5

Implications of Communication, Education, and Information Challenges

In Session IV, workshop participants considered a range of communication, education, and information challenges posed by a nuclear incident; the implications of these challenges for capacity building; and opportunities and approaches to addressing them. The session opened with the workshop keynote address by Steven M. Becker, professor, community and environmental health, Old Dominion University. Becker prefaced his address by noting that the information he would be presenting was informed by research as well as his own field experience at sites of various incidents around the world involving radiation emergencies, including the Tokaimura criticality accident in Japan in 1999, the Chernobyl follow-up in Ukraine and Belarus, and the Fukushima Daiichi nuclear emergency following the Great East Japan Earthquake of 2011.

Becker’s keynote was followed by a discussion among four panelists with expertise in communication related to nuclear detonation events. First, Hamilton Bean, associate professor of communication and director of the International Studies Program at University of Colorado, Denver, provided an overview of wireless emergency alerts (WEAs) and research on WEA messaging. In his presentation, Bean explained what WEAs can and cannot do currently and what remains to be learned. Next, Baruch Fischhoff, Howard Heinz University Professor at the Institute for Politics and Strategy and in the Department of Engineering and Public Policy at Carnegie Mellon University, discussed challenges and proposed solutions for improving risk communication in nuclear incident management. Robert Levin, public health officer of Ventura County, California, described Ventura County’s innovative video-based public service announcement (PSA) approach to educating its citizens about nuclear incident preparedness. Finally, Jessica Wieder, director, Center for Radiation Information and Outreach, Environmental Protection Agency (EPA), discussed the many communication tools for detonation events that have been developed by the interagency Nuclear/Radiological Communication Working Group. In addition to describing the many publicly available interagency nuclear threat communication tools, Wieder provided some personal perspective on nuclear detonation messaging based on her 14 years of work in radiation communications and nearly 10 years of work on nuclear detonation messaging in particular.

This chapter summarizes Becker’s keynote talk, the four panelist presentations that followed, and the open discussion with the audience.

NUCLEAR EVENTS: COMMUNICATION, EDUCATION, AND INFORMATION CHALLENGES

“Effective communication is one of the most important factors determining how any disaster or emergency situation unfolds,” Becker began. This is true of natural disasters, technological disasters, and especially a

nuclear detonation incident. Timely, credible, comprehensible messaging can reduce injuries and illnesses; prevent social, psychological, and behavioral impacts; help to maintain public trust and confidence; and facilitate recovery.

Becker pointed to the experience of Chernobyl to illustrate the importance of risk communication in radiation emergencies. The single most significant physiological impact of that accident was a dramatic increase in thyroid cancer. According to Becker, the World Health Organization (WHO) has made it quite clear that the main reason most of the cases occurred was because of the failure of risk communication and that if proper information had been communicated in a timely fashion, the results could have been different. Specifically, WHO concluded, “Since radioactive iodine is short lived, if people had stopped giving locally supplied contaminated milk to children for a few months following the accident, it is likely that most of the increase in radiation induced thyroid cancer would not have resulted” (Becker, 2012).

Becker emphasized, however, that while effective risk communication has enormous potential to reduce morbidity and mortality in a nuclear detonation scenario, this same scenario also poses enormous communication challenges. The event may occur suddenly and without warning. The devastation would be massive, with infrastructure damage close to the area of detonation. There would be the possibility and expectation of additional attacks to follow. Authorities would have very incomplete information initially yet at the same time would probably face a staggering and unprecedented demand for information, not only from the public but from the responder workforce as well. Time would be of the essence, Becker continued. Messages would need to be issued quickly. Finally, such an event would involve radioactive contamination, which is perceived by the public as one of the most feared of all hazards. “Radiation incidents have a remarkable capacity to produce widespread fear, a profound sense of vulnerability, and a continuing sense of alarm and dread,” Becker said, citing Becker (2004, 2007) and Slovic (2001).

Furthermore, Becker continued, a lot of radiation-related concepts and terms can be complex and difficult to understand. For example, there can be confusion about incident types. According to Becker, a number of studies have shown that at least half of the public does not understand the difference between a dirty bomb and an atomic bomb. In addition, people have repeatedly indicated in different studies that they know the least about how to protect themselves from radiological agents compared to other kinds of situations. People have also reported lower confidence in their ability to respond to radiation incidents compared to other types of threats. Finally, there is significant evidence of fatalistic attitudes among the public with respect to radiation and radioactive contamination. People make comments like “I

don’t think we’d have a chance,” “It’s radioactive material. Once it gets in you, [you’re] dead anyway,” and “There is nothing you can do” (see Becker, 2004; FEMA, 2009; Kano et al., 2008; Lasker, 2004; Wray et al., 2008).

“The good news,” Becker said, is that, despite these challenges and perhaps even because of them, there have been some very significant advances in nuclear incident communication over the past decade. Becker went on to discuss the research driving these powerful, improved communication tools.

Nuclear Incident Communication: Notable Advances

The foundational group of studies driving this past decade’s new advances in nuclear incident communication were funded by the Centers for Disease Control and Prevention (CDC) in collaboration with the Association of Schools of Public Health in what was called the Pre-Event Message Development Project (PEMDP). PEMDP brought together four nationally known teams of researchers with strong expertise in communication and messaging, public health preparedness and response, and the technical aspects of the threat agents being examined. The main body of work was carried out between 2002 and 2006, followed by several years of follow-on studies through 2008. In 2009, other agencies picked up where the follow-on studies had left off and funded additional work.

Becker described PEMDP as a “monumental undertaking” that is still today one of the largest studies of its kind ever conducted, not just in the United States but worldwide. It involved more than 1,000 participants from across 9 different population subgroups of the general public and from multiple regions. Although the project covered four different classes of emerging threat agents (plague, botulinum toxin, chemical/nerve agent, and radiation), radiation, including both radiological and nuclear agents, received the most attention in terms of the number of focus groups and interviews.

According to Becker, PEMDP resulted in the first peer-reviewed scholarship specifically on communication and nuclear detonation events. He described how this research identified ambiguity in the way people interpreted the term shelter in place and that it was necessary to move beyond using that phrase and come up with alternatives, which have since been adopted by CDC and other agencies; determined clearly that people want to hear from individuals and agencies that have high credibility on health issues because most people’s concerns center around health issues; found that people are very resistant to the idea of sheltering if they are not confident that their children are being well cared for in schools; and identified that there was no guidance on what people should do if they are in a vehicle during one of these events, findings that CDC put into practice (i.e., in guidance on what to do “if you are in a car, bus, or other vehicle during a radiation emergency”).

In addition to PEMDP, there have been two other major study initiatives fueling the development of new communication tools for use during nuclear detonation events. The first of these was a group of studies carried out at King’s College London in cooperation with the UK Health Protection Agency. These studies not only provided a British and European insight into population behavior and communication and information needs for this kind of event (Pearce et al., 2013), but because there were teams on the ground during the London polonium incident, they were also able to actually test messages and communications during the unfolding of an event (Rubin et al., 2007).

The second additional research initiative driving the development of new communication tools was the Study on Terrorism and Responses to Terrorism (START) and its groundbreaking work on WEAs. Becker lauded the work for providing a better sense of what WEAs can do, what they cannot do, and future directions that need to be explored. He noted that the panel would be discussing WEAs later (a summary of Bean’s description and discussion of WEAs is provided later in this chapter).

