Sunday, June 23, 2019

Politically Driven Public Health Disinformation - the Latest Examples: Dread Infections, Porn Causing White Male Impotence

It used to be all about the money. We had previously noted deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns, to sell health policies favoring big health care corporations.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.

Also, we had previously noted health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values. Again, most such examples seemed to be generated by leaders who put their organization's revenue, often in parallel with their own compensation ahead of patients' and the public's health.

But now, it seems to be all about religous or political ideology.  We discuss examples of disinformation in the health care and public health spheres that seems driven not by people wanting to sell products and services to make money, but by political ideology.

Rumors of Immigrants with Deadly Infectious Diseases

In 2018, we discussed nonsense about migrants supposedly infected with smallpox (look here).  In 2019, there are rumors of other deadly diseases.

[influenza hospital, Camp Funston, Kansas, 1918, for the Spanish Flu epidemic] 

Drug-Resistant Tuberculosis

In April, 2019, Rollcall and the Arizona Republic traced the course of a rumor that Central American migrants seeking US asylum were carrying drug resistant tuberculosis.   According to Rollcall, tt may have been inspired thus:

The unfounded rumor of a public health crisis in Yuma [AZ] follows several viral and misleading stories in conservative media that families seeking asylum from Central America were bringing in dangerous infections.

But the source of the particular story, according to the Republic, was that:

Yuma County Sheriff Leon Wilmot said he was told about 12 tuberculosis cases at a San Luis detention center by federal authorities in a March 23 briefing. He shared that information with Lines and said he stands by it still. 

Here "Lines" referred to one Jonathan Lines, "a former chairman of the Arizona Republican Party," according to Rollcall. He also is

a board member of the Arizona-Mexico Commission, a 501(c)4 advocacy organization chaired by Arizona Governor Doug Ducey with the aim of boosting bilateral trade, according to an aide.


Lines ... lead a delegation of Republican lawmakers along the border. The group also included Republican Reps. Duncan Hunter of California, Matt Gaetz of Florida, Sean Duffy of Wisconsin, Dusty Johnson of South Dakota and Pete Stauber of Minnesota.

Also on the trip was Dr John Joyce, a member of the US House of Representatives,

13th District [of Pennsylvania] Republican, a dermatologist by trade, [who] is a staunch supporter of President Donald Trump and has echoed his calls for a border wall.

Lines had "made unsubstantiated claims about tuberculosis in a video."  Joyce posted the video made by Lines to a Facebook page, since taken down. He also made a

bogus claim that immigrants seeking refuge over the Arizona border brought drug-resistant strains of tuberculosis to the U.S.

Joyce made the false claim in a briefing with reporters during a congressional trip led by Arizona GOP Rep. Andy Biggs last week to the U.S.-Mexican border near Yuma, Ariz. The claim was then echoed in the national press.

'My concern is what about the person who wasn’t coughing and wasn’t recognized as having tuberculosis, and they didn’t come here for treatment for their disease,' Joyce said. 'They could be released in a day and a half and be sitting at a restaurant (table) beside you.'

That was all ultimately debunked.

Local public health officials quickly shot down rumors of an outbreak, clarifying that there have been zero cases of multi-drug resistant tuberculosis in the county for the last six to seven years, and further, no present cases of tuberculosis in Yuma at all.

'I can say, after confirming with the Yuma County Health District, there is no drug-resistant tuberculosis in Yuma County,' Kevin Tunell, a Yuma County spokesman told the Arizona Republic. 'Further, there are no cases of tuberculosis involving migrants in Yuma County at this time.'

Who knows, however, how much traction the original warnings about tuberculosis got, and whether those who believed them saw, or credited the attempts to debunk them?

Note here that this little disinformation campaign seem to have been politically motivated, an attempt to justify the Trump administration's claims about the dangers of migrants at the border, and the need to build a wall.  It is particularly disturbing that the disinformation got picked up beyond the shadowy recesses of the web, to be propagated by political leaders into the main stream media.

Ebola Virus

We do not have such detailed information about he track of rumors of Ebola virus infected immigrants at the southern border.  However, the Associated Press did report in June, 2019,

Texas health officials said Tuesday there are no 'suspected or confirmed cases' of Ebola in the state as social media posts have falsely suggested in the wake of immigrants arriving from Africa, including Congo, where an outbreak in has surpassed 2,000 cases.

