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The role of the public in the management of public health risks

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The role of the public in the management of public health risks
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  2004 VOL . 28 NO . 5AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH415 The role of the public in the managementof public health risks John Beard and Hudson Birden Northern Rivers University Department of Rural Health, University of Sydney and Southern Cross University, New South Wales  Abstract Objective: To critique current models ofpublic involvement in the management ofpublic health risks. Methods: Two case studies are used tohighlight the challenges of contemporarypractice. Results: Current models often result inaffected communities having perceptions ofrisk that conflict with those responsible forrisk management. This can lead toineffective decision making. Conclusions: Involving the publicthroughout the risk assessment and riskmanagement process may lessen conflictand result in better decisions. Implications: Those responsible forresponding to public health risks shouldaim for transparent processes that highlightassumptions and uncertainties, and involvethe public wherever possible. ( Aust N Z J Public Health   2004; 28: 415-17) Correspondence to: Professor John Beard, Northern Rivers University Department of Rural Health, PO Box 3074,Lismore, New South Wales 2480. Fax: (02) 6620 7270; e-mail: jbeard@med.usyd.edu.au Submitted:  December 2003 Revision requested:  May 2004 Accepted:  July 2004 I n recent decades, public demand for asafe and healthy environment hasresulted in increasing resources beingdirected at the identification, assessment andmanagement of public health risks. However,these are not straightforward processes, andthis is reflected internationally in a diversearray of approaches. In Australia, guidelinesfor environmental health risk assessmenthave been established by the NationalPublic Health Partnership. 1  The most widely used model for healthrisk assessment is based on work developedfor the US National Academy of Sciences(NAS) in the late 1970s. 2  In this model, the‘scientific’ process of risk assessment is seenas independent of the political, social, andeconomic imperatives underpinning riskmanagement.However, some authors have rejected thisview and argue that probabilistic riskestimation can never be independent of subjective assumptions or inputs. 3  These mayinfluence many stages of assessmentincluding the initial structuring of theproblem, choosing endpoints or dose-response relationships, and the expressionor comparison of risk.How we ultimately manage an identifiedrisk is also influenced by a range of factorsbeyond quantitative risk assessment. Notleast of these is the way the risk is perceivedby affected communities. 4  When an affectedcommunity perceives the degree of riskdifferently from those responsible formanaging it, conflicts arise that can lead toineffective decision making.Lack of agreement between communityand ‘scientific’ assessments of risk isexacerbated by the limitations of currentmethodologies. 5  Often, meaningfulepidemiological data are scarce and we needto base our judgements on animal or cellularstudies. We assume such information can beextrapolated to predict a threshold belowwhich humans are unlikely to face a healthrisk, or that a dose-response relationship canbe calculated down to risks sometimes as lowas one in a million. These assumptionsthemselves are not universally accepted. 6 Good assessments identify theseassumptions and uncertainties, and a numberof safety factors are applied to ensure a‘conservative’ assessment. However, anyquantitative risk assessment is ultimatelypresented in terms of a numerical risk. Thismay reinforce unjustified confidence in thescientific basis for that estimate.Community perceptions of risk are alsoinfluenced by a number of factors that arenot considered in quantitative assessment. These include whether an exposure isperceived as voluntary, whether it is to anatural or industrial substance, and whetherit is being managed by trustworthy sources. 7  These factors have been summarised as 12principal components of community‘outrage’ (see Table 1). Individuals whoperceive little personal benefit from aparticular hazard also tend to perceive agreater associated risk. 8 Case studies  The problems inherent in traditional riskassessment and management are highlighted Brief Report Environmental Health  416AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH2004 VOL . 28 NO . 