Together, these sets of studies have fueled critical innovations and new tool development in nuclear detonation communication. These new tools range from CDC’s guidance on what to do if in a car, bus, or other vehicle during a radiation emergency to Ventura County’s unique communication initiative (which is described in detail later in this chapter) to the recently released A Decision Maker’s Guide: Medical Planning and Response for a Nuclear Detonation (HHS/ASPR, 2017). Other recently released federal documents that have been informed by research and message testing, making them stronger than past documents, include the Federal Emergency Management Agency’s (FEMA’s) Improvised Nuclear Device Response and Recovery: Communicating in the Immediate Aftermath (FEMA, 2013) and EPA’s Protective Action Questions & Answers for Radiological and Nuclear Emergencies (EPA, 2017b). Becker noted that Wieder would be discussing these and additional tools in greater detail later in the session (a summary of information presented by Wieder is provided later in this chapter).

So again, the “good news,” Becker said, is that there has been a tremendous amount of research and that this research has plugged directly into agency efforts and has resulted in a variety of very powerful, very effective communication tools. The “not so good news,” he continued, is that there are some major continuing gaps that need attention.

Continuing Gaps

First among the gaps is the need for additional large-scale, peer-reviewed research on nuclear incident communication. Becker argued this need to ensure that the field’s understanding of people’s concerns and

information needs remains current and not dependent on data gathered a decade ago. Second, research is needed to test the effectiveness of already developed tools and to ensure that the testing is rigorous. Becker noted that Fischhoff would be discussing this later in the session (a summary of information presented by Fischhoff is provided later in this chapter). Third, research is needed to fuel the next stage of development of nuclear incident communication tools.

“We have great tools,” Becker continued, but in his opinion, those tools have not been practiced enough. Thus, a second major gap, as identified by Becker, is a need for more attention on communication and information challenges in drills and exercises. There is usually more emphasis on practicing such skills as using a meter, measuring contamination, plume modeling, and so on—all of which are important, he acknowledged, but without extensive practice, the communication capabilities and skills that would be essential in a nuclear incident will not develop and will not be ready. In his opinion, it is not hard to incorporate content into drills. As an example, he cited a Community Reception Center (CRC) Drill Toolkit that was released by CDC and that included a set of drill actor cards, with each card pertaining to a different and what Becker described as “pretty taxing” communication-related challenge that either had to be addressed by the CRC staff or that was related to the CRC staff themselves (e.g., CRC staff being concerned that they will contaminate their families). These kinds of cards can effectively introduce communication issues and challenges into a larger drill and are the type of effort needed in every drill related to a nuclear incident, Becker urged.

A third gap is what Becker described as the desperate need for a communication strategy and messaging tools for areas receiving nuclear incident evacuees. Becker pointed to the Fukushima Daiichi experience to illustrate the importance of such a strategy and such tools. While there were many examples of helping and prosocial behavior in communities receiving evacuees and many impressive examples of courageous, kind behavior, there were also many documented problems. Some hotels refused to accept people from Fukushima. There were common suggestions that women from Fukushima were tainted, should not marry, and should not have children. Children from Fukushima were bullied, which was a problem after Chernobyl as well. They were bullied at school, nicknamed (“radiation”), ostracized, and isolated. Some health care facilities refused to provide treatment to people unless they showed certificates indicating that they had not been exposed to radiation. More generally, Becker said, there was immense stigmatizing of people, products, and geographic areas that were thought to be somehow associated with the accident. He suspected the same would be true of a nuclear detonation incident. Although there is content in some of the messaging documents that could be adapted for use in receiving

communities, there is no targeted strategy or single set of tools driven by research and experience that could be used to address the concerns and information needs of people in receiving communities. This is a crucial gap and one that needs to be addressed, Becker urged.

A fourth gap is communication with children. “Do adults have a tough time understanding what is going on in a radiation emergency? Understanding the terminology, understanding what it means, understanding test results, understanding screening?” Becker asked. “Absolutely,” he answered. Imagine what kids will experience in the context of a nuclear incident scenario. He described the large number of orphans, children who will never see their parents again, and the thousands of children who will be at least temporarily separated from their parents—perhaps for a long time, depending on where the device is detonated. All of these children will have concerns and information needs (Gurwitch et al., 2004). To prevent the situation from amplifying beyond what will already be a traumatizing one, it will be essential to have specialized, age-appropriate materials that can be used to answer kids’ questions and to explain key aspects of the situation and the screening process and results. Becker stressed that this is not something that can be done after an event. It needs to be done pre-event and be in place and ready to use.

Finally, Becker identified as a fifth gap the need to address the concerns and information needs of responders. Not only would responders be the front line in any effort to manage a nuclear incident, but they are also public trusts whom people look to for information. Thus, if their concerns and needs for information are not met, it will have an impact not only on the responders but also, secondarily, on the public as well.

Research shows that responders of all sorts, including police, fire, emergency medical services, health care professionals, and public health, have an extremely high level of dedication to duty (Becker, 2004, 2009, 2010; Becker and Middleton, 2008). At the same time, this same very large body of research has also shown that responders of all types have a lower comfort level with radiation compared to other threats. Becker said that survey studies carried out not just in the United States but around the world have found that responders express a lower willingness to be involved in dealing with radiation events compared to most and sometimes all other types of incidents. As just one example of these many studies, Becker mentioned Veenema and colleagues’ 2008 study on hospital-based nurses’ willingness to respond to a radiation emergency, where a majority of nurses indicated that they were willing to respond at least some of the time, but more than 15 percent said that they were unwilling to work in any of the more serious radiation event scenarios (Veenema et al., 2008).

That all of these surveys show a lower willingness to respond despite responders being very dedicated to their duties has led to a lot of debate

as to how many responders actually would respond to a nuclear incident. Will their dedication to duty overcome their fears, worries, and concerns? Or will their dedication be tested by the situation? In the context of that debate, Becker finds it useful to refer to what happened in Japan in the aftermath of the Fukushima Daiichi accident. Multiple surveys showed that large numbers of physicians and nurses left the area. The Japan Nursing Association reported a 40 percent drop in the number of hospital nurses in the area between March 2011 and September 2012. The Japan Nursing Association also reported that there were 768 open positions in August 2012 but only 174 applicants. “These are hard data,” Becker emphasized.

Furthermore, the loss of large numbers of health care professionals from an affected area is not something that quickly fixes itself. The Fukushima Diaichi accident occurred in 2011. In 2015, there were continuing reports of major staff shortages. Becker shared one quote from a March 29, 2016, Japan Times article: “The nursing home Kawauichi in the Fukushima village of Kawauchi, which newly opened in November 2015, is struggling to find workers, while the needs are high for nursing care as many residents returning to the village are elderly. . . . Some people living outside the prefecture have declined to work here due to concern about radiation, said Mitsuhiro Hayashi, head of the facility.”

Even 7 years post-disaster, while the number of medical doctors in Fukushima had finally reached and even exceeded pre-disaster levels, registered nurses, public health nurses, care workers, and clinical psychologists had still not returned in significant enough numbers to be able to fill available positions (Ohto et al., 2017).

For Becker, together these findings make it absolutely essential to have a messaging and communicating strategy to proactively address the concerns and information needs of responders. He stressed that this is not something that can be done “top-down.” It needs to be a collaborative effort that directly engages responder groups and that uses a peer-to-peer approach. According to Becker, a peer-to-peer approach is usually the most effective when working with responders. In addition, he stressed the need to be cognizant of the fact that a big driver of health care professionals’ leaving Fukushima was family concerns, including concerns about the well-being of children and the family unit as a whole. Thus, any effort related to messaging and communicating with responders needs to keep that in mind.

