WHO Expert Consultation on Outbreak Communications - Singapore's SARS Outbreak Communications

21 Sep 2004

By Jody Lanard M.D

Venue: Traders Hotel

The Director General mentioned "defensive pessimism" as one of the reasons Singaporeans coped so well with SARS. It is possible that some of the outbreak communication strategies that will be debated at this meeting really are more useful in Asian societies than elsewhere, and defensive pessimism is one reason for this. It doesn't mean a hopeless attitude; it means careful cautious planning, and consideration of many what-if scenarios, as opposed to optimistically barging ahead and hoping for the best, which also works for some societies. But given the broad cultural mix of people who call themselves Singaporeans, it is likely that many of these strategies will be adaptable across many cultures.

By the way, Singaporeans know the real word for "defensive pessimism": "kiasu"! Erring on the cautious side; working hard not to lose what you have; planning for all possible outcomes.

In this presentation, I will not discuss any aspects of Singapore's medical and epidemiological management of SARS. My subject is Singapore's SARS communication - what they did well, what they could have done better, and how people here and around the world saw it.

Singapore was praised by the World Health Organization, the American Chamber of Commerce, and even habitual critics like the Wall Street Journal for coping well with SARS. But even many of those who praised Singapore's management of the disease are not aware of Singapore's remarkable outbreak communications. Much of the world news media's praise - even when acknowledging Singapore's admirable transparency -- includes comments about Singapore's "harsh," "authoritarian," "ruthless" and "draconian" measures used to contain SARS.

[Here is a fairly typical example, from Time magazine's May 12 2003 edition:

"Authoritarian regimes don't win many popularity contests, but their one selling point is an ability to control their citizens. Singapore ruthlessly nipped its SARS problem in the bud with draconian quarantine measures -- one of the few times the island nation's authoritarian reflexes were cheered by the international community, which rewarded Singapore by keeping it off the World Health Organization's (WHO) travel advisory list."

In fact, one of my strongest criticisms of Singapore's SARS communication is regarding its failure to dispel the outside world's stereotypes, in cases where those stereotypes were inaccurate.

What Singapore mostly did with its SARS communication was to build trust with its own citizens and with other nations. I'm going to tell you Singapore SARS communication stories to illustrate some of the outbreak communication strategies that help accomplish this. But first, here are some non-Singapore SARS examples that did not help the public develop confidence in its leaders.

On March 13, 2003, an official in a city with mysterious cases of pneumonia breaking out amongst health care workers said:

"There is no cause for worry on the part of the public."

A couple weeks later, in another place that had no SARS cases, a local leader said, "[The public] shouldn't worry. SARS is something not to be afraid of, but to respect." He added that his region was prepared, should an incident occur.

In a third place with many SARS cases, officials repeatedly told the public, "The situation is under control," as the numbers of cases and clusters gradually, then rapidly, increased.

Unlike Singapore, these leaders did not seem to trust their publics to bear anxiety and fear. Unlike Singapore, they did not trust that their citizens would be resilient and full of community spirit to attack Sars. They were afraid of their citizens' fears -- without having studied the history of their citizens' resilience in previous crises. But -- they desperately wanted their citizens to trust them.

Early on, even Singapore started out a bit over-reassuring about SARS. Here is an excerpt from the world's very first article that discussed SARS risk communication, on March 27 2003, by Andy Ho, senior columnist from the Singapore Straits Times. The article was entitled, "Candour, Not PR, Will Calm Virus Fears."

>On March 18, medical services director Tan Chorh Chuan said: "We have taken all the measures that should be taken to contain this. Singapore is safe."

>There was no need to avoid crowded places or to don a face mask, he averred, saying that the infection occurred only after close contact with a sick person.

>A vigilant public disagreed - face masks flew off the shelves.

>ST reader Maria Loh said pointedly in a letter to the paper that she was confused by Professor Tan's advice. The three who brought the bug home from Hongkong, she said, were just shopping and eating there. So, perhaps people could catch the disease just going about their daily business, she suggested.

>At that point, the authorities were probably still operating in their public relations (PR) mode, as distinct from a stakeholder relations mode,< Andy Ho wrote.

