However, we currently are in the midst of a measles outbreak in the US. The current number of reported cases for the first three months of 2019 is greater than all cases reported in 2018. (See this CDC update.) Other so-called developed countries are also seeing more cases of measles. Why has measles returned? A likely cause is the number of parents with negative opinions about the vaccine is rising, and their clamor to exempt their own children is getting louder (look here for just the latest example.)
The negative opinions seem not to come from reasoned arguments based on logic and facts, but from disinformation campaigns.
Prelude: the 1980s Soviet Disinformation Campaign About HIV
How disinformation can disrupt public health is a story which seemed to have been largely forgotten until 2016. That year, how the campaign to control HIV in the 1980s was impeded by disinformation was brought up again after so many years by the Washington Post. The article opened
On July 17, 1983, a small pro-Soviet Indian newspaper called the Patriot published a front-page article titled 'AIDS may invade India: Mystery disease caused by US experiments.' The story cited a letter from an anonymous but 'well-known American scientist and anthropologist' that suggested AIDS, then still a mysterious and deadly new disease, had been created by the Pentagon in a bid to develop new biological weapons.
'Now that these menacing experiments seem to have gone out of control, plans are being hatched to hastily transfer them from the U.S. to other countries, primarily developing nations where governments are pliable to Washington's pressure and persuasion,' the article read.
The Patriot's article was subsequently used as a source for an October 1985 story in the Literaturnaya Gazeta, a Soviet weekly with considerable influence at the time. The next year, it ran on the front page of a British tabloid. After that, it was picked up by an international news wire. By April 1987, it was suggested that the story had appeared in the major newspapers of more than 50 countries.
The problem? The story was patently false.
It was a product of a deliberate Soviet disinformation campaign. A New York Times article from 2017 amplified the specifics:
Called Operation Infektion by the East German foreign intelligence service, the 1980s disinformation campaign seeded a conspiracy theory that the virus that causes AIDS was the product of biological weapons experiments conducted by the United States. The disease disproportionately impacts gay men, and the Reagan administration’s slow response had escalated into suspicions in the gay community that the United States government was responsible for its origins.
'The K.G.B. picked up on that, and added a new twist with a specific location: Fort Detrick, Md.,' where military scientists conducted biological weapons experiments in the 1950s and 1960s, said Douglas Selvage, the project director at the Office of the Federal Commissioner for Stasi Records in Berlin.
The K.G.B. campaign began with an anonymous letter in Patriot, a small newspaper published in New Delhi that was later revealed to have received Soviet funding. It ran in July 1983, under the headline 'AIDS May Invade India: Mystery Disease Caused by U.S. Experiments' and pinned the origin of the disease to Fort Detrick.
The choice of Patriot was deliberate, said Thomas Boghardt, a military and intelligence historian who traced how the campaign unfolded. 'It had no explicit links to the Soviets and was an English-language newspaper easily accessible to a global audience.'
'The Soviets intuitively understood how the human psyche works,' Dr. Boghardt said. He said the playbook was simple but effective: Identify internal strife, point to inconsistencies and ambiguities in the news, fill them with meaning and 'repeat, repeat, repeat.'
A September 1985 memo to Bulgarian intelligence from the East German secret police served as a conduit. The disinformation campaign aimed, according to the Stasi, 'to generate, for us, a beneficial view by other countries that this disease is the result of out-of-control secret experiments by U.S. intelligence agencies and the Pentagon involving new types of biological weapons.'
A month later, the Soviet journal Literaturnaya Gazeta published a paper titled 'Panic in the West or What Is Hiding Behind the Sensation Surrounding AIDS.' It included accurate information about the disease and Fort Detrick but cited the Patriot letter to connect the dots.
The paper received international attention and its allegations were repeated around the world including in Kuwait, Finland and Peru. CBS News, black newspapers, the gay press, niche publications critical of the C.I.A. and the right-wing presidential candidate Lyndon LaRouche all promoted the conspiracy theory. (Mr. LaRouche flipped the claim on its head, accusing the Soviets of using AIDS as a weapon.)
