This column builds on our December 2004 column “Pandemic Influenza Risk Communication: The Teachable Moment.” Readers unfamiliar with the H5N1 avian influenza pandemic threat and its risk communication implications may want to read the prior column before this one.

Government communication about pandemic influenza continues to be generally disappointing. As the bad news mounts in places like China and Vietnam, and the concern of experts mounts along with it, too many national and local governments have had little to say, and too much of that little has been over-reassuring bordering on misleading.

So we have been keeping an eye out for good examples. We’ve found a few, most of them local. But by far the best example comes from Australia’s national government, in an early May speech by Health Minister Tony Abbott. We have decided to devote a column to Minister Abbott’s speech, hoping for human-to-human transmission of great pandemic risk communication.

We had been monitoring Australia’s pre-pandemic communication since we read Chief Medical Officer of Health John Horvath’s over-reassuring news release on February 25, headlined “Australia Well-Prepared to Combat Bird Flu.” Before celebrating Abbott’s wonderful speech, we want to spend a few paragraphs on Dr. Horvath’s much more typical — not horrible, just typical — example.

“Australia is one of the most prepared countries in the world to detect and manage Avian Influenza,” Dr. Horvath accurately stated in the news release lead paragraph. What he didn’t say, anywhere, is that even the most prepared countries in the world are woefully unprepared. There were no hints in his news release that a pandemic might be a disaster, despite Australia’s excellent technical planning effort.

Instead, the release talked about the millions of dollars Australia has budgeted “to protect Australians from potential outbreaks of human pandemic influenza,” boasting that “Australia has a contractual commitment for the supply of up to 50 million doses of pandemic vaccine should there be an outbreak of pandemic influenza.” Unmentioned were these facts: that there is as yet no pandemic vaccine; that efforts to develop one are going slowly; and that most experts believe it will take at least three to six months to produce such a vaccine once a pandemic strain of influenza is identified.

If they are believed, over-reassuring statements like these can actually damage one crucial aspect of pandemic preparedness — public awareness and involvement. Australians who read only the Horvath news release would have been justified in assuming that pandemic preparedness was under control, and that there was no need for them to pay any further attention. Of course once a pandemic arrived and proved difficult to manage, such readers would very likely have suffered a loss of confidence in their leaders — just when confidence was most needed. Even before over-reassuring statements are proved wrong, moreover, they can have a paradoxical impact. Readers who are skeptically inclined or have other sources of information are often alarmed by over-reassurance; the lesson they learn is that their authorities are either over-confident or less than candid, leaving them alone with their fears.

The most objectionable passage in the news release wasn’t about a flu pandemic at all. It came when Dr. Horvath was discussing the lessons learned from SARS. Because of Australia’s “well planned and coordinated” response to SARS, he claimed, “we were able to prevent an outbreak on our shores” — the implication being that Australia can do it again with bird flu.

Attributing Australia’s good luck to its preventive efforts is a form of magical reasoning. We know of only one person ever confirmed to have had SARS while in Australia — a German tourist who arrived from Hong Kong, developed mild respiratory symptoms while in Australia, and was diagnosed with SARS after her return to Germany. During the peak of the SARS outbreak, between April 5 and June 16, 2003, 77 travelers arrived in Australia who were subsequently considered probable or suspected SARS cases (many were eventually ruled out, while others remained unconfirmed). Of these, 29 said they had been symptomatic at the time of airport entry screening. But “border screening had detected only 4 (13.8%) of these 29 symptomatic travelers,” according to a Medical Journal of Australia study funded partly by Dr. Horvath’s department. Australia did not “prevent an outbreak” on its shores. Australia got lucky, as did the United States and most of the rest of the world.

Even in unlucky countries like Canada and Singapore, SARS turned out to be a lot less contagious than flu. And unlike flu, SARS is thought to be contagious only after symptoms have begun, making screening far more useful (at least in principle) for SARS than for flu. Nobody knowledgeable — Dr. Horvath presumably included — believes any country can isolate itself in an influenza pandemic and thereby prevent an outbreak on its shores. Implying otherwise is rank over-reassurance.

So our pandemic communication surveillance antennae perked up a few months later when we read the following May 2 Sydney Morning Herald headline on Google News: “Nation prepared for flu pandemic: Abbott.” There they go again, we thought, another over-reassuring official statement out of Australia. We were wrong.

The headline was misleading. The actual article, covering Minister Abbott’s speech at a major infectious disease conference, was much more (duly) alarming. A pandemic could be a “worldwide biological version of the Indian Ocean tsunami.... We have to hope that this surge [of bird flu] does not hit us? If it does it will be something that our nation will not forget in a hurry.... We are doing everything we reasonably can, we are as well organised as is reasonably possible? But I have to say if we ever do believe a pandemic outbreak is imminent, no preparation will be sufficient.... This is a scary prospect.”

At that point, we knew we had to see the whole speech, which was readily available on the Australia Health Department website. The posted speech text was a little different from the newspaper quotations; as most good speakers do, Abbott had extemporized when he spoke. But the tone and meaning were the same. This is some of the best pre-pandemic risk communication we have seen anywhere.

We want to share Minister Abbott’s speech with you, along with our risk communication annotations. If you just want to read the speech without our interruptions, you can go to the link above.

The 25 Recommendations  Don’t over-reassure.  Put reassuring information in subordinate clauses.  Err on the alarming side.  Acknowledge uncertainty.  Share dilemmas.  Acknowledge opinion diversity.  Be willing to speculate.  Don’t overdiagnose or overplan for panic.  Don’t aim for zero fear. Don’t forget emotions other than fear. Don’t ridicule the public’s emotions. Legitimize people’s fears. Tolerate early over-reactions. Establish your own humanity. Tell people what to expect. Offer people things to do. Let people choose their own actions. Ask more of people. Acknowledge errors, deficiencies, and misbehaviors. Apologize often for errors, deficiencies, and misbehaviors. Be explicit about “anchoring frames.” Be explicit about changes in official opinion, prediction, or policy. Don’t lie, and don’t tell half-truths. Aim for total candor and transparency. Be careful with risk comparisons.

