PLANETARY HEALTH WEEKLY

JAY’s BLOG #5

By: Jay D. Kravitz, MD, MPH

Posted on February 11, 2021

This Blog continues last month’s conversation. I repeat part of that introduction with an ironic smile because this may be the most important reading of your day. This might be true especially if risk communication is part of your professional realm – or could be – because overstatement is a risk communication technique; a touch of hyperbole to gain people’s attention! 

Communication during a public health crisis is “an imperfect art.”¹ Organizations can compound problems during an emergency if pre-crisis communication planning has been neglected. The psychology and intentions of a public health emergency response must integrate effective local and national emergency agencies’ communications and recovery operations. Well-executed messaging directed to the public must include competent public health professionals. 

This effort is potentially problematic because we try to connect scientific assessments, knowledge and policy with people, who may not understand the messages and choose to disregard advice. As stated in my Part One Blog (January 14, 2021 PHW 7(2); please read), I predict some of you will admit, “I never realized how important conveying risk information was until faced with that responsibility in a difficult situation!”

How to best convey information to the public is the challenge: What is the extent of the problem? How serious is it? Which media sources should one use – if you have the option of deciding? Is your jargon appropriate for your audience? How can you evaluate whether your messaging achieves what you intended – to warn, inform and/or encourage action? Of concern is when warnings are issued and people do not listen. What should you or can you do if this happens? 

One chilling example of disregard occurred in the Western Pacific region related to a dangerous weather system. Typhoon Haiyan blasted through the island nation of Palau in 2013 before wreaking destruction in The Philippines. Kayangel Island residents were advised to evacuate to nearby higher ground islands. No one sought refuge. Although damage was severe, surprisingly, no one perished. The death toll could have been catastrophic. The provocative question: When must one intervene to urge – or even enforce – imperative action?

We live in an open and free society that allows for free speech. News media participate in this dialogue, an important societal value. Media entities often arrive at events concurrent with first responders even before youmight arrive. Media monitor police radio transmissions. Their quest? Information based on five talking points: Who, What, Where, When and Why? 

Obviously, answers to these questions may not be readily known. However, regular news briefings must be part of any risk management plan, as knowledge is gathered. The objectives are to assist in providing needed information: where a clinic is set up, boil water notices, hand washing advice, medical guidance or recommendations to evacuate or stay home.

People, unfortunately, may harbor misconceptions that a fix is always available, guaranteeing an entitled, risk-free environment. Obviously, this is not possible. And there are more complications. Few among the public really understand public health’s role. Perhaps these professionals could better explain themselves. With public distrust and public health trying to find a proper responsive balance, opposing perspectives can set the stage for an adversarial relationship. Potentially contentious communication always looms. Criticism may focus on lack of empathy, not unacceptable science lessons.

Be aware of the public’s information sources. While playing a crucial role in conveying risk, media sources possess varying degrees of competency, strengths and weaknesses. Communication problems can occur because of skill limitations on the part of risk communicators, limitations in the accuracy of scientific risk assessments at any given time and, importantly, proficiency limitations or partisan motives among mass media enterprises. Unfortunately, some messages can be confusing or poorly conveyed with contradictory statements. Politics and skepticism always hover in the background.

In my experience, most reporters are willing to be schooled about issues to be discussed during a consultation. If you are respectful and willing to help them do good work, they are usually receptive. Prior to being interviewed by a reporter, I would routinely ask the purpose and content of the interview and whether a science lesson would be helpful before the interview began. Reporters could still be adversarial, but cooperation set the stage for an improved, mutual working relationship. We both had jobs to do.

Occasionally, I encountered reporters who did not understand the basic science of the stories they were covering, provided little context or got facts wrong. Either they didn’t comprehend the topic at hand or were subject to an editor’s agenda, which wasn’t always public health inspired. Some media pundits offered misinformed, non-factual, simplistic, unschooled opinions. More contemporary social media platforms, regrettably, have created unprecedented opportunities to amplify and circulate conspiratorial disinformation.² Their inferred motive? Manipulating “reality.” The complexity of the COVID-19 once-in-a-century pandemic experience comes to mind.