5 Table 1: Twelve components of community outrage (afterSandman 7 ). Perceived as safePerceived as risky VoluntaryCoercedNaturalIndustrialFamiliarExoticNot memorableMemorableNot dreadedDreaded (e.g. cancer)ChronicCatastrophicKnowableUnknowableIndividually controlledControlled by othersFairUnfairMorally irrelevantMorally relevantTrustworthy sourcesUntrustworthy sourcesResponsive processUnresponsive process by a simple example from regional New South Wales, Australia.More than 1,500 cattle dips have been built in this region as partof a government program to control the introduced cattle tick. 9 Many of these sites are now contaminated by the pesticides usedin the past.In the mid 1990s, the parents of children attending a smallpreschool in the region complained to their local council aboutthe preschool’s proximity to an active dip. This resulted in animmediate site investigation by council staff and the dip’s closure. 10 Soil samples from the preschool were generally below all healthinvestigation levels. Soil from two small areas with pesticide levelsslightly above the investigation criteria was removed and replacedwith clean fill. Air monitoring was reassuring. The cattle dip sitewas fenced off and all staff were offered biological monitoring.Subsequent blood and urine samples were within an expectedcommunity range.In these circumstances the potential risk posed by contaminationat this site was too small to be quantified. From the perspective of human health, an adequate management plan would have been tomaintain the status quo. The responsible authority recommendedthat the dip be dismantled and a metre of clean fill placed on topto prevent exposure in the foreseeable future. However, thecommunity continued to apply pressure on the local council anda large and emotive public meeting ensued. The final result? Thepreschool was relocated to another site at the council’s expense. 11 A more complex example that also highlights the relevance of this issue to communicable disease is the Bovine SpongiformEncephalopathy (BSE) epidemic in the UK. As with many publichealth risks, concern for human health effects was raised beforehard evidence was at hand, and initially rejected by the relevantauthorities in favour of economic interests. 12  Faced with demandfrom an alarmed public for information, reassurance and action,the British Government responded by attempting to protect boththe beef industry and consumers throughout the early period of the epidemic. The Government “… tried to serve two masters andfailed both”. 13  Risk assessments were conducted without publicconsultation. The risk was new, unseen, unquantified and dreaded.It is not surprising this initial response did not satisfy the broadercommunity.In response to these concerns, more recent British BSE policieshave emphasised openness, trust and credibility and have achievedbetter acceptance by the public. 14 Discussion  These cases highlight the influence of public perceptions onrisk management. In one, the influence of public perception wasultimately greater than that of a formal risk assessment. In theother, public perceptions may have even changed the way riskwas assessed.In its attempt to keep science separate from politics, the NASmodel excludes communities from the assessment process, seeingit as a technical and objective exercise. But lack of trust anddiffering understandings of risk mean communities can havedifficulty accepting the findings of such an approach. This artificial separation of ‘scientific’ risk assessment fromrisk management may create a ‘them-and-us’ environment wheretechnical knowledge is the supposed domain of scientists andbureaucrats, while social judgement is owned by the community. This may also weaken the risk assessment process itself, sincethe assumptions and judgements inherent within it are driven bya culture lacking more diverse social perspectives.One early reaction to this impasse was the belief that bettercommunication of the assessed risk to the public would reduce‘outrage’ and improve decision making. However, researchsuggests that providing better evidence to the community doesnot moderate feelings of concern. 15  No matter how well an agencyarticulates risk, unless it is open and responsive to the communitythe message will not be heard.So what alternative approach could lead to better managementof public health hazards? We believe that involving the public asgenuine partners throughout the risk management process isfundamental to effective decision making. This is supported byresearch into published studies of stakeholder involvement, whichsuggests a generally positive effect on the quality of decisions. 16 Many choices in risk assessment are subjective and require littletechnical expertise, and there is little reason, apart from conflictof interest, to prevent stakeholder involvement in this process. This will almost certainly build trust in the findings and removesome of the barriers to effective decision-making.Since risk assessments are, at best, limited in their certainty,the subjective nature of many of their assumptions needs to beacknowledged. While quantitative risk assessment is the best toolavailable for estimating health risks, sometimes the evidence forthese estimates is extremely limited. In these cases it may be moreappropriate to apply simpler forms of management, such as settingdefault levels of unacceptable contamination that could be appliedto a wide range of substances where adequate evidence is notavailable.Stakeholders, industry and agencies or their officers all come Beard and BirdenBrief Report  2004 VOL . 