Nationwide Response Issues After an Improvised Nuclear Device Attack: Medical and Public Health Considerations for Neighboring Jurisdictions: Workshop Summary (2014)

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6 Risk Communication and Education Key Points Made by Individual Speakers x Effective risk communication after an improvised nuclear device (IND) attack can save lives, reduce social and economic impact, and foster resilience and recovery. x Effective risk communication staves off panic and mental distress. Mental disorders such as depression and posttraumatic stress disorder have been the most common health outcomes after nuclear accidents. x To avoid problems such as social stigma, effective risk communication will also be crucial in areas that receive evacuees after an IND incident. x Messages to the public should be brief, clear, and free of inconsisten- cies and scientific terminology. They must sound serious and urgent, yet instill hope. They also must provide concrete steps that members of the public can take to reduce risk to themselves, their families, and their homes. x First responders and medical professionals must be trained to reduce their own misplaced fears about low levels of radiation and to avoid unnecessarily stigmatizing patients and evacuees. x Addressing the information needs and concerns of first responders and other medical professionals during a radiation emergency is essential for an effective response. x Public health and safety officials in outlying communities need training in risk communication around radiation hazards. Because many people are unaware of the extreme implications of an improvised nuclear device (IND) attack, its differences from other nucle- ar emergencies, the public health consequences from such an attack, and the most effective life-saving responses, risk communication, and disas- ter education are extremely important. Providing more education—to 47 

48 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK both the public and first responders—before, during, and after an inci- dent can result in many more lives saved and a quicker, more efficient response overall. This chapter highlights important lessons that have been garnered from focus group research and real-life radiation emer- gencies to guide cities and states in their communication planning. LEARNING FROM FOCUS GROUPS Charles Miller, chief of the Radiation Studies Branch of the Centers for Disease Control and Prevention (CDC), opened his presentation with the observation that effective communication with the public during an IND attack will save lives. Given the importance of risk communication, the CDC sponsored a study that used focus groups to test dozens of mes- sages about an unfolding IND attack (CDC, 2012). The messages being tested had been developed in 2009–2010 by the Radiation Communica- tions Working Group, a federal interagency group of communication and radiation experts who issued an interim document, Nuclear Detonation Preparedness: Communicating in the Immediate Aftermath (Nuclear Detonation Response Communications Working Group, 2010). The idea behind developing messages in advance is for officials to have at their immediate disposal the capacity to communicate effectively with the public in the aftermath of an IND detonation. Focus groups were held in Atlanta, Boston, Chicago, Denver, Houston, Los Angeles, New York City, Seattle, and Washington, DC. The focus group study found that the radiation field does not speak clearly to the general public. The public is confused by radiation and is unaware that people are already being exposed to background radiation from natural sources. Further confusion is added by the message to seek shelter in the center of multistory buildings; people who neither work nor live in multistory buildings were confused about where they should go. Miller and his group also found that the distinctions between high and low levels of radiation and corresponding health consequences are not well understood. In addition, terms such as sheltering, responders, dose, contaminant, contamination, radioactive material, and radiation protec- tion standard add uncertainty to an already anxiety-inducing message. Analysis of the study’s findings led the authors to make these main recommendations: x Be brief and clear, and address public concerns. 

