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Crisis and Emergency Risk

Communication

Barbara J. Reynolds and Gilead Shenhar

OVERVIEW

Crisis and Emergency Risk Communication (CERC) is a recog- nized field of study that differs from health risk and risk com- munication. It is used in disasters and combines elements of the other types of risk communication, but has emerged as a new field recognized by academia. At the time of this writing, CERC is taught in 22 universities in the United States and is being diffused internationally. In addition, the Pan American Health Organi- zation, World Health Organization, and North Atlantic Treaty Organization have adopted CERC principles for their communi- cation work. Hence, CERC is the risk communication term that will be used in this chapter.

A CASE FOR EMERGENCY, CRISIS AND HEALTH RISK COMMUNICATION

Health risk communications are an important and necessary component of disaster management. Although a population or community faced with a PICE (potential injury/illness creat- ing event) will not overcome its challenges solely through the application of appropriate communication principles, an orga- nization can compound its problems during an emergency if it has neglected sound CERC planning. Failure to “be first,” “be right,” and “be credible” and deliver empathetic messages may interfere with what would otherwise be well-planned and exe- cuted response operations. Integrating CERC into the planning and early stages of disaster response will improve operations and speed recovery.1–3

Scenario 1. A chemical plant 3 km away appears to send a plume of black smoke directly over a neighborhood. A suburban parent of two preschool children calls the local emergency ser- vices number and expects to get answers. He is told there is no evacuation information for his address. He is given no alterna- tives.

Scenario 2. A single mom proudly moves into her first home. Three months later, she receives an official government packet in the mail – it contains iodine tablets for herself, and her children to take in case of a terrorist attack on the nuclear plant nearby.

All the joy in her new home evaporates as she anguishes over the potential future radiation threat to her children. She calculates the cost of leaving the area.

Scenario 3. People in the community are suddenly dying in high numbers from an upper respiratory disease and tests have not confirmed the infectious agent. Some in the media are spec- ulating that it could be a new disease and possibly a bioterrorist attack. Local health officials refuse comment until their tests are completed. Community members are demanding antibiotics from their physicians and local emergency departments are over- whelmed.

Three different public health scenarios with one common denominator – people in serious need of health risk informa- tion and officials who provided an inadequate communication response. In scenario 1, the family was not notified to evacuate because there was no risk to them. The government officials did not recognize that they may not only need to tell people when to evacuate, but also reassure families when it is safe to remain in their homes, especially when they observe families in nearby communities being evacuated. In scenario 2, government offi- cials believed they had communicated the necessary informa- tion to the community member and that no other follow-up or reassurance was needed. In scenario 3, the government was focused on ensuring that whatever message they communicated was complete and accurate. They refused to be pressured by media speculation in the interim, which left the public without guidance.

EMERGENCY COMMUNICATION PURPOSES

The initial objectives for public information releases from response authorities early in a crisis are to 1) prevent further illness, injury, or death; 2) restore or maintain calm; and 3) engender confidence in the operational response.4 During a cri- sis, good communication to the public is a necessity, not a luxury. For an optimal outcome, the public needs information from its leaders and leaders need support and cooperation from the pub- lic. Many predictable and harmful individual and community behaviors can be mitigated with effective CERC. CERC tools are

326 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-09 06:36:17.

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CR I S I S A N D EM E RG E N C Y RI S K CO M M U N I C AT I O N ■ 327

critical disaster resources and CERC uses sound psychological and communication research in its approach to the selection of message, messenger, and method of delivery.

WHAT THE PUBLIC EXPECTS

The public wants to know what officials know. Although this may not always be possible, officials must understand the motivations behind the public’s desire for information, especially early in a crisis. The public wants to accomplish the following five things with the information they obtain from responding organizations

■ Gain the facts needed to protect themselves, their families, and their pets from the dangers they are facing

■ Make well-informed decisions using all available information ■ Have an active, participatory role in the response and recov-

ery ■ Act as a “watch-guard” over resources, including public and

donated funds ■ Recover or preserve well-being and normalcy, including eco-

nomic security

Although the purpose of crisis response is to efficiently and effectively reduce and prevent illness, injury, and death and return individuals and communities to normal, the possibilities of harmful human behaviors combined with bad communica- tion practices can lead to overwhelmingly negative outcomes. The following are some of the damaging situations response professionals could face

■ Public demand for misallocation of limited emergency response resources

■ Public mistrust or circumventing public health recommen- dations

■ Opportunists who play on peoples’ fear or uncertainties to provide fraudulent alternative treatments

■ Increased disease and death ■ Overreaction and wasted fiscal and medical resources during

the emergency response.

If executed well and early, CERC can help reduce the tendencies of detrimental human behavior and prevent negative public health response outcomes.

CURRENT STATE OF THE ART

Defining Crisis and Emergency Risk Communication

Understanding how academics and practitioners define various categories of communication may be useful to inform disas- ter managers who face a broad and rapidly changing disaster response environment. Communication expertise that fulfills the needs of response professionals borrows from many areas of communication study. Professionals are increasingly calling this integrated model “crisis and emergency risk communica- tion” because they recognize that no single communication field can fulfill the multiple and overlapping roles required of this era’s complex sociopolitical environments, new technological media, and dynamic health disaster risks.2 For a response organization to communicate successfully in a crisis, they must be fast, accurate, credible, consistent, and empathetic. To navigate the information

needs of the public, media, and stakeholders during an intense public safety emergency requires more than attaching “appendix X” to an operational plan. In a crisis, the right message at the right time is a “resource multiplier” – it helps response officials get their jobs done. Many of the predictable, harmful individual and community behaviors can be mitigated with effective CERC. Each crisis will carry its own psychological challenges and dis- aster response officials must anticipate what mental stresses the population will experience and apply appropriate risk commu- nication strategies to manage these stresses.

Crisis communication: Crisis communication can be defined in two ways and, therefore, can cause some confusion for a prac- titioner looking for expert training and counsel. The term is most often used to describe an organization facing a reputa- tional crisis and the need to communicate about that crisis to stakeholders and the public.5 Typically, a crisis is an event that occurs unexpectedly, may not be in the organization’s control, and may cause harm to the organization’s good reputation or viability. An example of an organization facing a crisis is the occurrence of a mass shooting of employees by a disgruntled worker. In most instances, the organization is facing some legal or moral culpability for the crisis (unlike a disaster in which a tornado wipes out the production plant), and stakeholders and the public are judging the organization’s response to the crisis.

A second, simpler, definition of crisis communication sepa- rates the judgment or reputation factors in the communication and deals primarily with factual communication by an orga- nization to its stakeholders and the public when a disaster or emergency occurs. In this context, crisis communication could simply be the effort by community leaders to inform the pub- lic that, by law, they must evacuate in advance of a hurricane. In this definition, the organization is not being overtly judged as a possible participant in the creation of the disaster, and the information is empirically sound, so the individual can judge its veracity without the help of an expert.

The underlying thread in crisis communication is that the affected organization is experiencing an unexpected situation and must respond. Crisis also implies lack of control by the involved organization in the timing of the event.

Communicator: Participant Time Pressure: Urgent and unexpected Message Purpose: Explain and persuade

Issues management communication: Issues management com- munication is similar to crisis communication; however, the organization has the luxury of knowing the impending crisis. It also has the opportunity, to some extent, to choose the timing of its revelation to stakeholders and the public and reveal the organization’s plan to resolve the issue. Again, the organization is central to the event.

Communicator: Participant Time Pressure: Anticipated; timing somewhat in control of

the communicator Message Purpose: Persuade and explain

Health risk communication: Health risk communication is a field that has flourished in the area of environmental health. Through health risk communication, the communicator seeks to provide the receiver with information about the expected type (good

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-09 06:36:17.

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328 ■ BA R BA R A J. REY N O L D S A N D GI L E A D SH E N H A R

or bad) and magnitude (weak or strong) of an outcome from a behavior or exposure. Typically, the communicator provides information about an adverse outcome and the probability of that outcome occurring. In some instances, risk communication has been used to help an individual make a choice about whether or not to undergo a medical treatment, continue to live next to a nuclear power plant, pass on genetic risks, or elect to vaccinate a healthy baby against whooping cough. In some cases, risk com- munication is used to help individuals adjust to the knowledge that a previous event, such as an exposure to harmful carcino- gens, may put them at greater risk for a future negative health outcome, such as cancer. Risk communication would prepare people for that possibility and, if warranted, give them appro- priate steps to monitor for the health risk, such as regular cancer screening.

Communicator: Expert that did not participate in the event and is neutral regarding the outcome

Time Pressure: Anticipated communication with little or no time pressure

Message Purpose: Empower informed decision making

Crisis and emergency risk communication: CERC balances the urgency of disaster communication with the need to rapidly communicate risks and benefits to stakeholders and the public. It differs from crisis communication in that the communicator is not, at least initially, perceived as a participant in the crisis or disaster, except as an agent to resolve the crisis or emergency. CERC is the effort by experts to provide information to allow individuals, stakeholders, or entire communities to make the best possible decisions about their well-being within nearly impossi- ble time constraints and to help people to ultimately accept the imperfect nature of choices during the crisis. This is similar to the communication that occurs in emergency departments, not in doctors’ offices. CERC also differs from risk communication in that a decision must be made within a narrow time constraint, the decision may be irreversible, the outcome of the decision may be uncertain, and the decision may depend upon imperfect or incomplete information. CERC represents an expert opinion provided with the goal that it benefits its receivers and advances a behavior or an action that allows for rapid and efficient recovery from the event. CERC integrates elements of all of the afore- defined fields of communication and emphasizes each more or less depending on the type of disaster and the stage of the disaster response.

