How the Public-Health Messaging Backfired - The Atlantic
▻https://www.theatlantic.com/ideas/archive/2021/02/how-public-health-messaging-backfired/618147
Par Zeynep Tufekci
When the polio vaccine was declared safe and effective, the news was met with jubilant celebration. Church bells rang across the nation, and factories blew their whistles. “Polio routed!” newspaper headlines exclaimed. “An historic victory,” “monumental,” “sensational,” newscasters declared. People erupted with joy across the United States. Some danced in the streets; others wept. Kids were sent home from school to celebrate.
One might have expected the initial approval of the coronavirus vaccines to spark similar jubilation—especially after a brutal pandemic year. But that didn’t happen. Instead, the steady drumbeat of good news about the vaccines has been met with a chorus of relentless pessimism.
The problem is not that the good news isn’t being reported, or that we should throw caution to the wind just yet. It’s that neither the reporting nor the public-health messaging has reflected the truly amazing reality of these vaccines. There is nothing wrong with realism and caution, but effective communication requires a sense of proportion—distinguishing between due alarm and alarmism; warranted, measured caution and doombait; worst-case scenarios and claims of impending catastrophe. We need to be able to celebrate profoundly positive news while noting the work that still lies ahead. However, instead of balanced optimism since the launch of the vaccines, the public has been offered a lot of misguided fretting over new virus variants, subjected to misleading debates about the inferiority of certain vaccines, and presented with long lists of things vaccinated people still cannot do, while media outlets wonder whether the pandemic will ever end.
This pessimism is sapping people of energy to get through the winter, and the rest of this pandemic. Anti-vaccination groups and those opposing the current public-health measures have been vigorously amplifying the pessimistic messages—especially the idea that getting vaccinated doesn’t mean being able to do more—telling their audiences that there is no point in compliance, or in eventual vaccination, because it will not lead to any positive changes. They are using the moment and the messaging to deepen mistrust of public-health authorities, accusing them of moving the goalposts and implying that we’re being conned. Either the vaccines aren’t as good as claimed, they suggest, or the real goal of pandemic-safety measures is to control the public, not the virus.
Five key fallacies and pitfalls have affected public-health messaging, as well as media coverage, and have played an outsize role in derailing an effective pandemic response. These problems were deepened by the ways that we—the public—developed to cope with a dreadful situation under great uncertainty. And now, even as vaccines offer brilliant hope, and even though, at least in the United States, we no longer have to deal with the problem of a misinformer in chief, some officials and media outlets are repeating many of the same mistakes in handling the vaccine rollout.
The pandemic has given us an unwelcome societal stress test, revealing the cracks and weaknesses in our institutions and our systems. Some of these are common to many contemporary problems, including political dysfunction and the way our public sphere operates. Others are more particular, though not exclusive, to the current challenge—including a gap between how academic research operates and how the public understands that research, and the ways in which the psychology of coping with the pandemic have distorted our response to it.
Recognizing all these dynamics is important, not only for seeing us through this pandemic—yes, it is going to end—but also to understand how our society functions, and how it fails. We need to start shoring up our defenses, not just against future pandemics but against all the myriad challenges we face—political, environmental, societal, and technological. None of these problems is impossible to remedy, but first we have to acknowledge them and start working to fix them—and we’re running out of time.
The past 12 months were incredibly challenging for almost everyone. Public-health officials were fighting a devastating pandemic and, at least in this country, an administration hell-bent on undermining them. The World Health Organization was not structured or funded for independence or agility, but still worked hard to contain the disease. Many researchers and experts noted the absence of timely and trustworthy guidelines from authorities, and tried to fill the void by communicating their findings directly to the public on social media. Reporters tried to keep the public informed under time and knowledge constraints, which were made more severe by the worsening media landscape. And the rest of us were trying to survive as best we could, looking for guidance where we could, and sharing information when we could, but always under difficult, murky conditions.
Despite all these good intentions, much of the public-health messaging has been profoundly counterproductive. In five specific ways, the assumptions made by public officials, the choices made by traditional media, the way our digital public sphere operates, and communication patterns between academic communities and the public proved flawed.