RISK COMMUNICATION AND EDUCATION 49 x Tailor messages to different phases of the attack and to different zones. x Avoid scientific terminology, like the use of radiation exposure levels in rems or Sieverts. x Keep the tone of the messages urgent and serious, but impart a sense of hope. x Do not issue contradictory messages. x Ensure that messages contain simple action items people can un- dertake to protect themselves, their families, and their homes. The person delivering the message also matters, Miller said. The public wants to hear messages from subject matter experts. Having med- ical directors of public health “When the fear often associated agencies deliver messages is a with radiation combines with inad- good idea because they are seen equate or ambiguous communica- by the public as trustworthy and tions, the impacts of an event can credible. A television meteorol- be greatly exacerbated.” —Steven M. Becker ogist is also considered to be credible. Also, the public wants to hear a live voice rather than a voice recording. A live voice sends a message of reassurance that there are other people out there who have survived. Reliance on radios to transmit messages is problematic because the study found that less than half of the focus group members owned a radio other than the ones in their cars. Most people are reachable through cellu- lar phones, Facebook, and Twitter, but these methods of communication might be disrupted by the IND attack. Another finding was that a com- munity’s frame of reference should be taken into account. This was most applicable to New York City. On September 11, 2001, after the terrorist attack on the World Trade Center, people in the twin towers were told to remain in the building, a message that led to more deaths as the towers unexpectedly collapsed. Consequently, New Yorkers are likely to be wary of messages to stay inside their buildings. In other jurisdictions, Miller advised getting out IND-related messages by “piggybacking” them onto existing disaster planning, such as for earthquakes and hurri- canes. Finally, Miller said, the CDC’s next step is to translate messages into Spanish and test them with Spanish speakers. 

50 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK LESSONS FROM NUCLEAR REACTOR ACCIDENTS Steven M. Becker, professor of community and environmental health at Old Dominion University College of Health Sciences, said that effec- tive risk communication is one of the most important factors affecting the outcome of an IND attack: It can reduce fatalities, illness, and inju- ries; it can reduce the social, psychological, and economic impacts; and it can foster resilience and facilitate recovery in affected communities. Although streamlined and accurate risk communication is vitally im- portant, it is very difficult for reasons including the suddenness of the attack (which gives little time to formulate effective messages), the huge numbers of deaths, graphic images of burns and disfigurement, and the expectation of additional attacks to follow. Decades of research, as well as real-world experience, show that people perceive radiation as one of the most fearful of all hazards (Becker, 2007; Slovic, 2001). The combination of fear and inadequate communica- tion exacerbates the adverse effects of a radiation episode. For example, after the nuclear accident at Three Mile Island, officials delivered con- flicting statements about risk. Mixed messages, as well as inadequate messages, were partly responsible for leading an unnecessarily high number of people—an estimated 150,000—to evacuate the area despite radiation doses being below background levels (Talbott et al., 2003). Almost 45 people evacuated for each single person who was actually advised to evacuate. Inadequate information led to increased distress. Similarly, after the reactor accident at Chernobyl, disclosure to the public was minimal, and the most common health consequence was mental dis- orders—anxiety, depression, and posttraumatic stress disorder (Bromet, 2012). Although past radiation events have not been the same as an IND attack, Becker said that much can be gained by looking at the lessons learned. The most recent nuclear reactor disaster occurred in 2011 at the Fukushima Dai-ichi nuclear generating station in Japan following an earthquake and a tsunami which killed more than 15,000 people. About 150,000 people were evacuated from a 20-km “no go” zone established by the authorities around the crippled reactors where no one was allowed to enter. Becker was part of a three-member team of experts invited to Japan for a radiological assistance mission shortly after the accident (Becker, 2011). The team spent time in the 20-30 km emergency evacua- tion preparation zone and outlying communities, meeting with disaster 

