The coronavirus pandemic has not been an advertisement for the healthy effects of democracy. There have been some notable success stories among democracies, but it is also true that nine out of the ten nations with the highest cumulative COVID-19 cases are democracies. One possibility is that the mechanisms that ordinarily produce better health in democracies—accountability through free and fair elections and freedom of expression—may not function to produce the same result in a pandemic. In this Council on Foreign Relations roundtable, Drs. John Gerring and Ilona Kickbusch discuss this possibility and their work from a new BMJ series on democracy and health.
Thomas Bollyky: Well, thank you. Welcome. My name is Tom Bollyky. I’m the director of the Global Health program at the Council on Foreign Relations. It’s my pleasure to welcome you to this roundtable entitled, “Preparing Democracies for Pandemics.”
It is fair to say that the coronavirus pandemic has not, to date, been an advertisement for the healthful effects of democracy. Several of the countries that have acted quickly to contain COVID-19, such as South Korea, New Zealand, Uruguay, are democracies, but as of yesterday when I last looked, eleven out of twelve of the nations with the highest number of cumulative reported cases are democracies too. This mixed performance of democracies represents a departure from the success of this political system in confronting other health challenges relative to other forms of government.
Today, in this roundtable, we are going to discuss why the potential mechanisms that connect democratic government to better population health may not work as well in a pandemic—and we’re going to also discuss how to better prepare democracies for future pandemics. In doing so, I’m going to commend to you a new special collection of articles recently published in the BMJ on democracy and health that considers these questions. I will concede I am biased because together with Ilona Kickbusch, one of our great speakers today, I was a guest editor of the series, but it really is well worth your time, and I recommend it to you. Both the series and its publication in the BMJ were made possible by a generous grant from Bloomberg Philanthropies, for CFR’s involvement and my involvement, and with support from Konrad-Adenauer-Foundation to the Graduate Institute of International Development Studies for the involvement of Ilona and her great team.
I’m really pleased to have two terrific speakers today to help us explore this topic, generally, and this series. I am going to grossly truncate their biographies and just tell you their current titles, but you’re welcome to look at their biographies as well. Ilona Kickbusch is the founder and chair of the Global Health Centre at the Graduate Institute of International Development Studies in Geneva. John Gerring is a professor of government at the University of Texas at Austin. Ilona is going to start us off with a few minutes on the reason for this project in the BMJ and on the continued importance of political determinants for health, democracy in particular, despite what we’re seeing in this pandemic. John is going to educate us on some of the lessons from his paper in this series on whether or not health is even politically relevant, drawing on some experimental evidence during this global pandemic.
We are fortunate to have a number of the other authors of papers from this series here as well, and I’m going to try to loop in some of them in our discussion too. With that, I’m going to turn it over to Ilona with just one caution, of course, is that this meeting is on the record. It is for attribution. Anything you say can and will be used against you as part of your vetting process for the next administration. So, keep that in mind. And with that, I turn it over to Ilona to start us off.
Ilona Kickbusch: Thank you very much, Tom. Welcome to everyone to this discussion that, of course, we think is enormously relevant at this point in time. Tom has asked me to say a word or two about how it came about. That relates to the work of the Global Health Centre at the Graduate Institute. We’re an institute of international relations and development studies, and I have long been pushing that there needs to be a stronger contribution of the political sciences and international relations to the global health debate.
In global health, there is a strong discussion around what we call the determinants of health. Initially, the focus was on social determinants and particularly issues of inequality. That then moved on to get a better understanding of what we call the commercial determinants of health—how market forces actually drive the health of nations—and then moved on to say, what is it actually about the political determinants of health? This was also driven by the fact that the present director general of WHO very frequently says health is a political choice. And, therefore, the question arises: do certain regime types make better political choices in relation to health?
So, that was the starting point of our thinking, and I was incredibly lucky that, at the same time, Tom was thinking about things like that and had published his article around that democracy does matter in global health and that was in relation to responding to NCDs [noncommunicable diseases]. So, our interests came together, and as he indicated, we found some others who were ready to support us. We were able, with the authors, to have two meetings—one in Berlin and in Washington, DC—and then COVID-19 hit. And then our questions started to change because the question then also became: does democracy matter in response to a successful COVID-19 response? And as Tom has already indicated, it seems that democracies reacted very, very differently. Even if you take into account that there are different types of democracies, it does seem so, though, that democracies that are built on a binary system of the Westminster model seem to face, in some cases, stronger divisions than some consensus-oriented democracies. But then as we started discussing that, it took us even further that in the face of populism, of nationalism, critique of science, info dynamics—all those things that we’re going to come back to—we ended up with an even larger question that our project hasn’t yet answered, but that we are hoping to tackle in some of these dialogues. That is, and I’ll formulate it in this way, how can democracy save the lives of its citizens and itself?