28 NO . 5AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH417 to the process of risk management with underlying agendas. Theseneed to be acknowledged, spelled out and teased apart. 17  Onceuncovered, the influence of some of these agendas on decisionmaking can be minimised.Where mistakes have been made, it may be best for thoseresponsible to apologise. Legal advice often seems to argue againstsuch an approach, but the authors’ experience suggests that anopen and genuine apology may defuse outrage and minimise legalaction.Finally, any risk assessment should be transparent and of goodquality. Communities perceive the uncertainty inherent in riskassessment and, if this is understated, may distrust any reassurancesprovided. This distrust may be amplified by the perceived pastfailures and mistakes of government agencies. Franklyhighlighting assumptions, unknowns and risks will build trustand minimises, rather than exacerbates, conflict.For significant public health risks such as passive smoking,high levels of outrage are appropriate and have driven governmentsto improve their risk management. However, where health risksare low, high levels of outrage can lead to costly and ineffectivedecision making. Involving stakeholders as partners throughoutthe risk management process helps communities better understandthe risks they face and can lead to more appropriate levels of community concern. While public involvement will not guaranteesound decisions or magically resolve conflict, a large body of evidence now suggests it is likely to remove some significantbarriers to the effective management of public health risks. References 1. Environmental Health Risk Assessment: Guidelines for Assessing Human Health Risks from Environmental Hazards  . Canberra (ACT): Population HealthDivision, Department of Health and Ageing; 2002.2.National Research Councils. Risk Assessment in the Federal Government: Managing the Process  . Washington (DC): National Academy Press; 1983.3.Kunreuther H, Slovic P. Science, values and risk. Ann Am Acad Pol Soc Sci  1996;545:116-25.4.Covello V, Sandman P. Risk Communication: Evolution and Revolution. In:Wolbarst A, editor. Solutions to An Environment in Peril  . Baltimore (MD): John Hopkins University Press; 2001. p. 164-78.5.Hrudey S. Quantitative Cancer Risk Assessment – Pitfalls and Progress. In:Harrison R, Hester R, editors. Issues in Environmental Science and Technology  , Risk Assessment and Risk Management, Issue 9.  Cambridge (UK): The RoyalSociety of Chemistry; 1998.6.Hrudey S, Krewski D. Is There a Safe Level of Exposure to a Carcinogen? Environ Sci Technol   1995;29 (8):370-5.7.Sandman P. Responding to Community Outrage: Strategies for Effective Risk Communication  . Fairfax (VA): American Industrial Hygiene Association;1993.8.Alhakami A, Slovic PA. Psychological Study of the Inverse Relationshipbetween Perceived Risk and Perceived Benefit. Risk Anal   1994;14:1085-96.9.Beard J, Williams J, Stevens R, Grinter M, Wickens J, McDougall K, editors. The Management of Contaminated Waste at Cattle Tick Dip Sites in North Eastern NSW   [report]. Sydney (NSW): NSW Government; 1992.10.DDT levels in teacher ‘about average’, meeting told. The Northern Star   1993Feb 19.11.Pre-school moves today. The Northern Star   1993 April 1.12.Pallister D. ‘Culture of secrecy’ misled the public about risk of eating beef.Ministers ‘did not lie’, but embarked on mistaken campaign of reassurance.Special report: the BSE crisis London. The Guardian   2000 Oct 27.13.O’Brien M: Have lessons been learned from the UK bovine spongiformencephalopathy (BSE) epidemic? Int J Epidemiol   2000;29:731.14. The BSE Inquiry: The Report  . The Inquiry into BSE and variant CJD in theUnited Kingdom. London (UK): Ministry of Agriculture, Fisheries and Food;2000. Available from: http://www.bseinquiry.gov.uk/index.htm [cited 2003March 12].15.Sandman P, Miller P, Johnson B, Weinstein N. Agency communication,community outrage, and perception of risk: three simulation experiments. Risk Anal   1993;13(6):585-98.16.Beirle TC The Quality of Stakeholder Based Decisions: Lessons from the Case Study Record  . Washington (DC): Resources for the Future; 2000.Discussion Paper No.: 00-56. Available from: www.rff.org.17.Bostrom A. Risk perceptions: “experts” vs. “lay people”. Duke Environ Law Policy Forum   1997;8(101):101. Environmental HealthRole of the public in managing public health risks
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