may be asking the community to do to reduce the number of people who become ill or die and I think that it’s very exciting. I believe that there is an opportunity in this crisis situation or this public health problem for risk communication, for crisis communication to really be on the front line.

We often take a back seat to other aspects of operational response, and probably rightly so. But in this situation, when we start to explore what is different about pandemic influenza and the public health response, you will find that what is really different is how much of what we are going to need to do is to rely on the community helping itself, individuals helping themselves through behavior changes and that’s going to require really expert risk communication across the nation, is going to require trust and credibility between the government and the people, between healthcare providers and the people. And therefore, I believe that what we’re talking about today, this concept of how to talk to people when they are threatened, becomes even more vital than perhaps any other kind of crisis situation that we might be involved in. So, for the first time, I feel that we can take our rightful seat at the table and feel that we’re really contributing as much as any other part of operational response.

Next slide.

There are some things that we know without question can go wrong in terms of our communication that’s going to contribute to failure in operational response. If we make these mistakes, we’re going to have a harder time doing our job. Mixed messages from multiple experts. That doesn’t necessarily mean incorrect messages; we’re talking about just mixed messages.

Information released late. If you don’t get the information to people when they need it, they’re going to seek out information from other places, and, unfortunately, that information may be either inadequate or inaccurate. So when people need information, they’re going to go somewhere and they may not wait for you because you’re, you know, checking your grammar or punctuation and not getting it to them when they need it.

A big mistake that often bureaucracies and, unfortunately, government may make is to be paternalistic in that we, you know, figuratively pat people on the head and tell them that they needn’t worry about the situation because we have it under control. Well, it’s really not reasonable to tell people not to be afraid. When people are afraid, they are afraid; whether they need to be afraid or not isn’t relevant. You need to address the fact that they are afraid, acknowledge it at the very least. And then, without telling them they shouldn’t be afraid, you should be telling them information that might help alleviate that fear in some way.   So, paternalistic attitude is a recipe for failure in a crisis situation.

One problem that we have is not countering - excuse me, rumors and myths in real time. The longer that one allows a rumor to continue, the more likely it is to take hold and become what then is known as an urban myth where it’s almost impossible to make it go away over time, and it could actually interrupt the ability to do the work that needs to be done in an operational situation.

We see sometimes where this will happen in work that we try to do overseas where a rumor will start that perhaps a vaccine that we want to use is contaminated in some way and is going to cause harm to the children and so then therefore the parents of those children won’t let us vaccinate their children against polio or something like that.

And then, of course, public power struggles and confusion. It’s quite clear what happens is that people lose confidence in their response organizations because they don’t believe that people who are supposed to know what to do really know what to do because they’re goofing it out with each other in public. So those are things that actually get us in trouble in any crisis situation, including what could happen in a pandemic.

Next slide.

The next slide tells us what we should be doing to have success in any of our operations in terms of communication and one is to have a communication plan. I know that state health departments have been working around developing communication plans for pandemic influenza. And I think that any organization that wants to successfully communicate around pandemic influenza should consider that part of their overall crisis communication planning.

Being the first source for information, if the public sees you as a source for information related to pandemic influenza response, then it’s important that they get that information from you quickly and adequately.

One of the things we talked about in the training was at what point will the public start to seek information from you? We talked about pandemic influenza. Well, right now we’re monitoring the H5N1 avian influenza outbreak overseas. But if we have H5N1 show up in poultry in the United States, are you in an organization where people will start to question you and expect information from you about it? If you don’t have that information now, will they start to question whether you’re ready and prepared for “the pandemic”?

There’s going to be tests for us well before an actual pandemic by our stakeholders -- by the public -- who expect us to take care of them even before the pandemic arrives. So there’s some preparation that needs to be done to be that first source for information.

I said earlier that expressing empathy was an important component of good risk communication. We need to express empathy early when we talk to the public, when we talk to our clients, our customers and that’s because the research tells us that when people are feeling threatened, when they’re using that primitive part of their brain to process information that if you don’t express empathy within the first 30 seconds of talking to them, they’re not going to hear your message.

They’re so overwrought with their emotion that all they’re trying to figure out is do you get it, do you understand how upset they are, do you understand that their world is threatened? And until you acknowledge to them that you’re - you get it, that their world is threatened right now, they can’t hear what you want to tell them.

So it just makes sense to go ahead and express that empathy early. And you need to express it genuinely. It doesn’t mean that you have to feel frightened, but you have to be able to understand that they are feeling frightened.  And to express empathy means that you have to give in words to that person an understanding of the emotion that they are feeling so you would say “I understand how frightening this is for you.” That’s how you express empathy.

