Dr Audiey Kao: So, public health emergencies like this pandemic heighten several challenges in risk communication, including providing trustworthy sources of information, reaching underserved populations, and minimizing fear and confusion. However, in emergencies, information may not diffuse equally among all socioeconomic groups, and gaps in knowledge can increase, given the Internet divide. So, what can public health professionals and policymakers do to help address these knowledge gaps during this pandemic?
Dr Vish Viswanath: Mmhmm. Right. So, if there is one thing that keeps me awake in the night, this is it: the issue of equity. We have seen that clearly with COVID-19, where we did not even ask the question: who is being affected disproportionately by COVID-19? And when we finally began to ask those questions, we realized, as a society, collectively speaking, that certain groups in our system, our communities, were disproportionately affected. The interesting thing, Dr Kao, is these community groups have been alerting us, have been raising this issue of what has been happening in their respective communities with COVID-19, but nobody bothered to listen to them.
Viswanath: Right? So, that, to me, is the issue. Why didn't we pay attention to that issue from the very beginning?
Viswanath: Knowing what we know that there are profound health disparities, and these disparities are persistent, why didn't we ask that question?
Viswanath: And so, there are two things to do. And of course, we have been, in our own group, raising the issue of digital divide for many years now, almost two decades. And over the last few years, some people have not taken us very seriously, saying that the divide is closing, and therefore, it's not a problem. [coughs] Excuse me. And then we realized, when we started talking about remote learning, we suddenly realized that we, in the sense collectively again, that certain households are not equipped appropriately for remote learning. That's not a shock to some of us who have been working in this area for a long time, right?
So, I think we should start with the premise from the very beginning that all public health emergencies will affect different people differently. Certain groups will be disproportionately affected adversely because of emergencies, number one. That's the first thing we should acknowledge. Number two, we should put policies and practices in place before the emergency occurs, right? You can't make up stuff, create structures after the onset of emergency. That's what preparedness is about, as you know. You've got to have these policies and practices ahead of time with the anticipation that these emergencies will affect different groups differentially. And then you have to, part of that is how do you create a system in place where the groups that are likely to be adversely affected disproportionately—minorities, those from lower socioeconomic position, right, maybe undocumented workers—anticipate that they will be affected and put in place systems to make sure that number one, we are listening to them. How do we get them to the table so that they can help us listen and design the solution from the very beginning? Not bring them in later after everything has been decided?
I think COVID-19 has taught us one lesson. I mean, we don't seem to be learned and learning this. Every time there is a public health emergency, we seem to discover this problem again and again, as if it's new.
Viswanath: We know this from our work over the last three decades. We have been, all of us have been, working on these preparedness issues. I think we need to, number one, have them and create a system right from the beginning. Anticipate this emergency will occur, create a system, and make sure they sit with us at the table as we start collecting data and start developing solutions.
You know, this is, the last, I want to make one point before I stop here. The idea of data absenteeism has not taken root, which is very unfortunate. We always rely on data because that's how we develop evidence.
Viswanath: But all of our national surveys, the major surveys we rely on, the major databases we rely on do not have sufficient number of poor people, sufficient number of minorities in our samples. And so, when we don't have enough people in our data, which we call as data absenteeism—others have called it too—it creates a real problem. So, we really need to make sure that we collect these data regularly from these groups and ensure that we give these data back to them in a way that they can use it, in a way that we can develop policies and practices that can be helpful to them.
Kao: Yeah, no. I think your points about preparedness and listening and bottom up, so to speak, that's the right way of thinking about it, or at least talking to people who are in these communities that we know are going to be disproportionately affected from any type of kind of public health threat. And the COVID-19 pandemic is no different than that. And so, I think your points are both sobering and hopefully, lessons that we will learn going forward. If I can maybe go back to something you had talked about earlier in our conversation about shifting the burden from individual actors to institutional actors, given the accessibility of social media platforms, the ability to post information for public consumption is in millions, if not billions of people's fingertips. Given that, what should companies like Twitter and Facebook do to maximize the benefits while minimizing the harms of this democratization of information?