Becker added that it is important to remember that health care involves more than clinicians and public health. Hospitals cannot run without a staff. When contemplating the development of a messaging and communications strategy to meet the information needs of responders, it is crucial that all components of hospital staff be included. He mentioned the need for additional work to meet the information needs of other key personnel outside of the hospital—for example, utility workers and drivers.

In conclusion, Becker reiterated that effective communication has the potential to significantly reduce the public health impacts of a nuclear incident. However, while considerable progress has been made in research and the development of new nuclear incident communication tools, important gaps remain. For preparedness to improve, it is essential that these gaps be addressed urgently.

WIRELESS EMERGENCY ALERTS

“How many of you believe you have received a wireless emergency alert on your mobile device?” Bean asked the workshop audience. Almost everyone raised his or her hand. Bean said that when START work began on WEAs back in 2012, if he were to have asked this same question, almost no one would have raised his or her hand. Since 2012, WEAs have been used to alert people to flash floods, tornadoes, and other critical situations. Bean described in detail START’s work on WEAs and the current advantages and limitations of WEAs.

Background and Research on WEA Messaging

Bean described WEAs as 90-character first-alert messages. The Federal Communications Commission (FCC) recently approved their expansion to 360 characters. The wireless industry has until May 1, 2019, to implement this capability. They are accompanied by a distinctive audible tone and vibration. The messages are geotargeted by the alert originator, which is usually a local, regional, state, or federal agency, but distributed by the commercial wireless sector, thus functioning as a public–private partnership. Bean noted that there have been some issues with overalerting certain geographic areas in the past, but effective November 30, 2019, FCC is requiring that all WEAs be sent with not more than 0.1 miles overshoot. The message contents and order of information are generally set, with a description of the hazard first, followed by location, time, protective action, and source. In a mock example that Bean showed, the alert read, “Radiological hazard warning in this area until 12:00 AM PDT. Take shelter now. USDHS.” Because they are sent via cellular broadcast technology (“SMS-CB”), which is a little different than a typical short message service (SMS) text message, they cannot be backlogged during times of network congestion.

START began studying WEAs just as the WEA system was being rolled out across the United States. Other members of the START team, in addition to Bean, include Brooke Lu and Stephanie Madden, both of the University of Maryland; Dennis Mileti, University of Colorado Boulder; Jeannette Sutton, University of Kentucky; and Michele Wood, California State University, Fullerton. Dean led START’s qualitative research efforts.

The START team’s Mobile Devices Project (MDP) was divided into four phases. The first phase included historical research and an experts workshop to develop the mock WEA messages to be used. Phase 2 was all of the experiments, interviews, and focus groups that were used to test the messages. In phase 3, a community survey was conducted in the aftermath of the 2013 flooding in Boulder, Colorado, where WEA messages had been sent to the public alerting it of the flooding. Phase 4 involved the testing of longer, 280-character WEAs (Bean noted that this was before the FCC had decided on a 360-character limit). Together, these phases were intended to address the following question: What is the optimized content and form for public alert/warning messages about imminent threats distributed over new and emerging technologies?

Findings from the START work have been published in multiple outlets. Bean mentioned just two, the first being a paper in the Journal of Contingencies and Crisis Management, where Bean et al. (2016) described a study where they tested 90-character and 140-character WEA messages and tweets alerting people to an unfamiliar hazard, specifically a nuclear device detonation scenario. Participants were sent a message similar to the following: “Denver PD Take shelter now Radiological Hazard Warning in this area until 12:00AM MDT.” They tested variations of the message, some with maps, some without. Not surprisingly, Bean said, participants differed in their interpretation of the messages, but almost all variations were deemed confusing, difficult to believe, and impersonal. Moreover, participants also consistently found the messages to be fear inducing and uninformative.

The second paper that Bean mentioned was a study on milling that was published in Environment & Behavior (Wood et al., 2018), where the researchers integrated qualitative and quantitative research findings and also focused on longer, 1,380-character messages, which is the maximum number of characters in a Common Alert Protocol–compliant message. A key finding was that, relative to shorter messages, longer public warning messages reduce people’s inclinations to search for and confirm information, thereby reducing warning response delay. Bean interpreted these results to mean that shorter messages can cause confusion and fear, while longer messages can potentially help people and reduce the time it takes for them to respond to the message.

What WEAs Currently Can and Cannot Do

While there have been many decades of research on how to effectively alert and warn people via mass media channels such as television and radio, mobile devices create new opportunities and new questions. Of course, Bean clarified, many of the earlier research findings on how people under-

stand and respond to messages still apply, but mobile technology offers new affordances and new constraints that researchers are just beginning to understand.

Before launching into his discussion of what WEAs currently can and cannot do, Bean emphasized his use of the word currently given how quickly wireless technology changes. In addition, he noted that his discussion would rely heavily on a 2018 National Academies report, Emergency Alert and Warning Systems: Current Knowledge and Future Directions (NASEM, 2018a), which covered START’s MDP project as well as a number of other U.S. Department of Homeland Security (DHS)-funded WEA system research projects. In Bean’s opinion, the National Academies (2018a) report is the most comprehensive and up-to-date summary of WEA-related research available.

Current Capabilities of WEAs

Emerging research indicates that, first, WEA messages can currently provide enabled device users with a geotargeted alert and warning message when facing an imminent threat, thereby reaching people at new times and in new places—for example, while they are sleeping, driving, hiking, or traveling. A representative quotation from the National Academies (2018a) report was that a “cell phone was found to provide 99.4% spatial coverage, although the coverage is influenced by spatial variability of signal strength.”

Second, WEA messages can include vibration, sound, and light to help reach people with disabilities, although researchers indicate that some changes or adjustments are needed (NASEM, 2018a). Third, WEAs can also include a hyperlink for additional information, but only since 2016. Hyperlinks in WEAs were prohibited by FCC from 2012 through 2016. The current use of hyperlinks in WEAs is unclear. Bean said that he himself had yet to see an actual WEA that includes a hyperlink. Quoting from the National Academies (2018a) report, “Findings from our community event survey indicated that those who received a message with a hyperlink had a shorter delay (i.e., less milling) before beginning to check media” (Liu et al., 2018).

Perhaps the most significant finding, in Bean’s opinion, which he considered both a benefit and a challenge of WEA messages, is their role in sparking what is known as milling behavior. Milling is the seeking of additional, confirming information from others regarding alert and warning messages. Quoting from the National Academies (2018a) report, “WEA SMS text messages do have a significant impact on physiological arousal, emotional response, cognitive processing, and behavior” (Glik et al., 2018), and “overall, the WEAs tested proved to be highly effective across all disaster types and when compared to other social messages, the WEAs were

among the most shared by the test subjects” (Corley, 2018). Also quoting from the National Academies (2018a) report, “For 280-character messages, the message elements of guidance (what to do and how to do it) and time until impact (how much time people have to take the recommended action) play major roles” (Liu et al., 2018). The issue with milling, Bean explained, is that in a rapid-onset emergency, milling behavior can interfere with taking action quickly.

What WEAs Cannot Do (Currently)

Regarding what WEAs cannot do currently, first, they cannot include information to reliably overcome people’s preconceived notions of hazards, nor can they reduce milling behavior. Bean explained that people bring to a hazard experience their preconceived notions and earlier experiences with the hazard, and these are very difficult to overcome no matter what people are told, especially if the message can only be 90 or 140 characters long. Quoting from the National Academies (2018a) report, “Subjects perceived the threat or urgency posed by a flash flood quite differently than other disasters on a physiological level” (Corley, 2018). Also, “recent research has provided clear evidence that message length influences response; messages that can fit in the initial 90-character length of a WEA message and the 140 characters of Twitter foster milling behavior and delayed response” (NASEM, 2018a).