Communicator: Expert who is a postevent participant invested in the outcome

Time Pressure: Urgent and unexpected Message Purpose: Explain, persuade, and empower decision

making

ORGANIZATIONAL CREDIBILITY AND TRUST

Research indicates that the public perceives the success of the dis- aster operational response by the amount and speed of relevant information they receive from the emergency response officials.6

Messages are more or less relevant as they do or do not answer important questions about actions to empower the receiver and reduce uncertainty.7,8 Research also indicates that messages are most effective in a crisis if they are empathetic (taking the emo-

tional perspective of the audience), appear honest and open, are relevant, and come from a trusted source.1,9

In several surveys, the public was asked who they would trust most as a spokesperson or reliable source of information if a bioterrorism event occurred in their community. Respondents trusted the local health department or a local physician or hos- pital representative the most. Respondents also trusted “quite a lot” or “a great deal” their own doctors, the fire chief, the director of the health department, the police chief, the governor, and a local religious leader (Pollard, 2003).

Communicating in disaster situations has become increas- ingly more difficult for responding organizations for a number of reasons. A complicating phenomenon is the reality that one’s messages will compete with many others for credibility with the public before, during, and after the disaster occurs. Therefore, the organization’s credibility, the credibility of the spokesper- sons who deliver messages, and the messages’ soundness from the intended audience’s perspective are critically important. The explosion of alternative information channels and sources allow people to “shop around” for messengers and messages. In addi- tion, public suspicions of scientific experts and government are increasing. The suspicions are increasing for a variety of reasons, including access to more sources of conflicting information, a reduction in the use of scientific reasoning in decision mak- ing, and political infighting.5,9,10 Also, the media has a tendency to interview two “experts” with diametrically opposed views (a point/counterpoint technique) and this can serve to confuse the public because there is no unified message. Finally, confi- dence in government, traditional social institutions, and indus- try, at least in the United States, has severely eroded in the last 30 years.9

REPUTATIONAL RISK MANAGEMENT

Organization reputational risk management is paramount because of this increasing lack of confidence, shifting of cultural norms and new, faster communication technologies. Changes forcing this rethinking include the global explosion of informa- tion access, the emergence of a victim culture, a decline in the understanding and reputation of science, and the increase of advocacy groups.11,12

An organization can measure its reputation through the level of stakeholder trust or mistrust. Stakeholders are people or organizations with a special connection to the organization. The Ethics Resource Council teaches that “trust is the natural consequence of promises fulfilled.” Mistrust is an outgrowth of the perception that promises have been broken and values vio- lated. Trust and credibility are essential elements of persuasive communication.13 Empathy and caring, competence, commit- ment, and accountability contribute to trust.1 Three important elements: speed of response, avoiding errors during the cri- sis response, and asking for forgiveness when mistakes occur greatly contribute to maintaining and building trust during a crisis response. It is best if events that affect the organization’s trust never occur, but when they do, it is not the misstep itself that harms reputation, but the response to the misstep that harms the reputation, especially if an organization mishandles the early phases of correcting the erroneous action. An orga- nization can be forgiven when something goes wrong. How- ever, their apology may be ineffective if they are perceived as insensitive that problems have occurred. Early and empathetic

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action may mitigate damage. Unfortunately, most organizations are not structured to provide rapid responses. Furthermore, leaders are rarely trained for and committed to quick, caring action. If an organization and its leaders are unwilling to build and maintain trust with its stakeholders and the general public, then executing any other elements of the communication plan is a wasted effort. Trust is foundational to CERC. There are five key elements to building trust: expressed empathy, competence, honesty, accountability, and commitment.

EMPATHY

Research shows that an expression of empathy should be given in the first 30 seconds of starting to communicate.14 To do otherwise is to waste one’s time, because the public will be waiting to hear whether or not the spokesperson “get’s it.” The audience is wondering whether the response official understands that they are frightened, anxious, confused, or angry. If the official does not articulate what the audience or listeners are feeling in the moment, their minds will be consumed with the question: “do they get it” and they will not hear a thing the officials are saying. A sincere expression of empathy early in the communication will allow people to settle down the “noise” in their minds and actually hear what the official has to say.

When someone’s life is turned upside down, it is important for that person to hear from the people who are there to help that they “get it.” However, it is inappropriate to say “I know how you feel.” That lacks specificity. Officials must take a moment and discern what emotion community members are feeling such as fear, frustration, anxiety, dread, or confusion and actually name the emotion. If uncertain, say, “I can only imagine I would be feeling pretty frustrated right now” and wait to see if heads start to nod.

From Aristotle to today’s communication and psychological research, studies continue to emphasize that expressed empathy is a key component of building trust that cannot be omitted. Expressing empathy in a crisis situation is not a matter of luxury, it is a necessity and every credible response official who intends to be a spokesperson must be prepared to express and repeat empathy sincerely toward those affected by the event.

SHOW COMPETENCE AND EXPER TISE

Source competence is important.13 If officials have a title and are part of the response to a crisis, the public will assume they are competent until something occurs to indicate otherwise. Edu- cation, position title, or organizational roles and missions are quick ways to indicate expertise. Previous experience and demon- strated abilities in the current situation enhance the perception of competence. Another useful tool for building trust is to have established a relationship with the audiences in advance of the emergency.5 If that is not possible, using a third party, who has the confidence of the audience and expresses confidence in the response organization and its officials is useful.

REMAIN HONEST AND OPEN

According to recent research, communities believe that the U.S. government withholds information (U.S. Centers for Disease

Control and Prevention, unpublished, 2003). Before commu- nication with a community in crisis even begins, most of the population assumes officials are withholding information. Offi- cials should strive to treat people as they would like to be treated related to the release of information. It is inappropriate to with- hold information based on a well-meaning but misguided desire to protect people or to avoid a bigger problem. The motives may be noble, but the outcome could be the opposite. The U.S. Centers for Disease Control and Prevention (CDC) and five uni- versities conducted a series of 55 focus groups in 2003. Among the findings, three themes emerged from the participants: any infor- mation is empowering, uncertainty is more difficult to accept than knowledge of something threatening; and participants seek out multiple sources for information.

Holding back information as a way to “manage” the crisis in not only inappropriate, it is also impractical. With modern information technology, the public can readily find information. Assume that if more than one person knows the fact, everyone knows the fact. Then ask, “Do you want to present the facts in context or do you want to try to clean up a mess of someone else’s making?”

Bad news does not get better over time. There is consen- sus among professionals that the faster one delivers bad news, the better, because withholding information implies guilt and arrogance.

Do organizations choose to withhold frightening informa- tion because they do not want people to “panic?” Do they with- hold the information because they think it will minimize the number of phone calls from the public and media requests from reporters? In actuality, not knowing is worse than knowing. Peo- ple can cope with bad news and the anticipation of bad things to come. Conversely, at times there are good reasons to withhold certain information. When this is the case, respectfully tell the public you are withholding information and why. If the answer is “because we do not want you to panic,” then there is no reason to withhold the information.

Honesty and openness in crisis communication means fac- ing the realities of the situation and responding accordingly. It means not being paternalistic in communication but, instead, participatory – giving people choices and enough information to make appropriate decisions. In situations of great uncertainty, the public should be told why the information is not available for release at the time.12 To build trust, the public should be allowed to observe the process while being reminded that this process is what drives the quality of the emergency response.

ACCOUNTABILITY AND COMMITMENT

For most people accountability literally means “keeping the books open.” If government or nonprofit money is being spent in the response to a disaster, sooner or later the public and media will demand to know to whom that money or those resources are being distributed. A savvy official would anticipate the questions and have the mechanisms in place to be as transparent as possi- ble, perhaps keeping an accounting on an Internet site related to the disaster and updating it weekly or monthly as appropriate.

An organization’s credibility is important at any time, but especially so during a crisis. Although it is simple to analyze retrospectively another organization’s crisis and clearly see that its leaders should have released information to the public earlier and more fully, it is much more difficult when it is “your” crisis.

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Precrisis Initial Maintenance Resolution Evaluation

• Be prepared.

• Foster alliances.

susnesnoc poleveD •

recommendations.

• Test messages.

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public, in simplest form,

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courses of action

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get more information).

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accurately understand

its own risks.

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encompassing information

to those who need it.

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audience feedback, and

correct misinformation.

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recommendations.

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decision-making.

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response in future similar

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education.

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problems and mishaps,

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worked in the response

and recovery efforts.

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support public policy and

resource allocation to the

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agency (enforce internal

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plan performance.

Document areas for

improvement.

•

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to improve crisis systems

or the crisis plan.

Figure 22.1. Crisis communication life cycle.

To achieve the appropriate degree of openness and empathy requires written policies that are practiced during exercises, have full commitment from the highest organizational leadership, and are modeled during noncrisis situations.

CRISIS COMMUNICATION LIFE CYCLE

Understanding the pattern of a crisis can help communicators anticipate problems and respond effectively. For communicators, it is vital to know that every emergency, disaster, or crisis evolves in phases and that the communication must evolve in tandem. By dividing the crisis into the following phases, the communicator can anticipate the information needs of the general public, stake- holders, and the media. Each phase has its unique informational requirements (Figure 22.1).

The movement through each of the phases will vary accord- ing to the triggering event. Not all crises are created equally. The degree or intensity and longevity of a crisis will impact required resources and staff.

Precrisis Phase

Communication objectives during the precrisis phase are as follows

■ Be prepared ■ Foster alliances ■ Develop consensus recommendations ■ Test messages

This is when all the planning and most of the work should be completed. Types of disasters that the organization should address can be anticipated via a standard hazard vulnerability analysis. Reasonable questions can be anticipated, and prelim- inary answers can be sought. Initial communication templates can be drafted with blanks to be completed later. Spokesper-

sons, resources, and resource mechanisms should be identified. Training and refinements to plans and messages can be made. Alliances and partnerships can be fostered to ensure that experts are speaking with one voice.