And this is related to the fact that it seems many democracies, or some democracies, were not well prepared for the COVID-19 challenge on many counts. Also, in terms of their regulations, in terms of their parliamentary processes, in terms of involving their citizens. So, if we ask now, and I’ll end with that, the interest is what can we learn from the experiences of different democracies to actually say, is there a way to—and we put this in inverted commas—to actually “pandemic proof” democracies. And we’ve seen that some democracies have already started this process. Two countries I know of, both Taiwan and Germany, have already changed their infectious diseases law, for example, to allow for more participation of parliament in these big decisions. So, those are some things that we might take up as we move forward. Thank you, Tom.
Thomas Bollyky: Great, thank you so much, Ilona.
So John: the central theory for the connection between democracy and better health is accountability. Accountability enforced through free and fair elections means governments are more motivated to provide more effective health services to a broader share of their population because they’re subject to regular free and fair elections. But the United States has the most cases and the most deaths in this pandemic. We saw in the recent U.S. presidential election that 93 percent of the most currently affected counties in pandemic voted for the president. Despite all the U.S. challenges with COVID-19, the election ultimately swung on forty-five thousand votes in three swing states.
What does your research tell us about what we’re seeing on how democracy and that accountability function might operate in a pandemic and whether it might be different from how it operates on broader health?
John Gerring: Well, these are great questions, and I’m delighted to be here and really grateful to you and to Ilona for this initiative, which I think is really incredibly timely and important. As you know, Tom, I’ve been working on this issue of democracy and public health, and, like you, I’m convinced that there is a positive correlation, and the way that we would like to think that democracies seem to perform a little better than autocracies on measures like infant mortality, but the relationship isn’t incredibly strong. In fact, it’s, I guess you might say, surprisingly weak. And there’s also a question about why it exists at all. What are the mechanisms at work? And I think that’s—you know, both of these issues were driving, piquing my curiosity.
So, in the paper that you’re referring to that became part of this symposium at BMJ, I teamed up with a sociologist, Aaron Reeves, and economist, Arnab Acharya, and we tried to enlist experimental evidence to address this question. I guess we’re struck not only by the weakness of this relationship between regime type and mortality, but also that in democracies, one generally finds that economic issues are more salient than health issues. And so, even now in the United States in the midst of this terrible pandemic, as you pointed out, the U.S. is one of the worst affected countries, it’s still the case that a much higher number of Americans are very worried about the economy than are very worried about the infection; this is a series of tracking polls that FiveThirtyEight has put together the past year. And we can also see that Trump’s approval ratings have held steady despite what many would consider to be a disastrous handling of this pandemic. You know, I think we’re now at about a quarter million deaths and, you know—so what is really going on here?
Well, so our approach is to develop an experiment—a survey experiment, as it’s called—where we recruit people, we expose them to different treatment conditions that convey information about the health pandemic and its economic effects, and then ask them outcome questions about politics to see if that information moves the dial—if it affects their view of the incumbent or their willingness to blame the incumbent for what’s gone wrong. I’ll give you a little bit of detail on the research design. I don’t want to get too much into the weeds, but basically, we have a survey experiment that was run simultaneously in three countries—in the United States, United Kingdom and India. So, two rich countries and one poor country—all democracies. We used a recruitment platform, known as Mechanical Turk, which is run by Amazon, and fortuitously MTurk has lots of people in those three countries, especially in the in the U.S. and India. And so, we were able to recruit over thirty-five hundred respondents in the first round, and then in a follow up round an additional two thousand respondents. And this is a pretty high-powered experiment, so we don’t have to worry too much about stochastic threats to inference.
So, there were—the way the experiment was set up is that people are randomized into these different arms or treatment conditions. The control condition—the people are told nothing, just, you know, the basics about would you like to participate in this survey. And then there was a treatment arm that conveys information about the economic effects of COVID-19 on their country. So, in the United States, we said some estimates suggests that the economy could shrink by 3.2 percent this year, 52.8 million people could end up without work, and that the value of stocks and shares could fall by around 30 percent. This was is back in April. April through June is when the first round was administered.