Second, WEA messages cannot currently guarantee uniform issuance, interpretation, and response. In one study, a group of emergency managers was unable to effectively craft a 90-character message in a mock scenario (Griss et al., 2018). Bean explained that it is very difficult to do so under tight time constraints during an emergency. The National Academies (2018a) report summarized: “At this point, it is unclear what information is best included in a 360-character WEA message and what information is best included in linked content.”

Third, WEA messages cannot currently include embedded multimedia content, such as a map or photo. All multimedia content has to be provided via hyperlinks. Quoting from the National Academies (2018a) report, “Some AOs [alert originators] perceived a WEA message as a ‘bell ringer’ technology while others believed that wireless alerts should directly embed or reference additional information” (Griss et al., 2018). According to Bean, FCC is considering how to embed multimedia content. Meanwhile, the hyperlink is the best that can be done.

Fourth, WEA messages cannot currently be provided multilingually, although a new FCC ruling has mandated that Spanish language capability must be implemented by May 1, 2019. Quoting from the National Academies (2018a) report, “Almost half of the respondents . . . expressed their wish to receive alert and warning messages in languages other than English.”

Finally, WEAs cannot currently be integrated with social media. They are separate systems. Bean remarked that both alert originators and members of the public would like to see better integration because of how widely social media tools are being used. Quoting from the National Academies (2018a) report, “the WEA service needs to interface with social media to be relevant” (Griss et al., 2018).

Lessons for the Future

Bean noted that the National Academies (2018a) report goes into depth in terms of what needs to be learned about WEAs. Thus, again, Bean drew from the report.

Crafting More Efficient Messages

The first set of lessons that need to be learned is how to craft more efficient messages. Again, what information is best included in a message, and what information is best included in linked content? Bean mentioned evidence from recent studies that people are often very reluctant to click on hyperlinks because of their fear of spam or other cybersecurity issues. Some people do not even recognize a link as a link. This is important in the context of a nuclear incident scenario, where there would be a lot of detailed, technical information to communicate.

In addition to knowing where to put the information—that is, in the message or in a link—another lesson to learn is how to express time until hazard impact. What is the best lead time to ensure that appropriate action is taken? Currently, WEA messages include the expiration time of the message, which Bean said is not very helpful for some members of the public. They want to know when they need to begin taking protective action or when to stop.

There is a need to better understand the dynamics of opt-in versus opt-out systems. Currently, the WEA systems are opt out, meaning that when a person buys a mobile device, the device is automatically opted into the system. But if emergency managers send a false message or if over-alerting becomes a problem, people will be turned off and may opt out. What drives opt-in and opt-out behaviors?

Finally, how can longer, 360-character WEA messages best be used? What are the optimal message lengths for different hazards and different delivery mechanisms?

Meeting the Needs of Subpopulations

Bean called for a better understanding of the needs of nonnative English speakers and how to communicate messages in multiple languages. In what

cases will templates and machine translation be “good enough”? Emergency managers also need to better understand how to reach people with differing abilities. How can messages be best presented to physically and cognitively challenged individuals? Finally, because there will be people who do not have access to mobile technology and will be missing the WEA messages (the “digital divide”), how can these new technologies be used while also ensuring that those with less access receive timely alerts?

Geotargeting

The geotargeting issues that need to be studied are more technical than these other issues. How can location be best communicated? How can messages be targeted effectively to a given hazard area? How can in-building information be used? Bean referred workshop participants to the National Academies (2018a) report for more details.

RISK COMMUNICATION IN NUCLEAR INCIDENT MANAGEMENT

In his evaluation of what he referred to as the “business case” for investing in risk communication research and building risk communication capacity, Fischhoff began by sharing some “good news.” That is, there has been more than a century of research on human behavior that has been applied to many different risks and communication about those risks.

The National Academies have been producing reports on risk communication for many years. Fischhoff mentioned one, Improving Risk Communication (NRC, 1989), that is nearly three decades old but that still, he said, “reads well.” In addition, Toward Environmental Justice: Research, Education, and Health Policy Needs (IOM, 1999) addresses the challenge of approaching communities that are typically not addressed respectfully and making certain that they are provided information that is dedicated to their needs. He also cited Characterizing and Communicating Uncertainty in the Assessment of Benefits and Risks of Pharmaceutical Products (IOM, 2014a), Potential Risks and Benefits of Gain-of-Function Research (NRC and IOM, 2015), and Building Communication Capacity to Counter Infectious Disease Threats (NASEM, 2017a). In the latter report, there is some discussion on the uncertainty in communications when allowed only 360 characters. In addition to these various National Academies reports, Frischhoff mentioned a June 2018 meeting, Governance of Dual Use Research in the Life Sciences: Advancing Global Consensus on Research Oversight, hosted by the Croation Academy of Sciences.

Fischhoff described the basic communication design process that underlies much of the work just presented by Bean and, before him, Becker.

It involves four steps: (1) analysis (“What decisions do people face?”); (2) descriptive research (“How do people currently make those decisions?”); (3) science-based intervention, which Fischhoff described as providing a “best guess” at what to do to help people make better decisions; and (4) evaluation (“Is it good enough?”). Then repeat this series of steps as necessary. This process has been applied to a range of topics, from radon to breast cancer to palliative care to vaccines. Each application has its own unique properties. For many of these risks, because there is so much psychology, the hardest part is analysis, such as figuring out what few things can be said in a 90- or 360-character message that are relevant to the diversity of decisions that different people face.

As an example of an analysis of one of these risks, Fischhoff mentioned a study that he did with his colleague Keith Florig on individuals’ decisions that affect radiation exposure after a nuclear explosion (e.g., how urgently to seek shelter, when to evacuate) (Florig and Fischhoff, 2007). The genesis of the study was a National Academies meeting in this same room, but 15 years ago, which involved a radiological dispersal device (RDD) scenario exercise. One of the striking findings of that exercise was how imbalanced investments were in different components of the response. For example, there were five different plume models but no crafted message.

Despite all of this research, the bad news, Fischhoff said, is that each individual is himself or herself an intuitive behavioral scientist. “You would not get through life . . . if you did not have some ability to analyze other people’s behavior,” Fischhoff said. When interacting with someone one on one, if an individual does not communicate well, he or she receives feedback. But when going broadband, there is no feedback, yet whatever message is being sent probably works better for some people than for others. And one of the strongest psychological results, Fischhoff said, is that people exaggerate how well they communicate—that is, how well they understand others and how well others understand them.

Another challenge is that many of the organizations charged with managing risk can be limited by their own understanding of specific hazard, and this can impact how effectively they can communicate that risk to others. In developing communications it is necessary for organizations to have, or obtain, both a technical understanding of a specific hazard, like those related to a nuclear incident, and a developed sense of how the public will absorb and react to specific messages.

A final piece of bad news, Fischhoff continued, is that many organizations have no procedures in place for adapting communications to behavioral evidence.

Solutions for Improving Risk Communication

Fischhoff described three solutions to help improve risk communication.

Make Research Accessible

First, he called for making research on risk communication more accessible given the difficulty of reading scientific articles in peer-reviewed journals. This is something that he thought the research community ought to be able to do. He recommended several books: (1) Thinking, Fast and Slow (Kahneman, 2011), which Fischhoff described as a good introduction to the research and how the research develops; (2) Theory and Practice in Policy Analysis (Morgan, 2017); and (3) Risk: A Very Short Introduction (Fischhoff and Kadvany, 2011). In addition to these books, he mentioned an article he wrote for Science, “The Realities of Risk-Cost-Benefit Analysis” (Fischhoff, 2015).

