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Chapter 9

Risk and Crisis Communication

“Terror threat orange,” “A category four hurricane is heading toward Florida,” “Eat foods that are high in fiber,” and even “Put on sunscreen before you go outside today!” are common preventive risk messages we all frequently hear. Even at college you have likely heard your friends sending messages to you or other friends such as “Don’t drink too much,” “Be sure to have a designated driver,” and “Take condoms just in case.” As you get older, you are likely to hear more and more messages about changing diet and exercise habits, and messages about mammograms, colonoscopies, and prostate cancer exams as preventive measures for disease when you reach a high-risk age group. While many individuals in the US may not perceive that they are at risk for health problems, we are all vulnerable to some type of physical, psychological, or social health threat. From the examples given above, you may have noticed that health threats range from widespread threats (global and regional) to community and individual threats. As a result, health communication researchers have become increasingly interested in identifying groups of people who are at the greatest risk for specific types of threats and finding ways to design appropriate messages to help individuals avoid or reduce them.

The 21st century is a time in which people are much less likely to die from acute diseases such as pneumonia or an injury caused by a bad fall and far more likely to be harmed by chronic diseases like heart disease and cancer. The good news about these more modern times in terms of our disease susceptibility is that thanks to scientific advances people do live much longer, with the average life span for women around 76 and for men around 74 years. Another bit of good news is that effective, evidence-based communication efforts can dramatically reduce the harm that comes from chronic illness and actually result in better health outcomes and longer, more fruitful lives. However, we also are discovering that as science and technology advance, we increasingly understand that the causes of many chronic diseases such as cancer are quite confusing with no real end in sight. As one can gather, risk communication is very important and interesting!

We have also seen the world at greater risk for global and large-scale health threats, such as HIV/AIDS, environmental threats (e.g. pollution and toxic waste), and politically motivated threats, such as bioterrorism. The terrorist attacks on September 11, 2001, the anthrax mailings in the months following September 11, and viruses such as SARS and avian “bird” ’flu have made many people in the US realize just how vulnerable they are to health threats in our ever-shrinking world. Communication between government agencies, media sources, scientists, and healthcare providers around the world is crucial during times of health-related crises and in order to cope with pandemics, such as HIV/AIDS. In addition, health communicators must now be conscious of disseminating messages about some health risks to a worldwide audience.

In addition to these health threats, there are many populations within the US and all over the world who are at risk for various health problems due to reasons such as poverty, age, race, hunger, inadequate education, insanitary environmental conditions, and lack of access to appropriate healthcare. Many of these populations are marginalized groups who are at risk for health problems due to larger social issues, including political and cultural conditions, racial injustice, and lack of financial and social resources. Increasingly, we are seeing a greater divide between those who have the resources to deal with these health issues and those who do not. Communicating health risk and coordinating disease prevention and control efforts within these populations can be complex and challenging situations for healthcare promoters.

This chapter explores health risk and crisis communication issues at the global/large-scale, community, and individual levels. Specifically, it begins by defining risk communication and crisis communication. This is followed by a discussion of global threats to health, including HIV and terrorism, as well as communication strategies for coping with these threats. Next it examines several factors that are related to being at risk for health problems in the US and strategies for communicating about risk at the community level. Finally, it examines strategies for communicating about risk at the provider–patient level.

Defining Risk Communication

What Exactly Is Risk Communication?