But this was a rare example of Singaporean over-reassurance.

Goh Chok Tong, Prime Minister during SARS, did not use over-reassuring language. He said that SARS was potentially the worst crisis Singapore had faced since independence. BBC reporter David Bottomley asked him about this dramatic statement, on April 21, 2003:

Bottomley: "By talking in terms of this being potentially the worst crisis that Singapore has faced, aren't you in danger of stoking up [public] fear?"

Mr Goh: "Well, I think I'm being realistic because we do not quite know how this will develop. This is a global problem and we are at the early stage of the disease. If it becomes a pandemic, then that's going to be a big problem for us."

Bottomley: "How are you going about deciding where to strike the balance between warning people and making people aware of the virus and actually going so far that you're actually worrying them?"

Mr Goh: "At the moment, I'd rather be proactive and be a little overreacting so that we get people who are to quarantine themselves to stay at home. The whole idea is to prevent the spread of the infection."

PM Goh was illustrating an important outbreak communication principle, which is well-supported by the social science literature: Don't aim for zero fear. After SARS, published peer-reviewed psychology studies about Singapore and Hong Kong showed that people who were more anxious took more recommended SARS precautions than those who were less anxious. This is not an unusual finding. After the recent influenza season in the U.S., a CDC survey showed that increased fear was associated with higher levels of vaccination, among people who usually did not get an annual flu shot.

Singapore Health Minister Lim Hng Kiang also spoke bluntly about the danger of SARS. He said, "We're facing an unprecedented situation, this is a nine-eleven for health.... We're not going to go back to the pre-SARS situation for some time. We're in for the long haul."

Minister Lim was illustrating two important outbreak communication strategies here: "Don't over-reassure people," and "Tell people what to expect." This statement may well raise public anxiety a bit - and also public confidence that leaders are going to be honest with them. Paradoxically, over-reassuring statements tend to generate distrust - especially when the statements turn out wrong.

Later, when WHO said the worst in Singapore seemed to be over, Minister Lim's spokesman Eunice Teo responded by saying, "The WHO said the peak is over in Singapore, but our minister has said it is too early to tell."

In this and many other examples, Singapore occupied the middle ground between people's fears on one side and legitimate reassurance on the other. This kind of cautious tentative optimism, and the tactic of balancing good news with continued vigilance, generates credibility and confidence - building blocks of trust.

Another outbreak communication strategy for building trust is showing empathy for other people's fears and worries. Singapore demonstrated this in several ways. First, here are three examples of Singapore respecting other nation's concerns.

1. When Australia and several Asian countries warned against travel to Singapore, Mr Goh responded: 'We can understand that, because we also give travel advisories to Singaporeans not to go to [other] affected places.

'So we must expect other countries to advise their travellers not to come to Singapore... If we are open about it and all Singaporeans cooperate by being as careful as they can, we may be able to break this cycle early and if we do, then of course people outside will have confidence in Singapore and the way we manage the problem.'

2. Throughout SARS, Singapore showed strong empathic concern about every potential exported case. Officials investigated every rumor or suspicion, no matter how far-fetched and unlikely, that someone had caught SARS in Singapore and taken it home with them.

3. Early in the SARS outbreak, there was much public discussion over whether Prime Minister Goh should travel to India for a long-scheduled meeting. India had no known SARS cases at that point. Mr. Goh informed his Indian hosts about SARS in Singapore, and asked if they would rather he cancelled the trip.

He told the public: "The Indians thought it over. They thanked us for being considerate and said, 'Please come,' " PM Goh was erring on the alarming side, and validating other people's fears, and showing concern and compassion for others - very good outbreak communication strategies that lead to increased trust. Paradoxically, his compassionate concern for India made it more likely that India would feel comfortable having the Singaporeans visit.

India and Singapore worked on safety protocols. The Singapore delegation had medical evaluations before going. They all had their temperatures taken before boarding the plane, and they all had masks with them.

Here are two local examples of Singapore officials respecting and responding to people's fears, learning what the public thinks, and involving the public in decision-making, all important outbreak communication strategies important for building trust and confidence.