In addition to these publications, Fischhoff mentioned that the National Academies hosted a series of three colloquia on the science of science communication. The colloquia led to special issues of the Proceedings of the National Academy of Sciences (Fischhoff and Scheufele, 2013, 2014) as well as colloquium proceedings (NAS, 2014; NASEM, 2018b). In addition, there was a National Academies consensus study report on the science of science communication, Communicating Science Effectively: A Research Agenda (NASEM, 2017b).

Fischhoff also called attention to a book produced by the Food and Drug Administration’s (FDA’s) Risk Communication Advisory Committee, which he chaired. The book, Communicating Risks and Benefits: An Evidence-Based User’s Guide, contains more than 20 chapters on different topics (FDA, 2011). A criterion for being included was a claim on the part of the science that the science could not be made accessible, Fischhoff explained. Each chapter summarizes the relevant science, offers “best guesses” at the practical implications of the science, and shows how to evaluate communications based on that science.

Develop and Evaluate Prototypes

A second solution is to develop and evaluate prototypes for risk communication. Having a prototype for the communication process ensures that the audience, or representatives of the audience, knows that the problem is being addressed and that people are not going to be “blindsided” in some emergency situation. He suggested a template for communication that he described in Fischhoff (2015) that has a routine project development process (covering risk analysis, risk assessment, and risk management)

and two-way risk communication at each step along the way. “You cannot have what is sometimes called a ‘decide, announce, defend’ communication strategy,” he said.

Along with a prototype for the communication process, risk communication also needs content, something good enough that someone in a jurisdiction that does not have a research department can begin to adopt (see Table 5-1). He noted that the schematic shown in Chapter 2, Figure 2-5, serves as a terrific template for teaching the principles of sheltering. To further illustrate the usefulness of graphics, he showed an image of two human hands that is used to teach decontamination in an infectious disease situation. Different parts of the hands are shaded differently based on whether they are most frequently missed, frequently missed, or less frequently missed when one cleans one’s hands. “It tells you a story,” Fischhoff said—that is, that places on the hand that are likely to do the most damage are also those that are most frequently missed.

In addition to prototypes for process and content, prototypes are also needed for evaluation. Again he referred to FDA (2011), where each chapter contains a final section on how to evaluate communication with no money, little money, or money commensurate with the personal, organizational, or political stakes riding on effective communication. The simplest form of evaluation, which Fischhoff said there is no excuse not to do, is to ask a diverse group of people to think aloud as they read a communication. “You are always surprised by what it is that they take away,” he said. However,

while conducting an evaluation protects an organization from putting out something that does not say what the organization thinks it says, it does not protect from putting out a message that does not address people’s concerns.

Create Absorptive Capacity

A third way to improve risk communication is to create absorptive capacity—that is, the capacity to take in new information, incorporate it into products, and apply it appropriately to ongoing activities. This requires the right expertise, including subject-matter specialists who know the phenomenon, analysts who can extract the relevant information, behavioral scientists who can ensure the comprehensibility and credibility of the message, and practitioners who will make certain that the necessary interagency partnering, legal work, and other tasks are done to ensure execution. “If you miss any of these skills from your project, you are asking for trouble,” Fischhoff said. As resources for general models for how to create this shared space for people from different communities to come together when absorptive capacity does not exist, he suggested Intelligence Analysis for Tomorrow: Advances from the Behavioral and Social Sciences (NRC, 2011a), Intelligence Analysis: Behavioral and Social Scientific Foundations (NRC, 2011b) and Foundational Cybersecurity Research: Improving Science, Engineering, and Institutions (NASEM, 2017c).

Finally, Fischhoff mentioned FDA’s Strategic Plan for Risk Communication (FDA, 2009), which was developed during the Bush administration and revised during the Obama administration. He commended FDA’s dedicated staff for working on the plan over such a long period of time. He also commended the FDA’s Risk Communication Advisory Committee (RCAC) for providing so much good advice and for very little money. RCAC produces general guidelines on what to do during an emerging event—for example, if something goes wrong with a metal-on-metal hip joint—and when to put out messages. In addition, every quarter, FDA goes out and talks to mostly patients but also to patient representatives and technical specialists about a class of disease to gather information for use in setting the terms of a clinical trial or when deciding whether to approve a device. Fischhoff described it as a routine consultation, a way to find out what people want. It has earned FDA a lot of credit across diverse user communities. He suggested that the model could be adapted for use in this context as well.

A UNIQUE, VIDEO-BASED PUBLIC INFORMATION CAMPAIGN: VENTURA COUNTY, CALIFORNIA

“What I have learned as health officer over the years,” Levin began, “is that in a threatening situation, public health’s responsibility is to tell the

public what they can do to protect themselves and friends and loved ones.” He spoke about Ventura County’s nuclear explosion information campaign, which was launched in 2014. The public information campaign included a series of PSA videos produced by readyventuracounty.org. The videos were developed with FEMA and CDC funding. During his presentation, Levin showed four of these videos.¹

Ventura County Nuclear Planning

Ventura County Public Health began nuclear planning in the early 2000s. Levin wrote a 241-page nuclear explosion response plan, the Ventura County Sheriff’s Office wrote a law enforcement plan, and Levin and colleagues established a plume trackers group for the county. Levin explained that knowing the direction of the plume would be critical to both the county’s response and to public confidence but that if a detonation were to occur in Los Angeles County, Ventura County would not be able to count on their ability to track the plume.

Creating a Memorable Tagline: “Get Inside, Stay Inside, Stay Tuned”

Levin assumed initially that after these reports were written and groups were established, his work would be done. But he realized that if his concern was to minimize injury and death, the residents themselves would need to know what to do to protect themselves should a nuclear detonation occur. So in 2014, the county launched its public information campaign, with the goal being that every person in the county would know where to go and what to do if he or she were to see, hear, or learn of a possible nuclear detonation. And when would that goal be met? Levin asked. His answer: when people can recall a simple mantra. He met some classic great taglines: “Stop, drop, and roll,” “Only you can prevent forest fires,” and “If you drink, don’t drive.” Levin and colleagues wanted to define a tagline that was similarly memorable.

Ventura County Public Health worked with Wieder and the Nuclear Radiation Communications Working Group to come up with the tagline “Get inside, stay inside, stay tuned.” Its advantage, Levin noted, is that it is alliterative. Its disadvantage is that its relevance is perceived to change with historical trends. When people know “Get inside, stay inside, stay tuned” as well as they do “Stop, drop, and roll,” then, he said, “we will have taken a giant step towards local preparedness.”

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¹ Two of the videos can be viewed online, at https://www.youtube.com/watch?v=2jIs-Lwh6U0 (accessed December 10, 2018) and https://www.youtube.com/watch?v=jGPetxZ3iMM (accessed December 10, 2018).

Planning a Public Information Campaign: Challenges Faced

Levin described how local elected officials went along with everything that Ventura County Public Health did as it prepared the four PSA videos. Not only did they not object, but they provided crucially helpful suggestions. Although he was concerned that Los Angeles County would request that it also needed to have a public information campaign to launch at the same time, making the release of the Ventura County program dependent on Los Angeles County developing its own program, this did not happen. The biggest obstacle was locally appointed administrators, who obstructed the effort until a top appointed official in the county requested that they clear the way. Levin noted, however, that they still were not allowed to pursue a planned national component to the campaign, only the local campaign.

