Misinformation and the COVID-19 Vaccination Campaign

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: the dangers of the vaccine misinformation and what, if anything, public health teams can do about it.

DR. NIRAV SHAH:
We sometimes think about pandemic preparation as having enough masks, gloves, vaccines, and beds on hand. But what about in terms of increasing our scientific literacy so that, when we have those treatments, we can get people to use them?

DR. JOE SMYSER:
In the middle of this urgent mass immunization campaign, we're also trying to figure out how we as a society empower of community organizations and individuals, non-health professionals, to get out there and give them the good information and say things in their own way.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, fighting the COVID-19 virus while battling bad information about vaccines, and whether vaccine endorsements from infected critics now struggling to speak from their hospital beds will be enough to convince others to get vaccinated.

The vaccine debate is a matter of life and death. Certainly, many who've held off getting a COVID shot think they have good reason, but can they be moved to protect themselves when there's so much bad information about vaccines online? And are there ways we can address social media accounts that spread misinformation?

Our guests are thinking about the best approach to convince the holdouts and correct the record about vaccines, including those available to protect against the worst effects of COVID-19 and the Delta variant.

Dr. Joe Smyser is CEO of The Public Good Projects, a nonprofit working in the public health space. He'll be along later to share his thoughts on these questions.

But first, we hear from Dr. Nirav Shah, ASTHO president and director of the Maine Center for Disease Control and Prevention.

SHAH:
It's a significant concern, especially in light of the fact that everything we know about the vaccines speaks to their safety as well as their effectiveness.

The fact that we still have a sizable percentage of the population—some surveys put it at 15%, some surveys put it at double that—who have resisted the best recommendations of physicians, public health scientists around the world... that's a concern. It's a concern right now as we are trying to navigate our way out of the pandemic, but it's also a concern going forward.

What if the next pandemic—which there will be one—is even more severe and the costs of not getting vaccinated are even more significant? These are concerns that we're going to have to think about as we think through our preparation for the next pandemic.

We sometimes think about pandemic preparation as having enough masks, gloves, vaccines, and beds on hand. But what about in terms of increasing our scientific literacy so that when we have those treatments, we can get people to use them?

JOHNSON:
Why do you think vaccine confidence has eroded over the course of the pandemic?

SHAH:
Well, I think that, is in many respects, the $64,000 question we're going to have to address. We're all grappling with it now, but in the midst of the fight that we're in right now, it's difficult to look upstream and try to understand how it is we got here. I think there are a couple of hypotheses that are worth exploring though.

Number one is that it's part and parcel of longstanding skepticism, hesitancy, around vaccine that's existed. And now that the stakes are high, it's just more prevalent and more apparent.

Another hypothesis is that the speed of development has precipitated and generated more mistrust. That's an interesting hypothesis that warrants investigation.

The other, and the most concerning, is that there was an allied effort to undermine the confidence of these vaccines. We've all perhaps seen reports of the Disinformation Dozen who's out there, a small group of people responsible for an outsized effect. Now, what their motives are—that really is where the conversation should go; and whether we can make any inroads with them, whether we can find places where we agree rather than uniformly disagreeing, to move that conversation, that's really the key going forward.

JOHNSON:
How possible is it, do you think, to find areas of commonality given the circumstances?

SHAH:
I'm an optimist at heart, and so I believe that that remains a possibility.

Now, will we be able to get the most stalwart, strident anti-vaccine advocates to come on board and get vaccinated? I don't think that should be the goal. I don't think that is a viable goal, unfortunately.

I think the goal here is to get folks who are maybe not so stridently against the vaccine to find messages and agreement from them that there are circumstances under which getting a vaccine is a good thing.

I think the easiest place to start with that is by at least getting acknowledgement that certain individuals say those who are immunocompromised should absolutely, categorically, get vaccinated.

And then, moving beyond in almost concentric circles to try to acknowledge that even if you aren't immunocompromised but perhaps your spouse or mother is, getting yourself vaccinated is a good idea—building on that foundation and then trying to build from there.

JOHNSON:
Are those the approaches that work best in your view when it comes to dispelling conspiracies and myths?

SHAH:
I think so—or I will reframe it a bit.