And then we had a health arm which conveyed information about the likely health effects of COVID. And then, we did a second round of the U.S. survey, not in India or in the UK, but in the U.S., we did a second round several weeks ago in which we, you might say, primed the treatment even more. So, we told them that the United States has one of the highest infection rates of any country in the world, that an estimated 250,000 people have already died, and that some people blame this catastrophe on Donald Trump and the Republican Party. We say according to one estimate, approximately 50 percent of American deaths—roughly 125,000 deaths—would not have occurred if Trump had publicly acknowledged the severity of COVID-19 and followed expert advice on how to manage the shutdown of schools and businesses, social distancing, and the distribution of masks. So, this is a very strong treatment—not, I don’t think, a dishonest one—but, we’re really pointing the finger.
Thomas Bollyky: Not an entirely a fanciful set of facts.
John Gerring: No, no, not at all. We tried to keep this as real as possible, both for ethical reasons and also just in terms of generalizability.
So, the two outcome questions were: one, would you support the incumbent party and party leader if an election were held today, and two, do you hold the government at fault for allowing the disease to spread? And what we found is that there was no treatment effect across any of these treatment arms—even the strongest one that we added in the second round of the U.S. survey. And just to be very clear about this, what this means is that the respondents who were told nothing, their responses to these two outcome questions were the same, on average, as those who were given information about the severity of COVID, its economic effects, and so forth.
Thomas Bollyky: And to be clear, you found that in all three countries.
John Gerring: That is correct.
Thomas Bollyky: And is that similar to what you found on health in general?
John Gerring: Well, we did find that the experiment was effective in raising the salience of the issue and anxiety about it, but we didn’t find any political ramifications. And so, if this is to be believed, it means that there are no repercussions. As we put it in the title of the paper, it’s possible that public health—even a major pandemic of this sort—is politically irrelevant.
Now, there are a number of possible explanations for this, and I don’t want to consume a lot of time by going into them, but I’m happy to do so later on. And certainly, there are questions about the extent to which we can generalize from, you know, this one set of experiments with a sample that is not a random sample of the general populations. And there may be some special things going on, which I’m happy to elaborate on or discuss, and I’m sure people out there have some thoughts on this. So, our view is these are some pretty, I guess you might say, shocking results and we need to know more. You know, we would very much like to do some follow up work in different countries with random samples using other, you know, a variety of public health issues, not just COVID, and where we have a purely economic treatment as sort of the baseline. So that’s what I’ve got, and I’d be delighted to hear what people what people think.
Thomas Bollyky: Great. Great.
John Gerring: Thanks.
Thomas Bollyky: Thank you for that, John. And just to be clear, do I remember that one of the responses indicated most of the respondents considered the government was somewhat responsible for health generally, is that accurate?
John Gerring: That is correct.
Thomas Bollyky: So, one possibility is that people view pandemics differently than health generally?
John Gerring: It’s possible.
Thomas Bollyky: Possible. Interesting. All right, I’m going to try to pull in one of our participants, who’s one of our authors for a different paper, because it gets at a separate mechanism by which democracy is meant to improve health.
So, I’m going to call on Steven Wilson and ask you to indulge me on this, but I think you’ll find it really quite revealing. Steven is an assistant professor of politics at Brandeis and looked at a separate mechanism by which we believe democracy affects health—freedom of information. The theory is that in democracies when people are more able to share information freely, there will be more accountability for the government. People will also learn of more healthful practices and that feedback will inform the practice of government in providing health. So, lots of good things come–-we think–-from free expression. But I want to pull in Steven on the question of whether or not the free expression also has a downside in democracies when it comes to disinformation and social media. Please tell us a bit about your paper with Charles Wiysonge and how it connects to what we saw, perhaps in this pandemic.
Steven Wilson: Thank you very much, Tom. It’s been a pleasure to be part of this process, and we found some really interesting things in our research that I’d like to share with you. So most of my work in general has nothing to do with health. It has to do with the internet and the effect of social media on democracy and authoritarian regimes. So that’s sort of the way that I came into this.
But I think all of us have been concerned over, say the last decade or twenty years, in terms of the rise of anti-vaccination sentiment on social media, in particular, and concerns that, paradoxically, it is the richest, most educated countries that are seeing the largest resurgence in diseases that have effectively been defeated by vaccines over a period of time. And we’ve also become very aware that the internet and social media has played a major role in this spread–-the spread of Facebook groups and anti-vaccination content on Twitter and what have you. And there’s a concern here of how do we deal with this? Because, just on principle, freedom of speech matters. I don’t think we’d find very many people, especially in this call, that would argue that that’s very foundational to what we believe in. But in terms of anti-vaccination content, we’re wondering why is this happening, and what effect is it actually having? Like is it just, we can see it happening, but does it actually have an impact on real world outcomes?