1. Before very much was known about how SARS was transmitted, there was tremendous pressure on the government to close schools. Officials, many of whom had school-aged children, felt this pressure personally. But the Ministry of Health said there was no medically necessary reason to close the schools. Prime Minister Goh publicly described a cabinet meeting in which some members thought closing the schools was over-reacting, and some not; on balance, they decided that over-reacting was better. The education and health ministries jointly announced the school closings as a "precautionary step." Despite the lack of medical grounds, they said, "principles and general practitioners have reported that parents continue to be concerned about the risk to their children in schools." PM Goh added, "I think it's useful to do so just to assure the parents that by taking all actions in order to tackle the problem [we] try to break the cycle."

2. When hundreds of people were on home quarantine, people became worried and angry about quarantine violators, particularly a man who went to a local bar waving his quarantine order in the air, and bragging that he was supposed to be at home. The Prime Minister and other officials held public meetings where they posed the dilemma of posting the names of those under quarantine order, versus medical confidentiality. After much discussion, they would ask for a show of hands, pro and con revealing the names. The newspaper ran opinion polls on the issue. The public usually stated that they wanted other people's names published - but not their own, if they were quarantined! Ultimately, the names were not posted. And all during this period, volunteers were taking food to the quarantined families, providing them with cell phones - and making sure they were home.

(By the way, there were over 6000 people quarantined in Singapore in all. If the world remembers anything about this episode, it remembers the cell-phone cameras used to make sure quarantined people were actually home, and it remembers electronic monitoring bracelets. The Ministry of State for Health says that out of all these thousands quarantined, only 19 electronic bracelets were imposed -- on people who had broken quarantine. And only one person was legally charged with breaking quarantine.)

There were some press reports that the closing of the schools was pandering and caving in to people's fears. But a research study of this period in Singapore, published in a special February 2004 SARS edition of the U.S. CDC's Journal of Emerging Infectious Diseases, showed that one factor positively associated with Singaporeans compliance with SARS precautions was their belief that they could communicate with their government. So sometimes a responsive social intervention can have an important medical impact.

Officials and media commentators all around the world called their publics irrational or hysterical for "unnecessarily" wearing masks. Taxi drivers, flight attendants, and even nurses were sometimes forbidden to wear masks early on, for fear that they would scare the public.

Clearly people mostly wanted masks to protect themselves from others. But Prime Minister Goh told Singaporeans about the Japanese custom of wearing surgical masks when they have a cold, to protect others from them - he re-framed people's self-interested worries into empathic concern for others.

If this sounds a bit naive and idealistic, here is some research that lends support to Mr. Goh's ju jitsu about masks:

A year later, in April 2004, the Asian Journal of Social Psychology published an article about SARS precautions and empathy. Two studies in Hong Kong showed that people who took SARS precautions, including wearing masks, saw themselves as more motivated by pro-social concerns. Another article in the same journal reported that people who empathically responded to the threat of SARS were "less likely to report avoiding people perceived as being at high risk for SARS, and more likely to report engaging in effective health behaviors." In other words, some people who wore masks saw themselves as more empathic toward potential SARS victims, and were less likely to stigmatize them.

Another mask story illustrates two difficult outbreak communication strategies that will be discussed at this meeting: acknowledging uncertainty, and sharing dilemmas. During a television call-in show, Minister of State for Health Balaji Sadasivan was asked by a caller about whether to wear masks in public, and what kind to use. At this point, it seemed very likely, but not yet 100% definite, that SARS was mostly transmitted by close personal contact, through droplets and touching contaminated surfaces. Dr. Balaji told the caller that there was no evidence that wearing a mask [in public] helps, and no evidence that it doesn't help, and that is why they hadn't given a definite recommendation at that point.

People wanted definite answers - but officials said that for the long haul, they will trust that the public can bear the stress of genuine uncertainty. If Singapore officials could have helped the foreign press notice and understand this approach, it might have dispelled a little of the "Nanny State" image many outsiders have of Singapore even when it isn't true.