While visible but low-risk activities attract the scolds, other actual risks—in workplaces and crowded households, exacerbated by the lack of testing or paid sick leave—are not as easily accessible to photographers. Stefan Baral, an associate epidemiology professor at the Johns Hopkins Bloomberg School of Public Health, says that it’s almost as if we’ve “designed a public-health response most suitable for higher-income” groups and the “Twitter generation”—stay home; have your groceries delivered; focus on the behaviors you can photograph and shame online—rather than provide the support and conditions necessary for more people to keep themselves safe.
And the viral videos shaming people for failing to take sensible precautions, such as wearing masks indoors, do not necessarily help. For one thing, fretting over the occasional person throwing a tantrum while going unmasked in a supermarket distorts the reality: Most of the public has been complying with mask wearing. Worse, shaming is often an ineffective way of getting people to change their behavior, and it entrenches polarization and discourages disclosure, making it harder to fight the virus. Instead, we should be emphasizing safer behavior and stressing how many people are doing their part, while encouraging others to do the same.
Harm Reduction
Amidst all the mistrust and the scolding, a crucial public-health concept fell by the wayside. Harm reduction is the recognition that if there is an unmet and yet crucial human need, we cannot simply wish it away; we need to advise people on how to do what they seek to do more safely. Risk can never be completely eliminated; life requires more than futile attempts to bring risk down to zero. Pretending we can will away complexities and trade-offs with absolutism is counterproductive. Consider abstinence-only education: Not letting teenagers know about ways to have safer sex results in more of them having sex with no protections.
As Julia Marcus, an epidemiologist and associate professor at Harvard Medical School, told me, “When officials assume that risks can be easily eliminated, they might neglect the other things that matter to people: staying fed and housed, being close to loved ones, or just enjoying their lives. Public health works best when it helps people find safer ways to get what they need and want.”
Another problem with absolutism is the “abstinence violation” effect, Joshua Barocas, an assistant professor at the Boston University School of Medicine and Infectious Diseases, told me. When we set perfection as the only option, it can cause people who fall short of that standard in one small, particular way to decide that they’ve already failed, and might as well give up entirely. Most people who have attempted a diet or a new exercise regimen are familiar with this psychological state. The better approach is encouraging risk reduction and layered mitigation—emphasizing that every little bit helps—while also recognizing that a risk-free life is neither possible nor desirable.
Socializing is not a luxury—kids need to play with one another, and adults need to interact. Your kids can play together outdoors, and outdoor time is the best chance to catch up with your neighbors is not just a sensible message; it’s a way to decrease transmission risks. Some kids will play and some adults will socialize no matter what the scolds say or public-health officials decree, and they’ll do it indoors, out of sight of the scolding.
And if they don’t? Then kids will be deprived of an essential activity, and adults will be deprived of human companionship. Socializing is perhaps the most important predictor of health and longevity, after not smoking and perhaps exercise and a healthy diet. We need to help people socialize more safely, not encourage them to stop socializing entirely.
Moreover, they have delivered spectacular results. In June 2020, the FDA said a vaccine that was merely 50 percent efficacious in preventing symptomatic COVID-19 would receive emergency approval—that such a benefit would be sufficient to justify shipping it out immediately. Just a few months after that, the trials of the Moderna and Pfizer vaccines concluded by reporting not just a stunning 95 percent efficacy, but also a complete elimination of hospitalization or death among the vaccinated. Even severe disease was practically gone: The lone case classified as “severe” among 30,000 vaccinated individuals in the trials was so mild that the patient needed no medical care, and her case would not have been considered severe if her oxygen saturation had been a single percent higher.
These are exhilarating developments, because global, widespread, and rapid vaccination is our way out of this pandemic. Vaccines that drastically reduce hospitalizations and deaths, and that diminish even severe disease to a rare event, are the closest things we have had in this pandemic to a miracle—though of course they are the product of scientific research, creativity, and hard work. They are going to be the panacea and the endgame.
Just a few days later, Moderna reported a similar 94.5 percent efficacy. If anything, that provided even more cause for celebration, because it confirmed that the stunning numbers coming out of Pfizer weren’t a fluke. But, still amid the political turmoil, the Moderna report got a mere two columns on The New York Times’ front page with an equally modest headline: “Another Vaccine Appears to Work Against the Virus.”
