I think your approach is right on target, and I’d be glad to work with you in any way you think will be useful, whether behind-the-scenes or as an interviewee or both.
In October 2009, I spoke to the National Public Health Information Coalition on a topic that will sound familiar to you: “Trust the Public with More of the Truth: What I Learned in 40 Years in Risk Communication.” The speech is on my website in two versions, my written notes and what I actually said. You might find it useful, especially if you’re looking for some classic as opposed to recent examples.
Trust the Public with More of the Truth:
What I Learned in 40 Years of
Risk Communication
Written speech
Audio (they’re pretty different)
Link off-site to the video
One way of seeing this is that public health experts and officials want the public to trust them without being trustworthy – without earning the public’s trust. That’s certainly true. Your preferred frame, and mine, is less common, but it takes the analysis one step further: The main reason experts and officials are untrustworthy is that they don’t trust the public to bear the truth.
So they routinely mislead without lying if they can, and lie if they feel they must. Typically, high-stature experts and officials struggle valiantly to give the desired false impression without actually saying anything false. You can tell the dishonesty is intentional because of the careful craft that goes into skirting the boundaries of outright falsehood. But among those they succeed in misleading are lower-stature experts and officials – local health officers, for example, or individual clinicians. They rephrase their (mis)understanding of what their leaders had to say in their own words … and thereby veer unknowingly into the outright falsehood their leaders carefully avoided.
Journalists make the same error for the same reason; journalistic paraphrases of a source’s carefully misleading claims are often simply false.
Importantly, those high-stature experts and officials seldom consider themselves dishonest. Even on those rare occasions when they’re forced to confront the gap between what they know to be true and what they say publicly, they still don’t consider themselves dishonest. Why? Because their goal is pure. Misleading people into wise health choices doesn’t feel like misleading people at all. The fact that you’re leading them to make the right choice about their health is more salient than the fact that you’re misleading them about the science or the evidence.
One of the main points of my 2009 speech was that my corporate clients were typically less dishonest than my public health and environmentalist clients. Corporate spokespeople felt less entitled to mislead, in large measure because their goals were more self-serving. If you’re trying to save the world, a little dishonesty about inconvenient facts doesn’t seem like too high a price to pay. (The other main reason why corporations are more honest than public-interest folks: They’re likelier to get caught, and likelier to get crucified if they’re caught.) The toughest question in your very thoughtful email is whether public health messaging should be the way we’ve both described it. Part of that question is whether the goal of public health communicators ought to be truth or health. Faced with that question and forced to concede that the two goals sometimes diverge, virtually everyone I know in the field would choose health.
An everyday example that may help you see that they have a point: Childhood diseases like measles are rare enough in the U.S. that the tiny risk of adverse events from MMR (measles/mumps/rubella) vaccination is about equal to the tiny risk of adverse events from a case of measles. (Measles is more dangerous than the vaccine if you catch it, of course, but you probably won’t catch it. The two bad outcomes have roughly equal probability × magnitude = risk.) Vaccination makes sense only because if a lot of parents choose not to vaccinate their children, then measles will come roaring back – at which point measles will constitute a far bigger risk than the vaccine. So vaccination protects against a more dangerous future. But in the here-and-now, the risk of measles isn’t greater than the risk of getting vaccinated against it. So it’s totally rational to decide to postpone measles vaccination for your kids until you see signs that measles is making a significant comeback.
Absolutely nobody in public health or in medicine would ever consider explaining this to parents. One GP told me it would be medical malpractice for any doctor to tell a parent this particular truth.
Another vaccine-related example: lying to parents in developing countries about the oral polio vaccine. The OPV can rarely give a vaccinee polio; it can even start an outbreak of vaccine-derived polio. Until recently it was nonetheless the polio vaccine of choice in developing countries (but not in developed countries) because it’s cheaper, because it’s easier to administer, and most importantly because functional vaccine is shed in vaccinees’ feces, and thus can indirectly “vaccinate” children the vaccination campaign missed. For decades, right up until they switched to injected vaccine, polio campaigners were instructed to deny that the OPV can give anybody polio. They tracked cases and outbreaks of vaccine-related polio, wrote articles in public health journals about them, and told parents they didn’t happen, period.
