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Center for Public Health Preparedness


University at Albany Center for Public Health Preparedness

Risky Business: Communication During Crisis

Original Satellite Broadcast: 07/13/06

Moderator: Good morning and welcome to the University at Albany Center for Public Health Grand Round Series. I'm Peter Slocum and I'll be your moderator today. Before we begin, I would like to remind you to please take a moment after the broadcast to fill out your evaluations. Your feedback is very helpful in the development of future programs. Continuing education credits, including nursing contact hours, CME and CHES credits are available. The toll-free number for questions is 800-452-0662 and you can also send questions by fax to 800-426-0696, as well, at any time during the program. We'll remind you before we open the phone lines. Today's program is called Risky Business: Challenges and Opportunities of Communicating In a Crisis. Our guest is Kristine Smith, Director of Public Health Risk Communication for the Office of Science and Public Health within the New York State Department of Health. She coordinates risk communication activities related to health emergency preparedness and provides strategic direction relating to communication about emerging diseases and other priority health projects. Previously, she spent ten years with the Department of Health Public Affairs Group and was an award-winning radio and television journalist in Albany, New York. Thank you for joining us today, Kris.

K. Smith: Thank you, Peter. You know this is one of my most favorite subjects.

Moderator: Yes, indeed. You have worked in the communications business for a good while now and with all that's changed in the modern media, is it easier or harder to communicate with the public today?

K. Smith: It's more fun and definitely more challenging. For a variety of reasons, we're faced with the 24/7 multimedia environment that we live in. We also have an attention span that generally is in nanoseconds. And we have impressive technology, but that technology has a tendency to let us down when we need it most. Witness the aftermath of Hurricane Katrina.

Moderator: In other words, we depend so much on the great new electronic opportunities, but the plug can get pulled.

K. Smith: The internet is great. It's also often not there when you need it, and we need to keep that in mind when we plan our communication strategies.

Moderator: Let's start out with a general discussion of or definition of risk communication.

K. Smith: Can we start out with a discussion of what is a risk - which is really just the chance that a particular hazard will affect us? So risk communication is a science-based discipline - goes back a number of decades. It's based on myriad research in psychology, sociology, anthropology, speech communication, and it's intended to help people to really understand what the real chance of them being hurt is. It has its background really in environmental health issues. That's a traditional risk communication. Of late, though, we have seen some infectious disease applications, as well.

Moderator: Right. What's different about communicating with the public in a crisis about risk?

K. Smith: I think crisis and emergency risk communication is really the new iteration of risk communication. The traditional model was to hear and address people's concerns when they feared that a risk would hurt them more than, scientifically, it probably would. So they had a fear of the hazard that was not in line with the risk that the hazard imposed. Whereas in crisis and emergency risk communication, for the most part, they have a high hazard and a high fear of that hazard, so it correlates, but that makes communicating in a crisis doubly challenging.

Moderator: Well, what can communications professionals like yourself expect during a crisis?

K. Smith: First of all, that it will not be business as usual. All the communications models and the training that you've had and the abilities that you have in a normal situation will let you down unless you have practiced to be an effective crisis communicator, because people are not receiving your message the same way they would in a normal situation. So those intuitive things that you do may not only be ineffective; they may backfire on you. So you need to understand that, and you need to expect that people are going to be going through a lot of emotions in a crisis. There's going to be gossip, rumor and speculation, anger and concern. A lot of emotional factors that get in the way of a rational reception of a message. Moderator: I think that's a really important point for people to understand because it's not just the communicator-- you in this case-- but it's also the receiver, that the receptors are different in a crisis than they are when you're just sitting around the breakfast table having a casual conversation.

K. Smith: I think that's the critical point, and a little later, I think I have a slide in there that will show exactly how that message gets distorted. You know what I'm worried about right now is how are we going to communicate effectively in something, for instance, as challenging as pandemic influenza.

Moderator: And you'll have instant experts cropping up and offering solutions that may or may not be in line with what's really going on.

K. Smith: I don't know if "instant expert" is pejorative phraseology. I use it, so I hope it's not pejorative, but I think it's certainly what happens. And because of the 24/7 multimedia environment, it happens all the time. Before the real experts-- those who are on the front lines of the response-- are prepared to respond, a lot of people have general knowledge in the area and show up on TV, cable, radio, the newspaper, talking about what they think might have happened. And they have a lot of good theoretical knowledge, but often very little practical knowledge, and as a result their message is believed, and it may not necessarily be the correct message.

Moderator: Well, it's very likely, as you just suggested, that we're going to be facing, or the crisis and communications challenge will be around pandemic flu. What are some of the things that our audience ought to think about in connection with an event like that?

