text:
- Zika Rumors by Peter M. Sandman and Jody Lanard – February 22, 2016
- Some Additional Zika Risk Communication Notes by Peter M. Sandman and Jody Lanard – February 16, 2016
- Zika Risk Communication: WHO and CDC Are Doing a Mostly Excellent Job So Far by Peter M. Sandman and Jody Lanard – February 3, 2016
On May 27, 2016, Elizabeth Whitman of International Business Times emailed me to request a telephone interview with both me and my wife and colleague Jody Lanard about "how public health officials juggle the need to educate the public and convey a sense of urgency about the Zika virus without sending people into unnecessary panic." We did the interview the same day.
Column Table of Contents
Zika messaging before April 2016
The White House takes control and the messaging turns more alarmist
"Footnotes" re the alarmist messaging
Zika panic versus Zika adjustment reaction
Most reporters miss the Zika messaging shift
Zika messaging in New York City
Most domestic Zika precautions make sense even if the alarmist messaging doesn't
Examples of pre-April "limited local outbreaks" messaging
Examples of April alarmist messaging
Even in April (and after), CDC and NIAID stick to their earlier messaging
Competing Zika scenarios and mental models
Is the White House alarmist messaging politically motivated?
But instead of focusing on education/urgency versus panic, we focused on our judgment that public health messaging about Zika risk in the continental U.S. had become much more alarmist starting around the beginning of April. That was when White House officials preempted one of the CDC's key Zika messages: that domestic Zika outbreaks were very likely (but not guaranteed) to be small and local. Instead of preparing Americans to take limited domestic Zika outbreaks in stride, we told Elizabeth, the White House started preparing Americans to expect epidemic-level domestic Zika outbreaks; to see even small limited domestic Zika outbreaks as widespread and catastrophic; and to blame them on Republicans for failing to pass Zika funding.
Elizabeth's June 9 story made only a little use of our interview. She ignored our main point about the hijacked message. Instead, her main point was how hard it is for public health officials to communicate nuance to a frightened population. And she wrongly attributed to us the view that there was a "media frenzy" to cover Zika that made "crucial nuances disappear." We taped the interview. Since we didn't have Elizabeth's permission to record and publish her side of the conversation, a transcript of our side only is posted here, very slightly edited for clarity but not content. We have also added boldface headings, bracketed clarifications, links, and endnotes documenting a few of the many sources that led to our analysis.
The Interview[Elizabeth sets the stage for the interview by reiterating some of the questions she had emailed to Peter.]
Peter: Is it okay, Elizabeth, if we free-associate for awhile, because I think we may reframe the question for you? And after we've talked more than you want us to, you can mop up with questions that seem to be called for. [Elizabeth agrees.]
Zika messaging before April 2016
Peter:The place to start is: Zika is either very serious or probably not very serious, depending who you are or where you are. As I'm sure you're fully aware, it's not at all serious in the vast majority of cases except to fetuses, so if you're not a pregnant woman your risk from Zika is very low.
Jody: Or likely to become pregnant.
Peter: Or likely to become pregnant. But that's well understood. What's not so well understood is that there are places where Zika is likely to be bad, there are places where Zika is already bad, and then there are places where Zika is almost impossible. And then there are places in the middle where it is not absurd to worry about a worst case scenario where you have a lot of Zika, a serious widespread Zika outbreak, but it would be a worse scenario – and the likely scenario is very local outbreaks that are certainly frightening and upsetting and dangerous to the [pregnant] people they happen to, but that are relatively small and relatively quickly stopped.
Jody: CDC [1, 8, 9] and Tony Fauci [7, 10] from NIAID have been very clear that they think the most likely Zika cases in the states are small local outbreaks the way the small local dengue outbreaks have happened, in Florida, Texas, a couple other places.
Peter: Elizabeth, you know about dengue and chikungunya? [Elizabeth indicates yes.]
Jody: Now the small local outbreaks that have happened over the last couple years – despite hundreds and hundreds and hundreds of returning travelers infected with dengue and chikungunya – the small local outbreaks that CDC uses for a model for the most likely Zika cases have been between two cases and maybe fifty cases of dengue. There was one outbreak in Key West that maybe got about fifty people, of whom most likely one or two were pregnant. [Although the number of locally transmitted clinical dengue cases in Key West was relatively small, about five percent of the local population later showed laboratory signs of having been infected.]
Peter: As a predictor, if Zika, which is transmitted by the same mosquito, acts the way dengue has acted – and that's not guaranteed, but it's your best guess….
Jody: It's your most likely scenario.
Peter: If Zika works the way dengue has worked, there will be a few local outbreaks of two, five, ten, twenty, maybe fifty people, most of whom won't be pregnant.
Jody: And that's what CDC was trying to get across until April 1, when the White House hijacked the CDC message about that, and started trying to make it look like Zika was going to be catastrophically widespread in the United States [3, 5, 6].
Peter: Let's put some basic understanding under that. As risk communication people, we routinely say to clients that with an uncertain risk, there are two anchors that deserve a lot of attention in your communication.
One of those anchors is the likeliest scenario. The other is the worst case scenario that isn't so terribly unlikely that it would be silly to worry about. So it's not a literal worst case scenario, because they almost never happen, but it's a lot worse than your likeliest scenario. So it's the worst case that you're actively worried about. And those are the two anchors.
And the single most important thing we tell clients is: Make sure you cover them both, and make sure you are clear to your audience about what the difference is between them.
Now, CDC early on, in January, was doing a very good job of that [1]. And in particular, with regard to the likeliest scenario, it was making it clear that it did expect local outbreaks in the continental U.S. of Zika, and it tried to prepare the American people to take those outbreaks almost in stride. They were obviously going to be frightening when they happened, but CDC was working very hard to say, "It will happen, it happened with dengue, it will probably happen with Zika, but as with dengue, they will probably be small, they will probably be brought under control relatively quickly, they will probably not do a great deal of harm." That was the message. And right before we called, Jody and I emailed you an excerpt from something we wrote several months ago praising CDC for making that message so clear.
The White House takes control and the messaging turns more alarmist
Then – and this is the point Jody was getting to – then what happened, and we watched it happen in real time, it happened around March 31 and April 1….
Jody: First, CDC released a new map showing that the Zika-carrying potential mosquitoes are like all over the United States almost, and starting to make it look like Zika could really be bad everywhere, and then…
Peter: And you should understand: That map, what they did, instead of a map of where the Aedes mosquito is widespread, they produced a map of where the Aedes mosquito is occasionally found [13].
Jody: Or potentially able to survive. [We should have been clearer that we were talking mostly about Aedes aegypti. Aedes albopictus is genuinely widespread in much of the continental United States.]
Peter: Instead of producing a map that showed parts of the United States where the Aedes mosquito is widespread….
Jody: And well-established.
Peter: They produced a map that showed the parts of the United States where Aedes mosquitoes have occasionally been found, or where the climate is such that Aedes mosquitoes might survive. If you think of yourself as worried about tornadoes, you could produce a map that shows the places that have a lot of tornadoes, or you could produce a map that shows the places that have ever had a tornado. And which is going to be more helpful in helping you prepare for tornadoes? The former. And they had the former, and they replaced it with the latter on about March 30.
Jody: And I want to say something about that map. The map actually should have been reassuring, because the map showed all the places where Aedes albopictus exists across wide swaths of the United States, and all the places where Aedes aegypti has either ever been found, or could conceivably live. And you [could] look at that map and say, "But despite all that, we've hardly had any dengue outbreaks, despite all those mosquitoes and despite all the infected travelers" [13].
So that map could actually have been used as a reassuring map. But instead the White House grabbed that map, and ran with it, and turned it into a major alarm.
Peter: It started with the map. The next day, April 1, was a conference that CDC hosted called the ZAP conference, called the Zika Awareness….
Jody: I think of it as the Zika Appropriations Problem!
Peter: The Zika Awareness and Preparedness…. You'll have to look it up. [The actual name was Zika Action Plan (ZAP) Summit.] They gathered together state and local people for several days of meetings, and they had a news conference at the end of the ZAP meeting, and that news conference was dominated by spokespeople from the White House. Not by CDC people but by spokespeople from the White House. [We misremembered. According to the transcript of the ZAP Summit news conference, Amy Pope was the only White House official who spoke.] And instead of the language that CDC and NIH had been using for several months – language about "we have to be prepared for small local outbreaks…."
Jody: And "It's a terrible terrible crisis in Puerto Rico…."
Peter: Jody's quite right, Puerto Rico….
Jody: …is a disaster area.
Peter: But we're talking about the continental U.S. And where CDC and NIH had been saying for several months, "Let's get ready for small local outbreaks, and let's get ready to find them quickly, and stop them quickly, so that we can be confident that they will stay small and stay local," instead of that you had spokespeople from the White House using words like "widespread," and predicting almost clearly…. As you know, politicians try really hard not to lie if they can mislead without lying. So they tried very hard not to actually say that "the experts say this is going to be widespread," because the experts were on the podium and they hadn't been saying this is going to be widespread.
But from that moment on, the White House took control of the messaging. And it did so very, very clearly because the White House saw that Zika is a potent weapon against the Republicans in Congress [14]. By April 1, the Obama request for funding had already been pending in the Congress for several months. That request went in in February. And it was clear that the Republicans in Congress were reluctant to give Obama as much money as he asked for. It was clear that the Republicans wanted offsets; they didn't want to give him the money and add to the national debt; they wanted to take it out of the Ebola budget or some other budget.