In a consultation with the key consortium of polio campaigners, I suggested telling the truth. Their response: Many parents would overreact to this rare side effect of OPV and decide not to vaccinate their kids, leading to more cases of polio and possibly relaunching the worldwide spread of this nearly eradicated horrific disease. My response: Ultimately they will figure out that you’re lying to them, and the resulting loss in credibility can undermine not just the polio campaign but other vaccination campaigns and potentially all of public health. They didn’t buy my argument, and kept right on lying. (As I noted earlier, public health experts and officials prefer to mislead without lying, but that can be hard to do when answering a parent’s direct question.)
My response to the polio campaigners raises an empirical question aside from the values question: Even if maximizing health outcomes trumps telling the truth, over the long haul does dishonesty really maximize health outcomes? I think the answer is no. Even in the short term, publics often begin to smell a rat whether or not they can identify any specific falsehoods, In the longer term, inconvenient truths are likely to emerge, leading to a loss in credibility that can undermine decades of good public health work.
That’s what I believe – and your email says it’s what you believe as well. But my evidence is sparse. I can certainly cite examples where public health people have been caught in dishonesties that undermined their credibility. (If you want more such examples, ask me for them.) But cherry-picked examples don’t make my case. There are plenty of examples that point in the other direction: examples of dishonest public health campaigns (like the OPV campaign) where the dishonesty never got revealed in horribly damaging ways and seems have done more good than harm, even in long-term hindsight.
Arguably my belief that dishonesty ultimately backfires is grounded more in ideology than in evidence: I want dishonesty to backfire.
I’m pretty sure corporate dishonesty does backfire, and I earned a good bit of money convincing corporate clients that telling the truth was good business, not just good ethics. But as I pointed out earlier, dishonest public health professionals are less likely to get caught than dishonest corporate executives. (There aren’t many activists looking to defeat public health people or investigative reporters looking to expose their misdeeds.) And on those rare occasions when they’re caught, they’re more lightly punished and more quickly forgiven. My case against public health dishonesty is empirically weak.
One story I can’t resist telling you, because it illustrates how public health dishonesty is at least occasionally caught and punished: the story of the Dengvaxia vaccine in the Philippines. The only known dengue vaccine so far, Dengvaxia has a downside. Most times a first case of dengue is mild, but second cases are likely to be severe. In a vaccinee who has already had dengue at least once, Dengvaxia works pretty well. But in sero-naïve vaccinees (people who have never had dengue), Dengvaxia acts like a first case. It still makes them less likely to catch the disease – but if they catch it anyway, their first case will be in effect a second case, and thus likely to be severe. On balance, most experts believe people shouldn’t get the Dengvaxia vaccine until after they’ve been ill with dengue at least once.
Back when the Philippines was launching its massive Dengvaxia campaign a few years ago, this downside of the vaccine was widely suspected but not yet proven. To avoid the downside, officials aimed the campaign at children old enough that most of them would have already had dengue at least once. But they didn’t tell parents or the media that the vaccine might do more harm than good for the minority of vaccinees who had managed never to catch dengue until after they were vaccinated. Informed consent forms, such as they were, didn’t mention this possibility, even though experts were worriedly aware of it.
A few months after the campaign began, the truth emerged. And public outrage blew the campaign out of the water. Claims were made that the vaccine had killed many people – not just vaccinees who died of dengue, but vaccinees who died of all sorts of unrelated diseases as well. Politically ambitious prosecutors filed manslaughter charges against public health officials of the opposing party.
The prospects for vaccinating Filipinos against dengue anytime soon are dim. More importantly, a slew of other public health campaigns against everything from measles to malaria suffered a huge setback. Filipinos had learned not to trust Dengvaxia, not to trust vaccines, and not to trust public health professionals.
Well, I apologize for going on and on. I hope some of this is useful. You can find a lot more along the same lines on my website (www.psandman.com). Or of course we can set up a time to talk.
Obviously the pattern we’re talking about has manifested itself again and again during the COVID-19 pandemic. I have steered away from COVID-19 examples because you obviously have your own very good ones. But if you want me to provide a few more, they’re certainly plentiful.
Copyright © 2021 by Peter M. Sandman
