Early in the pandemic, Anthony Fauci – arguably the country’s top COVID scientist – famously told the American public that ordinary people had no reason to wear masks. He did so not because he thought it was true but because he wanted to save the limited supply of masks (especially the most effective masks) for healthcare workers.
Three things are unusual about this example of public health dishonesty in a noble cause. First, the lie was unsustainable; officials would soon be urging us all to mask up. Second, Fauci later acknowledged the lie. And third, public trust in public health significantly declined as a result.
What isn’t unusual is the dishonesty itself.
Public health officials and experts routinely face a messaging choice: Tell us what they think is true, or tell us what they think will get us to do the right thing. For them it’s a no-brainer. Of course saving lives matters more than being completely truthful!
This isn’t new. In 1981 I began volunteer communication work with an American Cancer Society state chapter. Then as now, a big ACS activity was corporate smoking cessation programs. To help sell these programs to companies, we commissioned a study of how employee smoking affected companies’ bottom line. We expected to show a big cost due to tobacco-related medical expenses. Instead, the study found that employees who smoked saved their companies both pension money and healthcare money by dying more rapidly after retirement. Smoking cessation simply wasn’t in a company’s economic self-interest.
We suppressed the study results and kept telling companies they would save money by sponsoring our smoking cessation programs. I lost my argument for dropping the false claim. Health is a higher value than truth, I was told.
I learned a comparable lesson from my environmental activist clients. The core task of activists is to arouse and mobilize stakeholder outrage to achieve social change goals. Activists remain faithful to the “truth” as they see it, but they’re almost always willing to cherry-pick, exaggerate, or even misrepresent some on-the-ground facts to make their truth more persuasive. The exceptions are rare enough to be memorable. I remember as if it were yesterday the day in 1985 when Environmental Defense Fund scientist Ellen Silbergeld refused to let EDF overstate the risk of dioxin in breast milk in an anti-dioxin campaign I was helping to craft.
Public health professionals (and other do-gooders) do try not to lie, since a carefully crafted half-truth can usually do the job. And they don’t consider themselves dishonest. Even on those rare occasions when they’re forced to confront the gap between what they believe and what they say publicly, they still don’t consider themselves dishonest – because their hearts are pure. Misleading people into wise health choices doesn’t feel like misleading people at all.
Measles
Should public health professionals be totally honest and let the chips fall where they may? My answer is almost always yes. But before you agree with me, consider this everyday example.
Once a common childhood disease, measles is so rare in the U.S. today that the tiny risk from getting vaccinated against measles is actually greater than the tiny risk from not getting vaccinated against measles. Of course measles is far more dangerous than the vaccine if your child catches it. But precisely because of near-universal vaccination in the U.S., your child is exceedingly unlikely to catch it.
For doubters, here are some CDC data. From 2010 to 2020, the U.S. averaged fewer than 300 measles cases per year. By contrast, U.S. children receive nearly ten million doses per year of the measles-mumps-rubella (MMR) vaccine – which is why we see so few measles cases. Roughly one in 20 kids gets pneumonia after measles. Roughly one in 200,000 kids gets anaphylaxis after an MMR shot. One chance in 20 for 300 kids with measles per year is an average of 15 annual cases of pneumonia. One chance in 200,000 for 10 million MMR vaccinations per year is an average of 50 annual cases of anaphylaxis. Similar calculations yield similar results for other measles sequelae and other MMR side effects. Q.E.D.
So why does measles vaccination make public health sense? If too many children go unvaccinated, measles will come roaring back – and then measles will constitute a vastly bigger risk than the vaccine. (CDC estimates that back before vaccines, three to four million kids in the U.S. caught measles every year; 400–500 died and 48,000 were hospitalized.) Widespread vaccination protects everybody’s children against a more dangerous future. But in the here-and-now for any one child in a highly vaccinated community, getting vaccinated against measles is more dangerous than not getting vaccinated against measles. Being a free-rider is safer than contributing to herd immunity.
Almost nobody in public health or medicine would countenance explaining this to a vaccine-hesitant parent. One doctor friend told me it would be medical malpractice for any physician to tell any parent this particular truth.
COVID
Fast-forward to COVID. By far the most important pandemic public health goal is to get more people vaccinated. In pursuit of that goal:
- In fall 2020 the FDA collaborated with Pfizer to slow the vaccine authorization process until after the Trump-Biden election, in part because it feared a Trump-encouraged pre-election rollout might exacerbate mistrust and undermine vaccine acceptance. (See discussion here, here, here, and here – and contrary discussion here.)
- In May 2021 the CDC decreed that vaccinated people didn’t need to wear masks – a recommendation that aimed in part to incentivize the unvaccinated to roll up their sleeves so they could abandon their masks, but soon had to be reversed because it mostly incentivized the unvaccinated to abandon their masks without rolling up their sleeves.
- In fall 2021 officials and experts kept insisting that nobody “needed” a vaccine booster, in part because they thought a booster rollout would provide ammunition for the view that the vaccines “don’t work.”
- In December 2021 the evidence wasn’t clear whether unvaccinated people transmit Omicron more than vaccinated people. It was a reasonable supposition, but data were scanty and superspreader events among vaccinated people suggested it might not be so. Public health people routinely said it anyhow, in hopes of encouraging vaccination.
