 A good number of people. Okay, so I want to welcome everyone to the always very interesting and well attended health policy and bioethics consortium today we're going to be talking about health information or sorry health misinformation. My name is Aaron Kesselheim and on behalf of Leah Rand, and myself wanted to welcome everyone to and thank you all for joining us today for what I think will be a really interesting conversation. Just as a reminder on a technical level. We are going to be saving some time at the end of the conversation today for for Q&A with the audience. You'll see a Q&A button at the bottom of your screen please submit questions to the Q&A feature. Feel free to submit them during the course of the conversations and then way our moderator will be able to see them and get to them at the end of the 90 minute period. We are, as always very Twitter savvy here at the program on regulation therapeutics and law and the Center for Bioethics. And so if you have if you do want to live tweet about anything that you hear today, please use the hashtag policy ethics. If any technical issues come up please use the chat feature. But if you have questions please submit your questions to the Q&A feature, use the chat feature only for technical issues. And as always if you are interested in the programming at the Center for Bioethics, you can see the link down there to be added to the to the email list. This consortium is a monthly consortium that we run here. The goal is to try to dig into key issues in the health care system and public health. Bring together experts with different perspectives or experiences to discuss these issues and propose solutions, and ultimately to try to stimulate conversation and further academic study of the topic. So a preview for what's coming up in this session in the future. We have next month's session is a is a combined meeting with the bioethics research consortium at the Center for Bio sorry the the by biotechnology research consortium at the Center for Bioethics. And we're going to be talking about using gene drives to reshape our environment and the health and ethical implications of that. And then next year, our agenda is already starting to shape up we're going to take the month of January off and then come back in February with an event co-hosted with the law school, focusing on using technology in the home, and then access to productive technology, and then in April, a conversation on supplying international health with former World Bank President Jim Kim. But today, we are going to talk about health misinformation and I would like to introduce our moderator Michael Sinha, who is then going to take an opportunity to talk a little bit about this topic and introduce our feature discussions for the day. Michael Sinha is a physician and lawyer who also has a degree in public health. He is a former fellow here at the program on regulation therapeutics and law and is now an affiliated researcher with our group. He is a former fellow at the Harvard MIT Center for regulatory science and teaches widely on public health and intellectual property law issues, and is, is a perfect person to talk about this given how much he has thought about and published around trying to provide accurate information about health care products to patients so Michael thank you very much for moderating today and for kicking off our session. Perfect, thank you, run see my slides. And, although they're not in slide mode yet. Now you had just I think you're just at the very end. At the end. Okay. No wait, that's the beginning that was the first slide my mistake sorry about that Mike. Yeah, all right, so this, this conversation is going to be dealing with health and misinformation in the coven era. So, some may believe that this conversation really starts out with the election of President Donald Trump in 2016. Soon thereafter, there was an article and I think a general consensus among policymakers that the administration was ill prepared for a global pandemic. Enter the first major test, which was the coven 19 pandemic, starting in early 2020 in the United States. Trump made an issue of raising and really challenging the news media, bringing up this issue of fake news. That narrative got translated very quickly into the narrative for coven 19 as you see here this gentleman holding a sign fake news is the real virus. So, this led to a lot of coven 19 misinformation, one of the primary vessels of disseminating this misinformation was through social media channels like Facebook, private Facebook groups, that sort of thing. And so I'd like to break this down and talk a little bit about the various aspects of coven 19 and introduce you to some of the misinformation that has been spread. So the first was one of the first things we learned about coven 19 is how long the new coronavirus lived on surfaces. And so this really in my eyes triggered a belief that we needed to really clean surfaces to eradicate coven 19. So, a hygiene theater, wiping down groceries, putting mail in a corner for three or four days before opening it, that sort of thing. Soon thereafter, you saw the World Health Organization and other public health entities, arguing that coven 19 spreads primarily from person to person, and really focusing on droplets as the primary mode of transmission. And really later, that the conversation really moved to aerosol transmission of coven 19, and the conversation expanded to focusing on ventilation and filtration, especially in indoor spaces. The, the misinformation cycle was quick to call this airborne coven 19 and discovery false. It became an ongoing talking point. And what what they essentially did was they took the evolving science and the evolving understanding of coven 19 and protections that are needed, and really turned it into something like this something like a meme, where we took Dr Anthony Fauci who has really been seen as one of the, the leaders at the forefront of our coven 19 response in the US. Starting out in March 2020 when he was quoted as saying there's no reason to be walking around with a mask by April, the narrative changed Americans should wear face masks. And then by January of 2021 double masking just makes common sense. And by highlighting this evolving and changing science. I think the intention here was to raise questions about whether or not the scientific community really knew what it was talking about. You saw a lot of concerns about First Amendment claims, the idea that masks are muzzles that people should be allowed to choose whether to wear a mask, unmasking or masking of children became a hot button item. And you'll see right here in the center. This really got linked to the reelection campaign of President Trump. So misinformation about treatment. We started out with a President Trump at a press conference, noting and I quote, I see the disinfectant that knocks it out in a minute, one minute. And is there a way we can do something like that by injection inside or almost a cleaning. So he is of course referring to the survival of COVID-19 with disinfectants on surfaces. But as you see here, some of the health officials in his administration were frequently dismayed by the tone and nature of his comments and speculations. President Trump also admitted to taking hydroxychloroquine as a prophylaxis for COVID-19. It took a number of published studies to reiterate the fact that hydroxychloroquine does not prevent illness or death from COVID-19, nor does it treat COVID-19. We quickly moved on to another narrative. The idea that Ivermectin, which is essentially a horse deworming agent used in animal facilities, would be useful as a prophylaxis and treatment for COVID-19. As you'll see here, Ivermectin will only be sold to horse owners, must show pick of you and your horse. And then on the right here, the FDA felt like it had to weigh into the situation and tweeted on August 21st, you are not a horse, you are not a cow, seriously, I'll stop it. Misinformation about vaccines also became extremely rampant as well. So we had two extremely successful early mRNA vaccines, one produced by Pfizer and BioNTech, the other produced by Moderna. And then we had an adenovirus vaccine that was produced by J&J. The narrative increasingly turned to resisting vaccines. Hashtag say no to Bill Gates, there is this concern that Bill Gates was somehow involved in a larger conspiracy. COVID-19 vaccination equals death. So a lot of these narratives challenging the fact that these safe and effective vaccines were proven and really driving people to resist being vaccinated in the US. Same thing here, this concept and idea that