If you want to pursue the annotations further, the numbers in brackets refer to our list of 25 crisis communication recommendations (see box). These recommendations are described in brief paragraphs in four handouts:

Crisis Communication I:
How Bad Is It? How Sure Are You? [1–7]

Crisis Communication II:
Coping with the Emotional Side of the Crisis [8–14]

Crisis Communication III:
Involving the Public [15–18]

Crisis Communication IV:
Errors, Misimpressions, and Half-Truths [19–25]

For more on the 25 recommendations, see the extensive handouts elsewhere on this website.

As you read the speech (with or without annotations) it is likely to seem pretty normal to you. It just reads like a speech — solid, informative, but not necessarily all that special. Even Australia’s Ministry of Health was surprised to learn that we planned a paragraph-by-paragraph gloss. In a sense, that’s exactly our point. Minister Abbott is saying the kinds of things government officials normally recoil from saying. They imagine that being this candid, this alarming, and this uncertain about anything is bound to boomerang badly: panic the public, give ammunition to the opposition, undermine faith in government, whatever. Abbott’s speech didn’t do any of that. In fairness, it didn’t accomplish a revolution in pandemic preparedness either. But the speech did treat the Australian people like adults. By leveling with the public, it made a solid, informative contribution to an aspect of pandemic preparedness that has been badly neglected around the world: the preparedness of the public.

The speech text that follows is in sans-serif type in white background. Our annotations come after the Abbott passage they comment on.

Speech Notes for Infectious Diseases Conference, Pandemic Preparedness by The Hon. Tony Abbott MHR On February 4 last year, I read an urgent brief from the Chief Medical Officer. Ministers receive all sorts of urgent departmental documents, usually to do with cabinet, legislative or regulatory deadlines. This one made the stuff of daily politics and routine administration seem utterly trivial. It advised of a possible re-run of the Spanish Flu outbreak of 1919. Since then, a significant part of Australia’s health policy establishment has been considering how to deal with a far-from-merely-speculative influenza emergency which could dwarf the health consequences of a conventional terrorist attack.

One principle of good risk communication is to be explicit about preconceived points of view — anchoring frames, or “mental models” — both your own and those of your audience [21]. This is especially important when you want to move people to a different and unexpected point of view. When trying to convey a message that conflicts with people’s anchoring frames, it is crucial to construct a well-lit path from their current beliefs to what you want them to believe, rather than just insisting on what you want them to believe. In his very first paragraph, Abbott shows good understanding of anchoring frames.

The paragraph offers three anchoring frames. First, ministers get “urgent” memos all the time; usually they’re no big deal. Thus the speech starts where Abbott himself started, and where most of his audience presumably starts as well: unworried about flu. Then Abbott constructs his path, by means of two much more alarming anchoring frames. The new threat, he tells us, was as serious as the 1918–19 Spanish Flu pandemic. And for listeners unfamiliar with the devastation wreaked by Spanish Flu, a pandemic is a “far-from-merely-speculative” health risk that could “dwarf” the risk of terrorist attack. Australians sensitized to terrorism by the 2002 Bali bombing (often called Australia’s 9/11) would surely have been jolted by this third comparison.

Compared with World War One, the Spanish Flu epidemic made very little impact on Australia’s consciousness, despite the large number of deaths it caused. AB Facey devotes just one paragraph of “A Fortunate Life” to the flu pandemic, noting that “Western Australia had an outbreak of a very severe kind of flu in 1920. It was called bubonic influenza and it killed dozens of people. I got it, but only in a mild form, and we were quarantined for three weeks. I was away from work for a month and it was many months before I felt well again”. Manning Clark’s History of Australia reports that in January 1919, theatres, picture shows, pubs, race meetings and schools were closed until further notice and that people were advised to wear masks over their faces in public. He also reports that people made light of the restrictions with one commentator lamenting: “all I can do during my enforced holiday is to stay at home and grow whiskers”. Perhaps 12,000 deaths in hospital made comparatively little impact alongside the 61,000 deaths in battle that the young nation had just suffered, even though 60 per cent of flu victims were aged between 20 and 45. Perhaps the reporting restrictions placed by many countries (but not Australia) limited people’s awareness of the worst disease outbreak since the Black Death had killed up to a quarter of the world’s population in the 14th century.

Returning to his second anchoring frame, the Spanish Flu pandemic, Abbott carefully and respectfully acknowledges the low concern of most Australians about flu and even flu pandemics. Only then does he start building his case that the Spanish Flu was the world’s “worst disease outbreak since the Black Death” six centuries earlier. He is helping people see that their low-concern anchoring frame about flu may get in the way of their understanding the dire hazard of a possible avian influenza pandemic in the near future [21].

World wide, Spanish Flu killed an estimated 40 million people (compared with about 15 million killed in the Great War). Because Australia delayed the repatriation of the First AIF, in part to avoid the flu pandemic, the virus had lost some of its potency by the time it struck here. In the United States, though, where it struck early, it’s estimated that the virus severely affected 25 per cent of the then population of 105 million with 650,000 deaths. Subsequently, there have been two further flu pandemics: Asian Flu in 1957 and Hong Kong Flu in 1968. Both were much milder than the Spanish Flu outbreak with less than 500 Australian deaths in each case, mostly among children and people over 65.

More acknowledgment of why Australians may have trouble imagining a flu pandemic as a major disaster.

