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Past time to tell the public: “It will probably go pandemic, and we should all prepare now”

Introduction by Croakey: As the novel coronavirus epidemic gathers pace outside of China, with cases ramping up in countries including South Korea, Italy and Iran, there is a growing consensus that we are entering a new, likely pandemic, phase of the outbreak.

Victoria’s chief health officer, Dr Brett Sutton, warned that with sustained local transmission now evident in several countries beyond China, a pandemic was now “very likely if not inevitable”.

According to the latest World Health Organisation situation report, there were 367 new cases reported in the last 24 hours outside of China for a total of 1,769 cases, with the bulk of these in South Korea, Japan, Italy and Iran.

Australia now has 22 cases of COVID-19, including seven repatriated Diamond Princess passengers who tested positive while in quarantine in Darwin.

The uptick in global cases, and clusters in several countries have spurred debate about whether the outbreak is now formally a pandemic (more on what a pandemic is and what it means here and here).

Science journalists Helen Branswell and Kai Kupferschmidt have some excellent explainer threads on the state of play with COVID-19, and global health lawyer Alexandra Phelan has dissected out some of the implications of declaring a pandemic, as distinct from a Public Health Emergency of International Concern (formalised by the WHO on January 30).

In this piece from virologist Ian Mackay‘s blog, republished here with permission, risk communication specialists Jody Lanard and Peter M Sandman argue it is past time to start using the ‘p’ word — pandemic — and to shift focus away from containment to mitigation.


Jody Lanard and Peter M Sandman write:

We are starting to hear from experts and officials who now believe a COVID-19 pandemic is more and more likely.  They want to use the “P word,” and also start talking more about what communities and individuals can and should do to prepare. 

On February 22, Australian virologist Ian Mackay asked us for our thoughts on this phase of COVID-19 risk communication. 

Here is our response.

Yes, it is past time to say “pandemic” – and to stop saying “stop”

It’s a good time to think about how to use the “P word” (pandemic) in talking about COVID-19.  Or rather, it is past time.

It is important to help people understand that while you think – if you do think so – that this is going to be pandemic in terms of becoming very widespread,  no one knows yet how much severe disease there will be around the world over short periods of time. 

“Will it be a mild, or moderate, or severe pandemic?  Too soon to say, but at the moment, there are some tentative signs that….”  

The most crucial (and overdue) risk communication task for the next few days is to help people visualize their communities when “keeping it out” – containment – is no longer relevant.  The P word is a good way to launch this message.  

But the P word alone won’t help the public understand what’s about to change: the end of most quarantines, travel restrictions, contact tracing, and other measures designed to keep “them” from infecting “us,” and the switch to measures like canceling mass events designed to keep us from infecting each other.  

We are near-certain that the desperate-sounding last-ditch containment messaging of recent days is contributing to a massive global misperception about the near-term future.

The theme of WHO’s and many governments’ messages – that the “window of opportunity” to stop spread of the virus is closing – is like the famous cover page of Nevil Shute’s On the Beach: “There is still time … Brother.”

For weeks we have been trying to get officials to talk early about the main goal of containment: to slow the spread of the virus, not to stop it.  And to explain that containment efforts would eventually end.  And to help people learn about “after containment.”  This risk communication has not happened yet in most places.

So here is one more pitch for openness about containment.  Officials: Please read Containment as Signal, Swine Flu Risk Miscommunication, which we wrote in 2009.  

One horrible effect of this continued “stop the pandemic” daydream masquerading as a policy goal: It is driving counter-productive and outrage-inducing measures by many countries against travelers from other countries, even their own citizens back from other countries.  But possibly more horrible: The messaging is driving resources toward “stopping,” and away from the main potential benefit of containment – slowing the spread of the pandemic and thereby buying a little more time to prepare for what’s coming. 

We hope that governments and healthcare institutions are using this time wisely.  We know that ordinary citizens are not being asked to do so.  In most countries – including our United States and your Australia – ordinary citizens have not been asked to prepare.  Instead, they have been led to expect that their governments will keep the virus from their doors.

Take the risk of scaring people

Whenever we introduce the word “pandemic,” it’s important to validate that it’s a scary word – both to experts and to non-experts – because it justifiably contains the implication of something potentially really bad, and definitely really disruptive, for an unknown period of time.  This implication is true and unavoidable, even if the overall pattern of disease ends up being mild, like the 2009-10 “swine flu” pandemic.

Validate also that some people may accuse you of fear-mongering.  And respond that hiding your strong professional opinion about this pandemic-to-be would be immoral, or not in keeping with your commitment to transparency, or unforgivably unprofessional, or derelict in your duty to warn, or whatever feels truest in your heart.