And the White House saw – I think absolutely correctly, maybe not honorably but correctly – that this was an opportunity to make very good political hay out of Zika funding.
From that moment on, you can look, as Jody and I have, day after day after day, at what the White House, and the Democrats in Congress who are working with the White House, have done about Zika funding. And it becomes increasingly clear that they don't want the money nearly as much as they want the fight. They are getting great benefit out of saying that the Republicans are callous, that the Republicans don't care about microcephalic babies, that the Republicans are more worried about the budget than they are about the American people. They are making hay out of that.
This summarizes it, I think: The CDC in January and February and March, until the end of March, was trying to prepare people to take small local Zika outbreaks in stride. Now, the White House is trying to prepare people to overreact to small local Zika outbreaks, and blame them on Republicans. And they're right – if you think politics matters, and if you think Zika's probably going to be a small deal….
Jody: In the continental United States.
Peter: So what's the most sensible thing to do if you think Zika is probably going to be small, and you really want to make political hay without doing serious harm to public health? You take $600 million out of the Ebola budget, so they can make some progress on Zika. You demand $1.9 billion [from Congress]. You demand it as offensively as possible because you don't want them to give you the money. And you've got enough money to cope [in the short term] with Zika, or at least your likeliest case for Zika, and you've got this spectacular fight. You prepare the American people to overreact to the likeliest case and think of it as a horrible outcome for which the Republicans are to blame. There were always going to be a handful of tragedies of Zika babies; if you can get that handful of Zika babies blamed on Republicans, and it gains you one or two or three percentage points in the November elections, why wouldn't you do that [14]?
Jody: And along the way, the White House came out with yet another map, from NASA, the National Aeronautics and Space Administration, showing a meteorological and environmental map of where Zika might spread across the United States, that showed even more widespread danger. And all of these [maps] should have been seen as reassuring, because if we have all these bad mosquitoes and we still have hardly any dengue, that should tell us that there's probably not going to be very much Zika.
The CDC people who we admire very much, like Anne Schuchat, Lyle Petersen, and Denise Jamieson have been very careful not to lie on behalf of the White House….
Peter: And include Tony Fauci [from NIAID].
Jody: And Tony Fauci, who is doing a very good job of being very honest but in a very quiet way [12]. So at this press conference, where the White House started talking about how terrible things were going to be with Zika, a reporter turned to Anne Schuchat and said something like, "Is this worse than you thought?" And Anne said something like, "It's a little bit scarier." [The correct quote is "a bit scarier" [8].] And what she meant that day was that what we thought was true about Zika but wasn't yet proven is now proven. The hypothesis about the microcephaly was now a definite proven point that people were accepting as scientific. So yes, that was a little bit scarier.
Her statement, "a little bit scarier," was interpreted by the media covering that press conference as: "CDC much more worried about Zika than a couple weeks ago" [12].
"Footnotes" re the alarmist messaging
Peter: Four footnotes:
Footnote one: We are talking about the continental United States. The situation is genuinely horrible in Puerto Rico, is genuinely horrible in large parts of Latin America and the Caribbean. When we casually say that the likeliest scenario is no big deal….
Jody: Please don't use the words "no big deal," because any [Zika] baby is a tragedy, but it's not a huge public health tragedy.
Peter: …that's true only of the continental United States.
The second footnote is the one Jody mentioned, that if something is not widespread, from a public health point of view it is no big deal, but from the individual point of view of the person to whom it happens it is still a tragedy. You can't talk about microcephaly and other kinds of horrible brain damage [without acknowledging] that even a few cases are devastating to the people they happen to.
The third footnote is: You can't be sure. Surprises happen. And surprises happen more in virology than in many other fields. Viruses are endlessly shocking the experts in all kinds of ways. Zika as you know is the first mosquito-borne illness to cause birth defects. That's never happened before. The best guess….
Jody: The most likely, the most likely.
Peter: …is that it's going to be like dengue, like chikungunya that is the likeliest scenario [according to CDC], but it would be incredibly irresponsible not to prepare, and not to talk about the need to prepare for things possibly being much worse.
Jody: To prepare to some extent.
Peter: So we're not saying the CDC should have said, "The likeliest scenario is something like dengue. Key West coped with dengue just fine; Brownsville Texas coped with dengue just fine. No need for a special federal emergency budget. It's gonna be like dengue and we know how to deal with dengue." We are not saying the CDC should have done that, the U.S. government should have done that. That's the likeliest scenario, but there [also] needed to be attention to the worst case, or to a much worse case.
One more footnote….
Jody: It may be more than one!
Peter: Well, I have one more footnote. When we blame the White House for trying to make people more frightened of Zika than the data justify or than our experience with dengue justifies….
Jody: People other than pregnant women in Zika areas.
Peter: Right, talking still about the continental U.S. When we accuse the White House of excessively alarming messaging, we have to notice that in fact the American public is not excessively alarmed. I keep on my computer a Google Trends chart of the number of Google searches for Zika, and it peaked way back several months ago, very briefly, and went way back down almost to where it had been, and it has hovered there ever since. [There was another small peak in U.S. Google searches for "Zika" the week of May 29 to June 4, after this interview.]
Jody: Even when the White House hijacked the CDC's messages.
Peter: So on the one hand, we think it's dishonorable of the White House, and it's horrible risk communication of the White House, to say scary worst case scenario things without [saying] those are worst case scenarios, and implying that they are the likeliest scenario. We think that's dishonorable. It's probably politically smart. But it is reprehensible risk communication.
Jody: Contemptible.
Peter: But it hasn't done any noticeable harm. It's interesting, public officials are worried about who is going to panic. There's some evidence that some public officials are panicky. There's some evidence that some public health people, who ought to know better, are panicky. You look at the general public, it's remarkably calm.
Jody: The general public is being set up to be really upset, probably briefly, when the first Zika transmissions occur in the U.S. That's natural; it will be worse than it would have been because of the White House making it sound like it was going to be a catastrophe, but people will still come through it. They'll have what we call an adjustment reaction. Maybe people will actually be driven to take more precautions, which was one of your [Elizabeth's] questions.
The thing that will drive people to take more precautions nearby is when Zika cases are locally transmitted. And then probably, because it's what always happens, people in areas where Zika is not being locally transmitted will also start taking precautions which will be technically unnecessary, but probably a good rehearsal.
Peter: If ordinary people slather on mosquito repellent, even though they live somewhere where there is no Zika, and they do that because the newspapers are full of stories about Zika, you kind of have to cut them some slack, and say, "That's a very human response."
Jody: And maybe they won't catch West Nile Virus.
Peter: And at least they'll have fewer mosquito bites. But if public health officials are telling them that it is critically important to slather on mosquito repellent, in a place that has no Zika, that's not acceptable to us. It's one thing for people to overreact when they first hear about a new problem, a new risk. That's an adjustment reaction, and it's normal.
Jody: They try it on emotionally; they imagine it happening to them or someone they love. The media always calls that "hysteria," but we call it emotional practice.
Peter: And that adjustment reaction is normal and appropriate and acceptable. But what's not acceptable in our judgment is for public health officials to exacerbate the adjustment reaction. They are supposed to help people get through it, not order people to have an overreaction.
Jody: Can I tell about the guy in Houston? There's a public health official in Houston, Texas – and Houston is very vulnerable to some level of Zika because of the kinds of mosquitoes they have, and the poverty….
Peter: And they did have a very small dengue outbreak.
Jody: So there's a public health official, fairly high level, state or city, who talked to the media last week and was very upset that his young grandson or nephew was not wearing bug spray that day. He noticed that his grandson did not smell like bug spray. And he ran to the kid's mother and made her put bug spray on the little six-year-old boy, right then and there. There was no Zika in Houston – or dengue, as far as anyone knows – in May 2016. So we thought that was a little bit hysterical.
I would like to add a footnote, footnote number 5, about the $1.9 billion.
If the problem is anywhere near as bad as the White House is trying to make it look, $1.9 billion is not nearly enough for what they say they can do to reduce or prevent the harm from Zika. I think $1.9 billion is just a good number for the fact that Zika is going to be around for a long time in the world; it's important to develop a vaccine, it's important to raise awareness, etc.
But the idea that $1.9 billion, 20% of which is budgeted for overseas use, can prevent the horrible thing that they are going to blame on the Republicans if they don't get the money? The $1.9 billion cannot prevent that problem [a widespread Zika outbreak].
Peter: Now we're open to questions.
Communicating Zika nuances
[Elizabeth says a lot of what we said makes some of her questions moot. Then she asks whether people are learning "nuances" about Zika risk, and where people are getting their information about Zika.]
Jody: People are mostly getting the information from people who have been influenced by the White House message at this point. So they are getting it from local health officials. Every time you do a survey of people, especially young pregnant women, they most trust their own doctors, but they also check with other young mothers.
They are getting messages from people who are being greatly influenced by the messaging coming out of the White House [12]. So even though they are getting messages from people they trust, those people – local public health officials, local doctors, and neighbors and fellow parents – are getting an overly alarmed message which they are passing on. People get their information from television, from their local doctors, and from their local officials, and from people they know.
And they are all getting a very consistent message that has been very successfully promulgated by the White House. So I think people are actually getting a message to be more alarmed. But if it's pregnant women, it's fine for them to be alarmed, and to pay attention, and as soon as there is any [locally transmitted] Zika in their area, to start really taking precautions.