Since late 2003, bird flu has been raging through the domestic poultry stocks of South East Asia. As of April 29, 44 people have acquired the disease, nearly all of them living in close daily contact with domestic birds, and 19 have died. So far, there have only been a handful of possible human-to-human transmissions, usually between family members in close contact with someone infected.

Many government officials around the world — including officials in the two countries where human-to-to-human transmission seems to have occurred — interpret the data in the most reassuring way possible and emphasize that there is no conclusive proof of human-to-human transmission. They are over-reassuring their publics — or at least they are trying to over-reassure their publics; they sound like the tobacco industry insisting to the bitter end that the evidence isn’t conclusive. Abbott, on the other hand, matter-of-factly states what most influenza experts believe. His use of the word “possible” acknowledges the uncertainty [4], but he leaves the impression that, despite absence of definitive proof, there have probably been a “handful” of human-to-human transmissions. He is erring on the alarming side [3] and not aiming for zero fear amongst his public [9]. Thus he is trusting his public to bear this scary news [18], while most other officials are not.

Since Abbott’s speech, by the way, the number of confirmed cases has increased to 108, with 54 deaths. The evidence of occasional human-to-human transmission is still compelling but not conclusive, and there is no evidence yet of frequent human-to-human transmission.

The risk is that bird flu, deadly and easily spread among chickens and deadly but very hard to spread among people, could mutate into a lethal new strain of highly infectious human flu with impact akin to the pandemic of 1918–19. Earlier this year, the World Health Organization’s Western Pacific Regional Director warned that the world was “now in the gravest possible danger of a pandemic”.

Abbott’s first sentence here is a stunningly clear statement of why the world’s infectious disease experts are losing sleep. The comparison to 1918–19 isn’t even necessarily the worst-case scenario. The current H5N1 fatality rate is far in excess of the Spanish Flu fatality rate; a true worst case would postulate that the virus learns to transmit easily from human to human without becoming less deadly in the process. Still, 1918–19 was the worst flu pandemic we know about. Minister Abbott explicitly errs on the alarming side [3], again not being afraid to scare his public [9].

Many government officials, by contrast, have based their bird flu communications on something close to a “best case scenario,” grounded in the fairly mild 1957 and 1968 pandemics. The frequently cited estimate of 2 to 7 million deaths worldwide derives from extrapolating these mild pandemics to the current world population. Officials often use the same model to calculate a fatality estimate for their country or state or city. They then present this fairly optimistic estimate of the bird flu risk as if it were the worst case, “warning” that “as many as” that number might die.

A Commonwealth Government report published last year estimated that a major flu pandemic could lead to 2.6 million Australians seeking medical attention, 58,000 hospitalisations and 13,000 deaths. This is a significantly lower mortality rate than in 1919. Health care is immeasurably improved and Australia is considerably better prepared. On the other hand, much greater mobility means that any new pandemic strain is likely to reach Australia at an earlier and possibly more virulent stage.

Once again Abbott steers a middle course. He cites his Government’s report estimating 13,000 deaths in Australia in a “major flu pandemic,” then cautions that this is a “significantly lower mortality rate” than in 1919. The implication is that 13,000 might be right, or a pandemic might be worse than that. He has carefully bracketed the risk comparison [25]: The Government estimate is far higher than Australia’s “less than 500” deaths in the 1957 and 1968 pandemics, mentioned a few paragraphs earlier, but “significantly lower” than the 1919 mortality rate.

At the end of the paragraph, Abbott offers reasons why Australia might do better today than in 1918–19 (better health care, better preparedness), and reasons why it might do worse (greater mobility, leading to quicker contagion). The listener gets a sense of candor and transparency [24] rather than propaganda. Even more important, the listener gets a sense of inevitable uncertainty [4]; we simply cannot know how bad an H5N1 pandemic might be. In the face of this uncertainty, Abbott resists the temptation to lean too heavily toward the reassuring side, which paradoxically might come across as less credible. He also avoids the temptation to refuse to make judgments until the answers are known. Instead he speculates responsibly [7], once again trusting the public [18] to bear uncertain and potentially scary news.

A “worst case“ scenario taken from a US draft pandemic plan, republished in version 1 of the 1999 Framework for an Australian Influenza Pandemic Plan, traces the possible course of a pandemic from initial outbreak in a small village in Asia: “Over the next two months, outbreaks begin to appear in Hong Kong, Singapore, South Korea and Japan. Although cases are reported in all age groups, young adults appear to be the most severely affected and case fatality rates approach 5 per cent. Widespread panic begins because vaccine is not yet available and supplies of anti-viral drugs are severely limited? “A few more weeks pass and focal outbreaks begin to be reported throughout the United States. Rates of absenteeism in schools and businesses begin to rise? Exaggerated accounts of illness are reported by the media. Citizens begin to clamour for vaccine but only 10 per cent of the estimated need is available.... Hospitals and outpatient clinics become severely short-staffed when the majority of physicians, nurses and other health care workers become ill? Intensive care units at local hospitals become overwhelmed and soon there are widespread shortages of mechanical ventilators for treatment of patients with pneumonia? Family members become distraught and outraged when loved ones die within a matter of a few days. Looting becomes a serious problem in major metropolitan areas due to shortages of police officers.?Further deterioration in health and other essential community services occurs over the next 6–8 weeks as illness sweeps across the country.?#8221;

Minister Abbott here offers an extended quotation from a very candid description of a possible worst case scenario. He is telling people what to expect [15] in a worst case, and he is doing so with real detail and real drama. He is certainly not aiming for zero fear [9]! Although this scenario is excerpted from a U.S. Government document, few if any U.S. Government officials have quoted from it this way in a public presentation. Many U.S. public health leaders believe — mistakenly, we think — that it would be unwise to frighten people about a possible flu pandemic.

We can’t resist commenting on three points in the scenario Abbott is quoting.