Showing confidence and expertise. The research tells us we get a break on that, that if you have a title, if you belong to an organization that is meant to respond to the crisis situation, people will expect that you are competent until you prove otherwise.

Remaining honest and open is a very important component of trust and credibility, but we don’t have enough time to talk about what it really means and so you just have to do your own system’s check about how honest and open you really are being.

And be careful not to be paternalistic, that’s where we get into trouble, by withholding information just because you think you’re protecting people, because you don’t want them to panic, or because it’s just easier for you and quicker for you not to give someone information.

So, do consider what it means to be honest and open and start to plan ahead of time of how much information you plan to give. And if you’re withholding information, question yourself why it is that you’re withholding that information and are you really doing it for reasonable reasons.

Next slide.

There are some barriers, psychological barriers to getting information to people in a crisis situation. Just understand that most people in a crisis and, you would expect, in a severe pandemic that this is what people might be feeling -- fear, anxiety, confusion, and dread. Our communicational alone cannot make those feelings go away, nor should we think that it’s our job to make those feelings go away.

What our job should be when we’re communicating is to try to tell people manage those emotions -- those that are still functioning. And what we’d like to do is, hopefully, is to help people not become hopeless or helpless because then what we have is a community of victims instead of a community of people who can function in a dire situation.

Understand that most people in a crisis situation are not panicking, that’s sort of a misnomer when we go around hearing from response officials or from the media that people are panicking. Don’t call that behavior “panic.” Most of the time what you’re seeing when people are behaving strangely in a situation is extreme behaviors of fight or flight. And so, when you call the behavior “panic,” they’re not relating to you because what they’re doing is not panic from their perspective.

Next slide.

Risk communication is important in a crisis situation and it’s because oftentimes response officials tend to measure the magnitude of a crisis in only two ways: they measure it based on the amount of harm to people, you know, disease, illness, injury, and death; and the amount of harm to property.

There’s another way that we should be measuring the magnitude of a disaster and that is the emotional toll on people, and that’s sort of the crux of risk communication - is what is the emotional toll to people and that will give us clues as to how we should be communicating to people in a crisis situation. The greater the emotional toll, the more concern we should have with the way we are communicating, and our messages may have to change based on that.
Those things on the right hand side, the more of those that are attributes of the crisis, the greater the emotional toll on people.

So when something is involuntary, controlled by others, exotic, man-made, permanent, anecdotal, unfairly distributed, and affects children that when they are characterized in a crisis, were more apt to have a greater emotional toll.

An example is if you took what happened at the World Trade Center on 09/11/2001, you can see how many of those are characterized in that event and I think most of us would agree that that was a pretty traumatic event especially for those people who were in that community, and actually for the nation and many people around the world.

Next slide.

We talked earlier about how important it is to have credibility and trust. It’s very important for your organization and for US response officials having a role in responding to pandemic influenza to know that trust is vital. And note, again, that all the research shows that these are consistent elements to building trust. And up at the top is empathy. So when I said if you have to leave early, empathy is really important to know as a concept. Expressing empathy is a part of building trust. Competence - I told you, you get a break on that. And here we have honesty, right up in there. Once again, commitment is just that people have to feel that you really are going to hang in there with them and help them get through it. And accountability, again, is part of that honesty part and safeguarding the resources that they’re interested in.

Next slide.

This is just a little model to show that when we go about trying to do our Crisis and Emergency Risk Communication that there are elements that are going to struggle with each other. We need to have accurate information, but we also need to get that information out quickly. And one of the ways that we can do that is to acknowledge that we don’t have all the information early, but the information that we do have that we know is accurate, we give that to them and then we come back and give them more information as we have it. And all the information that we give, we give it with empathy and openness. And if we combine our credibility and our trust, we get successful communication.

Next slide.

Any initial message that we give in a crisis situation, remember we say people take in information, process it, and act on it differently? Well, initially in a crisis situation when people are feeling very threatened, we know that they have to simplify messages, that they can’t take in a lot of information at that one time.

So, for that reason, our initial messages need to be short, we need to answer the questions that people have really on their mind, and mostly what they want to know is what do they need to know to make good decisions to protect themselves and their families, and yes, their pets.

Whenever possible, we should try to get people positive action step, move them in a direction that they need to go instead of telling them what not to do and try to repeat those messages consistently over and over and over.

Don’t mess with the messages. The more consistent your messages are, the more reassuring that is for the public initially in the crisis situation. So, don’t change messages unless it’s absolutely necessary.