And a secondary part of that is the rise in visible disinformation campaigns online where there is conscious effort by malicious actors to push false information, especially from foreign services, trying to influence domestic politics and countries. And one of the things that we’ve picked up on, through both scholarly research and then the Senate report a couple years ago that delved into this, is the overwhelming prevalence of Russians, both automated campaigns through bot networks and intentional disinformation campaigns, pushing and amplifying anti-vaccination content.
And so, what our paper tried to do was see can we actually measure some type of effect going on? So, we have lots of research that shows individually or one country case studies or experimentally, people’s exposure to anti-vaccination content having an effect. But we wanted to see is there an actual measurable problem worldwide? Like, if we look at data across every country in the world, or as many as we can get data for over the last decade or twenty years, can we actually see a measurable and substantive impact or is this just sort of concern for concern’s sake?
So, the basic design that we put together was relatively simple. We have some very good measures of the level of foreign disinformation campaigns on social media and countries from the Digital Society Project, in addition to measures of to what degree do citizens of each country use social media to try to organize offline action. Okay, so we use these as sort of measures of are people actually organizing online, so that way we can connect this to outcome measures, such as levels of vaccination rates that we got from WHO and also from survey data across countries from the Wellcome Global Monitor in terms of over time, are people more likely to say that they have safety concerns about vaccines in general. And we also took a different set of data in terms of a set of all the geo-coded tweets in the world over the course of several years and analyzed those for any discussion of vaccines and also through some sentiment analysis tools to understand whether people were negatively talking about vaccines.
And sort of the end result function that we got was, we found a very surprising substantive level of effect, where over time, a one-point shift in this five-point disinformation scale is associated with a two-percentage point drop year over year in mean vaccination rates in countries. We found that the same disinformation scale predicts a 15 percent increase in negative tweets about vaccines, and we also found that the use of social media by a population in a country to organize offline action of any kind is associated strongly with an increase in doubts about vaccine safety.
Now, there’s a lot of issues with the research that we did in terms of what we’re picking up is fundamentally correlative rather than causal, in the sense that we’re basically looking at: do these numbers on this side predict these numbers on the other side? But there is a pile of research showing the mechanism happening. And so, our look was just can we link the outcomes that we are scared that are happening to the mechanisms that we have seen in other research. And the fact that we did, I think, provides some very concerning information about the effect of social media and the internet and, in particular, it’s use by both malicious external forces through disinformation campaigns and just through the population itself, in terms of having bad outcomes, in terms of accepting vaccination.
Thomas Bollyky: That’s terrific, Steven. Thank you. And thank you to you and Charles for this great piece of work.
So many questions. I’m going to ask two to Steven first, and then I’m going to go back to John and Ilona, and then after that round, I’m going to turn it over to the audience, just so you can start to think of your questions.
Steven, I have two questions. You can answer them together, if you’d like. The first is on the scope. Obviously, your paper focused on vaccination, but from the lived experience of this pandemic, you wonder how much social media disinformation played a role in other behavioral interventions and their public adoption. So, did we see anything in connection to mask wearing and non-pharmaceutical interventions that promote healthful behavior? The second question is also timely––we’re a couple weeks away from potentially a rollout of the first vaccines. What are you and your colleagues seeing now? Is there anything you can update us on what we’re starting to see with the ramp up to vaccine roll-out? Obviously, your research looked at historical data, but this is a live issue that we’re going to see in this pandemic, and I’m curious if you have observations to share with the group.
Steven Wilson: Sure, in terms of the scope in terms of other interventions––mask wearing and such––we didn’t look specifically at disinformation about particular things like that. But we do have a lot of documented evidence over the last couple of years, in particular, of disinformation and organization around stuff besides COVID. So, for example, the 2019 Ebola outbreak, in which foreign disinformation campaigns were just pushing this overall narrative of don’t trust foreign health workers. And it led to a straight line you could draw to the dangers on the ground for foreign health workers as part of that.
But, in addition, we have some other projects in the works where we are looking at, and finding, that distinct connection of the moment that there were interventions possible––where okay we need to wear masks––there was an instant creation of disinformation networks focused around going against that. Basically, any intervention on any health issue that we come up with, there almost instantly seems to be a backlash of those that have doubts about it, and then pushing that information online.