First, note the reference to “widespread panic.” We probably won’t get through a serious pandemic without some real panic — and panic when it happens can be truly horrific. But even in extremely dangerous situations, panic is rare; people may well feel panicky but their actions are usually sensible, often helpful, and sometimes heroic. We wish officials (and journalists) would say what they’re envisioning when they refer to “widespread panic.” Virtually every unauthorized precaution people decide to take is called panic by those in authority — getting a Cipro prescription during anthrax, wearing a face mask during SARS, even standing in line during last season’s U.S. flu vaccine shortfall. Experts should try to be as careful when diagnosing panic as they are when diagnosing influenza [8]. Unlike so many other officials, Abbott does not use the fear of panic (“panic panic,” we often call it) as an excuse to withhold alarming information [3] and alarming speculation [7].

We’re also intrigued by the reference to “exaggerated accounts of illness ... reported by the media.” While there will certainly be a huge volume of pandemic coverage, experience demonstrates that media sensationalism usually goes on vacation during a real crisis, replaced by a sort of “Media Stockholm Syndrome.” Instead of exaggerating, the media in a crisis will go along with official efforts to reassure; in fact, they often downplay the most alarming information officials do provide. Media exaggeration in mid-crisis is mostly confined to information that reporters think has been withheld or covered up. (In addition, media far from the crisis sometimes exaggerate. During the SARS outbreaks, for example, media in unaffected countries sometimes ran exaggerated accounts of illness, and often ran exaggerated — but always vague — accounts of what they viewed, from afar, as panic.)

The fear of media sensationalism, like the fear of panic, often leads officials to understate the risk. If he was experiencing this fear, Abbott deserves all the more credit for not giving in to it. As we will discuss later, the coverage of his speech was less candidly alarming than the speech itself, especially in the headlines. The almost total absence of media sensationalizing about avian influenza — in fact, the repeated media tendency to downplay the risk and not use the most alarming official statements — is perhaps the best evidence we have that journalists, too, are worried.

Finally, note the U.S. draft’s incredibly optimistic assumption of enough vaccine for “10 percent of the estimated need” early in a worst case scenario [1]. Most experts believe there will be no vaccine at all for at least three to six months after a pandemic starts.

Of course, it’s impossible to say if, when and how a pandemic might develop. The next pandemic might be comparatively mild like the flu outbreaks of the late 50s and 60s. But it could also be a worldwide biological version of the Indian Ocean Tsunami. There are obvious limits to how much governments can invest in preparations for hypothetical events, however serious. Still, responsible governments should make extensive preparations for reasonably foreseeable contingencies. In this respect, the WHO has recently said that Australia is as well prepared for a flu pandemic as any country in the world.

This paragraph does a wonderful job of acknowledging uncertainty [4] and sharing the dilemma about preparedness [5]. Many officials react to accusations of inadequate preparedness by insisting that they have done “everything possible” or even taken “every conceivable precaution.” (Ironically, this insistence often comes from people who previously spent decades complaining that preparedness and the preparedness budget were both insufficient.) Abbott steadfastly refuses to take this untenable position on the risk communication seesaw. He concedes that there are “obvious limits to how much governments can invest” in preparing for a crisis that may or may not materialize. He advocates only “extensive” preparations for “reasonably foreseeable” contingencies — making it clear that preparedness is a judgment call, that there is no platonic essence of perfect preparedness. This is far better than the typical dichotomous frame — “Pandemic Influenza: Are We Prepared?” — that asks an unrealistic yes/no question and then usually provides a misleading yes answer. The public needs to learn, and be trusted to bear, the reality that there is no perfect preparedness. Abbott allies with people’s mature ability to cope [18], rather than with their less mature yearning to be over-reassured [1].

Abbott justifiably cites WHO on Australia’s good preparedness effort, and goes out of his way not to overstate that effort [1]. The tone of the paragraph’s last sentence, that Australia is as well prepared as any country in the world, strongly hints that no country can be fully prepared.

Australia began preparing for a possible flu pandemic after several people died in a 1997 outbreak of bird flu in Hong Kong. All the key recommendations of the 1999 Framework for an Australian Influenza Pandemic Plan (most notably for a national influenza surveillance network and the development of national and state pandemic contingency plans) have been acted upon — except those for availability on the PBS of anti-viral drugs because of fears that regular, long-term use of anti-virals could help develop resistant virus strains. In 2002, after the Bali bombing, the Government established a National Incident Room to help monitor and co-ordinate the response to potential health disasters. Also in 2002, the Government established a National Medicines Stockpile, mostly to deal with a potential terrorist incident but also to cope with natural disasters. The Incident Room was activated during the SARS epidemic and has been carefully monitoring the outbreaks of bird flu in Asia.

In documenting Australia’s preparedness accomplishments, Abbott is careful not to overstate the case. He is transparent [24] about the Government’s decision not to implement one of the key recommendations in the 1999 framework, thus acknowledging a dilemma [5], a disagreement [6], and what amounts to a recent shift in policy [22].

The SARS epidemic demonstrated the capacity of national health systems, the WHO, and co-operative neighbouring countries to monitor, treat and control the spread of a deadly (but not especially infectious) disease. Through the sharing of information, laboratory analyses and expert personnel, Australia was part of an international effort to help Asian countries contain the SARS virus with relatively minor disruption to international travel and trade and the domestic life of the countries most affected. Even so, it’s estimated that SARS cost the economies of South East and East Asia a collective $15 billion (or 0.3 per cent loss to GDP) as well as 770 deaths.

