d2.7 the new global health security regime

7/30/2019 D2.7 the New Global Health Security Regime

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D2.7Reportonthenewglobalhealthsecurityregime

TELLMEprojectGA:278723

D2.7TheNewGlobalHealthSecurityRegime

TELLME Transparent communication in Epidemics: Learning Lessons from

experience,deliveringeffectiveMessages,providingEvidence.

Project cofunded by the European Commission within the 7th

Framework

ProgrammeHEALTHtheme

1stReportingperiod

WP2Newchallengesandnewmethodsforoutbreak

communication

ResponsiblePartner:HU

Contributingpartners: CSSC,CEDAR3

Duedateofthedeliverable:M11(December31st2013)

Actualdateofsubmission:M14(March6th

2013)

Disseminationlevel:PU


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Allrightsreserved2012TELLMEProject

http://www.tellmeproject.eu

PROJECTFULLTITLE Transparent communication in Epidemics: Learning Lessons from

experience,deliveringeffectiveMessages,providingEvidence.

PROJECTACRONYM TELLME

Collaborative Project funded under Theme HEALTH.2011.2.3.33

Development of an evidencebased behavioural and communication

packagetorespondtomajorepidemicsoutbreaks

GRANTAGREEMENT 278723

STARTINGDATE 01/02/2012

DURATION 36months

D2.7TheNewGlobalHealthSecurityRegime

Task: 2.7

Leader:HUOthercontributors:BMJ,CSSC


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TableofContentsEXECUTIVESUMMARY....................................................................................................................................... 5

1.INTRODUCTION

............................................................................................................................................

7

2. THEINTERNATIONALHEALTHREGULATIONS.............................................................................................. 7

2.1. BackgroundtotheIHR................................................................................................................... 7

2.2. TheRevisedIHRandCoreCapacities............................................................................................ 9

2.2.1. Nationallegislation..................................................................................................................... 9

2.2.2. Policyandfinancing.................................................................................................................. 10

2.2.3. CoordinationandNFPcommunications................................................................................... 10

2.2.4. Surveillance............................................................................................................................... 10

2.2.5. Response................................................................................................................................... 11

2.2.6. Preparedness............................................................................................................................ 11

2.2.7. Riskcommunication................................................................................................................. 12

2.2.8. Humanresources...................................................................................................................... 12

2.2.9. Laboratorycapabilities............................................................................................................. 13

2.3. TheIHRandtheH1N1pandemicof2009................................................................................... 13

2.4. ChallengesofglobalsurveillanceandtheH1N1pandemic........................................................ 16

2.5. PotentialviolationsoftheIHR(2005)andtheH1N1pandemic................................................. 16

2.6. RequirementsoftheIHRandthesovereigntyofthestate........................................................ 17

2.7. Conclusions.................................................................................................................................. 17

3. COMMUNICATIONANDINFECTIOUSDISEASECRISES............................................................................... 18

3.1.

Introduction.................................................................................................................................

18

3.2. Methods...................................................................................................................................... 18

3.3. Findings........................................................................................................................................ 19

3.3.1. Communicationandcoordinationbetweenorganizationsandgovernments.........................19

3.3.2. RiskCommunication................................................................................................................. 20

3.3.2.1. Maintainingtrustamonggovernmentsandstakeholders...............................................................20


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3.3.3. Empowermentofthepublic..................................................................................................... 22

3.3.4. Facingsituationsofuncertaintyandgivinganswerstothe"unknowns"................................23

3.3.5.Communicating

the

vaccine

as

the

only

option

or

providing

information

on

other

alternatives?........................................................................................................................................ 24

3.4. SocialMarketing.......................................................................................................................... 24

3.4.1. Stakeholderinclusion............................................................................................................... 25

3.4.2. Identificationofsubpopulationsandriskgroups..................................................................... 26

3.4.3. Segmentation:choosingthechannelsandtailoringthemessages......................................... 27

3.5. Communicationflow................................................................................................................... 28

3.5.1.Intimidation

as

aresult

of

the

media

coverage,

but

not

astrategy

.........................................

28

3.5.2. Focusingontheonewayflowofcommunication................................................................... 29

3.5.3. Varietyofchannels:Oldparadigms.......................................................................................... 30

3.5.4.Mainsourcesofinformationinthemedia............................................................................... 30

4. DISCUSSION................................................................................................................................................ 36

5. CONCLUSIONS............................................................................................................................................ 37

REFERENCES.................................................................................................................................................... 39


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5

EXECUTIVESUMMARY

Background

Internationalpublichealthcooperationisessentialtomitigatethespreadofepidemics.Inordertoprevent

orminimize

harm

from

emerging

infectious

diseases

in

the

future,

it

may

be

necessary

to

impose

measures

thatconstrainnationalsovereignty.Thisencouraged theWorldHealthOrganization (WHO) to revisethe

InternationalHealth Regulations (IHR, 2005). These regulations have strengthenedWHOsposition as a

centralglobalforcewithauthorityandaccountabilityinthefieldofinternationalhealth.Thetrendtowards

aglobalhealthsecurityregime is likelytochangethetraditionalapproachestooutbreakcommunication.

However,therearestillmanyquestionsthatremainedunansweredregardingwhethertheWHOeventually

willbelegitimateasasupranationalpublichealthauthority.

Health organizations value the importance of using communication strategies in the management of

infectious disease crises, in order to improve the compliance of the public with public health

recommendations. It is importanttoexaminetheattentiontheygivethesubject intheirwrittenreports

andthe

actual

implementation

of

the

strategies

during

the

2009

influenza

pandemic.

Objectives

Theobjectivesof this taskwere to review the transformations that the IHRunderwentuntil its current

formulationin2005andtoreviewtheroleandperformanceofWHOduring2009H1N1pandemicinlight

oftherevised IHR. We investigatedtheeightcorecapacitiesdefinedbythe IHR.Theoverallaimofthis

document istohighlightthe8corecapacitiesdefinedbyWHO,astheyarereflectedthroughtherevised

IHR (2005)..Thiswill serveas abasis forunderstanding the communicationaspectsof the collaboration

betweenWHOandnationalagenciesduringthe2009 influenzapandemic.Ourobjectivewastoreviewto

whatextent theWorldHealthOrganization (WHO)and theCenters forDiseaseControlandPrevention

(CDC)reports

addressed

the

issue

of

health

communication

strategies,

such

as

risk

communication,

social

marketingandonewayversustwowayflowofcommunication.Weaskedhowtheseideasappearedinthe

reportsandhowtheywereactuallyimplementedinthecaseofthe2009H1N1influenza,accordingtothe

international organizations reports.We completed our analysiswith an empirical case study of Israel,

examininghowtheinstructionsandtheorieswereimplementedinthememberstates.

Methods

In the first sectionof this task,we reviewedpapers, officialdocuments and reports and evaluated the

variousaspectsoftheimplementationoftherevisedIHR(2005)duringinfectiousdiseasecrises.

Inthe

second

section,

we

conducted

two

studies.

In

the

first,

we

compared

the

CDC

and

WHO

reports

from

2005 and 2009 to examinewhat lessonswere learned regarding the use of the health communication

strategiesofriskcommunication,socialmarketingandonewayversustwowayflowofcommunication.In

the second study,we conducted 73 semistructured interviewswith stakeholders from Israel, including

policymakers,journalists and healthcareworkers. The aim of the interviewswas to find out how the

communication strategies and theoretical dimensions from the reportswere implemented in the field,

usingIsraelasacasestudy.


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7

1. INTRODUCTIONSince

international

public

health

cooperation

is

essential

to

mitigate

the

spread

of

epidemics,

the

control

of

infectiousdiseasesisnotonlyanationalissue.Thiswasdramaticallydemonstratedduringthesevereacute

respiratorysyndrome(SARS)epidemic(Fidler&Gostin,2006).Inordertopreventorminimizeharmfrom

emerginginfectiousdiseasesinthefuture,itmaybenecessarytoimposemeasuresthatconstrainnational

sovereigntyandareinherentlyglobal(Heymann,2006).ThiswasoneoftheforcesencouragingtheWorld

HealthOrganization(WHO)toformulatetherevised InternationalHealthRegulations(IHR,2005).Infact,

these regulationshavestrengthenedWHOspositionasacentralglobal force thathas theauthorityand

accountabilitytoactagainstinternationalhealthrelatedrisks(Ijazetal.,2012).Althoughitisclearthatthe

trend is towards a globalhealth security regimewhich is likely to change the traditional approaches to

outbreakcommunication,therearestillmanyquestionsthatremainedunansweredregardingwhetherthe

WHOeventuallywillbelegitimateasasupranationalpublichealthauthority.

Thisdocumentisdivided intotwomainsections.ThefirstdealswiththeInternationalHealthRegulations

andtheir implementationduring infectiousdiseasecrises.Thesecondsectiondealswithcommunication

aspectsof infectiousdiseasecrises, includingacasestudyofsomeoftheseaspects inonememberstate

duringthe2009influenzapandemic.

2. THEINTERNATIONALHEALTHREGULATIONSIn order to tackle some of those questions, we briefly review the different transformations the IHR

underwentuntil

its

current

formation

(2005).

We

have

reviewed

the

role

and

performance

of

WHO

during

2009H1N1pandemic in lightoftherevisedIHR.Finally,we investigatedtheeightcorecapacitiesdefined

by the IHR. It is important to note that this document will serve as a basis for understanding the

cooperationbetweenWHO andMember States. In the secondhalfofour report,wewill focuson the

communicational aspects of the collaboration between WHO and national agencies during the 2009

pandemic,throughanIsraelicasestudy.

