the mid-1980s, the National Toxics Campaign sent an organizer who helped create a local stakeholder group, the West County Toxics Coalition (WCTC) in North Richmond, a chronically impoverished area. WCTC activities have continued and focus on holding Chevron accountable for its accidents and pollution impacts. Another national organization, Communities for a Better Environment (CBE), also set up a local branch in Richmond and published an influential study of environmental justice issues (Kenney 2004).

In July 1993, a safety valve ruptured on a railroad car located on Chevron property. The valve leaked aerosolized sulfuric acid into nearby communities over a range of fifteen miles, causing 24,000 local residents to seek medical treatment. In the following year, Chevron and the community signed a Memorandum of Understanding (MOU) in which Chevron committed to taking action on several concerns including plant-wide replacement of valves, fenceline monitoring of specified air pollutants for data that would lead to further controls, waste cleanup and aesthetic improvements, areas for recreation, and funding for several community needs (Macey and Susskind 2003).

Nevertheless, accidents and emissions of pollutants that threatened public health and safety continued and actually worsened over the following years. In 2007, the EPA reported that Chevron had produced over 900,000 lb of toxic waste and that the Refinery was in “high priority violation” of EPA standards. Then, in 2012, a major fire took place at the refinery. After a leak was observed in a corroded carbon steel pipe containing hydrocarbon process fluid and several repair attempts failed, the decision was made to shutdown the refinery. But prior to shutdown, “hot work” repairs on the corroded pipe caused an explosive release of a vapor cloud that immediately ignited, causing a fire that sent a large plume of pollutants across the Richmond area. Nearby residents were instructed to take shelter with their windows and doors closed. 15,000 people from the surrounding community subsequently sought medical attention for respiratory complications due to the fire (Chemical Safety Board 2013a).

Residents claiming they are “disproportionately impacted” joined a multi-organizational protest March that gained international publicity. Community groups have brought several lawsuits against Chevron and the City of Richmond also went to court to seek orders that would bring about a new safety culture at the refinery. Several state and federal agencies and the national Chemical Safety Board (CSB) investigated the accident and presented findings at public meetings.

CSB reports identified technical, organizational, emergency response, and safety culture deficiencies at the refinery and inadequacies in the relevant industry codes. They also noted that the failed pipe should have been replaced earlier with an inherently safer corrosion-resistant alloy that the leak should have led to shutdown of operations before repair was attempted, and that reluctance among employees to use their “Stop Work Authority” and substandard equipment maintenance were evidence of a deficient safety culture (Chemical Safety Board 2015). The final report was presented at a public meeting in Richmond on January 15, 2015. Chevron refused to attend but responded in a letter in which they accepted most of the CSB findings and recommendations but disagreed with other findings as an inaccurate depiction of its process safety culture.
# Public Engagement and Risk Communication

In this section, we will look at characteristics and findings from, respectively, the Norwegian and US cases with the aim of exploring public engagement in assessing, interpreting, and responding toward hazard accompanying industries within the communities.

## Learning from the Norwegian Cases

The two Norwegian cases can be described both with similar and different characteristics. The similarities are *structural* with locations nearby urban areas, public ownership, a major seaport, and a complex diversity of companies with a variety of hazardous activities. The differences are *processual* and *communicative*, showing how state agencies and local actors respond, respectively, reactive and proactive in assessing and communicating risk issues. By using our analytical framework, three factors seem to be of relevance for the outcomes: First, limitations of the regulator in preventing and handling critical incidents and accidents creating domino effects affecting surrounding communities and environment; second, the conflicting roles with public ownership and third, the contextual and cultural basis for engagement within “local risk society” (Lindøe and Kringen 2015).

*First*, in Norway the state-managed approach to regulatory tasks is distributed horizontally as well as vertically among several ministries and national regulatory agencies. County governors at the regional level and local authorities including municipal planners give permission for locating hazardous industries. Emergency responses including fire services are organized at the municipal level. National port regulations specify the economic independence of the ports, and the ISPS Code imposes port security requirements.<fnref n="1" /> The Seveso Directive and other safety regulations are in place for the storage, handling, and transport of dangerous substances. The two cases highlight a major weakness within the regulatory framework, as shown in Fig. 1. Most safety regulations are implemented either by the state directly or delegated to county or municipality (1) are directed toward an individual enterprise. They do not call for an overall or holistic risk governance process when several enterprises or activities are sited in close proximity to each other. As a consequence, no holistic risk assessment regarding vessel traffic activity has been provided either by the Port of Oslo or Risavika, or by national coastal authorities. Although the county governor coordinates governmental regulation of municipalities,

<footnote n="1">¹The International Ship and Port Facility Security Code (ISPS Code) is a comprehensive set of measures to enhance the security of ships and port facilities, developed in response to the perceived threats to ships and port facilities in the wake of the 9/11 attacks in the United States. The ISPS Code is implemented through Chap. XI-2 Special measures to enhance maritime security in the International Convention for the Safety of Life at Sea (SOLAS), 1974.</footnote>
administration of the regulations is fragmented, and the regulations are less suited for addressing the composite risks that are encountered in industrial parks and ports. In Risavika, the locations of the LNG plant and the ferry terminal were largely handled as separate issues and the aggregated accident risks were insufficiently evaluated. However, the SD III has potential value because it addresses the clustering of hazardous enterprises and domino effects by requiring member states to identify groups of enterprises where the danger of a major accident is increased because of their location, activities, and the proximity of dangerous substances. In such cases, the exchange of information and cooperation among the enterprises is required and the coordinating mechanisms are anchored in enforcement of the SD, and to some extent in Norwegian HSE regulations.

Second, the public ownership of the harbor and industrial areas introduces multiple and partly conflicting goals, likely creating role conflicts for key stakeholders, particularly at the local level. Ports are often part of municipal developmental schemes that involve tradeoffs between benefits and risks, and socioeconomic considerations may tend to overshadow risk concerns, as in the South Port case. Public involvement and ownership should normally ensure democratic and trustworthy control mechanisms. The information on which public actors must base their decisions relies largely on risk studies from companies that have been developed by their contracted experts. These raises concern about the objectivity of risk assessments and risk communication. Such processes can lead to public mistrust as seen in Risavika. When the public is unable to deal with theoretical risk estimates related to their “real world”, or with disagreement among risk experts, mistrust may escalate and risk communication became a vicious circle. In Risavika, conflicts afflicted “the social contract” between the owner of the LNG plant and the municipality on one side and stakeholder groups and individuals within the local communities on the other side. The most contentious issues were the quality and relevance of the risk assessments, and the decision process for locating the LNG plant. The case illustrates the ambivalent and contested power of knowledge in proceedings where experts differ over risk assessments and frustrate the public’s quest for certainty.

Questions raised in the community were “Is the location correctly selected, and can we live with this industry close to our door?”. While a risk expert from the local university brought the risk issue onto the public agenda with strong criticism of the enterprise and the municipality, he was opposed by other experts (Vatn 2010). The heated public debate that followed appeared to be a reaction to uncertainties regarding the risk of possible events and to the mixed roles and interests of stakeholders in the project.

Third, different social climates in the two cases may have influenced perceptions of risk among stakeholders and civil society. In this respect, the two regions differ. Risavika is in the county of Rogaland, which also includes Stavanger, an exceptional area because it is the “Oil and Gas Region” of Norway. Industries, professionals, and media have over the years fostered a strong public awareness and attention to risk with extensive media coverage of incidents and accidents. This region also has considerable clusters of experts in safety research, education, and
consulting. These factors may have contributed to the public engagement, media
debates, and interventions among local citizens. The Oslo region lacks most of
these features and is mainly focused on developmental benefits rather than on risks.
A worst-case scenario indicates that an accident caused by a major leak of petro-
leum from a tanker in South Port and ignition and the spread of smoke and gas
would endanger the whole area toward downtown Oslo including housing, public
areas, and the iconic Opera building. Although a greater worst-case risk is posed in
South Port than in Risavika, there has only been one newspaper article and no
public engagement or debate followed.

*Learning from the Chevron–Richmond Case*

Chevron's Richmond refinery is subject to a multitude of safety and environmental regulations that are enforced by federal and state (California) agencies. It must also secure several permits from county, regional, and community (Richmond) units of government that set operational requirements. This regulatory framework includes the RMP rule and is supplemented by other components of risk governance (CCHS 2016).

Nevertheless, refinery operations have caused hundreds of accidents, spills, and other harmful events over several decades, with many attributed to regulatory violations. As a result, Chevron is continuously defending against enforcement actions and lawsuits, and has paid tens of millions of dollars in penalties and damage awards (Mattera 2016). Our research, which included the review of extensive reports (Macey and Susskind, Kenney, etc.) and other documentation and numerous interviews in Richmond, leads to the conclusion that the company, in aggressively implementing its business plans, subordinates regulatory compliance and avoids engaging with the public and taking other voluntary actions except when it needs a permit to continue or expand operations.

In the modern era of industrial safety, the Richmond refinery ranks as a worst
case. As such, it provides an opportunity to understand the circumstances that
undermine the effectiveness of the RMP rule and enable the continuation of its
accident-causing operations. The undermining circumstances arise mainly from
(1) the high socioeconomic value of the refinery and the low economic condition of
the community, and (2) national security policies and the failure of the oversight
agency, EPA, and the company to provide the factual information and analyses
needed for effective risk communication and dialogue.

Federal and state regulators, knowing that the refinery's operations are of con-
siderable importance to the national and state economies, dutifully take enforcement
actions to punish noncompliance but tailor them to avoid impacting operations to
the extent that their societal value would be impaired. Absent the threat of severe
sanctions, this highly profitable company absorbs the penalties and other monetary
loss consequences of their accidents and violations as costs of doing business,
continues to subordinate regulatory compliance, and sees little need to engage in
risk communications and dialogue with local stakeholders.

Similarly, local officials with permit granting authority know that refinery
operations are essential to the Richmond economy (e.g., jobs, tax revenues, and
local suppliers). They also know that despite many factions in the city with different
objectives and conflicts between them, there is an underlying position shared by
most if not all in Richmond, namely to keep the company in Richmond and not
drive it elsewhere. As a result, permit requirements are carefully crafted to address
issues by means that are acceptable to Chevron. Company promises to provide jobs
and job training, and contribute funds for social services and other community
betterments have also influenced community decision-making. The company has
also made political contributions to change community leadership.

In addition, the potential value of the RMP rule for promoting meaningful, risk
communications, engagement, and dialogue between the company and local
stakeholders has not been realized. One reason is that national security policies have
constricted information sharing, making it more difficult for local stakeholders to
access critical information about a particular facility's accident hazards, safety
management program, and offsite consequences, as noted earlier (Beierle 2003).

Another reason is that RMP implementation by the EPA has been weak. As
reported by the Chemical Safety Board (CSB), EPA has not required accident risk
reduction nor required that the company demonstrate that its safety systems are
functioning, and the EPA regional office lacks sufficient resources to fully inspect
and audit the numerous high hazard facilities within the area. The CSB concludes
that the RMP program as applied by EPA to refinery operations has not resulted in
Chevron's development and documentation of sufficient factual information and
analyses needed for control of major accident hazards and risks (Chemical Safety
Board Regulatory Report 2013b). Thus, EPA, as well as Chevron, has deprived
local stakeholders of the factual information and detailed studies needed for
effective risk communication and dialogue.

Finally, it is instructive to consider the case in which Chevron secured the
permits it needed to change and expand refinery operations in order to meet new
federal requirements for an environmentally friendly reformulated gasoline
(Kenney 2004; Macey and Susskind 2003). Permit approvals were granted in 1994
by the City Council and a regional regulator despite Chevron's performance record,
the occurrence of a spill and a major accident at the refinery during the permit
application process, and deep mistrust and hostility among Richmond residents. In
addition, a Mitigation Task Force comprised of three environmental organizations
and Chevron negotiated a GNA that contained additional company commitments.

Some of the Chevron commitments expressed in the permits and the GNA
involved reduction of emissions of toxic chemicals, replacement of leaking valves,
and cleanup of contaminated and unsightly premises. But many others involved its
funding of community social and health services, recreational facilities, and other
community betterments. This patchwork approach, sweetened by company
donations, did not provide a foundation for continuing engagement, communica-
tions, and dialogue, nor did it contribute to building a safety culture at Chevron. As
a result, the company continues to incur accidents, polluting occurrences, and
community hostility.

Conclusion

Our point of departure has been conflicts that arise when companies with hazardous activity cause local concerns about risks, impacts, and their consequences for the safety of workers, public health, and the environment. The analysis has identified different approaches and “modeling” of the risk governance process and the company–community relationship. The Norwegian cases with industrial areas and harbors represent a “regulatory model” that is administered by the state, involving many regulatory agencies and addressing the interest and concerns of stakeholders within the national legal framework as well as the European Seveso Directive. The US case with a huge refinery operation similarly involves national regulation, including the RMP rule, and also involves regional and local permit granting authority. It leaves the door open for company and community (or citizen groups) to voluntarily negotiate an agreement on specific steps to be taken to resolve residual risks and community concerns. It also enables negotiation of company donations for improving the community’s social programs. Each model has special features, contextual circumstances, and implications which differ from the familiar features of traditional regulatory and permitting procedures.

As presented in the analytical framework (Fig. 1), the SD and RMP components
of state regulation should be viewed as complementary policies for information
sharing and promoting engagement and dialogue between a company and its
community, including the workforce and local stakeholders. They also enhance
transparency of proceedings and respect for community concerns and local
knowledge (Lindoe 2017).

Our assessment has shown that obstacles to implementation can arise. They
include the following:

- Insufficient coordination of the regulatory framework causing a fragmented approach to risk,

- Technical complexity and stakeholder confusion arising from competing experts,

- Competing or conflicting interests of multiple stakeholders,

- Concerns about security that restrict the flow of risk information and communications,

- Prioritization of economic and developmental interests that subordinates local concerns about health and safety,

- Lack of factual detail in the company information provided.
Nevertheless, the societal benefits being gained, despite these troubles, justify
robust implementation of the SD and RMP approaches. They move corporate social
responsibility from theory to practice and establish a pathway for discourse between
company and community. They confirm the legitimacy of local stakeholders for
participation in risk decision-making on hazardous industrial operations and thereby
enable a more sensitive and holistic approach to risk issues by regulators and
companies. Overall, they contribute to making risk governance more democratic,
respectful, and responsive to the population sectors that are most vulnerable to
major industrial accidents.

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**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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Part II

When Reality Strikes Back: Tough Lessons to Be Learned from Crises
# How Risk Communication Can Contribute to Sharing Accurate Health Information for Individual Decision-Making

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Check for
updates

## An Empirical Study from Fukushima During a Post-emergency Period

Mariko Nishizawa

**Abstract** Risk communication is an established concept within the risk analysis framework. It is a tool for conveying the results of the scientific assessment and management of risk, for sharing safety-related information, and exchanging views and values amongst varying stakeholder groups. Its ultimate aim is to build trust through social interaction. However, the nature of effective risk communication is yet to be fully understood and, consequently, gaps in perception about risks between experts and nonexpert remain significant. In order to address this issue and suggest how risk communication can contribute to the creation of shared awareness of the risks and benefits of nuclear energy in Japan, this chapter will show an empirical study conducted in Japan between 2011 and 2012 in the post-Fukushima accident period. In the study, scientists explained nuclear safety and health effect of radiation to local residents evaluated from radiation-affected areas in Fukushima. It concludes that a carefully designed risk communication programme can serve as an effective tool to narrow gaps in perception between experts and nonexperts about risks, and as a useful and trustworthy source of safety information for individual decision-making.

**Keywords** Nuclear disaster · Fukushima · Public communication Participation

<footnote>M. Nishizawa (✉)
Litera Japan Corporation, Tokyo, Japan
e-mail: nishizawa@literajapan.com</footnote>
# Introduction

It is widely agreed that the accident at the Fukushima Daiichi nuclear power plant was triggered by natural events combined with technical failures and was a human-induced disaster as well (National Diet of Japan 2012; Investigation Committee 2012). From this unfortunate accident, we have learned that human and organisational factors associated with emergency planning, response and decision-making for nuclear safety need to be more carefully reviewed and enhanced. Contributions from the social sciences, especially from risk management and risk communication, play key roles.

