'Might help a lot, might help a little, might not help at all--and worth trying!'

(CIDRAP Source Weekly Briefing) – There are no perfect pandemic precautions. We need to say so—and push hard for imperfect precautions.

If you've been following the pandemic preparedness issue, here are some things you already know:

  • Social distancing should help a least a little, but we're not sure how much. Nor do we know how far people will need to be from each other. The necessary distance is a lot greater for aerosol transmission than for droplet transmission, and we don't know how big a piece of the problem each sort of transmission will be.
  • Handwashing won't help protect people from inhaling droplets or aerosols. But it will help keep people from getting or passing along the flu via doorknobs, elevator buttons, telephones, and the like. Objects that can transmit a disease are called fomites. We don't know how big a piece of the problem fomites will be either. But unlike trying to keep people away from each other, hand-washing has no real downside.
  • The usefulness of masks will also depend on which transmission routes matter most. Surgical masks help prevent droplet transmission. But masks can actually be fomites; touching a used mask is a risk. Preventing aerosol transmission requires N-95 masks, which are hard to fit and uncomfortable to wear—and will be in very short supply.
  • Antiviral drugs will also be in very short supply. And they may not work. Or they may work only at the outset of the pandemic, before resistant strains of the virus emerge. Or they may work only if taken very early in the course of the illness.
  • Developing and mass-manufacturing a tailor-made vaccine will take time; we don't really know how long. It may make sense to stockpile a generic H5N1 vaccine—but the vaccine will lose potency over time, and if the H5N1 virus mutates sufficiently, the vaccine may not work at all. Including H5 antigen in the annual flu shot might help—or might not. It would amount to "stockpiling" vaccine in people's bodies, and it would use up capacity that could otherwise be preventing cases of the seasonal flu.

All of this uncertainty is profoundly unsatisfying. Most people prefer solutions that solve problems, that take them off the table. "There. That's done. What's next?" A solution that might go part of the way toward ameliorating a problem has a lot less appeal. I'm tempted to say this disdain for halfway solutions is typically American. But it turns out to be typically human.

Imagine two equally dangerous diseases. Medicine A is a perfect cure for one of the two diseases, but doesn't touch the other. Medicine B is 50% effective against both. The two medicines prevent an equal number of deaths. When psychologists Daniel Kahneman and Amos Tversky studied situations like this, they found that people would pay substantially more for Medicine A than for Medicine B. Why? Medicine A eliminates one of their two worries altogether. B just cuts both worries in half. Cutting two worries in half feels a lot less valuable than taking one worry off the table.

Halfway solutions are a pain. But in pandemic preparedness, halfway solutions are all we've got. And despite the important research now under way to improve our knowledge of how well various pandemic precautions are likely to work, halfway solutions are probably all we'll ever have.

So we have to steer clear of two risk communication dangers.

One danger is to imply that because a pandemic precaution isn't going to work perfectly, and may not work at all, it isn't worth our time, effort, and money. I see this non sequitur all the time. It's pernicious. You should calculate the wisdom of a precaution by judging as best you can how likely it is to work, how much good it will do if it works, and how much it will cost (in money, time, discomfort, civil liberties, etc) to try. You don't eliminate an option because it isn't guaranteed.

The other danger is to imply that a pandemic precaution is actually guaranteed. Overselling the efficacy of a precaution has three main downsides. First, people who believe you will overinvest in that precaution at the expense of others. Second, people who believe you at first only to learn later that the precaution can fail will lose heart, lose confidence in you, and lose all interest in taking the precaution you're recommending. And third, lots of people won't believe you even at first; they'll sense that you're overselling the precaution and turn elsewhere for guidance.

Here is a typical example of overselling a precaution, based on virtually no data, from the Alberta (Canada) Government's "Health and Wellness" Web site (www.health.gov.ab.ca/influenza/influenza_washing.html): "Next to immunization, the single most important way to prevent influenza is to wash your hands often."

All too often pandemic communicators make both mistakes at once—criticizing any precaution they oppose on the grounds that it's not perfect, while overselling any precaution they support by pretending that it is perfect. Here's an all-too-realistic hypothetical example: "Individuals should not stockpile Tamiflu. It might not even work when it's needed. Instead, people should wash their hands as often as possible. What's that? You've heard that handwashing won't help prevent transmission via droplets or aerosols? That's a technical issue beyond the scope of today's presentation."

Good pandemic risk communication means making the case for pandemic precautions that are uncertain and incomplete. It also means empathically acknowledging that people would greatly prefer definitive solutions, if only there were some. We need to learn to say things like this: 'Unfortunately, the following precautionary measures are the best we've got. They might help a lot. They might help only a little. They might not help at all. And they're worth trying!"

An internationally renowned expert in risk communication and crisis communication, Peter Sandman speaks and consults widely on communication aspects of pandemic preparedness. Dr. Sandman, Deputy Editor, contributes an original column to CIDRAP Source Weekly Briefing every other week. Most of his risk communication writing is available without charge at the Peter Sandman Risk Communication Web Site (www.psandman.com/). For an index of pandemic-related writing on the site, see http://www.psandman.com/index-infec.htm.

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