2.1. BackgroundtotheIHRIn

1951,

the

International

Sanitary

Regulations

(ISR),

were

adopted

by

the

World

Health

Organization

and

focused on six communicable diseases requiring coordinated international measures to control their

transmissionbetweencountries.(Hardiman2012)Membercountrieshavemadeuseoftheconstitutional

provision that permits the Health Assembly to adopt regulations concerning sanitary and quarantine

requirementsandotherproceduresdesignedtopreventtheinternationalspreadofdisease(Tucker,2005).

In 1969, the ISR were renamed the International Health Regulations (IHR) (Hardiman&WilderSmith,

2007).TheIHRareaninternationallegalinstrumentthatisbindingonmemberstatesofWHO(essentially

allcountries intheworld[Wernlietal.,2011]).Theiraim istohelpthe internationalcommunityprevent


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8

and respond to acute publichealth risks that have the potential to cross borders and threaten people

worldwide.

In1995,itwasdecidedthattherewasaneedtorevisetheIHR.TherevisedIHRwereadoptedin2005,and

came into force in June2007.Hardiman (2012)describe themas "a legallybindingglobal framework to

support

national

and

international

programs

and

activities

aimed

at

preventing,

protecting

against,

controlling,andprovidingapublichealthresponsetotheinternationalspreadofdisease".Theydealwith

the actions to be taken during public health emergencies and strengthening of national public health

infrastructure.

ThenewIHR(2005)coversawidespectrum.This includescasedefinitionsofdiseases,thedefinitionofa

publichealthemergencyofinternationalconcern(PHEIC),andthedefinitionofpublichealthrisks.Thereis

considerableemphasisoncollaboration betweenorganizations.At the country level, the IHR (2005)are

supportedby thedesignationofanational focalpoint (NFP).NFPsarenationalcenters,and theyplaya

central role in conducting the communications aspects of the IHR, both within the countries and

internationally.

The mechanisms for advice and oversight of national capacity development include a number of

components.These includeanationalrosterofexpertsthatcanbecalledupon immediatelytodealwith

any crisis, special emergency committees tomanage the response to the crisis, review committees to

monitor progress and review lessons learned from the event and global support through policy

developmentat theWorldHealthAssembly (WHA)and regionalcommitteesof theWHO (Andrusetal.,

2010).Thememberstatesneedtostrengthen theexistingnationalstructuresandresourcestomeettheircore

capacity requirements with regard to surveillance, reporting, notification, verification, response and

collaboration activitiesandactivitiesatdesignatedairports,portsandgroundcrossings(Katzetal.,2012;

May,Chretien

&

Pavlin,

2009).

At

the

local

level,

it

is

recommended

that

the

capacities

be

expanded

to

detecteventsinvolvingdiseaseordeathaboveexpectedlevelsfortheparticulartimeandplaceinallareas

within the country and report all available essential information immediately to the public health

authorities.Atthecommunity level,reportingshallbeto localcommunityhealthcare institutionsorthe

appropriate health personnel. At the primary public health response level, reporting shall be to the

intermediateornationalresponse level,dependingonorganizationalstructuresMacDonaldetal.,2011).

Theessential information includes clinicaldata, laboratory results, sourcesand typeof risk,numbersof

human cases and deaths, conditions affecting the spread of the disease and the health measures

employed.

At the intermediatepublichealth response levels thecapacitiesneed toconfirm the statusof reported

eventsand

to

support

or

implement

additional

control

measures,

assess

reported

events

immediately

and,

if found urgent, to report all essential information to the national level. The criteria for urgent events

includeseriouspublichealth impactand/orunusualorunexpectednaturewithhighpotentialforspread.

This isparticularly important for suitable riskcommunication to thepublic (Hollmeyeretal.,2012). It is

recommendedthatthecapacitiesshouldincludetheabilitytoassessallreportsofurgenteventswithin48

hoursandnotifyWHOimmediatelythroughtheIHRNationalFocalPoint.Publichealthresponsecapacitiesshouldincludemeasurestorapidlyimplementcontrolmeasuresrequired

to prevent domestic and international spread. This includes specialized staff, laboratory analysis of


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9

samples, logistical assistance, onsite assistance for local investigations. There should be direct

communicationbetween seniorhealth for implementing controlmeasures,anddirect liaisonwithother

relevantgovernmentministries.Communication should includehospitals, clinics, airports,ports,ground

crossings, laboratories and other key operational areas. Clear procedures should be in place for the

disseminationofinformationandrecommendationsreceivedfromWHO.

Asregardsinfluenzapandemics,therevisedIHR(2005)regulatestheWHOasanorganizationthatservesas

a coordinating center at two levels. On the first level, WHO addresses questions of efficient global

monitoring of the pandemic. On the second level, WHO serves as a communication center which

simultaneously creates global messages and serves as a relay station which receives, examines and

validates information. Inorder to fullyunderstandWHOs role in lightof thenew IHR regulations,one

must focusonthemainrevisionsthedocumentunderwentatboth levels.Thus,weemphasizethemain

differences between the revised IHR (2005) and its former versions in order to highlightWHOs new

definedrole.Subsequently,wewillnotonlydiscusstheformallegalauthorityIHRgrantsWHObutalsoits

defactofunctionduringtheH1N1pandemicof2009.

2.2. TheRevisedIHRandCoreCapacitiesTheeightcorecapacitiesrepresenttheabilityandthewillofWHOandtheMemberStatestocomplywith

therevisedIHR2005(Hollmeyeretal.,2012).Itseemsthatachievingthesecapacitiesisanessentialglobal

objective but also it is an opportunity to examine our progress towards our mutual goal and, most

importantly, it isachance to raisequestions inorder to improve the IHRs implementation (Andraghetti

fromPAHO/WHO).

2.2.1. NationallegislationMartinetal., (2010) investigatedtheextent towhich lawsacrossEuropesupportorconstrainpandemic

preparednessplanning (2010).The resultsdemonstratewidedifferencesacross Europe in theextent to

whichnationalpandemicpolicyandpandemicplanshavebeen integratedwithpublichealth laws.There

seemstobesignificantdifferencesinlegislationandbylaw,theextenttowhichborderscouldbeclosed

tomovementofpersonsandgoodsduringapandemicandaccesstohealthcareofnonresidentpersons

(Martinetal.,2010).Thiscanhaveharshconsequencesofplanningandpreparationsonall levels(Kimet

al., 2012). Moreover, the revised IHR (2005) holds special challenge for federalist nations (Australia,

Canada,GermanyandIndia)becauseitimpartsnationalobligationsontowhatistraditionallyastateand

localfunction

(Katz

&

Kornblet,

2010;

Wilson

et

al.,

2008).

.In

this

case,

the

success

of

IHR

(2005)

rests

upontheabilityofthesenationstofindabalancebetweenpublichealthregulatoryintheauthorityofthe

localgovernmentopposingtheauthorityofthenationalgovernment(Wilson,vonTigerstrom&McDougall,

2008).


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10

2.2.2. PolicyandfinancingThe firstquestion that riseson the subjectofpolicy and financing iswhether theWHO can establish a

situation inwhichthere isanequalityofburdenamongthememberstates.Whiletryingtoestablishthis

formulaonemust keep inmind that some countrysburden ismuchheavier thanothers.Namely, the

distribution

of

financing

must

be

as

equal

as

possible

but

also

take

into

an

account

the

limited

abilities

someofthecountriesarefacingwith.Whiledevelopedcountriestakeofgrantedsanitation,hospitalsand

professionaldoctors,source limitedcountriessometimeshavetomakehardcuts inordertofaceWHOs

minimum requirements. However, in the global age surveillance problems thousands of miles away,

become very quickly our surveillance problem. If pandemics wont be contained at the area of their

outbreaktheywilltraveltoourdoorstep.Hence,thequestionshouldbenotwhetherdevelopedcountries

shouldhelplimitedresourcescountriesbuthowtheycanhelp(ortowhatextent).Thebottomlineisthat

efficientglobalsurveillanceisasharedinterestofallmembercountries(McNabb,2010).

2.2.3.Coordination

and

NFP

communications

Toestablisheffectivecommunicationchannels,theIHR(2005)requesteachmemberstatetodesignatea

NationalFocalPointandWHO todesignate IHRContactPointsat itsheadquartersor regionalofficesas

operationallinksforurgentcommunicationconcerningtheimplementationoftheIHR(2005)(Oshitaniet

al.,2005). Itcanbeargued thatNationalFocalPoints (NFPs) represent thecommitmentmember states

havetowardstheIHR(2005).AsuccessfulestablishmentofNFPsindicatesintentionforglobalcooperation

and communicationwithWHO andothermember states. Thus, it isnot surprising that themajorityof

member states successfully established NFPs. As Hardiman notices, NFPs are national centers, not

individualpersons,thatoccupyacriticalrole inconductingthecommunicationaspectsoftheIHR,within

their countries and internationally (2012). These centers have number of tasks, of which the most

importantones

are

to

distribute

information

that

comes

from

WHO

to

the

relevant

domestic

agents,

to

reporttoWHOaboutanyhealth regarding informationthatcanbearrelevanceonaglobal leveland to

provideWHOwith feedback about the national preparedness in case of an outbreak and,withWHOs

coordinationtoamelioratenationalcapacity.Furthermore,thelocalNFPscanserveasapipelinebetween

WHOandlocalaudience,helpingtounderstandandcommunicatepublicopinion.