Risk communication is an established concept within the risk analysis framework. It is a vital tool for conveying the meaning of scientific assessments and risk management, for sharing safety-related information and exchanging views and values amongst various stakeholder groups, or for triggering behavioural change and resolving conflicts. Its ultimate aim is to build trust through dialogue and social interaction (Rosa et al. 2014).

However, it would not be an overstatement that the nature of effective risk communication is yet to be fully understood. As a result, risk communication is sometimes only partially integrated into risk management practice or is not considered at all. This marginalisation of risk communication is observed in a variety of risk communication practices, or more evidently, in the perception gaps that exist between the lay public and experts about risks.

This chapter will address this pressing issue and suggest how risk communication can contribute to create shared awareness about the risks and benefits of nuclear energy by illustrating an empirical study in Japan conducted between 2011 and 2012 in the post-Fukushima accident period. In the study, scientists explained nuclear safety and health effect by radiation to local residents during a series of risk communication practices planned for the evacuees from a disaster-affected region, Iitate Village of Fukushima Prefecture. The author was directly involved as the planner and as the facilitator as well. This exploratory study investigated why communication between professionals and laypersons often fails and, ironically, how it can sometimes lead to a mistrust of science.

Before presenting the empirical study, the next section reviews literature on risk communication and public participation in general and about Japan in particular.

# Risk Controversy and Dialogues: Literature Review

Science and technology are inevitably associated with uncertainty. Neither 100% safety nor zero-risk exists. In other words, risk can be reduced but it can never be zero. What we need to achieve is not a situation of ‘zero risk’ but to a degree that society deems acceptable. In addition, society demands that risk managers are in control of the risk and not subject to reoccurring surprises, i.e., such as financial meltdowns and system failures.
Studies of risk communication in the past have shown that risk-related controversies depending on their characteristic (Rosa et al. 2014). And it is known that those in which even experts are divided on safety issues, or those that are closely bound with values, ethics, religious beliefs, or world views, tend to be intense. This makes forming a consensus more difficult. Worldwide disputes over genetically modified crops are a symbolic example (Krebs 2013; Nishizawa and Renn 2006). The debate over low-dose radiation exposure from the reactors at Fukushima is another example—risk perception remains high in contrast to expert's scientific risk assessment.

Social theorists have long recognised the existence of a new constellation of attitudes and concerns about risks derived from complex and uncertain aspects of science and technology such as the long-term and irreversible effects of global warming or economic impacts on agriculture by the application of genetic engineering; and they have pointed to the need for new ways of handling risk-related issues in the face of changing social circumstances (Beck 1992; Giddens 1991).

In this context, dialogue-based risk communication and citizen participation in risk controversies has increasingly come to be seen as a useful response. Scholars such as Forester (1999), Renn et al. (1995) and Schön (1983) suggest that it leads to critical self-reflection on the part of key actors and a greater mutual understanding between them, and that this in turn creates a more favourable environment both for problem-solving and for democratic governance. It is suggested that dialogue-based risk communication and participatory methods likely to be effective in risk debates that are complicated and for which scientific conclusions about the risks are ambiguous (Renn 2008).

In recent years, there has been more attention to dialogue-based communication in Japan. An example is a health communication practice for the residents during the volcanic eruption in the mountains on Miyake Island in 2000. A communication programme about health effects of volcanic gas was carried out by a team of university researchers (Kikuchi et al. 2006). There are also reports on community-based participatory disaster planning, as in the case of a village in Tottori (Okada et al. 2013; Okada 2015).

Notwithstanding of these, typical communication practices in Japan are still designed to be top-down. Hence, truly participatory and dialogue-based risk and crisis communication is limited (Nishizawa 2005; Nishizawa and Renn 2006).

It was therefore not surprising that the initial emergency communications on the events at Fukushima Daiichi nuclear plant by the central government were largely one-way. It was symbolised in a frequently quoted phase, 'no immediate impact (tadachini eikyoha nai)'. This was criticised by the public as well as the media who both felt that the central government and scientists were trying to make the effects of the radiation look less severe (Nakanishi 2014; Nishizawa 2013). Subsequently, local residents in Fukushima demanded their local governments provided them with more reliable safety information.

It was in this context that, 6 months after the accident, the author was appointed to be a risk communication advisor by Iitate Village Municipality of Fukushima
from September 2011 to March 2012 and involved in implementing a public communication programme for its concerned residents.

# Risk Communication for the Residents of Iitate Village, Fukushima 2011–2012

## Initial Group Interview in September 2011

Iitate is a small village in northern part of Fukushima that used to be known for its organic farming and for raising cattle. However, after the accident, it became to be known domestically and internationally as a village badly affected by the nuclear fallouts. The village is located 25–45 km from the Fukushima Daiichi Nuclear Power Plant. Initially, it was outside the mandatory evacuation zone that was set right after the explosions. Nevertheless, it was discovered a few months later that the radiation level was higher than initially estimated due to nuclear fallouts blown by the wind. Of the approximately 6500 people who lived in the area before the accident, virtually all left the village as a precautionary measure when the evacuation zone was widened 2 months after the disaster. As of April 2013, the level varied from 4.5 µ (micro) Sv/h in a heavily contaminated area to 1.4 µSv/h in a less contaminated area.<fnref n="1" />

Consequently, many village residents had become sceptical of both scientists and officials both from the central and the local governments—they had been initially told to remain in the village but later the entire village was advised to evacuate the area. They felt betrayed by the authority, left behind, frustrated and scared, without being given any substantial safety information to protect their families for half a year. The municipality was at a loss about how to convey accurate safety information onto the village residents, because it was unfamiliar with techniques for communicating with the public about radiation. It was in this context that they invited a group of experts who had expertise on radiation science and public health.

The Iitate Village municipality asked the Risk Communication Advisory Group, which consisted of four experts including scientists and a medical doctor, to plan and implement an emergency communication programme. The author was its primary architect as its only expert on risk communication. Its role was to help scientific experts explain the science of radiation and the health effects from exposure to radioactive materials to local residents who had been evacuated from areas contaminated by nuclear fallout from the Fukushima Daiichi nuclear plant. The Municipality agreed not to intervene in the programme and its structural and content-wise design was left fully to the hands of the Advisory Group.

<footnote n="1">¹By January 2016, the value had decreased even more, to less than 1 µSv/h, at the majority of measured areas; according to the official data from Fukushima Prefecture (Fukushima Prefecture 2016).</footnote>
Risk communication needs to be well-designed and the cost of poorly design communication is high (Baruch and Kadvany 2011). As noted in a preceding section, risk communication aims to create mutual trust through its process, yet, if such a programme was run primary one-way, it would raise scepticism that its hidden aims are to persuade participants towards certain directions and could result in creating distrust instead.

In order to conduct a pilot study, the author selected one particular residential complex (Y) in Fukushima City where approximately 250 had taken refuge. Nearly 40% of the refugees were children under the age of twelve. Parents and grandparents were particularly concerned about the health effects of radiation on their children. In order to design such a programme, the author visited the sheltering site with a graduate student for initial group interviews in September 2011. Twenty residents, ranging in age from 25 to 80, voluntarily participated in and were interviewed to assess their level of knowledge of radiation and to determine their needs. The interviews lasted for a day.

The interviews revealed that interviewees had received little information about radiation from the local government or from schools during the six months after the accident. When asked about their sources of information, they said it was primarily television or the Internet. They expressed anger, disappointment and fear and said that they needed safety information that was trustworthy. The information they had received from the media was contradictory or largely frightening and, consequently, they could not fully trust it. Many felt abandoned, frustrated and scared without any substantial safety information to protect their families.

## Communication Programme with a Radiation Expert in October 2011

Together with another communication advisor who was an expert in radiation science, the author attempted to implement a communication roundtable at the sheltering living complex, inviting about 20 local residents to participate, ranging in ages from 25 to 80 years.

The communication session lasted one and half hours, with a 60-min lecture about radiation and its health effects, followed by a Q&A session. The attendees, the lecturer and the author (facilitator) sat together on tatami mattresses. This created a friendly atmosphere in which participants could readily ask any questions or express their concerns.

Initially, the session looked to be successful. Feedback by questionnaire demonstrated that the participants had improved their understanding of radiation, and their fears about health effects were lessened. Yet, when the author conducted follow-up telephone interviews with several participants after the initiative, it was revealed that the programme had had little real influence on their thinking. They remembered very little from the lecture with a few exceptions. For example, in the
lecture, it was mentioned that bananas naturally contain a radioactive material, potassium 40. However, rather than calm her one woman's fears about radiation, she said that she would not give her daughter bananas anymore. Hot springs that naturally contain radon were also mentioned in the talk and people remembered this. Fukushima has several radon hot springs. In other words, people remembered some things from the programme, but these were not the things that would help them make better personal decisions about living in Fukushima. Accordingly, the communication programme needed to be changed so it better suited the needs of the attendees.

## Follow-up Interviews: More Active Listening Necessary

In order to implement a more adequate and effective programme, the author conducted another group interview in January 2012 with 11 volunteers. Interviewees were separated into two groups; a group of the elderly (average over 60 years old, *N* = 7) and a group of mothers (average 30–39 years old, *N* = 4).

The results of the interviews with the former group, the elderly, showed that this generation was more interested in prospects for rebuilding lives than radiation-related information. They saw the decision to return to the village as in the hands of the younger generation. They showed little interest in knowledge about radiation. A frequently referred sentence was: 'We want to know when we can return (home)'. Their primary concerns were not about radiation.

On the other hand, the results of interviews with the mothers illuminated two issues. The first was that they are seriously concerned about the health effects of radiation on their children and based on this, they had taken actions to protect them by changing the food that the children ate. The second was that a divergence occurred between what they actually wanted to know and what they actually heard from experts. What mothers wanted was hands-on information that they could use to help them protect their children and not the more detailed and scientific information provided by the experts.

The failure of the initial communication programme deployed in October 2011 made us realise that an effective communication programme can be planned only after active and careful listening to the target audience. The interviews with the group of mothers highlighted that they had a high interest in practical radiation-related information, but not in the science of radiation. They found it difficult to understand the science of radiation and its relevance to their situation. They wanted crucial information on how to protect their families, and not an academic classroom lecture. In particular, they wanted reliable information on the risks of consumption of radiation-contaminated food and the measures that they could take to limit their radiation exposure. In risk decisions, people feel safer when they have personal control over a risk (Slovic 2000). The group of mothers expressed its disappointment because they were yet to be given such hands-on information by the scientists.
Attentive listening is also important in risk communication for trust building. Earle et al. (2007) demonstrate that shared values are immensely important to public trust. Active listening conveys an unspoken message: ‘We care, and therefore we listen to you’. Charles (Chuck) Casto, former United States Nuclear Regulatory Commission (NRC) executive who provided support to the Japanese government and U.S. Ambassador after the Fukushima accident, suggests that explaining science to local residents can be only possible after carefully listening (Casto 2016). His observation corresponds to the experience that the author had in Fukushima.

In summary, the attendees of communication exercises in Fukushima felt frustrated because the information provided by the scientists was not what they expected and wanted. It was either too scientific, and thus difficult to grasp, or not relevant to what they needed for their everyday life.

Furthermore, the author realised that the two groups involved, the elderly and mothers, needed to be approached separately. Among other things, the younger generation expressed a reluctance to talk frankly and give honest views in front of the older generation. It is understandable, since Iitate is a small village and its social structure is strong and conservative unlike cities like Tokyo. In particular, the behavioural expectation for females to be silent and obedient prevails in Iitate. Without active listening, such important elements could have been easily overlooked.

## Revised Communication Programme in February 2012

Based on the results of the group interviews, the author formed a small study and designed and piloted a communication initiative that involved a study hour on ‘foods and radiation’. The programme took place in February 2012. Four mothers volunteered to take part. Three had participated in the earlier group interviews and the author was acquainted with them.

The author prepared information material on ‘How to deal with radioactive material in foods’. This explained that eating locally grown vegetables and drinking tap water was safe and why. In addition, the author asked a mother who acted as a quasi-leader of the group to bring in foods like milk and banana, to make it more participative, hands-on and more visibly clear. The discussion of how to deal with foods was deliberately slow paced and took almost 2 h. The author provided them with her email address and promised to answer any questions that they had later.

Before starting the discussion, the author asked participants what they wanted to know regarding the food they eat. Their interests varied; some wanted to know about the safety of eating local fish and others about drinking tap water. The author did not begin with a description of the risk of radiation, but instead, explained that there is no such thing as zero risk in foods. Some natural toxins are found in many vegetables, and non-pasteurised milk and raw eggs have certain risks that can be fatal. Conventional foods contain carcinogenic and neurotoxicants, such as acrylamide in potato fries, coffee and burnt bread. Hijiki (a sort of seaweed seen as a healthy food in Japan) contains inorganic arsenic and is banned from being sold in the UK.
The level of risks can be more readily grasped by being compared to accepted risks. The primary chemical of concern from Fukushima was caesium. However, potassium 40 has similar pharmacokinetics (ICRP 1990) and is a naturally occurring radioactive isotope in many foods. So, the author discussed that many foods, such as potato chips, milk and banana, contain 'natural' radioactive potassium 40 and that we consume as much as 100 Bq per a day of such radioactive material. That is, 20 Bq of potassium 40 is consumed from one bag potato chips, 20 Bq by eating a large-sized banana, 50 Bq by drinking 1 L milk, and 5 Bq by drinking a large can of beer; according to the Japanese Ministry of Education, Science and Technology (MEXT) (2011). In order to make this seem more real to participants, food was placed on the table in front of everyone.

This was followed by showing the results of sampling of vegetables that had been conducted by the Ministry of Health, Labour and Welfare of Japan. The current and future regulatory values of radioactive caesium in Japan were then explained. Finally, the author showed the results of monitoring tests conducted by Coop Fukushima that measured the actual amount of radioactivity found in cooked meals at home. The measurement conducted at 51 households in Fukushima pre- fecture demonstrated that the detected radioactivity came predominantly from potassium 40 and only a limited amount of caesium was detected (Fig. 1). Those households where caesium was found were reported to have used vegetables not on the market, but rather from edible mushrooms and plants taken from wild sources by the households themselves.

<figure><img src="image_23.png" /><figcaption>**Fig. 1** Radioactive cesium in meals in January 2012 (Study on 51 households in Fukushima Coop.) *Source* Fukushima Coop (2012) www.fukushima.coop/kagezen/2011.html</figcaption></figure>
The participants said that the dialogue was more helpful and practical than the conventional explanations they had heard from the scientists visiting Fukushima. They said that they had overestimated the risks from radiation and said they would change the way they choose foods and water. An example was the way they chose drinking water. Originally, they were afraid of giving tap water to their children and usually bought more expensive bottled water. However, after the dialogue they said they would stop purchasing bottled water. The dialogue appeared to deliver credible safety information and help households decide what to consume.

Discussion

Effective risk communication delivers to its audience a clear and convincing view of risks by appealing to it emotions and needs; people interpret information largely using intuitive (emotion-based) heuristics. Scientists tend to explain facts using numbers and logic but this approach is not consistent with intuitive heuristics. In other words, risk communication needs to be designed so that it speaks to System 1 (intuition (emotion)), rather than to System 2 (logic); as psychologists or beha- vioural economists like Kahneman (2012) discuss.

Another key element in risk communication is risk comparison as noted in a preceding section (Nakanishi 2014). There is a tendency that when focused on one risk, people tend to perceive that the level of the risk is higher than it actually is (Nakada et al. 2012). Therefore, the author tried to explain the strength of the risk from radiation in comparison to other socially accepted risks; particularly radioactive potassium 40 in foods.

There is a persistent misunderstanding that the primary goal of risk communi- cation is to ‘persuade’ the public, so that they will accept the risk in question, or to accurately convey scientific facts (Nishizawa 2015). In fact, the goal should be to give the information that people need to make appropriate decisions about their lives and community. As was argued in a preceding section, one needs to listen to those involved, so that risk communication can be tailored to their concerns, needs and interests. This is to say that risk communication starts by listening.