K. Smith: First, I would caution communicators that we have to start that dialogue with the audience. Certainly we have been alerting people about the need to prepare. But I think we need to be very frank about the challenges of pandemic as opposed to, say, challenges of a natural disaster, even a very bad one. In a natural disaster, it's generally fairly localized. A terrorism attack, generally fairly localized, and you can count on help from other sectors. A pandemic, by its very nature, is global, which means everybody will be dealing with it at the same time, and there's not likely to be that hero in a white hat coming over the -- I think I'm mixing analogies with the cavalry coming to the rescue. But the point needs to get out there and we need have a dialogue about these tough decisions and rationing scarce medical resources. I want to read a quote if I could from Peter Sandman, because I think it really is very germane to this discussion. He says, "Inevitably, fairness will be a key issue in widespread public health crisis, with scarce medical resources will need to be allocated to those in the most critical occupations rather than to those who are most vulnerable. Cops and water works and nurses will get priority over seniors and children." Now I don't know if Peter is right about who will get it, but we need to think this through now, balancing practicality and compassion. I think the discussion needs to happen right now, because people will operate from prior beliefs that we all get what we need, essentially, which may take a little while, but -

Moderator: That certainly runs counter to standard thinking that children and seniors go first and here we're talking about emergency workers maybe need protection before other people.

K. Smith: I'm not saying that decision has been made, but if it's a decision that needs to be made, it should be made from a two-way interactive discussion and not from the top-down and imposed on people.

Moderator: It needs to be communicated right now, up front, rather than waiting for the crisis.

K. Smith: The reason that needs to happen is that when the crisis hits, effective communication will be distorted by what's called "noise in the channel." For those of us who took Communications 101, a message model was developed by a couple of mathematicians called Shannon and Weaver, back in the 1940s. It's really simple. A sender sends a message through a channel and it gets to a receiver. But what these gentlemen theorized is that it never, ever gets there without being distorted. Think about the game of telephone that some of us played when we were kids. A message would go out, be whispered to someone in the room. By the time it got to the ultimate receiver, it didn't sound anything like what the message started out. And that's what happens in an emergency, as well. Shannon and Weaver were talking about physical noise, and they were talking about radio waves and static that distorts them, but that happens in an emergency as well. We often see physical noise. Think about the aftermath of the World Trade Center disasters, then Hurricane Katrina. You couldn't use your cell phone. The two-way radios malfunctioned. Or even those operating lines that were still in business, too many people were calling in at the same time and therefore that message could not be received. The slide I'm showing you now-- I think it's a sculpture. I hope it's not a traffic signal -

Moderator: Maybe a Christmas tree.

K. Smith: If you drove up to that, would you know whether to stop or go or yield, or what would you think? There's too much input coming in, and that's what happens during a crisis. There are many other sources of noise, as well.

Moderator: Have we made progress across the country at clearing up some of those physical noise issues, straightening out the communications channels, for instance, as first responders that came up in both Katrina and 9/11?

K. Smith: That's a great question and I'm glad you asked, because I can't give you the answer. What I can tell you is that organizations such as the New York State Department of Health and others are working very hard to work their way through that. For instance, we're using some ham radios and working with ham radio operators. But the question you asked is outside of my expertise. So hopefully, as a good crisis communicator, I wouldn't answer that because one of the rules is that you don't answer a question that's outside your area of expertise. And it's okay to say "I don't know." If you don't know, you're not supposed to know. But if you should know, you better have that answer in advance or promise to get the information out very quickly.

Moderator: We'll talk about that more in detail later in the program. I imagine language plays a significant role; too, both because we have a diverse population in our society and because of other experiences that may get in the way of people understanding crisis communications.

K. Smith: Precisely. I refer to them as literal barriers. It's not just that people don't speak English. They may speak English, but have a low literacy level so some of our smart-sounding, scientific publications, are not helpful at all. Or concepts simply due to cultural differences may not translate at all. I don't know if the audience can read that sign, but I think it's very descriptive of what can happen. This particular sign says "For rest rooms, go back toward your behind." Now, I think we kind of get the message, and it's not an emergency so-- well, it might be an emergency if we're talking about restrooms, but it's not a crisis. But still, it's not clear communication, and it's what we run into in trying to translate our messages to a diverse audience - those who might have cultural barriers, trust issues. We need to be very cognizant of that. We need to understand it's going to happen and plan on how we can effectively communicate despite that.

Moderator: It's not that you're concerned about translation issues at the bathroom entrance - more the question of making sure you understand as the communicator how your message-- that it's going to be clearly received with the right language, so people can get it.

K. Smith: Absolutely. One of the rules of social marketing: you are not your audience. When we have to communicate to a diverse population, we have to understand we don't have all the answers and we have to align ourselves with the trusted leaders and the opinion leaders who do know the issues and can help guide our communication or get them through the effective channels. So we need to reach out and partner broadly.

Moderator: What are some of the common public reactions to the news of impending disaster or emotional events that are coming at you?

K. Smith: These are psychological barriers or psychological noise, and unfortunately, I think we're all too familiar with them in many of our states now. Certainly as a New Yorker, I experienced them after 9/11: denial, confusion, anxiety, anger and concern. We may have been left feeling helpless or hopeless. Our fight or flight impulse may have engaged. Denial, especially. I remember watching the towers coming down and saying to myself, "This can't be happening," denying that it was happening. And I certainly felt anxious and confused and angry. And certainly the victims of Hurricane Katrina or local flooding in New York State, the victims in Mumbai the other day... It's going to happen and the emotional response gets in the way of being able to clearly think about "what do I do next to reduce my risk?"