Background on Soviet Disinformation
An earlier 2017 article in the Guardian expanded the background about Soviet use of disinformation:
Unlike misinformation, disinformation is constructed to be deliberately false, with the intention of sowing discord in enemy ranks. While there are undoubtedly historical examples, the industrialisation of disinformation emerged with the modernisation of media and mass communication. This is reflected in the etymology of the word itself, which by the advent of second world war had arisen independently in both Russian and English to characterise the spread of propaganda across Europe. Russia quickly recognised its enormous potential, and as early as 1923 the GPU (forerunner to the KGB) had established an office dedicated to it.
Disinformation fast became an integral part of Soviet intelligence, and by the birth of the KGB in the 1950s, it had become an essential component in the doctrine of 'active measures', the art of political warfare. Active measures included media manipulation, the use of front groups, counterfeiting of documents, and even assassinations when required. It was the very heart of Soviet intelligence, described by KGB Major General Oleg Kalugin as:
'... not intelligence collection, but subversion: active measures to weaken the west, to drive wedges in the western community alliances of all sorts, particularly Nato, to sow discord among allies, to weaken the United States in the eyes of the people of Europe, Asia, Africa, Latin America, and thus to prepare ground in case the war really occurs.'
Throughout the cold war, the Soviets were virtuosos in creating tensions between allies. In particular, they excelled at the use of 'black propaganda': crafting damaging material which purported to be from the other side. These attempts were nebulous and prolonged, and included Operation Neptune, a 1964 attempt to use forged documents with the intention of implying western politicians had supported the Nazis. While this was quickly exposed as a counterfeit, other ruses were more successful. Whilst dezinformatsiya was targeted chiefly at the US, it was largely ignored there until 1980, when a Soviet forgery of a presidential document claimed that the administration was supportive of apartheid. This got some traction in US media, and so appalled president Jimmy Carter that he demanded a CIA inquiry.
In fact, by the 1980s, Soviet disinformation was an old story.
Ladislav Bittman wrote in The KGB and Soviet Disinformation: an Insider's View, published in 1985 that disinformation is part of what the Soviets called
'active measures' directed by the KGB ... designed for internal demoralization and erosion of power in targe countries [p 2]
He later wrote [p 48]
Disinformation is a carefully constructed false message leaked into an opponent's communication system to deceive the decision-making elite or the public. Disinformation can be of political, economic, miliary or even scientific nature. To succeed, every disinformation message must at least partially correspond to reality or generally accepted views....
Then he noted that each message is crafted so that [p 56]
it dissuades leaders of the target country from critical analysis of the deceptive segments. The overall purpose is not only to deceive but to cause damage to the target. The victim of disinformation must be led to inflict harm upon himself, directly or indirectly - either by acting agains his own interests on the basis of spurious intformation or by remaining passive when action is needed.
These elements of disinformation now may seen as echoed in the Russian campaign to manipulate the 2016 and 2018 US elections to favor now President Donald Trump and his supporters, and in some of the UK campaign for Brexit.
The 2015 Measles Epidemic
As the years passed, and the USSR fell, the notion of disinformation seemed to fall into the dustbbin of history. Yet, in early 2015, before anyone thought of Donald Trump as a presidential candidate, there was a small US measles epidemic. In February, 2015, the New York Times discussed the strange inability of some then Republican candidates for the presidency to discuss the issue clearly.
The politics of medicine, morality and free will have collided in an emotional debate over vaccines and the government’s place in requiring them, posing a challenge for Republicans who find themselves in the familiar but uncomfortable position of reconciling modern science with the skepticism of their core conservative voters.
As the latest measles outbreak raises alarm, and parents who have decided not to vaccinate their children face growing pressure to do so, the national debate is forcing the Republican Party’s 2016 presidential hopefuls to confront questions about whether it is in the public’s interest to allow parents to decide for themselves.
Gov. Chris Christie’s trade mission to London was suddenly overshadowed on Monday after he was quoted as saying that parents 'need to have some measure of choice' about vaccinating their children against measles. The New Jersey governor, who is trying to establish his credibility among conservatives as he weighs a run for the Republican nomination in 2016, later tried to temper his response.
Senator Rand Paul of Kentucky, a physician, was less equivocal, telling the conservative radio host Laura Ingraham on Monday that parents should absolutely have a say in whether to vaccinate their children for measles.