However,notallNFPsworkaccordinglytothestandardwhichgoesalongwiththespiritoftherevisedIHR

(2005).ToimprovetheseNFPsactivity,WHOinitiatecoursesandworkshopsonwhichwewillelaboratein

thehuman resources section. It is import tonote that after the 2009N1H1 influenza therehave been

raisedsomecritiqueagainstthelevelofcollaborationbetweenWHOandsomeNFPs.Lowetal.,illustrate

thisnotionthroughtheSingaporeanexample(2011).TheclaimisthatwhiletheSingaporeanNFPprovided

WHOwith

timely

information,

the

IHR

NFPs

were

not

responsive.

This

lack

of

information

led

Singapore

NFPtoexplorealternativesourcesofinformationwhichobviouslyshouldnothappenintimesofasevere

outbreak.Itseemsthatthesesortsofdiscrepanciesshouldberesolvedimmediatelyinordertoestablisha

moreefficientandvalidwaytocommunicateduringcrisis.

2.2.4. Surveillance


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11

Oneof themost importantcorecapacities thatareyet tobeachieved is improving surveillance,and in

some cases establishing a surveillance system, in resource limited countries.Obviously,not always it is

merely a technological question and, in fact, the heart of every good surveillance system is

communication. It is the speed of communication which ismost critical to contain or stamp out an

outbreak, save lives and preventmisery (Kant & Krishnan, 2010) Although a variety of surveillance

systemshas

been

established

around

the

world

it

seems

there

are

still

alot

of

technological

gaps

between

developedcountriesand resource limitedcountries (Campbelletal.,2012).AsQuandelacyetal. (2011),

note many resourcelimited countries still lack access to appropriate electronic surveillance systems,

whichmaylimittheirabilitytorapidlydetectoutbreaksandotherhealtheventsthataffectresourcepoor

countriesandtheinternationalcommunity.Apparently,theassessmentshowsthatIHR2005constitutesa

majoradvance inglobalsurveillance fromwhathasprevailed in thepast (Baker&Fidler,2006). In this

aspect,WHOsagendashouldfocusonreductionofgapsbetweendifferentcountries.Thus,theultimate

goalofallmemberstatesshouldbeone;toestablishanefficientglobalsurveillancesystem.Obviously,this

cannotbeachievedwithouttheparticipationofeverystateinthiseffort.

2.2.5. ResponseThemainquestionthatincorporatesdifferentissuesregardingresponsetopandemicoutbreakdealswith

the acuteness or severity ofWHO andmember states reaction.Namely, how dowe act?What is the

criticalmassfordeclaringanoutbreak?Howwealertthepublicwithoutarousingpanic.Itisimportantto

notethat, intheaftermathof2009H1N1 influenza,oneofthevoicesagainstWHOsresponsemadethe

case thatWHOoverestimated the severityof theoutbreak resulting inamasspanic.However, itseems

that in the early stages of an outbreak when solid and verified information is sparse it is better to

exaggerate than to underestimate. This brings about the public healthparadox;while failure tomove

aggressively in the early stageof pandemic influenza canhave catastrophic consequences, actions that

proveto

have

been

unnecessary

will

be

viewed

as

draconian

and

based

on

hysteria

(Gostin,

2004).

Along

withGostin(2004)recommends itsafetoclaimthatwhatshouldcharacterizeawiseresponseisnotonly

itsseveritybutalsoitsethicalcodeandconsiderations(2004).

2.2.6. PreparednessThediscoursearoundtheconceptofpreparednessfocusesondifferentelements.First,wemustconsider

preparednesson theglobal level,consideringWHO,CDCandECDCandallmember statesasacomplex

networkthatmustachieveandmaintainanopencommunicationalchannelinordertoassessquestionsof

surveillanceand

coordination

(Azziz

Baumgartner

et

al.,

2009).

Moreover,

we

need

to

expand

initiatives

that includeWHOsconferences,workshopsandcoursestohelpdifferentagentstospecialize inworking

togetherinWHOinlightofIHR2005.Onthenationallevel,wetalkabouttwowaypreparedness.Namely,

workingwithregionalagentsinordertoestablishblessedpartnershipssuchasMECIDSandMBDSbutalso

achievinghighpreparednesslevelincommunicationwiththepublic.Communicationwiththepublicshould

bebasedonriskcommunication;workingwithcommunicationresearchers inordertounderstandpublic

opinionandassess the issues thatare relevant foreach specific subgroup.These tailored interventions

shouldpromoteprohealthinitiativesnotmerelyintimesofoutbreaksbutonaregularbasis.Althoughitis

notalwayscompletelyunderstoodwhatistheappropriateroleofeachagentinthisnetwork,responding


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12

to infectiousdisease threats iseveryStatesprerogative,and interState collaborationsareessential to

secureglobalpublichealthpreparedness(Bhattacharya,2007).

2.2.7. RiskcommunicationInaccordancewiththe lessonofSARSoutbreakandthespiritofIHR2005,WHOsdeterminedposition is

that massive mass media campaigns should be used in order to decrease transmission, inform the

population, promote hygiene (sick people should bemonitored and health should keep distance). It is

importanttonotethatsocialmediacouldpotentiallyplayamajorroleinthesesortsofcampaigns,helping

themessageget throughnotonly via traditional channelsbutalso through thenewmedia. Evenmore

important, Information should be communicated in a transparent, accurate and timelymanner (WHO

global conference on SARS: where do we go from here? (Summary Report, Kuala Lumpur, 2003, in

OMalley,Rainford&Thompson,2009). Itseemsthatsomeofthese lessonswere implemented intorisk

communicationduringH1N12009 influenzaoutbreak.FollowingtheMexicanPandemicPlan,aprogram

of

social

mobilization

was

implemented

through

a

multifaceted

mass

media

saturation

campaign

featuring

visual representationsandapreviouslydevelopedand testedmessage icon,"promi", toaddressMexico

Citysheterogeneouspopulationandliteracyrates(Belletal.,2009).

Nevertheless,therearestillsomequestionsremainedunanswered.IfWHOisresponsibleforthemessages

producedanddistributedduringanoutbreak,isitalsoincluderiskcommunication?Ifitis,whatisthebest

platform to achieve effective results? Will the WHO be in any way responsible for distributing or

monitoringmessagesthatarebeingusedfordifferentinterventions?Willsuchmessagesbehomogeneous

orwilltheybeculturallytailoredfordifferentmemberstates?Whathappensifastatedoesnotagreewith

themessageandwantstoproduceothermessages?Itisimportanttonotethatthereisrelativelyverylittle

researchontheeffectivenessofriskcommunicationduringtimesofcrisisandthiscouldverywellbethe

missinglink

on

the

way

to

achieving

better

surveillance

and

faster

containment.

2.2.8. HumanresourcesItisnotsurprisingthatstaffshortagessometimesprovetobeasignificantcauseforsurveillanceshortfalls

(Chretien,2010).Thisequationbecomesmuchmoresignificantwhenwearespeakingaboutthirdworld

countries,wheretrainingandqualificationofexpertsandmedicalstaffsometimesfallsshort.Oneofthe

mostsuccessfulWHOs initiativesaremedicaltrainingsandworkshopsthatcan improvethecapabilityof

domesticprofessionalstofacehealthhazardssuccessfully(Ottoetal.,2011).Itisimportanttonotethata

great

deal

of

the

training

focuses

not

only

on

medical

training

but

also

on

communicational

training

thus

opening a channel of communication can sometimes contribute to efficient surveillance just as good

medicalexperts.


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13

2.2.9. LaboratorycapabilitiesAccording to the declaration of the World Health Assembly in 2005 that urged itsmember states to

strengthen national laboratory capacity for human and zoonotic influenza (Wetheim, 2010), it is self

evidentthatmemberstates laboratoriesshouldstriveforthehigheststandards(NajjarPellet,2013).The

objectives

for

the

laboratory

strengthening

program

was

to

enhance

laboratory

facilities;

ensure

availabilityofnecessaryequipment;buildhuman resourcecapacityby teaching, trainingandmentoring;

andensurequalitylaboratorymanagementandtestingtocomplywithinternationalstandards(Wetheim,

2010). The Tanzania Field Epidemiology and Laboratory Training Program (TFELTP) serves as a good

exampleofcooperationonthenationalandinternationallevelsthatcanbringaboutchangeandestablish

laboratorycapacitiesthatcorrespondwiththeIHR2005.Althoughtheprogramisnotperfectandthereis

still room for improving incountry teaching capacity for the program, as well as a career path for

graduates (Mmbuji, 2011), it shows that with relatively small economical investment countries can

establishasurveillancesystembyupgradingtheir laboratorycapabilities.Nevertheless,there isstillmore

guidanceneededtoachievethestandardthatthespiritoftherevisedIHRstrivesfor.

2.3. TheIHRandtheH1N1pandemicof2009Themajor differences between the 2005 InternationalHealth Regulations (IHR) and its earlier versions

operateonthreedifferentaxes.Thesubstantialchanges includecontainmentattheborder[asopposed

to]containmentatthesourceoftheevent,shiftsfromarathersmalldiseaselistrequiredtobereported,

toallpublichealththreats;andshiftsfrompresetmeasurestotailoredresponseswithmoreflexibilityto

dealwiththelocalsituationsontheground(Andrusetal.,2010).

TheH1N1influenzapandemicof2009testedthecapacitiesofcountriestodetect,assess,notifyandreport

eventsas

required

by

the

2005

International

Health

Regulations

(IHR).