My view is that the place to start that conversation is to get to the root causes of the belief, to ask why.

I think the what is fairly well-established at this point, and it's not clear to me that doing a point-by-point refutation really changes minds. I think if we talk about the why people believe the things they do, there, I think, we might be able to convince a few folks to get on board.

A lot of these concerns—this outright opposition to vaccines—is driven by things like fear: fear that the vaccines were raced; fear that they are being driven by corporate interests, not public health.If you get to those whys, then it's a lot easier to have a conversation about what's going on rather than doing a point-by-point refutation of what that footnote said, and that sort of thing.

JOHNSON:
Speaking of fear, the media is now reporting that fear is driving people to go get the shot, that they're afraid of the Delta variant. Do you agree with that notion?

SHAH:
I do.

You know, the use of fear and its close counterpart, shame, in public health is quite interesting. And in some instances—although we generally think that motivations rooted in fear and shame are unadvisable in public health—there are some instances where they do seem to work and maybe are even advisable. This may be one instance where motivations are rooted in fear get the job done.

Again, generally in public health we think trying to change behavior through fear and shame generates not behavior change, but rather stigma. But in some instances, public health has resorted to fear. For example, the Tips from a Former Smoker campaign that the U.S. CDC launched many years ago famously, and quite effectively, used fear as a motivating tactic to get folks to stop smoking. The question right now is what is the appropriate use of fear or shame in the face of the COVID-19 opposition, vaccine opposition.

As you noted in some parts of the country, perhaps in relation to and driven by the surge in the Delta variant, vaccination rates are starting to increase. Certainly, we've seen that in the Southeast where states like, for example, in Louisiana, where our colleague Dr. Joseph Kanter about a week ago reported that vaccination rates have doubled perhaps in connection with Delta. And other states, even here in Maine, where vaccination rates have increased as well.

That's a good thing in so far as it gets folks vaccinated, but we still have the open question of what is the appropriate venue for when fear and shame should be used.

JOHNSON:
We've begun to see these stories quoting people who are now in hospital beds, uncertain if they'll survive the virus, testifying to journalists they wish they had gotten the shot earlier.

Do you think health departments ought to magnify those stories when people are willing to tell them?

SHAH:
I think so, but I will be careful to note that it is part of a broader strategy.

We ourselves are investigating going down that road ourselves. We've identified a patient who fits that bill here in Maine, and we're having a conversation with that individual to determine if they would be willing to share their story.

I think as part of a broader campaign around vaccines where doctors and nurses are in the lead—calling their patients, asking their patients to come in and get the vaccine—but buttressed by other messages: sometimes the messages from well-known figures; in some instances, messages of regret, those messages of folks who were eligible but declined and later suffered from COVID.

That entire constellation of messaging I think is effective, the messages of regret being one component of that. On its own, it's probably too stark and probably does not appeal to a broad enough group of folks. But in concert with other types of messages, I believe it has a place.

JOHNSON:
Those stories are frightening, though.

You read those in the paper and it really makes you grateful if you've gone and gotten the shot already.

It seems like a place you do not want to go.

SHAH:
I mean, really they are quite concerning.

And what you just noted a moment ago is essential, which is they do speak to folks. Often, they speak to folks who have already gotten the shot. Is it the type of message that will convince somebody who hasn't gotten a shot to get on board? Or will that person, for example, brush off those messages or view it as an attempt to be manipulated and thus harden their position against the vaccine? That's really the open question.

Again, the early evidence based on the uptake in vaccination rates in the South and the Southeast—actually nationwide—suggests that those messages of both the higher contagiousness of the Delta variant, and then maybe these visuals of folks in their hospital beds gasping for air, admonishing others to get the vaccine, maybe that's doing the trick.

Again, we are pursuing a strategy of that nature, but it's part of a broader strategy that we hope gets folks on board.

JOHNSON:
Of course, talking about all of this really is nothing more than a snapshot in time because this story is moving every day.

If you're trying to develop a message to reach the holdouts, you've got to be on your toes.

SHAH:
It really is.

I mean, I look back on the first TV ads that we started airing back in April, and I look back on those and I sort of chuckle and think, "Boy, there's no way that would work anymore." And that was only just four short months ago.