RISK COMMUNICATION AND EDUCATION 51 response officials, politicians, medical personnel, and members of the public. Maintaining Public Trust The first lesson the expert team learned is that in the midst of a nu- clear crisis it is easy to lose sight of the importance of risk communica- tion. Public announcements after the Fukushima Dai-ichi accident were delayed, press releases were held back, and explanations were intention- ally ambiguous in an effort to avoid panic. The failure of risk communi- cation had the opposite effect, however: It heightened fear, and it generated a profound lack of trust and confidence in authorities. The second lesson Becker imparted was that risk communicators need to find a way for the public to determine whether text messages, e-mail, and other communications are genuine. During the Fukushima Dai-ichi event there were many hoaxes, including fake e-mails purport- ing to show dead bodies and e-mails advising what medications could substitute for potassium iodide, which protects the thyroid gland from exposure to radioactive iodine. The substitutes mentioned were actually unhealthy. In the discussion period, Jack Herrmann of the National As- sociation for County and City Health Officials pointed out that rumor control is exceedingly challenging. When the Red Cross sought to keep track of rumors during Hurricane Sandy, he said, it found the task to be incredibly difficult. There were hundreds of thousands of tweets, Face- book posts, and other social messaging. For every erroneous tweet, it took multiple tweets to correct it. Herrmann said that public health agen- cies will need to identify credible sources for where the public can turn. Furthermore, Becker explained, government agencies should antici- pate and be prepared to meet widespread demand for potassium iodide. The demand for potassium iodide skyrocketed immediately after the ac- cident began. When people could not obtain it, they sought any iodine containing products, regardless of the life-saving potential, such as disin- fectants, iodine gargles, foodstuffs, and topical medications. Some of the products, including an herbal supplement, were actually dangerous, Becker said. Another lesson learned that Becker shared is that to combat mis- judgment and haphazard evacuations, authorities should disclose the path of the radioactive plume to the public as soon as it is known. Japanese officials failed to disclose this information to local governments and the 

52 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK public. One unfortunate consequence from this was that in a number of outlying communities people evacuated from a safe area to an area di- rectly under the path of the plume. This lack of disclosure left a legacy of fear, distress, and bitterness toward government officials. Finally, in receiving areas public agencies should be ready to re- spond effectively to questions about radiation and fallout in order to pre- vent the stigmatizing of evacuees. In an outlying community unaffected by radiation, hotels refused to accept evacuees, and children were bullied at school. Even medical professionals held stigmatizing views; many of them left the area. In a survey by the Hospital Association of Japan, re- sponding hospitals reported that 534 physicians and nurses moved away. This figure is an underestimate because more than half of the area’s 127 hospitals failed to respond to the survey, and a shortage of health profes- sionals still persists. Becker concluded that there needs to be a strategy for addressing this stigma in outlying communities. Becker concluded his presentation by emphasizing that risk commu- nication is crucial to the response after an IND event. There are major communication, information, and messaging needs in both the target city and outlying communities. BOX 6-1 Lessons from Fukushima Dai-ichi, 2011 (Steven M. Becker) x In the midst of a nuclear crisis, it is easy to lose sight of the importance of effective risk communication. Do not wait for better information to is- sue messages. x Include a way for the public to recognize whether a text message, e- mail, or other communication is genuine. x In all areas, including neighboring jurisdictions, agencies should antici- pate and be prepared to meet a rapid, widespread, and immense de- mand for information about and access to potassium iodide. x It is vital for authorities to be able to rapidly issue easy-to-read plume maps to the public. x In receiving areas, agencies should anticipate having to answer many questions about evacuees and radiation and fallout. Effectively meeting these information needs is an important part of efforts to prevent the problem of stigma. x As part of a risk communication strategy for neighboring jurisdictions, it will be crucial to be able to address the concerns and information needs of health care, hospital, and public health staff. 