Moderator: It's a real response and we have to deal with it. It's a real, honest, human response. We have to deal with it.

K. Smith: We have to assume it's going to happen and figure out in advance how to communicate around that. A lot of that is communicating before the responses engage, which means communicating before the fact so that people will then have some prior beliefs to base responses on.

Moderator: Is this what you mean by the term "vicarious rehearsal"?

K. Smith: That really refers to armchair victims, and it's a product of, again, our 24/7 global multimedia societies - where something can happen anyplace in the world and we will see that and our emotional response will be, "Could that happen to me?" And we'll start thinking, "What would I do if, indeed, it happened to me?" You feel like you're experiencing it even though it's happening far a field. One caution to that, though. People who are experiencing this vicarious rehearsal will be less likely to pay attention to risk-reduction advice because they know it's not happening here. Even though they're worried about it, they have a certain level of comfort that it's happening somewhere else.

Moderator: So the psychology of people riding the subway systems in the United States this week after the Mumbai attack is mixed up in that, you're saying that they can see it happening elsewhere, but think it's not happening here.

K. Smith: Here we enter into something called "optimism bias." Research shows - and I'm sorry if my numbers aren't exactly right, but about 90% of people figure bad things will happen - but not to them. We need it, but it makes it hard to communicate the true extent of risk. People will worry, but go about their lives. But that makes it hard to relay what is true extent of risk. And that's probably what's happening with the subway - people have to ride the subway and so will take their chances. They'll be grateful for any interventions taken - bag searches, etc. But, otherwise, they're going to go about their lives as usual.

Moderator: This vicarious rehearsal idea, does it lend itself to what we call the "worried sick" phenomenon?

K. Smith: It does. I'm glad you referred to it as the "worried sick," because in the very recent past, at least in public health circles, it was referred to as "the worried well." These are people who because of the psychological responses, are experiencing the multiple, unexplained, physical symptoms. Unfortunately, there's no reason for them to become ill, but this concern does result in symptoms, and these symptoms need medical attention. They can't just be disregarded. It puts a strain on health care resources. Even if they don't result in symptoms that require intervention by a doctor, we have seen research after 9/11 showing it dramatically increased people's reliance on alcohol and cigarettes, reverting to drug use and other destructive behaviors that are a result of these impulses. It can also result in stigmatization. We as a society may also decide some group is to blame for whatever crisis that's ensued - the modern-day Typhoid Mary - and then we point fingers. As happened in SARS when some people were afraid to go to Chinese restaurants. That's unfortunate, and we need to see as communicators how we can work to prevent that.

Moderator: Right. Now, this area that we want to get into next is a fascinating area, how people react differently to different kinds of crises or emergencies and it relates directly to communication challenges.

K. Smith: It's all based on research, and I didn't do the research, but I'm talking about research that has been done by a number of very gifted experts. They show that there's a real issue with risk perception, and bottom line: all risks are not accepted equally. There are some we'll deal with and others we just find unacceptable, and there're a number of reasons for that. If the risk is voluntary on our part - we choose to accept it; we're okay with that. If it's involuntary - sorry, that's not acceptable. If it's controlled by us rather than others, we feel better about that risk. As an example, how did you get here today, Peter?

Moderator: I drove my car here.

K. Smith: You drove your car - and I drove my car. I always feel safe behind the wheel of my car, and when I get into an airplane, I know that I have a far greater chance of getting injured or killed in an auto accident than I do in a plane crash, but I have a few seconds of trepidation. Why? Because I know my skills behind the wheel and I'm not sure whether the pilot has had a bad day or didn't get enough sleep, and that risk is not within my control, so it affects me a little more profoundly. Similarly, if it's a risk that we're familiar with versus a brand new threat, we're more willing to accept it. Take West Nile Virus that emerged in New York State in 1999. People were calling the health department because they saw a fly on their screen door. They figured it was close enough to a mosquito and were worried about that. Now the communication around West Nile has moved into social marketing, where we're trying to persuade people to do things to protect themselves from a risk they're now familiar with and not so much worried about. We have to deal with that as well. Natural versus man-made, that's the difference between radon gas, which can be a health threat, often is, and radiation from a nuclear power plant. And I think we all know which one is more acceptable to the general public. Reversible versus permanent risks, that just makes sense. If it's a choice between breaking my leg and breaking my neck, I will go for the activity that-- you know, if I voluntarily accept the chance of breaking my leg. Fairly versus unfairly distributed risks. Which goes to the idea of environmental justice and where is that trash-burning plant located? And why is it in my neighborhood - outside of my control? And then if a risk affects children, it absolutely is much less acceptable. And I think all of us as parents understand why.

Moderator: That's right. The involuntary risk gets into... As you know, I work with the Cancer Society and we work on the question of secondhand smoke and if we're imposing a risk on others who are not smokers. And it's now been found there's extraordinarily high risk from the toxins there and people who are victimized, including children, get the smoke involuntarily and that's the risk.