Next slide.

Here’s some not to do’s with your initial message: don’t use jargon; don’t be judgmental in your messages; don’t make promises that can’t be kept; and don’t include humor because it’s not funny. If somebody’s fifth cousin is still hurting in the crisis situation and you’re responsible for trying to make people not hurt, then don’t use humor.

Next message.

This is just a question. Evidence strongly suggests that coverage is more factual, media coverage, when reporters have more information. They become more interpretative when they have less information. So what should we conclude? Well, in the interest of time, what we should conclude is that we need to give people more information.

And if you’re responsible for sharing information in your community with the media, what we need to do is a better job at taking the media to school, and I put that in quotes. What we need to do is to be better at sharing background information about a situation. And I think that the Web site, pandemicflu.gov is a way to do that now.

I know the Department of Health and Human Services is doing workshops around the country with different media groups, helping them get a better understanding of pandemic influenza so that there is a greater understanding of this situation so there are fewer rumors and myths to have to correct along the time.

But if you don’t want one reporter interviewing another reporter about what another reporter just reported -- and I’ve seen that happen, I saw it happen during anthrax -- then we need to share more background information in a crisis situation.

Next slide.

The role of the spokesperson. This is an important role in a crisis situation. In your organization you need to decide who that spokesperson will be. It needs to be someone who can express empathy, who does have a base of information and knowledge along the way.

Next slide.

That spokesperson needs to be able to manage these risk communication principles. One is don’t over-reassure. Be able to give people things to do. And one that’s more important than ever in a crisis situation like severe influenza pandemic that may go on in a community for a long period of time is to ask more people, and we’re going to talk about that in the area of community hardiness.

Let’s talk specifically about a severe influenza pandemic situation, what is different in terms of crisis and emergency risk communication.

Well, we have a national strategy for responding to pandemic influenza. And HHS Secretary Mike Leavitt said that communication is at the heart of that strategy. And again, I think there’s a real case for that considering that we’re looking at, within the current context of what we know with science and technology, is that we can’t anticipate that we will have a vaccine ready to go in our stockpile nor antivirals ready to go because the current technology does not give us the ability to anticipate what the pandemic strain will be and it’s going to take us a month to be able to develop the vaccine and then to manufacture the amounts that we will need in order to respond. So that means that we’re going to have to use different strategies and part of that will be behavioral changes along the way.

Our strategy overall is to try to slow and limit the spread of the pandemic strain of disease across the United States as much as possible and to somehow sustain our society and its infrastructure in the context of a severe pandemic. And the numbers that have been tossed around is that we could see as many as 2 million deaths in the United States if there was a severe pandemic. So that’s the worst case scenario that we have to work against in planning, and it makes sense that we would work against the worst case scenario as we move forward in preparedness.

We’re also looking at what is different. We’re looking at differences in terms of this compared to other kinds of crises. On a biological level, what are the differences? On a psychological level, what are the differences? On a sociological level, what are the differences in terms of magnitude and concern? And that’s what we did from a communication perspective too.

Next slide.

On a biological level, what we’re looking at is a respiratory illness where the world has low or no immunity. We’re also looking at, as a nation, where we have more people who are at higher risk for respiratory illness. In fact, 36 million of us are over 65 years of age. Over 90 million people here in the United States suffer from chronic illnesses. So that puts us at more people at higher risk of illness. So, that’s going to be a greater challenge.

In this case, this is a respiratory illness that we know will probably sweep across the nation in two to three waves lasting six to eight weeks over 12 to 18 months. That’s going to be psychologically exhausting but also going to tax our healthcare system, there’s going to be incredible surges for medical care, and we’re going to have to manage that.

We do know that in terms of preparing for this that as individuals only 23% of the US population prepares for crisis. That’s the data that comes from the American Red Cross. Generally, 23% of the population if we ask them to prepare for crisis prepares.

Then, we have another percentage of the population, up to about 77% that will prepare just in time. But there’s another percent there left over that doesn’t prepare and there’s going to be some real challenges for us around that too.

Next slide.

What are the psychological spiritual differences of a severe pandemic?
There’s a great deal of uncertainty. We don’t know when it’s going to happen. We don’t know what strain of virus is going to be involved. We don’t know where it’s going to strike first. We don’t know which people are going to be hardest hit by this. We don’t know how virulent it’s going to be. We don’t know how long it’s going to take to develop the vaccine necessarily. We don’t know which antivirals will be most effective against it. There are just a number of issues around it that cause uncertainty.