Peter: I agree with that, but again I would underline that it doesn't seem to be working all that well. The messaging that people are learning is more alarming than the truth. I think if you ask a sample of the public in the continental U.S., "How likely is your community to have Zika [transmission], they will greatly overestimate the probability, because they have learned that it is much likelier than it actually is. But again, given the misinformation they have absorbed, they are responding sensibly rather than irrationally. They are buying more bug spray than they used to buy; pregnant women are asking their OB/GYNs what precautions they should take.
But again, there isn't panic. There isn't a lot of extreme behavior. In a country of 300 million people, there are going to be a few people acting weirdly, but there are very few examples to be found of people overreacting to Zika. There are quite a large number of examples of public health officials telling them they should overreact to Zika, but most people are in fact not overreacting.
Jody: And then in Puerto Rico, there are a lot of women, pregnant or otherwise, under-reacting to Zika – not using bug spray routinely, not wearing long pants and long shirts, because it is just too uncomfortable to sustain that, month after month. So where it really counts, far too many women are under-reacting to Zika. And that's in Puerto Rico. I don't think they are overreacting in the [continental] United States. I don't see much of any overreaction, except on the part of public officials, and some very angry Democrats. And I'm not saying whether I'm a Democrat or a Republican, but they [Democrats] have seized this issue to make a lot of anger out of.
Zika panic versus Zika adjustment reaction
Peter: You asked in one of your questions, Elizabeth, about panic, and I think you are right that we sort of mooted that, but just because you did raise it, I kind of want to respond to it. One of the things that risk communication experts know that people in political life often don't realize is that panic is quite rare. It's not easy to get people to panic. Apathy is a much bigger problem than panic, and panic is very unusual. What is more common is what Jody and I call the adjustment reaction, which is not really a panic reaction. It's brief.
Jody: People pay a huge amount of attention to a new issue. You imagine it happening to you; you're overly alarmed about it while you are learning about it. And if people respect you, and they teach you how to handle it, and what you should do if the problem comes to pass, you settle down very quickly into a new normal, where you are more prepared. Otherwise, if you have those same reactions, and officials and the media tell you that you're irrational, and you're panic-stricken, and you're hysterical, [then] you don't learn as much. You still come out of that adjustment reaction and go back into not worrying [excessively] about it, but you haven't learned as much.
Peter: And here is what that's for, Elizabeth. If you stay on the story, and I expect you probably will [Elizabeth says she expects to], you will in the next couple of months cover probably the first autochthonous outbreak in the continental U.S., the first local transmission in the continental U.S. And everybody at that point will be saying that the public is panicking. And Jody and I would like you to notice that the public won't be panicking, it will be going through a brief and useful adjustment reaction.
[Jody asks Elizabeth if she remembers the "Great Ebola Panic of 2014." Elizabeth says she does. Jody asks: Do you know anybody personally who panicked about Ebola? Elizabeth says that's a hard question because she was in the Middle East at the time. She remembers reading about it. Jody asks: Did you notice anybody there panicking about Ebola? Elizabeth says no. Jody asks: Did you know anybody who changed their behavior in any way because of Ebola? Elizabeth says no.]
Jody: Well we can't find a single reporter in the United States, and we know most of the ones who covered Ebola domestically, and we asked every one of them that question, and they almost never knew anyone who actually panicked, unless they interviewed the lady at the airport who dressed up in the homemade hazardous materials suit. We call her Haz-Mat Lady. Nobody knows anyone who actually changed their behavior in the United States during Ebola.
The day after the New York City doctor was diagnosed with Ebola, after running around all over New York on the subways, subway ridership was exactly the same as the day before. And yet it was called "panic." So it will go down in history as the Great Ebola Panic in the United States of 2014, and we couldn't find it. And we've already seen articles about Zika panic and Zika freak-out in the United States.
And what it really is, is people paying a fair amount of attention – not as much as the media think they're paying, judging by Google Trends – people paying a lot of attention, people being anxious, people being curious, people being fascinated, and it's being called a freak-out. But it is not a freak-out.
Peter: I don't think you need that for this story, but you're going to need that when you cover the first local transmission.
Jody: Let me directly answer one of your questions: How can public health officials talk to the public in ways that are less likely to lead them to overreact with what you were calling panic? The best way is to be very respectful of the overreaction, or what looks like an overreaction. Not to show disdain, not to mock it, but to show respect for the normal ways that people react to scary new information.
Peter: Tell the West Nile story [actually, the Eastern Equine Encephalitis story], it's a good….
Jody: Which story?
Peter: "People are scared; of course people are scared."
Jody: You mean Richard Besser?
Peter: No, what's his name….
Jody: Oh, okay – Jeffrey Engel. He's now the head of [the Council of State and Territorial Epidemiologists]. He was the state epidemiologist of North Carolina during West Nile Virus. [We remembered this wrong; we have accurate quotes from Engel validating people's fear of both SARS and Eastern Equine Encephalitis, both in 2003, in our column on "Fear of Fear."]
Some reporters were saying to him, "How come you're having all these pressers about [Eastern Equine Encephalitis]? Aren't you worried about scaring people?" And he said, "Look, this is a very scary thing. This is a mosquito that can kill. Of course people are scared." And the public in North Carolina did not freak out. They ran out and bought all the insect repellant they could. And all the Walgreens in North Carolina sold out of insect repellent. He generated preparedness, not panic.
Peter: Telling people they are idiots to be frightened, telling people that they are panicking, that they are hysterical, that they are irrational – all of those things leave them alone with their fear, and that exacerbates their fear.
Jody: If you're the person telling them they're idiots, you're not the person who can guide them through this problem.
Peter: Yeah, you can't guide them through it, you've left them alone with the fear, and that makes the fear both stronger and less usable. The value of fear is that it can be harnessed to motivate precautions. But if the people who know what precautions you ought to take are busy being contemptuous of your fear, then they lose their ability to guide you through the fear and advise you on the precautions.
A big piece of the proper response, when people are frightened, when people are going through an adjustment reaction, is to ally with that adjustment reaction, to tell them it's understandable and appropriate and right that they are frightened, that you're a little scared too, and we will get through this together. "We will get through this together" is a much better message in a crisis than "Calm down, you idiot" – which is all too often the message officials use.
So when [domestic Zika outbreaks] happen, try to be one of the very few reporters who put that in context instead of [writing] a story that misunderstands it.
Most reporters miss the Zika messaging shift
Jody: Elizabeth, two medical reporters have written the story about Zika and the exaggeration [coming from] the White House. Both of those reporters were not in the mainstream [mass] press. One was in Science News. That was Jon Cohen. And the other day, Dennis Thompson from Health Day wrote the same thing. They got lots of experts saying, "No, those maps are wrong, Zika's not going to be big in the continental United States, people are exaggerating it" [13].
Both of those were not in the mainstream [mass] media, and the mainstream media did not pick it up. Those are the only two reporters we have found. Jon Cohen in Science is an extremely reputable reporter. This is a story that is not being told.
Peter: And even those two reporters did not get that the White House had hijacked the [CDC] messaging. The political angle was not in either of their stories. They got that the messaging was wrong. [Elizabeth notes that they probably couldn't cover the political "hijacking" angle because they couldn't get sources to talk about it.] Yeah, well they could have called us. [Laughs.] Yes, I agree, you need a source to say it. Now you've got one. [Elizabeth says she means a White House source.]
Well, they're not going to get anyone in the White House to say, "We're doing this for political reasons." All the White House is going to say is, "This is horribly scary, and Congress is being irresponsible." But if you look at the statements coming out of the White House [3, 5, 6], and then you look at the statements coming out of the CDC and NIH [1, 7, 9, 10], particularly back in January and February, but even now, you will see the gap between those statements. You will see that the White House is predicting something that the CDC and NIH are not predicting. [We should have added that CDC and NIH officials are not challenging the alarmist White House messaging; they usually try to stick to their less alarmist scenarios, but phrased in a way that mostly goes unnoticed and doesn't undermine the White House message [12].]
You're not going to find anyone in the White House to say, "Well, yeah, of course we're doing that, we want to win the election in November." But I think that's a reasonable conclusion to draw [14]. If you don't want to quote us, you probably won't find anyone else to say it.
Jody: We're happy to have you quote us on that, because it's what we really truly believe. [Pause, then three-way laughter. Then Elizabeth notes that she'd prefer to get other sources saying it too.] Look at the sources in Jon Cohen's story and Dennis Thompson's story, and see if any of them are people you might like to ask questions of. I'll send you their stories.
Zika messaging in New York City
[Elizabeth then raises the issue of how New York City is communicating about Zika, since we live there. She asks if we've seen all the messages posted in the subway, on the sides of garbage trucks, etc.]
Jody: I've been taking pictures of those, before we left for Europe. Those [posters] are pretty straightforward, I think. What about you? [Elizabeth agrees. She asks how we would characterize New York City's Zika communication.] I will send you a picture of Mayor DeBlasio and Health Commissioner Mary Bassett holding up bug spray at a press conference where Mayor DeBlasio said, "We are going to take every possible precaution, for every possible scenario, no matter how unlikely, that Zika is going to cause a problem in New York City."
[Elizabeth wants to know what we think of DeBlasio's statement.] I think it's an outrageously hilarious and exaggerated and alarmist statement. I used the picture of him and Mary Bassett with that quote at a WHO meeting a few weeks ago, saying, "Look, even in New York City they are acting as if Zika is going to be this horrendous catastrophe." You don't say you're going to take "every possible precaution for every scenario, no matter how unlikely." This is the city that didn't want to quarantine people for Ebola.
Peter: Jody, I think you are conflating two things.
Jody: Okay, Peter will sort this out!
Peter: Let me sort this out. The worst sin is what the White House is doing, which is pretending that Ebola [Peter meant "Zika"] is going to be widespread throughout the United States.