Bill Gates is injecting 5G or something along those lines, right? This continues even to today. And so just last week, Green Bay Packers quarterback Aaron Rogers identified that he was immunized earlier, several months before, but reportedly did not receive a vaccination. However, what he was taking was zinc vitamin C and ivermectin. And so the question I think would be interesting to start with and flush out here is this health misinformation a larger problem that predated COVID-19. And so I found this book that was published in 2017 by Professor Tom Nichols, the death of expertise. Professor Nichols argues in this book, the bigger problem is that we're proud of not knowing things. Americans have reached a point where ignorance, especially of anything related to public policy is an actual virtue. It is a new declaration of independence. No longer do we hold these truths to be self-evident. We hold all truths to be self-evident, even the ones that aren't true. And he continues to reject the advice of experts is to assert autonomy, a way for Americans to insulate their increasingly fragile egos from ever being told that they're wrong about anything. And so the question we're going to discuss in more detail today, how do we address health information? We'll watching this talk save your life. Let's find out. And so we have two esteemed panelists with us today. Professor Wendy Parmet is the Matthews Distinguished University Professor of Law and the director of the Center for Health Policy and Law at Northeastern University School of Law. She also holds a joint appointment with Northeastern University School of Public Policy and Urban Affairs. Professor Parmet is a leading expert on health, disability, and public health law and directs the law school's JD-MPH combined degree programs. She has published articles on public health, bioethics, discrimination, health law, and AIDS law. She is co-author of two textbooks, Ethical Healthcare and Debates on U.S. Healthcare, and is the author of Population's Public Health and the Law. Professor Joseph Capella is the Gerald R. Miller Professor Emeritus of Communication at the Annenberg School of Communication at the University of Pennsylvania. Professor Capella has been a visiting professor at Northwestern University, the University of Arizona, and a visiting scholar at Stanford University and the University of California, Santa Barbara. His research has resulted in more than 200 articles and book chapters and four co-authored books in the areas of health and political communication, social interaction, nonverbal behavior, media effects, and statistical methods. The articles have appeared in journals of psychology, communication, health, and politics. And with that, I will turn it over to our first speaker. Great. Let me share my screen. Okay, have we seen the screen? Okay, great. So thank you for the opportunity to come here to talk to you today about misinformation and thank you, Michael, for that very useful introduction to some of the history that has been a part of all of our lives here for the last 18, 18 months regarding misinformation. This is obviously a big topic, and it's a topic that is difficult to encompass in just a short period of time. I will restrict myself to misinformation about the COVID vaccine and COVID era, and not about health misinformation more broadly. It's important, I think, to, it's important to make sure that we are talking about the same things when we talk about misinformation and disinformation and uncertain information. And the sort of standard definition about misinformation is that it is false misleading and inaccurate kinds of information relative to the best available scientific evidence at the time. And the definition that the Surgeon General used in his most recent report on confronting health misinformation. And so the claim, for example, that vaccines will change your DNA is a bit of misinformation. Disinformation refers to misinformation that's intentionally used to spread political and economic misinformation and to gain advantage as a result. Recently, some of the kinds of misinformation or disinformation in this case that occurred in the New York City area was directed at Polish communities and websites that they were using and making the claim that mRNA vaccines were designed to annihilate Christianity in the Polish nation. These were attributed to outside male factors and who are trying to carry out political misinformation and create conflict and reactance in the Polish groups in the New York City area. Uncertain information is a little bit different. Here, the truth value is unclear. So for example, we really don't know the long term side effects of the Pfizer vaccine. And so it's in uncertainty, but it's not the incorrect to say that the long term side effects are not well known. Well, one of the questions that is not whether there is misinformation, but is it still as prevalent as it has been as the pandemic has gone forward and present you here with one slide from an important set of work that's been carried out by the Kaiser Family Foundation. And this slide is about the falsehoods that people have been exposed to that they believe to be true or have heard about but don't know if they're true and know if they're and identify as potentially false. There are eight of them here. And this is a study that was done very recently just third week of October and 1500 adults in the United States, and the eight, the eight pieces of potential misinformation produced a very interesting finding which was that overall that at least that 80% of the population has heard at least and found to be either true or not sure that it's false 80% of the population has found the at least one of these tidbits of information misinformation to be acceptable. At least 80% still a foot and a third of the population has accepted four or more pieces of misinformation as true. So, for sure, misinformation is still a foot in the United States, and it hasn't, it hasn't gone away as the pandemic has changed over time. And it's one thing to say that misinformation is is public problematic it reflects sort of falsehoods that indicate misinformation, and we all kind of presume that misinformation is consequential to behavior such as the intention to obtain a vaccine vaccine or not. And certainly there is this is another slide from the Kaiser Family Foundation study that I just presented to you. And if you look at the first pair of lines, indicating COVID-19 vaccination status that compares the vaccinated to the unvaccinated. What you see is unsurprisingly, that 64% of the unvaccinated in the sample had four or more of the false statements that they did not identify as untrue whereas the vaccinated were, you know, far lower in terms of the number of false statements that they accepted. Other kinds of differences obtained that are consistent with some of what we just we just heard about with the Republicans having many more higher rate of for more false statements, rural and lower educated groups in the society, being more likely to accept the false information. So it would seem to suggest that in some ways, the misinformation that is present isn't is misinformation that would be consequential in affecting people's intentions to become vaccinated. But, and this is the title of this of the next slide, just because the two things are associated doesn't mean that there's a causal causal relationship. And a lot of the data that we have about misinformation and vaccination rates and beliefs and other unfavorable consequences is information that is really just associational. There are a few studies, one of which came out in October of 2020 that was done in the United States and the, and the United Kingdom, using 8000 cases this was a clinical study showing experimentally exposure to misinformation versus accurate information that indicated that there was a lower intention to vaccinate after exposure to just a few tidbits of misinformation. And these kinds of studies have not been widely widely replicated and this was pre vaccine of course, because it was October of 2020. These kinds of studies have not been widely replicated and the Office of the Surgeon General's statement on confronting health misinformation still holds that there is a kind of more causal association between misinformation and vaccine intent and vaccine, vaccine This slide just indicates what a few of the kinds of misinformation that were used in the, in the experimental study of the previous slide, and they're kind of outrageous bits of misinformation mRNA vaccine will alter your DNA, all the monkeys receiving the coronavirus