It may help to consider the “damned if you do, damned if you don’t” fallacy.  Feel free to say that “Jody Lanard and Peter Sandman say” that officials or experts – in this case YOU – are “darned if you do and damned if you don’t.”  You’re only darned if you warn about something that turns out minor.  But you’re damned, and rightly so, if you fail to warn about something that turns out serious.  

It’s simply not true, in principle or in practice, that you are damned if you do and damned if you don’t!  Over-alarming risk messages are far more forgivable than over-reassuring ones.

Push people to prepare, and guide their prep 

This is the most culpable neglected messaging in many countries at this point.

The main readiness stuff we routinely see from official and expert sources is either “DON’T get ready!” (masks), or “Do what we’ve always told you to do!” (hand hygiene and non-mask respiratory etiquette).

The general public, and many categories of civil society, are not actively being recruited to do anything different in the face of COVID-19 approaching.

A fair number of health care workers and communication officers tell us their hospitals and healthcare systems are just barely communicating about COVID-19. They want to be involved in how to prepare for “business not as usual.”  We’re guessing that many hospital managements are in fact preparing for COVID-19, but we worry that they’re doing it too quietly, without enough effort to prepare their staff. 

Lots of businesses, especially smaller ones, are doing off-the-cuff pre-pandemic planning.  Several trade journals have articles about how specific industries should prepare for a likely pandemic.  Around February 10, the U.S. Centers for Disease Control and Prevention posted interim guidance for businesses.  But we have seen almost nothing in mainstream media citing this guidance, or recommending business continuity strategies like urgent cross-training so that core functions won’t be derailed because certain key employees are out sick, for instance.

Pandemic planning research suggests that employees are likeliest to say they will show up for work during a pandemic if three specs are met – if they think their family is reasonably safe; if they think their employer is being candid with them about the situation; and if they have a pandemic-specific job assignment in addition to or different from their routine “peacetime” assignment.

Hardly any officials are telling civil society and the general public how to get ready for this pandemic.

Even officials who say very alarming things about the prospects of a pandemic mostly focus on how their agencies are preparing, not on how the people they misperceive as “audience” should prepare.  “Audience” is the wrong frame.  We are all stakeholders, and we don’t just want to hear what officials are doing.  We want to hear what we can do too.  

We want – and need – to hear advice like this: 

  • Try to get a few extra months’ worth of prescription meds, if possible. 
  • Think through now how we will take care of sick family members while trying not to get infected. 
  • Cross-train key staff at work so one person’s absence won’t derail our organization’s ability to function.
  • Practice touching our faces less. So how about a face-counter app like the step-counters so many of us use? 
  • Replace handshakes with elbow-bumps (the “Ebola handshake”). 
  • Start building harm-reduction habits like pushing elevator buttons with a knuckle instead of a fingertip. 

There is so much for people to do, and to practice doing in advance.

Preparedness is emotional too

Suggesting things people can do to prepare for a possible hard time to come doesn’t just get them better prepared logistically.  It also helps get them better prepared emotionally.  It helps get them through the Oh My God (OMG) moment everyone needs to have, and needs to get through, preferably without being accused of hysteria.

It is better to get through this OMG moment now rather than later.  

Offering people a list of preparedness steps to choose among means that those who are worried and feeling helpless can better bear their worry, and those who are beyond worry and deep into denial can better face their worry.  

Yet another benefit: The more people who are making preparedness efforts, the more connected to each other they feel.  Pandemic preparedness should be a communitarian experience.  When a colleague offers you an elbow bump instead of a handshake, your mind goes to those lists of preparedness recommendations you’ve been seeing, and you feel part of a community that’s getting ready together.

This OMG realization that we have termed the “adjustment reaction” is a step that is hard to skip on the way to the new normal.  Going through it before a crisis is full-blown is more conducive to resilience, coping, and rational response than going through it mid-crisis.  Officials make a mistake when they sugarcoat alarming information, postponing the public’s adjustment reaction in the vain hope that they can avoid it altogether.

Specific pandemic preparedness messages

Below are links to specific preparedness messaging we drafted for a possible H5N1 pandemic.  The links are all from our 2007 website column What to Say When a Pandemic Looks Imminent: Messaging for WHO Phases Four and Five.  Each item is in two parts – a draft message (a summary sentence followed by a few paragraphs of elaboration), then a risk communication discussion of why we think it’s an appropriate pre-pandemic message.  Because these were written with H5N1 in mind, the pandemic they contemplate is more severe and less likely than the one we contemplate today.  So some changes may be called for – but frankly, in our judgment, not many.