PM Goh also recommended the namaste bow, instead of shaking hands as usual, to reduce the risk of SARS transmission. Some western media thought Mr. Goh was over-reacting. The UK Guardian newspaper wrote: "Nerves were not improved on Sunday when the prime minister, Goh Chok Tong, conspicuously refused to shake hands with journalists after a press conference, as he usually does. He instead stood in an arms-folded, don't-come-near-me pose...."

But handshakes were quickly going out of fashion during SARS. Churches had already suspended traditional handshakes, and communion wafers were being placed in communicant's palms, not in their mouths. Catholic churches in western countries affected by SARS also adopted this precaution - several weeks later. Hong Kong also recommended avoiding handshakes, with a campaign telling people to "just say hi and wave goodbye."

With the recommendation about masks, and with the namaste bow, PM Goh and others were demonstrating another confidence-building outbreak communication strategy: Give people things to do. Local medical experts, while discouraging the use of N95 respirator masks which were in short supply, nevertheless published clear instructions on how to use the masks properly, if people decided they wanted to wear them. This illustrates another respectful outbreak communication strategy: Offer people a range of things to do. Tell people, "we really don't think this is necessary, but if you are more worried than we are, here's the right way to wear a mask." This helps officials define the more anxious people as being inside the system, instead of being rebels or hysterics - and thus builds more trust with those people. It also shares more control with the public - another outbreak communication strategy that builds trust and confidence.

I will conclude with one example of apologizing for an error (a very difficult outbreak communication strategy); one example of a kind of speculation that is usually not noticed; and an example of officials sharing the public's fear.

In mid-May, 2003, there was an unexpected potential new outbreak of SARS at a Singapore mental hospital. Before this turned out to be a false alarm, the Singapore Straits Times wrote: "SARS Combat Unit Chief Khaw Boon Wan....admitted that the fresh batch of possible cases at the Institute of Mental Health had caught him unprepared. The chronic-care hospital 'was not on my radar screen," [he] confessed, 'because we just didn't have the time to focus on it. It was a tactical error."

This was one of the most undefensive apologies from the age of SARS.

This next example is a critique of an unfortunate episode of speculation that occurred when a Singapore student who worked in a virology lab contracted SARS, months after the outbreaks had ended. People were naturally speculating - hypothesizing - that the student might have caught SARS on the job, since other researchers at his lab worked with live SARS virus. The head of the institute that oversees the lab said lab exposure could not have happened. "There is absolutely no way he could have been given the wrong virus," he said. This is an example of irresponsible over-reassuring speculation - an emphatic opinion offered as certainty, with no data to support it. The question of "what is speculation" will be raised at the meeting. The category of over-reassuring speculation is rarely discussed, although it is just as misleading as over-alarming speculation.

Lastly - here is an example of legitimizing and sharing the public's fear, an often difficult outbreak communication strategy that nevertheless builds trust and confidence:

While acknowledging SARS fear - his own, as well as his citizens' - PM Goh nearly always pivoted from the subject of fear to action and courage. A month after the outbreak officially ended, at his National Day Rally speech, PM Goh talked about all the humorous phrases people created out of the acronym SARS: Children excitedly coined, "Schools Are Really Shut!" A nurse who recovered from SARS said it stood for "Single And Really Sexy!" Then PM Goh became serious, and said:

"For me, the most appropriate coinage for SARS was 'Singaporeans Are Really Scared'. Yes, we were really scared. Scared for our lives and our loved ones. Scared of taking a taxi, scared of going to the hospital. Scared that tourists and customers would not return, and we might lose our jobs. For the first time in our history, all Singaporeans felt the same fear at the same time. But far from being frozen by the fear, the entire nation sprang into action."

In this example, PM Goh revealed his own humanity, shared his own fear, and showed that he knew and understood how his citizens felt. This illustrates several more outbreak communication strategies that will be raised at the Singapore meeting.

There are areas of risk communication where there is lack of consensus - speculation and "speaking with one voice" come to mind. But in the areas where risk communicators have formed a strong consensus, actual front-line practice only rarely catches up to these "best practices." In its SARS communication, Singapore came as close as many risk communicators have seen.