Many national leaders have said much more over-reassuring things [1] about the way SARS helped prepare them for a future influenza pandemic. The U.S. draft pandemic plan, for example, states: “After the SARS response of 2003, federal, state, and local public health colleagues conducted internal debriefings to prepare for future outbreaks of this magnitude.“ Of this magnitude? The U.S. had only eight confirmed SARS cases! (At the start of this column, we also noted an Australian overstatement of SARS success.) Abbott, by contrast, draws attention to the fact that SARS was “not especially infectious,” that a flu pandemic would be far, far worse. He is again telling people what to expect [15], and using an anchoring frame — people´s mental model of SARS — to make his point [21].

From March last year, once it became clear that controlled culling would not readily stop bird flu from becoming endemic in Asia, the Government began to build up a much larger anti-viral stockpile. Anti-virals can protect people exposed to a virus for which no vaccine is currently available. Australia has one of the world’s four WHO collaborating influenza laboratories and CSL (formerly the Commonwealth Serum Laboratories) is one of the world´s largest vaccine manufacturers. Still, producing a vaccine against a new pandemic flu strain could take at least six months because of the difficulty of producing a candidate vaccine virus which is effective and safe.

Abbott leads with the reassuring information about Australia’s anti-viral supply and vaccine production capacity. But he then emphasizes that this doesn’t mean a quick fix. In the structure of the paragraph, the reassuring first few sentences are subordinated to the alarming conclusion [2].

Abbott refuses to over-reassure his public with regard to vaccines [1]. His statement that “anti-virals can protect people exposed to a virus for which no vaccine is currently available” is a rare example of over-reassurance in this speech. No one knows for certain if the eventual pandemic strain of influenza will be susceptible to antiviral drugs — which is part of the reason why different countries have made different decisions about stockpiling antivirals. This is one of the dilemmas of pandemic preparedness: how much to spend on drugs that may not be needed and, if needed, may not work.

In last year’s budget, on the advice of the Chief Medical Officer after consultation with the National Influenza Pandemic Action Committee, the Government committed $114 million to purchase 3.3 million courses of oseltamivir (marketed as Tamiflu). Now that this order has been filled, after Finland, on a per capita basis, Australia has the world´s largest anti-viral stockpile — on shore and ready for use.

This is reassuring information that Tony Abbott has every right to convey. Australia is genuinely far ahead of most other developed countries with regard to stockpiling Tamiflu. Countries that have only recently decided to order large amounts of Tamiflu will not receive their orders for many months or years. If there is a pandemic, the output of the world’s only Tamiflu factory (so far) may well be nationalized by its host country, Switzerland. Nonetheless, many of these countries talk about their large orders without mentioning the supply/delivery problem. At least they have made the orders. The U.S., which has “on shore” only 2.3 million treatment courses (a miniscule amount on a per-capita basis), has so far not ordered any more.

As part of the annual inter-pandemic flu vaccine contract, the Government has negotiated with CSL and Sanofi-Pasteur to supply 50 million doses of pandemic flu vaccine should it become available. In addition, the Government is adding to the Stockpile 50 million syringes, 40 million surgical masks, pre-prepared equipment for six quarantine centres for 500 people for five days, along with extra ventilators and negative pressure units for hospital isolation rooms.

Note the “should it become available” that ends the first sentence of this paragraph. Unlike many other officials, Minister Abbott is not leaning on the over-reassuring prospect of having a vaccine supply at the start of the pandemic. He truly wants the public to understand that there is very little chance of this [1, 15, 24].

At the start of the column, we quoted Dr. Horvath about vaccines. He said: “Australia has a contractual commitment for the supply of up to 50 million doses of pandemic vaccine should there be an outbreak of pandemic influenza.” In Horvath’s rhetoric, the vaccine is guaranteed, though the pandemic is iffy. When Minister Abbott talks about the same issue, the “shoulds” are reversed. When the eventual pandemic inevitably arrives, he tells his audience, Australia will have prearranged access to the vaccine — if there is any to be had. This illustrates the difference between reassuring public relations and cautionary pre-crisis communication.

Both before and after this speech, Australia’s Green Party accused the Government of not doing enough to prepare for a pandemic. The accusers seem to have no awareness that Australia has done more than just about any other country. Remarkably, as far as we know Abbott and other officials have managed not to retort that Australia is fully prepared. The obvious but difficult lesson: When critics charge you with insufficient preparedness, agree. Share the dilemma of deciding how much preparedness is enough [5], concede that there is always more to be done, and ask for more funding for more preparedness.

The Government will shortly release the draft Australian Management Plan for Pandemic Influenza. This sets out in detail the steps to be taken by health authorities in the event of a pandemic flu outbreak. In any new pandemic, the critical moment would be the point at which the bird flu virus mutates into a new form of human flu. The first indicator that this had happened is most likely to be large numbers of people with flu-like symptoms reporting to hospital in a particular town or city. Because people can be infectious for about 24 hours before the onset of flu symptoms (and for up to seven days thereafter) the virus is likely to have spread well beyond the point of first outbreak before quarantine measures could be taken.

This is much more candid, and much more accurate, than the false promises from many other officials that “we will reinstitute SARS-type airport temperature screening to try to keep pandemic flu out of the country.” Because influenza is infectious before it is symptomatic, and because it is so very contagious, any implication that it can be stopped at the border is fallacious. A health official who implies this, or who allows the public to infer it, is either woefully uninformed or intentionally misleading the public [1, 23].

According to an official summary of an April 22 report in Science: “WHO officials are suggesting a change in the H5N1 virus towards greater infectivity. Together with a decrease in the case fatality rate, cases are now occurring across all ages and in larger clusters. The officials emphasise, though, that the results may be the result of better surveillance and that no human-to-human transmission has yet been observed“.

Here and throughout this speech, Abbott is careful to emphasize uncertainty and avoid overstating his case [4]. Yes, he says, it looks like H5N1 is getting more infective (more easily transmitted), but it also seems to be getting less fatal, and there still aren’t any confirmed cases of human-to-human transmission, and the whole thing could easily be an artifact of better surveillance. Having set a suitably alarming tone, he can now focus some attention on reassuring details without risk of over-reassuring his audience [2].