We're constantly looking on the horizon for other strategies that will work. Right now, we're focused, for example, on back-to-school and we're developing messages certainly for the children themselves, but also the parents. And we've been doing that, but we're refining them a little bit more as we get it into the last few weeks before school season starts.

Similarly, we're looking on the horizon to see what else is looming that may play a role in our messaging in a couple of weeks. Right now, there's a lot of discussion around the next variant that's out there. What Greek letter is going to be causing the greatest amount of concern not today and tomorrow, but next month or the month thereafter, whether it's the Lambda variant or variants we haven't even heard of? And we're thinking about how that intersects with our messaging right here.

The final thing is using some of these more stark images of individuals, as we just talked about, who have the opportunity but decided against it and are now contending with COVID. How we position those ads, to whom we serve those ads to—that's going to be really critical.

JOHNSON:
Is there a tipping point for the hesitant in your view?

I mean, how bad does it need to be for an anti-vaxxer to finally go and get a shot?

SHAH:
You know, like so many individuals who have not yet been vaccinated, the intensity of their belief against vaccines varies, and they are a heterogeneous group.

My hunch is that, you know, fundamentally the decision to get vaccinated comes down to a relatively simple fit of calculus or the equation, which is is the risk of the vaccine greater or less than the risk of COVID. That's fundamentally the decision that each of us is making.

And for those of us who have been vaccinated, we have all said the risk of the vaccine is a lot less, orders of magnitude less, than the risk of COVID.

Now, the risk of the vaccine may not change, but what may change is the individual's understanding of that risk. Full approval by the FDA may tilt in favor for some folks, although I'm somewhat skeptical.

So, the vaccine is probably going to be what the vaccine is, but as COVID becomes more and more concerning for the unvaccinated, what I think we'll see is that, almost in tranches, individuals will start getting vaccinated based on their intensity of belief against the vaccine.

What remains at the end will be a certain fragment of the population whose intensity is so tightly held, it almost becomes their identity. And for that group, it's unlikely that anything will be able to convince them in favor of the vaccine short of perhaps a mandate.

JOHNSON:
What's your best advice for your peers who are all struggling with vaccine disinformation right now?

SHAH:
We too here in Maine are struggling with that. And my approach here for my team is to try not to answer every single question because many of them are insincere and are fleeting.

What we've tried to do is identify the most recurring and concerning themes, things that are built on outright misinformation, and produce short videos of no more than two minutes each that directly address the concern, whether it's infertility or whatever the latest concern of the day.

Those short video clips—again, maybe 90 seconds, two minutes at most—can be easily shared and can be easily deployed in social media conversations where they can quash rumors before they start. That is something that I think is a tool that we are starting to see a benefit of, coupled with messaging consistently from doctors in Maine. Those two, I think, have our best shot at getting through this.

JOHNSON:
Finally, do you think we can still beat the virus even if we don't win the info war?

SHAH:
It will certainly be challenging.

Of course, we have to have a discussion of what it means to beat the virus. And I think where my head is at right now from an epidemiological perspective is that we need to acknowledge COVID is going to be with us for some period of time. What it means to beat the virus in that context is to try to reduce the number of outbreaks, to try to reduce the number of individuals who are high risk, who get affected, much in the way our influenza strategy is based there.

Even if we don't, as you say, win the info war, I still think we can make inroads against the virus and keep a lid on it. Whether it will be able to vanquish it—that's unlikely and, frankly, that was probably not the goal on the first instance.

JOHNSON:
Dr. Joe Smyser has campaigned for many public health causes during his career, but it's his work as CEO of The Public Good Projects monitoring media programs, engaging in social and behavior change interventions, that has him thinking about the amount of vaccine information—and misinformation—all around us.

SMYSER:
Misinformation finds you. There are a lot of concurrent campaigns that are pro-vaccine campaigns, pro-science campaigns, really earnest efforts by the federal government and state and local governments, other nonprofits, foundations. There's a myriad of really great efforts out there right now to reach different populations with tailored messages that are designed to hopefully resonate with them specifically.