Creating an atmosphere where one can ask ‘dumb’ questions is also an important factor, and one which is often neglected in practice. It was the reason that we all sat on the tatami floor together, drinking tea. This allowed the conversation to be sometimes derailed by talk about the weather, families and even fashion. However, it allowed it to flow and provided a platform for questions that were about risk and of importance to the participants. The session was set in the early afternoon before their children came home; this helped mothers attend the session.
In paying attention to the ‘risk-information route’, it is also essential to make risk communication programme more effective. It is known that risk-related information is conveyed mainly through two communication channels: the mass media and by word of mouth (Renn et al. 1995). In fact, the mothers in the study said they felt that the most reliable source of information was their mothers’ friends. Hence, it was hoped that accurate and useful information about radiation would pass on amongst the mothers’ circle; ripple effects in the horizontal connection. They did say that they would pass the information further onto their friends who were not able to come to the session. This experience illustrates the importance of peers for adding credibility to messages and demonstrates that people are more likely to believe important safety information from familiar and/or trusted sources/persons. Trust is of utmost importance.

From the series of largely exploratory studies in Fukushima, we may argue that common failures in providing safety information were identified not in scientific information itself, but in the ways such information was conveyed to lay people. As discussed in the preceding sections, scientists primarily try to explain the science of radiation by the use of numbers and logic. However, lay people understand health-related safety information by images and emotions in the context of their needs. Experts want to be scientifically correct whereas the public need hands-on, clear and concise explanation of practical use. Scientists’ adherence to scientific accuracy is understandable but communicating scientific information requires a different skill set and objective. This lay-expert gap is an element of mistrust of science and needs to be more readily acknowledged. In order to narrow the gaps, experts need to deliver the safety-related information that is asked for, tailoring their language to be more readily understood by their lay audience.

Our experience in Fukushima made us realise that more frequent science-lay encounters will help scientists become more aware of the needs of the lay people and of how they understand information. We also learned that it is best that the first encounter occurs during a noncrisis situation and not during a crisis itself. Furthermore, we learned that, before talking science, experts need to express empathy and concerns in front of the affected audience. This will lead to a more honest and trustworthy dialogue between them.

## Conclusion

The present chapter discussed how to provide information that is both accurate and of practical use for local residents in relation to nuclear risk. The present case was complicated as the local residents felt abandoned and had persistent mistrust towards scientists and authority. As a result, one-way communication failed. Hence, interactive and a dialogue-based communication was used not only to deliver
accurate information but also to create mutual understanding and build trust. In the event of an emergency, it is essential to deliver information concisely and within a short period of time. However, when a certain amount of time has elapsed, it becomes more important to consider delivering information tailored to the characteristics, emotions and needs of each population group. As reported in this chapter, demands for information about radiation information were notably different between the child-rearing generation and the older generation. It was the former group that needed hands-on and practical advice about radiation, not the latter. The programme used must to be tailored to the needs of its target audience. Therefore, it is necessary to actively listen to audience in the design of the programme in order to make it more useful and credible. It is good to remember that good communication starts from good listening.

With the increasing deployment of nuclear technology in developing countries in Asia and elsewhere, as well as the persistent negative perceptions within and outside Japan about agricultural products grown or caught in Fukushima and neighbouring regions, the bitter lessons from Fukushima need to be shared on an international basis. This will hopefully contribute to the creation of emergency communication programmes that are more robust, resilient and trustworthy. We learned from Fukushima that we can communicate more effectively regarding risks during noncrisis situations in a way that cannot be achieved during a crisis. Accurate safety information therefore needs to be shared during noncrisis situations and, in order to pursue this, the creation of truly participatory and dialogue-based public ‘spheres (platforms)’ for science-lay encounters need to be rigorously developed during noncrisis situations. Such platforms are also paramount for creating an atmosphere of trust and confidence that provide the basis for joint decision-making during crises. More fundamentally, risk communication needs to be paid more attention from the spheres of science and technology.

**Acknowledgements** The author is especially grateful to the local residents of Iitate Village who cooperated with the interviews and participated in the ‘food and safety’ study session. I also thank the Editors of this book and David Cragin and Ortwin Renn for their useful suggestions about this chapter.

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# Crisis Communication During the Ebola Outbreak in West Africa: The Paradoxes of Decontextualized Contextualization

<figure><img src="image_25.png" /></figure>

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Loïs Bastide

**Abstract** As organizations involved in the 2014–2016 Ebola virus disease (EVD) outbreak response in West Africa are now drawing lessons from the crisis, the “manufacture of consent” (Burawoy 1979) emerges as an important issue. Recommendations and public health interventions developed during the response were met with suspicion and often resistances by affected populations, pushing involved organizations and actors to reflect about the validity of their risk communication tools and concepts. These difficulties stressed the numerous shortcomings of risk communication practices, which proved inefficient in an unfamiliar social and cultural context. Many reasons can be pointed-out to explain this failure to communicate risks and public health measures effectively under these circumstances. They include: unrealistic goals for communication; lack of integration of social science skills and knowledge in communication guidelines and human resources; underestimation of the breadth of communication-related tasks; over-segmentation and lack of clarity of communication concepts and expertise (risk communication, crisis communication, social mobilization, and health promotion are all but a few of these categories). Among all these possible lines of inquiry, I want to address what can arguably be considered the most fundamental flaw of crisis communication during the West African EVD episode: its inability to take into account and analyze efficiently the *context* of the intervention.

**Keywords** Ebola • Public health interventions • Risk communication • Social mobilization

L. Bastide (✉)

Institute of Sociological Research, University of Geneva, Geneva, Switzerland

e-mail: lois.bastide@unige.ch
Introduction

As organizations involved in the 2014–2016 Ebola virus disease (EVD) outbreak response in West Africa are now drawing lessons from the crisis, the “manufacture of consent” (Burawoy 1979) emerges as an important issue. Recommendations and public health interventions developed during the response were met with suspicion and often resistances by affected populations (Fribault 2015), pushing involved organizations and actors to reflect about the validity of their risk communication tools and concepts. These difficulties stressed the numerous shortcomings of risk communication practices, which proved inefficient in an unfamiliar social and cultural context.

Many reasons can be pointed-out to explain this failure to communicate risks and public health measures effectively under these circumstances. They include: unrealistic goals for communication; lack of integration of social science skills and knowledge in communication guidelines and human resources; underestimation of the breadth of communication-related tasks; over-segmentation and lack of clarity of communication concepts and expertise (risk communication, crisis communication, social mobilization, and health promotion are all but a few of these categories). Among all these possible lines of inquiry, I want to address what can arguably be considered the most fundamental flaw of crisis communication during the West African EVD episode: its inability to take into account and analyze efficiently the *context* of the intervention.

To discuss this point, I will start by proposing an informed definition—to the extent that social sciences are concerned—of what a “context” might be. Drawing on this definition, I will then extract a few significant characteristics of the response context, by applying proper analytical tools assembled from the disciplinary archives of social sciences (thus, showing that the issue is more about *heuristics* than knowledge of local circumstances per se). In the last section, I will contrast this analytical framework with the techniques of inquiry available to health emergency communication experts. These tools and related practices were identified and investigated during different fieldworks involving interviews with risk communication experts at the World Health Organization (WHO) and at the US Centers for Disease Control and Prevention (CDCs), as well as observations at WHO’s Department of Communications (DCO).<fnref n="1" /> This will allow to show that these

<footnote n="1">¹Part of these fieldworks took place in the context of the *Organizing, communicating and costing in risk governance: learning lessons beyond the H1N1 pandemic* research project (2013–2017), funded by the Swiss National Science Foundation, with a core research team composed of scholars from the Department of Sociology, University of Geneva, and the Haute Ecole de Gestion, Geneva. Other observations and interviews were conducted in the context of a joint research project between the Department of Sociology, University of Geneva, and WHO’s DCO, titled “Generating evidences by capturing field experience from WHO-led deployment of risk communication experts do West Africa” (2015).</footnote>
techniques tend to erase contexts by taking an individual, psychological and behavioral perspective on affected populations, in the spirit of Evidence-Based Medicine (Brives et al. 2016).

Understanding “Context”

Looking back as far as at Jakobson's famous scheme of the functions of language (1960), which identified the context as a pivotal determinant of human communication, it is striking to see how communication, as a professional domain and practice, has paid little attention to this very dimension. In this respect, the Ebola outbreak in West Africa certainly acted as a powerful reminder: Most of international responders did not understand where they stood during the first months of the response, thus falling in all sorts of traps and pitfalls, causing much delays in necessary interventions: Ebola patients escaped; families and communities hid their ills; dead bodies were silently buried (Faye 2015; Moulin 2015); international funds vanished in the maze of national and regional bureaucracies. Puzzled by these facts, a common reaction among responders was to attribute these failures to backward beliefs, in affected countries, and to a lack of rationality (personal interviews, WHO; for a media account see Malagardis 2014). This kind of stereotypes outlines the lack of understanding of local circumstances in West Africa. Dangerously, these assumptions often served as a base for the development of public health interventions.

As Simmel (2007) has shown, stereotyping is a basic social process: it is a cognitive strategy aiming at offsetting a lack of knowledge about unfamiliar interactional partners, at the beginning of a relationship. When encountering new “others”, stereotypes facilitate interactions as they serve as a baseline to draw expectations and possible lines of conduct, thus structuring an incipient relationship. As the relationship unfolds, *actual* knowledge about interactional partners is gathered through recurring encounters. It then progressively substitutes the necessary but highly biased information encoded in the stereotype. This process of learning through interaction is obvious in the response to the Ebola crisis in West Africa. A good example is the idea of African people living in traditional *communities* rather than being constituted of highly mobile *individuals*. This pervasive social representation, permeated with primordialist assumptions, prevented understanding early enough that affected areas were crisscrossed by intense human circulations—rather than being composed of still, enclosed tribal entities—spreading the virus along roads, routes, and paths. This view also caused an underestimation of current political and economic dynamics across national borders. Realization that the concept of community was misplaced and might have had a problematic effect on the response slowly emerged as a result of actual experiences on the field, which proved the concept to be misleading. However, this understanding came late and it was just starting to develop as an emerging topic among the leading actors of the
response when WHO started to engage in a process of after-action analysis in order to draw lessons from the crisis, in November 2015.<fnref n="2" />

Rather than developing systematic analytical tools to investigate actual social and societal patterns in affected and “at risk” areas, responding institutions thus relied on such basic, lay social representations (stereotypes) to develop their actions, as no system was in place to gather and process the necessary information, not only in “real-time” but by tapping into existing knowledge on best-practices to deal with an Ebola outbreak (Bourrier forthcoming). This failure to analyze the social determinants of the crisis points toward a lack of understanding of contextualization, as a basic and pivotal building block of human communication (Winkin 2001). To analyze these difficulties, let me first outline a rudimentary conceptualization of what a “context” might be, as far as social sciences are concerned. By identifying relevant analytical tools, I will then be able to contrast a scientifically informed definition of contextualization process with the actual cognitive and communicative processes developed by responding institutions to characterize their field of operations.

Speaking of contextualization is recognizing that actions—communication being considered a specific type of action, and actions always having a communicative component (Winkin 2001)—are *embedded* in specific situations, which contribute to configure their semantic contents. Actions are always sited, and they aim at specific outcomes, *in a given situation*. Conversely, actions also contribute to *shape* situations, as they carry on their own effects. Situations are thus a condition, a dimension, and a product of actions.

Understanding action thus involves delineating how local situations are *socially* and *cognitively* constructed. Similar in this to what Dodier (1993, 66) calls a “sociological pragmatics”, I propose that this effort involves understanding how social dynamics, in a broad sense (as encompassing cultural, political, and economic phenomena) aggregate and interact locally to frame expectations about/ according to specific circumstances, by conveying meaning from past events and framing anticipations, *considering the structuring necessities of unfolding events* (Abbott 2016; Bastide 2015a; Tsing 2005).<fnref n="3" /> Contextualizing is thus a matter of relocating the present (unfolding events) in this *tensed*, multilayered temporality. In this analytical framework, the present thus has a logical precedence over the other time-spaces (past and future) since it is the only possible locus of action and cognitive operations, where past and future are linked according to the requirements of the here and now of social life (Abbott 2016).

Understanding local situations thus involves looking at (1) Current circumstances—how a specific event operates and reconfigures existing institutions and social arrangements, by introducing new stakes; (2) History, as a collection of past, individual and collective experiences, which can be used to attribute meaning to

<footnote n="2">²Personal observation, workshop on post-Ebola reorganization, WHO headquarters, Geneva.</footnote>

<footnote n="3">³Understanding these meanings, expectations and anticipations is critical since they form the base for action.</footnote>
current circumstances (Abbott 2001, 2016; Schutz 2011); and (3) Anticipations—based on “social imaginaries” framing the perception of possibilities and probabilities contained in the present (Appadurai 1996, 2013). Thus, for instance, one cannot understand the EVD outbreak in West Africa without clarifying its relation to colonial and postcolonial medical practices across the region; in the same spirit, it is difficult to understand the crisis without looking at prevailing social imaginaries to understand vernacular rationalizations of the event, involving culturally and socially formed expectations; and it is difficult as well to make sense of the situation without looking at how the event reshuffles social arrangements and draws a line between a before and an after (Bensa and Fassin 2002)—as when Ebola intersected with political elections, or with social relations by restricting body contacts or disturbing funeral rituals.

Therefore, I want to use this basic conceptual toolbox to look at each of these different time frames (present/past/anticipations) in order to analyze the logic of action deployed by affected populations. This, in turn, will allow shedding light on the “motives” (Mills 1940) underpinning action courses, thus pointing toward specific forms of rationality. However, I need to stress that my expertise concerns outbreak response rather than local societies and histories; thus, I want to show that, by applying a relevant set of analytical tools, one is able to map out and look for relevant information in any given situation, in a sensitive, meaningful and efficient way, in spite of knowledge gaps regarding local circumstances—social, cultural, political, and economic patterns.

## Current Circumstances, Past, Anticipations

### Current Circumstances: Mapping the Stakes

The EVD outbreak opened a period of high uncertainty. As with every crisis of such scope, deep uncertainties created all kinds of new political, economic or social stakes, and opportunities (Klein 2007). Within affected localities, power relations were reconfigured by the epidemic: for example, some fractions of the people were able to seize working opportunities and contributed to staff the response; local political or moral figures, who were hired in the response to create trust between responders and communities, saw their social prestige increase or erode due to this position (Faye 2015); Ebola became a political stake during parliamentary elections in Liberia (NYT, December 4th, 2014), Guinea (Al Jazeera, October 10th, 2015),<fnref n="4" /> as in the US during 2014 mid-term elections (Politico, October 10 2014; personal interviews at the US CDCs in Atlanta) due to an imported case and the development of a local transmission chain in Dallas. Communicators lamented about what they

<footnote n="4">⁴http://www.aljazeera.com/indepth/features/2015/10/deadly-clashes-flare-guinea-election-151010132336700.html.</footnote>
understood as political interferences; they also complained about media coverage, thus effectively ignoring that both politicians and the media conform to logic of actions articulated around different stakes and interests that those regulating public health experts' practices.

Stakes were also high within and among institutions and organizations involved in the response. Indeed, the organization of an emergency response structure had deep effects on organizations' processes, as specific organograms were drafted, put in place and populated to structure the response. Negotiation about appropriate functions and expertise to be involved fostered competition between different departments, and available positions sustained competition between different individuals, within individual organizations. The fact that Bruce Aylward was officially appointed as the head of Ebola response at WHO as late as January 26, 2015, six months after WHO's declaration of Ebola as a Public Health Emergency of International Concern (PHEIC), is a testimony of the intensity of underlying negotiations. In one of our interviews, an informant framed this issue in telling terms: "Ebola makes careers" (personal interview, MSF Swiss member, December 17, 2014).

As in any “humanitarian space” (Hilhorst and Jansen 2010), Ebola also shaped an “arena” (Céfaï 1996) where different stakeholders—national institutions, international organizations, local, and transnational NGOs—competed for different types of resources—to enhance their profile as emergency experts; for funding; in order to increase their authority; to capture existing or emerging fields of action; and so on. For instance, a competition developed around the issue of communication, as prevailing “social mobilization” and “health promotion” techniques failed to convince people to comply with the prescriptions of involved institutions. Social mobilization thus shifted toward “community engagement”, that is a more inter actional way of negotiating interventions. The opening of this new domain of action drove struggles around the definition of this new, still blurry, field of expertise, both within organizations, as it foreshadowed the reorganization of communication capacities, and at an inter-organization level as it opened a new cluster in emer gency response systems, in need of staff and leadership.