Although the WHO would formally declare that any new pandemic had broken out, it may be prudent for Australia to commence border security measures beforehand. The National Influenza Pandemic Action Committee is chaired by the Commonwealth Chief Medical Officer and comprises Australia’s leading epidemiologists and infectious disease physicians. The Australian Health Disaster Management Policy Committee is chaired by the Deputy Secretary of the Department of Health and Ageing and comprises the state chief health officers plus senior officers from Emergency Management Australia and the state disaster agencies. The Influenza Pandemic Committee, on advice from the observation and surveillance staff in the National Incident Room, would advise the Government that a pandemic was imminent. The Health Disaster Committee would then advise the Government on steps to be taken to prevent, if possible, the spread of influenza to Australia and to manage any outbreaks here.

This paragraph comes closer than the rest of the speech to over-reassurance [1]. Notwithstanding Abbott’s interest in launching border security measures before the World Health organization declares a pandemic, and notwithstanding all those committees, he must know stopping H5N1 at the border is a long shot. Travel restrictions (domestic as well as international) are an inevitable feature of pandemic response, and they can slow the progress of the disease a bit — but no responsible expert believes they can stop it. Abbott very nearly said so in an earlier paragraph. Even this paragraph — with that nuanced “...steps to prevent, if possible....” — concedes more than many official over-reassurances do.

Once a decision to impose border security measures had been made, every incoming passenger would be required to make a health declaration, thermal scanners would operate at international airports to detect possible flu cases on entry and quarantine isolation areas would be established. Influenza surveillance networks would be activated immediately and detection and treatment information would be sent to every GP and other health professionals such as pharmacists. Today I am releasing a pandemic influenza awareness kit which will be sent to every GP in the next few weeks.

Abbott might have made it clearer here that health declarations and thermal scanners are about slowing the spread of influenza, not preventing its entry. As for the “pandemic influenza awareness kit” Abbott promises to send to every GP in Australia, his willingness — his determination — to arouse increased concern among doctors and presumably among their patients reflects an unusual government commitment to aim for non-zero levels of fear [9] and to ask more of people [18].

In a severe outbreak, health authorities would have two objectives: first, containment to try to prevent the spread of disease; and second, once a lethal flu strain was generally established, maintenance of essential services. In the early stages of a severe outbreak, the highest priority for the provision of anti-virals would be people who had been exposed to the virus or who worked in areas of high risk of exposure such as health care workers and quarantine officers. Although anti-virals are regarded as effective prophylactics against infection, their effectiveness in treating people who are already ill is uncertain. Anti-virals would be used to treat the most severe cases as long as there was a reasonable chance that they might help save lives. In later stages, if a pandemic outbreak clearly could no longer be contained, the highest priority for anti-viral treatment would be health and other essential service workers and emergency personnel. No country in the world has enough anti-virals to protect essential service personnel for the likely six months duration of a flu pandemic, let alone to protect the general public. Even with a much larger per-capita stockpile than countries such as Britain, America and France, Australia could protect our one million essential service and emergency personnel for about six weeks.

These chillingly candid paragraphs lay out what officials and the public would be facing in a moderate or severe pandemic [24]. Abbott starts with a wonderfully succinct statement of goals, virtually conceding that the effort to “try to prevent the spread of disease” would probably be futile, leaving officials no choice but to focus on “maintenance of essential services.” Until very recently, discussion of the crucial need to keep essential services functioning despite the pandemic (not just health care and policing, but also things like water treatment and agriculture) has been largely absent in official pre-pandemic communications, which have emphasized mostly treatment issues [1, 15]. Then Abbott turns to the crucial dilemma of how to use scarce supplies of antiviral medications [5]. His answer is firm but surely not reassuring [1]. Ultimately, keeping essential service workers alive and healthy will take precedence over saving the lives of everyone else — and even for this purpose, there will not be enough medication in a bad pandemic.

These two paragraphs are among the most straightforward, candid avian influenza statements we have seen to date from a high-level government official. Clearly Minister Abbott wants his public to know what to expect [15], and he expects people to be able to bear it [1, 9, 24].

Two quibbles: Abbott’s suggestion that antivirals may also be used to treat “the most severe cases” is a little perplexing, since antivirals are ineffective unless they’re used soon after symptoms begin, often before the cases destined to be severe can be distinguished from the milder ones. And most experts think a pandemic is likely to roll around the world in several waves; each wave might last eight weeks or so in a location, but the overall pandemic would probably last a good bit longer than six months.

(Informational note: “Treating“ a case of pandemic flu with antivirals implies giving a patient Tamiflu twice a day for five days — ten pills in all. But to “protect ?essential ?personnel for about six weeks” you have to give them one pill a day — 42 pills per person for the six weeks Minister Abbott envisages.)

For the past year, the Government has been investigating ways to increase the availability of anti-virals and to reduce the lead times for the preparation of pandemic flu vaccine. Last year’s Australian anti-viral order took over six months to deliver (and largely cornered the world market) because of the technical complexity of anti-viral manufacture. Despite almost unlimited potential demand, it seems that anti-viral manufacturers have been unable significantly to expand or accelerate their production. At current prices, anti-virals to protect one million people for a month would cost about $90 million, if they could be obtained. With current technology and manufacturing processes, obtaining enough anti-virals to protect 20 million people for six months would be almost impossible at any price.

Officials in several other countries, in public relations mode, have proudly and reassuringly bragged about their (not yet delivered) Tamiflu supplies. Abbott, by contrast, cautions that even having “cornered the market” for six months isn’t nearly enough. The good news (Australia is better protected than most) is here, but it is subordinated to the bad news (Australia still isn’t adequately protected) [2]. And the worse news: Because of both cost and availability issues, Australia never will be adequately protected. This has the virtues so common throughout Abbott’s speech and so rare elsewhere: not over-reassuring [1], not aiming for zero fear [9], aiming for total candor and transparency [24].

