Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff. This episode is an audio version of a two-part video interview conducted by the Journal's Editor in Chief, Dr Audiey Kao, with Dr Vish Viswanath. Dr Viswanath is a Professor of Health Communication in the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health. He joined us to talk about the digital spread of health misinformation and falsehoods during the COVID-19 pandemic. To watch the full video interview, head to our site, JournalOfEthics.org, or visit our YouTube channel.
Dr Audiey Kao: Dr Vishwanath, thank you for being a guest on Ethics Talk today. [music fades out]
Dr Vish Viswanath: Thank you for having me. Delighted to be here.
Kao: So, spreading health-related falsehoods is far from a new phenomenon. The peddling of snake oil and other quack remedies dates back centuries. In fact, in 1849, the American Medical Association established a board to analyze quack remedies and to enlighten the public about its dangers. Physicians have long served a learned intermediary function for patients. But the speed by which misinformation can spread through today's digital media ecosystem can overwhelm any information gatekeeping, especially during public health emergencies like a pandemic. So, what should individual physicians do in response to the viral spread of health misinformation via Twitter, Facebook, and other digital media channels? For example, what can be done to refute misinformation without drawing more attention to it?
Viswanath: Thank you for that question. So, it's very difficult and maybe unfair to put the onus on individual physicians, given almost 90 percent of American population and others populations are on some kind of a social media platform. It would make it very difficult for them to chase every bite of misinformation out there and then try to refute it. I think that's almost an impossible task. So, what can individual physicians do? I think physicians remain the most trusted source on health information. That has not changed. So, that's the good news for us. So, at the end of the day, when there is a physician/patient interaction and the patient raises any myths or any questions, any doubts, I think it's a great learning opportunity and a great opportune moment for physicians to counter that myth and counter and educate the patient.
However, I think the challenge remains that the physician/patient interaction is very limited right? So, on any given month are a given week, I think we go to physicians either for a routine checkup or if we are sick. So, the opportunities to intervene are limited. So, I think my own feeling is that we have to shift the burden, if you will, from individual physicians to a more collective mobilization of physicians, such as AMA or other networks of physicians. And the reason I'm saying that is, given that there is tremendous credibility attached to physicians and the trust people have in physicians, it's very critical that they do not sit on the sidelines, but actively and aggressively intervene whenever it is warranted. That means certainly, individual physicians can play a role when there is a moment, an opportune moment. But it is more important, too, for physicians to mobilize collectively to counter these myths, I think. And that means it's very critical networks and organizations such as AMA become more important as gatekeepers and as arbiters of sound and fact-based, evidence-based information.
Kao: Yeah. So, reflecting on what you just said a moment ago about the ability and obligations of individual versus institutional actors, certainly in terms of the health care and medical field, here's a sampling the number of Twitter followers among different account holders. Barack Obama has 120 million. Justin Bieber, 112 million. Donald Trump with 83 million. Kim Kardashian has 65 million. The CDC, which in many ways is a medical/public health institution, has almost three million. You have about 600, and I have zero Twitter followers. So, to say there is asymmetric reach between health professionals and those in politics and entertainment would be an understatement.
Kao: So, how can health professionals and policymakers address the challenges, and possibly some of the opportunities, presented by this asymmetry to better inform and engage the public on COVID-19?
Viswanath: Mmhmm. That will always remain the case. There will be some exceptions when physicians have huge followers, but those are only exceptions. So, some of the physicians who are now on network TV, for example, or cable TV could have more number of followers. And so, I don't think we can ever compete with that, given the nature of our work and the jobs we have, not just as a physician. I'm talking about myself as a social scientist and physicians too. They have a day job. We all have a day job. And that's not being on Twitter and tweeting on Friday nights.
Viswanath: But given the credibility, so there are two things. What I am asking for is a somewhat more sophisticated look at this perceived impact of social media. And there are a couple of ways to think about it, right? So, one is, even if these people have a lot of followers, that does not necessarily mean that every tweet on every topic they tweet on will be believed, right? Their followers will believe them and follow them for certain reasons, for entertainment value. So, maybe the latest fashion, right? The latest outrageous tweets. But if they go out of their expert realm and start talking about something else, people may very well question it, right? So, they stay in their lane, which is not always a desirable thing. But what I'm saying is, and we can come back and talk about it, but so, that's one thing. So, not every Twitter follower they have doesn't mean that they have pronouncements on some of the things you and I are worried about. COVID-19 will have a profound impact, I think. It will have a big impact. But not too far.
The second thing is, we don't have to easily give up because the physicians, as a group, have tremendous credibility. And journalists, when they cover news, do rely on physicians.
