Richard Besser led the United States' top public-health agency as swine flu broke out on its doorstep. And his communication shaped the early days of a pandemic, finds Brendan Maher.
Swine flu officially became a national emergency in the United States on a Friday in late October, when US President Barack Obama signed an order giving health facilities extra power to implement crisis operations. The next morning, the daily news programme Good Morning America turned for analysis to its newest health editor, Richard Besser, whose two-metre frame was folded uncomfortably into a swivel chair in the studio's New York newsroom. "This is an extremely challenging communication issue for the government," Besser was saying, explaining why the White House was calling an emergency, but trying not to sound too alarmist. "How do you convey the fact that this is serious … but it's not a 1918 pandemic?"
Few people are as qualified to comment on this challenge as Besser. Nine months earlier he had been appointed acting director of the US Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, widely considered the world's pre-eminent public-health agency but one beleaguered with morale issues and a strained budget. It and the broader international health community had been gearing up for a potentially apocalyptic flu pandemic, one that would require a rapid global health response and candid communication to engender trust, not panic. In April, when reports started rolling in that a new influenza virus was infecting people in Mexico and the United States, that pandemic seemed to be emerging on the CDC's doorstep and on Besser's watch, even though he had been put in charge largely as a stop-gap in case of emergency.
Many public-health experts now say that they are glad Besser was there when the emergency struck. He has received little attention for his role, which lasted just a few weeks into the pandemic. Yet experts credit him — and particularly his decision-making and calm and upfront communication — with helping the agency through the first perilous days of the outbreak and setting the tone for a rapid and transparent response from the international public-health community. "I was pretty impressed with his style and the way he communicated uncertainty," says Jon Andrus, deputy director for the Pan American Health Organization, a regional office of the World Health Organization. He left you with a sense "that this guy's honest", Andrus says. The CDC has not been faultless: it stumbled on delivering guidance for school closures, and since Besser's departure in June, it has been criticized for over-promising and under-delivering on a vaccine. But Besser did so well with the media that the media invited him to join its ranks. He started at ABC News, which produces the Good Morning America programme, in September, and says he hopes to use his roles as expert and reporter to promote public-health issues.
It is hard to measure the effect that the early response and communication in the pandemic had on people's health. Besser can't take responsibility for the mildness of the pandemic thus far, which is due to the nature of the H1N1 virus. But experts, who are already looking to the next wave of this pandemic and any signs of the next pandemic, say that the episode has tested their preparedness plans and identified the spots to patch up. And at least some evidence suggests that communication is a vital part of those plans. Besser points to a poll commissioned by the CDC in late April showing that most of the US public had a fairly clear understanding of what swine flu was and how to avoid catching it. "That struck me," he says. "that communication can be a very powerful tool."
“I like working on a setting of crisis. Richard Besser , ”
The CDC first acknowledged the existence of swine flu in its Morbidity and Mortality Weekly Report on Tuesday 21 April. The dispatch described how, earlier that month, the CDC had received samples from two children in California who had come down with illness from a flu subtype the local doctors could not identify. CDC researchers determined that it was a virus of swine origin. Its substantial difference from seasonal H1N1 and the fact that neither child had had recent contact with pigs led the authors to suggest that this might be a new virus with the ability to spread from person to person (M. Ginsberg et al. MMWR Morb. Mortal. Wkly Rep. 58, 1–3; 2009).
By the next day, the CDC had learned of similar cases in California and Texas — and, more alarmingly, farther afield. "For about two weeks at that time we'd been hearing about unexplained respiratory outbreaks in Mexico," says Lyn Finelli who, as the CDC's chief of influenza surveillance, presented some of the results at the agency's weekly pandemic briefing, which Besser attended. The virus in Mexico seemed to be killing a large number of people who had been hospitalized, and it was clear that the CDC had to find out quickly whether the two countries' cases were related. The agency already had a plan for dealing with a potential pandemic, and Besser decided immediately to activate its Emergency Operations Center at its lowest level — level three — to help facilitate communication between the two countries.