All the world’s vaccine manufacturers (including CSL) are virtually round-the-clock investigating the production of candidate vaccines for a potential pandemic virus. Vaccine manufacture (which involves isolating a virus, creating an anti-virus, culturing it in sufficient quantities, and ensuring that people can be inoculated safely and effectively) is always a painstaking process but is particularly uncertain for an as yet unknown and highly mutant virus. Still, the Government is constantly talking to CSL about what might be done to make this process swifter and more reliable.

Once again Abbott declines to raise false expectations about an H5N1 vaccine [1, 15, and 24 again].

Compare Minister Abbott’s approach with recent U.S. official communications. As we were writing this column, the U.S. House Government Reform Committee held a hearing on pandemic influenza antivirals and vaccines. Acknowledging that the U.S. has only enough Tamiflu to treat 2.3 million people (which means enough to protect far fewer), Anthony Fauci of the National Institutes of Health said NIH was in “aggressive discussions” with manufacturer Roche about buying another two million treatment courses. Aggressive discussions to do what? Join the long line of countries already queued up for Roche’s next few years of Tamiflu production? Jump the line? Not to mention the paltry percentage of the U.S. population even this second order would cover.

According to a June 30 Associated Press story, Fauci “noted that Tamiflu is difficult and time-consuming to manufacture, which ‘makes it important for us to get our bid in now.’” — as if now were early and orders weren’t backlogged for years. AP added: “Other countries are depending mostly on Tamiflu to fight a bird flu outbreak, while the U.S. also is stockpiling vaccine and would use Tamiflu more to buy time until even [“even”?] more inoculations could be made, said Dr. Bruce Gellin of the National Vaccine Planning Office.” This isn’t an exact quotation from Gellin. We can hope he didn’t actually claim the U.S. has a usable vaccine stockpile. The U.S. has indeed stockpiled some two million doses of one experimental vaccine against one H5N1 strain, thought to be enough to vaccinate a million people (two doses each) if it works. And a different experimental H5N1 vaccine is now in its first clinical trials, being tested for safety and immunogenicity on several hundred U.S. citizens. The trials will not prove the vaccine’s efficacy against the eventual pandemic strain, and of course there is no stockpile.

Once pandemic flu was present in the Australian community, depending on its severity, the Government would have to decide whether to discourage or ban large gatherings and close schools. Any such measures would have serious economic consequences but they could slow the spread of disease and allow more people to be protected by any vaccine that´s ultimately developed. Once pandemic flu had spread beyond designated quarantine areas, the Government would also have to decide whether to rely on home quarantine of flu cases with mobile medical teams treating most patients and designated hospitals dealing only with the most serious cases.

“The Government would have to decide....” is a wonderfully candid way of telling people what to expect [15], acknowledging uncertainty [4], and above all sharing dilemmas [5]. Obviously these are painfully difficult decisions the Government has not yet made. In contrast to Abbott, officials usually keep mum about pending decisions, especially frightening and depressing ones; after a decision is made, officials usually announce it as if it were obvious, without acknowledging the painful, difficult discussions that led up to it.

Not since World War Two have Australians had to cope with very large numbers of premature deaths. Australians are unused to contemplating the possibility of death on a massive scale, especially from “natural causes”. The competing temptations are “it won’t happen here” complacency, “there’s nothing we can do” fatalism, or “no precaution is too great” alarmism.

This is a spectacular paragraph that puts on the table some of the public’s anchoring frames as it listens to warnings about a possible pandemic [21]. Note two unusual things about how Abbott sees the public’s anchoring frames. First, his worry about alarmism isn’t framed in terms of panic, but rather in terms of the impulse to go overboard on precautions. He’s not engulfed by “panic panic“; he just wants to keep reminding people that there are limits to how much preparedness is feasible for a risk that may never materialize [8]. By contrast, most officials are so preoccupied with their fear of public panic that they end up pretending that they have already taken all conceivable precautions. But Abbott doesn’t stop there. The second unusual thing about the paragraph is how it pays attention to emotions other than just fear [10]. Abbott is worried also about complacency and fatalism — risks far likelier than panic and almost never mentioned in official discourse about avian influenza.

Talking about “‘there抯 nothing we can do’ fatalism” gave Abbott an opening to talk about what people can do to help prepare themselves and their communities for a possible pandemic. One of the few serious weaknesses of this speech is its failure to offer people things to do [16] — ideally a choice of things to do [17], so their ability to act is supplemented by their ability to decide. Involvement and efficacy are among the most potent antidotes to the fatalism Abbott is worried about. And if what Abbott calls “complacency“ turns out to be more denial than apathy, involvement and efficacy are potent antidotes to that as well.

All these grave scenarios come from material already published and in the public domain. Even so, it’s hard to discuss potential disasters outside people’s ordinary experience without generating the sort of lurid headlines which make some scoff and others panic. It’s important not to over-react to potential threats. On the other hand, people and their governments need to take credible threats seriously and take reasonable and proportionate precautions against them. If a deadly flu pandemic ever seems imminent, no preparations will be enough. But if the current bird flu outbreaks in Asia gradually subside, the Government’s investment in a stockpile likely to be time-expired in five years will be the health equivalent of a redundant weapons system.

Again, Abbott does wonderful dilemma-sharing, while also telling people what to expect and acknowledging uncertainty [5, 15, 4]. Look at the structure of this paragraph: It’s important not to over-react ... but we need to take the threat seriously. If a pandemic comes no preparations will be enough ... but if the risk subsides we will have wasted our investment. Back and forth he goes on the risk communication seesaw. Unusually candid about both sides of the dilemma, this paragraph helps us find our way to the fulcrum, where we can face both sides at once.