Viswanath: When we talk about gatekeeping function, I continue to think, and I continue to bemoan the fact that journalism, especially local journalism, is waning. But journalists, national journalists, still remain important and critical gatekeepers. And certainly, we can influence through that gatekeeping function of journalists. And that's why I was originally proposing this idea, that even if an individual physician may or may not have a huge following, he or she has the ability to leverage the power of institutions because of her or his credibility. So, whether it is AMA, whether it is major mainstream media, and other organizations, they have the cover. They have that credibility. And that's one way to counter these people who have larger following and who are misleading people and ensure that you have a larger reach to spread as much as possible evidence-based information.
Kao: Yeah. No, I think you make some excellent points. And I'm thinking about the points you've made about public confidence and trust in physicians. That's still fairly high. And this notion of kind of staying in your lane.
Kao: That said, health misinformation on the Internet can sometimes come from health care practitioners.
Kao: For example, there are physicians who perpetuate false beliefs about the safety of vaccines.
Kao: What can and should be done to counter misinformation from health care practitioners?
Viswanath: Right. So, this is really a very critical issue, I think. Those two letters at the end of the name, MD, matter a lot. And we have been already, we have been discussing this notion of credibility.
Viswanath: And certainly, when a physician and a person with M.D. after her or his name comes forward and mistakes something, it carries weight. Particularly many journalists are very sophisticated, very thoughtful, but certainly, sometimes they do feel obligated if there is a counter medical with a doctor questioning something that is conventional wisdom. And that's how we are seeing, we have seen the anti-vaccine toots take hold, or beliefs take root or take hold when Andrew Wakefield, with those two letters to his name, started spreading this misinformation. But let us remember this: a physician can do it, not by himself or herself, but also with the abetting of other institutions. In that case, Lancet, which published that paper without asking the questions. And that's sort of magnified, I think.
Viswanath: So, that's one issue. Countering them right away is important there, right? The institutions have to be very responsible: journalism, journals, etc. The second issue is, of course, they don't need to publish in journals. These days, we have seen this COVID-19, the very pre-prints, for example, right?
Viswanath: So, where this, I think the challenge we are finding with COVID-19 is particularly interesting because now we are publishing papers without that kind of a rigorous review, particularly when the science is changing so fast. And I, as a physician scientist can publish a paper. But while waiting for a review, I can put it out on Twitter, right, as if it's news. I think that's where it's very critical for physicians, physician scientists, to counter it right away. We know that they should not repeat it, because by repeating that misstatement, it will plant a seed in people's minds. But without repeating that falsehood, they can still actively and aggressively counter it. And that's really critical because they have the credibility, and they should not let it lie out there in the public arena. Obviously, they cannot chase every myth, every false hope that is out there, but the critical ones should be countered, should be questioned, because I think that should not remain uncontested, so.
Kao: Yeah. No, I think you make some excellent points and that clearly, there's, in some ways, a confluence because obviously, misinformation about vaccines predated this current pandemic. And there seems to be an emerging confluence of these misinformation currents that we're having to deal with, especially when we get hopefully, a vaccine against COVID-19 in 2021.
Viswanath: Mmhmm. Yeah, I think it's very critical for us. And the confluence, in fact, I think it's an interesting choice of words, and I have used that to the confluence of interest. I think what is unusual now we are seeing is this anti-vaccine, anti-vaxxers and anti-vaccine people with anti-vaccine beliefs, people with Second Amendment beliefs, people with very conservative politics, almost reactionary right-wing politics, they're all coming together and finding some kind of a common cause, questioning government authority and government public authorities, I think. And that will make it a challenge if and when we have that vaccine. Obviously, we are several months away, at the very least, from a vaccine.
But it does become an important issue to what extent the vaccine that will be introduced will fit into, will it fit into the conventional narratives of the anti-vaxxer beliefs? In which case, a lot of people will refuse to take the vaccination. Or does it fit into a newer narrative? And that becomes very critical. The newer narrative is now we have a solution to get back to your normal routines and normal lives. Get back to that livelihood. The false debate between life, I mean, livelihood and life, I think can be countered when we say if the introduction of vaccination can now potentially let us get back to the normal. And also, I think which narrative, which frame wins is very critical. And we have to be prepared for that.
Viswanath: I can tell you today, there are people already waiting to talk about why COVID-19 vaccine is not important, and it's a false thing. And so, we have to be very aggressive. One bit of good news for us is that if indeed we have an effective vaccine, a lot of people are anxious to go back, you know? 60 to 70 percent said they will get vaccinated, 60 percent, 70 percent, depending on the subtle way. And then I think, so, it's not all bad. It's a question of pushing the other 20, 30 percent. There will always be 10 percent who are anti-vaccines. There's not much you can do. But given how much it has disrupted our lives, my assumption is that a lot more people will be open to get the vaccine.
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