As

detailed

in

the

IHR,

the

World

HealthOrganizationdrewonofficialreportsfromMemberStatesaswellasunofficialsources(e.g.media

alerts) toquickly reportanddisseminate informationabout theappearanceof thenovel influenzavirus

(Briand,2011).ThepreexistingGlobalInfluenzaSurveillanceNetworkforvirologicalsurveillanceprovided

crucialinformationforrapiddevelopmentofavaccineandfordetectionofchangesinthevirus.

Buildingon theexperiencefromepidemics in India,ParaguayandChina, the IHRseeks tocontainatthe

sourceoftheeventandnotattheborderwhichboundto increasehumanitarianandeconomicalcrises.

Thischangebecomescriticalwhenspeakingof limitedsourcescountriesandareasthatnormallycannot

effectivelytreatandcontaintheoutbreak(Kandun,2010).Oneofthemosteffectiveways inwhichWHO

canimmediatelyinitiatearesponseisbymanagingexpertgroupsandcomitiesthatcanbecalledtobegin

thesurveillance

in

any

part

of

the

world.

Obviously,

the

emphasis

is

on

developing

areas

that

historically

were connectedwith severaloutbreaks.Thisglobal reserve force is likely to save livesandmonitor the

outbreak as close to its source as possible but also it can prevent significant economical damages to

countrieswithlimitedmeans.

AlthoughMexicowasrelativelyquickinreportingtheoutbreakofinfluenzain2009,bythentheepidemic

hadalreadyspreadtotheUS.Thus,therewaslittlechance,ifany,tocontaintheepidemicatthesourceof

the event. The response to the H1N1 influenza outbreak underscores the importance of countries

developingrealtime,comprehensiveclinicalsurveillance inordertorapidly identifyoutbreaksthatmight


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14

occur (Wilson, Brownstein & Fidler, 2010). However, complying with the 2005 IHRs surveillance and

responseobligationsMexicodidcooperateinreceivingglobalhelpthatprecipitatedthemonitoringofthe

outbreak(Chanetal.,2010).

DespitetherequirementsoftheIHR,thereremainanumberofgapsintheglobalsurveillanceforinfectious

diseases

that

at

least

in

part

derive

from

the

inability

of

source

limited

countries

to

successfully

monitor

and report theoutbreakprior to itswidespread.The secondmajordifferencebetween the revised IHR

2005 and its former versions is a transition from a relatively short list of pandemic threats (smallpox,

cholera,plagueandyellowfever)toaconsiderablylessconstrainingdefinitionofhealththreats.Namely,

IHRintroducedanewsurveillancesystemforalldiseasesandhealththreatsthatmayconstituteapublic

health emergency of international concern (Edelstein et al., 2012). This very broad definition urges

countries to reporton any threat thatmight constitute as an emergency of international concern. It

seems that this extension of WHOs authorization was one of the reasons that led to an efficient

surveillance assessment of the 2009 H1N1 influenza (Paterson et al., 2012). The former outlook that

constitutedtheshortlistheldtheassumptionthatWHOmustdevoteextraordinarypublichealthresources

totrackingandpreparingaresponse[dependingontheestimated]riskthattheoutbreakwillreachinthe

caseof

serious

illness.

Nevertheless,theextentoftransmissionandthereforetheseverityofthediseasemaybeunclearduring

theearly stagesofapandemic. Forexample, infection inMexicowasalreadywidespreadby lateApril

2009whenthelinkwasmadebetweentheunusualcasesofpneumoniareportedinMarchandAprilanda

novelstrainof influenza(Lipsitchetal.,2011).Accordingly,thenewopennessthattheIHR2005 initiate

regardingwhatshouldbedefinedasapublichealthemergencymayresultinanefficientsurveillanceand

aquickerassessmentof thepandemic (Toboy,2010).Yet, some scholars see theelusivedefinitionofa

pandemicasadisadvantage.Doshi(2011)claimsthatWHOneverdefinedpandemic influenza.Thispoint

seemstoberathercontroversialbecausethisnotionimpliesthatpotentialconflictsofinterestanddoubts

aboutproportionalityofresponsecanintervenewithWHOsjudgment.Doshi(2011)hasstressedthatitis

importantto

notice

that

during

the

pandemic

caused

by

H1N1

virus

the

definition

derived

from

pandemic

phasedefinitionsratherthanapandemicinfluenzadefinition.

ThethirdshiftinsurveillanceandassessmentofapandemicthreatasitappearsintheIHR2005dealswith

the flexibility of WHOs guidelines. There is a clear departure from the strict general measures to

identifying the unique situation and then addressing a tailored solution. This change of thought raises

questionsregardingWHOsabilitytoproviderapidsolutionsandresponsestochallengesthatoccur.2009

H1N1servesasagoodexampleforworkingwithtailoredmethodsthustheidentificationofthepandemic

occurredalmostsimultaneouslyinMexicoandinUSbutobviouslyeachcountryneededadifferentkindof

monitoring.WhileMexiconeededbuildinganeffectiveandadaptableframeworksfordiseasesurveillance,

US

whom

has

the

monitoring

of

CDC

needed

much

less

global

support.

Anotheraspectoftheuncertainnatureoftheoccurrenceofpandemicsandtheirmanagementwasevident

intherelationshipbetweentheIHR(2005)andtheWHOpandemicalertsystem.Althoughthereseemto

be some controversy surrounding the applicationofWHOs influenzapandemicalert systemduring the

H1N1influenzapandemic(Wilson,Brownstein&Fidler,2010),itremainsagoodexampleofWHOsability

toassessandevaluatethesituationandtreatmentduringtheoutbreak.Toavoidthepolemic,wewilljust

mentiontheauthorizationofWHOdirectorgeneraltodeterminevariousalertphasesinordertostimulate

governmentstoprepare fororrespondtoapandemic. Inaccordancewiththe IHR (2005),thisauthority


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15

hastodowiththeunexpectednatureofpandemicoutbreaksthatrequirerapidassessmentandchangeof

strategy.

WHOsfunctionasaproducerandtransmitterofinformation,inthecontextoftherevisedIHR(2005),can

beexaminedduringH1N12009outbreak.Asmentionedearlier,therevised IHRdesignatedWHOasthe

central

player

in

times

of

pandemics

and

other

international

health

crises.

This

marks

a

communication

shiftfromashortlistofobligatoryreportsthatarepassedbetweenWHOandnationalagenciestoaglobal

partnershipandcollaboration; humanrights,obligation,accountability,andproceduresofmonitoringall

ofwhichareapartofWHOswiderresponsibility(Andrusetal.,2010).WHOstaskistoestablishaglobal

communication in order to spread information to all countries; either directly to people or through

intermediaryagentssuchashealthorganizations,governmentsandnewsagencies.Theinformationvaries

fromareasofoutbreaks, thenatureofpandemic,guidelines,validationofdata,availabilityofavaccine,

surveillanceandcontainment.Generallyspeaking,WHO identifies fiveessentialguidelines foreffectiveoutbreakcommunicationbased

ontheexperiencesofseveralcountriestodiseaseoutbreaks:buildtrust,announceearly,betransparent,

respectpublic

concerns

and

plan

in

advance

(Condon,

2009).

In

the

case

of

SARS,

China

was

criticized

for

notreportingtheoutbreakquicklyenough,whichledtonewreportingrequirementsunderIHR(2005). In

caseof the2009H1N1epidemic,MexicoandUS followedthenew regulationsand reportedtoWHOas

soonastheydetectedaproblem.ThishelpedWHOtodeclareapublichealthemergencyofinternational

concernwithin48hoursof laboratoryconfirmationthattheviruseswere infaceanewstrain(Condon&

Sinha,2009).Afterthesurveillancebegan,thecommunicationbetweenWHOandmembercountrieswas

veryeffectiveandmatchedthespiritofthenewIHR.

According to the IHR (2005), as Katz acknowledges the state party and WHO shall continue to

communicateinatimelyfashionaboutthenotifiedevent(2009),includingsharingupdateddetailedpublic

health information on the notified event (case definitions, laboratory results, source and type of risk,

numberof

cases

and

deaths)

.Moreover,

WHO

has

developed

asecure

website

which

distributes

timely

informationaboutpublichealtheventsandemergenciesamongstateparties.Theoverallagreementisthat

on the levelof informationWHOandMemberStatesdidaverygoodjob incontainingconstant lineof

communication.Thus,theMemberStatesinformWHOaboutnewcases, laboratoryresultsandconcerns,

whileWHOvalidatesandissuesrecommendationwiththegoalofmitigatingthepandemic.

Nevertheless,someraisethepointthatalthoughthedisseminationof informationwasmostlysuccessful

overall, it was still relatively slow. For example, although there was sharing of clinical experience via

networksofclinicianssetbyWHOandotherorganizations,thefirstlargescalequantitativeanalysisofrisk

factors forhospitalizationwaspublishedonline,almost4monthsafter thedataweregathered (Wilson,

Brownstein&Fidler,2010).Obviously, inthecaseofa largerscalepandemic,thisdelaycouldprove itself

much more critical. Furthermore, the IHR (2005) emphases on matters of global coordination and

communication,betweenWHOand themember states, resulted in aneffective channels thatprovided

instructionsandspecificupdated.Nevertheless,itseemsthatonthenationallevel,theinstructionswere

mostlytopdown,withlittleattentiontotheirimplementationinthememberstates,feedbackregarding

lack of information ormisunderstandings and local adoptions thatwere needed. The lastpoint can be

exemplified through a case study of communication coordination in Israel during the H1N1 pandemic.

