As Ebola raged in West Africa last fall, the United States battled an outbreak of "fearbola," the term the media invented to describe a paranoia that infected this country.
Although there were only 10 confirmed U.S. cases — all of them people who had direct, prolonged contact with Ebola patients — parents in Texas, Mississippi and New Jersey pulled children out of school after other students or administrators had chance encounters with Ebola patients or visited West Africa, and a teacher in Maine was put on leave after attending a conference in Dallas where the first U.S. case was discovered. The states of New York, New Jersey and Illinois mandated 21-day quarantines for health workers who had treated Ebola patients in West Africa, and Connecticut reserved the right to quarantine anyone believed to have been exposed to the virus.
Though the spread of Ebola may have come as a nasty shock to many, psychologists weren't surprised at people's outsized fears.
"What happened was quite consistent with what we know about risk perception," says Paul Slovic, PhD, professor at the University of Oregon and president of Decision Research, a nonprofit whose scientists study human judgment and decision making. "The minute the Ebola threat was communicated, it hit all of the hot buttons: It can be fatal, it's invisible and hard to protect against, exposure is involuntary and it's not clear that the authorities are in control of the situation."
For four decades, Slovic and other psychologists have studied how people perceive risk and what causes them to overreact to epidemics, terrorist attacks and other extreme events, even when their personal risk is infinitesimal, yet at the same time be less attentive to other threats that are far more likely to harm them, such as the flu.
Those misplaced reactions can lead to the stigmatization of people and shunning daily activities, ushering in a new set of problems on top of a current crisis. In response, psychologists are helping governments and other groups communicate real risk levels to the public to help make sure actions meet needs.
Novel threats provoke anxiety
Research has shown that different threats push different psychological buttons. Novel, exotic threats like Ebola or avian flu raise anxiety levels higher than more familiar threats do. This reaction may have to do with our amygdala, which research suggests plays a role in detecting novelty as well as processing fear. In one recent study, for example, Nicholas Balderston and colleagues at the University of Wisconsin–Milwaukee found that activity in the amygdala increased when participants looked at unfamiliar flowers right after seeing pictures of snakes (PLOS ONE, 2013).
And, at the same time, people often under-react to familiar threats. For example, influenza sickens as much as 20 percent of the population a year, and kills thousands. Yet because most people have had the flu and survived, or know someone who has, people may feel less urgency toward getting a seasonal flu vaccine. This may help explain why the U.S. vaccination rate for the 2013–14 flu season was only 46.2 percent.
Diseases that are familiar but with which people lack direct experience also rank lower than novel threats in terms of perceived risk, which may be a factor behind some parents' reluctance to vaccinate their children.
"We've gone a couple of generations now largely without pertussis and varicella, so society hasn't seen the risk," says Barbara Reynolds, PhD, a psychologist and director of the Division of Public Affairs at the Centers for Disease Control and Prevention (CDC). "It's hard to ask the parent to take an action to protect against a risk that's invisible to them."
It's that sense of immediate risk that leads people to take preventive measures in the face of contagion, Slovic says. Following the 2009 H1N1 influenza pandemic, for example, research looked at reasons people did, or didn't, get the vaccine. One meta-analysis showed that a perception of personal risk was the most influential factor in whether a person got the vaccine, followed by social pressure and past behavior (Vaccine, 2011).
Framing risk, reducing panic
Timely, honest communication from a source an audience deems credible is essential to containing fear during an epidemic, but governments have the tough job of explaining risk and telling people how to act without also seeding alarm, says Carnegie Mellon University psychologist Baruch Fischhoff, PhD. He chaired the Food and Drug Administration's Risk Advisory Committee and the Environmental Protection Agency's Homeland Security Advisory Committee.
"The discipline is very straightforward: Identify the few things that people most need to know and figure out how to explain them in clear, trustworthy terms," Fischhoff says.