Components of the Campaign and Its Launch

When planning the campaign and its launch, Levin and colleagues were aware that the biggest issue they would have to contend with would be people asking, “What do you know that we don’t know?” With this in mind, prior to launch, a letter was sent to parents of all schoolchildren the Friday before launch. The campaign was launched with a press conference the following Monday, followed hours later by a series of town hall meetings throughout the county. Levin himself was in attendance to address any concerns. They also set up a phone bank, but they only received about 40 calls the first 2 days, so the phone bank was discontinued.

In addition to the PSA videos, the campaign included an 18-page information document for the general public;² a website containing the products they had created (plus extensive bibliographies with links for the general public, emergency responders, and health care professionals); a curriculum for teachers to use in schools; a disaster plan for schools; talking points for Parent Teacher Associations; potassium iodide guidance for physicians; a mailer that could be used to remind people of the campaign and its most important messages; just-in-time pocket guidance; and frequently asked questions for the general public.

Mistakes and Unanticipated Consequences

In reflecting on the campaign, Levin shared that one of his mistakes had been assuming that ongoing preparedness for a nuclear threat had

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² Available online at https://www.readyventuracounty.org/wp-content/uploads/2018/05/VC-Nuclear-Safety-18pp-Education-Guide-Downloadable-FINAL.pdf (accessed December 10, 2018).

been accomplished by Ventura County and that nothing else needed to be done—in other words, that the impulse to maintain nuclear explosion preparedness would be self-perpetuating. He had been confident that different components of the county’s emergency response team would exercise one aspect or another on a regular basis. But this had not happened. “Emergency responders are busy,” he said, “and they have higher probability disasters to prepare for in California, like earthquakes and wildfires.”

Upon reflection, another potential mistake was that he had been neglecting his full-time responsibilities as a health officer by putting so much time into this low-probability, high-consequence event, trying the patience of his county superiors. After launch of the public information campaign, he felt that he had been discouraged from putting more time into nuclear preparedness.

Despite some possible missteps, Levin shared that the most significant yet unintended outcome was that the reception by the community had been positive beyond expectations. Ventura County Public Health received feedback such as “What took you so long?” and “Finally, somebody is doing something about this.” As far as Levin was aware, no public officials “got any heat” after the launch.

Improving Local Preparedness: Moving Forward

Levin described several steps to continue to improve Ventura County preparedness for a nuclear explosion.

Promote “Get Inside, Stay Inside, Stay Tuned”

First is to advance the level of knowledge of “Get inside, stay inside, stay tuned” by requiring health-related PSAs among the trailers in movie theaters. Some of these PSAs should be general public health announcements, Levin clarified, but some should also be nuclear preparedness announcements. In addition, he suggested conducting an exercise or tabletop every year that is visible to the public—even if it involves road closures for brief periods—and let the media know.

Second, Levin suggested picking a date, such as the anniversary of the Hiroshima explosion, and every year advertising on that date the “Get inside, stay inside, stay tuned” message. It would be similar to what is done in California every year during the Great California Shakeout, a yearly event where people participate in earthquake preparedness drills. He acknowledged that only about 1 percent of people would participate; nonetheless the news media would pick up on it and remind people of “Get inside, stay inside, stay tuned.”

Third, Levin listed some actions that FEMA and the surgeon general could or should take: clarify that nuclear preparedness is a local responsibility and that the county health department, with local Office of Emergency Services assistance, is responsible and is the lead; have useful materials that local communities can use and modify; and attach financial rewards for local accomplishments and exercises.

Fourth, Levin called for carefully analyzing the impact of social media and how it can mislead the public in terms of the role it can play as an event progresses. How can this be shaped and controlled?

Fifth, Levin suggested preparing a public information campaign for launch but waiting until a threat or “saber rattle” creates public anxiety and makes public preparedness desirable. Ask permission then, he suggested. Still, wait a few months until the anxiety has subsided before the actual launch so that people do not worry that it is an imminent threat. Set a firm date.

Finally, in hindsight, Levin wishes that he had contacted the national press.

Changes Since Ventura County Launched Its Public Information Campaign

Ventura County’s nuclear explosion public information campaign was based on one, two, or three devices of 10–15 kilotons. The increased power of the nuclear devices that characterize the North Korea threat significantly increase the expected number of deaths and casualties. Levin emphasized that although this new threat impacts all aspects of the emergency response, the “Get inside, stay inside, stay tuned” message still applies and would still save lives.

In addition, social media has changed, with both unofficial and official sources of news and opinion potentially exacerbating the tendency toward panic. People might be encouraged to flee instead of seek or remain in shelter.

NUCLEAR INCIDENT PUBLIC COMMUNICATION: TOOLS AND TEACHABLE MOMENTS

Get Inside, Stay Inside, Stay Tuned: Teachable Moments

Building on Levin’s suggestion that communities have their communication campaigns prepared and ready to go, Wieder spoke about “teachable moments”—that is, moments that serve as opportunities—to communicate about what to do in the event of a nuclear threat.

She reflected on the great amount of time and effort on her part and on the part of many people in attendance at the workshop to ensure that the

“Get inside, stay inside, stay tuned” tagline was grounded in science and that it met the needs of the science community, the response community, the medical community, and communicators. In addition, she noted that, in her opinion, the message is an all-hazards message. Get inside and get information, and then act on that information, with some exceptions (e.g., a burning building).

It was because of all of this effort that had gone into developing the message that she could not sleep the night of January 13, 2018, the day of the false ballistic missile alert in Hawaii. “So many people would have died if that had been real because they did not know to get inside,” she said. So at 1 a.m. on January 14, in what she described as a “very rare social media posting,” she posted the following message on her public Facebook page:

In the post, she attached a CDC infographic on “Where to Go in a Radiation Emergency”³ and another on “Decontamination for Yourself and Others.”⁴ The post was shared 431 times, with 99 percent of the shares happening within the first 48 hours. Wieder clarified that she was not boasting about her social media status, rather using this post to illustrate that there are moments when people want information. She encouraged others to take similar advantage of these opportunities—these teachable moments. Doing so can potentially save lives. The “good news” is that the information that can be communicated during these teachable moments is available. “We already have it ready for you,” she said, “so that you have it in your pocket for when those teachable moments come up.”

The day after the false alert, viewership of EPA’s “Protecting Yourself from Radiation” website increased 166 percent from the previous week. By January 17, it had returned to the typical viewership level. So although an entire state had been worried that a ballistic missile was going to hit them, the increased interest had been sustained only for 3 days. “These teachable moments are fleeting,” Wieder said. “If we do not have the information ready to present to them, we have missed our opportunity.”

Wieder went on to describe some publicly available interagency tools that have been put together over the past 9 years to help do just that: take advantage of teachable moments.

Publicly Available Federal Tools

First among the several federal tools issued in recent years for nuclear preparedness planning is the Planning Guide for Response to a Nuclear Detonation (FEMA and DHS, 2010). Wieder noted that the 2010 second edition included an entire new chapter (see Chapter 6) on public preparedness and emergency public information.

By 2013, significant leaps had been made in public messaging, with 14 different agencies agreeing on 85 pre-scripted questions and answers for the first 72 hours after an improvised nuclear device (IND) (FEMA, 2013). Although the messages included in that guidance (Improvised Nuclear Device Response and Recovery: Communicating in the Immediate Aftermath) were not written for state actor events, “Get inside, stay inside, stay tuned” is nonetheless consistent.

More recently, in Protective Action Questions & Answers for Radiological and Nuclear Emergencies, EPA (2017b) adapted Becker’s work on

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³ See https://emergency.cdc.gov/radiation/pdf/infographic_where_to_go.pdf (accessed April 10, 2019).