But at the end of the day, all of these efforts are contending with, if you get on social media, or if you walk out your front door and just talk to a neighbor, it's very, very easy to be told something that isn't true.

JOHNSON:
And hard to confirm whether or not you're getting the facts.

SMYSER:
Yeah. One of the things that we've learned during this pandemic—we knew it before the pandemic, but the pandemic’s really made it crystal clear—is the messenger matters more than the message.

And so, if I have something shared to me by a friend or a family member, whether or not that person's a healthcare professional, I still am more inclined to believe it than if I hear something as a radio ad, or if I see something as a television commercial. So that's a real challenge.

JOHNSON:
The government pitch for COVID vaccines is everywhere. There are many, many campaigns going on at different levels. Sometimes the same consumer gets four or five different campaigns in favor of vaccines. But they're also getting a lot of negative and misleading messaging online. They're hearing from people that they know on social media or in the neighborhood about vaccines and why they are or are not good. It's easy to see how people can be confused over these issues.

SMYSER:
I actually think it's the right thing to focus on, but this distributed information infrastructure, this need for so many different messengers in so many different communities is new. That's new to the United States. We've never done it on the scale of before. So, we're building the plane while we're flying it, to use that old metaphor. In the middle of this urgent mass immunization campaign, we're also trying to figure out how we as a society empower community organizations and individuals, non-health professionals, to get out there and give them the good information and say things in their own way.

So, it's a double challenge and it requires a dramatic restructuring of the way public health functions in this country. This is not the legacy that we had going into the pandemic. Our legacy was the very top down—listen to the experts, the CDC talks to state health departments, state health departments talk to you—and there's not a lot of other people involved in communicating health.

So, there's a lot that is brand new that is happening simultaneously right now.

JOHNSON:
Learning some of these lessons the hard way, no doubt.

SMYSER:
Yeah.

JOHNSON:
So, the media is pressing the case too—you know, they've really leaned into this the way they do on issues that they feel strongly about.

They're giving a lot of play recently to people who now regret not getting the shot. And maybe you've seen some of these interviews from hospital beds—people hoping that they survive, giving last wishes to the journalists and family members over the phone and such, urging people who are still holding out to go get a shot. Why isn't this sort of scary story enough to change the conversation?

SMYSER:
I have seen some of those stories and they're horribly tragic and really difficult for me to watch. I lost someone during the pandemic very close to me, myself, and it's very difficult to be reminded what that was probably like for them—no one was able to visit them—and just to know that that's going on in almost every community across the country is horrifying.

I actually do think it's making an impact, but it is arguable whether that alone is going to have the impact of that we'd need to get to the herd immunity, to get to the number of people to be vaccinated we really need to protect everybody.

So, I don't think there's any silver bullet in this scenario. I think a scare tactic approach like that has been shown to work in other areas of public health, like anti-smoking campaigns. So, I think we're trying everything in our toolbox right now, and that's going to convince some people.

It's not going to convince others; and for those others, they're going to need a very different means of communication very different kinds of message, framing, and messengers.

JOHNSON:
You've seen that fear approach used now in officially sponsored campaigns, or is it still just in the media?

SMYSER:
I haven't seen it in an officially sponsored campaign, and I think that's because the public health and communications professionals in the room are very wary of taking that approach with this topic because there's evidence from other immunization campaigns—like polio campaigns or seasonal flu campaigns—where that approach has been shown not to work and, in fact, backfire.

But I think it's understandable that news organizations and the media in general are covering it the way that they are. And I think it's an open question whether it's going to lead to the amount of change that we would all like to see.

But no, for now it's mostly just news coverage where I'm seeing it and a lot of social shares, so a lot of videos being shared around in social media.

JOHNSON:
Coverage of the Delta variant is also getting some credit for driving vaccination numbers. People have been going in greater numbers lately to get a shot.

Do you think a bump from the Delta variant is short-lived as it relates to drawing more people off the fence?

SMYSER:
I do. I think it's going to get people who you might call laggards, who were waiting until they saw more evidence or whatever the reason was. They're now motivated to go get the shot.

But I do think that's the only gonna get us so far, and then you're gonna reach another barrier that we're going to have to overcome with a different approach.