We really don’t know if people will be cooperative or not in terms of what we want them to do or not do. In terms of other psychological stresses, we don’t know when we’re asking entire communities as it sweeps across the nation in very short order, “Will our communities be able to sustain themselves?”

We saw what happened in ‘05 when we had one hurricane after another after another in our southeast just how exhausting it was to those communities psychologically and spiritually. What would happen if that same sort of order of magnitude of breakdown in our ability to respond to the crisis occurred across the nation? What would that feel like? What would be happening to us?

And then, having so many deaths at a time, I mean so many people, what if this severe pandemic was like H5N1 and we were seeing healthy, young adults, like the 1918 pandemic, occurring across the country, what would that do to us psychologically or spiritually? There’s a lot there that would be different.

Next slide.

Sociologically what would be happening? Well, we may be dealing with some breakdowns in terms of society. I mean we’re going to have a whole range of different behaviors in the way people will react to this.

We know that we have risk takers in our sociological makeup in this country. We also know we have people who are in denial. We have people who won’t be bothered to prepare as we talked about. We have people who don’t believe that they can prepare, who are going to be dependent in some way. And we’re going to have to manage this and we will have to deal with this through our community hardiness concerns.

And then, the whole idea that we’re not going to have enough vaccines and antivirals. We’re a country who believes there is abundance and that somehow we’re going to pull it off. But what if we don’t?

I think from a communication perspective this is vitally critical because we’re going to have to talk about this and we’re going to have to go into our communities and stress the realities of this. We’re going to have to be transparent. And we’re going to have to avoid the hint of any privilege related to this. I mean I think that that’s the most important thing is we’re going to have to be real careful around that situation.

Next slide.

Community hardiness. The reason I think this is such an important topic is because what we’re looking at is this idea of non-pharmaceutical intervention. If we don’t have vaccines and we don’t have antivirals, what are we going to do to try to slow the spread of this illness in communities?

And what we’re looking at is targeted layered containment. And there’s some modeling that’s been going on that is, you know, with researchers that are looking promising.

And some of the ideas that have been thrown out include that if the pandemic is severe enough that extended closing of schools in a community, the idea of staying home if you’re sick, staying home from work, staying home from school, and even going so far as having people stay home if anyone in their family is sick for as many as two to three transmission periods. So staying home for a week if anybody in your home is sick, and then targeted prophylaxis with antivirals if someone within the family or the community, is sick.

So, we’re talking about the involvement of the community and community behaviors to change the dynamics of that epidemiologic curve in managing the pandemic. These are old-fashioned sort of techniques being used in the 21st Century to wait for our 21st Century medical technologies -- the vaccines and the antivirals -- to catch up with the pandemic. That’s what we’re talking about right now.

Well, that means we need to be concerned about how well can our communities manage this because you can see that we’re balancing the benefits and the costs of taking these steps, meaning what would be the cost of having schools not send the children to school for an extended period of time, of people taking time off from work if somebody in their family is sick for an extended period of time. And so, community hardiness becomes more important.

Next slide.

And community hardiness is not a concept that’s really discussed that much in terms of public health response or disaster response or in risk communication. But it’s worth having another look at it. And community hardiness, a definition of it, is protective qualities and vulnerabilities and weighing of those within the context of what you need the community to do in a crisis situation. And we created, in the course materials for this fall, a checklist of how you can start to begin to sort of measure a community’s hardiness.

And it’s interesting to see how each community can start - and you can define your community as your neighborhood, as the entire city, it’s just dependent on your workplace, it’s like what is your community and how would you look at its plusses and minuses and its ability to take the steps that we would need it to take in a severe pandemic situation in order to reduce the possibility, you know, increase social distancing and reduce the possibility of the spread of the disease in that.

Next slide.

Some of the factors or ways that you could measure community hardiness is socioeconomic status. That’s pretty self-explanatory. The number of community-based organizations to give the community members support who may not have the luxury of being able to stay home, for example, without support of Meals on Wheels or something like that along the way.

The healthcare capacity and social stressors, that’s also important. Can the community come together and unite and help each other or are there stressors on the community that won’t allow it to come together when it needs to?

And political and civic perspective, I think it’s important. Is this a community that believes in helping itself or this is a community that believes in it being helped by others and when that help isn’t there to support it, it will fall apart.

And community cohesion and group self-efficacy. It even goes so far as do you have a community that has a motto and an identity, or is it a community that doesn’t? It’s really not a community. It’s a bunch of individuals who don’t really know each other and there is no community identity.

And then, can it build cohesion and group self-efficacy? And are we at a point where if we could identify communities that needed to build hardiness, is there time for us to begin to build that hardiness? And is there a role for us and within our community to start to do that? Those are the questions that we can ask.