⁴ See https://emergency.cdc.gov/radiation/pdf/infographic_decontamination.pdf (accessed April 10, 2019).

RDDs, with questions and answers consistent with the FEMA (2013) document but written generically for any type of radiological incident. Because EPA (2017b) did not need the 14 agency seals, it did not need to go through an interagency review. Thus, Wieder said, it was able to use plainer language. The EPA document also includes new messaging on potassium iodide, including what it is, what it is not, and why table salt should not be used as a replacement. It also addressed specialized populations, including pregnant women, people with disabilities, and especially children. As an example of a question pertaining to children, one is “Can I give my kid a bath?” The answer is yes. But try to keep children from drinking the water.

Also, in 2017, EPA published Protective Action Area Map Templates (EPA, 2017a) for states and local jurisdictions to use. The templates are available in both PowerPoint and Word and are easily adaptable, using a multiple choice format.

In addition to these guidance documents, between 2014 and 2018, CDC came up with a number of infographics, two of which Wieder attached to the previously described Facebook post. Those and many others are publicly available on the CDC infographic resource library website.⁵ They are available in 12 different languages. One of the CDC infographics is an animated infographic on where to go in a radiation emergency.⁶ Also, in 2018, FEMA posted a video that echoed the CDC video about where to go in the case of nuclear emergency. That multiple agencies are sending the same message makes the message more powerful, Wieder said.

Social Media Messaging

“Social media is not just for cat pictures anymore,” Wieder continued. “Social media is a place where people are getting their news.” She cited a survey conducted by the Pew Research Center on the growth of social media news acquisition. Whether it is Facebook, Twitter, YouTube, Instagram, or another platform, all social media platforms enable some amount of news acquisition. During the false alert in Hawaii, people looked to social media for information. But there were no messages for a nuclear detonation scenario ready to go, at least not for social media, Wieder said. She emphasized that this has changed, however, with the leadership of Lauren Matakas. Since that false alarm, interagency work has led to agreement on a set of social media messages pertaining to nuclear attack warnings or events and immediate safety. In addition to “Get inside, stay inside, stay tuned,” the messages also cover food and water safety, first aid, and

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⁵ See https://emergency.cdc.gov/radiation/resourcelibrary/infographics.asp (accessed December 10, 2018).

⁶ See https://emergency.cdc.gov/radiation/protectiveactions.asp (accessed December 10, 2018).

helping neighbors. Wieder noted that they include the 90-character WEA message format and expressed excitement that the message length is being increased to 360 characters.

One-Stop Shop for Guidance Documents

All of the documents that Wieder mentioned can be found via FEMA’s Emergency Support Function #15 (ESF#15) website.⁷ More specifically, ESF#15 has an annex specific to radiological incidents (Annex N), which unlike other annexes includes a whole series of public information tools that was added in 2016. Moreover, in 2018, the annex was updated with the social media messages for a nuclear detonation scenario that were developed after the Hawaii false alarm.

Ongoing Efforts

“We have done a lot in the last 8 years,” Wieder said. Although much has been learned from the Cold War civil defense era, the way people communicate now and the public mentality are very different than then. For example, after Fukushima, people were looking on EPA’s nationwide environmental radiation monitoring system, RadNet,⁸ for information on radiation levels across the United States. In the event of a nuclear detonation, they would do the same. Under the leadership of Angela Shogren, EPA is working to ensure that those data are presented in a way that the public will understand, knowing that radiation data and units mean very little to most people.

In addition to these radiation data visualization efforts, under the leadership of Stephanie Bacon, EPA is working with FDA and FEMA on an infographic on food, water, and medicine. This was a need that was identified during the Gotham Shield exercise, during which a protocol for an infographic was drawn up. EPA is finalizing it and considering ways to test it so that it is ready to use.

Wieder noted that Matakas, who worked on the social media messaging included in the ESF#15 annex, is also working with the interagency Nuclear/Radiological Communication Working Group to add a full social media annex to the interagency guidance on communicating in the intermediate aftermath of an IND (FEMA, 2013). The group is updating FEMA (2013) to ensure that it is based on the best possible science and that it is

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⁷ See https://www.fema.gov/media-library/assets/documents/34369 (accessed December 10, 2018).

⁸ See https://www.epa.gov/radnet (accessed January 18, 2019).

representative of not just an IND scenario but also other, larger situations and possible air bursts.

Finally, based on another lesson learned during Gotham Shield, the interagency group is working on content for a flyer drop. Specifically, it is trying to figure out what information could be put on a piece of paper the size of a dollar bill (i.e., the size required if the U.S. Department of Defense were to conduct a flyer drop) that would be effective with people. About 3 months prior to the workshop, EPA partnered with CDC to do some public message testing around a flyer drop. What Wieder found interesting was that with the drops occurring at 8 or 12 hours after an event, they were expecting people to ask why it took so long to get the information out, but instead people were thankful that they had not been forgotten. “Please, if this were to happen, send something like this” was the type of feedback they received.

In closing, Wieder encouraged anyone interested to join the Nuclear/Radiological Communication Working Group, coordinated by Bacon. The group communicates via e-mail and through two to four conference calls per year. It identifies best practices and gaps and works together to try to fill those gaps. She also encouraged workshop participants to identify teachable moments. For example, educate your Lyft driver when he or she asks you what you did today. “That is one way we can save lives,” she said.

DISCUSSION WITH THE AUDIENCE

Following Wieder’s presentation, she, Becker, Bean, Fischhoff, and Levin participated in an open question-and-answer period with the audience, summarized here.

“Get Inside, Stay Inside, Stay Tuned”—But What Exactly Does Inside Mean?

There was some discussion about what exactly inside means. An unidentified member of the audience described two scenarios. First, she recalled 9/11, when she had been about to drive to school to pick up her child but realized that her child would probably be safer inside the school cafeteria than outside or in the car, so she had gone back home. Then, after she had gotten home, she wondered if she should go down to the basement but worried that the house might crumble on her. Second, she recalled having heard recently that during emergency situations where a lot of people are going to hospitals, the hospitals themselves are unsafe. She relayed a suggestion that hospitals be built in caves to avoid crumbling during a disaster. Together, these scenarios made her wonder, what is the definition of inside?

Wieder referred to Buddemeier’s graphic (see Figure 2-5). She suggested that the best place to go for a hurricane or a tornado is also probably the

best place to go in a nuclear detonation scenario. If there is any pre-event warning, the concern is not only radiation but also flying debris and broken glass. “The basement, if you have one, is probably the best place to be,” she said. In terms of hospitals, Wieder reminded the workshop that there will be an area beyond the blast zone.

Hopefulness and Optimism

Beyond the blast zone, Wieder continued, will be many lives that can be saved. She recognized the difficulty in expressing hopefulness and optimism given that so many people are going to die in what will be an absolutely horrific situation. “You cannot deny that fact and the tragedy that will be,” she said. “The advice that we are giving at this point about where to go and how to get help and the discussions we are having about how to triage and how to get people to hospitals . . . it is all to save as many lives as we can under the infrastructure that we have.”

Miscommunication, False Messaging, and Opting Out of Alerts

Matt Wynia, University of Colorado, expressed concern about how things intended in one way may be interpreted in other ways by other audiences. In the past, one of the arguments for avoiding talking about preparedness for a nuclear weapon event is that doing so could be interpreted by adversaries as an offensive endeavor. He imagined someone in North Korea, for example, interpreting U.S. discussion about nuclear weapon preparedness as something that the United States is doing to prepare for a launch of its own. Although in his opinion this is certainly not an argument for not being prepared, he expressed uncertainty about how to address it. How can preparedness activities, which are viewed as defensive, not be interpreted as offensive acts by others around the world?