vaccine contracted the coronavirus. These are hugely incorrect claims that were a part of the prior study showing its effect on on intention so there's some evidence that is not overwhelming or strong that the misinformation that the people accept can have for their vaccine acceptance, their vaccine confidence their vaccine hesitancy, but the data is not as strong as we might like it to be. Now, I think we need to ask about, you know, why is it that misinformation is so common that it's so prevalent in the society at large and I think, of course, the first thing I'm going to do is blame the media. Because the media has a role in communicating this misinformation and I want to talk about two, two media sources, the more legacy media which is the media like Fox News, like the New York Times, the Washington Post, the Wall Street Journal, News and and all their broadcast sources, as well as social media but first of all the legacy kinds of kinds of media. And one of the reasons of course that the legacy media covers misinformation is because it's novel, it's new, and they, they consider it to be a potential threat and so media should cover that kind of threat. So that's one class of reasons that legacy media is covering this kind of misinformation and doing so, fairly extensively. It's also the case that groups like Fox News have a bias that's political. And so they're covering the misinformation because they have a political agenda in mind and they're trying to pursue that political agenda. My concern is the following and it I think was a very nice quote from Charles blow in the New York Times, just about a couple of couple of months ago, which he says sometimes the light you shine on evil also illuminates the path to it. Sometimes publicity is advertising. And the point that blow is making here is that when these kinds of misinformation are covered, and you're doing so because you're trying to do a public service, carrying out that public service also makes that misinformation available to the to the audience. One of the technical ways we we describe this in media effects research is what's known as priming that the that mainstream media is often priming information that is that is misleading and invalid. And even though they may be debunking that information as a part of their coverage, they're still covering it, and it becomes a part of the, the informational base that people have at their, at their disposal. This Kaiser Family Foundation study of the middle of October. This compares several different media sources three highly conservative ones newsmax one American news box news and four more liberal ones NPR MSNBC network news and sort of ABC CBS NBC and CNN. And what it is doing is it's focusing on people who already trust these sources so obviously it's going to be more conservative sources and participants on the top three and more Democratic liberal leaning participants in the bottom in the bottom and what you see here is, again, not terribly surprising, but that the number of false statements that participants who trust newsmax and one American news and Fox News, the number of false statements that they are finding acceptable is substantially higher than is the case for those who are exposed to and trust NPR MSNBC network news and CNN. So this is consistent with what we're expecting to be the case and we've always expected to be the case in the mainstream legacy media in terms of its impact. It doesn't tell us that these sources are affecting people's vaccine intentions or outcomes but it is telling us that it is at least reinforcing and confirming the dispositions that that audience might have. And I want to make the point to you that there are two kinds of effects from media implications. One kind of effect is sort of a direct causal effect where somebody's intentions to get a vaccine are affected by misinformation in the kind of direct way. Another kind of effect that is more confirmatory, where that effect does little more than taken already existing predisposition, a predilection, an attitude and reinforces it with information that is consistent with it. It's a kind of sometimes goes under the name of a congeniality effect. The information is congenial and simply reinforces an existing attitude rather than calling it into question. And that I think is as much a media effect as has not. Let's move over to social media and I'll take a couple of minutes to talk about one study. I don't like to don't want to talk about studies in any real detail but I want to talk about this one because it's a very important one by Vasugi that appeared in us in science in 2018. Initially before the pandemic hit, and this was a study of Twitter over a 11 year period and focused on over 126,000 news stories that had been tweeted over four and a half million times. And what they found in this study in a very carefully done line of work was that lies that were identified as lies by six different fact checking sources moved farther faster and deeper and more broadly through the Twitter sphere, then did truths and truthful and you might say to yourself well did people really know the difference between lies and truth. Truths and the answer was no, but what what what was the case was that the lies were more novel, but the lies were more induced more fearful and more disgusting responses more reasonable is a surprise responses in the recipients and those characteristics that the novelty of the information, what they elicited in others differentiated the lies from the truths and so, in effect what this, this shows is that information is more novel fear, fear inducing discussed inducing and surprise inducing moves more quickly through social media. And more deeply into social media and across more different places than does information that is more truthful and therefore as it turns out less novel and less emotionally, emotionally evocative. So, the presence of misinformation and social media is extensive, but it's not often the result of many, many people generating originally misinformation it's it does seem to be some evidence that there are very small number of sources that account for up to a 65% of the online vaccine disinformation, and one particular actor here that's gotten some attention, perhaps wanted perhaps unwanted attention. Dr. Joseph Mercola in the New York Times has been cited as one of the people who has generated a huge amount of misinformation through through social media. The other thing that is not quite obvious about social media information is that, as it is repeated, as new information that is untruthful is repeated. There is an interesting effect that the repetition alone of unfamiliar information increases the assumed truthfulness of the information. This turns out to be a remarkably robust finding. You might you might put it and say, gee, that's not that's not possible. But when you take into account that the that often this is information that is unfamiliar or not well known to people, then the repetition of that information has it has consequences for how truthful that it seems seem to be. So we have this kind of phenomenon that we, I think all understand to be the case but it is a very significant phenomenon and that is that that lies move more quickly through social media, they move more deeply into and through social and the greater the repetition, the greater the likelihood that those lies are seen as having more truthful character than they would otherwise. Just this past July, as we moved during to the delta era from a period in which it looked like we were going to escape the pandemic, as the number of cases jumped up so did the falsehoods that occurred in social media in from just a June to just June to July they went up 400% on falsehoods about vaccines not working about them containing microchips went up 150% natural immunity up 111% as more useful than vaccine kinds of immunity and vaccines were were touted as as falsely causing miscarriages. So the Delta upsurge essentially reactivated what was going on in social media at the at the time. So why do people believe misinformation. Obviously, we have a tendency as human beings to need to have accurate information, because that accurate information allows us to survive in the face of threats and so on and so on. But misinformation is is believed for a variety of kinds of reasons, some of which are not completely obvious. One of the more obvious is that misinformation is believed in part because it is seen to be compatible with prior beliefs. This is sometimes known in among social psychologists as bias processing or motivated reasoning, but we see it for example in the