K. Smith: Obviously many smokers have stopped because they are worried about the effect on their children. They're willing to accept the risk for themselves, probably that optimism bias kicking in, but when they see what could happen to their kids, that's when they stop. So the risk that affects children is not acceptable.

Moderator: Let's talk about some of the key points to keep in mind when communicating with the public during a crisis.

K. Smith: I think the most important component is to not try to be comforter in chief. Do not try to over assure. And that is our natural tendency. If we are in a response role, we feel it is our obligation to make people feel okay. No, it's our obligation to be honest and to give them the best advice to reduce their risk. So my personal opinion is you need to be very careful not to be falsely reassuring. It's important to overestimate rather than underestimate because people have-- research has shown that people will be more accepting of an estimate that's modified downward than if you have to modify it upward. In plain English, that means if you have done the computer model and it shows that this threat could potentially kill or injure 200 to 500 people, if you choose to say that your best science says that at least 200 people could be injured and then it turns out 399 people are injured - you're not trusted; you got it wrong. On the other hand, if you said up to 500 people and it turned out to be 399, you must have worked as hard as you could to make that risk less imposing on people. So that's a difficult one because people want to be reassuring, and reassurance is necessary, but not false reassurance. I think that's the point I really want to make.

Moderator: I like that term, "comforter in chief." You're right. It is a tendency and if people look and get a false answer from you, then it's throwing away that trust - which is very hard to get back.

K. Smith: You can't get it back. Once the trust is lost, especially in a crisis, you will not get it back. There's a theory are, the trust determination theory, that talks about how you get to be trusted in a crisis situation. But one of the things you have to do is not get caught in a lie, and even if you're perceived as having lied, you will not get that credibility back and credibility may be your most important quality.

Moderator: But at the same time, we have a problem of never having the full set of facts that we would love to have. So how cautious do you have to be in relaying the hard information that is partial, and you don't want to be overly comforting, as you say, when you've got positive information, but you have positive information that you need to get out there, too.

K. Smith: There are techniques, really just communication techniques that will help with that. One of those is when the news is good, if things are finally starting to come under control - put it in parenthetical. State the continued concern before giving them the good news. For instance, there're some examples on the screen "We're not out of the woods yet." "We have seen declining numbers of cases each week" and "Although the fire could still be a problem, we have it 85% contained." I saw Julie Gerberding, Director of the CDC asked when SARS first came out, "Could it be terrorism?" Obviously there was little chance it could be terrorism, but she did not dismiss it out of hand. Her actual reply was something to the effect that, "While we have no reason to believe this could be terrorism; we are not dismissing any possibility." And then she went on to explain why it looked very much like a natural threat. So she did not say, you know, right off the bat, "We're 99 and 44/100th percent sure that it's a newly emerged agent, but natural." She did allude to the possibility that it could be worse than what it turned out to be.

Moderator: Right. That goes to your point on the next slide of under promising and over delivering.

K. Smith: Absolutely. Again, when you say, "What can we say when the situation is emergent and we don't have all the information?" You can talk about what you're doing. You can't promise about the outcome unless you've got a crystal ball that's working particularly well on a given day. But you can explain all the things that you are doing to come to the result that everybody wants. So explain about the process. Explain what you think the issue is, all the things you are doing to combat the challenges, what you think will occur as a result and also tell people how they're going to get the information as it changes. An emergency is an emergent situation. We need to constantly keep aware of that.

Moderator: Right. And even though in describing the process, you're leaving holes or indications of things that have yet to be done to get answers, just giving people a sense that there's a process in place to get the answers is helpful to them.

K. Smith: And having said that, though, I really need to stress that you can't be bureaucratic and say "We have a plan. We can't tell you what the plan is because of security reasons, but we do have a plan. Just trust me." That's not the way to go about it. If we're talking about an infectious disease, we need to be able to say something to the effect of "We do have an unexplained cluster of illnesses in whatever part of the country or state. We are doing this surveillance to see if we have any patterns of illness and, by the way - this is what the surveillance entails. We plan to do x, y, and z afterwards, and then we plan to tell you what we found at a stated time." Bring people into the process. An emergency is a shared dilemma. It's not just up to a few people, despite their job titles, to be parental, to decide, to announce, to defend, and then tell people "Just do as I say and you'll be just fine." That will not be accepted.

Moderator: Nor do we need them to try to impress the public with all the acronyms they can think of and drive into one sentence.

K. Smith: And in public health, we're particularly guilty of this. Not just acronyms, but the jargon. The one I love is "We're going to prophylax the population." I don't know if anybody knows what we mean by that and based on prior beliefs, they may have other thoughts, so we're not speaking clearly. We need to use plain language, get rid of the acronyms, and certainly in public health preparedness, we have a number of them. I can't even keep up with them. Even something as simple as CDC, it's the Centers for Disease Control and Prevention and we know that, but others may not know what we mean. It may be the Canadian Development Corporation.