Initial Phase

Communication objectives during the initial phase are as follows

■ Acknowledge the event with empathy ■ Explain and inform the public, in simple terms, about the

risk ■ Establish and affirm organizational/spokesperson credibility ■ Provide emergency courses of action (including how/where

to get more information) ■ Commit to stakeholders and the public to continued com-

munication on a regular basis

Simplicity, credibility, verifiability, consistency, and speed are critical when communicating in the initial phases of an emer- gency.

The initial phase of a crisis is characterized by incomplete data and intense media interest. Information is usually imper- fect, and the facts are dispersed. It is important to recognize that information from the media, other organizations, and even within an organization may not be accurate. The communica- tor’s role is to learn the facts about what happened, to determine the organization’s response to the problem, and to verify the true magnitude of the event as quickly as possible.

In the initial phase of a crisis, there is no second chance to “get it right.” An organization’s reputation depends on what it does and does not say, when it says it, and the tone in which it is said.

One of the best ways to limit public anxiety in a crisis is to provide useful information about the nature of the problem and what the public can do to protect themselves. During the initial phase of an event, an organization must reaffirm or establish

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CR I S I S A N D EM E RG E N C Y RI S K CO M M U N I C AT I O N ■ 331

itself as a credible source of information. Even when there is little information to offer, it can still communicate what is currently known, how the organization is investigating the event and when more information will be available. At the very least, messages should demonstrate that the organization is addressing the issues head-on – that its approach is reasonable, caring, and timely.

The pressure to release information prematurely can be intense. Remember that all information must be approved by the appropriate managers before its release to the media and that the organization must speak with one voice.

In the initial phase of a crisis or emergency, people want information immediately. They want timely and accurate facts about what happened, where it occurred, and what is being done. They will question the magnitude of the crisis, the immediacy of the threat to them, the duration of the threat, and who is going to fix the problem. Communicators should be prepared to answer these questions as quickly, accurately, and fully as possible.

Crisis Maintenance

Communication objectives during the crisis maintenance phase are as follows

■ Help people more accurately understand their own risks. ■ Provide background and encompassing information to those

who need it. (How could this happen? Has this happened before? How can I prevent this from happening again? Will I be all right in the long term – will I recover?)

■ Gain understanding and support for response and recovery plans.

■ Listen to stakeholder and audience feedback and correct mis- information.

■ Explain emergency recommendations. ■ Empower risk/benefit decision making.

As the crisis evolves, anticipate sustained media interest and scrutiny. Unexpected developments, rumors, or misinformation may place further media demands on organization communica- tors. Experts, professionals, and others not associated with the organization will comment publicly on the issue and sometimes contradict or misinterpret a spokesperson’s messages. Expect to be criticized about the handling of the situation.

Remaining current regarding information flow and main- taining tight coordination are essential. Processes for track- ing communication activities become increasingly important as workload increases.

The crisis maintenance phase includes an ongoing assess- ment of the event and allocation of resources.

Resolution

Communication objectives for the resolution phase are as follows

■ Improve appropriate public response in future similar emer- gencies through education.

■ Honestly examine problems and mishaps, and then reinforce what worked in the recovery and response efforts.

■ Persuade the public to support public policy and resource allocation.

■ Promote the activities and capabilities of the organization externally and internally reinforce corporate identity.

As the crisis resolves, there is a return to stasis, with increased understanding about the crisis as complete recovery systems are implemented.5 This phase is characterized by a reduction in public/media interest. Once the crisis is resolved, an organization may need to respond to intense media scrutiny about how the event was handled. It may have an opportunity to reinforce public health messages while the issue is still current. A public education campaign or changes to a website may be necessary. Research has shown that a community is usually most responsive to risk avoidance and mitigation education directly after a disaster has occurred.

Evaluation

When the crisis is over, evaluate communication plan perfor- mance and determine specific actions to improve crisis systems or the crisis plan.

Communication in a Crisis Is Different

Communicating in a crisis is different from that during normal conditions. In a serious crisis, affected people may process and act on information differently. During crisis situations, individ- uals are often unable to collect and process information in a timely manner and, thus, rely on established routines for sit- uations that are, by definition, novel.5 Because people absorb information they receive during an emergency in a manner dif- ferent from that in nonemergency situations, the potential for miscommunication increases.7 The way people absorb informa- tion, process it, and act on it can change when they are under the threat of illness or death.15 Importantly, people will simplify complex information, attempt to force new information into previous constructs, and cling to current beliefs.16 Therefore, if the emergency message requires asking people to do something that seems counterintuitive, they may hesitate to act. Because people tend not to seek out contrary evidence and are adept at maintaining their beliefs, conflicting or contrary information may be misconstrued to conform to established beliefs.11 They may reject new information.

It is useful to understand the impact of imagery on deci- sion making and persuasion because people may be influenced by irrelevant factors.13 Scientists are finding that people’s brains are hardwired to engage in sensory-emotive logic. Messages cre- ated with the belief that people are linear thinkers who make logical decisions may fall short of their expectation.17 Hill con- tends that the old way of thinking is that individuals go through steps in decision making from cognitive, to affective, and then behavioral. Scientific results based on tracing the brain’s cir- cuitry, however, show that long before learning based on the logical basis of the message people have been influenced on a largely unconscious emotive level. When individuals feel threat- ened and become anxious they begin to process information on an emotive level and less on a logical one.1,17 Therefore, it is important that response officials consider what images are being presented to people and try to show people what they should be doing, not just tell them. Response officials should “model” the behavior they want from the public. The nonverbal behavior of the spokesperson is extremely important when people are feeling threatened.

Physical and mental preparation will relieve anxiety despite the expectation of potential injury or death. An “action message” can provide people with the feeling that they can take steps to

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improve a situation and not become passive victims of the threat. Therefore, to reduce the likelihood of victimization and fear, the public must feel empowered to take action. Show them the positive actions to take – avoid focusing on negative images.

Other aspects of decision making are also affected during a crisis. The following behaviors are commonly exhibited.

Simplify

Under intense stress and possible information overload, people will miss the nuances of messages or avoid the effort to juggle multiple facts by simplifying what they have heard.17 To cope, people may not attempt an analytical and reasoned approach to decision making. Instead, they may rely on habit, long-held traditions, following the lead of others, and such stereotyping as classifying participants as “good guys” and “bad guys.”

Maintain Current Beliefs

It may be difficult to change peoples’ beliefs during a crisis or emergency, especially if the response official’s communication requires asking them to do something that seems counterintuitive (e.g., getting out of a “safe” car and lying in a ditch instead of outrunning a tornado).13 People are adept at maintaining faith in their current beliefs and tend not to seek out contrary evidence. They also exploit conflicting or contradictory information about a subject by interpreting it as consistent with existing beliefs. (e.g., “I believe that chocolate is good. Some studies say chocolate is bad for your health. Some studies say chocolate is good for your health. I choose to believe that no one knows for sure, and I’ll continue to eat chocolate.”)

People may believe incorrect or conflicting information. People remember what they see. They tend to believe what they have experienced in their own lives; however, faced with new risks in an emergency, people must rely on experts. However, supposedly reputable experts may disagree regarding the level of threat, risks, and appropri- ate recommendations. The natural give and take among experts and their tendency to enjoy the peer review pro- cess could leave the general public with increased uncer- tainty and fear. The media will often augment this give and take with point/counterpoint discussions regardless of the validity of the differing views. Research indicates that, often, the first message to reach the listener may be the accepted message even though more accurate infor- mation may follow.

With this in mind, CERC principles stress that simplicity, credi- bility, verifiability, consistency, and speed are critical when com- municating in an emergency. An effective message must be repeated, come from a legitimate source, be specific to the emer- gency being experienced, and offer a positive course of action.

DURING A DISASTER, WHAT ARE PEOPLE FEELING?

People experience a multitude of feelings. Each person may or may not face any or all of a range of emotions. Patterns do emerge in a crisis, however, and response officials need to expect these and understand why communicating in a crisis is different.

There are a number of psychological barriers that could inter- fere with the cooperation and response from the public. Many of them can be mitigated through the work of a leader with an empathetic and honest health risk communication style.

Fear, Anxiety, Confusion, and Dread

Chaos theory related to crises emphasizes that disasters taking a toll on human life are inherently characterized by change, high levels of uncertainty, and interactive complexity.5 The majority of people will experience at least one traumatic event “outside the range of normal human experience.”18 How well someone may cope with those traumatic events will depend on the individ- ual’s level of personal resilience. Personal resilience is a person’s ability to maintain equilibrium in the face of trauma and loss. Resilience is often described as the protective factors that foster positive outcomes and help humans to thrive after extreme dis- asters.18 The following psychological resources protect victims of disaster: coping efforts, self-efficacy, mastery, perceived control, self-esteem, hope, and optimism.19 In disaster situations, some people may feel a sense of dissociation and that the familiar nor- mal world they knew is gone. These feelings may be mitigated with quick, firm directions for action.20 Survivors’ fear, anxi- ety, and despondency can be reduced to manageable levels by reducing situational uncertainty with information, by directing individuals or communities in activities that restore a sense of control, and by modeling optimistic behaviors.1,13,20 These are all activities that can be achieved through mass communication mechanisms; however, the messages must be crafted carefully and acknowledge the emotional toll.

In a crisis, people in the community are feeling fear, anxiety, confusion, and, possibly, dread. The responsible official’s job when communicating in a crisis is not to alleviate these feelings. If that were the goal, failure would be a certainty. Instead, these are the emotions that communications leaders should acknowledge in a statement of empathy. “We’ve never faced anything like this before in our community and it can be frightening.”