SomeofthefindingspointtoagapbetweenthetrustIsraelijournalistsandbloggershadtowardsreports

comingdirectlyfromWHOasopposedtoreportscomingfromIsraeliMinistryofHealth.Thisdiscrepancy


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16

suggests thatmaybe there isneed for closermonitoring of the receptionofmessages notonlyon the

globallevelbutalsoonthenationallevel.

A good illustration of a collaborative effort on the national level that applies IHR (2005) guidelines is

MECIDS (MiddleEastConsortiumon InfectiousDisease Surveillance). This surveillancenetwork includes

ministry

of

health

officials

from

Israel,

the

Palestinian

Authority

and

Jordan

and

serves

as

a

forum

for

the

exchangeof informationon the infectiousdisease crises. TheMECIDS partners invited representatives

fromWHO to conductaworkshopon IHR (2005) implementation inNovember,2007 (Greshamet al.,

2009).Asaresult,therewasahigherlevelunderstandingofIHRproceduresforcommunicationwithWHO.

This collaboration was expressed in shared lessons and mutual press releases during the H1N1 2009

pandemic.Anotherexampleofasurveillancenetworks isMBDS (theMekongBasinDiseaseSurveillance

cooperation). This network includes Cambodia, China, Lao Peoples Democratic Republic, Myanmar,

Thailand and Vietnam. Similar to MECIDS, this collaboration proved itself especially effect in areas

previouslyconsideredproblematic.TheinformationsharingamongthecountriesandWHOwascitedasa

specialstrength(Moore&Dausey,2011).

2.4. ChallengesofglobalsurveillanceandtheH1N1pandemicTheH1N12009pandemichighlightedthedifferencesinthesurveillanceandresponsecapacitiesbetween

differentcountries.Furthermore,itislikelythatmanycountrieswillhavedifficultycomplyingwiththeIHR

minimum core capacity requirementsby thedeadline set (Davies,2012).Developing countriesmaynot

havethenecessary resources forcomplyingwith these requirementsandwillneedoutsideassistance in

ordertoachievethem.

Anequitablesolutionmustbefoundtosolvetheproblemofsharingthebenefitsofresearchbasedonthe

transferof

virus

samples

from

less

developed

countries

to

the

richer

countries

(Aldis,

2008).

Equity

in

access to vaccineduringpandemics is another issuewhich needs to be resolved (Fidler,2003). Several

programsaim to improvepublichealth surveillanceand response indevelopingcountriesbyaddressing

specificdiseasecontrolneeds.TheWHOsIntegratedDiseaseSurveillanceandResponseStrategy(IDSR),

which is being implemented in all 46member states of theWHOs African RegionalOffice and in the

IntegratedDiseaseSurveillanceandResponseProjectinIndia,areexamplesofgeneralcrosscuttingpublic

health and response improvement programs that have originated in developing countries (Nsubuga,

2010).

2.5. PotentialviolationsoftheIHR(2005)andtheH1N1pandemicDespiteWHOsdetermination that traveladvisoriesand restrictionswerenotnecessary,manycountries

used suchmeasures in responding to the outbreak.Other countries implemented restrictions on pork

products exportedby countriesaffectedby2009H1N1 caseseven thoughWHO and theWorldAnimal

HealthOrganization (OIE) repeatedly stated that such restrictionswerenotjustified. Controversies also

arose fromthe isolationorquarantineof individualsandgroupsarriving from,orassociatedwith,2009

H1N1affectedcountriespoliciesthatwerealsoinconsistentwithWHOrecommendations.


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18/45



18

3. COMMUNICATIONANDINFECTIOUSDISEASECRISES3.1. IntroductionWhentheH1N1pandemicemergedin2009,thehealthorganizations(e.g.WHOandCDC)didnothaveto

operatein

avacuum.

Previous

health

regulations

and

insights

from

previous

influenza

epidemics

guided

the

riskmanagementoftheH1N1 influenzaepisodeandthestrategiesusedtocommunicate ittothepublic.

All the procedures thatwere followed by the international health organizations (CDC andWHO)were

documentedinfinalreportssummarizingtheiractivityduringthe2009influenzaoutbreak.

Inrecentyearsgovernmentsandhealthorganizationsaroundtheworldhavecometoagreethatthetwo

conceptualstrategiesofriskcommunicationandsocialmarketingplayacriticalroleinnationalprogramsto

preventand confront thediseaseof influenza (AllenCatellier&Yang,2012; Lee&Kotler,2011).These

conceptual strategies arewidely used in communication strategies and draft guidelines. In addition to

those two conceptual strategies, the literature has shifted in recent years to the study of twoway

communicationstrategies,which take feedback from thepublic intoconsideration, rather thanoneway

communication,in

which

information

flows

from

"top

to

bottom,"

directly

from

the

addresser

to

the

public.

ThischapterpresentsasystematicreviewoftheCDCandWHOreportsandregulationsforcommunicating

the2009H1N1 influenza.Wealsoreviewthesereports incomparisontopreviousproceduresthatwere

followed in2005.Wewishtocomparebetweenthetheoreticaldimensionsthatwere inuse in2005and

thoseusedto2009..

Our objectivewas to review towhat extent theWHO and CDC reports addressed the issue of health

communicationstrategies,suchasriskcommunication,socialmarketingandonewayversustwowayflow

of communication.Weexaminedhow these ideas appeared in the reportsandhow theywereactually

implementedin

the

case

of

the

2009

H1N1

epidemic,

according

to

what

the

international

organizations

reported.Wecompletedouranalysiswithanempiricalcasestudyof Israel, inordertoexaminehowthe

instructionsandtheorieswereimplementedinthememberstates.DespitethefactthatIsraelisacountry

withspecificcharacteristics,wecanlearnfromthiscasestudyhowthetheorywasimplemented.

3.2. MethodsForthefirstpartofthisstudy,reportswerecollectedinOctober2012usingthesearchenginesoftheWHO

andCDCwebsites.WealsousedGoogleScholar,searching for thekeywordscommunicationandrisk

communication.Fifteen

reports

were

located.

Theanalysiscontainedtwosteps.Firstly,wedividedthereports into2005and2009.Threeofthemwere

from2005whiletheother12werefrom2009.Thenwereviewedthereportsbysubject:coordination,and

threecommunicationstrategies:riskcommunication,socialmarketingandonewayversustwowayflowof

communication.Finallywemadeacomparisonbetween2005and2009.Weanalyzedeachcommunication

strategyaccordingtothedifferenttheoreticaldimensions,aswillbeexplainedbelow. Wewerespecifically

interestedinwhetherlessonsfrom2005wereimplementedinthecommunicationstrategiesof2009.We

werealso interestedtofindoutwhethersubjectsthatappeared in2005werealsocommon in2009.We


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19

were particularly interested in seeing whether responses changed as a result of the Severe Acute

RespiratorySyndrome(SARS)epidemic.

In the last stagewe conducted 73 semistructured interviews in Israel. Eight of themwerewith policy

makersandtheotherinterviewswerewithstakeholdersfivejournalistsfromIsrael'sbiggestnewsmedia

corporations,

11

health

bloggers

and

49

healthcare

workers

(25

nurses

and

24

medics).

The

aim

of

the

interviewswastofindouthowthecommunicationstrategiesandtheoreticaldimensionsfromthereports

were implemented in the field,using Israelasacase study.The interviewguidelines includedquestions

regardingattitudestowardstheepidemicandthevaccine,barriers,trust,empowerment,responsibilityand

communication.

Table1:Thetwostepsoftheanalysis

Whatwecompared

A comparison between thecoordination andthree

communication strategies, including their

theoreticaldimensions,in2005and2009.

FirstStep

Acomparisonbetweentheguidelinesinthereports

according to the theoretical dimensions and the

Israelicasestudy

SecondStep

3.3. Findings3.3.1. CommunicationandcoordinationbetweenorganizationsandgovernmentsThe analysis focusedon theorganizations communication strategies.However,oneof the themes that

emergedfromthereportswasthestrongemphasisonriskmanagementoftheepidemicandthevaccine

andcoordinationbetweentheinternationalorganizationsandthememberstates.Whileriskmanagement

andcoordinationissuesfilledalargepartofthereports,therewasverylittlereferencetocommunication

strategies.

In2005

the

International

Health

Regulations

(IHR)

were

enacted

and

came

into

force

in

2007,

in

order

to

ensurecompetentsurveillanceanddetectionsystemstomonitortheemergenceofepidemicoutbreaksin

the world. These regulations specified to member states how and when to report on new cases of

influenza,monitorthespreadofthediseaseandcoordinatebetweentheinternationalhealthorganizations

andthememberstates(Katz,2009).


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20

Both in2005and2009the internationalhealthorganizations instructedthememberstatestoreporton

any change inmorbidity that could signal the emergenceof an epidemic in certain areas.Themember

stateswere required to establish a national IHR focal point for communicationwithWHO,meet core

capacity requirements for disease surveillance, informWHO of any incident and respond to additional

requestsforinformationbyWHO.Theimportantthemethatemergesfromanalyzingtheseinstructionsis

thatemphasis

was

more

on

the

issue

of

time

than

on

the

process

of

providing

the

information.

Instructions

were given on the importance of providing the information in a timely manner, as fast as possible.

However, instructionsonhowtopassonthe informationbetweenthe internationalhealthorganizations

andthememberstateswerenotevident.

Despite the international regulations and instructions,we found in the reports that themember states

receivedfewspecificinstructionsonhowtofulfillthoseregulations.Itappearsthatthecommunicationand

coordination between the international healthorganizations and themember stateswas "topdown"

fromtheorganizationstothememberstates.Itwasnot"bottomup,"allowingthememberstatesnotjust

topassonreportsabouttheemergenceoftheepidemic,butalsotogivefeedback.Inaddition,therewas

nosegmentationbetweenthememberstatesallreceivedthesameinstructionsandregulations.