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While a fabricated or inaccurate discourse can be exasperating or even painful to watch, I recommend that you do pay attention because you need to know what is being served to the public! Influenced by editorial motive, some mass media entities may “focus on the news,” ignoring credible health professionals and anchored reasoning that respects the importance of rigorous methodological research. These “news” sources will fail to distinguish biased controversies from solid scientific data.³

When sharing information with the public, The U.S. Environmental Protection Agency offers its “Seven Cardinal Rules:”⁴

1. Accept and involve the public as a legitimate partner.
2. Plan carefully and evaluate your efforts.
3. Listen to the public’s specific concerns.
4. Be honest, frank and open.
5. Speak clearly with compassion.
6. Work with other credible resources.
7. Meet the needs of the media.

Strategic Planning must consider the following:

1. What is the extent of the problem?
2. How serious is it?
3. Should a warning be conveyed…or not?
4. Who is the target audience?
5. Does the target audience trust the risk communicator?
6. What language or tools should be used?
7. What media formats are best suited for message delivery?
8. How does one assess if delivered messages have been effective?

Four major categories guide risk communication action choices. Based on levels of concern and trust, these situations may require significant attention or, deferentially, can be left to the discretion of the agency providing information:

When giving a presentation:

1. Begin by stating your credentials, then go over the facts, as known, and concerns.
2. Express empathy. You may live among people with whom you are speaking and share similar concerns.
3. By showing respect, while conveying an honest assessment, you may increase your credibility and help your listeners adopt a common-sense response to present dangers.
4. Be prepared otherwise an audience can eat you alive. It is extremely important to have the latest information available at your disposal. Expect difficult questions, so that you can respond with confidence and grace.
5. Tailor your talk to the audience, as necessary, using appropriate, non-scientific language.
6. Appear attentive to questions, responding so audiences understand.
7. Repeat important messages in various ways to emphasize your points.
8. It is best NOT to over-reassure. Help people prepare without pacifying them by telling them not to worry, especially if they are angry. Vigilance is important.  Solutions and security endeavors can sometimes be complicated.
9. Use public meetings as teachable moments to explain the natural sequence of an epidemic or scenario. 
10. Uncertainty must be expressed. In many situations we won’t know whether an epidemic peak has been reached – the top of the bell curve – or if more a serious progression is unfolding. 
11. Introspective humility should be operative. Overconfidence will be considered arrogance and likely proven wrong.
12. Expect the unexpected, which may protect you from losing your cool when confronted by someone or an issue you didn’t consider…or you couldn’t anticipate.
13. People can come to risk communication presentations with their own agendas. Distrust may be great when you begin a presentation. You may encounter hostility you didn’t expect. Angry folks may sit in the front row to confront – or wait in the rear of the audience before becoming aggressive with different motives.
14. Risk messages typically evolve over time because data, hazards and behaviors do not remain static. As more information is gathered about a particular situation, it is important to explain that recommendations could change, either to advise people to be more careful or to assure them that they can relax.

When engaging media:

1. If you have an appointment, be on time.
2. It is important to be as open and accessible as possible, to respect deadlines and provide visual information if available.
3. It may be necessary at times to select which media vehicles would best disseminate information you think is important. But, that may lead to criticism or inaccurate reporting from those who are excluded. 
4. If you don’t want media to publish or broadcast what you say, don’t say it, even if you are familiar with the reporter or are fatigued.
5. There is no such thing as “off the record”!
6. You are responsible for your statements. It is easy to forget that you may still be “wired” after an interview concludes…or that the microphone on a camera is still recording as the cameraperson walks away. Embarrassing moments are captured by the unwary.
7. Stay on message. It is VERY easy to get side-tracked or manipulated. If a question is asked not in keeping with the purpose of the interview, ignore it. Answer with an appropriate response to the reason for the interview. Easy to say, hard to do.
8. Television: A television formula (at least in the U.S., according to reporters with whom I have spoken) governs what you say on camera: 3 messages in 7-9 seconds. When you watch TV, count the time an interviewee is on screen. You can identify schooled spokespersons…messages in 3’s. Reporters will recognize if you have been instructed regarding the TV formula.
9. Hit the 7-9 second target or your time could be co-opted by an adversarial point of view.
10. During a 30-minute news broadcast on commercial television, one can expect 20 minutes of reporting and 10 minutes of advertising. This reality certainly limits substantive content.
11. When being filmed by a television camera crew, wear a dark colored, upper garment to reduce light reflection into the camera.
12. Radio: Radio has a different format. Telephone interviews with radio stations may have time constraints, but can have a more relaxed time-frame expectation, not as rigid as television.  A live, radio broadcast interview will most likely be recorded. Excerpts can be played by the commentator to fit their editorial, allotted time slot agenda and can be re-broadcast at varying lengths at convenient times.
13. Don’t forget: Many media formats are designed to be “entertainment.” An interview may be viewed as a media event, rather than a professional forum to responsibly convey information.
14. If you don’t know the answer to a question, acknowledge that and say you will contact the inquirer with an answer.
15. Good media tools include stories and visuals, which help people understand an issue, decreasing distractions when people are upset or preoccupied. 
16. Limit speculation, admit mistakes and focus on solutions. Remember that you must win in the court of public opinion to be effective.
17. When self-evaluating, consider what you omitted, forgot to mention or might have done differently to improve your credibility and effectiveness. Unfortunately, there will be times when given advice is incorrect or incomplete. One must acknowledge that reality as part of providing the best available, evolving information.