Risk communication involves creating shared understanding about uncertain loss or danger. Historically, risk communication has evolved to examine theory and research related to the communication of scientific information about environmental, agricultural, food, health, and nutritional risks. It concentrates on social theories related to risk perception and behavior. Scholars interested in risk communication issues examine case studies involving pesticide residues, waste management, water quality, environmental hazards, and personal health behaviors. The multi-disciplinary risk communication field emerged in the 1970s and 1980s. In those decades, members of the public, scientists, engineers, corporate leaders, and government officials were coping with Love Canal, a Niagara Falls, New York neighborhood where 21 000 tons of toxic waste were discovered buried beneath neighborhood homes; the Three Mile Island nuclear accident in Pennsylvania; and the Bhopal, India, disaster, where thousands died from accidental release of hazardous chemicals. As Leiss and Powell (2004) explain, modern day risk communication investigates mad cow disease, climate change and genetic technologies, as well as oil spills, nuclear leaks, E. coli, vaccinations, etc. For instance, the story of the bovine spongiform encephalopathy (BSE) outbreak started in the UK in the 1980s. BSE is still being discovered in UK herds, and cases of mad cow disease have been found in twenty countries across the European continent and as far away as Japan with devastating consequences for the food industry. BSE has now been discovered on the North American continent in two cows born in Canada. The original cause of these two new cases is almost certainly importation of infected cattle, cattle feed, or both from the UK. Canadian government regulators and those in the cattle industry have failed to correctly assess the risks of the disease in the Canadian herd, take the precautionary measures needed to prevent the spread of disease, and communicate risks and precautionary measures to the public (Liess & Powell, 2004). Global warming and climate change are hot risk communication topics. Not only is every aspect of this risk debate both contentious and difficult for the public to understand, but the potential consequences of the risks extend all the way to global catastrophe for human civilization. Genomic science is a risk communication context that taps into both the health benefits expected from genetic manipulation and some of the risk factors associated with it.

Risk can take on a number of meanings depending upon the lens one places onthe operationalization of the definition. For example, in the business and finance world, risk usually refers to the strategies surrounding the volatility of an investment or the likelihood that a certain use of money will cause unpredictable losses or gains.

In the sciences (social, behavioral, life, or technical), risk is often viewed as an index of the severity of some harm and the chances it will adversely affect people or the environment. For instance, when a new pesticide helps farmers keep their crops from being eaten by pests is a good thing, but when that same pesticide use becomes toxic or harmful and the bad outweighs the good, then we have a problem to solve via risk communication. People constantly debate the risks and benefits of phenomena such as whether or not to take the three doses of the human papilloma (HPV) vaccine before the age of 26, smoking cessation, sunscreen protection, food, alcohol or drug use or abuse, safe sex practices, texting or drinking while driving, as well as pesticides, genetically modified organisms, processed foods, vaccination, and nuclear power. Therefore, effective risk communication is key.

The risks that upset people are not always those that kill them, and the risks that kill them may not be the ones that upset them. For instance, accidents at nuclear power plants, terrorist attacks, and contamination of processed foods cause considerable concern and outrage. Nevertheless, the numbers of people killed or harmed by these phenomena are far fewer than those killed daily by activities such as smoking and automobile accidents. Half of the 47 million Americans who smoke, and continue to do so, will die from tobacco-related diseases, according to the US Centers for Disease Control and Prevention. Those between the ages of 4 and 33 years are more likely to die in an automobile accident than in any other way, according to the US National Highway Traffic Safety Administration.

Roger Kasperson and associates studying risk perception issues developed the Social Amplification and Attenuation of Risk Framework to explain how social and communicative institutions and processes dramatize some disasters or harms and minimize others. A classic example is the 1989 Exxon-Valdez accident in the Prince William Sound of Alaska that involved 11 million gallons of crude oil fouling roughly 1 000 miles of once-pristine coastline. Media coverage of the accident was instantly accessible with vivid images of oil-soaked animals. The Chief Executive Officer of Exxon at the time, Lawrence G. Rawl, made a huge mistake by not immediately traveling to the site. Each of these elements amplified and dramatized public outrage, causing the Exxon Valdez to become one of the most widely known oil spills of all time. Literally dozens of other oil spills have impacted communities across the decades, but few have received the media attention and outrage of the Alaskan accident.

Oil spills are a telling example of the hundreds of hazards that interpersonal, organizational, mass communication, and social media processes dramatize or minimize. Many remember Hurricane Katrina as the worst disaster of 2005, a storm that killed over 1 300. However, according to the International Disaster Database in Brussels, Belgium, also in 2005, an earthquake in Pakistan killed over 73 000 people. It is important to remember that the location of a hazard and the ways it is communicated, from organizational leaders to the media to social networks, affect the degree to which that hazard is detected, recalled, discussed, and managed.