Powers of persuasion
On Thursday, he asked Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the CDC, and Nancy Cox, the head of the influenza division, to deliver a press briefing on what were now seven confirmed cases in the United States, but no deaths. "So far this is not looking like very, very severe influenza," Schuchat said at the briefing. But by now, most signs were pointing to a connection between the cases in the United States and Mexico. Besser pushed the Emergency Operations Center up to level one, its highest. He also e-mailed Dora Hughes, his contact at the Department of Health and Human Services, which oversees the CDC. He needed to get the message, through her, to the top layers of government. "We have a situation that I'm very concerned about," he wrote.
It took some convincing, Besser says, but that evening he was on a call with Hughes and Laura Petrou, the department's chief of staff. From the CDC, Schuchat and Phil Navin, director of the emergency-operations division, were on the line. As a thunderstorm raged in Atlanta, they broke down the information available. Besser says he knew he had to be clear that this was scary. When Petrou asked him to tell her how concerned he was, Besser remembers saying, "eight".
"She asked, 'Eight?' I said, 'Yeah. Eight.'"
After the call was over, Navin commented: "I would have said six!"
Navin now concedes that Besser was probably right. Even as they were on the call, Cox was leaving a message on Schuchat's phone. The lab results were in, confirming that the cases in Mexico were caused by the same swine flu virus as the US ones. The next morning, Friday 24 April, the World Health Organization activated its emergency response room and Besser prepared to deliver a briefing from the CDC.
Besser has had experience in briefing people in emergencies. After receiving his medical degree from the University of Pennsylvania in 1986, he trained as a paediatrician, and honed his skill at reassuring fraught parents. An interest in public health brought him into the CDC's Epidemic Intelligence Service in 1991 and, except for a brief period doing paediatrics at the University of California, San Diego, he has been at the CDC in various roles ever since.
In 2005, he took over as head of the Coordinating Office for Terrorism Preparedness & Emergency Response. It was a time bookended by excitement. He arrived in the office the day after Hurricane Katrina started pounding the southeast coast of the United States. "He had a truly unique leadership style," says Navin, who worked closely with him during the response operation. "People had confidence in him and he had confidence in them." And in January 2009, Besser was in the midst of a ground war in Gaza doing crisis leadership training when the Obama transition team called asking if he would consider running the CDC. He was told that he would not be considered for the permanent job; the administration wanted someone from outside the agency. Even so, Besser agreed. "I love a leadership challenge," he says. Part of the test was to boost morale in the agency after the unpopular restructuring instituted by Besser's predecessor, Julie Gerberding. "It was hard to describe — almost a sea change — when Rich became acting director," says David Sencer, who headed the CDC from 1966 to 1977. "People were much more open and willing to question decisions, which had not been the case before."
The circumstances change
In his office at ABC News in New York, Besser talks about the principles he looked to when talking about the H1N1 pandemic. He refers to a CDC pamphlet on crisis and emergency risk communication with the subtitle: 'Be First, Be Right, Be Credible'. Credibility was provided in large measure by Besser's relaxed and telegenic persona. But, he says, "there's an inherent challenge between being first and being right". The agency was working with incomplete information: in particular, data on the severity of the virus were changing rapidly. When the virus spread, would it kill tens — or millions?
In his first press briefing that Friday morning in April, Besser tackled the problem head on, admitting that much was unknown. "At the early stages of an outbreak, there's much uncertainty, and probably more than everyone would like." He explained that the agency's guidelines would probably change, and said: "It's very likely that this will be more of a marathon than a sprint." "That statement stands out as stunningly good," says Peter Sandman, a risk-communications consultant and formerly a social scientist at Rutgers University in New Jersey. Although authorities are often tempted to over-reassure the public, Sandman says, Besser gave a clear statement of concern and an indication that the agency would be searching for answers. It was a message he repeated at almost all his briefings for the next two weeks.
“The goal was to tell everything we knew and everything we didn't know. Richard Besser , ”
Some public-health experts contrast the CDC's recent response with that during the last swine-flu outbreak, which started in early 1976 at Fort Dix, a military base in New Jersey. Under Sencer's direction, the CDC launched a vaccination campaign that inoculated more than 40 million Americans, yet the virus never took hold, the vaccine was blamed for hundreds of cases of the neurological condition Guillain–Barre syndrome and the public-health establishment was demoralized. Harvey Fineberg, president of the Institute of Medicine and co-author of a book about the episode, says that it was a lesson in how to deal with uncertainty. "A fundamental strategic lesson was not to pre-decide what you will be able to decide with more information later," he says. "The second big problem was a failure to ask, 'What information could we learn that would lead us to change course?'" The third lesson, he says, was to work with the media, to maintain a consistent, honest message.