Okay, next slide.

Along with community hardiness is the idea of personal resilience. And personal resilience is the idea that mental promptness will be important in our ability to sustain ourselves as individuals in a severe pandemic especially one that goes two or three ways, 12 to 18 months, when we’re going to have to rely on ourselves and there isn’t a possibility perhaps of vaccines or antivirals.

And self-efficacy is a component of that and it’s basically if you believe that you can, then you can. It’s an amazing concept, brought forth primarily through the social learning theory of Albert Bandura. But it’s basically the-little-engine-who-could kind of thing.

Next slide.

Stigmatization. I do want to make sure I get this in, and I know we’re running out of time and I promised we’d have time for at least a couple of questions, and that maybe I’ll have to just beg Diana that I get to come back again for another time if we completely run out of time.

Stigmatization is the concern that I truly have because I saw this happen when I was in Hong Kong for the first outbreak of H5N1 among humans in ‘97. So, let me talk briefly about stigmatization.

Next slide.

Stigmatization is a concept where people, even absence of threat themselves, are identified with a threat and then, therefore, they are shunned or ostracized in some way. And stigma - excuse me, stigmatization can affect people, products, industries, animals, and places.

I won’t go into all of the psychology around stigmatization but just understand that to be stigmatized you have to be able to be identified some way as different from the people who are doing the stigmatization.

Next slide.

The example is very simple. Strawberries, fresh strawberries were stigmatized in ‘97 when Hepatitis A was associated with frozen strawberries in the school lunch program.

I told you about in Hong Kong. Those of you who may not know, weren’t familiar with that outbreak, the outbreak itself was primarily among guest workers from another country who did the shopping and cooking for families in Hong Kong. And so, that was pretty well-known. And those guest workers from this other country would congregate in parks in different places within Hong Kong, and before you know it, people were staying away from those parks and wouldn’t have anything to do with people from that guest country.

So, people were stigmatized. The places where these cases of H5N1 occurred were stigmatized -- the apartment complexes, the daycare centers, the hospitals where these cases occurred started to be stigmatized.

In ‘99, the first outbreaks of West Nile in New York not only were people dying from West Nile but also were horses. And Europe banned our horses from coming to participate in horse races that year. And even though West Nile was endemic in Europe, they still stigmatized our horses even though our horses wouldn’t be giving their horses West Nile, it would be mosquitoes that would have given them West Nile. So, animals can be stigmatized. And we know about the stigmatization that occurred around SARS in 2003 with people.

So, stigmatization does occur. It does occur in the modern era, and it can occur around H5N1, and it can occur in a severe pandemic. And I think it’s important for us to understand and recognize that. And those of us who are responsive or communicating around pandemic influenza that we need to be aware of it -- next slide -- and do what we can to avoid it whenever possible.

It sets people up to go into situations where they could be denied resources in some way. People who are stigmatized, their self-esteem can be reduced, which may mean that they may not get the support that they need.

Remember, we were talking about self-efficacy and how important that is to survival in a crisis situation? Well, if people are stigmatized, it reduces their self-esteem, which could reduce their ability to survive. I know that seems like a stretch, but it’s important to understand that.

Stigmatization does exist. It’s existed over time. But I think it’s our responsibility to fight against it where we can as communicators whenever possible to stop it in-group, out-group sort of thing if we can, especially if it’s unnecessary in any way and it’s sort of subconscious in the work that we’re doing with our communication, we’re not even realizing that we’re promoting stigmatization in our communication products, which I think is easier to do than we may realize along the way.

Next slide.

So these are some steps that I think that we should consider in the work that we do around our communication to avoid stigmatization. You can read these separately. Understanding loss and bereavement. Two minutes on this and then I go to questions.

In the United States -- next slide -- 2.5 million people roughly die annually. In a pandemic situation, we’re talking about adding another 2 million deaths within 12 to 18 months. So you can imagine how many more people we were talking about dying.

And as many of those people are also healthy adults or children, the emotional toll on the country could be unimaginable. We need to understand as we respond to this from a public health perspective and healthcare providers that this is going to be something we need to be able to deal with.

In the United States, our culture is very -- I hate to say this -- but anti-death, we don’t really manage it well and it’s sort of taboo as a dominant culture.

Next slide.

We may also find that we’re seeing multiple deaths in families. Our bereavement rituals will probably be truncated. We may even be asking people not to congregate for bereavement rituals, which could be very different.