Hopelessness and Helplessness

If the community, its families, or individuals let their feelings of fear, anxiety, confusion, and dread grow unchecked during a crisis, psychologists predict they will begin to feel hopeless or helpless.21 A reasonable amount of fear is tolerable. Instead of striving to “stop the panic” and eliminate fear, help the commu- nity manage its fears and set it on a course of productive action. Action helps overcome feelings of hopelessness and helplessness. As much as possible, direct people to perform relevant actions – things that are constructive and relate to the crisis they are fac- ing. Anxiety is reduced by action and a restored sense of control. This should be the primary objective for risk communication in a crisis.

The actions may be symbolic (e.g., put up the flag), or preparatory (e.g., donate blood or create a family check-in plan). Some actions must be taken in context. Care is necessary when instructing people which actions to take without telling them when to perform them. Phrase these preparatory actions in an “if – then” format. For example, “Go buy duct tape and plastic sheeting to have on hand, and if (fill in the blank) occurs, then seal up one interior space in your house and shelter in place.”

The public must feel empowered and in control of at least some parts of their lives in order for officials to reduce fear and

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feelings of victimization.21,22 Plan ahead and think of action messages that instruct people on activities they can perform, even if it is as simple as “checking on an elderly neighbor.”

What About Panic?

Contrary to what is depicted in the movies, people seldom act completely irrationally or “panic” during a crisis.7 While there are anecdotal reports that people have run into burning buildings, have refused to get out of a car stuck on the tracks with a train speeding toward them, and have gone into emotional shock and become paralyzed to the point of helplessness, the overwhelm- ing majority of people can and do act reasonably and rationally during an emergency. How people absorb or act on information they receive during an emergency may be different than how they behave in nonemergency situations. One cannot predict whether someone will choose fight or flight; however, everyone’s behav- ior will fall at some point on the continuum. Extreme “fighters” may resist taking most actions to keep themselves safe until the very last moment, and extreme “fleers” may take extraordinary additional steps to make themselves extra safe, well in advance of the threat. These normal reactions to a crisis, particularly when at the extreme ends, are often reflected in media reports and erroneously described as “panic.” In actuality, panic behav- ior is defined as behavior counter to survival. Although officials responsible for getting a recommended response from the com- munity may have the impression that people are engaging in extreme or maladaptive behavior, in reality, the overwhelming majority of people do not.23 The condition most conducive to panic is not bad news; it is conflicting messages from those in authority. People are the most likely to panic (although still not that likely) when they feel that they cannot trust what those in authority are telling them or when they feel misled or abandoned in dangerous territory. When authorities hedge or hide bad news to prevent panic, they are likely to exacerbate the risk of panic in the process.

During the U.S. anthrax incident in the fall of 2001, the media reported local shortages of ciprofloxicin because people began seeking prescriptions anticipating the threat of anthrax. If an individual wants a prescription for ciprofloxicin even though that person lives on the other side of the country from where the exposures had occurred, is that really a panic behavior or one that is counter to survival? On the contrary, it is a display of the individual’s survival instinct. If people hear a community leader saying, “don’t panic,” they may think that does not apply to them. By securing Ciprofloxicin prescriptions, individuals may think they are taking a rational step to ensure survival, and someone else must be panicking. If response officials describe individual survival behaviors as “panic,” they will alienate their audience and render them unable to receive the public health message. Instead, officials should acknowledge people’s desire to take pro- tective steps, redirect them to helpful actions they can take, and explain why the unwanted behavior is potentially harmful to them or the community. Officials can appeal to people’s sense of community to help them resist maladaptive actions aimed at individual protection.24

When people are overwhelming emergency hotlines with calls, they are not panicking. They want the information they believe they need and officials should have. As long as people are seeking information, they may be fearful but they are not acting helplessly; they are not panicking. Seeking information is an appropriate behavior during a crisis. Community leaders

should share the information that is available and share but avoid pedantic or paternalistic tones. State what is and is not known in the situation using an honest and humble style and empower people as much as possible to draw solid health conclusions for themselves and their loved ones.

Uncertainty

Uncertainty will increase anxiety if there is a perception of danger or threat.12 To reduce anxiety, persons will engage in informa- tion gathering and processing to look for options and to confirm or refute their beliefs. Individuals may believe information used in this process whether or not it is accurate. In fact, to improve coherence and reduce anxiety, persons may be selective about the data they absorb in the process of uncertainty reduction, thus discounting information that is distressing or overwhelm- ing. People seeking information in dangerous situations will be more attentive to behaviors and language styles of persons in power.12 They may choose a familiar source of information over a less familiar source, regardless of the report’s accuracy. Persons less certain of their ability to process information involving com- plex situations may choose an advocate to collect and interpret information for them.

Early in a crisis, there are typically more questions than answers. The full magnitude of the problem is unknown. Per- haps the cause of the disaster is unknown, often including the cause of the disaster itself. Even actions people can take to protect themselves may be unclear. It is dangerous to promise an out- come outside of one’s control, especially if one is in a position of responsibility. One should never utter a promise, no matter how heartfelt, unless it is in one’s absolute power to deliver. Officials can hope for certain outcomes, but most cannot be promised. New York Mayor Rudy Giuliani cautioned, “Promise only when you’re positive. This rule sounds so obvious that I wouldn’t men- tion it unless I saw leaders break it on a regular basis.”25

People can manage the anxiety about uncertainty if offi- cials share with them the process they are using to obtain the answers.7,24 “I can’t tell you today what’s causing people in our town to die so suddenly, but I can tell you what we’re doing to find out. Here’s the first step . . . ” or “It’s too early to declare that this is the pandemic we’ve been predicting – but this is still a serious health concern because the virus is transmitting between humans, and here are the steps we’re taking next.”

Remember, in a crisis, people believe any information is empowering. Tell them what is known now and, most impor- tantly, tell them what is not known and explain the process being used to determine the answers.

So if people are not panicking, why can things seem so con- fused and challenging in a crisis, especially in the early stages? Just because an action a person chooses to take may be driven by survival instincts, it does not necessarily mean it is the best behavior for the community as a whole. There are a number of troublesome expected behaviors that can and do occur in major catastrophes. A leader should be aware of these behaviors and be prepared to confront them in communications to the public.

ACKNOWLEDGE PEOPLE’S FEARS

When people are afraid, it is counterproductive to pretend that they are not or tell them they should not feel fear.1 Both responses leave people alone with their anxiety. (Mishandling people’s fears

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goes hand in hand with over-reassurance, but it is conceptually different: “Everything is under control” versus “Don’t worry.”)

Even when the fear is totally unjustified, people do not respond well to being ignored – nor do they respond well to criticism, mockery, or statistics. These approaches are marginally effective even when the fear is warranted. Instead, officials should acknowledge fears while concurrently providing people the infor- mation they need to put those fears into context. Giving people permission to be excessively alarmed about a bioterrorist threat makes it far likelier they will actually be reassured.

Stigmatization

In some instances, victims may be stigmatized by their commu- nities and refused services or public access.26 Fear and isolation of a group perceived to be contaminated or a risk to close con- tacts will hamper community recovery and affect evacuation and relocation efforts. In a disease outbreak, a community is more likely to separate from those perceived to be infected.

During the severe acute respiratory syndrome outbreak, which was believed to have originated in China, cities around the world reported that the public avoided visiting Chinatown sections of their cities. The governor of Hawaii publicly had din- ner in the Chinatown section of Honolulu at the time to help counter the stigmatization that was occurring. This is a good example of leadership modeling behavior desired by the public.

Response officials must be sensitive to the possibility that although unintentional and unwarranted, segments of their com- munity could be shunned because they become “identified” with the problem. This could have both economic and psychological effects on the well-being of community members and should be challenged immediately. This stigmatization can occur absent any scientific basis and could come not only from individuals but entire nations. During the avian influenza outbreak in Hong Kong in 1997–1998 and during the West Nile virus outbreak in New York City in 1999, policies of other nations banned the movement of people or animals, absent clear science indications for those measures.

Perception of Risk

The perception of risk is also vitally important in emergency communication. Not all risks are created equally.1,6 A wide body of research exists on issues surrounding risk communication, but the following emphasizes that the public accepts some risks more than others.

■ Voluntary versus involuntary: Voluntary risks are more read- ily accepted than imposed risks.

■ Personally controlled versus controlled by others: Risks con- trolled by the individual or community are more readily accepted than risks outside the individual’s or community’s influence.

■ Familiar versus exotic: Familiar risks are more readily accepted than unfamiliar risks. Risks perceived as relatively unknown are perceived to be greater than risks that are well understood.

■ Perceived origin of risk: Risks thought to be generated by nature are better tolerated than risks perceived to be inten- tional inflicted.

■ Reversible versus permanent: Reversible risk is better toler- ated than risk perceived to be irreversible.

■ Statistical versus anecdotal: Statistical risks for populations are better tolerated than risks represented by individuals. An anecdote presented to a person or community, i.e., “one in a million,” can be more damaging than a statistical risk of one in 10,000 presented as a number.

■ Endemic versus epidemic (catastrophic): Illnesses, injuries, and deaths spread over time at a predictable rate are better tolerated than illnesses, injuries, and deaths grouped by time and location.

■ Fairly distributed versus unfairly distributed: Risks that do not single out a group, population, or individual are better tolerated than risks that are perceived to be targeted.

■ Generated by trusted institution versus mistrusted institu- tion: Risks generated by a trusted institution are better toler- ated than risks that are generated by a mistrusted institution. Risks generated by a mistrusted institution will be perceived as greater than risks generated by a trusted institution.

■ Adults versus children: Risks that affect adults are better tolerated than risks that affect children.

■ Understood benefit versus questionable benefit: Risks with well-understood potential benefit and the reduction of well- understood harm are better tolerated than risks with little or no perceived benefit or reduction of harm.

In any discussion of risk, the scientist may perceive one risk in 10,000 as an acceptable risk when the listener may anecdotally be familiar with that one adverse outcome and believe that the personal risk is much greater. Perception of risk is not about numbers alone. These and other risk perceptions must be con- sidered during a crisis.