Risk Communication Vs. Crisis Communication

Risk communication and crisis communication are different from one another in one important sense. Generally, risk communication deals principally with communication about physical hazards such as tornadoes, toxic chemicals, and so forth (Rowan et al., 2008). Risk communication deals mainly with communication about physical hazards such as tornadoes, toxic chemicals, and so forth. Crisis communication may, but does not have to concern, physical hazards. For example, an unexpectedly negative news article could constitute a crisis for an organization or an unexpected disaster such as the 2011 Japan earthquake and Pacific tsunami could raise worldwide awareness in disaster preparedness as the near 9.0 earthquake has greatly devastated the country, impacted the economy, etc. Hurricane Katrina could constitute a crisis for Louisiana and the entire country by raising awareness of a nation lacking in preparedness and effective communication exchange among officials and the affected communities.

Risk communication also deals with a range of issues involving health/risk information and preparation strategies to the public and key state and local government and non-government response partners before a tragic event occurs. Risk communication strategies for public health preparedness often concern agriculture, food, water issues; infectious disease and vaccines; mental health and general public health; as well as chemical, biological, nuclear, and radiological threats (see jhsph.edu/preparedness, http://www.bt.cdc.gov/cerc/pdf/CERC-SEPT02.pdf, for detailed information). The Centers for Disease Control (see cdc.gov) have prioritized risk communication and health information dissemination since 2004. Risk communication topics can range from frightening diseases such as cancer and AIDS, to mental health, to earthquakes and tsunamis (e.g. Japan), and violence in schools (e.g. Virginia Tech University). Scientific uncertainty about diseases sometimes leads people to wonder about the possible ways in which they may have contracted them. Consequently, groups as diverse as trade associations, medical associations, public relations offices, and many government groups currently devote considerable effort to learning how best to communicate with the public about risk and safety.

Crisis Communication

After September 11, 2001, the term “crisis communication” took on greater meaning and urgency in the US. The phrase had been in use for decades, particularly by scholars studying military operations and international relations. In the post 9/11 crisis and terrorism environment, government officials, first responders, providers/practitioners, community leaders, community members, and researchers confront an alarming range of communication obstacles that can limit the effectiveness of responses to risk and terrorist events. Terrorism, not surprisingly, has become a significant topic in crisis management, academe, industry, and in our communities. The issues surrounding terrorism have now become an integral part of our daily conversations in America and throughout the world.

In the field of communication, crisis communication research involves the application of the use of strategically designed messages delivered through selected sources (mediated and interpersonal) to convey relevant information to targeted audiences in crisis situations that have the following features: (i) uncertainty; (ii) intense emotion; (iii) disparate target audience; (iv) time is of the essence; and (v) communication of appropriate and effective strategic message(s) is urgent. None of these aspects is unique to crisis communication (e.g. in health communication contexts, we know that a physician breaking bad news of a cancer diagnosis often faces a difficult emotional response), but when we consider these aspects jointly, we have a unique new communicative challenge worthy of systematic and thorough examination. Further, crisis communication involves creating ways for people to gather important information in a timely manner, while being able to adequately protect themselves when the information available is uncertain or equivocal.

Typically, a crisis is an event that occurs unexpectedly. When a crisis occurs, it may not be within a government or private organization’s control, and may cause harm to the organization’s good reputation or viability. An example of an organization facing a crisis is one where there has been an occurrence of a mass shooting of employees by a disgruntled employee. Or, as we saw with Hurricane Katrina, government agencies received criticism for not being sufficiently prepared to handle this particular crisis. In most instances, organizations face some legal or moral culpability for the crisis (unlike a disaster in which a tornado wipes out the production plant), and stakeholders and the public are judging the organization’s response to the crisis. The underlying thread in crisis communication is that the communicating organization is experiencing an unexpected crisis and must respond. Crisis also implies lack of control by the involved organization in the timing of the crisis event.

An important goal of health communication scholars is to raise public awareness of the importance of communication following a crisis, why communication about hurricanes, terrorist attacks, health epidemics, and other unknown disasters can be so difficult, and what people can do to improve these communication processes.

Global and Large-Scale Health Threats

This section explores some of the major threats to health around the world, including environmental threats, hunger, pandemics, and terrorism. In addition, we will explore several responses to these threats posed by health communication scholars.