African American community where a prior beliefs about the abuse of medical system through the horrific Tuskegee experiments undermined at least initially African Americans willingness to participate in in vaccine legitimacy and be greater except being a greater likelihood to accept misinformation, because it bought into their prior concerns about Tuskegee and the mistrust that it that it produced. Also, misinformation tends to tell a a coherent story and coherent to share not a logical coherence or a scientific coherence, but a coherence of ordinary reasoning. So if the story is that big pharma wants you to get vaccinated and they want is and the reason they want you to do that is because they will cash in, and that's consistent with the kind of ordinary reasoning that people have about big institutions in a capitalist society. Also the, the information that's a part of misinformation sometimes have has a little tiny tidbit of truth associated with it. And so, when there's discussion of the mRNA of components of the vaccine, and then linking those to genetic alterations. It's not as far a lead as might be the case, but for the for the uninformed. You know, a fourth reason is ordinary credibility, people who talk about misinformation and talk about their reactions to specific situations are often talking about their direct experience. A person who or this happened to me, and that kind of ordinary credibility carries a value that is sometimes greater than might be the case for a more didactic, a more descriptive kind of set of set of claims, a very subtle tidbit of information about misinformation is that has a tendency to persevere. Now, you might say well okay that's going to be hard to dislodge misinformation. And that's true. It is hard to dislodge misinformation but sometimes, even if you can dislodge the misinformation. You may not be able to dislodge the underlying emotional tone that has been created by that that disinformation. This is sometimes this has been studied under the label of belief echoes the belief may be able to be dislodged, but the underlying effect that that belief carries isn't completely dislodged. Now one of the things that's interesting about examining some of the bases for these sorts of psychological components to the acceptance of information is that it points us to the way in which you may need to respond to that misinformation in the messaging that comes later. If there's an emotional residue, your messages probably need to have an emotional component to undo that residue, even if the beliefs truth value has been successfully altered back to a more accurate representation. Another reason that misinformation is more readily accepted is that in the modern media era, we have many, many different sources of information. These informational sources are kind of siloed in some senses. And people take advantage of their psychological dispositions to go after a phrase that I used before congenial information within an information silo, and by by staying within that informational silo, they don't expose themselves to contrary information and end up confirming their existing biases that are consistent with the misinformation that they had. And this is this is not a characteristic of the media. It's a characteristic media system as being siloed siloed information. And in those silos, of course, our guess what people who are like you, who have testimony that is like your predispositions already this Balkanization of communities in terms of interests, and in terms of siloing is an effect that reinforces existing misinformation. And of course during the pandemic, all of this has taken place in the context of a high degree of uncertainty and anxiety, a change in lifestyle and fundamental ways. And as a result, conspiratorial thinking can can arise to fill the vacuum that is there from the uncertainty and lack of information about how we're going to proceed and how we're going to get ourselves out of this pandemic situation. All of which points to the fact that we are in a situation in which the psychological predispositions that that exists open us to accepting misinformation, can reconfirming that misinformation within silos and within groups of people who have who are consensually like us in the first place. And there's some components of those stories that make them sound coherent to an ordinary person, and that have the effect of staying and sticking against attempts to dislodge those sorts of beliefs. Now, the question of course is, how do we respond to to misinformation and this is where the world of communication meets the world of psychology and social psychology. And there's a lot to say about this and I will, I will not try to say too much about the ways in which communication can work here but I want to begin with and talk about what we should not do, and what then turned a little bit to what we should do in terms of the kinds of communicative strategies that we might undertake. Probably the most important thing that I can say to you today is that that's an education are not enough. We need to use the full array of persuasive strategies that may that that are responsive to the conversation that's that's present, but at the same time, do so in a way that maintains the truth value of what we are saying. We don't want to turn persuasion into propaganda, because we don't need to, but we do need to avoid being simply didactic simply factual and descriptive. That is problematic and I've had more than a few arguments with my colleagues in public health who say well let's just let's just give them the facts. The Joe Friday approach does not work. Not in general it doesn't it might at some stages and for some people and some populations, but we need to take full advantage of the persuasive tools and strategies at our disposal. There are a lot of them, but I'll just wave my hands over them in a couple of slides forward. Be careful about repeating the lie. The, the evidence here is not clear or unequivocal, but instead of worrying about whether the evidence says it's okay to repeat the repeat a lie and then debunk it versus not repeating the lie the safe thing to do is to not repeat the lie. And so here it's more likely to simply state the truth, or to ask a question that doesn't repeat the lie. Don't talk about the hundreds of monkeys who did not get the, who did not get the coronavirus after vaccine. Because it makes clear what the lie is and so it raises questions and people's minds and you get once again you get to this notion of inadvertent priming inadvertent queuing of the information that you may want not want to be in the business of queuing because you're trying to, you're trying to get rid of that misinformation. It's also not necessary to respond to every lie, because there are some lies which have very little reach. They circulate in very small communities and responding to them just gives them the light of day and so it's not always a good idea to respond to every single one. But certainly it's not it's important not to assume that the knowledgeable people are going to be immune to misinformation. Turns out there's good evidence to suggest that people are are who are knowledgeable are immune to misinformation when they don't care about the information, but when they care about it in some important way it's involving or it's part of their identity, then suddenly they become as susceptible to misinformation as do other people. And final point here under what not to do is, is to not quit. There's really three things that it's important to do with the communication when you're carrying out a campaign and that is that you need to be clear need to be consistent, and you need to be credible. But you also need to do that over a long period of time, especially now while we're facing the, the, the remnants of the final 15 to 20 to 25% of the of the population that is not interested in being being vaccinated. And so, same with misinformation, and it was to be persistent but I want to talk about some of the way, at least mentioned some of the ways to avoid being persistent without being, you know pain in the neck. This is an example of, I think, of a bad use of, of debunking of misinformation. This was about messenger RNA, which carries genetic information according to the National Cancer Institute, these vaccines would instruct cells to produce protein that resembles part of the COVID-19 virus. Notice that these vaccines would instruct cells to produce a protein that resembles all right. That's first of all, that's very complicated. Secondly, it sounds like these vaccines are going to instruct ourselves to do something. And