Responders usually failed to consider these overlapping dynamics, integral to affected populations and to responding organizations. And, as a consequence, they also failed to recognize that the response itself, as a set of specific practices and interactions, created new social networks and collectives involving *both* responders and local societies.<fnref n="5" /> Such social interactions and dynamics framed the *situations* in which individuals and collectives dug into the past to make sense of current circumstances.

<footnote n="5">⁵Considering this, analyzing the response itself as a specific social formation involving and cutting across responders and local populations, with its own social dynamics, would be interesting. Clues to this approach can be found in Ong and Collier (2005).</footnote>
## History, Expectations, Anticipations: Mapping Conflicts

Among the numerous historical “lineages” (Abbott 2016) which combined to frame
Ebola as a public issue in the different countries, let me mention just a few.

First, the legacy of colonial medicine (Anderson 2014; Marks 1997) and the
logic of postcolonial global health (King 2002) probably played a significant role in
raising people’s mistrust while confronting the massive public health enterprise
swooping down on them. Historical work has shown, for instance, that colonial
public health was not predicated upon the will to better colonized populations’
welfare, or only in minor ways. It rather aimed at ensuring the biological well-being
of European settlers (Lachenal 2014), at safeguarding the productivity of the local
workforce, or at experimenting with hygienist utopias involving, for instance,
segregated urban planning, or epidemiological or medical techniques such as mass
vaccination against trypanosomiasis (Lachenal 2010). In Liberia and Sierra Leone,
British colonial medicine did little to better local population’s circumstances (Cole
2015). In this context, it is easy to understand that the massive influx of organi-
zations and individuals from advanced industrial countries was met with caution, to
say the least.

This kind of reactivation of old, asymmetrical relations of exploitation could
only be reinforced by the militarization of the response, with the deployment of the
US, British, and French troops and/or logistical capacities in Sierra Leone, Liberia,
and Guinea, which gave an obvious neocolonial twist to the intervention, while old
colonial powers reinvested past dominions.

It would be useful also to investigate the effects of pharmaceutical companies’
dubious practices in the region (Chippaux 2005), which might have further con-
tributed to frame social imaginaries regarding Western medicine and to raise
suspicion.

Last, internal tensions within countries also played a major role in complicating
the response. Thus, entrenched conflicts between the central government and
affected communities, in Guinea, fueled suspicion toward the response as a whole,
be it domestic or international, since outsiders were being seen as working with the
State, and since the State was often seen as a Trojan horse for foreign interests
(Faye 2015).

Anticipations and expectations were thus framed against this backdrop, making
people’s individual and collective behavior toward the response all the more
rational.

## Re-assembling Rationality

Thus, if conflicts and violence arose between affected populations and actors of the
response, one of the most striking features of the crisis was the conflict of ra-
tionalities at play between responders and affected populations. More challenging,
misunderstanding arose from the entrenched idea, across response apparatuses that
local citizens were acting erratically, irrationally, or at best according to obsolete
traditional beliefs. Thus, many professionals deployed in the field more or less explicitly relied on sets of binary representations to characterize the relationship between response apparatuses and local populations: Us and Them, cutting-edge science versus traditional healing practices, rationality versus beliefs, expertise versus primitive knowledge, and so on. To explain sometimes violent encounters between intervention teams and affected populations, one of our respondent at WHO thus put forward the cultural violence entrenched in local cultural practices, mentioning cases of cannibalism—a claim which proved untrue. Her own fear was thus predicated upon misleading expectations, themselves related to phantas magorical lineages and stereotypes. Thus, misaligned expectations due to stereo- typing and superficial knowledge prevailed on both sides of the response. Developing a “symmetrical anthropology” (Faye 2015; Latour 1997) of the response would thus have helped debunking mutual stereotypes and relativizing West African people’s putative lack of rationality.

Indeed, as some anthropologists have shown, popular resistance to public health interventions surely retained their own rationality (Faye 2015)—a given for any social scientist. In relation to the proposed conceptualization of “context”, rationality can be understood as a cognitive path developed by social actors to process the relation between current events, history, and anticipations in order to make sense of the situation and to act consistently. Thus, as it has been clarified in social sciences at least since Weber’s seminal delineation between different types of rationality—i.e., value-oriented or means-ends oriented (Weber 2003)—the prob- lem is not to draw a line between rationality and irrationality, but to recover and outline the internal logic of specific forms of social action (Bastide 2015b).

This conceptualization helps understanding why the biomedical logic of the early response in West Africa was met with resistance. If it surely needs to be empirically documented, it is clear that affected populations could only relate to this deployment by referring to the past—hence, the importance of considering the legacy of colonial medicine, the intricacies of postcolonial global health, to reflect on the postcolonial aspect of the response and to consider local political dynamics —to ascribe specific motivations and intentions to the actors of the response, and by drawing anticipations according to this understanding. In this respect, the fear of entrusting one’s relatives to medical staff dressed in awe-inspiring Personal Protective Equipment (PPE), knowing that, at the beginning of the crisis, most of these patients would be buried without ever returning to their families, are easily understood. As one of our respondents at the Geneva University Hospital phrased it, this reluctance is very easy to grasp with a simple thought experiment, by transposing the situation in our own countries and families (personal interview, December 19, 2014). However, this individual understanding did not diffuse within collective practices developed across response structures. Furthermore, it is important to stress again that, on the side of responders, social imaginaries about Africa played a symmetrical role to this of local populations’ own expectations and anticipations, further blurring the response, as a social relation .

Framing popular behaviors as irrational bore important consequences. Referring to the issue of traditional funerals, a high-risk practice considering that rituals
involve close contact with highly infectious bodies, M. Osterholm, a prominent US expert on emerging infectious diseases wrote:

> Public health workers haven't been able to curtail this traditional practice; it's a challenge that puts religious and cultural beliefs in direct conflict with infection control. (*The Washington Post*, August 1st, 2014)

Trying to *redress* what medical practitioners widely perceived as obsolete, dangerous, and backward beliefs, by means of social mobilization and public marketing, rather than *leveraging* on this rationality to renegotiate biologically safer funeral practices in ways respectful of and meaningful to affected populations, caused much delays in the response. Indeed, communicators were very slow to understand that, for many, the very real risk associated to the transgression of funeral practices could well exceed the perceived risk of dying from Ebola (Brives et al. 2016). Conflicting definitions of risks were thus at play, between a biomedical risk and a moral risk associated with breaching rituals.

## Conceptualizing Populations, Analyzing the Crisis

The purpose and methods of crisis communication developed at the onset of the outbreak failed to consider these different dimensions. At the same time, however, the fact that emergency response faced different forms of resistance among affected population also stressed the importance of putting professional communication specialists at the forefront of the response. This move was unprecedented in public health. It was the first crisis of this magnitude that saw communicators being embedded in the US CDCs health “swat teams” (Anderson 1994) deployed in the field, at the request of technical teams who had long looked down upon them (personal interview, CDC Headquarter, August 18th, 2015, Atlanta). At WHO as well, communicators quickly gained momentum within the response structure, for the very same reason, since biomedical interventions were often rejected by affected population, a refusal sometimes escalating into violent attacks (see for instance: Afrik.com, February 13th, 2015). Communication was expected to bridge the all too apparent divide between the logic of action enacted by responders, and their perception by affected populations. As a matter of fact, it only brought mixed results. Let me focus on this semi-failure. I will proceed by contrasting the proposed conceptualization of “context” with the tools available to communicators, across organizations, during the EVD outbreak in West Africa. These tools are indeed remarkably standardized and consistent.

When the international response deployed in West Africa, organizations behaved as if they had reached a *terra incognita*. Ebola was not an expected pathology in this region, and it displayed unusual features such as multiple epidemic locations and its spread to capital cities. In an emergency setting, organizations were usually unable to identify, consider or to tap into available knowledge, including local knowledge and previous scientific surveys, to develop an accurate understanding of
the situation.<fnref n="6" /> What they usually did, in order to quickly assemble information on the *local context*, was to run Knowledge, Attitudes, and Practices (KAP) surveys to design “evidence-based” communication strategies. This type of survey, originally developed in the 1950s to measure attitudes and practices with regards to family planning, has gradually become a ubiquitous technique to plan and to measure the outcomes of a broad range of public health interventions in countries in the South. They aim at measuring a population’s knowledge, attitudes, and practices around a specific issue, through the use of questionnaires, and to assess the impact of implemented interventions, by being ran at regular intervals. This excerpt from an end of mission report (organization cannot be named for confidentiality reasons) illustrates these following points:

– Analysed an existing KAP survey in [Location name] and integrated findings into communications and social mobilization strategy; and supported and reviewed proposals for two new KAP studies:

a. one in [Location name] to set a baseline for communications and social mobilization work there,

b. and the second a repeat of the one done previously in [Location name] to measure against the existing baseline survey to evaluate the outcomes of communications and social mobilization work there.

KAP surveys thus framed public health interventions throughout the crisis: they acted as a context-making practice, allowing organizations to stabilize an understanding of their field of action; they also played the role of an evaluation device, providing a feedback on the efficacy of implemented interventions. KAP surveys thus made action possible, by generating information, allowing to identify needs and gaps, and to design appropriate strategies. Critically, it allowed gathering data in a speedy way. As such, they proved well fitted to the time-frame of an emergency. And indeed, speed, cost-effectiveness, and the production of seemingly hard data, under the form of statistics, is what makes them popular among health-oriented organizations.

However, this technique suffers from numerous flaws. Let me mention a few, extracted from a paper by Launiala (2009): first, KAP surveys only measure people’s *biomedical* knowledge; as such, they neglect vernacular practices and knowledge about health, diseases, and cure. Moreover, the information they produce is over-reliant on language and formal knowledge, thus neglecting more practical, less formalized types of knowledge. Being framed as standardized questionnaires, they also raise issues in terms of translation and the use of an appropriate language with local populations. Eventually, they rely on personal knowledge, thus individualizing knowledge and practices by abstracting them from their embeddedness in social networks and dynamics.

<footnote n="6">⁶This stresses the issue of *knowledge management* rather than knowledge production per se. Knowledge was available, but institutions were not able to retrieve it in a timely manner. More than a scientific issue, we are thus faced with an *organizational* problem.</footnote>
This conceptual privilege of the individual over collectives is reflected also in available crisis communication guidelines. A look at the latest CDC's Crisis and Emergency Risk Communication guide (CDC 2014), the most comprehensive institutional resource for risk communication in the field of public health emergencies, helps grasp this issue: in the document, public behaviors in health crises are depicted in purely psychological terms, in a chapter entitled: "Psychology of a crisis". The context is reduced to a series of *stimuli* inducing a narrow variety of psychological states, aroused by specific events, namely: uncertainty; fear, anxiety, and dread; hopelessness and helplessness; denial; panic. These states then translate into a limited number of behaviors. This model empties social and cultural patterns of all substance, as it draws on very basic versions of behaviorist psychology, typical of the professional literature on risk communication: the link between message production and emission and behavior change is understood in terms of simplistic causal relations. Just as KAP surveys, this model is well fitted to the specific temporality of a crisis as it provides a base for a speedy reaction by allowing to design simple algorithms of the type, in *this case*, implement *that intervention* in order to produce *the following outcome*. In terms of communication, KAP surveys provide the baseline to define the case, under the form of a situational assessment. Once the situation is characterized, it becomes possible to design a specific *stimulus*, aimed at producing a *behavioral twist*—the outcome. Another KAP survey then reassesses the situation, by including previous outcomes. Like KAP surveys, these plans are action (rather than knowledge)-oriented; like KAP surveys, they leave "responders" with the feeling of developing evidence-based actions and strategies.

However, as an interviewee at the CDCs rightly underscored, conflicting needs emerge in such a crisis between speed and accuracy of information, and between rendering complexity and the need for operational decision instruments. It is easy to see that, during most crises, the urge for quickly actionable information prevails over the need for depth and precision. KAP surveys can thus be seen as a middle-road in the highly constrained environment of an emergency: it provides speed, actionability, entitlement (they produce the *evidences* needed for *evidence-based* interventions). However, they also produce low-quality data. While my conceptualization of the context stresses the need to look at current individual and collective dynamics, in relation to past events and to culturally framed expectations and anticipations, this type of tools shapes the context as a collection of timeless and socially disembedded individual opinions and knowledge. Therefore, the need for speed somehow results in the production of what can be termed, quite paradoxically, a *decontextualized contextualization*, where individuals are abstracted from their social embeddedness in social networks, in lineages of past events, and in a specific cultural horizon and are reinscribed as simple parameters in the realm of *evidence-based* interventions.

As a matter of fact, the dramatic emergence of the context as a prominent agent in the crisis underlines the weakness of these models. And institutions and individuals enrolled in the response were ill-equipped to face this challenge, as they lacked appropriate analytical tools to deal with this dimension. Hence, the belated
and somehow improvised resort to anthropologists when affected populations’ resistance derailed the deployment of response systems (see for instance: NPR, September 28, 2014). The current reflection, at WHO, to integrate social scientists within emergency response human resources is a clear recognition of this fact (SciDevNet, April 29, 2015): failing to consider and analyze sociocultural patterns plagued the response and pointed toward the need to shift from quantitative data collection, informed by a reductionist, solipsist behaviorist bias, toward more qualitative, inclusive ethnographic research practices. Of course, behaviors evolved during the crisis, making infection control easier as it unfolded. However, in the absence of reliable data, it is impossible to attribute these changes to implemented communication interventions. Most likely, they are in good part the result of populations’ own agency and capacity to draw lessons from their experience in dealing individually and collectively with the crisis.

Conclusion

In a context of high uncertainty, information is gold; as mentioned in most public health emergency communication plans and guidelines, the first step to be taken during a crisis is to make sense of the situation, in order to establish evidence-based response strategies. Hence, the critical role attributed to *situational assessments*, and the need for ready-made tools and algorithm-like plans of action: they allow speeding-up the process of data collection, to trigger action, and to orientate the response. However, the EVD episode in West Africa showed that these techniques produce low-quality data, with few remaining relations to the complexity of actual social dynamics. It is partly when anthropologists were brought into the response structure that relevant issues could be mapped and addressed. Yet, many responders expressed frustration with the lengthy temporality required by the logic of ethnographic inquiry. Thus, we witness a two-fold movement taking place as after-action evaluations are being developed: first, anthropological consultant firms and anthropological staff in organizations advocate the development of a new field of “emergency anthropology”; their first requirement is to develop methodologies consistent with the high pace of a crisis, combining the production of accurate *and* actionable knowledge, in a speedy way. However, this tendency is not without raising concerns among more critical, academic anthropologists.<fnref n="7" /> Second, organizations such as WHO are thinking about shifting their recruitment policy in the area of communication staff, by hiring less public communication specialists in favor of a more social science-oriented workforce. It remains to be seen, however, whether sound survey methodologies are compatible or not with the time compression that characterizes emergency situations. What can be said, at least, is that, after all, much

<footnote n="7">⁷This is somehow a classical dynamic of professionalization, well documented in the sociological archive.</footnote>
time was lost, in this episode, by *not resorting* to these qualitative survey tech-
niques: speeding-up action based on too fragile knowledge is a risky business.

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<figure><img src="image_26.png" /></figure>
# Part III

## The Collapse of Absolute Trust

### in Absolute Truth
# Transparency in Health Care:
## Disclosing Adverse Events to the Public

<figure><img src="image_27.png" /></figure>

Check for
updates

Siri Wiig, Karina Aase, Mathilde Bourrier and Olav Røise

**Abstract** The topic of transparency has received increasing academic interest in recent years. Transparency can be interpreted as conducting affairs in the open, being subject to public scrutiny, or admitting to problems when they arise. This chapter analyses transparency in disclosing adverse events to the public in Norway. We use the widely publicized Daniel case to show the communication between the regulator and the public, discussing key elements of transparency in the healthcare setting, including the role of media. The Daniel case describes an accidental tonsillectomy characterized by cover-up, failure of the initial regulatory and hospital follow-up, coming to a head when media shone a spotlight on the case. The media coverage caused social amplification of the risk communication resulting in regulatory follow-up having to apply new forms of transparency strategies to rebuild trust in the public. By using the Daniel case as emblematic of Norwegian risk communication strategies in health care, improvements should be made along the lines of direct and adequate information exchange according to patient rights, and efforts to foster open and transparent regulatory and organizational cultures to ensure public trust.