Jody: Widespread and horrible.
Peter: I'm sorry, I meant Zika. That's unforgiveable, in our judgment. The White House is doing it on purpose, and lots of public health agencies are doing it because they haven't climbed the learning curve themselves and they are not thinking it through on their own. That's horrible.
What New York City is doing is different from that. New York City is saying, "One of the mosquitoes that is chiefly responsible for Zika we've never had, and the other one which seems to be probably capable of transmitting Zika but less effectively, we do have, but we've never had any dengue to speak of, and we didn't have chikungunya so far. Our best guess is that this is not going to hit New York at all, and almost certainly isn't going to hit New York hard" [11]. They are saying all of that, and that's to their credit. That's real different from what the White House is saying.
And then they go on – and here I agree with Jody – to say, "But even so, we're gonna spend $21 million of New York City taxpayer money taking additional precautions. And we're gonna do X, and we're gonna do Y, and we're gonna do Z. And we urge you to make sure, if you've got a stoop or a yard, make sure there's no place where the mosquitoes can breed. And use a lot of mosquito repellant, and make sure the screens are repaired."
The two messages are not married very well. One message is: "We're probably not going to have a big problem here in New York." And the other message is: "But we're going to act as if we think we are." We think the second message is getting too much attention. But the first message is there, which makes it enormously better than what the White House is doing.
Jody: DeBlasio is saying, "Even though the most likely case is that it will be a small problem, if any, the worst case is so bad that we're going to really work hard to reduce the odds."
Peter: And I think you could defend that, much more than you could defend what the White House is saying.
Jody: But nobody takes every possible precaution for every scenario, no matter how unlikely. You always decide you're not going to prepare for every possible Category 6 hurricane. I know there's only 5 categories. You sometimes say, "It's reasonable to prepare for Category 4, but it's not reasonable to completely prepare for Category 5. I think [the Mayor] is reacting to Hurricane Sandy, he's reacting to some of his approval rating issues, and he's reacting to the battle between the White House and the Republicans. And that's what I think Mayor DeBlasio is doing in New York.
Peter: I see it a little bit more charitably. Politicians endlessly say we're going to take every possible precaution. And risk experts know that if you're taking every possible precaution – well, first of all, they know it is not possible to take every possible precaution. But if you are coming even close to taking every possible precaution, you're taking too damn many precautions – because some of them are very expensive and only help a teeny tiny bit, and it's not good management to take all the possible precautions. The statement "We're taking every possible precaution" is always a dumb thing to say. But it's such a common thing to say that I don't want to damn it the way we're damning what the White House is saying. Does that make sense? [Elizabeth says yes.]
Jody: Let me give you a fun datum. There have been hundreds and hundreds of travelers who have returned to New York City and New York State in recent years with either dengue or chikungunya. One returning traveler infected one person [via a mosquito] in Suffolk County [NY] with dengue. That's it.
Peter: Well, as far as we know. That's the only one that has come to the attention of the public health people.
Jody: One case, transferred to one person, in all the recent years of dengue travelers and chikungunya travelers coming in [to New York].
Most domestic Zika precautions make sense even if the alarmist messaging doesn't
Peter: In spite of all of that, if I were running the CDC, I would certainly want to beef up my ability to surveil for Zika outbreaks in humans. I would want to have a SWAT team – the term "SWAT team" has never been more appropriate than when you're talking about mosquitoes. I would want to have a SWAT team that could swoop in and eradicate mosquitoes anywhere where there was a human Zika outbreak. I would not be spending a lot of money on killing mosquitoes in places where there isn't any Zika. Because if there's going to be Zika in three or four places, and you're killing mosquitoes in three or four thousand places, then the vast majority of your effort is wasted as far as Zika is concerned.
So mosquito control is not a good way to fight Zika…. [This is overstated; see "Interim CDC Recommendations for Zika Vector Control in the Continental United States."]
Jody: Except where there are Zika cases. Mosquitoes that carry Zika are the kinds of mosquitoes that don't fly more than a couple hundred yards. So the other idea that the White House has promoted is the idea of the "Migrating Mosquitoes," traveling across the United States bringing Zika. The mosquitoes don't travel, except like in [used] tires or in freight cars or stuff like that.
The fact is, you can do mosquito eradication around a Zika case, and that's what they have mostly done with the dengue outbreaks. It's mostly that after you know you have a human case, then you swoop in, try to find the people's contacts, see if some of the people who live in the same place are also infected, and kill the hell out of all the mosquitoes in a radius around that person's house or work.
So that's mostly what they need to be ready to do, and that takes a lot of preparedness. They should be doing that preparedness. And they should be focusing that preparedness on the places most likely to have Zika, and have SWAT teams ready to go into other places that are less prepared when it happens.
Peter: This is something it took me awhile to understand. The Aedes mosquito travels practically not at all. It is not even a neighborhood mosquito, its [radius is] a couple of blocks. So the idea is that you find [human] Zika cases, and deal with mosquitoes where there are human Zika cases. My immediate reaction was, "Well, isn't that locking the barn door after the horses escape?" And the answer is, "No it isn't." That turns out to be much more sensible than killing mosquitoes where there aren't any Zika cases.
Jody: All over Texas, all over Florida, all over Mississippi (laughs).
Peter: So lots of things that CDC and NIH are doing – research on a vaccine; research on a better test that doesn't cross-react with dengue; better surveillance, so you find the Zika outbreaks more quickly; certainly research to understand what kinds of birth defects result how often from getting bitten by a Zika-infected mosquito in which term of your pregnancy – there are lots of important questions that need to be answered. The research is worth doing, the SWAT team is worth doing, lots of what they want to do is worth doing. Except for widespread mosquito control where there isn't any Zika, which strikes us as pork. Everybody can use a [new mosquito-fogging] truck. All the evidence we've read suggests that doesn't make much sense. But except for that, everything they want to do makes sense. It's what they are saying about what's likely that doesn't make sense.
Examples of pre-April "limited local outbreaks" messaging
1. On February 3, we extracted and paraphrased what looked to us like CDC's five key messages about Zika as of January 2016. Here is how we summarized CDC statements about the most likely scenario for Zika transmission in the continental U.S.:
We hope and expect that local transmission will not become widespread because the U.S. has better mosquito control and living conditions (screened windows, air conditioning) than most of Latin America. In the past, imported dengue cases have caused only small, brief local outbreaks.
Example One: On January 15, CDC's Dr. Lyle Petersen talked about the "most likely" scenario, but appropriately cautioned that it was important to prepare for something worse:
We're not able to predict how much Zika virus will spread in the United States. Many areas of the United States have mosquitoes that can become infected with and transmit Zika virus. However, recent chikungunya and dengue outbreaks in the United States suggest that Zika outbreaks in the U.S. mainland may be relatively small and focal….
Because of this uncertainty, however, it is important that we maintain and improve our ability to identify and test for Zika and other mosquito-borne diseases.
Example Two: A January 28 Washington Post article paraphrased NIAID Director Tony Fauci as follows:
Fauci is playing down the potential for a significant eruption of Zika here. He notes that dengue and chikungunya, diseases transmitted by the same kinds of mosquitoes, are widespread in Latin America. But their foothold in the United States has been controlled, with only small clusters of cases.
Example Three: CDC's Dr. Anne Schuchat's February 24 congressional testimony laid out the most likely scenario versus more severe ones:
The most recent data available suggest that Aedes aegypti are found in 13 states and Aedes albopictus are found in 31 states and the District of Columbia. Recent chikungunya and dengue clusters in the United States suggest that Zika outbreaks in the U.S. mainland may be relatively small and localized due to protective factors like window screens and less dense living conditions; however, any local outbreaks will be of deep concern to the people living there, and we must be prepared for different scenarios including more extensive transmission risk.
This was all superb anticipatory guidance – telling people what to expect.
But starting on April 1, that CDC and NIAID key message was drastically overshadowed by a different key message from the White House, making a much more severe scenario sound like the most likely scenario.
2. As late as March 16, before the White House hijacked the CDC's message, here is how a Zika Q&A in Vox described the most likely Zika scenario in the continental U.S.:
Will Zika spread in the United States?
Officials are predicting that Zika is likely to follow the same pattern as dengue fever in the United States….
Outbreaks here are expected to be small and local.
Examples of April alarmist messaging
3. At the April 1 ZAP Summit news conference, Deputy Homeland Security Advisor Amy Pope said:
If we wait until the public is panicking because babies are being born with birth defects, we have waited too long.
She also said that "we cannot wait until we see widespread transmission in the United States before taking steps to prepare. It's just too late at that point."
4. At the April 1 ZAP Summit news conference, March of Dimes Medical Director Ed McCabe said:
We have the opportunities to slow the spread of Zika into the United States over the next few months. If we're successful, we could save dozens or even hundreds of infants from being born with devastating birth defects. We must act now.
He also said: "We have a few short months to stop Zika from gaining a foothold in the U.S. If we don't the consequences will be dire."
5. Some of the most strenuous and consistent assertions of alarmist Zika messaging have come from White House Press Secretary Josh Earnest, who has also worked hard to link Zika alarmism to Republican resistance to the President's Zika funding request. On April 6, for example, Earnest said:
There's no reason that Democrats and Republicans should disagree about the need to protect the American people from an impending epidemic that has serious consequences for pregnant women in this country….
Mark my words, at some point – and I don't know when it's going to be – at some point later this spring, maybe later this summer, all of you and your news organizations are going to be sounding the alarm about the significant threat that is posed by the Zika virus. That is going to happen….