Abbott is trusting the public to bear the weight of the truth. Even though this speech doesn’t offer people things to do [16, 17], emotionally it asks a great deal of them [18]. If a pandemic comes, Australia’s public will be that much better prepared. By contrast, most officials around the world do not trust their publics to bear this weight. Less prepared for the pandemic if it comes, their publics will feel blindsided and misled; they will be less ready to cope, less likely to cooperate, and more inclined to blame their leaders. In Australia like everywhere else, people naturally yearn for “perfect protection.” It is tempting but profoundly unwise for leaders to cater to this yearning. Abbott allies instead with our more mature, more resilient traits.

Abbott was understandably wary of generating “lurid headlines,” panic, and scoffing. But as we have noted, the media usually abandon sensationalism when the risk is serious, and media coverage of Abbott’s speech was anything but lurid. There were no reports of panic, though we can hope some people were appropriately alarmed by his speech. The only scoffing we found was the Green Party saying he wasn’t doing enough.

This paragraph and the preceding one add up to a very respectful acknowledgment of public emotions. And Abbott does not ridicule these emotions [11]. Instead, he matter-of-factly points out that some people may understandably over-react, while others may understandably under-react. This point in the speech would have been a perfect moment to empathize with these early reactions — whether scoffing or scared — and then to point out that people naturally need time to absorb bad news before getting down to the business of proportionate preparedness [13].

Since 1998, and with much greater urgency since late 2003, all Australian governments have been preparing for a flu outbreak that might, if not prepared for, overwhelm the health system and paralyse normal society for months. Those preparations are far from complete. It’s clear that we cannot guard against all contingencies and that a severe outbreak would test our national capacity in ways unknown for half a century. Even so, much work has been done and it´s important that experts and policy makers take the Australian public into their confidence lest people one day say they had never been warned.

If any reader still wonders whether Abbott’s speech is merely accidental good risk communication, this sentence should answer the question. Abbott is dramatically insisting that the public be told — and bear — the frightening prospect of a pandemic, the realities about preparedness, and the uncertainty surrounding it all. He knows and says what most officials around the world are ignoring or denying: that people can take bad news, and that they will eventually punish any leader who withholds that bad news.

Frequent (and frequently exaggerated) public controversy notwithstanding, Australia has a very good health system with generally advanced equipment and infrastructure and highly professional and dedicated health staff. Our “have a go” culture means that we can usually improvise to meet the unexpected or the daunting. Precisely because it is a good system, people have very high expectations that it will cope under any circumstances.

Abbott moves toward his close with another explicit acknowledgment of the public’s anchoring frames — both its accurate sense that Australia usually copes well with problems and its unrealistic sense that anyone can cope well with a serious pandemic [21]. We also like the reference to improvisation, where most officials would focus exclusively on planning. This accurately reflects the reality that in a crisis resilience often counts for more than preparedness. And it’s a subtle warning that if and when the pandemic comes, everyone will be improvising in response to uncertain and unprecedented events, and that errors and failures and disagreements are therefore inevitable [4, 5, 6].

At every level, the officials and experts involved in pandemic preparedness have been fully alive to the urgency of the task and determined to get things done. So far, they’ve well and truly confounded the stereotypes of government by committee. On the record so far, Australia’s health security is in good hands. This should be some consolation to those tempted to dwell on the fear and confusion which would inevitably accompany a deadly scourge.

The two “so far’s” are more realistic and more humble than the usual self-congratulatory tone in official speeches. Paradoxically, this sort of candor probably inspires more confidence than a PR-dominated promise to be ready for whatever comes [24]. And that last sentence! The Government’s good job so far “should be some consolation” — but only some, since “fear and confusion” are inevitable. This is not the traditional over-reassuring “upbeat” ending. In his last sentence Abbott chooses instead to legitimize people’s appropriate fear of an influenza pandemic [1, 12].

A Postscript on the Coverage

Reporters covering Abbott’s speech conveyed his frank, “duly” alarming content well. They didn’t sensationalize it, and they didn’t treat it as a huge story — but they covered it accurately.

The headlines were another story — literally. All the headlines reflected the dichotomous thinking typical of headline writers. Only one online headline that we could find chose the alarming side of the dichotomy, obviously the right side for Abbott’s content (if you accept that a nuanced middle is unachievable in headlines). “Australia not ready for flu,” wrote The Australian on May 2, 2005. Numerous other headlines erred on the reassuring side:

• “Nation prepared for flu pandemic: Abbott” (Sydney Morning Herald, May 2; the same headline was used in The Age/Australia, also May 2)
• “Aust prepared for flu pandemic: Abbott” (ABC/Australia, May 2)

A month later, when Australia released its pandemic plan, Abbott told reporters about Australia’s excellent pandemic planning, but cautioned, “On all the best advice we have, we’re looking at a whole lot of pretty grim possibilities.... I think we need to be very concerned — not panic-stricken — but concerned.” He talked about the need to keep essential services up and running while a vaccine was developed, adding: “We cannot be certain that any candidate vaccine would be effective.” The headline on most of the online articles covering Abbott´s statements on June 6? “Australia ‘prepared for flu pandemic.’”

Between Abbott’s May 2 speech and the June 6 release of Australia’s pandemic plan, we spent time in Perth and Adelaide, where we found very few people who were aware of the prospect of an avian influenza pandemic, and virtually no nonmedical people who were concerned about it. Adelaide held a four-day “bird flu response exercise” (called “Adventurous Goose“) while we were there; it received virtually no media coverage. Even Tony Abbott is having a hard time getting people concerned, let alone alarmed, about a pandemic. But at least he is trying.