'While I think it’s a good idea to take the vaccine, I think that’s a personal decision for individuals,' he said, recalling his irritation at doctors who tried to press him to vaccinate his own children. He eventually did, he said, but spaced out the vaccinations over a period of time.
The Times article speculated that
The vaccination controversy is a twist on an old problem for the Republican Party: how to approach matters that have largely been settled among scientists but are not widely accepted by conservatives.
In fact, Mr Christie had walked into a similar controversy earlier, about Ebola:
As concern spread about an Ebola outbreak in the United States, physicians criticized Republican lawmakers — including Mr. Christie — who called for strict quarantines of people who may have been exposed to the virus. In some cases, Republicans proposed banning people who had been to the hardest-hit West African countries from entering the United States, even though public health officials warned that would only make it more difficult to stop Ebola’s spread.
It all seemed odd. After all, a lot of conservatives up to that time cultivated an image of hard-headed realism. Why would understanding of the favorable benefit/ harm profile of the measles vaccine, or of public health measures used to combat diseases like Ebola not be accepted by conservatives?
A 2018 Study of an Internet Based Disinformation Campaign About Vaccination
In 2018, a study of the role of twitter bots and Russian trolls in online vaccine discussions appeared (Broniatowski DA et al.Weaponoized health communication: Twitter bots and Russian trolls amplify the vaccine debate. Am J Pub Health 2018; 108: 1378-1384. Link here). It was an observational study designed to compare "'bots'—accounts that automate content promotion—and 'trolls'—individuals who misrepresent their identities with the intention of promoting discord."
To summarize its methods:
In our first analysis, we examined whether Twitter bots and trolls tweet about vaccines more frequently than do average Twitter users. In a second analysis, we examined the relative rates with which each type of account tweeted provaccine, antivaccine, and neutral messages. Finally, in a third analysis, we identified a hashtag uniquely used by Russian trolls and used qualitative methods to describe its content.
To summarize its results:
Compared with average users, Russian trolls (χ2(1) = 102.0; P < .001), sophisticated bots (χ2(1) = 28.6; P < .001), and “content polluters” (χ2(1) = 7.0; P < .001) tweeted about vaccination at higher rates. Whereas content polluters posted more antivaccine content (χ2(1) = 11.18; P < .001), Russian trolls amplified both sides. Unidentifiable accounts were more polarized (χ2(1) = 12.1; P < .001) and antivaccine (χ2(1) = 35.9; P < .001). Analysis of the Russian troll hashtag showed that its messages were more political and divisive.
The authors' discussion of results asserted:
Russian trolls and sophisticated Twitter bots post content about vaccination at significantly higher rates than does the average user. Content from these sources gives equal attention to pro- and antivaccination arguments. This is consistent with a strategy of promoting discord across a range of controversial topics—a known tactic employed by Russian troll accounts. Such strategies may undermine the public health: normalizing these debates may lead the public to question long-standing scientific consensus regarding vaccine efficacy. Indeed, several antivaccine arguments claim to represent both sides of the debate—like the tactics used by the trolls identified in this study—while simultaneously communicating a clear gist (i.e., a bottom-line meaning).
Note that they felt these results were applicable to the 2015 measles outbreak:
We recently found that this strategy was effective for propagating news articles through social media in the context of the 2015 Disneyland measles outbreak.
So here we have at least some evidence suggesting that the Russians were mounting a modern version of a disinformation campaign focused on scientific information meant to sow discord in the US and perhaps other developed countries, and to enable its victims to harm themselves or their children by dissuading them from measles and perhaps other generally beneficial vaccination. Probably because disinformation had largely not been the subject of polite conversation since the fall of the Soviet Union and the disappearance of the old KGB (or at least, its name), US public health authorities and politicians had failed to critically analyze what was going on.
The 2018 study got a bit of attention, and several authors suggested some responses. In StatNews Beier and Sullivan suggested lessons learned:
First, we’ve learned that the Russians operate from a playbook that links seemingly disparate events. In the case of both AIDS and vaccine safety, they exploited pre-existing cynicism among groups or individuals outside the mainstream, planting doubts without apparent Russian links. For vaccines, Russians exploited a controversial report in the Lancet (that was later retracted by the journal) to exacerbate skepticism of vaccine safety so more parents would decline to vaccinate their children. (To be sure, the article had already generated home-grown anti-vaccine sentiment in the U.S.)