**Keywords** Transparency • Adverse events • Risk amplification
Health care

S. Wiig (✉) • K. Aase • O. Røise

SHARE—Center for Resilience in Healthcare, Faculty of Health Sciences,
University of Stavanger, Stavanger, Norway

e-mail: siri.wiig@uis.no

M. Bourrier
Department of Sociology and Institute of Sociological Research,
University of Geneva, Geneva, Switzerland

O. Røise
Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway

O. Røise
Institute of Clinical Medicine, University of Oslo, Oslo, Norway
# Introduction

## Background

It is commonly claimed that we live in an age of transparency (Hood and Dixon 2015) or in a ‘transparency society’ (Han 2015). The topic of transparency has therefore received increasing academic interest, resulting in theoretical and empirical propositions. Transparency can be interpreted as conducting affairs in the open, being subject to public scrutiny, or admitting to problems when they arise. Transparency may improve the communication of benefits and risks, and support the spread and sharing of knowledge. There is little doubt that transparency is fundamentally important from democratic and efficiency perspectives, although it may also have negative implications. More information and more communication do not necessarily lead to better decisions about risk, and the call for increased transparency may also increase costs and complicate decision-making processes (Han 2015; Hood and Dixon 2015). Some transparency strategies may involve dedicated web portals, publication of recommendations, introduction of public hearings, establishment of safety and quality committees and disclosure of the minutes of meetings and meeting agendas (Bouder et al. 2015).

In Norway’s healthcare context, transparency trends are developing in line with greater international emphasis on holding healthcare providers accountable and relying more on performance indicators (e.g. Kurtzman and Jennings 2008; Tavare 2012). More specifically, more hospitals are making their adverse event rates public and posting hospital infection rates on their websites. Hospitals also disclose the number of patient complaints, their performance on national quality indicators, and waiting times (e.g. AHUS 2015; OUS 2015).

Promoting patient safety using a system perspective has shown promising results in improving health care and reducing adverse events. However, the use of error disclosure and the creation of transparent safety cultures have not been rigorously assessed or implemented (Francis 2015; Liang and Lovett 2013; Waring 2015). Healthcare scandals in several countries have shown that uncaring and ineffective practices can flourish if the organizational context goes wrong (Braithwaite et al. 2015; Francis 2013; Mannion and Davies 2015). There are still intimations of a culture of individual blame within health care, supported by professional cover-ups of adverse events (Johnstone and Kanitsaki 2006; Wiig and Lindøe 2009; Woodier 2015), and a fear of whistleblowing (Mannion and Davies 2015; Waring 2015). Healthcare professionals, managers and regulators alike have been accused, especially by the media, of avoiding transparent and open communication with patients and next of kin after adverse events (e.g. Aase and Rosness 2015; Francis 2013; Hannawa et al. 2016; Helsetilsynet 2015a, b; NOU 2015:11; Woodier 2015).

The nature of communication and regulation of risk has changed in Europe (Lofstedt et al. 2011; O'Connor 2016). Regulatory scandals have resulted in greater public distrust of regulators and policymakers and new models of regulation emerged with focus on public participation, transparency and increasingly powerful
non-governmental organizations. The call for greater transparency developed to ensure more open decision-making processes, as regulators and policymakers were no longer trusted. The role of media as an independent ‘watch dog’ is crucial and implies that journalists may become advocates and take strong stances, and in many cases amplifying the risks associated with the topic that they are covering (Kasperson et al. 1988; Lofstedt et al. 2011).

The Norwegian Board of Health Supervision (NBHS) is the national regulatory body for health and care services. It is a public institution organized under the Ministry of Health and Care Services. At the regional level, 18 county governors oversee services within primary and specialized health care. In 2010, a new investigative group was established as part of the NBHS to improve regulatory follow-up after serious adverse events in Norwegian specialized healthcare services. To ensure transparency, the NBHS publishes anonymized versions of investigative reports, summary reports, and has recently increased its transparency approach by publishing a draft report. The 2015 draft report was based on an in-depth regulatory follow-up investigation of the death of a 3-year-old child after a routine tonsillectomy (the Daniel case) in 2009 (Helsetilsynet 2015a, b). The regulatory follow-up and the police investigation in the Daniel case were initially closed in 2010, but new information from the news media caused the regulatory case to be reopened in 2014 (Aftenposten, June, 20, 2014). At that time, the new investigation unit within the NBHS was operative and took on the task.

## Aim

This chapter analyses transparency in disclosing adverse events to the public in Norway. We use the widely publicized Daniel case to show the communication between the regulator and the public, discussing key elements of transparency in the healthcare setting, including the role of media.

## Theoretical Approach

This paper applies the Social Amplification of Risk Framework (SARF) (e.g. Kasperson et al. 1988; Pidgeon et al. 2003), as the theoretical foundation to understand the role of media in a high-profile case. It identifies how a new regulatory transparency approach has implications for the portrayal of events, interpretation of the event from different societal actors’ perspectives and has unforeseen implications. In brief, the SARF is an integrative framework that depicts the dynamic social processes underlying risk perception and response. It is founded on the belief that hazards interact with psychological, social, institutional and cultural processes in ways that may increase or decrease the perception of risk and shape risk behaviour. The experience of risk is not just an experience of physical harm; it
is also the result of a process by which individuals or groups learn to acquire or interpret hazards (Kasperson et al. 1988; Pidgeon et al. 2003).

Hazardous events hold a signal value, which individuals and social groups may perceive differently. These signals are subject to transformations as they are filtered through individual and social amplification stations (e.g. mass media, groups of scientists, governmental agencies, and politicians). Social amplification may have repercussions far beyond the initial impact of the event, bringing effects such as demands for regulatory constraints, litigation or loss of credibility and trust. These processes imply that diverse hazards are given more or less attention due to the diverse understanding of signals among individuals and groups, causing an amplification or attenuation of risks (Pidgeon et al. 2003).

## Methods

We apply a retrospective case study strategy in the ‘Daniel case’ to understand the trajectory of the event and its implications for different stakeholders between 2009 and 2015 (Stake 1994). In this study, we conceive the case as the adverse event and the following activity among the stakeholders in the aftermath of Daniel’s death. This paper is based on a qualitative content analysis (Pope et al. 2006) of publicly available data material on the Daniel case. The data material includes newspaper articles, news briefs from national media, and the preliminary draft version and the final investigation report published by the Norwegian Board of Health Supervision (NBHS). The main data sources are the draft version and the final version of the investigation report from the NBHS. The newspaper articles and news briefs have been used as a supplement to the investigative reports, adding narratives and voices related to the event, and also to provide insight into details, not covered by the mandate of the NBHS’s investigative reports. All of the data material was downloaded from the Internet, and the study did not require ethical approval for collecting and analysing the data. The institution names, occupational positions, roles and responsibility were all present in the data material as it appeared in the published public documents. We have not disclosed any new information in this case. We analysed the material using a thematic approach where we read all of the material and then categorized the data according to the themes emerging from the data (Pope et al. 2006). We analysed the data to gain insight into (a) the chronological process between the regulator and the public, (b) the implications of a new transparency approach and (c) the influence of the media on the development and escalation of the case from the beginning of 2009 when Daniel died, to the end of 2015, after the NBHS published the results of the final investigation.
# Findings

In this section, we present the findings chronologically. We begin with a description of the adverse event, the internal follow-up, and the regulatory and police investigations in 2009. Then, we describe how media dug up new information in 2014, the reopening of the case, and the implications of the new transparency policy in 2015. Figure 1 gives the timeline of the Daniel case.

## The Daniel Case: What Happened?

Daniel, aged 2 years and 11 months, was referred for chronic tonsillitis to the otorhinolaryngeal unit of Molde Hospital in north-western Norway. He had been having monthly throat infections, snoring, difficulties with speech and food intake and was accepted for surgery by the chief consultant. At admission for surgery January, 16, 2009, the patient was re-examined by a resident who classified the large tonsils as grade 3-4 according to Friedman's four-grade scale and confirmed the indication for surgery. No documented information was given to the parents on the particular risks associated with this surgery on such a young child. The patient underwent an uncomplicated adenotonsillectomy and was discharged from the hospital the next morning.

On day three after surgery, the patient was readmitted for bleeding. At admission, the bleed had stopped and the patient was prophylactically treated with antibleeding medication and surveyed fasting at the recovery unit. The patient was treated with penicillin due to elevated CRP. Neither blood screening nor reservation

<figure><img src="image_28.png" /><figcaption>Fig. 1 Timeline of the Daniel case</figcaption></figure>
of blood for potential transfusion was ordered. After 3 hours, the patient was transferred to the general ward and observed in a four-bed room close to the nurses' guardroom. The patient's mother was concerned and uncomfortable with the nurses' lack of observational behaviour. At approximately 3:30 a.m., the patient's father became alarmed when the patient vomited blood. The nurse called the operating theatre team. According to the patient's father, they entered the operating room 20 min after he alarmed the nurses at 3:50 a.m. According to the nurse anaesthetist, the patient was in shock, but according to the surgeon the patient was still awake. The patient was unsuccessfully intubated with a tube without cuff guided by laryngoscope in general anaesthesia as blood hindered visualization of the deep part of the throat. The second intubation attempt was successful in terms of correct tube placement. A few seconds later the patient had cardiorespiratory collapse and cardiorespiratory resuscitation was started. During ongoing resuscitation, a bleeding spot was secured with compression and diathermia. The senior consultant surgeon, who arrived at the operating theatre at 4:12 a.m., heard a strange sound and suspected a tube dislocation that was corrected. Several attempts of venous access restoration were unsuccessful so fluid transfusion was not possible. The ATLS-trained (Advanced Trauma Life Support) resident surgeon was then called to assist the resuscitation. He established intraosseous access in the left tibia and transfusion of fluid, medication and blood was immediately started. Two hours later the patient was transferred to the Regional University Hospital, St Olav Hospital in Trondheim, where he died 4 days later. Autopsy showed massive brain oedema. Death was caused by severe hypoxemia due to bleeding shock with cardiac arrest (Helsetilsynet 2015a, b).

## Internal Follow-up Immediately After the Adverse Event

Several critical issues for the case development were raised shortly after the adverse event. The hospital management did not carry out any formal debriefing. After Daniel's transfer, the involved healthcare professionals at Molde Hospital gathered, and the otorhinolaryngeal surgeon requested data from the anaesthesia monitoring equipment. However, this was impossible, as the data had already been deleted. The reason for this is not clear, but the nurse anaesthetist could not rule out that she had pressed 'the finish patient button', deleting all patient data. On February 2, the deputy managing director of the hospital called a joint meeting for all anaesthesia and otorhinolaryngeal doctors. There were major discrepancies in the narratives of the adverse event between the two professional groups. The chief otorhinolaryngeal doctor, who had not been present during the adverse event, argued that the meeting should not be held, partly due to old professional conflicts, and partly because of the upcoming police investigation. The otorhinolaryngeal perspective was negative, and they did not have an open and constructive discussion about the treatment of the patient. The meeting became a discussion of the reason for the patient's cardiorespiratory collapse. The anaesthetists suggested a loss of blood. The resident
otorhinolaryngeal surgeon and the chief otorhinolaryngeal doctor were not given the opportunity to counter this suggestion. In addition, memories from a similar meeting in 2006 involving personal attacks on the otorhinolaryngeal staff revived old conflicts and the atmosphere was experienced as tense. According to the investigative report (Helsetilsynet 2015b), the anaesthetists claimed that the meeting as being normal. No minutes were written.

A few days later, the anaesthesia consultant visited the resident otorhinolaryngeal surgeon and asked him to reconsider the information he had included in the medical record. In addition, the resident explained that the anaesthesia consultant, who chaired the library meeting, had said, ‘Remember that everybody did a good job’, just before the resident went into the police interrogation. The resident felt threatened and pressured to revise information (Aftenposten, June, 5, 2015; Helsetilsynet 2015b). Shortly after this episode, the chief otorhinolaryngist explained that the chief anaesthesia doctor had come to his office. They had a rough discussion on causality, the rumours spreading through the hospital and challenges of developing common procedures between the otorhinolaryngeal and anaesthesia units. The discussion degenerated into a scolding, according to the chief otorhinolaryngist (Helsetilsynet 2015b). The investigative report does not present data on the chief anaesthetist’s perception of this situation.

## Process of Police Investigation and Regulatory Follow-up in 2009

In 2009, a regulatory follow-up and a police investigation were initiated. Both closed the case and concluded that there was no reason for regulatory sanctions or prosecution. The Regional Board of Health Supervision in the county and the police received reports from the hospital on an unnatural death, as required by law. Almost 6 months later, the Regional Board of Health Supervision requested the National Board of Health Supervision (NBHS) to assess prosecution. The NBHS did not find sufficient grounds for prosecution under the Health Professional Act, and the decision was upheld after a review of the documents from the police investigation (Helsetilsynet 2015b). The police had interrogated the healthcare professionals involved and consulted an expert in children’s diseases. Based on the expert’s opinion, and because the NBHS did not find sufficient evidence to prosecute, the police dismissed the case, concluding that there was no evidence of a crime. The expert on children’s diseases concluded that even though mistakes had been made, no individuals were to blame. The hospital did not follow up the expert report with a learning perspective strategy and plan (Aftenposten, June, 22, 2014).
Media Push Causing a Reopening of the Regulatory
Case in 2014

The Daniel case was subject to regular media coverage in local and national news press and TV. A turning point came in June 2014 when media released new and highly relevant information:

In the documents that Aftenposten [newspaper] has access to, severe allegations are put forward indicating that hospital employees coordinated their depositions to the police. There moreover appear allegations on pressure and intimidation of healthcare professionals who refused to conform. Several at the hospital feared the results of the police investigation. (Aftenposten, June, 20, 2014)

Moreover, the parents expressed a need to clarify several unanswered questions, and the media information described a culture of fear, cover-ups, and claimed that healthcare professionals involved in Daniel's surgery had given incorrect information about his care. Based on the new media information in June 2014, the NBHS investigation group reopened the case and conducted an in-depth regulatory investigation to assess if the healthcare services provided in January 2009 had been done according to legal requirement of sound professional practice (a legal standard involving both institutions and individual healthcare professionals) (Helsetilsynet 2015b). The targets of the investigation included duties of documentation, internal follow-up of the event and whether the information and follow-up with the next of kin complied with the law.