We may have a window of opportunity now to make some practical preparations. We must make the most of it – even though the effort may be wasted if a severe pandemic doesn’t happen.
What matters most is how households, neighborhoods, community groups, and businesses prepare.
Individual and community preparations will focus on three tasks – reducing each person’s chance of getting sick, helping households with basic survival needs during a pandemic, and minimizing and coping with larger societal disruption.
Social distancing will be important but unpleasant.
School closings present a particularly difficult social distancing dilemma.
Hand-washing is far from a panacea. But it’s easy, it’s under your control, and it has no significant downside.
Like washing your hands, wearing a facemask may help a bit. But it has more downside than washing your hands.
Getting ready for a pandemic is largely about preparing for possible shortages.
It’s probably too late to stockpile much now, but do what you can.
Now is also the time to think about how you will care for loved ones at home.
To get ourselves through the hard times that may be coming, we will need volunteers. How can you help?

One of the scariest messaging failures in the developed world is not telling people vividly about what the end of containment will look like, for instance the end of contact-tracing and most quarantines. 

The FAQs on the Singapore Ministry of Health webpage can serve as a model that other developed countries can adapt to start talking to their publics about this now, to reduce the shock and anger when governments stop trying to contain all identified cases. 

What’s working for us

We’d like to share with you some of our recent everyday life experiences in talking about pandemic preparedness with people who perceive us as a bit knowledgeable about what may be on the horizon.  Some of this overlaps with the more generic comments above.

  1. We’ve found it useful to tell friends and family to try to get ahead on their medical prescriptions if they can, in case of very predictable supply chain disruptions, and so they won’t have to go out to the pharmacy at a time when there may be long lines of sick people.  This helps them in a practical sense, but it also makes them visualize – often for the first time – how a pandemic may impact them in their everyday lives, even if they don’t actually catch COVID-19.  It simultaneously gives them a small “Oh my God” moment (an emotional rehearsal about the future) – and something to do about it right away to help them get through the adjustment reaction.
  2. We also recommend that people might want to slowly (so no one will accuse them of panic-buying) start to stock up on enough non-perishable food to last their households through several weeks of social distancing at home during an intense wave of transmission in their community.  This too seems to get through emotionally, as well as being useful logistically.
  3. Three other recommendations that we feel have gone over well with our friends and acquaintances:
    1. Suggesting practical organizational things they and their organizations can do to get ready, such as cross-training to mitigate absenteeism.
    2. Suggesting that people make plans for childcare when they are sick, or when their child is sick.
    3. And the example we like the best, because it gives every single person an immediate action that they can take over and over: Right now, today, start practicing not touching your face when you are out and about!  You probably won’t be able to do it perfectly, but you can greatly reduce the frequency of potential self-inoculation.  You can even institute a buddy system, where friends and colleagues are asked to remind each other when someone scratches her eyelid or rubs his nose.  As we noted earlier, someone should develop a face-touching app – instead of a step-counting app to encourage you to walk more, how about an app to encourage you to auto-inoculate less!  And track your progress, and compete with your friends, even!

The last message on our list – to practice and try to form a new habit – has several immediate and longer-term benefits.

Having something genuinely useful to do can bind anxiety or reduce apathy.  You feel less helpless and less passive.

And you can see yourself improving. 

And you can work on your new habit alone, and also in a pro-social communitarian way.  Others can help you do it, and you can help them. 

And it yields real harm reduction!  It is arguably the endpoint of what washing your hands is for, and it helps when you can’t wash your hands out in the world.

Like all good pandemic preparedness recommendations, it helps you rehearse emotionally, as well as logistically. 

The bottom line

Every single official we know is having multiple “Oh my God” moments, as new COVID-19 developments occur and new findings emerge. 

OMG – there is a fair amount of transmission by infected people with mild or subclinical cases! 

OMG – there is a high viral load early on in nasal and pharyngeal samples! 

OMG – the Diamond Princess, how can that have been allowed to happen! 

And on and on.  

Officials help each other through those moments.  They go home and tell their families and friends, sharing the OMG sensation.  And then what do they tell the public?  That they understand that “people are concerned” (as if they themselves weren’t alarmed), but “the risk is low and there’s nothing you need to do now.”

Ian, it sounds like you want to argue on behalf of preparedness.  Encouraging all stakeholders to prepare logistically should start now, if not sooner.  And you are in a position not just to encourage logistical preparedness, but also to encourage government sources and other experts like yourself to do the same.  Perhaps even more important, in our judgment: You can try to encourage emotional preparedness, and try to encourage other official and expert sources to encourage emotional preparedness – guiding people’s OMG adjustment reactions instead of trying to stamp them out.

Jody Lanard and Peter M Sandman are risk communication experts

You can visit their site, including a dedicated COVID-19 risk communications page here

Our thanks to Jody, Peter and Ian for allowing us to cross-post this important and timely piece, which you can access in original form at Ian’s blog

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