Moderator: Or Canadian Broadcasting -- that's CBC. Are there tips about how to reduce anxiety in your communications with the public that you want to give us?

K. Smith: Not only are there tips, but it's critical to know what they are and use them because that helps people make that risk within their span of control and makes it more accepting of the risk. And importantly, the ways they can reduce the risk for them and their family. Some of the things we can do is understand that anxiety is reduced when people can take action steps. Symbolic behaviors are often very helpful. Preparatory behaviors such as we are advising now because of the potential for a pandemic. We're asking people to stockpile two weeks of food and other essential supplies; contingent “if then” behaviors. If this happens, then what will you do? If, for instance you cannot get back to your home, where will your family members meet? In flooding, that's a perfect example. People may think if something bad happens, let's all go back home and huddle together. What if you can't get back to your home? What do you do? What if the local phone lines are down? How do you communicate? You need to communicate this in advance. And give people a three-part action plan -- x, y, and z -- rather than do this and you'll be just fine.

Moderator:  Why does a three-part plan help reduce their anxiety?

K. Smith: Puts it within their control, makes it their own choice. It's not decide, announce, defend. It's "Here are some options. We think all are valuable. You're a partner in this shared dilemma and we count on you to make a good decision.

Moderator: And your circumstance may be different from mine.”

K. Smith: Absolutely. We're not all the same.

Moderator: Right. Should we allow people to feel their fear?

K. Smith: I think we should encourage people to feel their fear. That happens so rarely. Certainly there have been very effective examples of crisis communication when that was encouraged, but for the most part, I think people in leadership roles think they have to be very stoic and convince people to be stoic as well. How often have we heard people say, "There's no need for undue alarm," when in fact the situation is quite concerning. When we tell people they need to be stoic, what we're saying is, "This is a concerning situation, but you need to buck up." So they're worried. They feel helpless or hopeless, and now they also feel guilty for a natural and expected response. We need to validate that response and then they'll trust us more if they know we understand it's a worrisome situation and we're not trying to make it seem less worrisome - we're all in this together. They might wonder what's the matter with us if we can't see the sky is falling when it really is.

Moderator: I'm worried about my kids getting the flu, so it's a rational reaction.

K. Smith: And an emotional reaction. They're processing information in a different part of the brain and research has shown that as well, a very emotional, visceral reaction, and if we don't validate, they stop trusting us.

Moderator: You can use the fear - you can say, "Here are three things to do to help protect your kids..."

K. Smith: I might not be wording this as precisely as I would have if I made my message maps, but you have to say, "We understand why you're concerned about this particular situation. We are concerned as well, and here is what we are doing so that we can reduce all of our risks. And here is what we would suggest you do based on all we know so far to help reduce the risk. Here are several options."

Moderator: Right. What can we expect the public to ask of you, of us, in an emergency situation?

K. Smith: What would you ask?

Moderator: How do I fix it? How do I prevent my kids from getting sick?

K. Smith: Bottom line: am I safe? Is my family safe? What do I need to do to stay safe or reduce my risk? What have you found out about this - I'm really concerned. What do I need to know? Because knowledge is power. And what caused it and importantly, can you fix it? That's a tough one because at this point, you may not know you can fix it or you know it's going to take quite a bit of effort and time to do so, but you need to then go with the process and you need to say, "It's a devastating situation. It will not be fixed overnight. Here's what we have done so far, what we plan to do next, and here's what you can do to help solve this problem that affects us all.”

Moderator:  I'm curious as to whether there have been studies to determine if those kinds of questions or the thinking of the public has changed at all since 9/11, since Katrina. Certainly with Mumbai this week, we certainly have all suffered an encroachment of our optimism factor there. We certainly realize that the world is a different place than we thought it was maybe and are people more likely to believe the possibility of a disaster striking them now?

K. Smith: You know, Peter Sandman talks about something called an “adjustment reaction”. That's when the novel risk strikes. We go through vicarious rehearsal and go through being overly fearful, and then as a little time passes, we adjust to the risk because we have to. Otherwise, we can't go about our daily lives. I think that's probably what happens. Even with risks we really need to pay attention to, there's something called "message fatigue," just sick of hearing about it. That may be the case with pandemic influenza now. We have people who are probably on a spectrum. On one side is irrational concern and another is irrational complacency. What we need to do is bring them to a point that we could responsibly refer to as aware and prepared. I think that's going to be a continuing challenge for us.

Moderator:  Speaking of continuing challenges, I know you have spent a number of years in the media and working with the media, and that's a major way you need to communicate with the public - through the media. But they're going to ask different questions, necessarily, many times, than the public asks, and how to line those things up is tricky business.

K. Smith: Who, what, why, when, where, how are absolutes. As a matter of fact, research Dr. Vincent Covello conducted looked into the questions of the 77 most frequently asked questions in an emergency. And there's a list of them on the internet if anybody wants to refer to that. What's happened? Who's in charge? How is it being contained? Are the victims being helped? What can we expect now? What should we do? And then we get into the blame game: Why did this happen? Did you have forewarning? What did you know and when did you know it? And we need to keep in mind that news is visual. Even talking about radio, it's visual because they create mind pictures. But all the other formats are also visual, so they'll be looking for photo-ops as well. You need to understand that. That blame game is interesting because I think pre-Katrina, we would have a little more leeway to try to get our response in gear. The media are often the most effective partners in an emergency. They're part of the community, want to be part of the solution. But as a result of Katrina, I think they will probably be much quicker to ask why did this happen? Did you have forewarning? Why weren't you prepared?