Conclusion

My blog effort over the past two months was intended to impress upon Planetary Health Weekly readers the complexity and difficulties of being a competent and credible risk communicator. In our complicated world, we must identify and confront wide ranging threats to our health and safety, whether these are man-made or natural complex disasters – or potential hazards that must be addressed. The participation of the public health profession is most certainly part of that communication equation. I sincerely hope that a description of my professional experiences and recommendations, based on wisdom shared in the listed references, will provide guidance, perspectives and some assurance to those who might assume that most important role of risk communicator. J

References:

1.  Reynolds B, Galdo JH, Sokler L. Crisis / Emergency Risk Communication. Be First, Be Right, Be Credible.Centers for Disease Control and Prevention. 2002.

2.  Gerberding J, Haynes B. Vaccine Innovations — Past and Future. New England Journal of MedicineFebruary 2021;384(5):393-396.

3.   Vineis P. Denialism chapter. Health without Borders; Epidemics in the Era of Globalization. Springer International Publishing AG;2017:36-37.

4.  Covello V, Allen F. Risk Communication. Seven Cardinal Rules. United States Environmental Protection Agency Archive (1988). https://archive.epa.gov/care/web/pdf/7_cardinal_rules.pdf/

Recommended readings:

1. *Quammen D. Spillover: Animal Infections and the Next Human Pandemic. 2012 !!
2. Rosenbaum L. Communicating uncertainty – Ebola, public health and scientific uncertainty. New England Journal of Medicine November 2014:1-2.
3. Smith A, Lingas E, Rahman M. Contamination of drinking water by arsenic in Bangladesh: a public health emergency. Bulletin World Health Organization 2000;78(9):1093-1103.
4. Kluger J. Why we worry about the things we shouldn’t…and ignore the things we should. Time MagazineWeb Service. November 2006.
5. Talbot M. Hysteria, Hysteria. New York Times. 2002:1-15.
6. Taylor M. Is there a plague on the way? Farm Journal. March 2005.
7. Thurston M. Why social media is important to public health. NW Center for Public Health Practice. November 2011.
8. Editorial. The media and the message of Ebola. Lancet 2014;384:1641.
9. Chalaud D, Aghan D, Otindo V, Bennet A, Baldet T. Correspondence. Ebola: Improving science-based communication and local journalism. Lancet 2015;356:2139.
10. Ebola in West Africa. Lancet Infectious Disease. Editorial. August 2014:1.
11. Gonsalves G, Staley P. Panic, paranoia, and public health – The AIDS epidemic lessons for Ebola. New England Journal of Medicine November 2014:1-3.
12. Chan M (Director-General World Health Organization). Learning from Ebola: readiness for outbreaks and emergencies. Bulletin World Health Organization 2015;93:818-819.

Communicator Score Care

When you watch a communicator, sometimes it is good practice to evaluate what was said…a lessons-learned opportunity for when it’s your turn.

Did the communicator…?

Score the competency 1 to 10 (10 highest; 1 lowest)

Competency	Speaker Scores
	1	2	3	4
State their credentials
Know the facts
Tailor the talk to the audience
Express humility
Show empathy
Speak in understandable terms
Repeat important messages
Place risk in context
Not over-reassure
Use the opportunity as a Teachable moment
Address the 5 W’s
Acknowledge the public’s fears
Engender credibility
Total: Best score is…130