RISK COMMUNICATION AND EDUCATION 53 RISK COMMUNICATION EFFORTS AT FEMA The Federal Emergency Management Agency (FEMA) has spear- headed two major activities supporting risk communication through its interagency Radiation Communications Working Group, according to Bruce Foreman, the working group’s co-chair and an analyst in the Chemical, Biological, Radiological, Nuclear, and Explosives Branch of FEMA’s Response Directorate. The first activity is the development of 96 messages for the public in the immediate aftermath of an IND attack. This was the set of messages, published as an interim document in 2010 that the CDC tested in its focus group study. A final version of the doc- ument, which has been revised from the interim version to incorporate comments from focus groups, has recently been given approval by the National Security Council and the White House Office of Communica- tions and was publicly released in June 2013 (FEMA, 2013b). FEMA is developing a roll-out strategy to accompany the document as well. The roll-out will likely include a separate document containing messages about responding to a nuclear power accident. With the release of these documents, the theme of translation continues, and state and local author- ities will have another set of tools that can be readily used in the event of a radiological incident. Translating Information to the Local Level The Radiation Communications Working Group has also produced a video that explains to the lay public the shelter-in-place recommendation. The video, similar to the one developed by Ventura County (described in Chapter 4), carries the pre-incident message “Get inside. Stay inside. Stay tuned.” FEMA is working with other federal agencies as well as with state and local authorities on a roll-out strategy for the video to en- sure that its impact is maximized. With the help of the U.S. Defense Threat Reduction Agency, the working group is developing a tool for states and localities to map the plume of fallout and advise people where to go to avoid it. A final activi- ty under development is a risk communication tool for state and local authorities to better handle the “worried well,” i.e., people with minimal radiation exposure whose health is not threatened but who are concerned about their health. Because of the need to optimize resources in this type of event, it is critical for the worried well to be deterred from seeking 

54 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK care at hospitals because hospitals will already be overwhelmed with people harboring more serious threats to health. THE ROLE OF PUBLIC INFORMATION OFFICERS Public information officers are the “boots on the ground” after an IND incident, said Edward McDonough, a public information officer for the Maryland Emergency Management Agency. Citing the complexity of the task facing public information officers, McDonough called for train- ing of public information officers in radiation risk communication, whether in person or by webinar or conference call. He concurred with the CDC’s focus group finding that, in the aftermath of an IND attack, members of the public need to know what protective actions they can take in order to give them a sense of empowerment. The public needs hope about survivability. McDonough also concurred with the point that risk messages should eschew scientific jargon. For example, instead of describing exposure in rems for a message to the public, the radiation dose from an IND could be compared with the dose one gets from flying from Washington, DC, to Denver, using relevant terms the public would understand. He also advised that risk communicators should take into account how people actually behave in disasters. He pointed to the ex- ample of the accident at Three Mile Island and the public’s overreaction, which led to unnecessary evacuation. After an IND attack, it will be dif- ficult to ensure that people shelter in place without a strong pre- and post-event messaging strategy. McDonough made the case that even in the face of scant infor- mation, risk communicators should err on the side of giving more infor- mation rather than less. He also raised the point that public officials in a crisis should avoid making promises that cannot be kept. Doing so will undermine confidence and trust in authorities. Finally, risk communica- tors need to be aware that, although a trusted public health official should play a leading role in risk communication, the press will reach out to fire, law enforcement, and emergency management. Representatives from these agencies also need training in risk communication. SUMMARY Effective risk communication during and after an IND attack can re- duce fatalities, illness, and injuries; it can reduce the social, psychologi- 

RISK COMMUNICATION AND EDUCATION 55 cal, and economic impact; and it can foster resilience and facilitate recovery in affected communities. Although risk communication is vital- ly important, it is very difficult. Several years ago, FEMA’s Radiation Communications Working Group developed 96 messages for the public in the aftermath of an IND attack. The CDC tested the messages on focus groups, only to discover that the messages were generally confusing and ineffective. The authors of the focus group study interpreted their find- ings to mean that messages must be brief and clear and address public concerns; they should be urgent and serious in tone but impart a sense of hope; and they should include actions that the public can take to protect themselves, their families, and their communities. As a result of the focus group study, FEMA is revising its messages. Further, FEMA has created a video carrying the shelter-in-place message “Get inside. Stay inside. Stay tuned,” which will reach the public sometime soon to help improve current awareness of the IND threat. Risk communicators can take advantage of important lessons learned from the Fukushima Dai-ichi nuclear accident in 2011. Some of the les- sons include the need for rapidly disclosing the path of the radioactive plume and the importance of using credible and trustworthy communica- tors who must swiftly respond to counteract hoaxes and fake information promulgated through social media and other technology.