A blind spot for response officials is in measuring the mag- nitude of an event. Typically the magnitude of the event is mea- sured by the number of people injured, ill, or dead, or the dollar amount and geographical spread of property damage. One must also consider the causative agent of the event. The principles of risk communication are vital when developing messages during an emergency. If it is the first emergency of its type – irrespective of etiology or magnitude – the communication challenges will increase, even if the severity of the crisis is not as great as previous events. Health officials must measure the magnitude of a crisis based on three things: the degree of physical and mental impact on people (i.e., ill, sick, or dead), the degree of property damage, and the emotional toll the crisis takes on the population based on its attributes.

ROLE OF THE SPOKESPERSON

The right spokesperson at the right time with the right message can save lives. The following emergency risk communication principles should be incorporated into messages.

■ Acknowledge fears. Do not tell people they should not be afraid. They are afraid, and they have a right to their fears. Expert spokespersons should simply share reasons why they are not afraid (based on expert knowledge) and let people conclude for themselves why this expert is less concerned. Never follow with “so do not be afraid.”

■ Express wishes. “I wish we knew more.” “I wish our answers were more definitive.” An “I wish” phrase expresses empathy.

■ Give people things to do. Offer a range of responses – a min- imum response, a maximum response, and a recommended

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middle response. (e.g., Do not drink the tap water; buy bot- tled water; boil the tap water.)

■ Acknowledge the shared misery. Some people will be less frightened than they are miserable, feeling hopeless, and defeated. Acknowledge the misery of a catastrophic event and then help move people toward hope for the future through the actions of the organization and through actions that they too can take.

■ Give anticipatory guidance. If officials are aware of future negative outcomes, they should let people know what to expect (e.g., side effects of antibiotics). If it is going to be bad, tell them.

■ At some point, be willing to address the “what if” ques- tions. These are the questions everyone is thinking about and wants answered by experts. Although it is often imprac- tical to encourage “what ifs” when the crisis is contained and not likely to affect large numbers of people, it is reasonable to answer these questions if they could happen and people need to be emotionally prepared for them. If officials do not answer the “what if” questions, someone with much less expertise will likely answer them. If spokespersons are not prepared to address “what ifs,” they may lose credibility and the opportunity to frame the “what if” questions with reason and valid recommendations.

■ Be a role model and ask more of people. Many trauma experts agree that the psychological outcome of a community as a whole will be resilience. Perhaps the most important role of spokespersons is to ask people to bear the risk with them. Peo- ple can tolerate considerable risk. If spokespersons acknowl- edge the risk, its severity, and complexity and acknowledge fears, they can then ask people to bear the risk during the emergency and work toward solutions.

Case Study: The Israeli Risk Communication Experience During the past several years, Israel has suffered from sev-

eral large-scale events that necessitated development of a robust risk communication program preparing the Israeli population to best protect themselves.

1) The War Against Terror a) Over a 6-year period beginning in September 2000,

more than 5,600 civilians were wounded and more than 785 civilians were killed due to terror events in Israel.

b) Most of the casualties occurred during 2002–2003, usu- ally resulting from suicide bomber attacks.

2) The Second Iraqi War (Operation Iraqi Freedom)

Israel had only a few months to prepare the population and to provide protection in case of a conventional or unconventional attack (2002–2003). Iraq fired 39 Scud missiles at Israel during the first Gulf War, all armed with conventional explosives. It was known that they possessed weapons of mass destruction.

3) The Second Lebanon War (2006) a) During the second Lebanon war, Hezbollah (an extrem-

ist Shiite Muslim organization in Lebanon) attacked the northern part of Israel with more than 4,000 rock- ets. This resulted in more than 4,300 civilian casualties (half of them with mental illnesses) and an additional 42 civilian deaths.

b) The war started precipitously without any warning time to prepare the population and lasted 33 days.

Table 22.1: General Information on the State of Israel (at the time of this writing)

√ Seven million inhabitants, many being recent immigrants. From 1989 to 1996, approximately 670,000 people emigrated from Russia√ Area – 20,770 km2

√ Gross domestic product (GDP) – 179 billion dollars U.S.√ Religion: 76.5% Jewish, 16% Moslem, 2% Christian, 1.5% Druses, 4% other√ Only democracy in the Middle East√ Israel is a single state with a single command structure (single national police force, fire department, and emergency medical system)√ Multilingual – Hebrew, Arabic, English, Russian, and Amharic√ High percentage of population with military service background√ Population is well educated√ Majority of hospitals are public√ Has a “Home Front Command” (established in 1992). One of its main goals (by law) is to prepare the Israeli population and to instruct them on civil defense issues

Understanding Israel’s basic infrastructure is critical to place the information to follow into context (Table 22.1).

Insights and Observations OBSER VATION 1

Preparing a country’s population requires extensive time and effort, willing and engaged decision makers, and a sub- stantial budget. Preparations must be coordinated with all rele- vant organizations and should begin in advance and be revised during and after the event.

OBSER VATION 2

A country must identify and be prepared for legitimate threats. Using cost/benefit analyses, decision makers must set priorities because limited resources (including the public’s time and attention) make it impossible to prepare for all hazards concurrently. As an example, in preparing for Operation Iraqi Freedom, Israel focused on mitigating both a conventional and unconventional missile attack through public education on the use of gas masks and how to prepare a shelter (Figure 22.2).

Figure 22.2. A child’s gas hood. See color plate. Source: HFC.

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OBSER VATION 3

The plan must be developed, tested, and evaluated in advance and be continuously updated. It should include roles for all relevant organizations and the media. Periodic exercises, some of which include the community, must be conducted to test the plan (Figure 22.3).

The plan should include

■ Instructions for protective behaviors ■ Emergency announcements ■ Films that provide guidance to the public (these are labor

intensive to prepare) ■ Expert analysis and explanation via interviews. Simply hav-

ing information is inadequate. Experts must also be able to clearly and honestly communicate their knowledge to the public

■ Information centers ■ Informational websites ■ Information sheets (e.g., separate pamphlets or inserted

into phone books)

The plan must be continuously reassessed. The situation is dynamic and therefore the plan must be adjusted to the chang- ing environment.

Figure 22.3. WMD Drill. See color plate.

OBSER VATION 4

WORKING W ITH THE MEDIA

The media is the key source of information for the public before and especially during events (Figure 22.4). Therefore, positive collaboration is essential. In Israel, the media are con- sidered to be First Responders. Therefore, they must be edu- cated and take part in exercises. They need to understand the threats and the needs of the population. For example, they must understand that a terror event is a double-edged sword. When the media brings publicity to a terror event, it may assist the terrorists in achieving their goals by bringing attention to their cause and creating societal disruptions. In today’s infor- mation age, there are many opportunities for bystanders to transmit video or pictures from the event. For example, during the second Lebanon war, television studios broadcast real-time footage generated from third-generation cellular phones within minutes of events.

For an effective relationship with the media, it is useful to understand the characteristics they seek

■ Timely news coverage, 24/7

■ Up-to-date information ■ Relevant material ■ Newsworthy events ■ Both breaking news and smaller stories with emotional

appeal

During events, it is important to deliver the known information as soon as possible. The goal is to be first, be right, and above all to be credible. If officials do not provide information directly to the public, someone else might do so (and it might be the wrong information and also lead to rumor reporting). Once rumors are spread, it will be very difficult to change the public’s mind and convince them to trust authorities again.

The media also provides critical information to emergency managers from the scene of an event, at times even before the traditional first responders arrive.

Figure 22.4. News screen capture. See color plate.

OBSER VATION 5

CONTINUOUSLY REASSESS THE PUBLIC’S NEEDS

To be effective, officials must assess the status of the public in real time. Providing guidelines is necessary, but not sufficient. In addition, the public requires instruction and support. Several methods are useful to assess the public’s needs.

■ Surveys – during crises times, daily surveys should be con- ducted. Ask the population the key questions that allow assessment of the effectiveness of preparedness or response actions. For example, in the War against Terror, officials learned that the public fully understands instructions and implements the protective actions they should take.

■ Focus groups – Conduct focus groups to evaluate the effec- tiveness of plans. For example, focus group participants gave feedback on educational films or evaluated experts and spokespersons.

■ Special officers trained in the psychosocial effects of war serve as observers throughout the country.

■ Media – It is important to monitor and evaluate how the media present information to the public.

■ Call centers – Officials have established call centers where the public can receive information. During times of crises, the volume of calls increases dramatically. For example, during the 33 days of the second Lebanon war, the Home Front Command received and processed 161,380 phone calls from the public.

■ Interviews – Direct interviews with the public can provide useful feedback.

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OBSER VATION 6

Public interest and awareness varies depending on the stage of event preparation.

During non-emergent times, the public is occupied with day-to-day problems and concerns. Therefore, it is nearly impossible to persuade them to prepare for something that might happen. However, when the situation is rapidly changing, the public immediately wants all available relevant information. Because it requires significant amounts of time to prepare this information, officials should prepare it in advance to the extent possible and use it at the relevant time.

Risk communications experts also use special methods to deliver important information during non-emergent times. For example, at a designated time each year Israeli officials conduct a “Day of Preparedness” in all the schools in the country. Chil- dren then bring home key preparedness information to their families.

OBSER VATION 7

Leaders must deliver an answer that satisfies the majority of the population.

In the words of Pareto, “20% of people consume 80% of your time.” The Israeli approach, however, is to provide infor- mation to the entire public and not only to the majority. Chil- dren, older people, and people with disabilities have special needs. For example, when an alert is being announced, the same alert is sent to deaf people via a pager that was given to them in advance of the event.

OBSER VATION 8

A key principle is achieving resilience – life must go on as close as possible to “normal.”