Yet as the Ebola situation unfolded, experts say, health agencies lost credibility. "Initially there were some cases of infection that were seen as mistakes or errors and [that] cast doubt on whether CDC was being careful enough and suggested that protocols weren't being followed, so that was quite alarming," Slovic says.
Hyperbolic media coverage also exacerbated the situation. As Reynolds says, "Modern communication allows people to have a more intimate experience with a threat that's not real."
American media have the propensity to find — and publicize — aberrant behavior, helping to perpetuate a myth that people tend to respond to a crisis with panic, Fischhoff says.
"Disaster researchers know that brave behavior is the norm," he says. "If we had the evidence — some of which we're now collecting — I think that it would show that Ebola had little effect on most people's lives, even if they paid attention to it," he says.
The Lancet reported that in October there were more than 21 million tweets about Ebola in the United States and that reporting on the disease in the United States and the United Kingdom "tended to encourage substantial misunderstanding about the risks of exposure and where the real threat and causes of Ebola lie."
But the media can be an ally when it spreads precise and useful information. During the 2009 H1N1 influenza pandemic, for example, Australian and Swedish media both accurately framed the risk of contracting the illness. Swedish outlets, however, were even more effective because they reported ways viewers could protect their health and openly admitted the uncertainties about the epidemic, while Australian media reported more negatively on public agency missteps (Scandinavian Journal of Public Health, 2013). Despite having similar vaccination rates overall before the pandemic, during the outbreak of H1N1, the vaccine rate in Sweden was 60 percent, versus 18 percent in Australia.
Focusing, as Swedish media did, on what people can do to protect themselves is particularly important for people who are vulnerable to stress and anxiety, research suggests. In a survey conducted during the H1N1 pandemic, researchers from Carleton University in Ottawa, Canada, found that people who were least able to tolerate uncertainty overall experienced the most anxiety during the pandemic and were less likely to believe they could do anything to protect themselves (British Journal of Health Psychology, 2014).
Experts agree that giving people concrete, detailed actions to take can help reduce panic and overreaction when a new threat emerges. When a number of schools in Texas faced a threat of MRSA bacterial infection a few years ago, Reynolds counseled local health officials to explain, step by step, how to wash hands thoroughly, so that the procedure resembled a ritual.
"When you tell people they can protect themselves simply by washing their hands, it seems an inadequate action," she says.
Messages may be more helpful when delivered in creative formats, too, Reynolds adds. "Infographics and visuals are very powerful. We can't just tell people things, we have to show them. When people are using the more primitive part of their brain, visuals are more powerful than our higher order tools, including language."
It's also important that the content and tone of communications speak to the intended audience.
"Scientists and public health officials may assume that other people will be convinced by the same evidence that convinces them, when it in fact needs to be explained differently to a lay audience," Fischhoff says. "People can understand just about anything if you do your job right as a communicator."
That includes keeping it simple and communicating what people need to know, versus what is nice to know; expressing risk in numbers — "there's a 30 percent chance of rain" — and reminding people of the opportunity cost of waiting for more evidence. Messaging should also be tested on individuals to spot any potential misunderstandings, he says.
One example he cites of making sense of reams of information: Lisa Schwartz, MD, and Steven Woloshin, MD, both professors at the Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, drew on behavioral decision research to create a "drug facts box," a label similar to the FDA's nutrition fact box. The label clearly spells out a drug's potential benefits versus harms, and enumerates how well it performs versus placebo or alternative treatments.
Effective communication also requires scientists and others to be honest about underlying uncertainties, as Fischhoff wrote in a recent paper for the Proceedings of the National Academies of Science (PNAS, 2014).
Such is the goal of the CDC, which prioritizes candor and immediacy in its communications, Reynolds says.
"Science is a messy arena," she says. "I think psychologists working in the realm of risk communication assume we have too much control through our messaging. We need to step back and allow for high emotions and missteps by people as long as we work to help them make well-informed decisions that ultimately protect them and the people around them."