Environmental Threats/World Hunger

Environment-related diseases and injuries cause millions of preventable deaths each year. Hazardous waste disposal, overpopulation, smog, and pollution are just a few of the many adverse environmental factors that have been linked to health problems. As we discussed earlier in this chapter, people who are poor and/or marginalized tend to be at most risk for many of these health problems. Overpopulation is most common in developing countries, many of which already lack sufficient financial and structural resources. In countries with overpopulation problems, more people mean that there are greater demands on farm land, water supplies, and other natural resources, many of which are often affected by pollution due to the number of people. Around the world, millions of tons of hazardous waste are produced annually by industries, and these materials are often linked to many different health problems. Unfortunately, minority and/or low-income populations within many countries face environmental injustice, or disproportionate exposure to environmental dangers due to race, ethnicity, or socioeconomic status (Anderton, Anderson, Oakes, & Fraser, 1994). Hazardous waste disposal often occurs in locations that are in close proximity to where minority and/or low-income populations live, areas which are considered “undesirable” by higher-income individuals within the greater community. While most of these hazardous materials are contained within landfill, toxic emissions from landfills, such as methane gas, can create health risks for people in the surrounding areas. For example, methane and other gases emitted by landfills are carcinogenic, leading to long-term health problems.

Environmental injustice appears to be a global phenomenon. Ethnic minorities in Central Asia, Australia, Africa, and South America have all suffered acute and prolonged health problems caused by radiation tests, toxic waste from the petroleum industry, and many other hazardous materials (Bullard, 1993). In the US, several studies have found evidence of toxic waste materials being dumped near minority and/or low-income neighborhoods (Rowan, 1996).

More than 840 million people in the world suffer from hunger or are malnourished, and while hunger is certainly a problem in the US, most people facing hunger live in developing nations (Care.org, 2006). Millions of children suffer from hunger around the world, putting them at risk for developmental problems associated with malnutrition, such as stunted growth, susceptibility to disease, cognitive impairment, and early mortality rates. About 5 million children around the world die from problems related to malnutrition each year. In addition, hunger affects an individual’s productivity, sense of hope, and overall well-being. There are many causes of world hunger, including the economic condition of countries and regions, land rights and ownership, inefficient agricultural practices, war, famine, drought, poor crop yields, and environmental problems.

As you can imagine, dealing with problems such as environmental injustice and world hunger is no easy task. At the very least, health communication scholars and other individuals can help to raise awareness about environmental problems and environmental injustice by conducting more studies that demonstrate the link between industry waste disposal practices and health problems, by interventions designed not only to raise awareness of these issues among people living in communities where these practices occur but also to give them the tools to promote change, and through health campaigns designed to change industry practices or that create new legislation that will end them.

While the world has the capacity to produce enough food for everyone, we are well short of achieving this goal. A variety of economic, political, educational, and cultural issues, such as the wealth of a region, rights to land, racism, and knowledge about agricultural practices, contribute to the inability of regions to produce and distribute food to everyone. Donating food as aid or charity in non-emergency situations is more or less a short-term solution to world hunger. While such donations can be crucial during emergency situations, the long-term solution to hunger may lie in economic, educational, and political reform efforts. Again, campaigns designed both to raise the awareness of those individuals who have the greatest needs and to improve economic and educational conditions are ways in which health communication scholars can help to make a long-term impact on hunger.

Pandemics

A pandemic is a global epidemic of a disease or health problem. The world is more vulnerable to pandemics than ever before due to increased travel around the world and immigration. The HIV/AIDS threat is the most prominent pandemic the world faces today. However, other diseases have the potential to become pandemics if efforts are not taken to contain them. We will focus on the impact of HIV/AIDS and the emergence of new threats, such as SARS and avian ’flu, and responses to these threats below.

HIV/AIDS 

More than 20 million people worldwide have died of AIDS since the beginning of the pandemic, and 38 million people were estimated to be living with HIV/AIDS by the end of 2003 (Joint United Nations Program on HIV/AIDS, 2004). Women now account for about half of the number of people with HIV worldwide. Young people (between the ages of 15 and 24) account for most of the new HIV infections worldwide.