The false claims, ranging from there is an Ebola 'outbreak' in Texas to reports of a few confirmed cases, have been circulating since April. The erroneous claims are also spreading at a time when Border Patrol officials said last week there has been a 'dramatic' rise in the number of migrants arriving at the Texas border from African countries, although they remain a small fraction of the total number of migrants apprehended.

'We do not have any suspected or confirmed cases of Ebola right now in Texas,' said Lara Anton, spokeswoman for the Texas Department of State Health Services.

The U.S. Centers for Disease Control and Prevention is also unaware of any Ebola cases nationwide, spokesman Benjamin Haynes said.

Note that propaganda accusing hated others of being infected with dread diseases is an old part of the authoritarian playbook.  In particular, from the US Holocaust Museum, the second version of the Nazi propaganda film Der Ewige Jude (The Eternal Jew)

contained notorious antisemitic sequences. These scenes compared Jews to rats that carry contagion, flood the continent, and devour precious resources.

Disinformation about disease outbreaks may make it harder to fight real disease outbreaks.  An op-ed in the New York Times by Bruce Schneier, a fellow at the Harvard Kennedy School, warned

When the next pandemic strikes, we’ll be fighting it on two fronts. The first is the one you immediately think about: understanding the disease, researching a cure and inoculating the population. The second is new, and one you might not have thought much about: fighting the deluge of rumors, misinformation and flat-out lies that will appear on the internet.

He speculated,

Misinformation can affect society’s ability to deal with a pandemic at many different levels. Right now, Ebola relief efforts in the Democratic Republic of Congo are being stymied by mistrust of health workers and government officials.

It doesn’t take much to imagine how this can lead to disaster. Jay Walker, curator of the Tedmed conferences, laid out some of the possibilities in a 2016 essay: people overwhelming and even looting pharmacies trying to get some drug that is irrelevant or nonexistent, people needlessly fleeing cities and leaving them paralyzed, health workers not showing up for work, truck drivers and other essential people being afraid to enter infected areas, official sites like being hacked and discredited. This kind of thing can magnify the health effects of a pandemic many times over, and in extreme cases could lead to a total societal collapse.

Pornography as a Plot to Render White Males Impotent

Sometimes you cannot make this stuff up.  We have discussed, most recently in April, 2019, here, how many US state legislators have been promulgating resolutions condemning pornography as a major public health hazard, despite the lack of clear evidence to justify this belief.  They seem to have put more emphasis on this supposed threat than on much more evidence-based public health hazards.

[Porn has been around for a long time in the US: Times Square, 1973]

We had speculated that this peculiar focus was based on sectarian religious beliefs about the evils of pornography.

Note that since April, another state legislature has gotten on board.  In May, 2019, the Arizona Republic reported,

Republican senators on Monday adopted a measure declaring pornography a public-health crisis and urging the state to 'systemically prevent exposure and addiction.'

The resolution — approved by the House in February — deems the 'societal damage of pornography…beyond the capability of the individual to address alone.'

It argues that porn can lead to human trafficking, sexual abuse, infidelity, low self-esteem and eating disorders, among other issues.

The Republican supporters of this measure did not cite any epidemiological evidence about the dnagers of porn. Their Democratic opponents suggested that the state should focus on better substantiated public health threats, such as the measles outbreak, rising suicide rates, and the opioid epidemic.

Instead, per a Republican backer of the measure:

'Billions of dollars worldwide are being made upon this industry that is poisoning the minds of our citizens,' [Sen Sylvia] Allen said, calling porn 'the root problem for many of the other problems that we're experiencing.' She said it contributes to sexual activity at young ages, sexually transmitted diseases and unplanned pregnancies.

'It has morphed into something … horrible,' she said.

Although perhaps her remarks had a religious tone, religious justification for her non-evidence-based beliefs was not apparent.

In June, 2019, the New York Times reported that the sudden emphasis on the evils of pornography may have come from not just religious fundamentalist beliefs, but political extremism from the deepest internet.  The article opened with this chilling example,

Buried in the anti-Semitic manifesto of the 19-year-old man who recently opened fire in a synagogue near San Diego is a sentence in which he blames Jews for 'causing many to fall into sin with their role in peddling pornography.'

