Note from Peter Sandman: The The shorter, published version of the article is also provided on this site. On September 21, 2004, Jody told another version of this story as one of the keynote presentations at a World Health Organization conference on “outbreak communications.” The conference was scheduled in Singapore in part because of the superlative job Singapore had done communicating with its population about SARS – an accomplishment WHO wanted to help other countries emulate in other outbreaks. Entitled “ WHO Expert Consultation on Outbreak Communications – Singapore’s SARS Outbreak Communications ,” the speech text was on the website of the Singapore Ministry of Health for a while, but now is available only on this site.

In coping with SARS anxiety, Singapore’s grace under stress provides a rebuke to Canada, and an admirable risk communication model for countries preparing for a possible SARS outbreak. Of course the most important factors in managing SARS are medical. But risk communication matters also, and for weeks now Singapore has done state-of-the-art risk communication.

Typically, leaders and public health officials tend to box with the public's fear, as if trying to knock it out. Risk communication in a crisis is more jiu-jitsu than boxing – respecting the public’s fear, allying with it, and helping the public pivot on its fear toward appropriate vigilance, attentive learning, and productive preparedness.

Singapore has been widely 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 many of those who have praised Singapore’s management of the disease have not entirely understood some of what it is doing right.

The single most important risk communication recommendation during an evolving crisis is to avoid over-reassurance – in fact, to err on the alarming side rather than risk falling into over-reassurance. Also important: acknowledging uncertainty rather than claiming to be confident; using anticipatory guidance and emotional rehearsal to help people get used to what has happened and what may happen; treating emotional reactions with respect rather than contempt; sharing dilemmas so people come to understand the pros and cons of difficult pending decisions; and offering suggestions for things people can do themselves to reduce their risk and the risk to others.

Taken together, these strategies amount to harnessing the public’s fear instead of trying to squelch it. Prime Minister Goh Tok Cheng and his health ministers have used them all superbly. We consider him the Rudy Giuliani of SARS.

Paradoxically, over-reassurance on the part of the authorities breeds outrage, doubt, and sometimes even panic in the public. It leaves people alone with their fears. Despite how well-established this risk communication principle is, “experts” nearly always get it wrong in crises. Singapore has mostly gotten it right.

Early on, several Asian countries warned against travel to Singapore. Prime Minister Goh responded, “We can understand that because we also give travel advisories to Singaporeans not to go to the 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.”

This compassionate respect for the fears of others is in stark contrast to Canada’s insistent whiny complaint that Australia and later WHO were over-reacting by issuing travel warnings. Toronto Mayor Mel Lastman said, “I’ve never been angrier in my life.” Toronto microbiologist Donald Low said the travel warning was “Bulls__t.”

Canada sounded like Hong Kong in the days when it wouldn’t even admit there was an outbreak. “Hong Kong is absolutely safe and no different from any other big city in the world,” said Hong Kong Minister of Health Yeoh Eng-kiong on March 15. “The streets of Toronto are safe from SARS. They are as safe as the streets of London, Paris or Washington,” said James Young, Commissioner of Public Security in Ontario, on April 29. (Mr. Young couldn’t say the same of Toronto’s hospitals.)

The same day WHO lifted Canada’s travel warning, the international health agency said that the worst of Singapore’s SARS outbreak seemed to be over. Singapore health ministry spokeswoman Eunice Teo responded, masterfully, by moving to the fulcrum of the risk communication seesaw. “The WHO said the peak is over in Singapore,” she noted, “but our minister has said it is too early to tell.”

In this and many other examples, Singapore has occupied the middle ground between people’s fears on one side and tentative medical reassurance on the other. This generates more credibility and confidence than Canada’s angry protests and premature celebrations. Canada’s foreign stakeholders (and in private, even its own citizens) are likely to sit on the worried, distrustful seat of the risk communication seesaw, since Canada is occupying the over-reassuring, over-confident seat.

Mr. Goh does not mince words with his citizens. Announcing a high-level task force on SARS, he said one of its missions was “to think in terms of worst-case scenarios. The committee will be asking a lot of ‘what if’ questions: What if a housing block has several members stricken by Sars? We can take care of the medical side, but what about the quarantine? What if foreign workers are affected? Where do we quarantine them?” He even talked openly about trying to avoid a complete quarantine of Singapore. Clearly he expects his citizens to bear these worries with him.