The lack of specific instructions for different member states emerged also from the interviews we

conductedwithpolicymakers in Israel.Aseniorhealthofficialexplainedthatthedecisionofwhowould

communicatethefeaturesoftheepidemicandneedforthevaccinetothepublicandwhich instructions

wouldbegivenwasmadebythe IsraeliMinistryofHealth,withoutany instructionsor interventionfrom

WHO:"Therewereno[instructionsfromWHO]...They[theMinistryofHealth]controlledtheguidelines...

oneoftheseniorofficialsattheMinistryofHealthinstructedthem."Anotherseniorhealthofficialadded:

"Thereweremany recommendationsfrom internationalorganizations thatweresent toall [themember

states]... It wasn't specific to Israel... It was mainly about epidemiological issues... not how to

communicate."

3.3.2. RiskCommunicationTheriskcommunicationapproachtoemerginginfectiousdisease(EID)drawsonthetheoreticalconceptsof

health promotion communication, crisis communication and environmental or technological risk

communication.Theriskperceptionofafluepidemicandvaccineisrelatedtothetheoreticaldimensions

oftrust,empowermentanduncertainty.Allthesetheoreticaldimensionswillbeexplainedanddiscussedin

thechapterbelow.

3.3.2.1. MaintainingtrustamonggovernmentsandstakeholdersTrust isan important factorofriskcommunication,especiallyonhealth issues.The literatureshowsthat

without trust in theorganization thatwants topromote thehealthybehavior, in thiscase the influenza

vaccine, itwillnotbeadoptedby thepublicandother stakeholderswhoarepartof theprocess (Allen

Catellier&Yang,2012;Cvetkovich&Lofstedt,1999;Earle &Cvetkovich,1995;Lofstedt,2005).Therefore,

itisimportanttoconductevaluationstudiesinordertounderstandwhethertrustwasachieved.


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21

Oneoftheaimsthatthe internationalorganizationssetupontheoutbreakofthe2009epidemicwasto

establish trust with the public and the other stakeholders. The CDC reports from 2009 indicate that

communicationstrategiestoestablishtrustwereimplementedintheprocedures.Duringtheearlydaysof

theoutbreak,andevenafterwards,thereleaseofinformationwasfast,ona24hourcycle,withfrequent

updatesbytheconsistentuseofacoregroupofspokespersons.Thedeclaredgoalwasnotonlytheneed

tobe

as

transparent

as

possible,

but

also

to

maintain

credibility

and

be

atrusted

source

of

information

for

thepublicandthememberstates(CDC,2011a).However,itisimportanttostressthatsincenoevaluation

studiesorotherpublic/healthcareworkers'opinionstudieswereconducted,wecouldnotfindoutwhether

thisgoalwasachieved.

Whilethe importantmatteristhe lackofevaluationstudies, itemergedalsofromthe interviewsthatwe

conducted, that the internationalorganizationswereconsidereda trustworthy sourceof informationby

Israelipolicymakers,healthcareworkers and themedia.However, it is important to keep inmind that

these interviewsreflectonlyanIsraelicasestudy,andshouldnotbegeneralizedtoothermemberstates.

The policymakersmentioned that every instruction theWHO gave the member states was followed

unequivocally. Questions may have emerged from time to time, but they were mostly about the

clarificationof

processes

and

not

expressions

of

distrust,

as

asenior

health

official

explained:

"We

had

directcontactwiththeWHO...WefollowedtheinstructionsoftheWHOandtheCDC.".

Healthcareworkers andjournalists also expressed trust in the international organizations.Medics and

seniornursesusedWHOandCDCpublicationsassourcesofinformationfortreatingpatients,alongsidethe

local publications of the Israeli Ministry of Health, which will be discussed below: "We could find

information in theWorldHealthOrganization" (amedic); "Thequotingofexternal sources likeCDCand

WHO... It'scorrectandvalid... Itaddsadimensionofvalidity...TheCDCupdated its informationdaily (a

medic);"IusedtheCDCwebsitealot"(aseniornurse).Mostofthejournalistsstatedthattheinternational

websiteswereamajorsourceofinformation,whilethebloggersspecificallyreliedonthem.

Whilewe

did

not

interview

members

of

the

general

Israeli

public,

the

sense

of

trust

in

the

international

organizations reflected a differentiation between them and the local health organizations. While the

international organizationsmaintained high levels of trust among the interviewees, a different picture

emergedwhendiscussingtheIsraeliMinistryofHealth.Whileahighnumberofmedicsexpressedtrustin

theMinistry of Health, few nurses andjournalists expressed distrust on some issues. A senior nurse

explained that the Ministry of Health was perceived as a political organization motivated by political

interestsandnotthepublicgood

Another salient theme of distrust that emerged from the interviews referred to a possible conflict of

intereststhehealthorganizationshadinrelationtothevaccine.Theintervieweesclaimedthattherewere

strong suspicions that the pharmaceutical companies affect the health organizations decision to buy

vaccines.Themajorfearthattheintervieweesrepresentedwasthattheinternationalhealthorganization

assessmentswerenotbasedsolelyonepidemiologicaldata,butoncommercialinterests.

Ahealthjournalistexplainedthatthiscouldreducethepublic'sfaithintheMinistryofHealth:"Therewasa

senseofconspiracy...somepeoplethoughtthatthevaccineswerenotneededandhadbeenboughtforno

reason." This matter did not only compromise trust in the local health organization, but also in the

internationalorganizations.However,mistrustoftheinternationalorganizationsfocusedonlyonthatissue

andwasnotgeneral.


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22

3.3.3. EmpowermentofthepublicInthischapter,wediscussthedifferencesbetweenempowermentofthepublictomakedecisionsabout

risks for itself and the authorities' exercise of power (Covello, Peters,Wojtecki,& Hyde, 2001).While

empowerment plays a key role in communicating health issues, it received little attention as a

communicationstrategyintheinfluenzareportsweanalyzedbefore2009.Thedeclaredgoalofthereports

in2005wastohelpthepublicmanageitsexpectations.Itwasclearthatthepublicneededinformationto

inform itsowndecisionsaboutvaccinationand toknow the reasons for thevaccinenotbeinggenerally

available.Inordertoidentifythepublicsconcerns,focusgroupswerecreated(NHS,2005b).However,we

are unable to report exactlywhatwas learned from those focus groups, aswe could not locatemore

information about them in the reports. Another question was the timing issue of matching vaccine

availabilitywithperceivedpublicneeds.

Inthereportsfrom2009,wedidnotfindexplicitreferencestoempowermentasastatedgoal.Mostofthe

instructions

concerned

"providing

information"

and

"delivering

it

to

households"

(CDC,

2011b,

p.

4).

As

in

2005, the focuswas topass the information to thepublic as quickly aspossible.However, the goalof

passing the information focused on knowledge and not an empowering the public.We could not find

explicitreferencestofocusgroupsorevensurveysthatcouldhelptheorganizationsknowonwhichissues

thepublicneededempowerment.

Agroupthatcanplayakeyrole inempoweringthepublicduringanepidemicoutbreak isthehealthcare

workers,especialprimarycareproviders(CDC,2011a,2011b).Thehealthcareworkersmediatethehealth

instructions to thepublicandcanadapt the treatmentandmessage to theirneeds.However, thereare

reports in the literature thatwhilehealthcareworkers canhelpmediate themessage for thepublic to

complywiththeinstructions,notallofthemarecompetenttodoso(Lasseretal.,2008;Maurer&Harris,

2010).Therefore,

it

was

important

to

identify

the

instructions

that

were

given

to

healthcare

workers.

Itappeared,bothin2005and2009,thatthe instructionsforhealthcareworkersweremainlyprocedural,

with littleconsiderationofcommunicatingthediseaseandthevaccinetothepublic.Healthcareworkers

received instructionsregardingwhotovaccinate,when,andhowthevaccineworks(CDC,2011a,2011b).

Theydidnotreceiveinstructionsonhowtocontendwithfears,questions,andskepticism.

ThispointalsoemergedfromtheinterviewsweconductedwithIsraelihealthcareworkers.Whilemostof

themshowedahighdegreeofknowledgeofthe instructions,whoneededtobevaccinatedaccordingto

the health organizations, and how to do it, they claimed that they received no guidance on how to

communicate thevaccine.Anurseexplained that thegeneral impressionwas that thepublic shouldbe

forcedto

take

the

vaccine

and

that

this

process

lacked

active

communication:

"In

our

meetings...

we

were

instructed on how to behave when a patient comes in..." Other nurses added: "We had a written

procedure...whatweneededtoknow,whowouldgetit...wedidnotknowhowtogettopeople"(asenior

nurse). "We were instructed that we should vaccinate and that's it, goodbye" (a nurse). "We received

instructionsfrom above and nothing more (a nurse). "There werejust general instructions" (a senior

nurse).Thesamepictureappearedalsowiththemedics:"Wereceivedonlygeneralinstructionsonhowto

treatpatients...wedidnotgetinstructionsaboutcommunicating thevaccine"(amedic)."Wedealtmainly

with...whoneedstogetavaccineandatwhatage...notcommunication"(amedic).