To enlarge on this example,

some of the suspects in racist attacks and their supporters have invoked the societal ills caused by pornography in manifestos or online forums.

White nationalists, misogynistic clubs and online forums have also drawn a connection between pornography and anti-Semitism. Many of the adherents appear to be young men who blame the prevalence of pornography online for their own struggles and what they perceive as society’s decline.

'Any right-leaning dude on the internet in 2019 is at least aware of the phenomenon,' said Daniel Harper, a podcaster who tracks white nationalism online.

For example, a forum on Reddit is a support group of sorts for 440,000 members who take breaks from masturbation and porn for what they believe to be mental, physical and sexual-health reasons. The Proud Boys, a self-professed 'western chauvinist' group, encouraged a similar message.

These dark beliefs turn out to be nothing new, but perhaps are having more influence in the current era in which political extremists now seen to be welcomed into the mainstream.

The theory that Jews are trying to control the West by using porn to render white Christian men impotent has deep roots. Among its exponents are several elder statesmen of the current white nationalist movement, such as David Duke, who, in a 2016 Twitter feud posted: 'Jews dominate porn — why are ‘Christians’ ok with that?'

During the 2018 race to fill Paul D. Ryan’s Wisconsin congressional seat, long shot candidate Paul Nehlen, a self-avowed 'pro-white' advocate, was suspended from Twitter for circulating a video titled 'The Jewish Role in the Porn Industry.' He has since made other racist comments and been suspended again.

There are also hints that the extemism of white supremicist politics on this topic may not be entirely divorced from the more open condemnation of pornography by some fundamentalist religious groups.

Michael German, a former F.B.I. agent who is now a fellow at the Brennan Center for Justice at New York University, said the anti-porn rhetoric was baked into the culture of the violent white supremacist groups he investigated in the 1990s.

'In any sort of fundamentalist culture, there is a desire to control sexuality, and this one’s no different,' he said.


There have always been snake oil salemen and quck health care practitioners.  Some years ago, proponents of evidence-based medicine (EBM) were dreaming of a world in which honest discussion based on critical thought about the best available evidence from clinical research would lead to a health care revolution.  Early on, though EBM  faced difficulties from deceptive marketing and manipulation and suppression of medical research in service of promotion of drugs, devices, and other medical goods and services.

Now EBM seems under seige by a new wave of propaganda and disinformation, not so much to sell products, but to further religious or political ideologies (for other examples, look here) , or national interests of hostile countries (look here). The health care dysfunction we now see will seem like nothing compared to the dark sort of dysfunction that could be generated by health care and public health based on sectarian beliefs, extreme political ideologies, and the interests of hostile foreign powers. The time for complacency and excuses is past.  Any health care professional who cares about our national future must get on the information barricades and fight for science and the truth in health care.   

Sunday, June 09, 2019

How to Counter Medical/ Health Care/ Public Health Disinformation

It used to be so simple.  Yes, we had to cope with deception in marketing.  Commercial sponsors of clinical research were known to manipulate the research, and even suppress research with results unfavorable to them.  Key opinion leaders spun medical education and the media.  But it was all releatively straightforward in some senses.  It was all at least mostly based on medical knowledge and clinical research.  The purposes of the spin and deception were commercial: the goal was selling more products or services.  With some digging, the conflicts of interest sometimes could be discovered.

But that was before stealth health policy advocacy morphed into propaganda and disinformation (look here).  Disinformation campaigns were everywhere, and even in one case, were supercharged by a disinformation campaign run by a hostile foreign power, apparently meant to destabilize western democracies (look here).  We are now drowning in a sea of propaganda and disinformation.

What can health care professionals do before we go under?

How Medical/ Health Care/ Public Health Disinformation Works

A May, 2019, MedPage article entitled "a prescription for treating fake health news," noted how the rise of social media enabled disinformation:

Although patients' misconceptions, lack of logic, and superstitions have complicated the work of doctors since the first doctors existed, the advent of social media has taken the problem to a new dimension.

With social media, patients can more easily find misinformation, says Dominique Brossard, PhD, chair of the University of Wisconsin-Madison Department of Life Sciences Communication. They can also share that misinformation more easily.

The articles listed a series of factors that increased the potency of disinformation spread by social media:

Lies may spread faster than the truth. Researchers at the Massachusetts Institute of Technology analyzed a set of about 126,000 news stories disseminated on Twitter from 2006 to 2017. They found that more people retweeted false information than true information. The researchers speculated that people may have passed along the fake news more readily because it was more novel and evoked more emotion.

