Natural Hazards Observer
| September 2004 | Volume XXIX | Number 1 |
Invited Comment
Biodefense: If Risk Communication is the Answer, What is the Question?
"How will the public react to a biological attack?" is a fundamental question underpinning U.S. policy and practice pertaining to terrorism preparedness and response. In recent years, widely divergent approaches to the issue of mass response to bioterrorism have emerged. When catastrophic terrorism was a serious but postulated danger, officials often considered public reactions to a biological event as part of the crisis to be contained (e.g., the "worried well" would pour into hospitals, hindering health care workers' ability to treat real victims). The complex realities of September 11, 2001, and the anthrax letter attacks that same year, however, have helped refine the understanding of the public not simply as a problem to be managed, but as a constituency to be served-anxious people in need of good information about the danger and what to do about it.
This essay advances a third approach, encouraging authorities to place the challenge of public communication within a broader understanding of the governance dilemmas that bioterrorism poses for the U.S.
From Crowd Management to Credible Communication
The attitudes of decision makers and responders to-ward the public in the context of bioterrorism have shifted from an emphasis on containing disorder to communicating information. In past hypothetical scenarios, members of the public usually surfaced as mass casualties or hysteria-driven mobs that self-evacuate affected areas or resort to violence to gain access to scarce, potentially life-saving antibiotics and vaccines. Prior to 2001, official response systems were often built around the notion of the public as a problem to be managed during a crisis. This bias, which remains to a certain extent today, precludes consideration of and planning for ways to solicit the cooperation of affected populations.
Communication failures during the serial tragedies of 2001 spurred recognition of the essential role of public outreach in managing the effects of a bioattack. Following the anthrax crisis, federal health authorities identified risk communication and health information dissemination as one of seven priority areas required to upgrade the ability of state and local health departments to respond to bioterrorism. Critical reflection on responses to the 2001 terrorist attacks prompted the release of many helpful analyses and guidebooks for officials regarding successful communication with the media and the larger public. Today, practitioner and policy-maker interest in public communication remains high.
Communication as the Means to an End, Not an End in Itself
As 2001 demonstrated, open and informative relationships among citizens, government, and public health and safety authorities are fundamental to the nation's ability to cope with unconventional terrorism. U.S. leaders and responders should be lauded for embracing effective crisis and risk communication as remedies for a potentially anxious, skeptical, or resistant public. However, authorities should be careful not to approach improved communication as a "quick fix" for the more complex underlying tensions that can precede or emerge during bioattacks or other health crises.
Public communication and risk communication have become code words with which to skirt the multifaceted realities associated with community response to terrorism, bioterrorism in particular. When authorities say they want better communication with the public, what they tend to mean is they want public buy-in, compliance, and understanding-possibly even absolution-when tough choices arise (e.g., how to distribute scarce resources in an emergency). When the public calls for better communication from officials, they are asking for inclusion, consideration, and mutual respect as peer decision makers; expert guidance on which they can act; and proof that their needs have been considered. As the U.S. gravitates toward communication as a key to improved bioterrorism readiness, we need to reflect more thoughtfully on what exactly we want that communication to accomplish.
Leadership, Public Engagement, and Governance Dilemmas
The aim of a bioattack is to create suffering and disruption by introducing an epidemic of infectious disease. Whether natural or deliberate, such an outbreak poses unique dilemmas. Leaders must tend to immediate life-and-death matters, such as caring for the sick; ward off socially corrosive effects, like ostracism of the afflicted; and curtail negative economic effects. Conflicts of interest, priority, and purpose can emerge in pursuit of these goals. The Center for Biosecurity of the University of Pittsburgh Medical Center convened the Working Group on "Governance Dilemmas" in Bioterrorism Response to develop a set of analytic templates for decision makers faced with these difficult situations.
Goals of Bioterrorism Response
A larger focus on strategic goals helps stave off the temptation to focus on managerial and scientific aspects of response while neglecting civic, social, ethical, and economic dimensions.
- Limit death and suffering through preventive, curative, and supportive care; tend to the vulnerability of children, the elderly, and the physically compromised.
- Use the least restrictive interventions to defend civil liberties while containing infectious agents that cause communicable disease.
- Preserve the economic stability of victims as well as hard-hit industries, cities, and neighborhoods.
- Discourage scapegoating, hate crimes, and the stigmatization of people or places as contaminated or unhealthy.