Instead of photo-ops at Singapore food courts to show that everything is perfectly safe (the reassuring side of the seesaw), Mr. Goh is seen having his temperature taken before entering his office. When he introduced his SARS task force, he demonstrated the “namaste” bow to reporters instead of shaking hands, recommending this Indian-style greeting for the duration of SARS. While other leaders are telling their citizens they are silly and hysterical to worry so much, Mr. Goh is helping his citizens figure out how to take action to help protect themselves and their neighbors – in essence, how to worry better.

With their desire to take precautions respected rather than squelched, private organizations in Singapore responded with initiative and resilience. They were not told to wait for the government to give them orders.

By March 20, the Catholic Church in Singapore had announced that communion wafers would be placed on church-goers’ palms, not on their tongues. Hand-holding customs in other churches were suspended. Not much of this happened in Canada until around Easter. Singapore companies designed contingency plans, separating staff members into different locations to lessen the likelihood of entire companies being quarantined at the same time. Singaporeans are acting empowered.

One of our favorite stories about Mr. Goh involves a trick question. Early in the SARS outbreak, there was much public discussion over whether he should go 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. “The Indians thought it over. They thanked us for being considerate and said, ‘Please come,’” he said.

The two countries 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. When Mr. Goh boarded the Singapore Airlines plane, airline staff assured him they had thoroughly scrubbed and disinfected the plane. The trick question: “I asked them: ‘Is it just for me?’ They said: ‘No, it’s for all the airplanes, for all the passengers. Not just for you,’” Mr. Goh said. “I was comforted to hear that.”

Officials all around the world have called their publics irrational or hysterical for unnecessarily wearing masks. Air Canada’s flight attendants were forbidden to wear masks early on, despite their desire to do so. People mostly wanted masks to protect themselves from others. Mr. Goh told Singaporeans about the Japanese custom of wearing masks if they have a cold, to protect others from them – pivoting on their fears instead of ridiculing them.

Paradoxically, but not surprisingly, people become less fearful when their desire to wear masks is reframed as both wisely cautious and altruistic, rather than as foolish. The result is more esprit de corps, less panic – even if people are wearing masks when a strictly medical policy might suggest they do not need to do so.

Singapore’s leaders don’t even mind appearing overly cautious themselves. On April 8, an official with a fever and an upset stomach participated in a cabinet meeting by phone to avoid exposing his fellow ministers, even though he was sure he didn’t have SARS. PM Goh said, “We were probably overreacting. But why risk the whole Cabinet being quarantined?”

By sharing the public’s fears, these leaders are building trust and credibility; they are professional, but not hiding their humanity. It is easier for the public to emulate a leader who is bearing his fears than one who appears fearless.

More explicitly than any official anywhere in the world in any crisis we can remember, Mr. Goh has acknowledged that neither extreme of the seesaw is ideal, that the goal is to move people toward the fulcrum. “We do not know enough of the disease, so it’s quite natural for people to swing to extremes,” he said. “I can understand that anxiety and sense of panic in the beginning…. The other extreme is … complacent Singaporeans. We have to bring both to the middle ground, to take a realistic approach.”

Singapore Health Minister Lim Hng Kiang also speaks bluntly now, after a more typical over-reassuring start in March: “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.”

Right now Singaporeans may be truly miserable, a bit frightened, and worried about the future. But when we all get through the SARS epidemic, or get used to it, Singaporeans and Singapore should recover well. And the world will notice, even without a $25-million PR campaign like the one Canada is so prematurely preparing.

Prime Minister Goh will be visiting the U.S. this week, to work on a free trade agreement. Weeks ago he announced that his whole delegation will have medical evaluations before they come, as they did before they went to India in March. We didn’t hear anything similar when the Canadian delegation angrily flew to Geneva last week, to demand that WHO lift the travel ban.

If we could meet Mr. Goh during his U.S. visit we would offer him a namaste bow. And some day when we get through this, we would love to shake his hand.

Copyright © 2003 by Jody Lanard M.D. and Peter M. Sandman Ph.D.