Moderator: It's sort of like losing the trust, having had a bad performance for whatever reason at all levels of government, and the public clearly got that message, and now the media, now believing that there's a likelihood of that happening again.

K. Smith: Yeah, and you're not going to get the wiggle room you would have had, so that means you need to prepare in advance. But media being media, and since I come from those ranks, it's not a criticism; it's just a reality. The question is going to be asked, “Are you also preparing? Are you wasting valuable taxpayer dollars getting ready for something that potentially won't happen?” I think that's occasionally asked about pandemic preparedness, but on the other hand, the actual risk that the levees would break in New Orleans was fairly low. But the consequences should it happen was known to be devastating, and unfortunately the planners in that case went with the very low risk rather than planning for the devastating consequences. And we saw what happened, so we can't allow that to happen in the future.

Moderator: Right. Is there a way to -- this sounds like sort of a naive question -- but is there a way to manage the risk communication process here?

K. Smith: Let's just say that the most effective risk communication will not in and of itself solve the problem, but ineffective communication will arguably make it much, much worse. So you need to know what you are going to release. When are you going to release it? How will you release your information? Where will you release it? Should you go to the scene of the disaster or be in the state capital or nation's capital with flags behind you? Who should tell the public about it? What's your motivation for letting them know? And in an infectious disease crisis, by the way, the World Health Organization recommends that the reason you release information is because it can help people to reduce their risk of illness or death. And they say that you cannot hold on to that information the minute that having that information would allow the public to take action that would benefit them, it's not right to hold it past that moment.

Moderator: We owe the public an opportunity to take steps to protect themselves if they're available.

K. Smith: Absolutely. Again, anything less is that decide, announce and defend, very parental approach, which will not engender trust and in fact will be much less effective. Same principle public health uses in basic disease transmission.

Moderator: If we know how the disease is transmitted (HIV), we have obligations to let people know so they can reduce risk.

K. Smith: Absolutely, even if we're not sure about the extent of transmission and even if it will lead to hard questions like "why don't you know more?" We need to get that information out there.

Moderator: Let's talk about building trust with the public. There's the talk in New York of Mayor Giuliani's performance in 9/11.

K. Smith: That was a model for building trust and it goes back to the trust determination theory that states there are five essential elements for being trusted. The first is to express empathy. Research shows you have 30 seconds to do that. Often you do it verbally, but your body language or other elements can express empathy. You need to be competent and appear to be competent. You need to be honest and appear to be honest and open. You need to be committed, and you need to be accountable. That last means not shifting the blame, not saying, "It wasn't our fault; it was the other agency's fault," as unfortunately happened in the aftermath of Katrina. Legitimate complaints about things that were not done were in fact viewed as trying to shift blame. It's just not the time for it. There is a time for after-action reports and making things better, but if you're accountable, accept your accountability and convince people that you're going to do the best you can.

Moderator: Why is speed so important in getting information out?

K. Smith: Yeah, and this is again risk communication research. The speed of your message is a marker for how people perceive your preparedness. If you are not the first out there with your message, then you are not in control of the message. The instant experts will have already pontificated on what the situation is and they're bound to be wrong - at least in terms of specific details - because they're not on the front lines. When you finally get around to telling all you know -- if it's different from what people already heard or learned -- they believe the other guy and not you. And an example of that -- and this is not something that might have been prevented, but it's certainly something that I dealt with -- was when West Nile Virus emerged and we were asked, "Well, who's the highest risk?" There was no research to help us know who really was at the highest risk, so we trotted out the usual suspects. We said that we believed it would be elderly, children, and those who are immuno-compromised. It turned out that two of those three were correct. But kids were not at a higher risk - after the surveys were conducted. But for two or three years afterwards, they needed to continue to call media outlets that kept suggesting kids were at a higher risk. They heard it, believed it, and it's hard to counter-believe when it's already in place.

Moderator: What's the goal of the initial message to the public at the onset of an event?

K. Smith: Without appearing falsely reassuring, it is important to ease people's concern so they can get rid of some of the mental and psychological noise, and listen to what they need to hear and take the actions they need to take. You need to give guidance on how to respond and that's usually going to encompass a three-part action plan. You should do x, could do y, but at least do z.

Moderator: And it needs to be short and crisp at the beginning.

K. Smith: Absolutely.

Moderator: Can you offer advice for people who are watching today who might be playing your role as spokespersons for an agency in a crisis anywhere around the country?