And I think that there’s a deeper mechanism going on here, which is sort of part and parcel with how the internet works both in good ways and bad ways. Which is this notion that you might have heard of: the long tail effect, where the idea is because communication is so cheap and easy, and finding other people is so trivial through internet and social media, it means that any fringe group can find other people that agree with them and find their own little bubble and start amplifying their effect on the world. And this has some great things, like the fact that repressed minorities can find other repressed minorities and communicate and organize safely. But it also means that the Nazis and the anti-vaxers can all find each other also. And we’re kind of seeing the repeated pattern that way, in terms of both health interventions and everything outside of health also.
Thomas Bollyky: Great, that’s terrific. So, we promised, with the title this event, to also talk about preparing democracies for future pandemics And I want to do a round with our speakers where we to talk a bit about solutions, but also what you’ve been seeing in this pandemic. For each of the speakers, please put forward an idea of what you think might make democracies better, more, as Ilona put it, pandemic-proof for the future, or ideas on addressing the deficiencies and the mechanisms that John talked about or Steven talked about on the accountability—through free and fair elections for John and this freedom of information for Steven. Ilona, let’s start with you.
Ilona Kickbusch: Thank you, Tom. I think there’s a number of elements. I don’t think we’ve really realized in the past, how much the basics of democracy and particularly of demos—meaning, you know, that there is a community that people are willing to debate and discuss with each other––how important they can be in terms of health. We tend, and maybe that’s also one of the outcomes of, you know, a strong focus on American democracy, we tend to continuously highlight the individual liberties that come with democracy, the individual freedoms, the individual rights, and they are incredibly important. But a democracy is not only about me, it’s about us, and it’s the us also, you know, what you are experiencing now. I see this from afar, with the American elections, that, you know, whoever wins, then speaks for the whole country and tries to move it forward.
So, some of the real basics of how our modern democracies function come to the fore in a situation of a pandemic. I think that’s one issue that we need to look at much more carefully, and we see that. We also see that a lot of our pandemic preparedness plans, laws, regulations, etc., are actually made for very short pandemics. You know, it’ll be over in three weeks kind of thing. And therefore, we don’t need to worry about decision making processes. I live in Switzerland, and what has made Switzerland really, really nervous is that, you know, basic functioning of democracy. The parliament didn’t meet. Some of the decisions that needed to be taken by a popular referendum had to be moved. So, if a pandemic takes a long time, your basic functioning of democracy and who takes the decision. And this is, you know, of the largest concern now also in this revision of the German infection law, particularly if you have a democracy that functions at various levels and no matter, you know, how knowledgeable your chancellor is on what exponential growth means, she still has, you know, a whole bunch of state ministers that she has to get into a consensus.
And so those kinds of issues are becoming clearer and clearer that––who has the controlling power in a democracy in a period of an extended time of a pandemic? And I don’t think we have really been prepared for that. And this is also what the colleagues from Taiwan have told us. Even SARS was relatively short term. But what happens over a period of one or two years?
Interesting, if I take, you know, John’s results is that Germany, in the first wave, went through relatively well through the pandemic. In the second wave, not so well but still better than its neighboring countries. The two most popular politicians, you know, Merkel is up there with, you know, 80 percent approval rates, but the health minister, at present, is the second most popular politician in Germany. About 45 percent of the population in a recent survey think the government is doing enough. 25 percent think they should be doing more. And in relation to Steven, yes, while this new law was discussed in parliament, outside of parliament we had, you know, very, very emotional collection of people protesting from right-wing groups to homeopaths to anti-vaxers, who are calling out the corona dictatorship and who are, if we are talking about foreign financing, by the way, actually, financed also with American money.
So, these are the kinds of tensions that are there, and you have to see which are these key points that keep a democracy stable and how big the health literacy, the digital literacy, and the civic literacy of your population is. And sadly, in many of our societies, we have deeply neglected really pushing and practicing our civil literacy, not just our civil liberties.
Thomas Bollyky: Great, thank you, Ilona. I’m going to ask John and Steven each to take a couple of minutes to answer the question as well. But for those of you that have questions, you can start raising your hand. I’m going to call you after John and Steven speak, in the order that I see you. Again, we also have authors of our other BMJ papers, including Roopa Dhatt, on the phone, who had a great paper on participation. So, I’m hoping she will get involved in this discussion, too. And I think Simon Wigley and Tara Templin also on autocracy and UHC [universal health coverage].