Second, we need to pay closer attention to public health measures that generate fear among those they are intended to protect, like vaccinations for children or fluoridated water.
Third, we must pay special attention to areas in which the West is widely seen as 'winning' compared to Russia — in this case public health — making them targets for disinformation campaigns.
The authors then suggested what should be done:
The federal government must take the lead on alerting the media and the public to the risks of purposefully misleading disinformation attacks. Public officials, including President Trump, must show a greater dedication to truth and facts. Whenever a prominent public official espouses support for baseless science, it helps those trying to subvert democracy. By relying on a swamp of bogus science, Russia has exploited loving parents with false, misleading, and dangerous information.
The federal government needs to work with the tech community to develop programs and algorithms to detect threats to our vital health information infrastructure from harmful lies about public health. Once such attacks are detected, Americans must work together to erect cyberwalls to thwart them.
That seemed well-intentioned, albeit unrealistic. In particular, why would you expect the Trump regime, which appeared to gain power with the help of Russian disinformation (look here), suddenly turn into a tough, clear-headed foe of such disinformation?
Junaid Nabi in Project Syndicate made some more global suggestions:
health officials and experts in both developed and developing countries need to understand how this online misinformation is eroding public trust in health programs. They also need to engage actively with global social media giants such as Facebook, Twitter, and Google, as well as major regional players including WeChat and Viber. This means working in tandem to create guidelines and protocols for how information of public interest can be disseminated safely.
In addition, social media companies can work with scientists to identify patterns and behaviors of spam accounts that try to disseminate false information on important public-health issues. Twitter, for example, has already started using machine-learning technology to limit activity from spam accounts, bots, and trolls.More rigorous verification of accounts, from the moment of signing up, will also be a powerful deterrent to the further expansion of automated accounts.
Again, this seems well-intentioned. But why expect social media companies, which seemed to be making lots of money through the viral spread of both information and disinformation, to be so helpful?
Of course, none of that happened. Now we are in yet another measles outbreak, considerably bigger than the one in 2015, with no end in sight.
Life used to be so simple. We used to write about propaganda and disinformation used to market health care goods and services (stealth marketing campaigns), and advocate for policies favorable to private health care organizations, usually under the auspices of pharmaceutical/ biotechnology/ device companies, health insurance companies, and hospital systems (stealth health policy advocacy and stealth lobbying). The organization and complexity of stealth marketing, lobbying and policy advocacy campaigns have often been sufficient to characterize them as disinformation. For example, we characterized the campaign by commercial health insurance companies to derail the Clinton administration's attempt at health reform in the 1990s, as described by Wendell Potter in his book, Deadly Spin, as just that (look here). The tactics employed in that campaign included: use of front groups and third parties (useful idiots?); use of spies; distractions to make important issues anechoic; message discipline; and entrapment (double-think).
While these efforts were done to improve corporate bottom lines and thus enhance the income of top corporate management, at least these organizations had some interest in providing or facilitating health care.
Although I had heard about Soviet disinformation, and even thought that some of the modern techniques used by big corporations for marketing and advocacy were uncomfortably close to disinformation, I, like many others, was not particularly worried about disinformation again used as a powerful weapon by a hostile foreign power. How naive I was.
Now we see propaganda and disinformation in the service of hostile and authoritarian foreign states meant to disrupt more democratic governments, whatever the cost in human health and lives. And we see at best indifference to this problem on the part of politicians who may benefit from such foreign largesse. (The hope in the StatNews piece that President Trump would become more dedicated to truth and facts was already naive at the time of publication.)
So we may need much more energetic and muscular solutions to the propaganda and disinformation that is now rotting our already dysfunctional health care system. We cannot complacently expect a conflicted and corrupt government executive to help us. Health care professionals, and all people who care about health care and the public health are going to have to stop wringing our hands and actually do something. Or measles outrbreaks will be the least of our problems.