K. Smith: Yeah, I think you really need to, first of all, understand that this is difficult. As good as you are, in emergency, things change. So practice and train. Your goal, your ultimate goal, is to be an effective communicator, to get the messages out there that will reduce people's risk of injury or death and remove those psychological barriers that get in the way of people understanding critical information, and so you have to be trusted. You have to be the face of your organization. Move it from that bureaucratic "it" to "we," a shared dilemma, we're all in this together. I have spoken about the three-part action plan and in case people need an example of it, it's what we're suggesting in terms of pandemic preparedness. We are suggesting that right now people should stockpile two weeks of essential supplies, to have them on hand in case of a pandemic. If that's not enough, if they feel they need to do more, they could, and we would actually appreciate if they volunteer to get prepared in pandemic preparedness throughout their communities. But if they're unwilling to do that - they have this optimistic bias that it's never going to happen, at least stay informed about how a pandemic is potentially emerging so it won't come as a complete surprise. Could do x, please do y, but at least do z.

Moderator: And your primary goal as a spokesperson is to do that, to get the public thinking in the right direction and ultimately reduce the incidence of illness, injury and death.

K. Smith: Certainly from a public health perspective - that's why we come to work every day. In an emergency, it's all the more critical to be an effective communicator, and unfortunately, it's that much more challenging for all these very real reasons. If we don't practice, don't think about this in advance, if we don't get the training we need, we will be saying things that will be inconsistent, will not be perceived as credible, and people will then make up their own mind based on their individual experiences. That's something called "anchoring." If you don't have good, solid information quickly - I'm not going to just sit there and accept what happens to me. I'm going to do whatever I think is going to be helpful. And then we in public health and other response roles might say people are panicking. That's not right. Panicking is when you take actions that would arguably lead to a bad result. People are generally taking actions that they think are best for them because they don't have clear guidance soon enough.

Moderator: Right. So judging the message that you're putting out -- your slide talks about speed as the marker for preparedness and the fact that you have to be consistent.

K. Smith: Right, and that seems so simple, but look at when we have a flood and we tell people, "You need to boil your water." Some people say for one minute and others for two and a third for three, and then I'm sitting at home hearing I should boil my water and take your best guess. It doesn't engender a lot of trust. Am I going to depend on information from that source later on when the experts themselves don't agree? So that's a real challenge as well.

Moderator: Let's get into some of the practical do's and don'ts that you have prepared here. What are the most important lessons a communication professional should learn for dealing with a crisis?

K. Smith: I'm going to say "plan ahead." You have heard this throughout the course of our conversation, but it's critical. You need to understand that bad things can happen to good localities and to plan for those, because you need to be able to respond quickly. The first 24 hours will tell the tale. Also, you need to be straightforward and don't hide behind jargon or statistics or scientific knowledge. Talk frankly and treat people as legitimate partners. Be accurate, which is difficult in an emerging situation where the facts are changing all the time. But the way to do this is to state, "this is what we know right now. Here, by the way, is how we came to this knowledge, and here is what we're doing to quantify this knowledge. And if it changes, you're going to know about it as soon as we do." We need to strive to reassure, to be trusted as a source, as well as to inform without falsely reassuring. And also exhibiting compassion. That's key. You have 30 seconds to persuade people that you really care, and if you don't care, they don't care about you. Will Rogers said "They don't care that you know until they know that you care." And that was the Rudy Giuliani model in New York City after 9/11. I don't have this quote precisely, but when asked how many people died, his answer was something to the effect that "Not as many as we feared, but far more than we can bear." There's no better way to say it than that. And one of the reasons he was able to say it so well was that he came up with message maps for an attack on a landmark building in the wake of the first World Trade Center attack. Now you may say that seems cold and calculated, but it's not - it's very professional. And understanding that - as a communicator, if you're looked to for leadership, your communication skills may be the most important countermeasure that you have.

Moderator: It helps in that case, that the leader - the mayor appear or broadcast the sense that he was in control and in command, which the public needs, too.

K. Smith: He didn't need to tell everybody he was comforter-in-chief. Just by understanding that he really did care and being able to be trusted, he served the role of comforter-in-chief, without falsely reassuring at any point.

Moderator: Okay. On the flip side, you have a "Don't" slide or two.

K. Smith: Yes, and I put this in here because I think, especially on the part of many leaders, there is that optimism bias that a terrible thing will never happen here. Certainly, we always hope nothing as horrible as terrorism or bio-terrorism or pandemic flu will happen, but we have seen of late that natural disasters happen all the time, and they can be very problematic. So plan ahead and don't assume it will never happen here. Don't allow someone else to define your issues. That happens when they get out there first with a message. So don't delay that information release until you're 100% sure because when will you be 100% sure? Well, probably many years in the future when you're writing the journal article.

Moderator: Or when you have all the lab reports that you could possibly dream of...

K. Smith: Exactly. But right now it's a developing situation and new facts are emerging and you will not be 100% sure. So as soon as you know there's an issue that can be helped by communicating the facts, you have an obligation to communicate those facts. Don't provide false reassurance. I know I'm becoming kind of a mantra on that, but it's important for trust and credibility. Another way that you can engender trust, by the way, is because there are so many people out there giving so many messages - try to synchronize your message with trusted sources in the community. It's a concept of third-party verifiers, but trusted leaders, opinion leaders, faith community leaders. Research shows, by the way, that health care providers are very trusted to give information in a health crisis, so we need to engage them as well.