A New Transparency Strategy—Publishing a Preliminary
Regulatory Investigation Report in 2015

In June 2015, the NBHS chose a new transparency strategy, by publishing the draft version of the investigation report. The published draft concluded that the health care had been provided according to sound professional practice, but the internal follow-up and the hospital's error management and learning system had not met regulatory standards. The draft report, however, did not go into detail about the culture of fear, and the negative psychosocial work environment. The Daniel case was a high-profile case, and the conclusion created extensive media interest. The analysis, methods and perspectives applied by the regulator were heavily criticized by the public for leaving out the key subject of a negative psychosocial work environment (Aftenposten, July, 6, 2015; June, 19, 2015). The NBHS countered by saying that the work environment was outside of its mandate (Aftenposten, June, 19, 2015).
# Taking Public Input into Account—Major Revision of the 2015 Final Report

In November 2015, the NBHS published its final report. The NBHS explicitly stated that by publishing the draft report, it wanted to promote openness and obtain input on the draft report to shed new light on the case. As was customary in similar investigations, the health trust (providing specialist healthcare services, teaching and research), involved health professionals, and the next of kin can give feedback on the draft report. In this case, the media and several actors were able to provide new input on the draft. The NBHS also invited different stakeholders (Daniel's parents and grandparents, experts on clinical leadership, anaesthesia and law, patient ombudsman, patient association) to meetings to elaborate or clarify their input:

> We have invited several of those who provided input [to the draft report] to meet us and elaborate their points of view, to ensure we have a correct understanding of their view. (Helsetilsynet 2015b: 14)

The NBHS changed its conclusion about the effects of the negative psychosocial work environment on patient safety. In the final report, several amendments appear. One key amendment is how the NBHS elaborates on the management's responsibility for ensuring a sound psychosocial working environment, as a prerequisite for patient safety. The establishment of this link between managerial responsibility, working environment and patient safety appears to be required if working environment issues are to be incorporated under the NBHS jurisdiction. The report, moreover, states that the supervisory follow-up of issues in the working environment falls under the jurisdiction of the Labour Inspection Authority, but when the working environment affects patient safety and the public trust in healthcare services, it will require an interface with the NBHS's supervision (Helsetilsynet 2015b). In the conclusion of the final report, the conclusion regarding sound professional practice, documentation requirements and follow-up with the next of kin remained the same, but the NBHS added a new paragraph on the psychosocial working environment:

> After publishing the draft report, we have received new information indicating that there are still challenges related to working environment, which is of relevance for patient safety. We will therefore ask the County Governor [regional regulatory body] to follow up this issue as a specific case [new].... The further supervisory activity on how the health trust ensures the psychosocial working environment will be in collaboration with the Labour Inspection Authority. (Helsetilsynet 2015b: 79)

An additional amendment addresses the suggestions for future safety recommendation for learning purposes. Most of the recommendations pertain to the revision or establishment of procedures related to tonsillectomy on children; storage of data in anaesthesia monitoring equipment and surveillance units; information to and taking care of next of kin after severe adverse events; and handling of professional conflicts and personal clash of interest to prevent them from developing into conflicts that may threaten patient safety. The NBHS, moreover, suggests
considering the establishment of new national guidelines for tonsillectomy, including an assessment of which hospitals should offer this surgery, their competence needs and guidelines for observation of post-operative haemorrhage. At last, the future recommendations state that NBHS will initiate dialogue with the Labour Inspection Authority regarding the overlapping jurisdiction concerning the psychosocial working environment in relation to sound patient treatment.

## Details on the Role of Media and Public Critique

The final report provided amendments related to the media coverage of the Daniel case. In the draft report (Helsetilsynet 2015a), the role of media is described in one short paragraph. The comparison between the draft (Helsetilsynet 2015a) and final report (Helsetilsynet 2015b) illustrates much greater attention to the details of the media's role. In particular, we find more information on how the *Aftenposten* journalist worked on the case. The journalist claimed that in 2013, an employee who was not involved in the case tipped him off about 'war-conditions' between doctors at Molde Hospital, after a child's death following a routine operation in 2009. The journalist met with the child's parents and relatives, who described a situation of total repudiation of liability. He also obtained a disc containing all files in the case. The investigative report does not say anything about how the journalist got access to the disc, but he presented it to a lawyer and two doctors. Based on their feedback on the content, the journalist focused his attention on accusations of collusion and pressures and on why the regulatory authorities had closed the case in 2009 (Helsetilsynet 2015b).

After publication of the draft report, one of the experts that *Aftenposten* asked to comment on the case (co-author Olav Røise) argued that NBHS did not go into details on several issues in the report, including the accusations of pressure to adapt their version of the story to the police. Possible reasons for this could be a lack of competence or clinical experience among the investigatory team members, as he explained in the newspaper interview (*Aftenposten*, July, 6, 2015). Shortly after this critique, the head of the investigatory unit in NBHS called the expert. In a letter to the director of NBHS, the expert explained how the head of the investigative unit had approached him (*Aftenposten*, Sept. 3, 2015):

> In the letter [Expert] writes that [head of investigation unit] told him that it could “harm him” if he presented the critique in public. She pointed out that this would harm doctors at Molde Hospital as well. According to the letter, [Head of investigative unit] also said, that [expert] had made “horrible accusations” about her unit, not holding the correct competence to assess if Daniel had received sound professional treatment at Molde Hospital.

Shortly thereafter, the head of investigatory unit resigned (*Aftenposten*, Sept. 3, 2015). The media's role in the Daniel case has been acknowledged both by Daniel's parents and the NBHS. Both the parents and the NBHS argue that the case would not have been reopened, and the conclusions would not have been revised, without newspaper attention (*Aftenposten*, Nov. 19, 2015).
# Discussion

## Tonsil Surgery—What Do We Know About the Risk from a Medical Perspective?

Tonsil surgery, with or without adenoidectomy, is technically a simple procedure learned at the early stages of surgical training. It is among the most common surgical procedures in the world. However, the procedure is associated with potential severe and lethal complications that are very rare and therefore not considered an important risk factor when operation is offered to the patient or to a child's parents. In a Swedish study based on data from the National Patient Register (NPR) matched with the National Cause of Death Register over an 8-year period (2004–2011), the incidence for lethal outcome after benign tonsil surgery was 1 out of 41,263 operations (Ostvoll et al. 2015). This means that an operation with lethal outcome, based on the Swedish data, will be seen about once every 8 years in Norway, providing that the indications for surgery are the same.

In Austria in 2006 and 2007, five children under the age of six died after tonsillectomy (Sarny et al. 2013). This led to a public and emotional discussion on risk after tonsil surgery resulting in a consensus paper with the goal of making the procedure safer. The indication for doing tonsillectomy was restricted and tonsil-lotomy—a less invasive procedure—was advocated for children younger than 6 years of age. This consensus strategy was followed up with—to our knowledge—the only large-scale register study including all tonsil surgeries in Austria for 9 months in 2009—2010 disclosing safety data (Sarny et al. 2013). In their series, a haemorrhage rate of 12.3% for tonsillectomy and 2.3% for tonsillotomy was reported. Four percent of the patients with haemorrhage after tonsillectomies needed secondary surgery. Almost none in the tonsillotomy group needed secondary operation. The study also showed that repeated episodes of minor post-operative bleeding were a warning sign for further bleeding. According to the authors, the Austrian experience brought changes in education prior to surgery. Patients were given detailed information about what to watch for after a child's operation and what to do in case of haemorrhage.

## Media as Whistleblower in Risk Communication

By exploring the Daniel case, we have seen how a tonsillectomy case characterized by cover-up, failure of the initial regulatory and hospital follow-up, came to a head when media shone a spotlight on the case (Hinchcliff et al. 2012; Mannion and Davies 2015; Millenson 2002; Waring 2015). By bringing new information to the table including critique of regulatory follow-up, the regulatory body appeared left with no other option than to re-open the case. They then continued with a strategy of transparency (Bouder et al. 2015), uncommon in a Norwegian setting, releasing
draft report to the public, inviting experts to provide input, reflecting upon the
media role and by making new safety recommendations to a wide range of actors.

The role of journalism in patient safety is interesting (Hinschcliff et al. 2012; Millenson 2002), and our study is reminiscent of findings from the early days of the patient safety movement. Millenson (2002) argued that until journalists took an interest in patient safety, it had not received much attention. As our study showed, this has similarities with the Daniel case where the regulator and the police closed the case, despite having collected information on possible cover-ups and professional battles after the event. News media gave the Daniel case renewed urgency. Moreover, the ‘people-like-you’ perspective in Millenson’s (2002) study, is part of the Daniel case, where people like the readers or their children could die from a routine tonsil surgery. This framing places a human face on the formal parties involved (hospital, healthcare professionals and regulators).

Amplification of Events and Transparency

The regulator applied a new strategy of transparency in the Daniel case. The Social Amplification of Risk Framework (Pidgeon et al. 2003) claims that the social and economic impacts of an adverse event like Daniel’s death are determined not only by the direct physical consequences of the event but also by the interaction of psychological, cultural, social and institutional processes amplifying or attenuating public experience of the event, resulting in secondary impacts (Pidgeon et al. 2003; Renn et al. 1992). By publishing new information and consulting powerful experts, we contend that the news media started an amplification process with consequences of loss of credibility in the initial regulatory follow-up, causing the case to be reopened and the findings in the final report substantially changed. This new transparency can be interpreted as a way of reconstructing the credibility of the regulatory investigation (Lofsted 2010) by making the process as open and transparent as possible in terms of information sources, regulatory assessments and rationality, use of input from journalists, experts, healthcare professionals and next of kin. In the transparency literature (Bouder, et al. 2015; Coglianese 2009), this approach is termed a *reasoned form of transparency*.

This is different from *fish-bowl transparency*: full disclosure without explanatory information or contextualization. Reasoned transparency accepts that transparency, as information disclosure alone, is not a solution. Reasoned transparency policies demand that regulators or government officials ‘offer explicit explanations for their actions’, the facts and evidence they base decisions on (Bouder et al. 2015; Coglianese 2009). In our case, we revealed several links to the reasoning approach, for example when and why the NBHS initially excluded psychosocial working environment from the draft report, and then argued why it had been added to the conclusion of the final report. The media coverage and reasoned transparency approach had societal impacts (Pidgeon et al. 2003). The safety recommendations manifest some of the societal impacts by suggesting new procedures, guidelines and
clearer interface between regulatory authorities (Board of Health and Labor Inspectorate) and the coordination of inspection activities.

Transparency related to the adverse event is high on the agenda in Norwegian health care and elsewhere (Blomgren 2007; Kurtzman and Jennings 2008; Tavare 2012). The development can be interpreted as part of a risk communication strategy focusing on openness to patients and the public (Bouder et al. 2015; Kasperson et al. 1988; Lofstedt et al. 2011). Under the Social Amplification of Risk Framework (Pidgeon et al. 2003), the increased demand for transparency is not necessarily welcomed by healthcare professionals or regulators. These actors may fear the role of media and wish to go under the radar to avoid negative publicity and reputation risk, following media's role in risk communication and amplification processes. We saw this in the Daniel case when healthcare professionals were pressured to align their explanations, and when the director of the investigation unit at NBHS called one of the experts, and warned him that public criticism in the media would damage him and other doctors at the hospital. We can interpret these reactions, as an attempt to reduce the expected amplifications and ripple effects (Pidgeon et al. 2003) caused by fleshing out the event and critics in the media.

## Conclusion

Transparency is not a panacea and involves trade-offs. More democracy, more freedom of information and more efficiency are expected from transparency, but may cause a society of control, with few confidential spaces (Han 2015), and escalating costs to meet performance demands (Hood and Dixon 2015). Healthcare innovations, regulation and safety improvement processes involve conflicts, professional discussions, mistakes and new ideas. Healthcare professionals and regulators need confidential space for debate and disagreement (Becker 1999). This is not the same as a cover-up or collusion to conceal an adverse event from the public. By using the Daniel case as emblematic of Norwegian risk communication strategies in health care, improvements should be made along the lines of direct and adequate information exchange according to patient rights, and efforts to foster open and transparent regulatory and organizational cultures to ensure public trust.

**Declaration of interest** Co-author, Olav Røise, was involved in the media coverage of the Daniel case as a clinical expert who was asked to give an assessment of the draft report described in the results section: *Details on the role of media and public critique.*

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<figure><img src="image_29.png" /></figure>
# How Safety Communication Can
Support Safety Management:
The Case of Commercial Aviation

<figure><img src="image_30.png" /></figure>

Check for
updates

Michel Guérard

**Abstract** Commercial aviation traffic has increased so dramatically over the past decades that virtually everyone can identify him/herself to a passenger or a passenger's relative. With the evolution of communication means and pace, every accident or incident induces an unprecedented amount of reactions and communication from many actors outside the aviation community. These newcomers on the safety communication scene challenge the historical safety management world and actors, traditionally limited to aviation professionals.

**Keywords** Safety management • Aviation • Safety communication

## Introduction

Air travel has grown steadily since the end of the Second World War, doubling every 15 years. This industry is still expanding at roughly the same rate thanks to the emergence of new markets as well as to the development of new business models such as low-cost carriers.

Had the accident rates of the 60s and the 70s been kept at the same levels, the air transport safety situation would have become unacceptable to the travelling public and the development of the air travel industry would have unavoidably been severely impacted. The average fatal accident rate during the 60s was 4.4 per million flights, compared with 0.15 per million flights in 2016. An American researcher named Curt Graeber published in 1995 a study in which he applied the then prevailing accident rates to traffic projections and concluded that unless something was done in terms of safety, the industry would have to cope with one serious accident every week by 2010 (Graeber 1995). This conclusion did not go unnoticed and strongly contributed to the promotion of safety enhancement initiatives within the air travel industry.

<footnote>M. Guérard (✉)
Toulouse, France
e-mail: michel.guerard@airbus.com</footnote>
This reasoning was perfectly sound but this terrible prophecy never materialized, because in the meantime safety drastically improved. However, this frightening warning had been heard worldwide and positively contributed to the increased mobilization of the entire industry towards a safer air transport system. Graeber's study was not only about safety projections; it was also about communicating them to all stakeholders in a powerful and effective way.

With the spectacular development of commercial air transport around the world in the past decades, a growing number of people feel concerned by aircraft accidents. Air transport is an international activity by nature, and from an outsider's vantage point, nothing looks more like an airline, an airport or an aircraft than another airline, airport or aircraft. Almost everyone can identify him/herself to a passenger or a passenger's relative.

In addition, the accelerated development of information and communication means and channels makes each and every event, especially significant incidents or accidents known to almost everyone on the planet, and its interpretation by whoever communicates on it as well.

Over the years, safety-related topics have progressively been dealt with by new audiences, such as Internet sites, independent experts, lawyers, victims' associations, social media groups, pilot unions. The objectives were not the same and comments could sometimes be critical towards the air transport industry. This has opened new issues for air travel industry safety communications specialists, who found themselves facing higher levels of criticism than ever before.

In parallel, the overall image of the aviation industry has changed. Air transport began as a dream, even though only a few people were initially directly concerned. The early years of aviation triggered considerable enthusiasm among vast portions of the population. As it became a more banal way of moving around, the acceptability of accidents decreased and the identification of the public at large to air travellers increased, since more and more people could afford travelling by air.

The enthusiasm that initially surrounded air travel progressively faded and new environmental preoccupations arose. Aviation has been progressively associated with noise, pollution and global warming. Building a new airport or simply adding a runway to an existing one can be a major challenge in many countries. The difficulties encountered in Japan in the 70s concerning Narita airport and those concerning Heathrow's fifth terminal in the 80s or recently in France for the projected new Nantes airport illustrate this situation.

This changing environment is a challenge for the air travel industry in terms of communication. In other words, the perception framework of commercial air transport safety has evolved significantly.

If safety communication has always existed, its scope, actors and pace have changed, thus modifying its impact on safety management. It is therefore in the interest of this industry to better understand the ongoing changes in order to address them in the best possible way.
# Safety Communication Among Industry Actors: A Historical Driver for Safety Enhancement

Organizing activity in commercial air transport dates back to its earliest years, after World War II. Indeed, ICAO was created in 1944 and IATA followed in 1945. As for Authorities, they were already in place in the countries where air transport had begun. Most legacy carriers were created around that time and the then big manufacturers (Lockheed, Douglas, Boeing, De Havilland, etc.) were already producing airliners.

One can say that a solid frame was in place and ready to be used for safety matters as well. In fact, aviation actors realized fairly early that safety was not a matter of competition but rather a condition for the survival and the development of the industry as a whole. Indeed, whatever the area of the world, the aircraft operated and regulations are similar, as are air traffic control mechanisms. In other words, sharing information about safety has been identified as a crucial need for a long time.

The US National Transportation Safety Board, for example, has been keeping records of civil aircraft accidents since 1967. The National Aeronautics and Space administration administers a confidential and voluntary Aviation Safety reporting System since 1976.

However, with the evolution of technology and culture, the types of information gathered and shared as well as sharing practices evolved over time. It started with the lessons learned from accidents identified as an obvious source of information to contribute to improve safety. This sharing between operators did indeed help to identify major hazards, such as the metal fatigue phenomenon that was only understood after the De Havilland Comet fatal crashes in the 50s, and ‘deep stalls’ that were not known until the 1963 BAC 1-11 accident.

Experience feedback has always been and still is a vital flow, especially in aviation, because airliners are complex machines which are flying in increasingly large numbers. In addition, every new aircraft experiences its lot of early problems, but it will stay in service for 20 to 30 years; ageing problems will in turn feed this experience feedback. In other words, disseminating across the entire industry the lessons learned from adverse safety events has always been and will remain of prime importance to enhance safety.