they are. But if you're naive about it as most of us are. It sounds like there is some intervention by the vaccine into the proteins that are a part of the of the of the immune system. My point here is not to talk about anything other than the fact that this message, which is purely factual is too complicated. It's unclear, and it provides just enough of a, of a link to for the misinformed to produce the conclusion that messenger RNA somehow is inter, inter intervening affecting potential sources of genetic genetic information. And that's despite the fact that there's an explicit denial of that in in the in the message. This is not a good response to factual misinformation. What about what we should do. There's a lot that we should do to respond appropriately, but the kinds of things that I'm going to mention in this slide are a little bit unusual ones. One is, of course, the notion that it's important to surveil as to be in the surveillance business associated with miss with misinformation and the on top of that top of that misinformation. So, a lot of this is being done by, by newspaper groups by academic groups and so on, and it's starting to be done by by grant grant work being funded by the National Institutes of Health. You've got to people will respond to information if you can get it in front of them. And so somehow entering the information silos that are promoting misinformation is is crucially crucially important. You need to make the acceptance of legitimate information visible. And so the example of Aaron Rogers was given, but on the other side of that among athletic folks who have been very positive and very pro vaccine and pro accurate information is Charles Barkley. And so, making him a social influencer, a fourth kind of approaches to inoculate people by inoculate we mean in this case, a cognitive inoculation, not debunking the information but if it's possible to pre bunk that is to give people a heads up that information is going to be misleading, and it's going to be crucially important for you to be on your guard. And that can have a very good effect that minimizing the impact of misinformation, but it can only happen after the in advance of the you know, after the misinformation as well established to last to last observations here. And this has to do with the notion that narratives are indeed important, but they need to operate within the disbelievers world worldview so for example, there was a lot of that the vaccine development was very fast, and that that speed undermined its its accuracy is legitimacy is reliability validity and so on. But on the other hand, the mRNA technology that was behind it was were years in development. And that can create an alternative narrative about the about the speed with which the vaccine has been developed, and take advantage of what the disbelievers are already accepting, and that is that it was done fast, but take advantage of by saying that that that that speed was in in response to a technology that had been long term in development. A final approach is is a little bit similar, but it is to affirm the worldview of the targeted in the targeted subgroup, and then debunk that information so for example, a community that you know saying that the community that you're talking to values doing the right thing. So that's an affirmation, and then talking to that community about what it means to do the right thing, think research and do, and do what's do what's right. These latter two are not alternatives that are well explored in the in the communications literature but they are I think important kinds of approaches. I'm not going to go over this slide I just wanted to suggest to you that there are three broad components to persuasive strategies, the messaging tools, the need to do those use those messaging tools with a credible source. They are trustworthy and expert, and to do so in a way that the relationship to the audience is preserved, and that they are not that they are not the missed talks down to are treated treated as an equal partner and so on. These are some of the tools for that information. Finally, I think we have faced a series of significant conundrums that we have to engage in have to simply acknowledge, and I'll just talk about the first one here and that is, we can say that information should follow the science and that's fine. But as our initial speaker pointed out, the science sometimes changes. And when the science changes, that means that the information, if it's going to follow the science is going to have to change as well. And that's going to lead to inconsistency. And so this kind of conundrums are problematic for all of us to deal with, but it also reflects the fact that science is a changeable process, and the world is a changeable set of events and one needs to be responsive to what's going on there. My final slide here is that we need a lot more rigorous research to guide the next campaigns, because we have been operating on a shoestring in the campaigns that are being carried out against the COVID misinformation. And then we've had to use data and literature that doesn't quite fit. We also need to be addressing the needs of high disparity, high effect highly affected communities and minority communities, not only to deal with trust but to address systemic trust. And of course, we have to deal with institutional interventions. And in response to the way in which those institutional interventions might or might not run afoul of the first First Amendment, which I think is what our next speaker is going to spend some time talking. Thank you. I don't know if I'm supposed to just jump right in now. But thank you for the introduction and the transition to the First Amendment. Let me share a nice. So thank you. I'm going to follow up on that great presentation about that problem and some of the do's and don'ts and the science, the do's and don'ts to talk about sort of what's law got to do with it or more precisely, what the First Amendment has to do with it. A couple of background points before we get going. First of all, although the First Amendment's text speaks to what Congress can do. It says Congress shall make no law. For almost 100 years, the Supreme Court has held what the First Amendment applies through the 14th Amendment, one of the reconstruction amendments to the Constitution to the states. So the amendment limits both the actions of the federal government, Congress, and actually all federal government and states. Secondly, it doesn't apply to this actions of private actors in popular discourse. It's common to talk about the First Amendment, not as a legal doctrine, but sort of as a general social norm, supporting robust and free speech. But the amendment itself does not apply to the speech of private actors. It doesn't have anything to do with what I say today. It doesn't have anything to do with what private universities say or other private figures and I'll come back to that, but it's really important, I think, for us to think about sort of the larger social meaning of the First Amendment as a sort of pro speech principle and the legal impact of the amendment itself. On the other hand, the First Amendment, especially as the Supreme Court has come to interpret it in recent years, really significantly limits the government's ability to regulate private speech, including a speech that is injurious to health. In my talk though, I thought it might help to break this down into a couple of different categories because not all speech and not all misinformation is created equal. For purposes of this discussion, I'm going to focus on four different categories of health related information, all of which have played a role in the pandemic or the info. So first is the ordinary speech of private actors. We'll come back to that in a second. Second is a professional speech, primarily the speech of health professionals in discourse with their patients, but perhaps then I'll talk about this more broadly. Third is commercial speech, the speech that's related to the marketing and sale of products, and then fourth, government speech, think President Trump, where I noticed somebody in the chat or Q&A asked about the Surgeon General of Florida, so we can talk about government speech. I'd like to start with private speech. This is the speech that the First Amendment protects the most robustly, right? And it's the speech, as I said a moment ago, that I'm doing right now. I mean, it's public in the sense that this speech is not, you know, private between me and my best friend or me and my family. And I'm saying in a publicly available forum, but it is private speech. I am a