Viswanath: I think this is a very important question. The people, most people, don't have bad intentions. When I hear something that is interesting that I feel other people in my network will also be interested, I forward it. I post it. I'm finger happy, or trigger happy, or finger happy. It takes me very little effort, maybe five seconds to forward something to my network. And my intention is to amuse or entertain my friends in the network or to share something I know that I feel they should know. So, you cannot, if you take 60 percent of the people or 70 percent of the people are on Facebook. 60 percent of the young people are on Instagram. Facebook is, what, a couple of billion people. You cannot teach each and every person not to forward everything that they see, right? It's very difficult. So, who can do this?
I do think the platforms have the computational prowess and resources to do this. They are obligated now to some extent, and up to a point, I would argue, now they are like a public utility right?
Viswanath: They are like an electricity; they're like water. Right? That means, I'm not saying that information should be censored or regulated. But given the immense reach they have, given the immense power they have, it is their obligation to use the computational resources they have to counter these things. They cannot keep blaming individuals and putting the responsibility and burden on individuals to counter the misinformation. I totally, completely agree with some people who have said Facebook or Twitter or others should step forward, and some of them are stepping forward. Twitter is a good example. They are taking tentative steps to counter these things. But is it sufficient? We don't know. Is it sufficient to just flag these things, or should there be more that needs to be done? That could be a part of the public discussion, but they should not be in a discussion and don't say that there are obligations. They have a duty to come forward and do it.
Viswanath: And any reason, any claims they are making that they cannot do it is only an excuse at this point.
Kao: Yeah. So, switching gears a bit from the information technology platforms like Twitter, Facebook, Instagram, to talking a little bit more about human motivation, which I think you started to allude to, about people's intentions in terms of why they post certain things on their networks. Scholarship on media sociology describes a distinction between gatekeeper and advocate journalism. So, gatekeeper journalists emphasize objectivity and the separation of those facts from opinions and commentary. In contrast, the advocate journalist is a critic and interpreter who strives to present all viewpoints, is sensitive to social injustices, and often develop their stories with an eye towards addressing those injustices. In today's information landscape, we have many so-called citizen journalists whose motivations may or may not be in keeping with what I just described. So, should we and can we counter stories generated by citizen journalists that may undermine and threaten the health and safety of the public?
Viswanath: Mmhmm. Yeah, so, you know, the advocacy versus so-called objective nature of journalism, the gatekeeping function, I think it's a nice typology. I am not sure whether it ever existed. I think the very famous sociologist Morris Janowitz talked about it. It's a nice contrast, but journalism always fell in between. The lines are somewhat blurred. I think what social media have done, has blurred that line, those lines completely, right? Internet has done that. There is no difference between work and home. You can't switch off at 5:00 and say, okay, now I'm not going to work. I think what Internet and social media have done is it blurred those lines on variety of aspects of our lives. And journalism is no exception in that.
Now, on the one hand, the Floyd murder in Minneapolis would not have happened if there were no videos. It's a good question to ask. Would we have taken it as seriously? It was so heartbreaking to see it right in front of our eyes, as if we were a part of the scene in Minneapolis, right? So, to that extent, ordinary, regular events and videotaping by people has actually highlighted the problems, particularly with those who don't have power. So, our African-American colleagues have always raised the issue of systemic racism, and the challenges African Americans have always had with the police. But how many of us have taken it seriously? You know, we did, but have taken it seriously enough to do the kind of actions we are taking today to make, right? On the other hand, what this has done is uncovered them and demonstrate to us that this is a reality. This is what's happening every day of their lives, right? So, to that extent, I don't see a need to counter it. In fact, this kind of a citizen journalism, citizen participation in production of information and the phrase you used, “democratization of information,” I think is actually a good thing. Because the barriers to production of information have come down, so it's not the elite few, educated few who are controlling the production and dissemination of information. Now, anybody can do it. So, to that extent, it is great news. To me, that is actually the most salutary part of the recent technology developments, I think.