- On February 20, 2022, the New York Times published a blockbuster article entitled “The C.D.C. Isn’t Publishing Large Portions of the Covid Data It Collects.” Reporter Apoorva Mandavilli noted: “The performance of vaccines and boosters, particularly in younger adults, is among the most glaring omissions.” A recurring reason for these omissions, she wrote, “is fear that the information might be misinterpreted” – that is, might be factual ammunition for antivaxxers.
- As the winter 2021-22 Omicron outbreak draws to a close, the evidence comparing natural immunity to vaccine-induced immunity is all over the map. The weight of the evidence suggests that natural immunity is at least as good as one mRNA shot, maybe as good as two, maybe even better than that. But U.S. officials continue to refuse “credit” for prior infections because they want everyone to get fully vaccinated.
Vaccine side effects
One halfway exception deserves discussion: Public health professionals have been candid about rare-but-serious side effects of COVID vaccines – most notably blood clotting problems with the Johnson & Johnson vaccine and heart problems with the Pfizer and Moderna vaccines. There were even “pauses” early in the vaccine rollouts while experts assessed the relative risk of the vaccines versus the virus. It’s arguable whether the pauses were wise in terms of encouraging vaccination; they seem to have exacerbated hesitancy more than they built credibility. On the other hand, trying to keep these side effects secret would have been not just unethical but doomed to backfire. With or without pausing, I don’t think officials and experts had any choice but to tell the truth.
Especially in the early days when they weren’t sure how severe or widespread COVID vaccine side effects might be, officials and experts were candid – maybe even a bit alarmist. But their public acknowledgments of the side effects became pretty perfunctory once they had satisfied themselves that vaccinating everybody was still the right course. Side effects continued to play a significant role in meetings of the FDA’s and CDC’s vaccine advisory committees. But at the vaccination centers I visited, I never saw anybody urging prospective vaccinees to learn about thrombocytopenia or myocarditis before rolling up their sleeves.
Some antivaxxers assert that COVID vaccine side effects are deadly and far from rare, and that the public health leadership is engaged in an all-too-successful conspiracy to keep these side effects secret. I find their claims unconvincing. Unlike the antivax movement, I don’t believe public health professionals would ever conspire to hide a vaccine side effect they thought was serious. I do, however, think they might very well downplay a side effect they weren’t too worried about if they thought prospective vaccinees might overreact. Hence the near-invisibility of informed consent protocols at vaccination centers.
In sum, officials and experts have consistently sifted their COVID statements and policies through the filter of how best to encourage vaccination, often at the expense of candor.
The same is true of other pandemic priorities: mask-wearing, social distancing, isolation and quarantine, testing, etc. First they figure out what public behaviors they think would be best in the current phase of the crisis. Then they figure out what they think they should tell us to get us to do what they’ve decided would be best for us to do – cherry-picking data as needed but trying to avoid actually lying.
Trust and trustworthiness
Public health professionals want the public to trust them without being trustworthy – without earning the public’s trust. They don’t see it that way. They have a blind spot when it comes to trustworthiness. I have read countless analyses in which public health professionals try to divine why they aren’t trusted. They rarely even consider the possibility that they aren’t trustworthy.
Their most frequent explanation for the mistrust is that COVID misinformation in social media is inculcating false conclusions. I think this gets the causality backwards. I doubt that COVID conspiracy theorists are convincing a lot of people to mistrust public health professionals. Rather, I think a lot of people who have come to mistrust public health professionals turn to COVID conspiracy theorists instead. The conspiracy theorists aren’t greatly responsible for the decline in trust; the untrustworthiness of public health professionals is.
But in a sense public health professionals really are trustworthy. We can trust them the way a child can trust a parent – not necessarily to tell us the entire truth, but to tell us what they genuinely think is best for us to know or believe. They’re looking out for our interests, at least that portion of our interests that pertains to infectious disease prevention. But they’re worried that we don’t always do such a good job of looking out for our own interests. So of course we can’t trust them to include in their messaging things they think we’ll “misinterpret” or take too much to heart – things they think we’re better off not knowing.
Based on 40+ years of risk communication consulting for corporations, governments, and activist groups, I long ago reached the counterintuitive conclusion that corporate spokespeople are more honest than do-gooders. Largely because their goals are more self-serving, corporate spokespeople feel less entitled to mislead. Also, corporate spokespeople have learned through painful experience that for them dishonesty doesn’t pay. They’re likelier to get caught than public health professionals, and likelier to get crucified if they’re caught.
I have argued for decades that prioritizing health over truth risked undermining the credibility of the entire public health enterprise. I didn’t have many examples. Even when my public health clients reluctantly conceded that, yes, they do sometimes say not-quite-honest things in order to save lives, they invariably pointed out that their dishonesty did indeed save lives, lives they could document, whereas I had scant evidence for my claim that they were eroding trust in the process.
Sadly, COVID has given me a lot of new ammunition.
Or maybe not so sadly. In our new pandemic world, and in the post-pandemic world we all devoutly hope to see, maybe public health professionals will realize that they can no longer count on being trusted, and will therefore be forced to learn to trust the public with more of the truth.
Copyright © 2022 by Peter M. Sandman