So we didn’t get our initial vaccine jubilation.
But as soon as we began vaccinating people, articles started warning the newly vaccinated about all they could not do. “COVID-19 Vaccine Doesn’t Mean You Can Party Like It’s 1999,” one headline admonished. And the buzzkill has continued right up to the present. “You’re fully vaccinated against the coronavirus—now what? Don’t expect to shed your mask and get back to normal activities right away,” began a recent Associated Press story.
People might well want to party after being vaccinated. Those shots will expand what we can do, first in our private lives and among other vaccinated people, and then, gradually, in our public lives as well. But once again, the authorities and the media seem more worried about potentially reckless behavior among the vaccinated, and about telling them what not to do, than with providing nuanced guidance reflecting trade-offs, uncertainty, and a recognition that vaccination can change behavior. No guideline can cover every situation, but careful, accurate, and updated information can empower everyone.
What went wrong? The same thing that’s going wrong right now with the reporting on whether vaccines will protect recipients against the new viral variants. Some outlets emphasize the worst or misinterpret the research. Some public-health officials are wary of encouraging the relaxation of any precautions. Some prominent experts on social media—even those with seemingly solid credentials—tend to respond to everything with alarm and sirens. So the message that got heard was that vaccines will not prevent transmission, or that they won’t work against new variants, or that we don’t know if they will. What the public needs to hear, though, is that based on existing data, we expect them to work fairly well—but we’ll learn more about precisely how effective they’ll be over time, and that tweaks may make them even better.
Psychologists talk about the “locus of control”—the strength of belief in control over your own destiny. They distinguish between people with more of an internal-control orientation—who believe that they are the primary actors—and those with an external one, who believe that society, fate, and other factors beyond their control greatly influence what happens to us. This focus on individual control goes along with something called the “fundamental attribution error”—when bad things happen to other people, we’re more likely to believe that they are personally at fault, but when they happen to us, we are more likely to blame the situation and circumstances beyond our control.
An individualistic locus of control is forged in the U.S. mythos—that we are a nation of strivers and people who pull ourselves up by our bootstraps. An internal-control orientation isn’t necessarily negative; it can facilitate resilience, rather than fatalism, by shifting the focus to what we can do as individuals even as things fall apart around us. This orientation seems to be common among children who not only survive but sometimes thrive in terrible situations—they take charge and have a go at it, and with some luck, pull through. It is probably even more attractive to educated, well-off people who feel that they have succeeded through their own actions.
The focus on individual actions has had its upsides, but it has also led to a sizable portion of pandemic victims being erased from public conversation. If our own actions drive everything, then some other individuals must be to blame when things go wrong for them. And throughout this pandemic, the mantra many of us kept repeating—“Wear a mask, stay home; wear a mask, stay home”—hid many of the real victims.
Study after study, in country after country, confirms that this disease has disproportionately hit the poor and minority groups, along with the elderly, who are particularly vulnerable to severe disease. Even among the elderly, though, those who are wealthier and enjoy greater access to health care have fared better.
The poor and minority groups are dying in disproportionately large numbers for the same reasons that they suffer from many other diseases: a lifetime of disadvantages, lack of access to health care, inferior working conditions, unsafe housing, and limited financial resources.
Many lacked the option of staying home precisely because they were working hard to enable others to do what they could not, by packing boxes, delivering groceries, producing food. And even those who could stay home faced other problems born of inequality: Crowded housing is associated with higher rates of COVID-19 infection and worse outcomes, likely because many of the essential workers who live in such housing bring the virus home to elderly relatives.
Individual responsibility certainly had a large role to play in fighting the pandemic, but many victims had little choice in what happened to them. By disproportionately focusing on individual choices, not only did we hide the real problem, but we failed to do more to provide safe working and living conditions for everyone.
But also, after a weary year, maybe it’s hard for everyone—including scientists, journalists, and public-health officials—to imagine the end, to have hope. We adjust to new conditions fairly quickly, even terrible new conditions. During this pandemic, we’ve adjusted to things many of us never thought were possible. Billions of people have led dramatically smaller, circumscribed lives, and dealt with closed schools, the inability to see loved ones, the loss of jobs, the absence of communal activities, and the threat and reality of illness and death.
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