Now, the question is, of course, the good will always come with the bad. And certainly, I think you will see, I know there are, you know, all you have to do is go to YouTube or other places. That are videos which are totally counter to any scientific evidence on any medical topic you pick. My reaction has always been, on these issues, you cannot control it. The horse has left the barn, so to speak. But we can manage it. And the only way to manage is what I have been saying all along, which is developing the institutions, developing the practices among existing institutions to take a much more aggressive and active part in it and not sit back, but be very proactive. This is what I mean, our institutions, whether it's AMA, APA. Other organizations that have a lot of credibility, a lot of resources, lot of expertise within them should be much more proactive in doing this.
Some of them may be hesitant because their job is to provide objective, science-based, evidence-based medical care. But at the same time, they have an obligation because they are the most trusted people, I think, you know.
Viswanath: So, whether it is universities, whether it is organizations, we should all work together with community groups to counter these things when warranted.
Kao: No, I think you make some excellent points. So, as we near the end of our interview, I'd like to focus on COVID-19-related information that is posted by the U.S. President on his Twitter account. Regardless of what motivates his tweets, what communication advice can you provide public health officials in an environment where false and misleading information is coming from the President of the United States?
Viswanath: Right. So, people's reactions have varied on these tweets from amusement or entertainment to outrage. And certainly, these tweets, because they are from the President, get a lot of attention what people are calling to share of the voice. They almost suck up the air and that environment. So, if you think of a bandwidth, there is a limited bandwidth air space. And so, what will you fill in that limited bandwidth? What kind of information these kinds of tweets will take up so much air space because it's just not the tweets. It is an incessant saturation coverage that these tweets receive, both the debunking them as well as the repeating back, right?
Viswanath: I think the reputation has its disadvantages. As I said when he tweets, it's just not his followers. But unfortunately, when it is covered in the media, the rest of us all become aware of those tweets so that the falsehoods get repeated, unfortunately. Now, our journalist colleagues will say, how can they ignore it? It's the President of the United States. It is having one significant, unfortunate impact that in practice, which is increasingly countering the authority of those who are in medicine and public health. And it's undermining their authority, unfortunately. And I think all of us have an obligation. It doesn't matter whether you are the President or whether you are an ordinary, regular person. It doesn't really matter. In fact, it's a greater obligation to counter. As I said, it's very difficult to chase every tweet out there. But at the end of the day, you have to think about your own professional obligations. What is my obligation to truth? What is my obligation to evidence? What is my obligation to my profession? And counter it.
It becomes that much more important because it is an authority figure. If it is a regular citizen, person on the street, so to speak, maybe she or he may not get that much traction, so it's not that, something to worry about. But certainly, when somebody at that high an authority level does it, it's important.
Again, it becomes very difficult for individual physicians to do this. But collectively, the institutions have to do that. And some people are doing it. Several institutions have gotten together—media, fact checking organizations, medical organizations have gotten together—to counter these tweets when warranted, when they become egregious. And it is unfortunate because I think it is having some deleterious, negative impact. But again, we can't control what motivates somebody to do what he does. But we have to now manage with that by being very proactive and countering it, you know, so.
Kao: Yeah. Well, on that professional call to action, I want to thank Dr Vish Viswanath for sharing his deep expertise and insights with our audience today. Vish, thank you for being a guest on Ethics Talk.
Viswanath: Thank you so much for having me. Enjoyed it.
Kao: For more COVID ethics resources, please visit the AMA Journal of Ethics at JournalOfEthics.org. And to our viewing audience out there, let's speak truth to power during this COVID-19 pandemic because lives depend on it. Be safe and be well. We'll see you next time on Ethics Talk. [bright theme music plays]
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