Acknowledging that this was outside of his area of expertise, Levin compared the situation to the U.S. military exercises conducted just off the coast of North Korea. “It would irritate the heck out of them,” he said, “but they would not necessarily see it as a specific and direct act of war.”

Also on the topic of miscommunication, and based on his experience with miscommunication with respect to infectious disease emergencies such as Ebola and pandemic flu, Andy Pavia, Infectious Disease Society of America, asked the panelists what they have learned about how to ensure that their messages are communicated clearly, understandably, and with minimal hyperbole when they have to be sent through other messengers. He commented on how beautifully crafted and well-researched messages so often get filtered through news media and social media and are often lost in translation or amplified. He imagined a medical correspondent breathlessly

standing in front of the television camera sweating about Ebola coming and attacking him.

A finding from his work, Bean replied, is that messages distributed from multiple authoritative sources are generally more effective. He described a focus group study where some people trusted the police department, while others absolutely did not. So any message coming only from that department would alienate a certain portion of the message receivers. But when the message is issued from DHS, the county office of emergency services, or other relevant departments or offices, more people are more willing to listen. Wieder agreed with Bean.

Related to miscommunication, there was also some discussion around false messaging. Cullen Case, Radiation Injury Treatment Network, asked whether there were any data on people opting out of WEAs after the false message was sent in Hawaii or under any other circumstances. Bean was unaware of any hard data, only anecdotal reports that people turn off their alerts after these kinds of incidents. Becker added that false messaging was an area requiring additional research, not only with respect WEAs but more generally. For example, following the Fukushima Daiichi accident, a number of false communications were issued by third parties that were disguised to look like authentic communications. He recalled in particular a message that provided wrong protective action information but was disguised to look like a communication from the Japan Medical Association. In addition to looking at what happens when false messages are issued, he called for more research into how to ensure authentic messaging and how to rapidly correct a situation when a false message is issued.

Developing New Communication Strategies

Erik Caull, Applied Research Associates, mentioned a project at Stevens Institute of Technology called Reinventing Civil Defense that focuses on nuclear risk communication, specifically how to reach millennials and other people who are “glued” to their cell phones. He noted that the proceedings for a discussion back in June 2018 would be posted soon on the institute’s website⁹ and that the institute would be posting several novel communications projects as well.

A Role for Poison Centers

Ziad Kazzi, American College of Medical Toxicology and Georgia Poison Center, explained the role of poison centers in guiding public health communication messaging during the Fukushima response. There were

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⁹ See https://reinventingcivildefense.org (accessed January 18, 2019).

about 400 calls to the poison centers in that 1-month period (March 2011). Most of the calls were information requests (e.g., on radiation exposure but also potassium iodide or other iodinated products), but there were also some exposure calls. According to Kazzi, these calls helped CDC to craft messages. He encouraged states to look to poison centers and other sources of information to help guide their messaging in emergency situations.

Another Teachable Moment?

Touching on Wieder’s discussion of teachable moments, Caull described how in the 58 minutes following the issuance of the Hawaii alert, Pornhub activity on IP addresses in Hawaii decreased by 66 percent, on average, with a low of 75 percent less traffic than usual. For Caull, the decrease is instructive in that people’s attention actually is diverted. They are looking for information.

The Importance of Emergency Preparedness Exercises

McDonough commented on the fact that even though it is 2018, social media messaging is not required in any of the exercises undertaken by the Maryland Emergency Management Agency. “If we are not required to do it, nobody is going to spend money for us to do it,” he said. “We need to be forced to do that.”

Becker concurred and emphasized the need to practice all aspects of the communication component of nuclear preparedness. He added that there is also a need to practice when things go wrong on how to recover. Without practice, he said, “we are really not going to be adequately prepared.”

Prioritizing Nuclear Safety Messaging

David Snyder, local elected official and chair of the National Capital Region Emergency Preparedness Council, commented on the competition for time with first responders, with public information officers, and with emergency managers. He asked the panelists how they have attracted the attention of these various groups to prioritize nuclear safety messaging and then, once it is a priority, how they weave nuclear safety messaging in with all the other messages out there.

“When the time is right, that is when you present the idea,” Levin said. He described how he was able to get the attention of the decision makers in Ventura County. After 9/11 and concerns about further terrorist acts, Levin approached the sheriff who was leading the county’s terrorism preparedness group with the idea that something should be done about nuclear threats. Levin was enthusiastically provided resources to immediately begin

preparedness efforts. It was not until about a year and a half later that he learned that the sheriff had received some classified information about a potential terrorist attack, and that was why he had been so enthusiastic. So, serendipitously, Levin had presented his idea at the right time.

Wieder described a different situation. At a 2010 national-level IND exercise, the White House Office of Science and Technology Policy and National Security Council together realized that they had no idea what they would tell the public in the event of an IND. They pulled a group of scientists, policy makers, and communicators together to figure it out. Initially, there was a lot of momentum given that the request had come from the White House. The challenge is maintaining that momentum. Relationship building and trust building are key. With those in place, then, Wieder said, “when opportunities present themselves to get the message across, you are the first person that they call.” She said that the same communications group that was formed back then, in 2010, is still being maintained for no other reasons than because Wieder wants to continue having those working group conference calls and other people continue to participate. “Think coalition of the willing,” she said. “These are people who want to do something. There is no mandate to do it. There is no funding to do it. But we recognize the need for it.”

Also, as a way to compete with various groups’ attention, Wieder suggested using “Get inside, stay inside, stay tuned” as an all-hazards message not specific to nuclear detonation. It could save a lot of lives in a number of different types of situations. She said, “Just getting people off of the streets for almost any emergency is good for getting responders to an event and helping people who need it.”

Becker added that with respect to getting the attention of responders in particular, at no point has he experienced a shortage of responders to participate in any of the meetings, focus groups, workshops, hospital discussions, law enforcement facility discussions, or other preparedness gatherings that he has held. The key to getting their attention is not framing preparedness as “I have information I want to give you.” Rather, tell them that there is a threat that could possibly affect them and their organization. Then ask them what resources they think they need. What information do they need? He and his team approach responders with the intention of helping them to do their jobs effectively in a way that is safe for them, protects their families, and allows them to discharge their duties and responsibilities.

Communicating with Responders

Blakely emphasized the importance of addressing not just the public but also responders in the event of nuclear emergency. He was reminded of being invited by the International Atomic Energy Agency to participate in

a biodosimetry symposium in Hiroshima, where he had the opportunity to hear from an emergency medicine physician in Japan who had been asked by the government during the Fukushima incident to evacuate an older adult home of several hundred people. But after having transferred the elderly residents onto a bus and then transported them to another facility farther from the radiation contaminated area, the new facility had refused to accept them. They had been afraid that the residents would bring contamination with them and that they would lose funds. A number of the residents died during this time, with their deaths attributed to the disruption caused by moving them back and forth. Blakely called for better education and training for responders.

Becker agreed that first responders, hospital and health care personnel, and public health nurses and physicians are all professionals with a strong dedication to duty. At the same time, they are also people. “We need to remember that they have concerns and information needs,” he said, underscoring that addressing those concerns and information needs is critical. He added that another lesson learned from Fukushima Daiichi was that even professionals with some past training wanted just-in-time refresher training that was not generic but informed by the specifics of the event. There was a radiation emergency assistance team on the ground in Japan that put together such a training. Over the course of its mission, it ended up training about 1,100 personnel. Becker described the demand as “enormous.”