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23

3.3.4. Facingsituationsofuncertaintyandgivinganswerstothe"unknowns"The2009H1N1pandemicflucreatedasituationofuncertainty.Unpredictabilityastothedevelopmentofa

pandemic creates a situation of uncertain risk which needs to be communicated to the public. It is

necessarytoinformthepublicnotonlyabouttheconditionsofuncertaintybutalsowhen,whyandunder

what circumstances they occur (Frewer, 2004; Frewer et al., 2003;Mebane, Temin,& Parvanta, 2003;

Rudd,Comings,&Hyde,2003).Twoquestionsrelatedtouncertaintywereaddressed bytheinternational

healthorganizations inthe2009reports (CDC,2011b;WHO,2009).Onerelatedtotheepidemicandthe

othertothevaccine,bothofwhichwerenewin2009.Welearnedfromthereportsthatuncertaintyover

boththeepidemicandthevaccinewerebeingdealtwithtogether.

In2005,theinternationalorganizationstriedtoplaninadvancehowtoconfrontandcommunicatefuture

influenza pandemics (NHS, 2005a, 2005b) The assumptions were that susceptibility to the pandemic

influenza subtypewould be universal, the clinical disease attack ratewould be high and sowould the

number

of

hospitalizations

and

deaths.

Other

assumptions

related

to

the

duration

of

the

pandemic,

secondary infectionsandriskgroups,andfatal infections(NHS,2005a).Basedontheseassumptions,the

international health organizations had to decide how to communicate the 2009H1N1 epidemic to the

governmentsandthepublic,whenitsseveritywasnotyetknown.

Anotheraspectofuncertaintythatappearsinthereportsreferstothevaccineitself.Manyquestionswere

raisedregardingthesafetyofthevaccineanditsabilitytopreventthedisease.Thisalsocausedalargepart

ofthepublicnottogetvaccinated.Otheruncertaintiesrelatedtothevaccineincludedavailability,safety,

efficacyandprioritygroupdistribution.Wecheckedwhether theorganizationsdealtwith thematterof

uncertainty.

The

international

organizations

argued

that

the

emergence

of

the

2009

epidemic

presented

many

communication challenges. The international organizations reported that "the emergence of a novel

pandemic H1N1 (pH1N1) influenza strain presented many communication challenges for public health

officials.Therewere unknownsaboutthedisease,suchasseverityandspread,duringthe initialstages"

(CDC,2011b,p.1).The2009reportsarguedthatcommunicationrouteswerepreestablished inorderto

copewiththeuncertaintyandtopassthe information inatimelymannertothememberstatesandthe

governments. This was the solution that the international organizations applied to confront issues of

uncertainty. The conclusion that appeared in the reports was that despite the uncertainty that

characterized the early stages of the epidemic, the system responded fast to solve those issues. This

solutionwas foundtobeusefultodealwithuncertaintiesuntil theepidemicprogressedandmore facts

were known (CDC, 2011b).While this reflects reference to thematter of uncertainty, the theoretical

dimensionand

recommendations

available

in

the

literature

were

not

implemented

in

the

communication

strategy.

IntheinterviewsweconductedintheIsraelicasestudy,itemergedthattheissueofuncertaintybothered

thepolicymakersforthewholeperiodoftheinfluenza.Amongthepolicymakers,thethemethatemerged

focusedonthevaccineitselfandnottheepidemicingeneral.AnIsraelipolicymakerexplainedthatinthe

first stagesof thedisease,when importantdecisions (e.g.buying the vaccine)needed tobemade, few

answerswerereceivedfromtheinternationalhealthorganizations:"Oneofthecentraldilemmaswaswhat

wasgoingtohappen.Wewere inaseriousconditionofuncertaintyandthedilemma...washowmuchto


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24

invest inthisuncertainty...andhowtomoveforward."AnotherhealthofficialaddedthatwhiletheWHO

recommendedthevaccine,therewasstillinformationmissing:"Weknewwhatothercountriesweredoing

andwhattheWHOrecommended...thereweremomentsthatwefeltthatweweregoingtomissthetrain

andtherewouldbeashortageofvaccines."

Among

the

healthcare

workers

we

identified

two

groups.

The

first

group

consisted

of

healthcare

workers

who followed the instructions regarding the epidemic and the vaccine, without being bothered by

uncertainties.Thisgroup includedmostof themedicsand someof thenurses.However, the important

group was the second one, which followed the health organizations instructions with a feeling of

ambivalence, as they feltmany questions had been left unanswered. "On the one hand, we received

instructions to vaccinate people, but we still had questions about this process... there were many

unknowns...howcouldIvaccinatesomeoneandconvincehimwhenImyselfhaddoubts?"askedanurse.

3.3.5. Communicatingthevaccineastheonlyoptionorprovidinginformationonotheralternatives?InthischapterweexaminedthecommunicationprocessforthepreventionoftheH1N1influenzain2009.

Wecheckedwhetherthevaccinewastheonlyoptionrecommendedbythe internationalorganizationsor

whetherotheralternativeswerepresentedwithfullinformation. Itmustbestressedthatwedidnotdeal

withtheepidemiologicalquestionwhetherthealternativeswereagoodsolutionornot.Inthisreportwe

dealonlywiththequestionofcommunicatingthem.

The reportsdidnot ask thisquestion specifically,but ratherweposed itourselves.We found that this

question could not be fully answered by the reportswe examined.However,we can assume that the

vaccinewas presented as the onlyoption.We are basing this assumption on several factors. First, the

reportsweanalyzedreferredfrequentlytotheknowledgethatthepublic,healthcareworkersandothers

had

about

the

vaccine.

In

addition,

we

found

few

references

to

other

solutions,

besides

medications

for

peoplewhoalreadysufferedfrominfluenzasymptoms(CDC,2011b).

Further supportcanbegathered from the interviewsweconductedwith Israelihealthcareworkersand

policymakers.Theyarguedthatalargepartoftheguidancetheyreceivedwasabouttheimportanceofthe

vaccine:"Mostofthetime intheteachingsessiontheytalkedaboutthevaccine" (anurse)."Wereceived

someinstructionsabouthownottoinfectothers,nottosneezeonyourhand,butitwasnotpresentedasa

solution"(anurse)."Noalternative[solution]waspresented"(amedic)."Thevaccinewastheonlyrelevant

solutionatthattime"(policymaker).

3.4. SocialMarketingThequestionoftheepidemicanditsvaccineconnectstothefieldofsocialmarketing,whosepurposeisto

changethehabits,behaviorsandlifestylesofvarioustargetaudiences.Socialmarketingdealswithbarriers

thatthepublichaswhen tryingtoadoptanewbehavior,suchascompliancewiththe influenzavaccine

(Lee& Kotler, 2011). Those barriers relate to subjects thatwere discussed above (e.g.mistrust). This

chapterwilldiscussthetheoreticaldimensionsthatcanhelp lowerthosebarriers:stakeholder inclusion,

identificationofsubpopulationsandsegmentation.


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25

3.4.1. StakeholderinclusionThe question of inclusion relates to the part stakeholders, such as healthcareworkers, communication

expertsandthepublicitself,playincommunicatingthehealthmessages(Duffy&Thorson,2009;Holmes,

Henrich, Hancock, & Lestou, 2009; Kotalik, 2005; UscherPines, Chernak, Alles, & Links, 2007). We

examinedwhat part these stakeholders took in communicating themessage of the epidemic and the

vaccine.Whileitmustbenotedthathealthcareworkersarenotahomogeneousgroupwithinorbetween

differentcountries,itisimportanttounderstandtheirpotentialroleinthecommunicationprocess.

Asmentioned in the chapter on risk communication, therewas no reference topublic inclusion in the

reportsfor2009thatcanteachusaboutthisprocess,unlike2005,whenfocusgroupswereconducted.The

CDC sometimes conducted polls inorder tomake sure that themessageswere clear, but no inclusion

methodswerementioned (CDC,2011b).Both in2005and2009healthcareworkersplayed thegreatest

partof the threegroupsof stakeholders.However,even theirpartwas small.Theprocess in2009was

similar

to

what

the

reports

from

2005

revealed.

It

was

based

on

the

assumption

that

healthcare

providers

obtain information fromavarietyofsources includingtheir regionalpublichealthunit,provincialhealth

organization and professional associations. The process of developing influenza epidemic plans

necessitatedconversationsandcollaboration withhealthcareworkers.

However,fromananalysisofWHOandCDCreports,whilemostofthecommunicationrouteswerepre

establishedandallowedfortherapidexchangeofinformationbetweenkeypartnersduringtheepidemic,

therewaslittleinclusionduringthedevelopmentofthosecommunicationroutes.Afterthecommunication

routeswereestablished,therewaslittlefurthercollaboration withhealthcareworkers.Afterthefirstwave

of passing information to the healthcare workers, an evaluation process was initiated in order to

understand their attitudes. Based on this evaluation, some programs were changed and others were

created,as

can

be

seen

from

the

following

quote:

"Frontlinecareproviderswereanothergroupthatfoundthepandemicplaninsufficientinthefirstwave

ofthepandemic.Theyrequestedthatinformationapplicabletoprimarycaresettingsbedisseminatedin

atimelymanner.Afterthefirstwave...collaboratedwithfamilyphysicianstodevelopPandemicH1N1:

FastFactsforFrontlineClinicians,whichfrontlinehealthcareworkersfoundhelpful"(CDC,2011b,p.3).

Asmentioned in the risk communication chapter, even these programswere apparently not sufficient,

while even the international organizations reported conflicting results regarding healthcare worker

participation(CDC,2011b).

In

the

interviews

we

conducted

in

Israel,

the

general

image

that

the

healthcare

workers

presented

was

quitesimilar.Theyarguedthattherewereinclusionprocesses,buttheydidnotalwaysfindthemhelpful.