private actor. This is non-governmental speech. Okay. When Aaron Rogers talks about COVID vaccines, Dr. Sina talked about that, right? Even though he's a public figure, a really famous public figure, it's private speech. It's the type of speech that the First Amendment protects the most robustly. Although there are a few types of private speech that remains subject to some regulation, think defamation, or perhaps, and I put that, say that purposely with some curiosity right now, and incitement of violence that the government can regulate. In general, government regulations that are based on the content, what is said of private actors are subject to what we call strict scrutiny. This is the most stringent form of judicial review. So to give an example, a law that said you can't say anything negative about vaccines or a law prohibiting vaccine misinformation or any particular type of vaccine misinformation, vaccines have chips, they'll magnetize you, right? Any of that would be subject to strict scrutiny. So too would a law that prohibited individuals from saying, and even if they're shouting about the rooftops or posting it on social media, that either met in cures COVID. This information, potentially dangerous information, not regularly. Once a regulation or subject to strict scrutiny. A regulation is subject to strict scrutiny, the burden is on the government to show that it is the least restrictive means of achieving a compelling state interest. Traditionally, public health has always been considered a compelling state interest, and where regulations of speech related to health would get into problems is on the least restrictive of the analysis. I will say that last month, kind of shocking to me three justices of the Supreme Court in a decision refusing to take a vaccine case, suggested that it wasn't clear that stopping the pandemic or protecting people from COVID-19 would remain a compelling state interest. I have to say it's hard to know if that's not a compelling state interest. What is a compelling state interest? Certainly more people are dying of COVID every day than probably would die from shouting fire in a crowded theater. I would always assume that some speech that was dangerous could be prohibited. It's not at all clear to me right now what is a compelling state interest or what health is. It's very hard and it has been very hard for many a year now to regulate even dangerous health-related misinformation. On the other hand, regulations that are so-called content neutral, so-called time, place and manner regulations, the classic example, no loud noise in a hospital zone after 10 p.m. These are subjected to a less rigorous form of review known as intermediate scrutiny. Here the government must show that the law serves an important but not necessarily compelling objective and is narrowly tailored to achieving that. And that there remain other forms of communication. I don't think this has a lot to do with the misinformation problem. There were a lot of cases that talked about this early in the pandemic. For example, people challenge shutdowns of theaters, concert venues as regulations of speech and the courts said, well, those are not content neutral. They weren't just shutting down theaters that talked about the virtues of vaccines and not the ones that talked about the dangers, right? It's content neutral and the courts appell those. Professional speech. A couple of years ago in 2018 in a case called National Institute of Family and Life Advocates versus Becerra, which had to do with a so-called crisis pregnancy center. The Supreme Court stated that professional speech was not a separate category of speech and that regulations, content-based regulations of speech were not considered differently than other forms of speech. On the other hand, in that same opinion, sort of at the other side of their mouth, there's an opinion by Justice Thomas, the court conceded that it had long accepted certain traditional forms of regulation of professional speech. That's probably no practice law, being a great example, informed consent law, and probably professional licensing law. So, you know, if I go to the doctors and I say, should I be vaccinated? The doctor said, no, it's been on my physician saddle. That will implant chips into you, false, right? And I don't get vaccinated. And I die of COVID. And the First Amendment, the court, in a sense, conceded in NAFLA, a few that scholars have long accepted that the First Amendment doesn't prohibit these kinds of traditional regulations of healthcare professionals. Okay? Importantly, the regulation that is set and where the First Amendment allows is the regulations, is the professional standard itself. So if reasonable physicians and its physician, you know, medical consensus to tell people that COVID vaccines have microchips in them, that wouldn't be a non-practice. I'm obviously assuming that that is not the medical standard. What is less clear is whether the speech of professionals is fully protected by the First Amendment when uttered outside of the context of a physician-patient relationship, right? We want professionals to be able to debate, to advance science, to criticize each other and their findings, right? I mean, that's part of the process of science itself. So what if a physician gets on TV, right, and this has happened, and says, you know, COVID's a hoax or vaccines make you sterile or any matter of other misinformation? Or what if a group of physicians, as has happened, sets up a website and says that COVID is a hoax and Ivermectin is the treatment, the only needed treatment. And they face licensing incriminations, okay? They're not giving this information in the classic physician-patient relationship, but they're using their stature and credibility as physicians to disseminate flaws and dangerous information. My colleague, Claudia, helped with what I've written about some of this. She believes, and I think she's right, that such speech can be sanctioned by professional licensing boards. Physicians really are under an obligation, not utter falsehoods, right? It's not a dispute about science. It's to really go and utter falsehoods in public ways, in ways that can be harmful, but I will say that that is not, you know, that some people will disagree with our conclusions about that. And I also want to be clear that we're talking about, in this case, misinformation. Supposing a physician gets on TV or social media or tweets and says, you know, vaccine mandates are tyranny. That statement might in fact lead many people to say, well, if the physician says that, our famous TV doctor says that it must be vaccines or dangers. That's why mandates are tyrannical. But that statement itself is not, of course, false. It's a normative statement of policy judgment and probably clearly protected by the First Amendment. I'm going to talk a little bit about commercial speech, another category. And think here about drug ads, or think about the ads on the websites that I referred to before, that also, you know, tell you that vaccines are dangerous and also sell t-shirts and other goods to push their viewpoint. The Supreme Court first applied the First Amendment to such commercial speech in the 1970s, right? For almost 200 years, it was assumed that the First Amendment had absolutely no application to the regulation of commercial speech at all. There was a little ED in a case called Central Hudson, the Supreme Court laid out a four-part test for the regulation of commercial speech. And the test without going through all the details made clear that governments could regulate false and misleading commercial speech. And even if speech is true, they could regulate it in some circumstances subject to pretty much what's known as intermediate scrutiny. In more recent cases, without overruling Central Hudson, the court has moved to ever increasing First Amendment protection, even for commercial speech. Presumably, the court still allows the regulation of false commercial speech. So again, if I try to sell ivermectin and tell you that it's the best thing to protect you from COVID, it probably can be subject to regulation. But I will say it's really important to understand that the court's application of commercial speech has made it very difficult now to police false advertising around drugs that we could talk a lot if we want about what this means for the FDA's ability to regulate. The court is really pushing towards sort of a more speech, better speech, deregulatory approach. Equally important is the government's ability to compel speech. So usually when we talk about the First Amendment, we're talking about