In addition, social media enhances repitition of false messages:

The wide dissemination means that some patients may receive the same false messages repetitively. In another study, Yale researchers found that the more often people receive the same message, the more likely they are to believe it, even when the message is labeled as disputed by social media fact checkers.

Also, people attend more to the immediate source of information than its origin:

when people are evaluating the reliability of health information shared online, they care more about who shared the information than they do about the original source, according to an American Press Institute study.

The article went on to discuss how individual physicians could help individual patients understand how disinformation may dupe them.  However, this is is a retail solution to a huge wholesale problem.

What Can Health Professionals Do on Social Media to Counter Disinformation?

Note that while we know something about how medical/ health care/ public health disinformation is spread, we still know little about the cause of the plague.  Unlike the old style of deception, it is not obviously based on the self-interest of companies trying to sell products or services.  Nonetheless, we need to fight disinformation even if we do not fully understand its causes.  And we know a little bit about how that could be done. The bottom line is that health care professionals need to use the same social media that is spreading disinformation to counter it with the truth.

Two recent articles specifically encouraged physicians to get online now (even if they are uncomfortable with the brave new world of the internet.)

[We cannot pretend the internet is only for computer nerds, as it may have been at the time of the debut of this original Compaq 286 Portable, the original Microsoft DOS based "portable," actually "luggable" computer]

In June, 2019, a CNBC article profiled one physician pioneer who urged all concerned health care professionals to confront disinformation on social media.

The antidote to fake health news? According to Austin Chiang, the first chief medical social media officer at a top hospital, it’s to drown out untrustworthy content with tweets, pics and posts from medical experts that the average American can relate to.

Chiang is a Harvard-trained gastroenterologist with a side passion for social media. On Instagram, where he refers to himself as a '“GI Doctor,' he has 20,000 followers, making him one of the most influential docs

Note that,

Every few days, he’ll share a selfie or a photo of himself in scrubs along with captions about the latest research or insights from conferences he attends, or advice to patients trying to sort our real information from rumors. He’s also active on Twitter, Microsoft's LinkedIn and  Facebook (which owns Instagram).

He exhorted his fellow physicians to get involved:

'This is the biggest crisis we have right now in health care,' said Chiang. 'Everyone should be out there, but I realize I’m one of the few.'

According to Chiang, doctors have historically been reluctant to build a following on social media for a variety of reasons. They view it as a waste of time, they don’t know how, or they fear they might say the wrong thing and get in trouble with an employer. Others prefer to spend their time communicating with their peers via academic journals.

But as Chiang points out, most consumers do not pore over the latest scientific literature. So health professionals need to take the time to start connecting with them where they do spend their time — and that’s on Facebook and Instagram.

So he’s working to recruit an army of physicians, nurses, patient advocates, and other health professionals to get online.

Similarly, a June, 2019, commentary in the Lancet by social media pioneer Dr Jennifer Gunter, an obstetrician-gynecologist, who described her realization

Clearly, we needed a better medical internet. So, I decided to help fix it. I started blogging to help parents navigate the gauntlet of prematurity, but greeted with so much misinformation and disinformation about vaccines I began to think about my own field, gynaecology. What disastrous information were my patients finding online?

The answer was

There was not just misinformation and disinformation about medical care. Practical day-to-day things, not typically addressed by medicine, were especially ripe for abuse—for example, how to select menstrual pads or pubic hair grooming. And many sites contained even greater dangers, notably, exposure to anti-vaccine or other medical conspiracy theories.

We have huge gaps in medicine—in both the science and how we communicate, especially in women's health—but much of what I found when I first started my online quest and what I still find today is exploiting those deficiencies, not fixing them.

Her exhortation was:

The more I see fake medical news, the more I realise we need to use all mediums and media to tackle it. The glut of medical misinformation is real and it harms. It turns people away from vaccines, fluoride, and leads them to useless products. And don't underestimate the weight of 'it can't hurt, so why not?' advice. Whether it is useless underwear changes or forgoing all sugar, it compounds desperation when it is ineffective. And snake oil peddlers are always standing by with a confidence we evidence-based practitioners can only dream to emulate.
Everything we read and share builds the internet, so we in medicine should especially take that to heart.