Moderator: And I think the most important item here on the next slide is don't get caught in a lie.

K. Smith: Yes. That seems fairly simplistic. Don't get caught in a lie. But what's important to remember is that you can lie by omission, you can lie by misdirection - that's referred to as spin. And risk communication is not spin-control. It has no bearing at all on spin control, and there should be none of that in your risk communication. So-- and by the way, you'll get caught. You will always get caught. And then you won't be trusted and then you might as well just take your PSAs and news releases and microphone and go home because you won't be an effective communicator.

Moderator: Right. What are some of the pitfalls to avoid, Kris?

K. Smith: In a crisis situation, as we discussed -- there's going to be a lot of anger and concern. If you're the person who is the face of this crisis, people who don't have anybody else to blame or be angry at are going to be angry at you, arguably. You are also a human being, dealing with complex emotions and working probably 18-20 hours a day, 7 days a week. And it's going to be very instinctive to attack back and tell people why they're so wrong to do this, but you have to respond to issues and not the person. You have to be very clear on that, and your spokesperson needs to be able to do that. I don't care how intelligent or gifted they are - if they can't do that, they shouldn't be your spokesperson. And non-verbal cues are also huge. Your position in the room, the wardrobe that you choose can send a very real message. So be careful about that. Especially those of us who work with scientists or in the field of science or health, we love our statistics. But the public will perceive them as a way to avoid clear communication. And the public, by the way, doesn't care about statistics. All risk to them is anecdotal. It may -- all risk to them is anecdotal. It may have happened to a million people elsewhere, but until it happens to my neighbor, I won't worry much about it. You see it with disease, I'm sure you see it with cancer all the time. When it happens to someone we care about, all of a sudden it's a real concern.

Moderator: Exactly. How can communication professionals relay technical information most effectively without getting into all the jargon and statistics problem that you talked about?

K. Smith: I like to use examples. Avoid the acronyms and jargon, and be consistent. If you're going to use terminology, be consistent throughout the course of your communication. Don't use the word "epidemiology" one time and "epi" the next. By the way, using the term “epidemiologist” can be a problem. I used it when I was telling people that help was on the way - that we were sending an epidemiologist to look into a potential disease cluster, and they thought it meant epidemic... So please do explain it, and use demonstrations and points to make clear what you're saying. For instance, I do some nuclear power plant drills, and every time there's a scenario involving a leak of radioactive water to the containment room. I had visions of a waterfall - when actually it's about a teacup worth and it's important to make that clear to people.

Moderator: So what's the bottom line here? I think we have a great slide that illustrates your point.

K. Smith: Yeah, I love this slide. It really is. The bottom line is that the public does not all appear to be rational, and our job as communicators is not to change their rationality, but to understand it and to communicate effectively in that environment. You know, we don't have to persuade people. We don't have to decide, announce and defend. We have to understand why people feel as they do and we have to communicate effectively through all this noise in the channel.

Moderator: All right. I'm afraid we don't have time for calls, but we do have one fax here I would like to read. It's a question in from Vermont. “Who will ensure that coordinated messages get to the media? The public will be very confused if they're getting different stories all the time.” We have about one minute to go.

K. Smith: We're working on that right now. We work as a state in New York and as a region. I often have discussions with my counterpart at the Department of Health in Vermont, recently went to a meeting in Boston about how to communications across the northeastern region, and one in New York City for communication thru the middle-Atlantic. We understand it's an issue, and are working with the media on that as well, and will continue to plug away.

Moderator: Are there additional resources available? The audience will get the slides, but I know we have one here that talks about some of the sources...

K. Smith: Absolutely, and these are the people I want to thank as well. I would refer you to the CDC website, Agency for Toxic Substance and Disease Registry, the Center for Risk Communication - Dr. Covello's Research Center, the Consortium for Risk and Crisis Communication, which is run by Drs. Vincent Covello and Tim Tinker. www.psandman.com is a wonderful web site and the Society for Risk Analysis has a wealth of resources, as well. We're on the credit slide and I do want to thank all these folk because I am a practioner - not an expert. I like to talk about what the experts have learned. And Thom Berry from the South Carolina Department of Environmental Health and Control gave us a lot of these slides.

Moderator: Kristine, thank you very much. A very informative hour. We're running out of time, but it's been great and I'm sure the audience got an awful lot out of it. Thank you all out there for joining us today. I would like you to take a moment to fill out your evaluations: www.ualbanycphp.org/evals. Your thoughts and comment are really important as we plan future programs. Continuing education credits are available free of charge to viewers who complete the on-line evaluation and the short post-test. Please visit our web site for details. This program, as well as other previous programs, will be available via web streaming, online, within the week. See our web site for an archived collection of past broadcasts. I'm Peter Slocum and I'll see you next time for the Albany Center for Public Health Preparedness Grand Round Series.



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