Those opposed to the state of Israel (both countries and ter- ror organizations) believe it would be much easier to achieve their goals by fighting against the population than by fight- ing directly against military forces. The Israeli population has been educated about this concept. For example, Israeli citizens understand the goal of terror – “to kill one and to frighten thousands.” To show resilience, the Israeli population contin- ues its normal life, even after a terror attack (they keep going to the cinema, eating at restaurants and using public transporta- tion, even minutes after a terror event). This is a good example of resilience and risk communication is an important tool to achieve it.

The same concepts apply to wartime scenarios. The goal is for the population to continue their normal lives as soon and as much as possible. Therefore, it is critical to provide the public with timely information. Although information about the threat can cause a rise in anxiety, when it is accompanied by guidance for feasible actions, it leads to preparedness, self- sufficiency, and lower fear levels.

OBSER VATION 9

Different people learn and are affected in different ways. It is important to use a wide array of methods to commu-

nicate with the public. The following are some of the techniques used

■ Public exercises and training.

Figure 22.5. Leaflet in English. See color plate. Source: HFC.

■ Media – television channels remain the principle way to address the public, with radio channels being the second most frequent.

■ Internet – public officials should prepare and present important information in several languages and include pamphlets that the population can download from the Internet (see the Home Front Command web link: www. idf.il/oref).

■ Written materials – during the Lebanon war in 2006, spe- cial information pamphlets were distributed through sev- eral methods (e.g, mail, newspaper delivery, at major food stores). These pamphlets provided key information regard- ing actions a family should take and how they should per- form them before, during, and after an attack.

■ School and workplaces – these are important sites for infor- mation distribution.

Figure 22.6. Leaflet in Russian. See color plate. Source: HFC.

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Figure 22.7. Leaflet in Hebrew. See color plate. Source: HFC.

■ Cell phones – major security announcements can be sent to cell phones via instant messaging.

■ Call centers – a national call center provides standardized answers to the public’s questions. This call center manages all issues regarding civil defense. At every local authority, there is also a call center. Coordination of the national and local call centers is critical to ensure that callers receive a single, uniform message.

OBSER VATION 10

Because Israel is a country of new immigrants, it is a mul- tilingual society. For example, Arabic is one of the official languages. Therefore, risk communication messages must be prepared and delivered in several languages. It is essential to deliver comprehensive risk communication in Hebrew, Ara- bic, English, Russian, and Amharic (see Figures 22.5–22.7). In addition, tourists and foreign laborers may need information in other languages. Officials should take into consideration that they must adjust the message to different cultures. For exam- ple, the same pictures cannot be used for both orthodox and nonreligious audiences.

Summary Risk communication is an essential tool to achieve pre-

paredness. The Israeli experience provides valuable informa- tion, but it must be carefully evaluated and modified as appro- priate before being applied to another system. Many challenges remain. Officials must strive to ensure clear, effective, and coordinated risk communication both before and during an event.

FIVE COMMUNICATION FAILURES THAT INHIBIT OPERATIONAL SUCCESS

Communication experts and leaders who have faced disasters have discovered that certain approaches will cripple or even destroy the success of their disaster response operations.8,27

■ Mixed messages from multiple experts ■ Information released late ■ Paternalistic attitudes ■ Not countering rumors and myths in real time ■ Public power struggles and confusion

Mixed Messages

The public does not want to “select” from one of many mes- sages in which to believe. During the mid-1990s, the Midwest- ern United States suffered a series of great floods. Response officials determined that the water treatment facilities in some communities were compromised and that a “boil-water” direc- tive should be issued. A problem developed when multiple gov- ernment and response organizations issued directions for boiling water and each of them was different. In the United States, people generally turn on the faucet and expect clean water. Few people know the “recipe” to boil water because they have never needed it. So for individuals under stress either directly due to an event or as a consequence of providing extensive care to a sick relative, simply “picking one” instruction for sterilizing water is unac- ceptable. Even healthy people do not like the thought of risking a bad case of diarrhea if they do not choose the right boil-water instructions.

When faced with a new threat, people want a consistent and simple recommendation to follow. They want to hear absolute agreement about what they should do and they want to hear it from multiple experts through multiple sources. Messages can be damaging even if they are not wrong. If they are inconsistent, the public will lose trust in the response officials and begin to question every recommendation.1,8,27 Local, state, regional, and national response officials and their partners must work together to ensure messages are consistent, especially when the informa- tion is new to the public.

Information Released Late

Following the September 11, 2001 U.S. terrorist attacks many individuals wanted advice about whether or not to purchase a gas mask and requested information from the CDC. Three weeks after the attack, CDC had an answer on its website. During the 3 weeks that the CDC required to develop and vet its answer, a number of experts were willing to provide an answer; however, it was frequently not one that was scientifically valid. By the time the CDC issued advice to the public not to purchase gas masks, the “gas mask” aisles at the local Army-Navy Surplus stores were already empty. At the time, few U.S. officials could contemplate the consequences of such an attack. Subsequently, it became clear that officials must anticipate and create a process to quickly react to the information needs of the public. If one cannot provide people what they need when they need it, others will, and those “others” may not have the best interests of the public in mind when they offer advice.

As such, citizens will be vulnerable to receiving inappropriate advice from unscrupulous or fraudulent opportunists or even well-meaning people who do not have adequate expertise.

Paternalistic Attitudes

Imitating the American film actor John Wayne’s swagger and ostensibly answering the public’s concerns with a “don’t worry little lady, we got ya covered” is ineffective in the information age.

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People want and expect information that allows them to form their own conclusions.28 As a response official, it is insufficient to satisfy one’s own worries with copious bits of information and then state a bottom line message that is unsupported by the currently known facts. As difficult as it may be, one must help the public to reach the same conclusion by sharing with them what one learned to reach that conclusion. Response officials should determine what they learned that made them believe the situation was not worrisome and then share this information.

Treat the public like intelligent adults and they will act like intelligent adults.7,21,29 Treated any other way, they will either reject advice from officials or behave in ways that seem illogical. It is ineffective for officials to instruct the public “do not worry.” Rather, provide information to individuals that they need and allow them to reach the appropriate conclusion that they do not need to worry. By engaging the public in the process, they will follow.21,30

Not Countering Rumors in Real Time

During a pneumonic plague outbreak, an organization’s drug distribution program will fail if rumors circulate that there are not enough drugs for everyone. A system is needed to monitor what is being said by the public and the media that permits rapid reaction to false information.

Rumor management: Holding press conferences every time a rumor surfaces may actually serve to spread it. Instead, a press conference may be necessary if a rumor has been widely published. If the rumor is circulating on the Internet, post a response on the Internet and have a telephone information service ready to address the rumor. The media will report rumors or hoaxes unless officials can rapidly explain why they are false. Have an open, immediately available channel to the media for use when monitoring systems detect a troublesome rumor. Officials should not think “this is preposterous, and no one will believe it.” In a crisis, the improbable seems more possible. Deflect rumors quickly with facts.

Public Power Struggles or Confusion

In an actual event, one state’s governor held a press conference about a public safety crisis at the same time the mayor of the city was holding one. This set the tone for speculation about who was in charge and what was or was not true.

In the information age, it is easy to see how this could happen. Sometimes there may be a power struggle over jurisdictions or other issues. These issues should be resolved quickly and confi- dentially. It is disconcerting to the public to think that the people responsible for helping them are not cooperating with each other. All partners need clearly defined roles and responsibilities. When they overlap, make sure officials settle power struggle concerns out of public view so response officials are not confused. When all else fails, stay in the scope of one’s responsibility and refrain from declaring authority over an issue without being certain that such authority exists.

Even if everyone attends the same press conference, officials could send the wrong message to the public. If people are jockey- ing for the microphone or looking back and forth at each other hoping someone will answer a reporter’s question, the public

Figure 22.8. Audience relationship to the event. See color plate.

will be left with the impression that there is confusion and that power struggles exist among the leadership.

Early in the sniper shooting incident in metropolitan Wash- ington D.C., Montgomery County Police Chief Charles Moose formally requested involvement by the U.S. Federal Bureau of Investigation (FBI). Although there were concerns about what that might mean to local law enforcement, the chief chose to involve the FBI and did it quietly and apparently seamlessly, at least to the public. At no time did the public perceive a power struggle among the response agencies. This, however, was a com- munity that had previously survived a terrorist attack at the Pentagon and an anthrax attack at the Capitol. It had learned the value of a united front with multiple jurisdictions working cooperatively for the good of the community. Interagency dis- putes need to end the moment a crisis begins. A good plan can help avoid such disputes from the start.

Content is Critical in an Emergency: Identify Audiences and their Concerns

The receiver of one’s communication will be judging the con- tent of the message, the messenger, and the method of delivery. Each of these aspects must be considered in planning for crisis and emergency risk communication. The public’s awareness of government is heightened during a crisis. A lack of continuity, control, adequate resources, or full knowledge of the event can invoke fear and threaten social unity.28 The public’s needs can be judged three ways: 1) their relationship to the incident, 2) their psychological differences (e.g., fight or flight response and emotional versus adaptive coping), and 3) their demographic differences (see Figure 22.8).

Possible audiences for crisis and emergency risk communi- cation are

1) Public within the circle of disaster or emergency for whom action messages are intended.

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Concerns: Personal safety, family safety, pet safety, stigmatization, and property protection.

2) Public immediately outside circle of disaster or emergency for whom action messages are not intended.

Concerns: Personal safety, family safety, pet safety, and interruption of normal life activities.

3) Emergency response and recovery workers and law enforce- ment involved in the response.

Concerns: Resources to accomplish response and recov- ery, personal safety, family safety, and pet safety.

4) Public health and medical professionals involved in the dis- aster response.

Concerns: Resources adequate to respond, personal safety, family safety, and pet safety.

5) Family members of victims and response workers. Concerns: Personal safety, and safety of victims and

response workers 6) Healthcare professionals outside the response effort.

