Pandemic communication: honesty is the best policy

If a flu pandemic hits it will be extremely important for the public, and the press in particular, to have a trusted source of information in regard to what is going on and prevention measures. But this may be more easily said than done.

If H5N1 (avian influenza) causes a pandemic without losing a lot of its current virulence, death and sickness rates could rise dramatically - worse than most people in this country have ever experienced. We either will not have vaccines and drugs, or if we do there will not be enough for everyone - which makes the information situation even harder and credibility more important. There will be lots of rumours and snake-oil salespeople for the public to listen to if officials lose credibility. To reduce panic and disorder, authorities need to say the right things and be believed.

This conclusion is self-evident. In the British pandemic plan released in March it states: "Risk communication both before and during a pandemic is a key element of the response, with emphasis in the inter-pandemic period on the uncertainties… Clear, active engagement of the public will be a priority [during] a pandemic through, for example, sharing the advice of expert groups with the public… briefing the specialist media on the preparations and plans… training trusted spokespeople in advance… ."

To me, as a member of the press, this seems to be an excellent information policy. It suggests officials should be honest about the fact that there are limits to what they can do and that they do not know everything.

As Britain learned from the outbreaks of Bovine Spongiform Encephalopathy (BSE), it is extremely tempting in a crisis for public officials to try and put a brave face on things. But people live with 'constraints and uncertainty', and tend not to believe that all is well when they can see, or even when they suspect, that it is not. BSE taught Britain that when that dissonance creeps in between what the government says and what people suspect, credibility ceases to exist. I think the current pandemic plan is an admirable outcome of that lesson.

But such intentions can be hard to put into practice. The first question any official has to answer in a crisis is: how much bad news do we relay to the public? If we are going to talk about public-openness policies, we need to consider worse-case scenarios. The psychological impact of a pandemic with a substantial death rate will be enormous. Even the flu epidemic of 1918 with a case fatality rate of four per cent would be beyond the experience of most people living in Britain today. This has to be considered in planning information policies.

So does the possibly crippling social and economic effect of widespread absenteeism, either due to actual illness, caring for ill dependents, or simply due to fear of infection. With few staffing redundancies in most sectors this could have damaging effects on the supply of electricity and water, and grocery and postal delivery, to say nothing of the impact on health services.

The first question people will ask will be: what can we do? This is also the first question that will put the public-openness policy to the test.

After the pandemic starts, presumably in Asia, but before it actually reaches Britain, there will be wall-to-wall reporting from places already hit, complete with fancy logos and suitably menacing music.

Up to this point, spokespeople and scientists will have been dealing with the specialist medical reporters in the media.

Once this becomes a huge story, the star reporters, who normally do politics, will be onto it. Now this can be good - sometimes we specialists forget to ask the questions the person in the street wants to know the answer to. But suddenly the experience of dealing with the press could become very different for spokespeople.

There will be lots of numbers floating around for the apparent death rate. There will be scary TV images from hospitals - especially if this flu produces the deep blue cyanosis of the skin that was a hallmark of 1918, because oxygen is one of the first things hospitals in developing countries will run out of.

It seems safe to predict that at this point people will be panicking. Obviously the most important message to get across now is that everything is all right, we are in control and have everything we need to face the flu.

Is it? If officials say that, they will already have shattered the policy of openness called for in the pandemic plan. Because they will not have everything they need. We may have a little vaccine or anti-viral drug or we may not. We will not have enough hospital beds. Countries such as Canada are detailing in their pandemic plans what to do if we can no longer bury people fast enough. This will be the moment when good intentions succeed or fail. But it will also be the moment when we desperately need the openness policy to succeed.

Taking stock

Even if we do make some vaccine, or stockpile some anti-viral drug, neither will be distributed evenly. More than half the world's vaccine and drug manufacturing capacity is in Western Europe. Virtually none is in developing countries.

There are precedents for national heavy-handedness over flu vaccine. In 1976, the US feared the 1918 flu pandemic was about to return, as a similar virus emerged at an army camp. Some of you may remember swine flu. The US said it would make enough vaccine for every citizen - and nationalised it. No one else would get any until everyone in the US was vaccinated. Countries such as Canada that relied on US manufacturers for flu vaccine were obviously concerned.

In a pandemic, international tensions such as this are virtually certain to emerge. People will start showing up at the border. There will be pressure to keep people out entirely. At some point, some group is going to accuse some other group - the rich, the political elite, doctors, other countries - of having a drug or vaccine and withholding it. In such a tense situation the charges will be made whether there is evidence or not. Maximum openness with the facts will not stop it, but it may be the best thing you can do.

Similar tensions will emerge domestically. If Britain has any Tamiflu (a treatment for influenza), you will have to tell people that it will be distributed only to people with early flu symptoms and priority goes to those in critical professions such as healthcare and emergency services. This implies making sure that sick nurses, for example, take their medicine instead of smuggling it to their sick children. This could be difficult. You are going to need massive security around any place that has drugs or vaccines. People are going to have to get in line for vaccination, or teams are going to have to go door to door. Again the level of public panic might make this hard to manage.

You might then be able to convince people, for example, that there are things they can do besides taking drugs and vaccines. There must be very clear messages about hand washing and avoiding crowds. Some people may self-quarantine if they become sick, or just barricade themselves in their houses for the first months or until vaccination is available, which could be a perfectly sensible policy in some cases and which employers should be ready for.

The final reason for safeguarding official credibility is that the government is not the only place people, or journalists, will be getting information. There will be internet conspiracy theorists. Most specialist journalists receive these bulletins because they are an excellent source of news, but we treat the hysterical and obsessive interpretations that come with them with considerable caution. Non-specialist journalists may not be so cautious.

So what is a government to do? During the anthrax attacks of 2001 the Centers for Disease Control (CDC) in the US started doing conference calls for journalists. This was so effective they have continued and it has worked well from the CDC's point of view in getting their message out.

Now some of you may be thinking that I am advocating openness out of journalistic self-interest. Well, I am. But I also believe this is important partly because I covered the spread of BSE in Europe, where we saw the effect of what might be called, politely, the utter opposite of openness. I also cover biodefence, where people have done the most extensive work on managing mass medical emergencies. Just as one example, a simulation exercise modelling an international release of smallpox, conducted in 2001 by Johns Hopkins University, US, concluded that fast, entirely open communication with the public was crucial to containing spread.

But even though it may be the official stated policy to be open about all of this, in the midst of the chaos of a pandemic the message could well get lost in delivery. Every single press spokesman has to be drilled in this for openness to work. This is not always easy. A slightly panicky press person not sure what to do will apply the universal PR prime directive: when in doubt, clam up. This happened after the recent bombings in London.

It will take a huge effort to make sure it does not happen if the flu pandemic is as bad as some scientists fear it may be. I believe it will be very much worth making that effort. Although I hope the public message when and if the pandemic does strike will be slightly less terse than the one a professor in the US gave the press last month: "If the pandemic were to hit today, I don't know what we could do about it except say, we're screwed."

Debora MacKenzie is the Brussels correspondent for the New Scientist and has published extensively on the threat and consequence of pandemic flu.