But let me turn to John for a couple of minutes. How important is it to have more of an accountability function attached to pandemic performance to shore up democracies? Is there, what do you think, is there something that needs to be put in place to make that more of a salient connection between pandemic performance and accountability? Or is that the wrong way to think about it? And for Steven. How do we preserve freedom of speech but still address disinformation on social media? How do we save the baby and still get rid of the bathwater? Please go first, John.
John Gerring: Well, thanks. These are these are big topics and, of course, super important ones. I’m not sure that accountability is the best prism through which to view this sort of a challenge. I think of a pandemic of this scale is like a war. And by that, I mean a total war that really threatens the entire country and requires coordination at every level. And in a war, I guess, there’s the ideal that parties come together, you know, that there’s some cross-party consensus, that they work out a plan and listen to the generals and so forth. And so, the analogy here would be you listen to the public health experts. Now, I think this is a somewhat unusual situation in that the public health experts weren’t entirely sure which way to go with this, and hence you see different, you know, countries take somewhat different directions.
But at least that that would be the prescription that I would have, and party politics doesn’t play into this so much. I think it’s more about having some kind of consensual culture, which, I guess, maybe we used to have in the United States. We don’t have so much anymore. and Ilona mentioned the problems of majority rule—first past the post electoral systems—that tend to exacerbate this sort of left, right, us-versus-them dynamic, where the out party feels its job is to criticize, no matter what goes on. And since they have a certain number of supporters, then those supporters become, you know, alienated. And that that can play out very badly because you really need everyone’s participation in a situation like this. So, I’m not sure that, I mean, maybe we can learn from this, maybe, going forward, democracies will be more capable.
But I do want to call attention to one issue that I think is sometimes neglected in this debate. Maybe I’ll be a little contentious here. I think that the public health community are people like us, you know, very highly educated, generally pretty well remunerated, and we have jobs that can carry on, you know, electronically. A lot of people don’t. A lot of people’s job depends on face-to-face contact. A lot of people are living, you know, from paycheck to paycheck, and I’m not sure that––I mean, their voice is reflected in President Trump’s rhetoric. And we can debate, what’s in their best interest. But I think we can also appreciate that their interests are a little bit different from ours. And so, I don’t think this sort of debate can be a just a sort of consult the experts type of discussion.
And in the United States, where we have a very weak welfare state, where a lot of people don’t qualify for unemployment, or not very much unemployment, you know, of course health care is a problem, and the stakes are much higher. And it’s easy to see why you get this dynamic of, no, I got to keep my job. I don’t care. I’m willing to lose lives. I think that’s a little less true in Europe where welfare states are more robust.
Thomas Bollyky: Great, thank you, John. Lots there to get back to you if we have time. Steven, I know you’ve thought about this, and we’ve talked about this in the past. What can democracies do to protect themselves against this onslaught of social media disinformation?
Steven Wilson: Sure. I think there’s sort of two levels to look at it with, which is very tactically in terms of how do we deal with COVID right now, and strategically in terms of the long run issues that we’re seeing.
So, I think the idea of fighting misinformation being intertwined with freedom of speech is sort of inaccurate. Because this isn’t a free speech issue, even if some people are insisting that it is, and this comes back to just the very, very old like cliched arguments we have where, you know, you have a right to your political opinion. You do not have a right to your own facts. You don’t, you know, freedom of speech doesn’t mean you get to yell fire in a crowded theater, like all of these kind of generic examples.
Saying that vaccines cause autism online with fake scientific information is not a free speech issue about political opinion. It’s the same thing as yelling fire in a crowded theater, especially in the middle of a pandemic. It might have been one thing a year ago or five years ago, but at the current moment this is actively hurting the health of society. So, I don’t think this is a free speech issue, so much as it’s an issue of we need to have coordinated action against misinformation online. And the social media companies have been doing a much better job over the last few months, and they have been over the last few years, I would definitely say that, in terms of trying to systematically take down just absolutely false content.
The secondary thing is the fact that intentional disinformation is playing a major role in this. And the bottom line is that we know where it comes from, and we know the motivation for it. This is coming out of pseudo-state actors from Russia––is a huge proportion of this anti vaccination amplification through bot networks––and this means that it is a political problem that has political and diplomatic solutions. If you want them to stop, apply diplomatic pressure. What the actual in between there of how do you make this happen is up to the diplomats, on some level, I think, but it’s not an unknown problem with an unknown solution.
