The WHO That Cried Flu?

When it comes to public health scares, nothing titillates like a juicy gaffe.

Back in November 2004, pandemic-panic was on the decline, with SARS firmly in the past and bird flu henpecking only the occasional human in villages around Asia.

Enter Dr Shigeru Omi, the World Health Organization’s regional director for the Asia Pacific. Fronting a delighted media, the doctor pressed the panic button: If a bird flu pandemic occurred — which he considered "very, very likely" — the death toll could be 20 million, 50 million, or even as high as 100 million.

WHO officials in Geneva scrambled. The WHO-sanctioned fatality prediction on bird flu was only in the order of between two and seven million. Omi’s remarks had not been approved, there was no new basis for his estimates, and they had no idea why he considered a pandemic was so likely.

Omi had just broken a cardinal rule of Pandemic PR: outrage management.

Or had he? On the one hand, Omi had risked angering the public and damaging the WHO’s credibility.

On the other hand, the WHO was dealing with a virus that had a fatality rate greater than 50 per cent and could start passing from human to human at any given moment. It desperately needed international cooperation to find a reliable vaccine. And it had an apathetic public to convince.

In which case, Omi had followed another cardinal rule of Pandemic PR: soft warnings and reassurances don’t work. You have to scare people.

So Omi had bent the rules. But was he wrong to make this prediction? And if so, would he have been wrong if bird flu had jumped the species barrier the following week?

Welcome to the precarious world of pandemic management, where public health officials must negotiate an unpredictable virus capable of killing millions, a hungry media demanding 24-hour news, and a public that can oscillate from fear to denial to anger in just a few days.

Last week, after extracting every last drop from public health officials and telling us we could all conceivably die of swine flu, the media predictably swung to the other extreme: it’s all a beat-up. And we were left clutching facemasks and feeling a little silly.

If it’s any consolation, we weren’t the only ones who were scared: the WHO was scared, too.

Peter Sandman, a risk communications expert based in New Jersey, advised the WHO on how to inform the public about the SARS outbreak in 2003, back when the WHO had no outbreak media strategy. "During my 40-year career, having worked on over 500 crises, there’s only been three times when everybody has said, ‘This could be the big one’," Sandman told me on the phone from Salt Lake City. "The first was [nuclear reactor accident]Three Mile Island, the second was SARS, and the third was swine flu."

When it first turned up in Mexico, swine flu looked to be three times as deadly as the oft-invoked Spanish Influenza of 1918. It’s little wonder the WHO panicked — and went into overdrive. Immediately, the WHO reverted to its now finely tuned pandemic PR strategy, based on principles that so-called "risk communicators" have been developing since the 1980s.

I spoke (and argued) with Sandman to get an insight into just two of the strategies that underpin risk communication.

Strategy Number One: Get your Slice of the "Fearfulness Pie"

When Omi foresaw wheezing deaths for the millions in 2004, he was making a greedy grab for what risk communicators call the "fearfulness pie". Lots of people want a piece of it: think environmental campaigners, anti-smoking advocates and politicians.

Yes, that’s right — our capacity for fear is referred to as a pie, and it’s regarded as a prize to be won. Sandman writes, "Fear is a competition. The competitors are many. And there’s a slice of the fearfulness pie with your name on it. Use it or lose it."

"Fear is finite," he told me on the phone. He argues that people have a limited capacity for fear; sometimes it’s directed at the melting of the polar ice caps, sometimes at the risk of a severe pandemic flu. People are already as fearful as they’re going to be — by scaring them about a pandemic, you’re just going for a bigger slice of their existing pie.

Once the WHO have our attention, risk communication strategy teaches them to assure us that we’re all in this together, that there’s no need to panic, but we all must remain vigilant in case the worst case scenario eventuates. It’s what risk communicators refer to as the "Watch out!" and "Stop worrying" approaches. Just enough fear to get us worried, but not too much to make us think there’s nothing we can do — a delicate balance also negotiated by environmental groups communicating on climate change.

But what about "warning fatigue"? Won’t people be less likely to believe the WHO next time they warn of an impending pandemic? Sandman concedes that health officials may have a harder time convincing people of future potential threats, but his wife and colleague, Jody Lanard, disagrees. Lanard is an advocate for "crying wolf", as long as there is just cause — in an interview with Ha’aretz she quotes studies on warnings about hurricanes, including evacuation orders, that have shown that as long as people see their leaders are concerned about their welfare, they can forgive them for a false alarm, and will still adhere to subsequent warnings.

Okay, but what happens, I asked Sandman, if people’s fear keeps getting ratcheted up on a regular basis? Doesn’t that make the population more chronically concerned?

Yes, Sandman replied. And that’s the point.

Strategy Two: Use "Teachable Moments" to establish "The New Normal"

"Once in a while a chance comes along to provoke a brief spurt of pandemic fear," he writes. "Seize the moment. Use it to achieve concrete goals — to teach specific facts … to establish specific behaviours."

Risk communicators call it the "issue-attention cycle". The theory is simple. Consider sharks. Last summer, nobody gave a toss about sharks. After the shark attacks this summer, we could barely go in the water without giving a thought to how edible we were. Next summer, even if there are no shark attacks, we won’t be as scared, but we may still think twice before swimming at dusk or dawn. A new baseline of fear has been established — the New Normal.

The same logic applies to pandemics. When swine flu hit Mexico in April, public health officials basically picked up where they left off with bird flu, talking to a public that was highly attuned to the threat of a severe pandemic.

This time around, risk communicators had a few key "teachable moment" victories. After a rush on facemasks during bird flu and again when swine flu appeared, the media informed us that garden variety facemasks did not protect against the virus.

The public also learnt that the word "pandemic flu" referred only to a virus with global spread, not to whether it would kill as many people as the 1918 Spanish Influenza.

If you took Queensland Health’s chief minister, Jeanette Young, seriously, you’ve no doubt got canned goods occupying every square inch of your pantry. (For the record, Sandman agrees with her approach.)

But before you start burning effigies of public health officials, it is worth noting the communication improvements made since the bird flu outbreak.

Measure and control were in far greater order this time. In 2005, then-WHO director general Dr Lee Jong-wook described avian flu as "the most serious health threat the world is facing today". There have been no similar statements about swine flu; the only thing that competes came from WHO Director General Margaret Chan, who said that all of humanity is under threat during a pandemic.

And you won’t hear any public health official describing a pandemic as being "overdue". Back in the bird flu days, everybody from WHO spokesperson Dick Thompson to our friend Dr Omi was saying a pandemic flu was more likely, because we were overdue for one. That, according to Sandman, was a "gambler’s fallacy".

"It’s like somebody playing roulette who decides to bet on the number 17, because it hasn’t come up yet," he told me. "Every year we go without a pandemic doesn’t make us more overdue for one." This time, only a couple of questionable scientists and errant politicians have publicly claimed that a pandemic is overdue.

As of today, there have been 4694 cases of swine flu in 30 countries (including one in Australia), and 53 deaths. Researchers in London have just published the first detailed analysis of the global spread of swine flu, reporting that millions of people across the world are likely to become infected, and its severity will probably be similar to the 1957 pandemic virus, which killed two million people.

Three days ago, in the only interview she granted all week, Margaret Chan defended the WHO against media criticism. "I’m not predicting the pandemic will blow up," she said, "but if I miss it and we don’t prepare, I fail. I’d rather over-prepare than not prepare."

This article has been edited since it was published.