As a matter of fact, in order to further improve safety, authorities have made it mandatory to report significant events, regulating in a sense one of the aspects of safety communication. In Europe, for example, occurrence reporting is defined in a document called AMC 20-8. However, the resourcing of aviation authorities is variable and this basic two-way flow of information is not always in place. It nonetheless forms the basis of a learning process that constitutes the foundation of industry-driven safety communication. If accident and serious incident investigations enable us to learn from what happened, they fortunately remain very rare events. All potential safety events do not end up in incidents or accidents.

The main stake for an industry growing at such a pace became to learn from other sources of information in order to try to further enhance safety. Therefore, voluntary reports from crews were encouraged by Authorities and within airlines in order to
gather additional information on actual practices possibly inducing safety issues. This new form of safety communication involved setting up a specific framework. Indeed, voluntary reports were much more numerous in environments where they were not systematically punished when reporting mistakes, i.e. where ‘just culture’ principles (Havinga and Dekker 2014) translated into practice. A blame culture does still exist in certain parts of the world and deprives organizations and the industry as a whole of an opportunity to learn from experience. Safety communication is a powerful tool in terms of safety enhancement, but it must be fed.

With technological progress in terms of data recording and processing, another source of information was made available to further enhance safety: flight data analysis. A number of parameters are systematically recorded all along a flight and deviations from a safe envelope defined a priori are pointed out. Therefore, even in the absence of any incident or accident, safety-related information can be retrieved, processed and the outcome of the safety analysis disseminated. In a more recent approach, an auditor may also fly with a crew in order to attend the flight and evaluate the general performance of the pilots.<fnref n="1" />

This shows how far the air transport industry is ready to go in order to learn from day-to-day operations and to collect safety-related information. These various sources of information are potentially a very effective way of enhancing safety, but require a good safety communication system both within the operator and outside. In fact, practices in terms of communication to feed the analysis and disseminate the safety lessons learned may vary significantly around the world.

It is worth noting that most of these safety enhancement practices were put in place by numerous operators even before they became mandatory. In other words, safety communication is regulated between individual aviation actors and the Authorities. However, as mentioned earlier, the industry has soon realized that safety is a matter of survival of the activity as well. Therefore, additional safety communication practices developed with time on a voluntary basis.

In the US, a system was launched in October 2007, and an associated forum as well, for all aviation actors to share their safety information and perform joint analysis: Aviation Safety Information Analysis and Sharing (ASIAS). Volunteer airlines, airports and air traffic control centres get together on a regular basis, share their flight data analysis, incident reports and other sources of information to collectively learn lessons from operations. A similar approach is currently under study at European level.

Aircraft manufacturers also communicate about safety on a regular basis with airlines. It is done through technical bulletins, safety conferences and magazines. Similarly, airlines report operational occurrences to manufacturers on a voluntary basis. The number of events reported increases regularly, because airlines increasingly understand the benefits of reporting and communicating about their events. More generally, the awareness of all aviation actors of the benefits to learn from as much experience as possible is increasing. Indeed, even though each airline

<footnote n="1">¹A mechanism known as Line Operations Safety Assessment, or LOSA.</footnote>
operates a limited number of aircraft, in a limited number of operational conditions, the overall experience accumulated by the industry is huge, since there is more than one aircraft taking off every second around the globe. However, as mentioned earlier, even if the safety communication system collects more and more data, with again some variations among actors, making sure that the appropriate safety information reaches the relevant targets is a different story.

Indeed, experience has shown that sometimes safety lessons were shared among safety managers but stayed with them, without reaching the operational people concerned.

This internal aspect of safety communication is now addressed by a recent regulatory requirement. Indeed, safety promotion within an organization is one of the four pillars of the Safety Management System (SMS) regulation. SMS is basically a new approach to safety which asks aviation actors to identify and evaluate their risks in order to mitigate them and therefore enhance safety. It is detailed in the International Civil Aviation Organization Annex 19 (ICAO 2013).

It includes the dissemination of lessons learned as well as the enhancement of safety culture. In this area as well, practices may vary significantly from one actor to another.

In order to dispatch safety-related information, the air travel industry has progressively launched a number of initiatives. An overall frame has been provided by the ICAO and enforced by local Aviation Authorities but numerous steps in safety communication have been taken by other organizations, resulting in a number of conferences, exchange forums, safety programs and training initiatives.<fnref n="2" />

For a rather long period of time, the major part of safety-related communication took place within the air travel industry itself, including official organizations. It was consistent and to a large extent consensual. The state of air travel safety was clear, as well as the priorities. No external party was interfering and safety was indeed progressing on a continuous basis as proven by statistics. More recently, aviation safety has come increasingly under scrutiny, especially from new stakeholders, not belonging to the traditional circles within this industry.

## New Actors, New Safety Communication, New Influences on Safety Management

Today, other stakeholders, such as victims' associations, law firms, pilot unions, social media, have entered this arena and have earned their share of voice. Through safety-related communication, they claim a right to access all the information and sometimes to perform their own analysis of an event. It is the advent of a system of checks and balances on the historical select club of professionals. Two worlds, two types of practices, one strictly regulated based on a technical approach to safety, the

<footnote n="2">²https://flightsafety.org/category/safety-calendar/.</footnote>
other one ‘self-regulated’, often driven by reactions to an accident (general public, associations of victims’ families such as FENVAC in France, politics, etc.) with different timelines (delayed response due to ongoing investigations vs. immediate response under public pressure).

Aviation accidents have always generated strong media coverage. There are many reasons for this, but we first of all have to recognize that aviation accidents generally result in a significant number of victims. In this respect, they can be considered as big industrial accidents. The overall perception that air travel is an extremely safe means of conveyance also contributes to making each accident a kind of exceptional event. Everybody expects no accident and the safety rate is indeed very high, with one fatal accident every ten million flights for the latest generation of airliners.

When an accident occurs, it contradicts this expectation to a certain extent and the general public, not only aviation professionals and the travelling public, are eager to know what might have happened. This interest in air crashes and subsequent investigations is a well-known fact which materialized in an impressive number of TV reports, films, books and event theatre events.

Back in 1999, a play named Charlie Victor Romeo (CVR also stands for Cockpit Voice Recorder) was created on the basis of audio recordings from several fatal accidents. Actors installed in a cockpit mock-up on a stage would replay the last moments of these crew members. It was a very successful enterprise and *Time* magazine included Charlie Victor Romeo in their 2004 Best Plays of the Year list. A number of TV series such as ‘Air Crash Investigation’ produced by Cineflix since 2003 and many others also account for this wide interest in air accidents and the associated investigations. Back in 2012, the famous American actor Denzel Washington played a captain in ‘Flight’, a successful drama based on a jetliner accident. In 2016, Tom Hanks appeared in the film ‘Sully’ which related the successful landing of a jetliner in the Hudson River after having hit a number of geese.

Travelling by air is no longer reserved to the wealthy, and millions of people can therefore identify themselves to the unfortunate victims of an airplane accident. There are many reasons for the public at large to be interested in air accidents, but it is a fact and every new unfortunate event confirms this situation. As mentioned previously, accidents are statistically extremely rare but air traffic volume is large and continuously growing. More than 100,000 commercial flights are performed every day, this means more than one aircraft taking off every second.

However, what the public remembers are absolute numbers, not relative ones. And accidents are absolute numbers. It means that safety must progress in proportion as traffic grows if we do not want the general public to develop the feeling that the air transport industry is no longer delivering its promises in terms of safety. Obviously, air accidents coverage always highlights a failure of the safety system at some point. It is clearly negative publicity for the air transport community.

Beyond the general public and its overall interest in these catastrophic events, a number of persons took a far more active share of voice in recent years. It is the case first of all of victims and relatives. The way these communities were treated in the past has not always been to the credit of the air travel industry. Authorities have
been made aware of the need to clarify everyone's duties and a number of rules have been specified in order to ensure that care, respect and dignity prevail following an accident. The US Federal Family Assistance Plan for Aviation disasters illustrates this approach (NTSB 2008).

Following the accident of the Asiana aircraft in the US, in July 2013, the airline was fined by the Federal Aviation Administration for not providing the expected assistance to families in due time. Victims of an air accident and their families have rights. This is also made more concrete by the level of financial compensation following an aircraft accident, especially in the USA.

Such accidents often generate legal proceedings and some law firms such as Kreindler and Kreindler have specialized in aviation disasters. Because civil damages are substantially higher in the USA, lawyers will often try to sue in this country. The recent accident of Germanwings (March 2015) illustrates this. Some families tried to sue Lufthansa, the parent company of Germanwings, on the basis that the suicidal First Officer was initially trained in the USA. Obviously, law firms will have their own strategies and therefore their own communication objectives following an accident.

Another recent evolution has also seen the growing implication of political staff. On the occasion of the Germanwings accident, three heads of state (President François Hollande from France, Chancellor Angela Merkel from Germany and Prime Minister Mariano Rajoy from Spain) gathered on the crash site for the memorial service. Such a strong presence creates a precedent and is likely to be expected again in comparable cases. This trend can be seen as the reflexion of sociological trends in modern democratic societies. It is nonetheless a confirmation that victims now have a specific and recognized status. This status gives them more influence and their opinions are better heard than before.

Politicians make laws and can change the framework in which safety investigations or justice, for example, are pursued. These are medium to long-term evolutions but they are real possibilities. The family assistance act in the USA is a relevant example of such regulations being introduced. Victims' associations will form quicker than before thanks to the Internet and social media and also because they receive official support from governments. In France, bodies such as INAVEM and FENVAC are officially backed by the authorities in their support to victims and their associations.

Other groups, such as pilot unions, may also get involved in order to protect the reputation and the interests of their members. As a matter of fact, the vast majority of accidents are due to operational factors in which crews often play a part. It is quite common to read articles putting the blame on either the aircraft or the crew. Accident investigations most of the time demonstrate that truth is more complex. Beyond the main cause of an accident, a number of contributing factors may place the event in a different perspective. Understandably, pilots' unions will focus on issues such as Human-Machine Interface in order to explain and defend crew behaviour.

Traditional media will logically follow the move and reflect these numerous activities surrounding an accident whereas social media will generate additional communication involving more actors. The multiplication of 24 h news channels
has also increased the coverage of events such as aircraft accidents. The media investigation into the potential causes of the accident will start almost immediately with the support of numerous private experts who quickly elaborate possible scenarios even in the absence of consolidated facts.

It has now become current to see dedicated sites launching their own investigations with limited information from various origins such as flightradar24, weather reports, pictures and videos. One of these groups is Aviation Herald, a site based in Austria and run by Simon Hradecky. It is extremely reactive and has become a kind of reference for several media. Other communities share extensive information quite quickly following an accident or a serious event.<fnref n="3" />

While communication from the aviation community during an accident investigation is highly regulated by the ICAO Annex 13 (ICAO, 2016) which specifies the conditions of an investigation following an accident or a serious incident, the emerging ‘new’ communication is not subject to such constraints. However, a kind of self-regulation can be observed, especially on social media with common intense exchanges and challenges of untrue statements. This phenomenon by the way leads to the emergence of some influencers recognized by a large community for their expertise.<fnref n="4" /> They enjoy a real status and are taken very seriously by airlines as well as other aviation stakeholders such as Original Equipment Manufacturers.

Eventually, safety communication has progressively increased leading to more information exchange with more actors among aviation professionals, taking place in a continuous manner, silent and invisible to the public. What changed dramatically over the past decade is the safety communication landscape following an accident.

## To What Extent Does the Evolution of Safety Communication Impact Safety Management?

The emergence of new safety communication actors such as victims’ associations, justice, political staff, social media has led to an evolution of pressures, stakes and power that eventually influence the way safety is managed. It is worth noting that these new actors’ primary motivation is not necessarily to contribute to safety enhancement. Motivations include the right to know, the request to perform an independent analysis, but also an opportunity to promote convictions about technology, training or any other aspect of the aviation industry.

With the strict rules imposed by ICAO Annex 13 on communication about accident investigations (ICAO 2001), requiring an exclusively consolidated factual

<footnote n="3">³See for example: http://www.airliners.net/forum/; http://www.pprune.org/.</footnote>

<footnote n="4">⁴See for example the following significant influencers on twitter:
* Jason Rabinowitz https://twitter.com/AirlineFlyer
* Alex Macheras https://twitter.com/AlexInAir
* Mary Kirby « Runway Girl » https://twitter.com/RunwayGirl.</footnote>
basis, the pace of official communication induces a timing that leaves an empty space for too long a time with respect to the current communication and societal landscape. The delay of official communication often creates frustration from media and families and feeds impressions that there is a lack of transparency and that pressure might be applied on authorities in order to protect industrial interests. Such a situation is often observed and may undermine the credibility of investigating authorities.

This lack of trust in investigation bodies also involves an almost systematic challenge of their accident reports. This pressure on investigation authorities may delay the publication of accident reports and sometimes influence the content. Eventually, whatever the motivation of the emerging safety communication actors, their share of voice is consequential on safety management.

First of all, the growing appetite for real-time information encourages speculation to compensate for the lack of facts available immediately after the event. In this respect, it is adding pressure on investigation authorities who generally take more time to communicate their first findings, for they need to rely on validated information.

Every accident leads to the expression of a variety of logics with respect to safety. A rational one turned towards safety enhancement that of the industry and more specifically of the investigation body; an emotional one, that of the victims and families of victims; a rational but more individual one, that of individual experts or critics whose visibility will obviously increase on these occasions.

As previously mentioned, all these logics do not share the exclusive objective to enhance safety. It is therefore almost inevitable to see controversies, polemics, delayed decisions, misperceptions. Moreover, the two latter logics sometimes lead to decisions which do not obviously and directly contribute to safety. For example, following the Sharm El Sheikh accident in which 134 French passengers were killed in January 2004, a parliamentary commission was created in France as a response to public emotion. Forty proposals were made the same year.<fnref n="5" />

Among these 40 proposals, some were by nature doomed to failure whereas others were heavily challenged. Indeed, because air travel safety depends on an international system, it is quite challenging for any country to act independently and efficiently. Therefore, the proposals challenging ICAO recommendations for example about pilots licensing were not realistic. Another proposal was made in order to enforce the exclusive use of English in exchanges between crews and air traffic control in France. It was in fact never enforced because of opposition from some pilots' associations in France. Eventually, despite the publicity made around these 40 proposals, it does not seem that this work had an obvious influence on air travel safety.

Later on, following the crash of the Rio-Paris flight in 2009, a law was proposed in order to create an Aviation Safety Authority ('Haute autorité de la sécurité aérienne') The objective was to control investigation authorities through a board of nine members. The law was not passed but it illustrates how public emotion and political reaction could impact safety management.

<footnote n="5">⁵http://www.assemblee-nationale.fr/12/rap-info/i1717-t1-05.asp#P6209_573114.</footnote>
On the other hand, one can argue that the existence of a counter-power, through emerging safety communication actors, can support safety enhancement by putting the aviation industry under scrutiny and forcing it to do even more. Up to now though, it has not led to the identification of new safety issues.

It seems that the contribution is rather in terms of pressure applied to the overall safety system. One can see this as a recurrent move that will prevent the air travel industry from becoming complacent. Given the extremely low rates of accidents achieved by the industry, the public could fear that air transport actors see themselves as having reached a ‘good enough’ level in terms of safety. From this point of view, new safety communication actors could be seen as a useful power, a kind of watchdog. However, to keep this role that could contribute to safety enhancement, this counter-power needs to keep an appropriate balance. Indeed, going too much in the direction of negative communication impacts the industry, the authorities and their credibility. It may even give credit to alternative and private accident investigations carried out with less expertise and objectivity. This may result in blurred pictures concerning what needs to be done in order to enhance safety.

Within the framework defined by the ICAO Annex 13, investigations are international task forces involving a number of stakeholders with their own objectives and constraints. Any mishandling would be immediately known.

## Conclusion

Safety communication has been for a very long time a continuous activity, undertaken by professionals within the aviation community. It is still the case to a very large extent when it comes to learning from operations and sharing safety-related information in the absence of accidents. However, the communication landscape changes dramatically in case of an accident. If communication used to translate into aviation professionals providing validated information to journalists who in turn informed the public, the sources of information have become diversified, the nature of information as well, not to mention the motivation of those entering the communication scene. In brief, there is on one hand a permanent exercise carried out by professionals, and on the other hand, ad hoc communication triggered by unfortunate events and led by specific and temporary stakeholders.