I do think that we may find some kinship in our shared misery, which might be a positive if you can look for a positive. We also may find that those people who are responsible for trying to mitigate the magnitude of this disaster that we may be feeling some guilt and we need to acknowledge that from a mental health perspective.

Next slide.

I do think that one of the things that we have to understand in our very diverse nation with all the different cultures we have is that we have striking differences in our culture in the way that we go about mourning and our bereavement rituals. They’re very rich, very different. And if you have not experienced the bereavement rituals of different cultures, you owe it to yourself and to the people that you serve in your organization to understand the bereavement rituals of other cultures and respect them as much as you can.

In a pandemic influenza situation, we may not be able to respect all of the different rituals, but at the very least, we should know them, be able to speak to them and to acknowledge them and acknowledge that we’re asking people to truncate their bereavement rituals, and then find some way in the community to acknowledge all of these losses at some point when it is safe to do so.

And we actually have materials that talk about how to go about having community memorial services when it is safe to do so because you cannot have that many more excess deaths in your community and not have a heavy toll no matter what culture you’re from, whether it’s one that accepts death more readily or not.

I’m going to stop there. I’m very sorry that it took us so long, but Diana assured me I could go a little over. So if there are some questions, we’ll take as many as we can for as long they allow me to do so.

Diana Hadzibegovic:  Thank you very much, Barbara. And we can certainly in about a month, if you have the time, we can certainly repeat this same presentation. And right now, I will ask our audience if they have any questions, and for those who don’t have the time to ask a question and need to leave, please email us, send us an email to coca@cdc.gov. Also, Barbara, if you want to send some material for our audience, you can let them know about arrangements. And whoever needs materials from Barbara about this same presentation, you can email us and we will be glad to provide you that material. Deb, can you please ask our audience if someone has a question for Barbara?

Coordinator: Thank you. At this time, if you do have a question, please press star-1 on your touchtone phone. You will be asked to record our name, please do so for correct pronunciation. And if anyone would like to access the instant replay of today’s conference, you may dial the toll-free number of 866-491-2914. Again, the instant replay can be accessed for this conference at 866-491-2914, and no passcode is required for that. Thank you.

 

Question: Hi Barbara. I think this is the second presentation I’ve heard you give and they’re really outstanding. I’m very eager to know if the one-and-a-half-day course material is available for either purchase or whatever.

Barbara Reynolds:  Yes, it is in limited quantities right now. If you’re patient with me, later this year we’ll have it more widely available.

Question cont: So how do we find out about that?

Barbara Reynolds: You can through the Coco -- COCA, I’m sorry. You can tell, I’m hungry -- the COCA email address. We can keep you on file and send it out to you later.

Question cont: Thank you.

Barbara Reynolds: Uh-huh.

Diana Hadzibegovic:  Yes, we can let you know about that. Just check our updates, weekly updates.

Barbara Reynolds: I actually have it available electronically if that’s good enough for you, but I don’t have it in hard copy in wide numbers yet - high numbers yet.

Diana Hadzibegovic:  We can send that link to our audience, Barbara.

Barbara Reynolds: Okay.

Question cont: That’d be great.

Diana Hadzibegovic:  Thank you. Next.

Coordinator: Okay. If you do have a question, please press star-1 on your touchtone phone.
One moment, we do have another question here.

Question: Hi, Barbara. I was wondering what kind of pre-messaging CDC has done in regards to pandemic flu. I know you all published quite a bit of message maps. I was wondering what else you all were working on that you would be making public most likely through the Web site.

Barbara Reynolds: To tell you the truth, I don’t know everything that we’re working on. I know HHS and CDC both have been working on messaging and I’m only a part of that work.  So whatever we do create, it goes right up on the Internet site when we have it cleared and ready to go.

I know that we’re getting ready to do quite a bit of work around this idea of the community mitigation or the idea of the targeted layered containment. There’s some real exciting work around that. And I think you could probably tell it in my voice, even if I have a cold, that I’m really excited about the idea that the community can be involved to help themselves. And it’s going to take us a little bit of time. And fortunately, we seem to be getting that time. Mother Nature is allowing us this time.

So, all I can say is just continue to look at the Web site for updates. And I do wish we had some way to give you a tickle when something new comes up, and that’s something that we should explore too.

Question cont: Great. Thank you.

Diana Hadzibegovic:  This is Diana. Correct, Barbara. You can go to pandemicflu.gov Web site and you can find all kinds of information -- federal planning, state and local planning, individual planning, business planning, school planning, healthcare planning, community planning -- all kinds of information you can find on that Web site and we all work together on this, CDC and other agencies, government agencies. Please check pandemicflu.gov Web site.