JOHNSON:
So what do we do? Health departments are listening to this conversation right now, they're struggling with misinformation or disinformation or both. They're still trying to respond, still trying to talk people into getting shots.

Dr. Shah says we should hit bad information head on—maybe not every single thing we see, but the big things that are wrong with what's being said out there.

What's your recommendation to people who are trying to solve this puzzle right now?

SMYSER:
I think living through this is going to create some fundamental changes to how we approach health broadly, and immunizations specifically, in this country.

So, we are already seeing state health departments and some city health departments stand up teams to identify and monitor and respond to misinformation and disinformation—purchasing media monitoring software off the shelf, or, in some cases, creating their own tools, or using tools with other organizations—and very quickly learning the trade of responding in real time, making those editorial decisions on, "Do I inform the public about this or in, so doing, am I making it worse and adding fuel to the fire?"

Those are skills that are acquired over time, and people in public health have not historically been responsible for that. That is much more than the domain of news organizations, and researchers who study propaganda and disinformation. It's not something taught in schools of public health. So, that's another example of very quickly learning on your feet that's going on right now.

I think another thing that we are going to need to see is we saw a lot of community organizations stand up and do the extra work of getting people the right information and getting them vaccinated. And I hope that we see those organizations continue to be supported and empowered. And that would be, like I mentioned earlier, a very different way of doing public health than we have in the past—usually it's just your health department.

So, those two things I do think we need to hit misinformation and disinformation head-on. I think not doing so is a luxury we no longer have.

I think we're going to have to decide as a culture and as a society what we do with the identifiable individuals and organizations who spread disinformation. In many cases, they are not hiding in the shadows; they want to be known because they want the influence or the money that comes with what they're doing. And so, we have to decide what's our role there. Does the FCC play a role? Does the FDA play a role as they do with other false health information that's monetized?

We need to stand up a new field of public health called infodemiology—doesn't exist right now, but we need you to be able to get a master's or a PhD in infodemiology, the study of infodemics.

There's a lot that needs to be done and that I think will be done. So, in some ways it's a very exciting time. There's so much new happening altogether all at once, but it's also a very daunting time, I think for the same reason.

JOHNSON:
Rapid response was at the top of your list of things we should do or need to do, but that's generally, traditionally, not baked into the DNA of government. In general, it's always the last to respond.

It would seem to me that teaching departments—governments—how to be more like political campaigns would be in their best interest in the long run, don't you think?

SMYSER:
I do think that. And I think a challenge there not only is we do not have the institutional memory or knowledge within public health to train people yet how to enter this field, but we also have the challenge of news deserts.

So, the field of journalism that was with fact checking and informing the public on these topics was capable of doing rapid response to misinformation and is currently—was gutted prior to the pandemic and has been gutted more so during the pandemic. So, we've lost a lot of journalists during a really critical time.

And we also have a growing patchwork of news deserts in the United States. So, these are areas where people have no source of local health information, no source of local news in general. And in those areas, there may be a local health department but that local health department, again, has not ever played the role of informing the public in this manner, in this rapid response kind of manner, nor do they have the resources to do so.

So, this interplay between the fields of journalism and the fields of health communication—we are still figuring that out and what that dynamic needs to be and where is there overlap and where is there a distinct scopes of work.

So, I don't have the answer there; but I think, speaking for public health, we don't have the luxury of hoping that this is going to be handled by our friends and colleagues that are journalists. I think we have to figure this out on our own, presuming that we're not going to have that help. And that is, again, that's a fundamental shift, that's a sea change, in how we do our work.

JOHNSON:
I don't want anyone listening to think I was suggesting public health needs to operate like a political campaign in the truest sense.

What I meant by that was learning how to answer more quickly, how to deal with things as they come through the door and address them sooner than three or four or five days from now. That's what I mean by that.

SMYSER:
Yeah. And I think another similarity in what political campaigns are, and political organizing is in the DNA of that sort of work, that you understand there is no one message for everyone. People need to hear things that are going to resonate to them specifically, and all of those messages need to ladder up to your platform.

That's not something I think my field has done particularly well in the past. So, I think it's another example of another field where we can learn a lot. There's good lessons out there in areas other than public health.