barring speech, limiting speech, but the First Amendment also protects against compelling speech. And in the commercial context, particularly in the FDA context, we have required warning labels that, you know, the makers of vaccines have to give some specific information, right, that the FDA requires them to carry. This area is also uncertain right now. In, in the same case I mentioned earlier, the Nifla case, the National Institute of Life and Family Advocates, the Supreme Court suggested that compelled commercial speech may not be permissible if the, even if the compelled speech is true, if the speech is controversial. And the truthful information in that case dealt with abortions. And this actually led my colleague Claudia and I, a pre pandemic to opine. Could you imagine that any information about vaccines because there's a large debate in the population about vaccines could no longer be compelled. And I throw that out to you again. I feel like I think our concerns were a little prescient, and in a bad way back then. If anything is controversial, if it can't be compelled, could the FDA require warning labels from vaccines. I leave to leave that question to you. And then there's government speech. Without the pandemic we've had government actors at all levels. Dr center mentioned President Trump, I mentioned, there have been a lot of them uttering misleading claims and offering dangerous advice. Now again, sometimes it's, it's not so much that it's false, but it's, you know, suggestive and if we really want to parse what he didn't say going just bleached sort of wonder whether people shouldn't just bleach and how people hear something is an important question. Traditionally, the First Amendment does not limit the regulation of government speech. In fact, the government can regulate the government speech and we want the government to do that. Right. We, I should be able to go up and say smoking is great and doesn't cause cancer but we don't want the CDC to put on its website and so some people think smoking causes cancer and some people don't. Right, I mean, we, we want government to make regulate and ensure that it is not contra content neutral. In addition, um, we want the government. Let me back. Another reason the First Amendment doesn't apply is because we often think right that the remedy for government misleading speech is more speech and electoral accountability. And unfortunately, I think for many of the reasons we just heard that doesn't work very well in this particular informational environment. So health related speech can have a directed imminent harm, just like shouting speech in a crowded theater, but also people are silent people hear what they want if you're a Trump supporter and Trump offers misinformation, you are, you don't hold him accountable you believe it. If you're not a Trump supporter you hear him say you assume the opposite is true even if what he says is true right worse. Our informational environment is so affinity based right now in deeply troubling ways that traditional First Amendment ideas and remedies don't necessarily work. In forthcoming paper, Claudia and I analogize government speech to bad professional advice and argue that it should be subject to the same kind of regulation as professional about bad erroneous professional malpractice. But that's an argument, it certainly is not something that courts have followed. Let me end with a few concluding thoughts and we have some time for discussion. First of all, free speech, the debates that the First Amendment allows can be really important to public health, we're focusing today on the misinformation and the downsides. We could talk about many instances where freedom of speech has been critical to disseminating important health information if you look up for example just go back to the early years of the HIV epidemic. And it took courage to inform people about how HIV was transmitted. One would not want to live in a society where that kind of speech could be bar. Likewise, we want to be among science, right this first scientific information is not always accurate right so free speech and the debate among scientists are critical to public health. On the other hand, I think that the evolution of the First Amendment doctrine in the past two to three decades, combined with the current informational environment, particularly as created by social media permits the proliferation of misinformation in ways that make it increasingly dangerous. And so one of the things that's happened is we not only have a social and media environment and algorithmic environment that often favors the dissemination of misinformation, but we have a First Amendment doctrine that is new. It is more robust that allows less regulation and controls on speech, including, importantly, commercial speech, then we've had in the is really as important that we understand that what we say the First Amendment allows and requires today is not what was the case for most of our history. The hope is that we can fight misinformation with more or better information is naive, as I think Dr. Capella's presentation such that just more information that you said the Joe Friday approach does not work. But that was the traditional First Amendment answer. So I would like to argue that one solution lies with a return to a more traditional First Amendment jurisprudence this doesn't mean chucking the First Amendment which we can't of course do and but nor would we want to do. But it might be to returning to a more nuanced application of professional speech and commercial speech doctrine that allows some space for holding people responsible and accountable for when they're spreading very dangerous misinformation. And I will stop with that. Hopefully allow some time for conversation. Thank you both for incredibly detailed and nuanced presentations. The first question I have for the both of you, trying to sort of fuse the different approaches that you've taken to discussing the topic of health misinformation is looking at the role of loyalty and morality in the dissemination of health information and health misinformation. Given that the discourse around COVID-19 has been intensely partisan and may actually be more affiliated with a political party, perhaps one that doesn't align with one's background affinity or moral compass. Do you think there's a danger in damaging the credibility of information by classifying policy or value judgments as misinformed facts. I'll jump in I mean I do think there's a danger. I think the line between misinformation and, you know, normative arguments with which one might agree or not agree can often be difficult to discern. I think as a lawyer, you know, we have ways and mechanisms and our law we all long have had right of understanding when information is misleading understanding what a reasonable person would hear it to me. So I think there are tools for that but I definitely think we need to be sensitive, and I do think that the public health side and I think probably most people in this event are on the public health medical side of it. I think we do need to be careful of not condemning arguments over values and principles which we may believe to be dangerous and long headed with this information right so saying the government should not be able to mandate vaccines and these vaccine mandates destroyed freedom. I mean, that's something I intensely disagree with, but that's not misinformation saying you know the government is putting microchips in me with vaccines and they magnetize me that's misinformation so we do need to be careful about that. And I think they're, you know, what Wendy just did was point to clear cases. And I think when there are clear cases then I think labeling them as misinformation is is fair and legitimate and actually, you know, we've done that. We've done that forever in communication campaigns of all sorts, sometimes it takes a long time to get to the point of saying this is indeed, you know, accurate versus inaccurate as certainly was the case with with the work in in the area of tobacco. There was being a health hazard versus versus as a health source, a healthful source of influence. And once, you know, once that happened, then it became legitimate to, you know, call out tobacco companies and public health officials who were misrepresenting what was happening with that domain. And I think the same is true with, you know, with with COVID. The other thing is as to the question of, you know, of treating a claim as somehow representative of a personal of a personal freedom. I can understand when people do that and why they do it and so on. But sometimes in