Concerns: Vicarious rehearsal of treatment recommen- dations, ability to respond to patients with appropriate infor- mation, access to treatment supplies if needed/wanted, and how to volunteer for service in the disaster area.

7) Local, state, and national civic leaders. Concerns: Response and recovery resources, liability,

leadership, quality of response and recovery planning and implementation; opportunities for expressions of concern; and trade and international diplomatic relations.

8) Congress or equivalent legislative body. Concerns: Protecting and informing constituents, review

of statutes and laws for adequacy and adjustment to needs, and opportunities for expressions of concern.

9) Trade and Industry. Concerns: Business issues (loss of revenue, liability, and

business interruption) and protection of employees. 10) National Community.

Concerns: Vicarious rehearsal, perceived personal risk, readiness efforts initiated.

11) International Neighbors. Concerns: Vicarious rehearsal, perceived personal risk,

readiness efforts initiated. 12) International Community.

Concerns: Vicarious rehearsal, perceived personal risk, and exploration of readiness.

13) Stakeholders and Partners Specific to the Emergency. Concerns: Included in decision making and access to

information. 14) Media.

Concerns: Personal safety, access to information and spokespersons, and deadlines.

Each of these audiences will desire a specific message. Response officials should prioritize the development of messages for each audience based on their involvement.

Remember the basics when creating messages. Audience seg- mentation and demographics remain relevant during a crisis. Consider the following

■ Education ■ Current subject knowledge and experience ■ Age ■ Disability (hearing or sight impaired)

■ Language spoken/read ■ Cultural norms ■ Geographical location

How Audiences Judge Messages in a Crisis

Expect an audience to immediately judge the content of a message in the following ways.

■ Speed of communication. Was the message timely? Research indicates that the first message received on a subject sets the stage for comparison to all future messages on that subject. If the public first hears that the world is flat, and then someone comes along and says “the world is round,” that message may be less well accepted. Also, the speed with which one responds to the public can be an indicator of how prepared one is to respond to the emergency. More rapid responses can indicate that there is a system in place and that needed action is being taken. If the public is not aware that officials are managing the problem, the response is inadequate. The public may then lose confidence in the organization’s ability, and it will need to commit further resources to convince the public that the response system is working.

First impressions are lasting impressions. If an organization fails to gain public confidence early, it will be nearly impossible to recover the public trust. This does not necessarily mean hav- ing all the answers; it means having an early presence so the public knows that the organization is aware of the emergency and that there is a system in place to respond. A great message delivered after the audience has turned their attention to other issues is a message not delivered at all. There are two impor- tant reasons to be the initial source of information in a crisis. First, the public uses the speed of information flow in a crisis as a marker for judging preparedness.6 A perfect operational response may be irrelevant without concurrent health risk com- munication. Even when a hazardous materials team in the U.S. city of Atlanta responded within 2 minutes of a chemical plant fire and made all the correct decisions. The local news coverage was filled with sound bites from angry families. People saw the black smoke and wanted to know if they should evacuate, but were unable to receive rapid, practical information. Parents, gripping the hands of their small children, castigated the people who knew but did not tell them that they were safe. Living in the informa- tion age means being expected not only to save lives but also to tell people that lives are being saved at the same time as the event unfolds.

The second reason is a psychological reality. When people seek information, the first message they receive carries the most weight.23 The tendency is for people to accept the initial infor- mation they receive. If they hear a second message that conflicts with the first, they start to weigh them against each other, but tend to give the first message greater value. This is especially dangerous if the first message is incorrect but sounds logical.

For example, the news media reports that health officials are swabbing the noses of congressional staffers for anthrax spores to establish if they need to take antibiotics. A member of the lay public is exposed to a white substance in the break room of the local factory, and thinks a nasal swab should be performed. In fact, a positive or negative nasal swab for anthrax spores is not a reliable way to determine if someone should be given antibiotics.

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That determination is made with other data such as proximity to the exposure site and ventilation systems. Even so, reasonable people who were misinformed that nasal swabs were useful in making medical treatment decisions will expect to receive the same care as people in the news who they perceive as being more privileged.

It is better to expend resources and distribute an early correct message, rather than risking the need for excessive resources later to correct a faulty first impression.

■ Factual content of the message. The public will listen for fac- tual information, and some will expect a recommendation for action. It is important for officials to present the facts accurately, repeat them consistently, avoid the initial delivery of vague details, and ensure that all credible sources deliver the same message. Preparation is critical and consistent mes- sages are vital. Inconsistent messages will increase anxiety and will quickly damage the credibility of experts.

Crafting the Best Messages

Consider the following when creating an initial communication to an audience:

■ For the general public, present a short, concise, and focused message (6th-grade level). It is difficult in a heightened state of anxiety or fear to internalize copious amounts of infor- mation. Get the bottom line out first. In time, the public will want more information.

■ In the beginning, provide relevant information only. Avoid starting with a lot of background information. Spending significant time establishing the identity of the spokesperson or the organization is not useful. One sentence should be sufficient.

■ Provide action steps in positives, not negatives (e.g., “In case of fire, use the stairs,” “Stay calm,” are positive messages. Negative messages are “Do not use the elevator” and “Don’t panic.”)

■ Repeat the message. Repetition reflects credibility and dura- bility. Correct information is correct each time it is repeated. Reach and frequency, common advertising concepts, teach that the message is more apt to be received and acted on as the number of people exposed to the message (reach) and the number of times each person hears the message (frequency) increase.

■ Create action steps in threes or rhyme, or create an acronym. These are ways to make basic information eas- ier to remember, such as “stop, drop and roll” or “KISS – keep it simple, stupid.” Three is not a magic number, but in an emergency, officials should expect the audience to absorb three simple directions. Research indicates that somewhere between three and seven bits of information is the limit for people to memorize and recall.23 It makes sense in the stress of an emergency to ask the audience to remember fewer bits of information. (For example, anthrax is a bacterium that is treated with antibiotics. Anthrax is not transmitted from person to person. One should seek medical care if exhibiting the symptoms of anthrax: fever, body aches, and breathing problems.)

■ Use personal pronouns for the organization. “We are com- mitted to . . . ” or “We understand the need for . . . ”

Avoid

■ Technical jargon and medical terminology ■ Instead of saying “people may suffer morbidity and mor-

tality,” say, “people exposed may become sick or die.” ■ Instead of “epidemic” or “pandemic,” say “outbreak” or

“widespread outbreak.” ■ Instead of “deployed,” say “sent” or “put in place.” ■ Instead of “correlation” say “relationship” (avoid using

“cause”). ■ Unnecessary filler – background information (save for other

outlets/times). ■ Condescending or judgmental phrases – (e.g., “You would

have to be an idiot to try to outrun a tornado.” “Only hypochondriacs would need to walk around with a pre- scription for Cipro.”) Most people are neither idiots nor hypochondriacs, and both ideas have crossed their minds. Insulting the audience by word or tone destroys your chance to influence behavior. That does not mean condoning the behavior; instead, validate the impulse but offer a better alter- native and the reasons why it is better.

■ Attacks – Attack the problem, not the person or organization. ■ Promises/guarantees – Guarantee only what one can deliver;

otherwise, promise to remain committed throughout the emergency response.

■ Discussion of money – In the initial phase, discussion of the magnitude of the problem should be in the context of the health and safety of the public or environment. Loss of property is secondary. Also, a discussion of the amount of money spent is not a surrogate for the level of concern and response from an organization (what does that money provide?).

■ Humor – Seldom is humor a good idea. People usually fail to understand a joke when they are feeling desperate. Humor is a great stress-reliever behind closed doors. Inappropriate humor is sometimes used as a coping mechanism during a crisis, but can be detrimental. One should be cautious not to offend others responding to an emergency, even behind closed doors, and be especially sensitive when speaking to the public.

KNOW THE NEEDS OF YOUR STAKEHOLDERS

Stakeholders are identifiable groups of people or organizations who can be reached in additional ways besides through the media. They self-identify as stakeholders. Response organizations do not determine whether these groups have something at stake in the crisis – the stakeholders do. They believe the organizations are beholden to them in some way and these groups expect to communicate with the organization directly and not only via the news media.

The highest level of respect toward a stakeholder group is demonstrated by an organization’s leader willing to meet face to face with them. Organizations need to determine who, in a crisis, should be invited to meet with, be called by, or receive a hand written note or personalized e-mail from its leaders. The organization’s leaders cannot do all of these things for all stakeholders, so they must delegate some of these activities. For example, Mayor Giuliani tried to attend as many funerals as possible for the firefighters, police, and government workers who

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died on September 11, 2001 in New York City. He tried not to delegate that task.

Stakeholders are people or organizations with a special con- nection to an organization and its involvement in the emer- gency.21 It is wise to anticipate and assess the incident from the stakeholders’ perspective. They will be most interested in how the incident will affect them. Stakeholders are expecting some- thing from the organization. It could be as simple as information released through a website and e-mail or as complex as in-person meetings with key organization officials.

In crisis communication planning, the first step in respond- ing to stakeholders is identifying them. Stakeholders may vary according to the emergency, but core stakeholders will be inter- ested in every emergency and will expect a response from the organization.

Not all stakeholders are supporters of the organization; nonetheless, it is critical to identify unsupportive stakeholders and be prepared to respond to them appropriately. Stakehold- ers fall into three categories based on their responses in a crisis: advocates, adversaries, and ambivalents. The response to stake- holders will depend on to which of the three groups a stake- holder belongs. The key is to anticipate stakeholders’ reactions based on their affinity for the organization and the way that sim- ilar groups have reacted in the past when this type of crisis has occurred.

An emergency or crisis may be an opportunity to strengthen an organization’s partner and stakeholder relationships as they see it in action. A positive response will enhance the organi- zation’s credibility. Therefore, it is prudent to consider existing stakeholder controversies or concerns and how the ongoing rela- tionship will color their attitude during this incident.