We have an opportunity to get out ahead of this disease…. [T]he sense is not that we can prevent it entirely, but we can begin to take steps right now before the disease is widespread in the United States that can prevent it from having the worst possible impact on our public health….
[Appropriating $1.9 billion] is going to seem pretty common sense if and when we reach the scenario where there is genuine public panic about the spread of this disease. And again, I take no joy in suggesting that Republicans are going to look back on this time that they've had to act on the Zika virus and deeply regret it….
[W]e do anticipate that the mosquito that carries this virus, or is capable of carrying this virus, is likely to be more widespread in the United States than previously thought.
Note that Earnest's references to an "impending epidemic" and the expectation that Zika would be "widespread" all referred to the continental United States. The epidemic was already well underway and the disease widespread in Puerto Rico and Latin America.
6. A White House official, Shaun Donovan, director of the Office of Management and Budget, said on April 7: "We should not play with fire here. We should not risk the outbreak spreading and getting out of control."
Even in April (and after), CDC and NIAID stick to their earlier messaging
7. An April 7 interview with NIAID Director Tony Fauci in The Hill included the following:
U.S. health officials have said that a widespread outbreak is unlikely, given their experience with other mosquito-borne viruses like dengue, that have been limited to small caseloads in places like Florida and Texas.
"We still feel that that is the very likely scenario," Fauci said in the interview Thursday.
But he cautioned that "Zika seems to continue to surprise us a bit," leaving open the possibility it could be more widespread than dengue.
8. At an April 11 White House news conference, CDC's Dr. Anne Schuchat said:
[E]verything we look at with this virus seems to be a bit scarier than we initially thought. And so while we absolutely hope we don't see widespread local transmission in the continental U.S., we need the states to be ready for that.
Dr. Schuchat has been pretty consistently clear about "most likely" scenarios versus more severe and/or more widespread "worse case" scenarios. (The literal worst case is too extreme and too unlikely for anyone to discuss seriously.) In her statement above, she was talking about a worse case scenario, not the most likely scenario. But since April 1, despite CDC and NIAID officials continuing to be quietly clear about the most likely scenario, virtually all state and local public health officials, politicians (both Democrats and Republicans) and reporters – with a few exceptions – have talked about worse case scenarios as if they were the most likely scenario.
Dr. Schuchat's acknowledgment that Zika "seems to be a bit scarier than we initially thought" was misperceived by most reporters covering the White House news conference to mean that CDC was now seeing worse case scenarios as likely. This link gives a good feel for how reporters covered Dr. Schuchat's "a bit scarier" statement.
9. At an April 11 White House news conference, CDC's Dr. Anne Schuchat said that "there could be hundreds of thousands of cases of Zika virus in Puerto Rico, and perhaps hundreds of affected babies."
A reporter then asked, "Do you have a prediction or a range of how many you expect in the United States broadly?" Dr. Schuchat answered:
In the continental U.S., […] we have seen travel-associated cases of chikungunya and dengue. We haven't seen large numbers, we haven't seen thousands of cases of locally transmitted disease from the mosquitoes. We've seen dozens of cases. But we absolutely need to be ready….
So I don't expect there to be large outbreaks in the continental U.S. I can't give a number to how many cases, but I can say that we can't assume we're not going to have a big problem. We know with other viruses we've had bigger problems than we expected, so we're taking this very seriously."
10. On April 17, NIAID Director Tony Fauci was interviewed by Chris Wallace on Fox News. Wallace asked about the new CDC map showing widespread potential distribution of Aedes aegypti mosquitoes. As you read the exchange that followed, keep in mind that Dr. Fauci was referring to all potential Zika cases, not just cases in pregnant women. About two percent of the U.S. population is pregnant at any time.
- Fauci:
- Well, it is likely we will have what's called a local outbreak. Right now we have, in the continental USA, we have over 350 imported cases, namely people who have traveled to a region, gotten infected and come – came back. The concern is, once one comes back, would a mosquito, which you saw on that map, bite someone and then locally transmit it to someone who's never left the country? It would not be surprising at all, if not likely, that we're going to see a bit of that because we've seen similar types of things with other similar types of infection, like dengue. We've been able to control it so that it doesn't become sustained or widespread. But the threat of at least having some local outbreak is – is – is likely, I would think. It's up to us now to make sure when it happens we contain it.
- Wallace:
- Now, you've used a couple of words in that answer that – that – that struck me. A bit of an outbreak. Local outbreak.
- Fauci:
- Right.
- Wallace:
- So are we talking about hundreds of cases?
- Fauci:
- Yes.
- Wallace:
- Are we talking about thousands of cases?
- Fauci:
- No….
- Wallace:
- And – and – and also, is there a threat – because I read somewhere this week that there can also potentially be a threat of brain damage to adults.
- Fauci:
- Right. Exactly. So there are a couple of issues you brought up that are important. When we say local, we talk not about thousands of cases, we're talking about scores of cases, dozens of cases at the most that historically with dengue were able to be contained.
11. On May 30, New York City Health Commissioner Mary Bassett was quoted in the New York Times as follows:
"We're optimistic that we won't see Zika transmission in New York City," the city's health commissioner, Dr. Mary T. Bassett, said in an interview, "but we have the potential for it, so we are taking very seriously the potential risk and seeking to reduce it."
Competing Zika scenarios and mental models
12. Since early April, two very different predictions of the likeliest Zika scenario in the continental U.S. have competed: The CDC/NIAID scenario of small, local outbreaks and the White House scenario of widespread, catastrophic outbreaks. The White House scenario has usually won.
Undoubtedly, some experts and local public health officials simply believe that a domestic Zika catastrophe is a likely scenario. Peter Hotez, for example, is dean of the National School of Tropical Medicine at Baylor College of Medicine and a noted Zika alarmist. His April 8 New York Times op-ed entitled "Zika is coming" begins this way:
If I were a pregnant woman living on the Gulf Coast or in Florida, in an impoverished neighborhood in a city like Houston, New Orleans, Miami, Biloxi, Miss., or Mobile, Ala., I would be nervous right now. If mosquitoes carrying the Zika virus reach the United States later this spring or summer, these are the major urban areas where the sickness will spread.
Other experts and local public health officials may be influenced by their understandable budgetary interests; an alarmist view of Zika may help them secure a much-needed federal appropriation.
But for those who know less about Zika – many local public health officials and the vast majority of journalists – we think something quite different is going on. By the time they started paying close attention to Zika in early April, the White House scenario was dominant, overshadowing the less alarmist CDC/NIAID scenario. So the White House scenario determined their "mental models" of what's likely in the months to come.
The crucial thing about a mental model is that it constitutes both a lens and a set of blinders. Information that's inconsistent with your mental model tends to be misperceived or ignored.
This helps explain why so many reporters could quote an alarmist expert like Hotez without feeling obliged to balance his alarmism with something along the lines of "on the other hand, CDC says…." We suspect most of the reporters quoting Hotez didn't realize that the CDC's likeliest Zika scenario was quite different from his. What Hotez was saying was congruent with what the White House was saying. It was congruent with the reporters' mental models. So they didn't understand that it needed balancing.
Similarly, even when reporters run across a comment from CDC or NIAID suggesting that domestic Zika outbreaks will probably be limited, they may well not notice. Sometimes we have read news stories in which such a comment is actually quoted, deep down in the story, with no evidence that the reporter realized the quote conflicted with the more alarmist lede angle that dominated the story. This is a pristine example of a mental model being so strong that contradictory information is reinterpreted as not contradictory.
Here is an example of mental models at work in a reporter's single long paragraph. In a May 18 article entitled "Republicans Really Need to Stop Withholding Zika Funding," Slate writer Nora Caplan-Bricker wrote:
To recap briefly: In April, the CDC told the public that Zika is "scarier than we initially thought." As of last month, 570 people in Puerto Rico, including 48 pregnant women, had contracted the disease, and doctors along the Gulf Coast – the part of the U.S. likely to be affected first – were advising pregnant and would-be pregnant women to take extra precautions. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has said he expects limited outbreaks in the U.S. this summer – a prospect made more worrisome by the wildly uneven resources and level of preparation for fighting Zika at the local level. As Peter Hotez, dean of the National School of Tropical Medicine at the Baylor College of Medicine, wrote recently in the New York Times: "If I were a pregnant woman living on the Gulf Coast or in Florida, in an impoverished neighborhood in a city like Houston; New Orleans; Miami; Biloxi, Mississippi; or Mobile, Alabama, I would be nervous right now."
Note how CDC's and NIAID's messages are reinterpreted as congruent with even Peter Hotez's very alarming messages. Anne Schuchat's "a bit scarier" becomes simply "scarier." Even Tony Fauci's "limited outbreaks" are integrated into the author's "worrisome" gestalt. That's how mental models work.
Changing somebody's mental model is always difficult. It is nearly impossible unless you explicitly (but empathically) point to the gap between what you're saying and what your audience is probably thinking. Once the White House scenario was established in reporters' minds, in other words, a CDC or NIAID official who wanted to "sell" the limited outbreaks scenario would have had to say, in so many words, "This is quite different from the impression you may have gotten from recent White House statements."
Not surprisingly, nobody at CDC or NIAID was or is prepared to say that. So they get to tell the truth as they see it, quietly but repeatedly, without upsetting the White House's political messaging applecart.
We do not see CDC and NIAID as willing to lie to support the White House. But we do see them as understandably unwilling to contradict the White House explicitly. This has resulted in what we consider a serious risk communication problem: CDC and NIAID have failed to teach the public the difference between the most likely domestic Zika scenario and the worse case domestic Zika scenario promulgated by the White House.