Barbara Reynolds: That is correct and that’s where our new information would be too.

Question cont: Thanks.

Diana Hadzibegovic:  Next.
.
Question: Thanks for an excellent program. I do hope we can see another one a little later on. And I will check out the pandemicflu.gov website. I have kind of gone - clicked on down to your PowerPoint here and it looks like you’ve got some other interesting information.

And I guess my big concern at this point is what are you seeing at the various state levels or the national level indeed regarding the death arrangements, the death certificates handling of that, any streamlining of that process at the national level?

Barbara Reynolds: That’s an excellent question, and it’s out of my area, but it’s something that I think between Diana and me, we could find out and get an answer back to you.

Question cont: Thank you very much.

Question: Hello, I wanted to thank you for such a great presentation. My question has two parts. One, for my company, I’ve been involved with pandemic planning for over a year and my - I guess what I’m seeing in some aspects of my planning in terms of keeping people involved is something I would personally call “pandemic fatigue” where you continually send out communication, wanting people to stay vigilant about the onset of possible pandemic flu, and then nothing necessarily happens in the person’s backyard per se to make that immediate connection to all the messages that you’ve been given about of aiding your recovery plan, staying vigilant, engaging in proper cough and health hygiene. What is your advice in terms of combining that? That’s part one.

And part two: is there any, I guess, message or plan on the national level that you’ve heard of in terms of enhancing the current communication plan should pandemic influenza come into the United States?

Barbara Reynolds: Okay. You’re going to hate the first part of my answer.

My background before coming to public health was in marketing, and so I’m a realist. And there is a time for push marketing and a time for pull marketing and that means that there are too many risks and too many threats that people need to deal with that you absolutely identified what they’re dealing with such as pandemic fatigue.

It was very interesting at first for them because it was a new threat and it was exotic and they were interested in it. But it didn’t happen. And now, it’s not in the forefront and they’re not interested in playing anymore. So it’s going to be very hard to get them, and I almost wonder if you need to because they’ve obviously engaged, they’ve gotten some information, and they know where to go get what they need if it starts to heat up again.

As a matter of fact, almost a year to the day, in January 24, 2006, we had the highest spike of hits on the CDC Web site at the time, it was before we had pandemicflu.gov on our Internet site, and, you know, interested in pandemic influenza and I was like “What was it that made that spike?” You know? Why is it suddenly that all of the United States, all of these people, it happened right at 4 pm Eastern Time, from 4 to 5 pm, suddenly that we had this big spike?

And it turned out it was because Oprah Winfrey did something on H5N1 and pandemic influenza and it was, you know, the Oprah Winfrey show. Well, that shot right back down and we haven’t had a spike like that since and it was because it was new and exotic for that audience and they were interested in it, and that’s okay.

You need your response people to be interested. But don’t expect that you’re going to have everybody at a high level of interest in response to this threat all the time. They have more important things to do right now and it’s like they’re worrying about who’s going to be the next American Idol and whether they’re going to be able to pay off they credit cards after the holidays. That’s what they’re really interested in, and that’s okay.

Twenty-three percent of the population will get prepared, the rest of them will prepare just in time, most of the rest of them and some will never be prepared and that’s our reality.

What you do in this phase when the threat is not feeling real to people is try to get them to at least understand what a pandemic is and let them know where to get the information for when the threat becomes real. But when the threat is not real for them and it’s not even exotic enough to be worthwhile to make a hit on your Web site or whatever, there is nothing you can do.

And I’m sorry, will you please ask the second part of your question because I didn’t quite understand what it was you were asking me.

Question cont: On the government level, is there a plan that you may be aware of to increase communication in terms of a public health strategy that would be enacted should pandemic influenza hit the United States?

Barbara Reynolds: There is. Where in fact, we have some public service announcements that are going to be launched soon and this community, what I call community mitigation about this idea that we’re going to engage the public more in helping themselves.

We’re going to go out with a little splashy thing here soon once we all agree on what that strategy will be from a government perspective. And then you’ll see us back off for a while too. And then as the threat becomes more real, when a pandemic does start to seem possible, you’ll see a lot more communication from us.

But there’s no reason for us to spend lots of money trying to get 300 million people to pay attention to the pandemic until a pandemic threat is more real too.

Question cont: Thank you so much.

Question: Thank you. This is very informative. I have a similar question related to where to find current data on the number of outbreaks. I kind of check a Web site daily to see how many deaths are occurring. Is that the best way to kind to keep updated? Are we going to have another Web site that will actually tell us a little bit more any of the evolution or the mutation from person to person?