Whenaskedwhether theywere includedand consultedonhow tocommunicate theepidemicand the

vaccinetothepublic,agreatmanyofthemansweredintheaffirmative.Theyreportedstaffmeetingsand

otherconversations inwhichtheywereasked fortheir ideas.However,theyclaimedthattheycouldnot

identifyanychange.Anurseexplained: "Wehadmeetingseveryonce inawhile...Theypresentedwhat

theyknewandwhattheprocedureswere...Theyaskedifwethoughtthatthingsshouldbechanged...There

wasdiscussionandsomearguedandprovidedothersuggestions...Mostofthetime,wehadthenotionthat

westilldidn'thavethefullpicture...Afterwards...Ihadnocluewhattheydidwithit."


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26

Designing communication strategies for promoting the epidemic and the vaccine requires expertise in

communication.Apartof thecommunicationprocess isworkingwith themedia,which isan important

channelofcommunicationbetweentheorganizationsandtheotherstakeholders.Therefore,wechecked

the reports for consultations with communication experts, such as journalists, bloggers and others.

Consultationswith communication experts regarding the design of the communication strategieswere

foundin

the

reports.

Intheinterviewsweconducted,theIsraelijournalists,andespeciallythebloggers,expressedtheirneedfor

participation intheprocess.Mostof themagreedthatbecause theyplayedakey role inpassingonthe

message,theycouldmakean importantcontributionto theprocess,asexplainedahealthjournalist:"If

youallow themediapeople toparticipate...andexplainandhear...noonewill say that theydontcare

aboutpublichealth...Weneedtoworktogether,tothinktogether,howtopasstheinformationontothe

public...We can representour side in theprocess,which is important."While thejournalistshad some

cooperation fromthe local Israeliorganizations,bloggersarguedtheywerecompletely leftout:"Wehad

only thepress releasesfrom thewebsite [of theMinistryofHealth]...Wedidn'tworkatallwith Israeli

sources.Justfromabroad...Wesometimesneeded to,buthadnoaddress" (an Israelihealthblogger).A

minorityof

the

journalists

argued

that

they

should

not

have

been

involved

in

designing

the

messages,

out

ofthefearthattheirfunctionas"democracyswatchdogs"wouldbecompromised.

3.4.2. IdentificationofsubpopulationsandriskgroupsVaccinationandcommunicationstrategiesneedtobebasedonacleardelineationofthegoal e.g.limiting

thespreadofthediseaseortryingtoprevent individualcases,apublichealthoraclinicaloutcome.The

goalmustbestatedatthebeginning,whiletheotherstepsderivefromthisgoal.However,wecouldn'tfind

inthereportsaclearcutgoalthatdefinedtheotherstagesintheprocess,butrathergeneralgoalsabout

preventingthe

pandemic.

Oneofthesubjectsthat issupposedtobethesecondstep,afterdefiningthegeneralgoal, is identifying

riskgroups. Identificationof subpopulationsand riskgroupswas very clear, inboth the2005and2009

influenza reports. Subpopulation refers to any part of the general public that should get different

treatmentbecauseofavarietyofreasons,suchas language,culturaldiversityandothers.Thepeople in

these groups are not necessarily in risk groups. They are just members of groups that need special

attention from the authorities. Some of these subpopulations are risk groups (e.g. pregnant women,

children).Thedistinctionbetween riskgroupsandother subpopulations is that the internationalhealth

organizationsrecommendriskgroupsbeadvisedmorethanotherstotakethevaccine.Aspartoftherisk

assessment, risk groups were identified. Identifying risk groups with incomplete information in an

atmosphereofuncertainty, a situation that characterized the early stages of the influenza outbreak, is

boundtoresultinsomedegreeofpoordecisionmaking.

Itappearedfromthereportsof2005and2009thatsubpopulationsandriskgroupsweretargeted.Among

differentsubpopulationsthatarementionedinthevariousreportswecouldfindschoolchildren,children

indaycare,homelesspeople insheltersandevenculturalcommunities(e.g.aboriginal).However, itwas

not always reported how those subpopulations were determined. One of the strategies that were

mentionedwasholding informationsessionswith localcommunitypartnersandculturalorganizations in


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28/45



28

focusedon subpopulations ingeneralandnoton specific riskgroups.Very fewexamplesweregivenof

targetingmessages to vulnerable groups in settings such as schools, daycare centers, universities and

others.However,eveninthesecasestherewerenoclaimsaboutdesigningthemessage.

3.5. CommunicationflowThelastpartweexaminedinthereportswastheimplementationofthestrategiesmentionedaboveinthe

media.Herewefocusedontheuseandcontentofmassmediaandnewmediaingeneralandsocialmedia

in particular. We checked whether the flow of information was oneway, from "topdown," or also

considered feedback from the "bottomup.We analyzed this theoretical dimension on four different

levels.First,wecheckedthestrategyofintimidationaspartofaonewayflowofcommunication.Second,

weexaminedthegeneraluseofthecommunicationchannels,whilethethirdstepfocusedonthevarietyof

channels.Inthefourthstepweexaminedthecontentsofthereportsandtheirsources.

3.5.1. Intimidationasaresultofthemediacoverage,butnotastrategyIn the face of uncertainty surrounding a health situation, the media sometimes uses a strategy of

intimidatingthepublic (Holmes,etal.,2009).Thismightbea resultofmessagesdesignedbythehealth

organizationswhowanttoencouragethepublictocomplywiththerecommendationsbypresentingthem

withthepossibledetrimentalresultsofnotadoptingthehealthybehavior.Itmightalsobearesultofthe

mediastendencytosensationalizeintheinterestofviewershipratings.

The international health organizations declared clearly in the reports that the general aimwas not to

intimidate

the

public

(CDC,

2011a,

2011b;

WHO,

2009).

Therefore,

we

cannot

point

to

a

strategy

of

intimidation.Massmessages focusedonthe importanceofthevaccineandonrecommendedbehaviors.

However,we could not find in the reports the rationale that stood behind themessages, in order to

ascertainwhether they reallywere not part of an intimidation strategy.Whatwe foundwas that the

international organizations reported daily on the spread of the epidemic, including statistics about

fatalities.This reportingcannotbeconsidereda strategyof intimidation. Itmustbeconsideredpart the

reportingprocessitself,aswillbeexplainedbelow.

InacontentanalysisofhowthemediacoveredtheH1N1epidemicaroundtheworld,70%ofthearticles

werefoundtobefactualprovidingfactsandhelpfulinformation.Thereportcametotheconclusionthat

proactiveengagementwith themediaby internationalandnationalpublichealthauthorities resulted in

factual,non

alarmist

reporting

of

the

first

stages

of

the

2009

H1N1

epidemic

(Duncan,

2009).

Was themedias reporting truly factual,andnonalarmist, in the Israeli caseaswell?Whilewedidnot

conductanempiricalcontentanalysisofthereportsinIsrael,wecantalkaboutperceptionsoftwoofthe

threepartiesinthereportingprocess:thepolicymakers,asoneofthesourcesfortheinformation,andthe

journalists,asthereporterstothepublic.Sincewedidnotconductinterviewswiththepublic,wecannot

drawconclusionsaboutitsperceptions.


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29

IntheinterviewsweconductedwithjournalistsfrommajormediaorganizationsinIsrael,theyexpressed

the perception that their coverage of the epidemicwas always factual. They claimed they did not use

intimidationasastrategy,butpreferredtoreferto"truehuman intereststories."Bythisdefinition,they

referred toall the stories thatdealtwithpeoplewhomighthavediedbecauseof thevirus.Ajournalist

explained: "We sometimes reportedaboutpeoplewithmasks,because it's interesting... It'sjournalism...

Sometimesthere

were

uncertainties

and

'hysterics'

that

we

reported,

but

it

was

pure

facts

about

what

had

happened."Itisnoteworthythatthebloggersclaimedthejournalistsusedastrategyofintimidation,while

insistingthattheyreportedfactualinformationfromdifferentsources.

Fromthepointofviewofthepolicymakers,thejournalistsreportingprocesswasnotalwaysfactualand

wassometimes intimidating.Onepolicymakerreferredtothepressreleasesthatweresenttothemedia

organizationseveryday:"Ioncetookajournalistandtoldhimtotakearandompressreleaseandtosee

whatitsaid.Hetookone...Hefoundasimple,twoline,quiteinformativepressrelease,aboutasuspicious

caseofH1N1... Itoldhim: 'Now,havea lookatthereportonthispressrelease'...Hetooktheheadlines:

'Pandemic!Fear!'Afullredpage...Itoldhim:'Arewetheonesmakingpeoplehystericalorisitthemedia?'"

Therefore,wecanconcludethatiftherewasintimidation,itwasaresultofthemediacoverage,andnotan

intentionalstrategy

by

the

international

or

national

health

organizations.

3.5.2. FocusingontheonewayflowofcommunicationBesidethequestionofthevarietyofcommunicationchannelsavailable,thereisthequestionofhowthey

arebeingused.This is thequestionofoneway flowversus twoway flowof communication,whichwe

posedandwhichdidnotappear inthereports.Aonewaycommunicationflowdescribestheprocessof

passing information from the "topdown," directly from the addresser to the public,with little, if any,

feedback.Ontheotherhand,atwowaycommunicationflowalsoconsiderstheinformationthatisbeing

passedfrom

the

"bottom

up,"

such

as

feedback,

worries,

objections

and

problems

(Sandman,

1994).

While

examining this theoretical dimensionwe checkedwhether the use of communication channels for risk

co

d2.7 the new global health security regime

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