Besser and the CDC weren't the only ones practising good communication. The day after Besser's briefing, the World Health Organization declared a public-health emergency, and gave the first of what were to become daily briefings on the virus. Most health officials also heap credit on Mexico for reporting its first cases early, despite the economic hit it took from closed businesses and lost tourism. "It was a level of transparency and communication that was exemplary," says Cox. Julio Frenk, dean of the Harvard School of Public Health in Boston, Massachusetts, and former health minister for Mexico, credits decades of investment in pandemic surveillance and communication internationally. "You don't start building communication lines and trust once the outbreak occurs," he says.
By 27 April more than 60 flu cases had been confirmed in the United States and Mexico. By that point Besser had been to Washington DC to brief the White House and appeared on numerous television news programmes. "I was doing all the morning shows, a press conference at noon and then a fair number of the evening shows." The goal, he says, was to "tell everything we knew, everything we didn't know and what we were doing to get the answers", Besser says.
One step at a time
Not every step was sure-footed. On 28 April Besser approved CDC recommendations that schools — hubs of flu transmission — should close if one student or staff member came down with confirmed flu, and stay closed for 14 days. "Well, that's science. You can shed virus for a week. If you really want to be certain, two weeks," he says. Although the costs and benefits of school closures had been actively debated, Besser wanted to take an aggressive approach.
But he didn't fully appreciate the political ramifications. People at the education department, for example, weren't happy that they hadn't been consulted. On 1 May the issue was discussed when Besser was called into White House Chief of Staff Rahm Emanuel's office with others including Kathleen Sebelius, just confirmed as the head of the Department of Health and Human Services. Emanuel wanted to redraft the guidelines; Besser was uncomfortable with changing what should be science-based recommendations. In the end, Besser was handed guidelines with a modest revision — closure for one week followed by reassessment — and asked if the science supported them. From what they knew, it did. "It was extremely gratifying to see that they wanted to ensure that science was supporting the policy," Besser says. Over the next week, as it became apparent the flu was milder than expected, the recommendations were revised, and local health officials struggled to keep up with what they should do. (Epidemiologists have yet to determine whether the guidelines affected the virus's spread.)
Observers also cite communication missteps around the vaccine. Health officials promised some 160 million doses in the summer, but only a fraction of those had materialized by October. The reason was that the H1N1 virus grew slowly in the chicken eggs required to produce the vaccine — exactly the type of uncertainties that Besser and others had warned about. Nevertheless, Mark Nichter, a medical anthropologist at the University of Arizona in Tucson who looks at responses to pandemics, says that the problem dented public trust in the agency and made further advice hard to swallow. "What are these elderly people thinking, or mothers with kids in daycare, with the CDC telling us how important vaccines are, then saying that they're not available?"
As fears about the virus abated, the frantic sprint of the first few days stretched out into the marathon that Besser had predicted. Case counts climbed; contracts for vaccine production were signed; and attention turned to the Southern Hemisphere's winter flu season. Everything seemed to be going as well as could be expected, at least according to pandemic plans.
Many people were shocked when it was announced on 15 May that Tom Frieden, then New York City health commissioner, would replace Besser the following month. "It was something like a punch in the stomach," says Navin, who had worked with Besser for more than four years. Besser, who had known it was coming, started casting about for other jobs. The long shots, he says, were the two television networks who had contacted him during the outbreak, impressed by his performance on screen. He started at ABC just as the number of autumn swine-flu cases was increasing in the Northern Hemisphere.
Besser's audience is now smaller: Good Morning America reaches five million — during CDC press conferences he was playing on every news broadcast in the country. But the atmosphere suits him. "I like working on a setting of crisis," he says. "The news business is a constant crisis."
As for flu, Besser still projects uncertainty. At that Saturday morning broadcast in October, he warned that the worst may be yet to come. "With a pandemic they come in waves," he said, adding that "there likely will be further waves, maybe this spring, maybe into next year".
But by that point in his two-minute-long slot, Besser had already delivered his message. Get the vaccine when it arrives, he said. "Do those things to protect your health that you can. But this is not a flu like 1918. This is — the flu."
See Editorial, page 135 .
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