By planning ahead and identifying as many stakeholders as possible before the event occurs and the means by which to com- municate with them, an organization can respect stakeholders by addressing their special needs for communication.

Expending energy on stakeholder communication during a crisis is valuable for at least two reasons other than one may owe them this attention. First, they may have information of value to the organization. They have points of view outside the organiza- tion. Few stakeholders will be shy about pointing out deficien- cies. It is preferable for the organization to hear these criticisms directly rather than indirectly through the media. Stakeholders may also be able to help communicate messages for the organiza- tion. They may have credibility in circles where the organization lacks influence. If an organization is forthcoming with them, it may face fewer problems during the crisis recovery.

Research has shown that leaders and their organizations make five mistakes during a crisis according to stakeholders.13,22,27

These errors include: inadequate access, lack of clarity, no energy for response to them, too little too late, and perceptions of arro- gance. Most of these represent a lack of resources and planning directed at stakeholder communication.

The Town Hall Meeting

Facing a community in a town hall meeting or citizen’s forum during a crisis may be the most difficult communication task asked of a response official. Nonetheless, response officials owe the community the opportunity to meet and discuss aspects of the response. In addition, officials will be held accountable.

However, convening a townhall meeting without preparation and practice is not advisable. A poorly managed meeting can

lead to lack of community support. In addition, the people who come to a town hall meeting are not representative of the entire community. They are usually the most angry or frightened. The basic principles for a successful meeting are

■ Let people talk. Do not allow experts to lecture. The more people talk, the more successful they will judge the meeting.

■ Solicit questions. Listen to their questions before offering solutions. Officials may be surprised to find out that their issues, are in fact not the community’s issues. The key is not to offer solutions to problems, rather empower the audience to discover solutions.

■ Meet every person’s input with respect. Praise people for being willing to offer ideas. Encourage participation.

■ Tell the truth. Organizers should admit when they do not know something and follow up to obtain the information people are seeking.

■ Do not express anger. Meeting participants may have been emotionally hurt, feel threatened by risks out of their con- trol, feel they are not respected, or have had their fundamen- tal beliefs challenged. Set aside irritation. Instead, strive to understand.

Town hall meeting management: Sometimes people appear angry because they are advocates for a partic- ular position on an issue. These people become “angry” when the cameras are focused on them. Sometimes peo- ple appear angry because they hope to litigate. Set ground rules and remind people that, in this town hall meet- ing, everyone must behave respectfully if they want to be heard. Do not allow hecklers to gain control. Remain calm and take a little more abuse than most people would expect. In so doing, the legitimately angry community members will soon come to the rescue, demanding that the hecklers behave.

Despite all the risks one faces in holding a town hall meeting, officials work for the people and should provide this opportunity. Setting realistic goals for the meeting is important, as it is not the responsibility of organizing officials to have everyone leave the meeting happy. Sometimes, the goal should be to simply listen. One should avoid promising what cannot be delivered, no matter how easy it would be to do so in the moment. In general, it is wise to under promise and over deliver.

Seldom has the approach of giving a lecture led to a change in anyone’s mind or behavior. Lecturing is easy – the speaker can vent emotions and is not required to address others’ points of view. A lecture, however, does not engage the audience. If people are upset, they want to be heard. Limit opening remarks to 5 minutes or less, because the audience will likely be thinking about what they want to say, rather than listening to someone else.

Providing instructions is easy, requesting input is more diffi- cult. Asking questions is a deliberate action. It forces the process to slow down and forces everyone to stop and think before reply- ing. Instead of attempting to persuade individuals or commu- nity groups to take an action, allow them to convince themselves through a self-discovery process. The key is to not provide the solution but to help the audience discover its own answers.

One can assist an audience discover its own answers by asking the right questions. Using feedback as a tool, ask the audience questions that will create awareness about the situation in such

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a way as to empower them to make difficult choices. As many therapists will attest, people who discover their own answers and say something in their own voices will take ownership of the idea. It is better to ask a leading, open-ended question than to make an interpretation. The right questions can help audiences to make the necessary connections between the information provided by experts and the best possible choices for them in the situation. This strengthens the audience’s tendency to claim ownership for the insights.

For example, if a severe communicable disease outbreak were to occur, a challenge for officials in emergency response and public health is the possible need for temporary suspension of civil rights to control the spread of disease. An extreme case would be the need to quarantine individuals or communities. A population that understands the need for quarantine will be more likely to follow officials’ instructions.

The following are questions to assist the lay public with taking ownership of protective public health measures

■ Start with broad, open-ended questions.

Examples: “What challenges have (you or your community) faced that required consensus building to solve the problem? How did it go? What did you learn from those experiences? Were there difficult choices to make?”

■ Then, ask questions to discover the explicit wants, needs, and desires of the audience.

Examples: “What is most important to (you or your community) when faced with a problem to solve? Consensus building? Putting the greater good for the greatest number first? Avoiding conflict? That the solution is fair and equitably distributed? Ensuring that everyone has a voice and is heard? That reasonable alternatives are fully explored?”

■ Follow with questions that are more specific to the situation now being faced by the audience.

Examples: “What are the ramifications to (you, your family, your community, the nation) when faced with this current problem? What consequences are you hoping to avoid? What do you see as the worst outcome for (you or your community)? What courses of action do you believe could mitigate this outcome?”

■ Then, ask questions that encourage audience members to state the benefits they would like to see result from a course of action.

Examples: “What benefits would (you or your community) expect if this disease did not spread further? Since you’ve brought up quarantine, what benefits would (you or your community) expect if you accepted quarantine as a course of action to reduce spread of disease?”

■ Once the audience sees and expresses the benefits, it will be much easier to demonstrate how a particular strategy can solve the problem.

Examples: “From what I understand, you are looking for a way to protect (yourself, family, community) from more illness or death? If I can go ahead and explain how quarantine will meet

those needs, are you open to implementing it? If you think quar- antine would work in this effort, how do you see the quarantine being explained to the entire community and implemented?”

Allowing people to persuade themselves is not an easy pro- cess. Done poorly, it can seem condescending or manipulative. It takes practice and a great deal of empathy. It is worth the effort, however, because it is truly the most effective way to gain acceptance in thought and behavior.

RECOMMENDATIONS FOR FURTHER RESEARCH

Following the U.S. anthrax events in 2001 and the struggles the CDC experienced with communication, it developed key prin- ciples for use of CERC in future potential injury creating events. CDC successfully applied these principles in response to Hurri- cane Katrina and in preparation for pandemic influenza. There are vital areas of emergency risk communication that require urgent consideration and research such as those related to vicar- ious rehearsal and outreach to special populations.

Vicarious Rehearsal and Risk Communication

In an emergency, some recovery and specific health recommen- dations are directed at victims, those exposed, or those who are potentially exposed to the event. The communication age allows some people to participate vicariously in a crisis that is not an immediate danger to them. These people will mentally rehearse the crisis as if they are experiencing it and consider the courses of action presented, which, in reality are being presented to those directly affected by the crisis. Because these observers have the luxury of time to decide their chosen course of action, they may be much more critical about its value to them. In some cases, these people may reject the proposed course of action and choose another or insist that they too are at risk and deserve the recommended remedy (e.g., an emergency department visit or a vaccination). These concerned but unexposed persons may place an undue burden on already thin response and recovery resources. Research is needed to help determine the best way to manage the anxiety created by those who are vicariously involved in a crisis event and who then believe they also should be tak- ing a mediating action. Perhaps alternate “action” messages are needed for people who are not really threatened but are vicar- iously feeling threatened and may be primed to take an action that is unnecessary. In addition, how should treatment messages be communicated to ensure that only those who should act on them do so?

Emergency Messages in Multicultural Settings

Can emergency communication reflecting a nation’s dominant culture’s perspectives appropriately influence behaviors of per- sons from minority groups? Research related to culture and cri- sis is inconsistent.12 In crisis situations, development of event- specific messages is needed swiftly. Efforts to tailor messages could, however, slow information flow, creating additional prob- lems regarding credibility and trust. In addition, if messages were culturally tailored in some crises, there may be potential for messages to be misinterpreted as “selective” or culturally biased, which could increase mistrust or create a perception of stigma- tization. For example, because most cases of influenza H5N1 historically occurred in Asia, messages tailored by health officials

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specific to Asian Americans might be perceived by some in the population as focused on their differences and separateness, thus stigmatizing them.

If cultural differences in messaging are neglected during a public safety emergency, will it result in increased levels of ill- ness or death among minority groups? Are people’s information needs essentially the same when reacting to serious threats, thus obliterating cultural differences and rendering culturally attuned messaging unnecessary? When the entities communicating with these diverse populations are authoritative governments (i.e., local, state, and federal) that have the power to suspend civil rights, ration scarce pharmaceutical resources, and control infor- mation flow, will the absence of culturally appropriate messages complicate disaster operations? These questions should form the basis of crisis communication research to ensure equitable sup- port to all members of the community.

In an international setting, differing cultural norms (e.g., collectivist versus individualistic societies), political structures, media practices, and aversions to risk make the use of CERC prin- ciples more challenging. An important area of future research is determining to what extent these principles are universally accepted across cultures and which must be adapted based on national and cultural differences. Zaltman’s31 research empha- sizes the commonalities among all human cultures and suggests people are more alike than different. Can health risk communica- tion mitigate inherently harmful behaviors such as the tendency for people to gather at the seashore to watch for the tsunami or discuss as a group whether to exit a burning building? Is there a difference between cultural adaptation for pre-event messaging versus messaging during the event?

The initial objectives for release of public information in a cri- sis are to prevent further illness, injury, or death; restore or main- tain calm; and engender confidence in the operational response. With looming crises such as pandemic influenza, which will involve many national and cultural groups, additional research on these issues is urgently needed.

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