- Bolster the ability of individuals and communities to rebound from unpredictable and traumatic events; provide mental health support to those who need it.
Novel Dangers Posed by Bioattacks
The premeditated use of bioweapons magnifies the already unfamiliar dangers posed by large disease outbreaks. Epidemics are complicated events due to their biology, but also because they provoke fear, contradictory impulses, and competing social aims.
- An epidemic's outcomes-suffering, death, lost livelihood, and commerce-are troubling. Leaders and the public may deny that a problem exists, or intervene too quickly without regard to the effects of their actions
- People need to make sense of random and terrifying events, but epidemics elude quick and easy explanation. The nature of a disease, a population's vitality, and the responsiveness of health institutions affect how an epidemic will unfold.
- A mysterious disease can prompt an individual to isolate oneself and blame others for the tragedy or, in contrast, to care for victims while disregarding one's own safety.
Recurrent Governance Dilemmas during Epidemics
Once acknowledged, an epidemic exerts immense political and social pressure for decisive, visible action-especially when due to a bioattack. Apparent and sometimes genuine conflicts among strategic goals can arise, such as balancing disease control imperatives with those of civil liberty, economic stability, and stigma prevention.
The ability to stop disease that spreads person-to-person and uphold individual freedoms rests largely on leaders taking proactive measures.
Make bioterrorism response plans public before a crisis occurs; a well-informed population is more likely to cooperate with advice for reducing the spread of disease.
Sketch out the big picture; make it clear that personal actions can affect the safety of others (e.g., remind people that staying home from work or school when ill protects others from getting sick).
Use disease controls that respect ideals of autonomy, self-determination, and equality.
Provide goods and services that help people comply with health orders (e.g., set up vaccination clinics in locations accessible to people without cars).
Restrict civil liberties, if necessary, only in a transparent and equitable way.
Social Trust and Coping with Crisis
Breaches of social trust are likely during a bioattack. Social and economic fault lines as well as preconceived notions about the government, the public, and the media can alienate leaders and the public from one another.
Officials' ability to earn the public's confidence regarding the allocation of scarce resources may hinge on the following steps:
- Account for income disparities in response plans; anticipate the need for free or low-cost prevention and treatment;
- Make planning transparent so that the public sees that access to lifesaving resources is based on medical need and not on wealth or favored status;
- Be open about eligibility criteria for goods and services, especially when tough choices arise unexpectedly; and
- Show thorough preparations to protect vulnerable populations, thus bolstering everyone's sense of security.
The collective purpose of the analytic templates highlighted above is to refine leadership skills. The goal is to create realistic expectations on the part of leaders about the societal challenges posed by large disease outbreaks and bioattacks, so they are better prepared to protect and actively support cooperation and trust between a community and its leaders. Increasing emphasis upon enhanced public communication is a positive development within biodefense that must be supplemented with robust discussion among leaders, and between leaders and the public, as to what constitutes an optimal response.
Monica Schoch-Spana
Center for Biosecurity
University of Pittsburgh Medical Center
Asia Pacific Natural Hazards Information Network
The Pacific Disaster Center (PDC) in Kihei, Hawaii, is hosting the Asia Pacific Natural Hazards Information Network (APNHIN), a resource that enables disaster and resource managers, planners, governments, and nongovernmental organizations to tap into high-quality geospatial data for the purpose of reducing disaster risk and vulnerability for the three billion people who reside in the Asia-Pacific region. The network provides access to a wide variety of information, including remote sensing and other Geographic Information Systems (GIS) data. APNHIN comprises a community of organizations who create and share disaster and hazards-related information.
A unique feature of the network is the ability to access real-time information by constantly updating dynamic data, such as tropical storm tracks and forecasts as well as information on other natural hazards (e.g., earthquakes, volcanoes, and wildfires). Built upon the underlying specifications and technologies of ESRI's Geography Network (http://www.geographynetwork.com), APNHIN is customized to provide natural hazards information for the Asia-Pacific region.
The PDC provides applied information research and analysis to develop more effective policies, institutions, programs, and information products for disaster management and humanitarian assistance communities of the Asia-Pacific region and beyond. For more information about APNHIN, including how to become a network participant, contact Chris Chiesa at (808) 891-0525, x953, e-mail: apnhin@pdc.org, or visit http://apnhin.pdc.org/.