Africa is the continent that has been hit the hardest by the HIV/AIDS pandemic, followed by South and Southeast Asia. Nearly 25 million individuals with HIV/AIDS live in African countries, while over 6 million live in Asian countries (Joint United Nations Program on HIV/AIDS, 2004). A large proportion of individuals living with HIV/AIDS are from low-income countries, such as many countries in sub-Saharan Africa and Asia, and lack access to antiviral medications that could prolong their lives. Even within higher-income countries, such as the US and a number of European countries, people who have reduced economic means typically lack access to these medications and are at greater risk for developing opportunistic infections associated with HIV/AIDS and dying from the disease sooner. The number of people with HIV/AIDS is expected to rise despite increased knowledge about prevention and treatment of the disease.

Patterns of infection vary among regions of the world. The populations that are at greatest risk for HIV/AIDS include pregnant women between 15 and 24 years in African countries (Joint United Nations Program on HIV/AIDS, 2004). In many Asian countries, injecting drug users, sex workers and their partners, and men who have sex with men are the most vulnerable to the disease (Steinfatt & Mielke, 1999). Within Europe and the US, injected drug use and sex between men are currently the greatest risk factors for contracting HIV. However, infection due to heterosexual sex is on the rise in the US, particularly among minority groups. These at-risk behaviors are associated with socioeconomic issues. Many people in Southeast Asian countries become sex workers because it is often a better economic alternative than other types of employment in economically depressed areas (Steinfatt & Mielke, 1999; Wenniger et al., 1991). In some cases, young women are forced by their family members to engage in sex work in order to financially support their family. Many people who inject heroin and other drugs often cannot afford clean needles, and so sharing needles (and the chance of contracting HIV) is more prevalent among low-income populations. In addition, lack of education about HIV/AIDS and low condom usage in many countries contribute to high incident rates.

Communicating about HIV/AIDS risks to vulnerable populations around the world has proven to be a difficult task. The risk factors for HIV/AIDS vary by region and culture around the world, and many at-risk behaviors are related to cultural beliefs and behavioral norms. These beliefs and behaviors are shaped by an array of complex social, economic, and political factors (Amaro, 1995), all of which health risk communicators need to take into consideration.

For example, Cameron, Witte, and Nzyuko (1999) found that the high prevalence of HIV infection in Kenya was related to the cultural practice of prostitution among young women and truck drivers on the Trans-Africa highway. Young women in this part of Kenya are often drawn to prostitution because of their economic situation. Cameron, Witte, and Nzyuko (1999) found that it was the cultural norm among male truck drivers in this culture to have sex with multiple partners, and they tended to have fatalistic beliefs about contracting HIV (e.g. the belief that everyone has to die of something, so what difference does HIV make?), and many held the belief that sex with a condom was not “real” sex. The women interviewed in this study said that they found it difficult to verbalize their desire to use condoms due to male/female power differentials in the culture (e.g. women are not typically assertive when interacting with men). In addition, economic and structural issues within the culture contributed to a shortage of available condoms or condoms that were damaged due to inadequate storage procedures.

In other parts of Africa and many cultures around the world, men are admired for having multiple sex partners, they often demand sex with females, or they forcibly engage in (unprotected) sexual intercourse with women (du Pré, 2005; Kamwendo & Kamowa, 1999). In China, knowledge about HIV/AIDS is related to the restricted control of media. In recent years the Chinese government has not perceived HIV/AIDS as a major health threat despite the fact that over a half-million people have been diagnosed with AIDS (Geist-Martin, Ray, & Sharf, 2003), and many people are unaware of the disease or lack basic information about how it is spread (Rosenthal, 2001).

SARS/avian Flu

While few diseases have had the global impact of HIV/AIDS, there is always potential for the spread of disease worldwide. In February of 2003, we witnessed the advent of SARS, a viral respiratory illness that quickly spread from Asia to more than 24 countries in North and South America and Europe before it was contained. According to the World Health Organization (WHO), a total of 8,098 people worldwide became sick with SARS during the 2003 outbreak, and 774 people died from the disease (WHO, 2004). One of the frightening aspects of SARS was that rather than being spread by sexual contact or through the exchange of blood (such as HIV/AIDS), the disease could be contracted by casual human-to-human contact. People traveling to different countries were able to spread the disease to different continents relatively quickly. It is not difficult to imagine how similar types of viruses that are more lethal than SARS could spread around the world in the future.

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