The safety strategy, and therefore the associated communication delivered by the air travel industry, is a long-term one, somewhat self-centred and raising potential safety issues in a consensual fashion. It is mostly done by aviation experts representing various domains. The other approach is by nature more critical and often challenges the ability of the air travel community to do an effective job in terms of safety. It is done by very diverse actors and increasingly relayed by social media. The industry has no choice but to face this changing and challenging context.
Ignoring it would just make things worse. Some key actors have already started to change their communication practices after an accident, especially investigation authorities. They have realized that a lack of communication could impact their credibility; two important investigation bodies, the NTSB in the USA and the BEA in France, have done a lot over the past years. They now give public information much more quickly than before and they do take care of victims' associations in a dedicated way.

For example, depending on the magnitude of the event, US investigation authorities may decide to organize daily press conferences and sometimes to use Twitter in order to inform the general public in an efficient and fast way. It must be noted, however, that such initiatives are not always welcomed by some stakeholders who believe that more time must be taken in order to prevent hasty conclusions. The French Transportation Investigation Board (BEA), for example, ensures that at all times families learn first about their official communications. They also publish a list of ongoing serious incident and accident investigations in an effort to enhance transparency.

Nonetheless, communication practices around safety vary significantly among aviation actors. It is also fair to say that talking about air travel safety between accidents is not easy for two main reasons: first of all, media are more interested in news than in general speeches. Second, talking about safety indirectly means talking about accidents and companies are not always comfortable with this.

The industry nonetheless needs to find a way to be more present in this new world of safety-related communication. Failing to do so would leave an empty seat and limit its role to firefighting. Every safety communication specialist knows that it is difficult to react when you are in a defensive mode, which is almost unavoidable following an accident. A way forward for the industry seems to be to explain its efforts to a wider public with an appropriate approach, not waiting for accidents to occur to communicate on the public scene. Improving its image in terms of transparency can only help.

## References

* Graeber, C. (1995). *Accident prevention strategy*.

* Havinga, J., & Dekker, S. (2014). Just culture: Reporting, the line and accountability. *Journal of Aviation Management*, 49–57. Published by Singapore Aviation Academy, http://uat-web.saa.com.sg/documents/65465/149063/SAA_Journal_2014.pdf/d06550de-9a92-4632-9746-c2f2e874c556.

* ICAO. (2001). Aircraft accident and incident investigation (9th ed.). ICAO.

* ICAO. (2013). Safety management. ICAO.

* NTSB. (2008). Federal family assistance plan for aviation disasters. NTSB.
**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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<figure><img src="image_31.png" /></figure>
# Risk Communication from an Audit Team to Its Client

<figure><img src="image_32.png" /></figure>

Check for
updates

Petra Haferkorn

**Abstract** The article discusses the paradoxical foundation of a risk decision and the challenges the paradox puts on the management of risk communication. The exploration is done from a social systems theory perspective; a theory that provides a comprehensive theoretical framework for social systems and their communication processes and addresses the complexity, risk and conflicts of interests (Section ‘Systemic Audit: Widening the Perspective of Traditional Audit Approaches’). From this theoretical setting, the conclusion is derived that a statement about an organization’s risk cannot be proven as a ‘true’ statement and that a receiver of an audit report (the client) will always have good reasons to question an audit team’s risk communication (Section ‘The Paradoxical Foundation of a Risk Decision and Associated Challenges for Risk Communication Illustrated by the Example of an Audit Finding’). The article gives some hints on how an audit team can deal with clients’ needs by incorporating their requirements in its audit process, using concepts and tools from family therapy, brief therapy and systemic counselling (Section ‘Unpicking the Paradox of Risk Communication’).

**Keywords** Risk communication • Risk management • Social systems theory
Notion of risk • Risk perception • Paradox of risk • Meaning dimensions of risk
Connectivity of communication • Audit process design

## Systemic Audit: Widening the Perspective of Traditional Audit Approaches

Traditional standards for internal (Standard 2012) and external auditors (ISAs 2012) assign a wide range of responsibilities to a team that audits an organization (cf. Fig. 1, left column), e.g. while being independent and objective (e.g. Code of Ethics 1100 Independence and Objectivity, Standard 2012), auditors are to trustfully interact with clients and auditees (e.g. core Principles for the Professional Practice

<footnote>P. Haferkorn (✉)
German Federal Financial Supervisory Authority, Bonn, Germany
e-mail: petra@sebastian-haferkorn.de</footnote>
<table><caption>Fig. 1 Traditional audit approaches compared to systemic approaches</caption><thead><tr><td>Traditional approaches</td><td>Systemic approaches</td></tr></thead><tbody><tr><td>Objectivity of an auditor (masking blind spots and contradictions)</td><td>Reality is the construction of an observer and based on contradictions</td></tr><tr><td>Successful risk communication depends on audit team</td><td>Success of risk communication depends on its participants and its current context; connectivity might be increased by the audit team</td></tr><tr><td>Audits are steered by the audit team</td><td>Audits are operatively closed, therefore the audit team can only influence the audit to a limited extent</td></tr><tr><td>Static and cause oriented explanations aiming for final solutions</td><td>Dynamic communication-based, multicausal and recursive explanation models</td></tr><tr><td>Risk can be managed and safety can be attained</td><td>Risk is a social construct (which cannot be proven as a "true" statement)</td></tr></tbody></table>

of Internal Auditing, Standard 2012). Though the audit is initiated by a client and, in the beginning, the audit team is not in a position to know all the details of its engagement (e.g. 1000 Purpose Authority and Responsibility, Standard 2012), it is nevertheless held responsible for planning and performing the audit (2000 Managing the Internal Audit Activity et seqq., Standard 2012). At the end of the audit, auditors are supposed to negotiate management actions that remedy the organization's deficiencies and make organization safe again (2400 Communicating Results et seqq., Standard 2012).

To handle these challenges, a social systems theory perspective (Luhmann 1984) and related tools and methods of different systemic approaches proved highly efficient (e.g. for family therapy, see Selvini Palazzoli et al. 1977, for brief therapy, see de Shazer 1989; Weakland et al. 1974, for systemic counselling, see Königswieser and Exner 1998). They resulted in the development of systemic audit theory and a systemic audit approach (Haferkorn 2010; cf. Fig. 1, right column).

Social systems theory does not operate with concepts such as ‘objectivity’ and ‘truth’, but postulates that every truth depends on an observer and therefore must remain hypothetical (von Foerster and Pörksen 2013; von Glaserfeld 1995, 1996). In this theoretical setting, reality is a cognitive construction derived from an organism’s experience (Glaserfeld 1995) and therefore limited to the abilities and experiences of the organism (Maturana and Varela 1987; Luhmann 1990).<fnref n="1" /> Every

<footnote n="1">¹The doubts and concerns regarding a “total objectivity” or a “complete capture of risk”, expressed by social systems theory, are in no way intended to ignore the justified expectations of society on the communication of risk. Quite the contrary, we need a theory which allows for ambiguity and blind spots to develop appropriate tools and measures for risk experts to discover the limits and options of their risk communication and to deal with the expectations of society</footnote>
observation of the organism draws a distinction, which specifies a unity distinct from a background (Spencer-Brown 1969; Maturana and Varela 1987). Taking a concept from biology, systems theory calls the unseen background ‘blind spot’ (Maturana and Varela 1987; Luhmann 1990). Every observation has therefore a limited focus and cannot claim to be all-embracing (cf. Fig. 1, second row).

As participants of a social system thus have different perceptions, they cannot take for granted that each party understands the other’s viewpoint—misunderstandings between involved parties are therefore likely (Luhmann 1986). For this reason, a systemic audit approach explores the context and conditions of risk communication to the stakeholders of an audit (Haferkorn 2010) and strives for connectivity (cf. Fig. 1, third row).

In this framework, an audit is operatively closed (Haferkorn 2010; Luhmann 1990), i.e. for example audit team depends on the auditees. Consequently, an audit team is not able to steer the audit towards a given objective, but rather focuses on what is possible and feasible in the existing audit context (e.g. available resources in experts, equipment and time) (Haferkorn 2010; Fig. 1, fourth row).

In this theoretical setting, it proved helpful to observe communication processes which can explain the functioning of social systems (Luhmann 2000 in relation to organizations, Haferkorn 2010 in relation to audits). Moreover, organizations are only able to survive when their communication continues to involve and balance the conflicting interests of important demands on the organization (Simon 2007, cf. Fig. 1, first and fifth row). Based on these assumptions, the following section discusses the interpretation of Luhmann’s notion of ‘risk decision’ (cf. last row of Fig. 1) and explores its practical application in audits.

## The Paradoxical Foundation of a Risk Decision and Associated Challenges for Risk Communication Illustrated by the Example of an Audit Finding

Power’s (2007) research on risk management draws on Luhmann’s notion of risk (Luhmann 1991), which implies that future damage is not caused by natural disaster or other external, unswayable events but by a decision.<fnref n="2" /> ‘*Uncertainty is therefore transformed into risk when it becomes an object of management*’ (Power 2007, 6).<fnref n="3" /> By incorporating more of Luhmann’s theoretical program, we can gain an improved

<footnote n="2">²Luhmann presumes the concept of a ‘second-order observer’; the decision-maker bases his decision on his observations and is the ‘first-order observer’ (Luhmann 1991, 235–247).</footnote>

<footnote n="3">³The following considerations are based on the notion of risk, since an organization that realizes to be threatened by danger (or in Power’s word ‘uncertainty’) should think about the possibilities of protection and thus about a risk decision (Luhmann 1991, 32–40; Haferkorn 2010, 175).</footnote>
<figure><img src="image_33.png" /><figcaption>**Fig. 2** A statement in risk communication cannot be proven as a 'true' statement (example of an audit finding)</figcaption></figure>

understanding of the paradoxical foundation of a risk decision and the associated challenges of risk communication.

According to Luhmann, a risk decision, i.e. a decision that assumes a relationship between a decision and a probable future<fnref n="4" /> damage, has a paradoxical foundation (cf. Luhmann 1991, 9–40 and 1995). This is demonstrated using the following example of an audit team that informs its client about a risk to the organization, which in turn leads to discussions about the audit finding. The audit team informs the client that if a certain decision is taken, e.g. a certain control is not introduced in a workflow of the company, damage will occur within the next 5 months. Figure 2 exposes the four possibilities for future developments:

1. The organization introduces the control mechanism but the damage occurs nevertheless. The forecast—or in Luhmann’s words ‘the assumption of a relationship between risk decision and future damage’—was wrong.

2. The organization introduces the control mechanism and the damage does not occur. Consequently, the audit team cannot prove that the assumption of a relationship between the lack of a certain control and future damage was correct, as the forecasted damage did not occur.

3. The organization does not establish the control mechanism and the damage occurs. The risk communication was not successful: if the decision-makers had trusted in the audit team's expertise, they would have followed its suggestion.

<footnote n="4">⁴Remark: The notion postulates a forecast horizon. Some risk communication ignores such a forecast horizon (e.g. some audit findings) and just states that certain damage might occur. I think that the inclusion of a time horizon is essential for the notion of risk (and the core of its difficulties), since otherwise a risk statement will always be true and therefore redundant. This is the parallel case of Keynes’ statement: ‘*The long run is a misleading guide to current affairs. In the long run we are all dead. Economists set themselves too easy, too useless a task if in tempestuous seasons they can only tell us that when the storm is long past the ocean is flat again.*’ (Keynes 1923, 80).</footnote>
4. The organization does not introduce the control mechanism and the damage does not occur. As in the first and second case, the assumption proved wrong.

In summary, Luhmann states that a risk decision is founded on a basic paradox. Either the assumption (relationship between a decision and a future damage) underlying a risk decision holds and the damage occurs—in this case, the risk decision has been in vain (case 3 in Fig. 2), or the assumption does not hold—which means that the decision was based on a wrong assumption (case 1, 2 and 4 in Fig. 2). Since either the final risk decision or the assumption of the relationship is wrong, risk communication is based on a fundamental paradox (Luhmann 1991, 2002, 189, last row in Fig. 1).<fnref n="5" />

## Unpicking the Paradox of Risk Communication

For a comprehensible communication of risk, experts often focus on a professional explanation of underlying facts and on the interpretation of corresponding research results for laypersons (e.g. Gigerenzer et al. 2010; Hollands and Lipkus 1999). Though facts play an important role, we have to bear in mind that communication is more than transmitting facts (Luhmann 1986; Roussy 2012 in relation to internal audits, Simon and Weber 2004, 91–97 in relation to systemic therapy).

Moreover, unlike damage, which can be experienced, Luhmann’s notion of risk is not a hard and fast fact, since risk is not an observable or demonstrable phenomenon. Risk is rather a social construct and must therefore be dealt with in communication processes. The remaining question of section two is therefore how an audit team can increase the connectivity of its audit findings.

## Luhmann’s Dimensions of Meaning

Social systems theory assumes that the negotiations taking place in communication can be examined by distinguishing three meaning dimensions: the ‘fact dimension of meaning’ (Sachdimension) refers to the facts and the knowledge exchanged, the ‘social dimension of meaning’ (Sozialdimension) considers the social relationship

<footnote n="5">⁵In his argumentation, Luhmann adds that the transformation of the logical statement into a probability statement by using the notion ‘probable’ damage does not unpick the paradox. Both concepts, logic as well as probability theory base their assumptions on a foreseeable and calculable future. Instead of one scenario probability theory uses several (in relation to continuous distributions even infinite) scenarios, but nevertheless the statement is still based on an observer (e.g. a person or a model) to predict future damage. In either case, whether a logical or a probability statement is given, the observer cannot foresee the future and has a blind spot (Luhmann 2002, 189). Thus a statement in risk communication (made by an audit team to its client) cannot be proven as a ‘true’ statement and its recipient will always have good reasons to question it.</footnote>
between communication partners and the ‘temporal dimension of meaning’ (Zeitdimension) deals with the timeline of communication processes (Luhmann 1984, 112 et seqq.; Simon 2014, 7 seqq. and 78–84 in relation to counselling).

With this differentiation in mind, I now can establish methods for dealing with challenges that arise within the complex risk communication from auditors to clients, notably the paradox described in the previous section. It should be noted that these dimensions of meaning overlap, for instance when the client does not acknowledge the facts underlying an audit finding (fact dimension of meaning), the audit team can try to gain a better understanding of the client’s context and concerns (social dimension of meaning, cf. Collins 2010 in relation to communication between experts and laypersons) and invest time to gather further relevant information (temporal dimension of meaning) and adapt the presentation of audit results to the client’s needs. Moreover, as the example indicates and as will be shown later, if connectivity poses problems, it can be helpful to change perspective.

## Risk Communication Embedded in an Ongoing Process of Expectation Management

Against this background, it seems necessary to manage the expectations of involved parties (cf. Simon 2014; Königswieser and Hillebrand 2004 in relation to counselling). It is important for the audit department (or audit firm) to build a trustful relationship with the client from the beginning and to establish a generally accepted standing in (and outside) the audited organization (including, e.g. the supervisory body, cf. Roussy 2012). This foundation allows auditors and client (using the temporal dimension of meaning) to develop a common understanding and agreement on their mutual roles during the audit (i.e. a consensus on roles according to the social dimension of meaning, cf. Haferkorn 2013, 35–49).

Given this starting point, the audit team should balance interaction with auditees and other stakeholders in the course of the audit process (Haferkorn 2010, 71–89 regarding auditors’ independence; regarding counselling cf. Königswieser and Hillebrand 2004, 94; Pfeffer 2001, 130–132). The team can manage the stakeholders’ expectation by respecting their opinion when it seems appropriate (e.g. when asking for the self-image of the organization) and if they comply with the Code of Ethics, but it should also be prepared to politely reject their standpoint later in the process, e.g. when judging the facts underlying an audit finding (cf. Section ‘Independence and Need for Social Interaction’ in relation to independence of the audit team).

Furthermore, audit actions and observations can change a stakeholder’s opinions and attitudes (i.e. the fact dimension of meaning affects the social dimension of meaning). For example, decision-making about the next steps in the audit process would be different if an internal auditor detected fraud. In such a case, he or she