response to that it's not to call that, you know, a falsehood, but to reframe the discussion in some ways so as to, you know, talk about other responsibilities, not necessarily deny the desire to maintain one's personal decision making. I mean, you know, we know that personal decision making is limited. And it has to be, you know, it has to be balanced against responsibility. So, you know, I think reframing those discussions rather than trying to deny a person's point of view is an art form, but it is, you know, it is something that's doable from a communications point of view. Can I just add your comments about tobacco remind me I think we do need to recognize, you know, that a lot of the dangerousness of tobacco advertising was not actually the false information right it was the aura, the style, the puffery that the image was never trying to convey. And when I when I talk about how the First Amendment has changed. I think it's important to realize that probably if we were trying to bar TV advertising of tobacco of cigarette ads right now, the string or would not allow it. I think that that's pretty clear. Right. Congress bar TV advertising of cigarettes, you know, way back in the 60s, because not because the information was false. It was, it was, they were selling an image, but the image was dangerous right because people are buying it and smoking and enormous numbers and dying from such numbers. If that hadn't happened then and the tobacco companies hadn't agreed to it because of the settlement. We probably couldn't do that. And that's where I talked about think that the evolution of the First Amendment is leading us to some dangerous place. Thank you. We have a couple of questions that I'm trying to fuse here. How granular do you think information and public discussions needs to be. And do we actually hurt credibility of information through an inability to communicate science and nuance. And then following up on that. Should we be tapping into fields like epistemology and social psychology to help address questions of credibility credence fact and assertion. Go back to go back to the first of those questions which I think is separable from the second. You repeat it. Sure. So how granular should be information in public discussions be and do we hurt credibility of information through an inability to communicate nuance and uncertain science. One of the principles of of old line mainstream journalism is so called kiss principle keep it simple stupid. And it becomes very difficult to to represent the subtleties of a scientific claim. It becomes just as difficult to sometimes communicate that what you're saying as a scientist is consistent with the prevailing science and in the process, trying to imply that it's a, it's very possible that the science will change. But it will be in the not so distant future. And so as a result, you know, communicating that contingency, and getting people to buy into that contingency, while we are also saying things like follow the science, the science will, you know, the truth will make you But in fact, we simultaneously say to the audience, or at least we try to that science is a is a transient set of claims and in response to the available knowledge and we know the scientific claims change over time. There's a wonderful book by Paul often called I can't remember the lab pans laboratory or something like that talks about a six cases of clear change in in well accepted science and what led to those changes over a course of sometimes, sometimes decades, but you know we've seen in the pandemic changes and in fact, you, you referred to refer to a couple with regard to the masking claims by by Dr. Fauci. And you know he was trying to make claims that were consistent with the available knowledge at the time. And that undermined the claims about masking. There's a question here, a couple of different questions. Again, that I'm trying to fuse but thoughts about how to handle health misinformation that comes from presumably credible sources, such as Florida's new surgeon general. And then what about if it comes from celebrity physicians like Dr. Oz. Well, I think that actually those were some of the examples I was thinking about, without being quite so daring to name. As I said, I believe that frankly the medical profession has not been as vigilant as it might be and could be about celebrity physicians, giving dangerous misinformation. That's a real problem. And I think that they really should be enforcing. I have to say an analogy I have your thought about was, you know, think about some of the statements that Rudy Giuliani made pride he's a lawyer and we've now seen some bars bars state bars for public statements. So I think that there's space for that and I think it's something that the medical profession really needs and stay licensing boards need to take more seriously. With respect to government speech, as I said, you know, we believe that it should be analogize to a form of professional malpractice, but that's certainly new ground and pushing it, but it is important to recognize the first moment does not apply to government speech said by government speakers in their government capacity. So actions brought against them should not be protected by the first one. So I noticed I saw and Professor Capella noted in his talk that US Surgeon General Vivek Murthy recently released a community toolkit for addressing health misinformation. Is this a welcome addition to the tool source or perhaps is this too little too late. I don't think he generated a toolkit. I think what he did was he, he set out a call for action, rather than a set of strategies or a set of approaches. And I think if you look at that document carefully he ends by by talking about the various constituencies that need to be responsive that need to be involved in dealing with misinformation as a problem. You know, he goes to, he goes right down to the individual that essentially says to, you know, to all of us, you know, we need to be more careful in terms of what we are willing to accept with regard to health information, as we are making decisions for ourselves and making decisions for our family members, but he takes it all the way up to, you know, the National Institutes of Health themselves. And so, for example, one of the things that has happened in in NIH is that there are various initiatives which don't really need to talk about that are pertinent to misinformation that have suddenly come out. I think it's not social science research council also just come out with some big requests for intervention and and funding consistent with dealing with with health related misinformation, whether it's coven related or not. And I think I can't say that that it was because of Dr. Dr. Murthy's call to action or not but certainly didn't hurt. I ask, since we're running out of time, if you would like to give a brief, I generally consider this like a tweet 280 character synopsis of your thoughts and ideas to take home as as we move forward. I mean, I think I tried to mention what I thought is the sort of key key issue in all of the work that I've done for a very long time and continue to do and that is that we have to balance our concern with providing factual didactic descriptive explanation of information with persuasive tools to make that information engaging and effective in terms of acceptance, which is not the same thing as saying we propagandize our health information. No, not at all. In fact, what we're doing is we are simply making our health information more engaging and more likely to be effective and using all the tools at our disposal to achieve that. I'm going to pick up on the word balance. Because I think that's so critical here. We often in this country think about speech freedom of speech as all or nothing right on the one side is just unfettered discourse no matter how uncivil no matter how dangerous. On the other side is, you know, some night is 1984 Stalinist Russia. We need to come back to a balance that we've had for most of our history with a great space for free speech, but also with some modest reasonable protections to protect public health and safety, whether it's in the selling of drugs or whether it's in the misinformation about drugs or vaccines or disease. Terrific. Well, please join me in thanking our esteemed panelists for lively discussion on health misinformation. Certainly more questions than we could answer today, but please do continue the conversation on Twitter using the hashtag policy ethics. Thank you all for attending. Thank you all very much. Thanks Mike for moderating and we will see everybody next month. Thank you.