I think there’s a larger strategic issue, though, in terms of the elements of free speech and such, going back to that right to your own opinion but not right to your own facts. At this point, there is, say, an epidemic in the middle of the pandemic, of distrust of experts and distrust of educated authority in the Western world going back for quite some time, over the last, probably, generation of politics. And this is a larger issue that we somehow have to figure out how to grapple with, because there’s a large proportion of people that simply say the expert doesn’t know what they’re talking about. The guy I know online does. And that’s a larger issue that we have to combat that I think is intertwined with the internet and is causing issues with COVID in particular, but is a larger, say, crisis of democracy in the long run if we don’t, fundamentally, have a trust of people who know what they're doing. This is a societal crisis in general.
Thomas Bollyky: Great, terrific and provocative points. We have three people in line and thirteen minutes, so without further ado, I want to turn to them. We have Henry Greenberg first, and then Roopa Dhatt, who’s one of our authors in this series, and then Sonya Stokes. Henry, please. And if everyone will state their name and affiliation when you ask your question. Thank you.
Event Manager: Mr. Greenberg, please accept the “unmute now” prompt. I’ll move on to the next question.
Thomas Bollyky: All right, we’ll circle back to you. I’m sorry for that. Roopa, please.
Roopa Dhatt: Thanks, Tom and Ilona and John. I just wanted to act on the prompt of really trying to answer a bit of the question really around just, you know, what are the other pillars really needed for a functioning democracy? And I think one of the things that this pandemic has really shown us is that we need public trust, and to really have public trust, we need to have civil society that is engaged, funded, and protected.
And part of the paper that I wrote together with colleagues, including Loyce Pace and colleagues from Kenya, as well, particularly Allan and Nerima, the perspective we really wanted to highlight there is that it’s also very critical that the decisions that are being made are truly representative of the population. So, this is a challenge in achieving the dream of democracy, do we truly have leaders in leadership that represent the population? And so, there really is an opportunity there to make sure that the civil society pillar is a way to build public trust, that civil society is engaged––civil society from diverse backgrounds, especially the most marginalized backgrounds. Every nation has an underserved community, whether it’s women, sexual minorities, migrants, abled people, and all those different groups are not necessarily represented in decision-making. And I think the point that was alluded by John earlier about the fact that there is a difference between health literacy in the population. But if we use civil society as an engagement mechanism and really, you know, bring them into the conversation when it comes to public health, it can help bring public health trust, but it needs to be an intentional part of building democracy and an intentional part of creating strong health systems. So yes, I encourage everyone to check out the paper. We do have some very concrete recommendations around this, but it is a very much part of increasing health literacy and also increasing, as Ilona said, about civil literacy as well.
Thomas Bollyky: Great, thank you, Roopa, and I’m glad you spoke up. It’s a terrific paper––I recommend it. Roopa does not just write about the role of participation and improving health, she lives it with the organization that she runs too. So, I do recommend that you check out the paper. With that, let’s try Professor Greenberg, if we can go back to you again, and see if we can manage to get you online and unmuted, that would be terrific to get your question.
Henry Greenberg: Thank you. I’m Henry Greenberg from Mailman School of Public Health. President Elect Biden’s panel on COVID does not include a single epidemiologist. And I’m just wondering, does that reflect a broader view of what American public health is doing, or does it reflect something else? You know, I have my own opinion, but it’s rather a striking observation that in what must be considered the most epidemiological phenomenon in the world, the best panel put together by a thoughtful and committed politician includes no epidemiologist. What does that tell us?
Thomas Bollyky: Provocative question, thank you for that. I’m going to give Sonya Stokes a chance to ask her questions, and let the speakers take them both. Sonia.
Sonya Stokes: Thank you so much, Tom. And thank you so much for this panel. Dr. Dhatt may have answered part of this question, and I’ll have to review her paper. Thank you so much. But the resistance, a reluctance, towards vaccines is prevalent not only among my patients, but even among some of my fellow providers across the U.S. In New York City, I’m part of a working group of physicians looking at strategies to improve vaccine acceptance within our communities. The solutions that have been discussed on this panel so far––health and media literacy––these things do take time. And even though they’re welcome solutions, are there any shorter-term solutions that you are aware of that can help us more immediately through the next several months ahead? Thank you.
Thomas Bollyky: Great question. So, to broaden Henry’s question, you know, what’s the role of trust in experts and in particular epidemiologists, and are we likely to see greater acceptance of them in democracies? And then Sonya’s question––do we need broad societal change before democracies can perform better? Or can we do something for the near and medium term? Why don’t we go through the group in order and start with you, Ilona. Keep in mind, we have seven minutes. So, let’s make sure we have time for everyone.