CDC communicators have an acronym they often use internally when talking about the purpose of a particular announcement or interview. They talk about their "SOCO" their Single Overriding Communication Objective. After the White House hijacked the CDC's SOCO vis-à-vis Zika risk in the continental United States in early April, we coined a new term to describe CDC and NIAID efforts to keep mentioning "limited local outbreaks" without undermining the new White House SOCO about the "impending epidemic." CDC's and NIAID's SOCO, we said to each other, had become their VITA: their Virtually Invisible Truth Acknowledgment.
Two things made the VITA virtually invisible. First, the White House SOCO quickly came to dominate the mental models of most journalists and lower-level public health officials, who then seldom noticed that CDC and NIAID were saying something different. And second, CDC and NIAID never explicitly pointed to the discrepancy, but just kept reiterating their original SOCO about the most likely Zika scenario.
But as we began drafting these endnotes in mid-June, we noticed what may be the start of a shift back to the earlier CDC/NIAID SOCO. More news stories in the past week than in the preceding two months have emphasized that the likeliest Zika scenario in the continental U.S. is limited local outbreaks. Two developments seem to be facilitating this shift, both orchestrated by CDC:
Another "new" map.
On June 9, CDC researchers released yet another map showing the range of Aedes mosquitoes. But instead of showing where environmental conditions permit Aedes to survive, this one showed – county-by-county – where Aedes had actually been found in the past decade, once, twice, or more than twice. That map looks a lot emptier and less scary, and it got through to at least a few mainstream reporters. (By the way, this newest "new" map closely resembles a CDC Aedes county-by-county map from about 2013 that was removed from the CDC website at some point prior to April 1.)
A June 13 NPR story entitled "Here's Really Where Zika Mosquitoes Are Likely In The U.S.," for example, treated the White House alarmist message as the "old" message and noted that the news from CDC was good. And a similar June 14 Weather Channel story that cited the NPR story was entitled "Will Zika Mosquitoes Come To Your Town? New CDC Map Shows Likelihood." It stated explicitly that the "old" mental model (the White House SOCO) was now out of date, thanks to the "new" CDC map:
While the Zika virus has proven it can spread rapidly in countries near the equator, the risk of contracting Zika in the United States may be lower than previously thought, according to a new map released by the Centers for Disease Control and Prevention.
The words "may be lower than previously thought" are strong evidence that the White House SOCO had become the dominant mental model … and that it might be slipping.
Detailed local guidelines.
On June 10, CDC followed up on its ZAP Summit by hosting a "National Call to Introduce the CDC Zika Response Plan for Contiguous US and Hawaii – For State Health Officials." The plan, publicly released a few days later, provides guidelines for responding to "the first locally acquired cases of Zika virus infection in the continental United States and Hawaii."
The June 14 guidance document (largely identical to an earlier one issued in April) emphasizes surveilling for small local human Zika outbreaks and focusing mosquito control efforts in the immediate vicinity of the outbreaks. The guidelines do not emphasize trying to prevent outbreaks by broad-based preemptive killing of mosquitoes, and pay little attention to the more apocalyptic scenarios coming from White House spokespeople and many local officials.
Media coverage of these two news pegs – the conference call and the response plan – had the same focus. We didn't see a lot of stories explicitly saying the White House got it wrong. But at last we saw a spate of stories that got it right, in terms of CDC's "most likely" Zika scenario in the continental United States.
It's way too early to say that the CDC SOCO is back and the White House SOCO is in retreat. We're still seeing plenty of alarmist stories about how summer 2016 will bring disaster to the continental U.S. and Republicans are to blame. But we're seeing more stories than we've seen since March that matter-of-factly say the likely domestic Zika scenario is limited local outbreaks.
13. The story of Zika maps is too complicated for us to do justice to in an endnote – even a long endnote – but we can't resist telling at least part of the story.
On April 1, CDC published new maps showing the estimated "potential range" of the two mosquito species thought to be capable of transmitting Zika – that is, the parts of the U.S. with a climate capable of supporting those two species. As we have already noted, this is a much wider range than the places where the two species are established and often encountered.
So the maps were factually accurate (as far as we know) but easily misused to spread alarm. To be informative rather than misleading, the maps would have needed to clarify three points:
- That the two species of mosquitoes are not actually known to be present, currently or historically, everywhere within their "potential range."
- That Zika-infected mosquitoes are not known to be present yet anywhere in the continental United States, and aren't expected to be present ever in most of the places within the mosquitoes' range.
- That other diseases carried by the same species, dengue and chikungunya, have never been observed in most of the places within the mosquitoes' range.
- Maybe White House officials are genuinely more worried about domestic Zika than CDC and NIAID officials.
- Maybe White House officials believe that overstating the short-term domestic Zika risk is the best way to secure funding for longer-term priorities like vaccine development and non-domestic priorities like aid to Latin America.
- Maybe White House officials believe the U.S. public is insufficiently concerned about Zika, and are seeking to ramp up public concern with exaggerated warnings. Maybe they've stopped worrying about Zika panic and started worrying about Zika apathy.
- Maybe White House officials are worried that the public will hold them responsible for any domestic Zika tragedies that materialize on their watch, and are seeking to build a record of concern to protect themselves (and Democrats in November) from being blamed.
- The administration has been consistently hostile to offsets – both to the specific offset (unspent Ebola money) that Republicans put forward and to the generic idea of finding some less urgent priority than Zika to cut back or postpone in order to free up Zika money. Even when the administration finally repurposed existing budgets – which it did in two tranches – it continued to insist that "robbing Peter to pay Paul" was unwise and that Congress must replenish every penny of the depleted budgets. Somehow the administration has managed to convince nearly everyone in public health and the media that it is unconscionable for Congress to let Zika go inadequately funded rather than add to the national debt by passing a supplemental appropriation, but perfectly appropriate for the administration itself to let Zika go inadequately funded rather than spend less on something – anything – else.
- When Republicans in the House of Representatives complained that the White House Zika funding request was insufficiently detailed, the White House and congressional Democrats had only snarky responses, and (according to Republicans) refused to submit additional written details. We take no position on whether there were or were not legitimate unanswered questions in the original request. But when the people who control the purse strings ask follow-up questions, the logical response if you want the money is to swallow your irritation and provide answers.
- Similarly, Democrats in Congress have turned up their noses at Republican compromise offers. Consider for example this April 27 comment from New York Representative Nita Lowey about the $1.1 billion compromise bill the Senate passed, as quoted in The Hill:
House Democrats plan to reject a bipartisan effort by Senate leaders to boost emergency funding for the Zika virus because it falls short of President Obama's request, a top lawmaker said Wednesday.
Rep. Nita Lowey (D-N.Y.), the top Democrat on the House Appropriations Committee, said Congress has an "absolute responsibility" to approve the $1.9 billion requested by the administration in February.
"I think the $1.1 billion is not realistic, and it's not in play, and we're not discussing it on the House side," Lowey told The Hill on Wednesday. "We're convinced it needs to be $1.9 [billion]."
Despite their own reluctance to compromise, for months the White House (especially Press Secretary Josh Earnest) and Democratic leaders in Congress have been explicitly contemptuous of what they represented as Republican intransigence. On June 8, for example, Roll Call reported: "This is the fight of the month," said Sen. Amy Klobuchar, D-Minn. "It sure better get done in this work period. What, are they going to go home for six weeks and not have any funding done for Zika as we go into these summer months? That would be atrocious." The same day, The Hill published an article entitled "Dems zing House GOP over Zika funding," which began:
Senate Democrats knocked Republicans Wednesday over lack of progress in funding a fight against the Zika virus.
"They are bringing a watering can to a house fire," Sen. Patty Murray (D-Wash.) told reporters.
Whether or not the contempt is sincere, and even whether or not it's justified, surely it isn't the optimal way to get quicker action on a bigger appropriation.
Even in states like Texas and Florida, where the Zika risk is greater than elsewhere in the continental U.S., there is very little pressure on state and local governments to pony up. Florida in particular has a sizable unspent rainy day fund. Nonetheless, Florida politicians of both parties keep urging Congress to act, not their own state legislature. Similarly, public health experts have written countless op-eds accusing Congress of being irresponsible, and no similar commentaries that we can find suggesting that anyone else might have to spend a lot of money on Zika. We accept that Congressional appropriation of "new money" (that is, increased indebtedness) is the first choice of all these op-ed authors. But as they all point out, it has been four months and counting, and Congress can't agree on a bill. What does it mean that their second choice is to leave Zika preparedness and response insufficiently funded?
As published by the CDC, the text accompanying the new maps at least implied the first of these three points. Readers who wished to avoid being over-alarmed by the maps needed to study the two detailed captions and especially this all-important sentence, buried at the end of a footnote: "Maps are not meant to represent risk for spread of disease."
Not surprisingly, most reporters interpreted the maps through the lens of their mental models, seeing them as scary new information. They told their readers and viewers as much. And in the interests of simplification – guilelessly, we suspect, in most cases – many newspapers, magazines, broadcast stations, and blogs displayed the maps without some or all of their accompanying text (two long captions and a footnote). And some gave the maps new titles explicitly stating what the maps (absent their accompanying text) had misleadingly implied: that this was the highly likely range of "Zika-carrying mosquitoes" across a wide swath of the continental United States in the summer of 2016.
On May 5, we sent CDC an email asking whether it agreed that the maps had been "widely used in misleading ways" and, if so, what it planned to do to "reduce this misuse of the maps." We didn't get an answer.