Barbara Reynolds: The WHO Web site, and you can link from the pandemicflu.gov right over to WHO, keeps a tally of what’s going on around the world and right now I believe they’re updating it weekly.

Question cont: Thank you.

Diana Hadzibegovic:  And you can also from our site pandemicflu.gov, you can find on the main page, you can find Avian Flu Watch. You can find information from WHO on animal infection situation in Indonesia, even all information you can find from - if you go to www.pandemicflu.gov.

Barbara Reynolds: Thank you, Diana. That’s what I meant when I said our Web site. I missed that one.

Diana Hadzibegovic:  Sure.

 

Question: Hi. Yes, thank you for you an excellent presentation. It seems to me that communication that would work best should be multidirectional. I think that will increase self-efficacy, it will increase buy‑in, and it will increase people’s sense of participating. The CDC Risk Communication seems to focus on telling people things rather than listening to the various groups of who will be involved in the response.

I’ve been thinking a lot about how different groups and different people see moral issues in the decision making process and how they’ll show up to work or not show up to work. Do you have a plan to maybe listen to concerns of say health professionals or businesses or especially the disenfranchised or faith communities, education communities? Where do we go next to make sure that we’re listening and not just talking?

Barbara Reynolds: That’s an excellent point. And I wish Dr. Roger Bernier from here at CDC could be on the phone to answer this question. But if he were, we’d be here for at least another hour because he would tell you all about the listening that he has been doing over the last year at least. And I won’t do him real service, but I’ll try to.

What you are saying is what he has been doing especially around, again, community mitigation. We know that there won’t be a magic way of managing the next pandemic, though we wish that there was, you know. We wish that there was going to be plenty of vaccine and plenty of vaccine and plenty of time to manage this, but it isn’t going to happen, which means that we will be looking for individuals and communities to help themselves. And so, if that’s the case then we do need to know what they’re thinking and what can be done.

And all of these different segments of the society that you’re talking about have been engaged and are being engaged, and it’s been quite fascinating to tell you the truth, and you see the differences regionally and demographically, as you can imagine, in that. And I’ll have the privilege of attending one of those listening sessions just back in December that was held here in Atlanta, I didn’t get to travel too long, and it was absolutely fascinating to get to do it.

And I don’t know where you are here in the country, but if there is one to come, they’ll advertise them in the newspapers and on radio and stuff and if they’re open to anyone who wants to come who’s interested, they’re fascinating.

And we do learn from them, and I believe that our strategies are changing. And it’s not just us at the federal level, you have to understand that. It’s important that response organizations at all different levels, especially at the community level, to be listening and adjusting their planning accordingly too.

Question cont: Thank you.

Diana Hadzibegovic:  We have time for two more questions.

Question: Thank you. Yes, my question is about use of blogs during this time and any guidance or suggestions that you have about that?

Barbara Reynolds: Yes, thank you. And I apologize if I didn’t get to my slides on that. You know I included them in…We think that new media is interesting and should be considered as what is different for our next pandemic in that there’s going to be differences in that.

One of the things we have to be humble about as communications people, professionals, especially for official response organizations is that people have the ability to get information from lots of different places. And so, we’re going to be competing to give out information, which means our credibility is more important than ever. And that if we do anything to lose our credibility, we’re really going to be hampered. So I think that’s important.

And one of the things that will happen is that when we have to engage in social distancing, one of the things the blogs will do for us, for those people who are more inclined to go online and to engage in blog communities, is that will help us maintain our sense of community.

I also think that we may use blogs and the Internet and family sites to help in our mourning and bereavement processes. And I would encourage that to be an alternative, that if we have families can’t come together and have reunions as we lose numbers of our family that we at least have memorial sites for our family members on the Internet.

So I think the Internet, including blogs, will be a way to deal with it. One of my concerns of course is that what will blogs do in terms of creating rumors and misinformation. But it depends, there are good blogs and there are bad blogs.

Question cont: Thank you.

Question: Hi, I was really interested in the community hardiness checklist. Is there is a place I can find that?

Barbara Reynolds: Yes, if you send an email to the COCA address, I can send you the electronic version of it right now.

Question cont: Thank you.

Coordinator: Okay. And again, to access that replay, you may dial the toll-free number 866-491-2914. Again, that number is 866-491-2914, and it requires no passcode. That does conclude our conference for today. Thank you for joining.

Diana Hadzibegovic:  Thank you everyone for listening. And to Barbara, thank you again for such a wonderful presentation. Stay tuned for our next presentation next month. Thank you. Goodbye.