Ilona Kickbusch: Yeah, I leave the epidemiology questions to the American colleagues, except just saying that we have found that nearly all groups have always tended to exclude someone. You know, the social scientists have not been considered in many of the German groups. For example, we had loads of epidemiologists and virologists and whatnot, but I guess you’ll have an answer to that.
I think when we talk about making democracy pandemic proof, what we’re learning now is really that the light is being shone on those things that we have really neglected for decades. You know, like the inequality issues, like certain participation issues, like health literacy and science literacy issues. And if we look, you know, all the things that were stopped in our schools, at least in Europe—you know, learning about democracy was thrown out because, you know, supposedly you needed other things in life more than knowing how your own political system functions and what your own role in it was. So, I do think we have to face up to some of those long-term issues.
In terms of short-term recommendations, I think a lot of professional organizations have tried to develop guidelines. How one talks, you know, one-to-one, and it’s really, you know, like knocking on every door during an election campaign, talking one-to-one with patients who don’t want to vaccinate their children, who don’t want to participate in a vaccination program. And it’s incredibly hard work, because, you know, I can see it in Germany, the government can say until it is blue in the face, there will be no––what’s the English word––there will be no vaccination that everyone has to take––what’s your word for it–– you know, the compulsory vaccination. Irrespective of that, you know, there are groups who, either for reasons of wanting to sow discourse or because they fundamentally don’t believe in their political system and that they can trust it. So, it’s an incredibly hard job. But we have to face that job, and we have to train people to do it, and we have to invest in them. And I hope, you know, Germany, for example, has spoken, you can’t believe it, you know, public health was neglected for decades. Suddenly, Germany is putting an enormous amount of money, in the billions, into public health, and we would hope, you know, that those kinds of jobs are also created so that you have that interface with civil society, with the population, and with the people who fear for, example, a vaccine.
Thomas Bollyky: Two minutes each for John and Steven. Pick one of the questions how to better incorporate experts in policymaking moving forward, or what democracies can do to protect themselves in their short and medium term. John, in this lightning round your two minutes come first.
John Gerring: I really don’t have good answers to these great questions. So, I’m going to cede my time to the distinguished gentleman from Massachusetts.
Thomas Bollyky: All right, distinguished gentleman from Massachusetts.
Steven Wilson: Thank you, distinguished gentleman from Texas. I’ll just quickly answer “the what can we do right now to make an impact” because these are very large issues that take social change over a large period of time, but I emphasize that doing simple things like taking down fake information about vaccines online really does make a short-term difference, not because it’s going to sway the people that are extremists, who insist that vaccines are giving their kids autism and cancer, etc., etc., but that it reaches that very large gray area of people where vaccine hesitancy is the problem. Where the reaction is not, “Oh, vaccines are terrible.” It’s the: “Well, I saw some people talking about it, so I’m going to wait a few months to get the COVID vaccine even once it’s available because even if it’s a small chance, why take the risk...” And I think that’s where we can make an immediate short-term difference is in that gray area of hesitant individuals making sure they’re not seeing this disinformation content.
Thomas Bollyky: Great! Steven, you are not alone. I just had a long conversation with Peter Hotez, who if you don’t follow him, you should. He’s terrific on many issues on the challenge of dealing with the anti-vaxxer community, and the fear is heading is that the U.S. has a broad strategy of just engagement and communication and as a solution to the problem that will not be enough. Heading into what will be our largest vaccination campaign in history, that we need to censor effectively and take on the anti-vaxxer empire and take down websites. So that’s, you’re not alone in that regard.
Ilona, as the co-editor here, do you want to say any final remarks in your last minute, otherwise we’ll sign off?
Ilona Kickbusch: No, I just think we really, really must continue this debate. I think we’ve seen how many open questions there are. I’m delighted that political scientists are getting involved in these issues. I plead with them to stay with us—with us public health people, even though I’m a political scientist myself—and that we really seriously invest in making our democracies pandemic-proof because, as our colleagues in Taiwan said this morning, we are already preparing for the next pandemic.
Thomas Bollyky: Great, perfect timing. Again, I recommend the audience members take a look at the series. You heard a lot about the great papers today. There are even more in there, including a paper from Jennifer Prah Ruger, and a paper from Simon Wigley, Tara Templin, and others. I commended them highly to you. And thank you for joining us today and look forward to the next roundtable.
Ilona Kickbusch: Thank you.