For a similar story about a different map, see Jon Cohen's May 13 article in Science, "Yes, Zika will soon spread in the United States. But it won't be a disaster."
Is the White House alarmist messaging politically motivated?
14. We have no "smoking gun" that proves the White House and the Democrats in Congress have seized on Zika funding as a political weapon, preferring the fight to the money and setting up Republicans to be blamed for whatever harm Zika does to Americans.
That probably explains why Elizabeth Whitman showed no interest in publishing our hypothesis.
There could be other reasons for the White House to adopt a more alarmist take on Zika than CDC and NIAID.
We don't have conclusive evidence for our hypothesis that the White House wants the fight with the Republicans more than it wants the money. (CDC and NIAID certainly want the money more than the fight!) But we think we can build at least a prima facie case. Here are a few points we find persuasive:
Copyright © 2016 by Jody Lanard and Peter M. Sandman


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US Open golf: Why do Merion pins have wicker baskets?June 11, 2013 Golf News
Ever wondered why Merion uses wicker baskets instead of flags?
One of the most frequently-asked questions you will hear this week is: 'why are Merion's pins topped with baskets instead of flags?'
The short answer? Nobody knows. There are some theories, though.
One of the most widely believed is that designer Hugh Irvine Wilson, a Scottish immigrant, liked the look of the baskets on the staffs of shepherds, used for keeping lunch out of reach of wildlife.
Another is that baskets were used on many UK courses in the early 1900s and that Merion is merely the last one upholding the tradition.
Some even say that Wilson had nothing to do with the inclusion of them as they were first spotted in 1915 – three years after the course opened.
Whatever the origin, the baskets on Merion's East Course, which are red on the front nine and orange on the back, present a unique problem: they are clearly visible from all angles, but give no indication of wind strength or direction.
Joe LaCava – caddy for Tiger Woods – was quizzed by USA Today on the difficulty this could present: "It's obviously different. It will be fun. But as a caddie, I won't say it's more difficult but we do use the flags to determine where the wind is up around the greens. It's a hindrance but I think it's neat and cool.
"We'll have to use the trees a little bit more, the wind charts, throwing up a lot of grass. We'll do a lot of things, but at the same time I like to think we'll get it figured out."

subset: commoncrawl


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Home » Themes » Technology » Industry
Paddle Steamer Mary Anne Print Page
Mary Ann Reserve, was named to honour the first Paddle Steamer on the river Murray. There are monuments in the reserve commemorating the paddle steamer.
William Randell was born in England in 1824 and travelled to South Australia with his parents in 1837. By the 1840s his father had established a steam driven flour mill at Gumeracha and held pastoral leases along the Murray River. William, as the eldest son, was often sent there to herd cattle. And there began his dream of creating a steam driven paddle boat to trade on the river. William wrote that he was seized with the determination that he would be the first man to put a steam boat on the river. When the news of gold discoveries along the Goulburn, a tributary of the Murray, reached William in 1852, he decided it was time for him to turn his dream into reality and build his steam driven paddle wheeler.
The "Mary Ann" was mostly built at Gumeracha by William Randell and his brothers, Francis (Frank). Thomas and Elliott and dragged by bullock train across country to Noa No Station owned by their father William Beavis Randell, 5 kms upstream from Mannum. There it was launched in 1852 and so commenced the River Boat era.
|River Lane, Mannum, 5238
|GPS Coordinates:
|Lat: -34.915772
Long: 139.311463
Note: GPS Coordinates are approximate.
|Monument Type:
|Monument Theme:


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Cannes is putting finishing touches to its famous film festival which opens Wednesday with a star-studded line-up of movies featuring Cate Blanchett, Matthew McConaughey, Colin Farrell and a new version of "Mad Max".
Plastic was protecting the red carpets and workmen were still hurriedly erecting the beachfront venues on Tuesday as the first onslaught of film fans, movie moguls and the press pack gathered on the French Riviera for the 68th edition of the world's top international cinema showcase.
Among the highlights over the 12-day event will be Woody Allen's latest, "Irrational Man", a new Pixar animation called "Inside Out", and Michael Fassbender risking the cursed role of Macbeth.
McConaughey is in with "The Sea of Trees", hoping to extend a successful run that has transformed him from romcom jock to serious thespian in the past couple of years, while Blanchett appears in "Carol", teaming up again with Todd Haynes, who directed her Oscar-nominated turn as Bob Dylan in "I'm Not There".
In one of the more bizarre entries in the official competition, Farrell and Rachel Weisz are appearing in "The Lobster", a dystopian tale in which hotel guests have 45 days to find a lover or face being turned into animals.
The other film guaranteed to create buzz is the unabashedly pornographic "Love" from director Gasper Noe, which is playing outside the official competition but promises to generate as much controversy as a graphic rape scene in his previous "Irreversible".
There were no public posters for "Love", but online versions showed either a three-way kiss or a particularly graphic moment of male excitement. There were, however, giant banners draped over the famed Carlton Hotel for "Mad Max: Fury Road" starring Tom Hardy and Charlize Theron, set for its worldwide roll-out at Cannes on Thursday.
- France, Italy lead pack -
France and Italy are leading the charge for the coveted Palme d'Or trophy, awarded on the last day of the festival on May 24 by a jury headed by the quirky, Oscar-winning siblings Joel and Ethan Coen.
Energised by a new generation of French female directors and an unexpected embrace of English by Italian filmmakers, the two countries have the strongest contingents in the official line-up.
France has five films in the Palme race, while Italy has three -- a remarkable show of strength in a field that counts just 19 movies from around the world.
- Sunny Riviera -
Under a blistering sun, the famed Croisette beachfront was filling up on Tuesday with agents shouting down mobile phones and some of the more avid fans already lining the road opposite the Palais du Festival.
"We're waiting for the big French stars -- Catherine Deneuve, Sophie Marceau. But I think the Americans are great, too," said Malika Hachani, from Nancy in eastern France, who had staked out a prime perch in front of the main entrance of the red carpet.
She sat with her friend, Nordine Yami. They have come for the past six years and built up a small community of film fanatics.
"There's a whole group of us who meet up here every year. We come from all over France. One comes from Tunisia even -- he's a surgeon," said Yami.
Cannes is more than just a film competition and a chance to see the stars. It is also the biggest platform for cinema industry professionals to meet each year, with financiers, creators and distributors coming from all over the world to strike deals or hawk their films.
Some 12,000 participants come from 116 countries, with over 5,000 films for sale. Some 960 films will be shown -- about 80 percent getting their public premiere at Cannes.
"It's dizzying because there's so much happening everywhere you look," said Michelle Carey, of the Melbourne International Film Festival. "You have to wear sneakers because you're constantly running all over the place."
GMT 09:53 2017 Saturday ,18 NovemberU.S. Ambassador Celebrates Global Entrepreneurship
GMT 08:39 2017 Saturday ,18 NovemberAdvisor to HRH Premier attends Palestinian embassy's celebration
GMT 18:40 2017 Friday ,17 NovemberAdvisor to HRH Premier attends Palestinian embassy's celebration
GMT 13:35 2017 Friday ,17 NovemberTurkey capital bans German gay film festival
GMT 08:33 2017 Friday ,17 NovemberArabian Nights with an English Twist at Sharjah International Book Fair
GMT 23:04 2017 Monday ,13 NovemberSharjah to host biggest national gathering to raise UAE flag
GMT 11:14 2017 Monday ,13 NovemberUAE Embassy in Washington supports "Arabian Sights" Film Festival
GMT 22:51 2017 Sunday ,12 NovemberDepartment of Culture and Tourism celebrates heritage


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On the Road to Great Charter Schools: State Policy Analysis 2016
NACSA's third annual analysis of state charter school policies across the nation, On the Road to Great Charter Schools, is now available.
Each state is scored against eight known best practices in state policy that ensure a consistent, high-performing charter sector.
Since 2012, more than half of the 44 states with charter schools have strengthened their laws by adopting one or more the report's eight recommended policies. However, the need to focus on good policy as a vehicle to ensure more children can attend a great charter school remains critical: One out of every three charter schools across the country operates in states with weak charter laws.Report Homepage
New Resource: State-by-State Authorizer Data and Policy Analysis
Complete State Policy Agenda
These recommended policy provisions are based on NACSA's Principles & Standards for Quality Charter School Authorizing are based on NACSA's Principles & Standards for Quality Charter School Authorizing, developed a decade ago and continually refined to keep pace with developments in the field. The Principles & Standards promote high academic standards, protect school-level flexibility, and safeguard the interests of students and the community.
View our State Policy Agenda View State-by-State Summaries View State Policy Resources


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KODO, Taiko Performing Arts Ensemble
KODO: "Dadan 2017"
35th Anniversary Season
Tamasaburo Bando, artistic director
A rare combination of supreme artistry, seamless choreography and physical endurance, the Kodo ensemble explores the limitless possibilities of the Japanese drum, the taiko. Since its debut at the Berlin Festival in 1981, the group has given over 5,800 performances in 49 countries on five continents. Allow yourself to be immersed in this mesmerizing 2,000-year old tradition — as old as Japan itself and as much a form of pure, physical athleticism as it is musical entertainment.
"Superlatives don't really exist to convey the primal power and bravura beauty of Kodo."
— Chicago Tribune
"Indeed, if there is such a thing as perfection in music, Kodo comes as near to it as any group in the world." — Boston Globe
Presented through support from DePauw University's Asian Studies Department.
