Communication expert endorses WHO's delay on pandemic declaration

Jun 12, 2009 (CIDRAP News) – A well-known risk-communication expert said the World Health Organization (WHO) acted wisely in delaying its declaration of an influenza pandemic until yesterday, but he simultaneously expressed concern that the move may lead to complacency about the situation.

The WHO drew considerable criticism for putting off announcing a phase 6 pandemic alert in the face of evidence that the virus was spreading on several continents. But Peter M. Sandman, PhD, a New Jersey-based consultant and close watcher of pandemic preparedness, said the WHO's go-slow approach gave the world a chance to get used to the idea that a pandemic declaration was coming soon.

However, he also worried that declaring a pandemic of an illness that is usually mild may lead many people to think that a pandemic is not a serious concern.

Sandman observed, as have others, that the WHO has been trying to steer a course between unduly frightening people and lulling them into complacency.

Officially, yesterday's WHO announcement means that the H1N1 virus is spreading in communities in more than one region of the world. The virus first emerged in April in the United States and Mexico and has since spread to 74 countries. Its spread in places far from North America, including Australia, Chile, and the United Kingdom, had led to growing pressure on the WHO to announce that a pandemic was under way.

But at the urging of several governments, the WHO held off on taking the step for weeks out of concern that it would cause excessive alarm in a world that has learned to link the concept of a pandemic to the H5N1 avian influenza virus, which rarely infects humans but kills about 60% of those it does infect.

"I think WHO was wise to wait to declare H1N1 a pandemic, while clearly signaling that it would do so soon," Sandman commented yesterday by e-mail.

The delay has given everyone a chance to get used to the idea, allowed governments and companies time to adjust their preparedness plans, shown due deference to governments that urged delay, and allowed time for the evidence of H1N1 transmission in widespread parts of the world to grow indisputable, he said.

"Those are all good objectives," Sandman said. "An urgent health necessity would have trumped all of them, but I have trouble seeing what urgent health necessity would have been served by an earlier declaration. (It is worth remembering that the WHO's recommended action steps for phases 5 and 6 are identical.)"

An adjustment reaction likely
Sandman said the pandemic announcement is likely to cause anxiety in some people, who will undergo an "adjustment reaction"—a temporary state of overanxiety that can lead to precautions that are unnecessary or premature. This response is natural, and it typically passes soon, leaving people more concerned than before they learned about the threat but not overly anxious.

"The key task of leaders is to guide the adjustment reaction instead of ridiculing it," Sandman stated. "That helps people get through it more quickly. And it helps people come out in a better place."

He said leaders need to try to keep people who initially reacted with fear from later swinging to the opposite extreme, where they "end up feeling foolish for having been concerned, angry at those who warned them, and resistant to later evidence that the situation is worsening (a virulent pandemic second wave, for example)."

But Sandman said he is much more concerned about complacency than fear in response to the WHO announcement: "Instead of learning from swine flu that influenza is a more serious disease than they thought and that a severe pandemic is an ever-present threat that deserves more preparedness that it has received, what millions of people 'learned' (mislearned) is that pandemics are a paper tiger and health officials are fear-mongers.

"Insofar as the phase 6 declaration has an effect, I think confirming complacency will be a more important and more long-lasting effect than provoking a fearful adjustment reaction."

He hoped to hear the WHO, in its press conference yesterday, talk very explicitly about the dual concerns of undue alarm and complacency, but he was somewhat disappointed by what he heard.

"It is disappointing that [yesterday's] actual news briefing contained comparatively little that spoke to either concern," he said. WHO Director-General Margaret Chan and Assistant Director-General Keiji Fukuda "said much less than they might have said to validate that people may overreact temporarily but will recover quickly; that their governments should neither ridicule the overreaction nor take inappropriate 'precautions' in deference to it; that the pandemic we declared today isn't the much more virulent pandemic we have lived in fear of since 2004; and that that more virulent pandemic may still be on the horizon (whether from H1N1, or H5N1, or a reassortment of the two), requiring both vigilance and preparedness."

On the other hand, he said WHO officials in several press interviews preceding the announcement did make some comments about these considerations, especially the adjustment reaction.

Markets unfazed by declaration
Sandman also observed that world markets mostly rose yesterday, apparently unfazed by the WHO announcement. The Dow Jones average was up 31.9 points.

"In other words, investors do not expect an economically damaging response to the phase 6 declaration; they are betting that few if any governments are going to close borders or take other steps that would materially damage economic prospects," he said.

Meanwhile, a business continuity specialist with Marriott International said today that the business world's reaction to the pandemic declaration is likely to be moderate.

"I think the initial response will generally remain quite restrained as businesses and governments have had a few weeks to adjust their plans to the realities of a more moderate H1N1 pandemic," said Penny Turnbull, senior director of business continuity at Marriott.

"It also appears that there is a good understanding that the virus may change in the coming months, requiring more restrictive policies and procedures to be implemented—particularly in the realm of community mitigation measures," she said. "In the meantime, overall the response seems quite well scaled to the risk. In these early weeks I think this is the most important message—make sure the response is scaled appropriately and be ready to escalate as, and when, necessary."

See also:

Index of Sandman's writings about H1N1 flu risk communication
http://www.psandman.com/index-infec.htm#swineflu1

Sandman's periodic updates on the topic
http://www.psandman.com/col/swinecomm.htm

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