JOHNSON:
If departments listening want to be proactive, if they wanted to engage now—maybe they haven't done much so far—what are two or three things they could do without having to ask for more money?

SMYSER:
Well, there are free tools out there.

My organization, Public Good Projects, or PGP, runs one of them, but it's not the only one. That tool is called Project VCTR—it's projectvctr.com, anyone can sign up who works in public health or healthcare journalism—and that tool provides you with a summary of the misinformation and disinformation currently circulating along with resources that pertain to what to do about it. And it's updated in real time, and then once a week with more context. Again, that's not the only tool, but it is one.

There are big initiatives that are out there. There are excellent resources. First Draft News, I would say, is a leader in the space for fact checking, lots of excellent trainings. Stanford Internet Observatory does excellent work on misinformation and disinformation around campaigns and the pandemic in general. It can be hard to find all of these resources. They're not all in one place, and everyone is so busy these days—nobody's keeping an index of every great initiative that's out there. But those are few of them.

I think in a way, too, there are some new things that we need to learn how to do, and there are some new places we need to learn exist.

On the other side of it, it also comes down to the doubling down on what we do excellently in public health; and that is we know our communities better than anybody. And we know the community organizations that reach priority populations in our communities often better than anybody.

And so, going back to the tenets of community health, the tenets of shoe-leather epidemiology, and building those coalitions and leaning into those coalitions and being comfortable taking a back seat to community leaders who may not be health professionals—in many cases, they won't be—and allowing them to speak on our behalf.

I think that kind of work is, in my view, that's how we're going to get through this is empowered communities and empowered community members. And we can be the technical assistance providers and the background and the subject matter experts in the background. The recognizing that it's become so clear during this whole thing, that subject matter expert means a lot of things now, and there needs to be a whole bunch of different kinds of subject matter experts around the table, not just the public health one.

JOHNSON:
Do we also need to realize or accept the fact that disinformation, misinformation, is here to stay so we might as well learn how to deal with it?

We can’t ignore it and hope it goes away?

SMYSER:
I'm all for better regulations of social media and tech companies. I think that's work worth doing. I don't think that's going to entirely solve the problem.

I think the anti-vaccination movement is now a political movement and it's reflected in the platforms of major political parties and members of those political parties during their campaigns. This is something that we're going to have to contend with for a really long time now in this country.

That's one element. And then you have individuals and organizations that are too heavily incentivized to create this stuff, this misinformation, to ever stop, unless they're forced to.

And what we've also seen is a convergence. It's not just your old fashioned anti-vaxxer who thinks that there's mercury in vaccines or that vaccines cause autism—that's a quaint notion.

Nowadays, it's people who are anti-government, are conspiracy theorists. They're anti maskers, they're anti-vaxxers, they're white nationalists. There's a whole bunch of different groups that never spoke each other before that are now all using the same talking points and showing up at the same rallies and signing up to the same email newsletters.

It's a much bigger problem than it used to be. And they're much savvier because they've all been stuck at home like the rest of us with a lot of free time, and they've learned how to do what they do better. And a lot of them didn't stop showing up in person, unlike us in public health.

So, I think if you add that to massive confusion—ongoing confusion and concern and information seeking—from everybody and you add it to, regardless of which side of the aisle you are on, the perception is a very bungled federal and state response to the pandemic. That's people's belief.

And so, we have to now re-earn trust and double down on trying to make our decision-making very transparent and clear and honest, and that's not something that's going to happen in a few months or a year. That's a legacy now that we're going to have to contend with, and it's going to take real effort to claw our way back from some of that.

JOHNSON:
Wrapping up here, if the audience remembers one thing from this conversation, what should it be?

SMYSER:
I think that misinformation and disinformation is here to stay, and it’s now the work of public health. We decided that climate change was the work of public health, we decided that violence was the work of public health—this is now the work of public health, whether we like it or not.

And we are not enough people and we do not have enough resources to tackle this problem on our own, and we need a lot of partners and stakeholders and allies to mount any kind of effective response.

And that is supposed to be what we're very good at doing. Public health people know how to work in teams. So, I think we just need to build some new teams.

JOHNSON:
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For Public Health Review, I'm Robert Johnson. Be well.