Kodo also thanks Al Nippon Airways for its support of the "Dadan 2017" USA Tour / Kodo 35th Anniversary Production.
Learn more about Kodo and the art of taiko drumming at www.kodo.or.jp
General admission: $15 in advance, $20 day of event
Tickets for seniors, youth and all students are free.


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A WELSH vicar has been charged with child pornography offences.
The Church in Wales yesterday confirmed that the Rev Darryl Gibbs, of Heol-y-Plwyf, Ynysybwl, near Pontypridd, a former college chaplain in Carmarthenshire, had been charged on five counts by Dyfed-Powys Police.
A police spokesman said, "A 30-year-old man has been charged with three offences of possessing indecent images of children and two of making indecent images of children and will appear in Llanelli Magistrates' Court on Friday."
The vicar, who works for the diocese of St Davids, which covers the former Dyfed area, has been suspended by the Church from all clerical duties. He had been a Llanelli-based chaplain at Coleg Sir Gar (Carmarthenshire College) but was in the process of transferring to another post in the Llandaff diocese when he was arrested.
In a statement issued through the Church yesterday the Bishop of St Davids, Carl Cooper, said, "Clearly our initial thoughts and prayers at this time are with those associated with this case and with their families.
"During the coming weeks the diocesan authorities in St Davids will be doing all they can to support those individuals associated with the case and offering them pastoral assistance.
"Mr Gibbs has been suspended from all clerical duties pending the outcome of any additional investigations or court hearing and the Church in Wales is co-operating closely with the police in the conduct of their inquiries."


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Built to tackle the coldest conditions, the Piquet is a men's quilted jacket featuring a clever reversible construction.
This robustly warm baffle-quilted jacket is filled with a 350-gram high-loft wadding, which offers unbeatable warmth without excess weight. Stud fastenings close through to a cosy stand collar, while simple front pockets are perfect for keeping hands warm. The Piquet's reversible construction offers a choice of a plain outer or Barbour's signature Classic Tartan.


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joshua reid
You Are - Poem by joshua reid
an angel from heaven is what you are
in my sky you're definitely a heavenly star.
you're an angel with beauty and grace
you're so kind and sweet, with your angel's face.
you have a pair of angel's wings
happiness and joy are just some things,
that an angel can give
in my heart and mind is where you live.
i know you have lips as soft as the white clouds
they scream kiss me but not out loud.
your voice is like a sapphire that shine bright.
when everything is dark, they give me light.
you're an angel that teaches me the right things to say.
you're friendship i can never repay
you're my angel and i'll always care.
you're my angel and you know i'll always be there.
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text: Principal 2.0 Tweet This piece was originally posted on Powerful Learning Practice's Voices from the Learning Revolution blog. Visit Voices and be inspired! "The principalship is the kind of job where you're expected to be all things to all people." (Fullan, 2001) "Wanted: A miracle worker who can do more with less, pacify rival groups, endure… Read More


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MOVIE SYNOPSIS [ General Audiences ] Starred by Aunjanue Ellis (see full cast), this film directed by Russell Costanzo was premiered in TV or cinema in 2010. The feature film "The Tested" was produced in USA. You can watch The Tested online on TV cable or theaters with original audio in English at different dates. This film premiered in theaters in 2010.
Rating: 5 by 49 users./
Runtime: 100 minutes
Aunjanue Ellis, Armando Riesco, Michael Morris Jr., Frank Vincent, Annie Parisse, Nathan Corbett, Tobias Truvillion, Kristen Dowtin, Al Thompson, Antonio Edwards Suarez, Roderick Pannell, Charles Dumas, David Fonteno, Sheena Addison and Bobby Bank.
100-minute film (full movie) directed by Russell Costanzo.
The original audio of The Tested has dialogues in Dolby Digital, it was produced in USA.
It premiered in cinemas or television in 2010.
Screenplay written by Russell Costanzo.
Chris Scarafile.
Andrew Waranch, W. Michael Weinstein, O. Valerie Pratt, Eric Nyari, Melissa B. Miller-Costanzo, Craig Syracusa, Frank Vincent, Alex Corrado, Raymond K. Javdan, Jean-Raphael Ambron and Garrett P. Fennelly.
This film was produced and / or financed by Shoebox Pictures.
Composed by Michael Damon and Zachary Kamins.
Without commercial breaks, the full movie The Tested has a duration of 100 minutes; the official trailer can be watched in streaming on the Internet. You can watch this full movie free in EnglishDolby Digital in movie TV channels, renting the DVD or with VoD services (Video On Demand player, Hulu) and PPV (Pay Per View, Netflix).
See the page of this full movie, The Tested in FULLTV Movies.


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Yes, even if you do not have much knowledge about nutrition, you can participate in this course. It is possible that you may need a little extra time to go through all the information, but anyone with the pure intention of healing herself is eligible for this course. The fact that the course is online, will give you the benefit and freedom to choose how much time you need for each module. You will learn a lot. Guaranteed.
Yes, for sure. Whatever your background or interest in regards to nutrition, there is always room to deepen your knowledge. Hormones are very delicate, and to operate with nutrition for the purpose of harmonising the hormonal system, it requires an understanding for details. It is possible that you are merely missing a few essential links in your diet, that are necessary to balance your system.
In this course we will pay lots of attention to the entire system of glands in the body which control the communication of all the hormones. Hormones are very delicate and they therefore require delicate attention to re-balance.
Some women will start the course and seek more personalised information. Other women will skip the online course and directly contact me for a personalised report. This option is always available. In any case, I invite you to email me directly on email@example.com if you desire a more personalised approach. I will send you a nutrition questionnaire to get a good sense of where you are at. This personalised report will include detox information, herbal and supplement advice, information about your Ayurvedic dosha, and step-by-step guidance of how to implement the given information into your daily life.
The course is focussed on balancing and re-harmonizing your entire hormonal system and will therefore surely benefit you when you are pregnant or breastfeeding. Many women experience a hormonal imbalance during and after pregnancy. If this is you, please contact me via email@example.com and I will make sure you receive the additional information you need to work with the HHH protocol. Especially the information about herbal remedies and other supplements needs to be consulted with me before you proceed.
No. It does not matter if you have one, a few or many of the symptoms mentioned – when you are looking to balance your hormones, this is the course for you. I highly advice you take the "Hormone quiz" to get a deeper insight in your case. This will help you understand where the symptoms originate from in your system. You may reflect upon the answers from the Hormone Quiz by contacting me via email.
No, they are not included. Different women do the course for different reasons and will need a different combination of herbs and supplements to suite their needs. Women from all over the world are working with the Happy Healthy Hormones protocol – it is advisable to look for what is available locally or what is produced in your country or continent. I am always happy to answer your questions in regards to this subject.
The course is built inside the website. Once you register you can log into the website and the course will be there, available to you forever. It is a completely self-directed course that allows you to build effective and healthy practices into your everyday life for radically improved hormonal health and general wellbeing.
All in your inbox! This course is 100% virtual, confidential and intimate. You can start at any time and go at the pace that suits you. Plus you'll get access to the study materials forever. Meaning you can always return in the future to refresh your memory and see what needs adjusting in your habits. This course is packed with information – you can't absorb it all at once. Luckily it's always available at your fingertips.
You can send an email to firstname.lastname@example.com and explain what difficulties you are experiencing. It is best to make a print screen so that we have an understanding what is happening behind the screens. I will refer the issue to our technical team and have it fixed a.s.a.p.
My 100% Guarantee: I am so confident in my program and your success that I am offering you a 100% Satisfaction Guarantee. If you read all the materials and do all the assignments and you still are not happy with your progress, then email me within 10 days from the start of the program and I will fully refund you.
This is difficult to predict. There are so many factors that contribute to how much time you may need for each module. Some women prefer to study all the material on one day and implement it in the week that follows. Other women will read a little piece of information every day and take it slower. Both are great – different women want different things. One thing is for sure: the more time you take for yourself, the better. There is no rush in doing this – this is concerning your mental, emotional and physical wellbeing – so we better take care.
Some modules will include more reading material than other modules. This depends on the topic and what is necessary. Perhaps one of the modules is easier for you than some of the others (depending on your current lifestyle ad knowledge) – this will also indicate the amount of time you will need.
Healing from any condition takes time. Many factors play a rol in this healing process, such as: how severe are your symptoms? How long have you suffered from this imbalance? What attempts have you done before doing this course? Are you taking birth control or other medication? For some it can take weeks, for others it can take months. With this course your journey will begin, and it will take you through the foundational changes that are needed to fully re-balance your system.
It is exactly like getting into shape – you will need to walk before you run. This course will get the foundations of your hormones in balance, so that you can continue to build a healthy life from there on.
My name is Nalaya Chakana. My expertise and passions come from my life-experiences and personal self-healing journey. I have been a Holistic Female Health Coach for several years and have treated, helped and coached many women worldwide since then. I am a certified 'Holistic Health Coach' from the Institute for Integrative Nutrition, and also received my certificate of 'Women's Health & Nutrition' from the Pelvic Institute. Jessica Drummond, Sara Gottfried, Alisa Vitti and Christiana Northrup are just a few of the health guru's who have inspired and helped me when I was dealing with my own disruption and hormonal issues.
The support is there when you need it via email. If you require more personal advice, I will advice booking a Skype consultation. Depending on your needs, this will follow with a personalised report that you receive in PDF format. The course is very clear and to the point, but it always possible that things come up for you which you are unsure about. If you require more personal attention or additional information that will help your specific situation, you are free to ask for this at any time. I am here for you.