But Dr Jen, as she is now widely known, also had some practical advice for health care professionals out to defend the truth on social media:

First, a very simple beginning:

How does one even try? Find good medical content and post it on Facebook, Twitter, or the social media platform that works best for you. Even in a small circle of friends and family you can make a difference. If you read something accurate, well sourced, and bias free click the like button. The more clicks the greater the chance that piece will appear favourably in an algorithm. Ignore bad pieces—social extinction is the best strategy.

 Then learn some simple rules:

Everyone should learn the following four basic rules of internet health hygiene. The first is never read the comments as ad-hominem attacks beneath the content can lead people to question the very facts that were just presented. The second is avoid sharing bad information—even in jest. We are all primed to remember the fantastical and sadly medical truths are usually stodgy. Also, sharing makes the bad content more popular algorithmically speaking. The third is don't get information from anyone selling product. Bias has an impact. And finally, steer clear of content from practitioners who are against vaccination or who recommend homeopathy.

Meanwhile, do not neglect to provide your patients with accurate information, or spreading the truth by older means:

Guiding your patients to accurate information is also important. Find good online resources and offer them as handouts or e-mail the links directly if you can do that securely. Your patients are looking online, whether they tell you or not. Offering them curated content from trusted sites, such as the National Health Service in the UK or professional medical societies, validates their search efforts and I believe it makes people more likely to share with their health-care provider what they found online.

Create content, be it quality medical research in a journal or opinion pieces for the lay press. 

For those who heed these exhortations, know that fighting disinformation will not be easy.  In particular, expect strident opposition, as discussed in a commentary in the May, 2019, BMJ by David Oliver, using examples pertaining to debating anti-vaccination fanatics:

Persuading individual parents is one thing. But trying to debate with the more determined anti-vaccination activists can be a futile endeavour, not played by the rules healthcare experts are used to.

Every scientific paper in support of the cause (whatever its quality) and every commentator sympathetic to the cause (expert or not) is selectively harvested and cited. Allegedly hidden harms and risks of vaccination are highlighted. If you’re not a genuine content expert it’s impossible to wade through each individual source to appraise it or understand its limitations. If you really are a content expert, steeped in the science and leadership of mass vaccination—or an official body, from Public Health England through to WHO or the UN—you’ll be labelled as being close to (and influenced by) the vaccine manufacturers, and the impartiality of your advice will be questioned.

Reports of outbreaks and rising infections will be dismissed: 'How many of those cases were actually verified?' The severity of the disease we’re trying to prevent will also be questioned. Measles and other preventable childhood infections can kill or bring serious long term damage and disability, but these consequences will be minimised to suit the cause. You’ll be told that not all vaccinated people mount a sustained immune response (which is precisely why we need a high uptake for herd immunity).

Don’t be surprised if your defence of mass vaccination against refuseniks leads to attacks on social media or impassioned private correspondence. If you push back, the whole cycle will start again.

The idea of children developing natural, normal immunity through exposure to infections will be romanticised. Arguments about the collective societal need to vaccinate our own children so that we don’t put other children at risk will be either ignored or represented as a callous attack on parents and dismissal of their concerns—potentially a bad look for doctors and nurses, even when acting for a greater cause. And suggestions that vaccine refusers are putting their own children at risk will be used to make those doctors look even worse.

However, while it may not be reasonable to expect to convince whoever are the people who are central to the spread of disinformation that they are wrong.  Instead, the goal should be to decrease the spread of disinformation by informing those who have not yet become cultists.

Final Exhortations

However, this is not the time for the faint-hearted.  While one may not persuade the fanatics, but have some hope that it is possible to advance the truth.   Do not forget the importance of the battle.

To quote a June, 2019, Bloomberg op-ed about the the need to challenge disinformation in the political sphere,

The culture war gets a lot of attention, in part because it’s easy both to understand and to pick a side. But it’s the epistemology war – the partisan effort to break the power of facts, knowledge and expertise, and to destroy the means of assessing them -- that will determine whether the U.S. can secure a decent society in the future.

Have courage, because:

That war is Sisyphean, with victory perpetually subject to savage reversals.

What we have to do is

roll the stone uphill day after day.


Speak. Repeat. Speak again. Lace up your Marine boots and put on your Republican suit. There’s a war on.