Travel report: On unpolluted & polluted public health science communcation environments--the cases of the HBV & HPV vaccines (presentation summary & slides)
A rational reconstruction of the talk I gave—in 15' 22" [I can talk 9x faster than the average man, woman, or trained circus animal can read; and I pride myself on the 30-min sentence]—at the truly amazing “How we Can Improve Health Science Communication Conference” at U of Mich.’s amazing Center for Pol. Studies last week. Pretty sure the talks will be or perhaps already are on line.. . . Now am in UK for 7th Annual Cambridge Centre for Risks Studies Confernce – will write a postcard on that soon! Slides for the U of M talk here.
1. As you know, my paper (in press) is on what I call the Science Communication Problem—the failure of valid, compelling, widely available scientific evidence to quiet public dispute over risks and like facts to which that evidence directly speaks.
The paper argues that our understanding of the Science Communication Problem is being distorted by fixation on conspicuous and specular instances of it—particularly the conflict over climate change.
Obviously, empirical researchers should be focusing on how to decipher and ultimately dispel the Science Communication Problem. My claim, however, is that we won’t achieve these goals if we focus on instances of public dissensus to the near-total disregard of public consensus, which is far and away the norm on decision-relevant science.
A research program that never diverts its gaze from climate change and other instances of the Science Communication Problem distracts our attention from evidence that would reveal the falsity of many popular accounts of why we have the Problem. It also steers us toward prescriptions that won’t repair the dynamics that ordinarily generate public convergence on the best available evidence and could even, perversely, inflict even more damage upon them.
I won’t rehearse my argument in detail, though. Instead I will try to illustrate it with a specific example not discussed in the paper: public conflict over the HPV vaccine.
2. As I’m sure y’all know, the HPV vaccine confers an imperfect but still important degree of immunity to the human papillomavirus, an extremely common sexually transmitted disease that causes cervical cancer.
The HPV vaccine also has the distinction of being the only childhood shot recommended for universal administration by the CDC that is not now on the schedule of mandatory school-enrollment immunizations in US states. Legislative proposals to add it were defeated in dozens of states in the years from 2007 to 2012 as a result of deep, pervasive political controversy over the safety and effectiveness of the vaccine (Kahan 2013).
It’s tempting to think this outcome was inevitable. The vaccine is for a sexually transmitted disease and was to be administered, initially, to pre-pubescent girls as a condition of their eligibility to attend public schools. Of course, such a proposal would provoke controversy between groups that subscribe to opposing understandings of sexual morality, of parental sovereignty, and of role of the state in securing individual well-being.
But that conclusion—that the HPV-vaccine conflict was inevitable—reflects exactly the tunnel vision I’m attacking.
The HPV vaccine was not the first one that was aimed at a sexually transmitted disease recommended for universal administration to children. The HBV vaccine was.
The HBV vaccine confers immunity to hepatitis-b, which also causes cancer, of the liver.
The CDC proposed it be administered universally to adolescents (now to infants) just a few years before it proposed the same for the HPV vaccine. With no significant controversy, the HBV vaccine was incorporated into the mandatory, school-enrollment immunization lists of nearly every U.S. state in a wave of approvals that crested just as the HPV-vaccine controversy began. At the time the HPV-vaccine controversy was raging, the HBV vaccine had an national uptake rate of over 90%--compared to the anemic 30% for the HPV Vaccine today (Kahan 2013).
Thus, the HPB vaccine, is in the “denominator”—the vast class of decision-relevant science issues on which there isn’t public controversy but could be. What it shares with all the other members of that class is the benefit of having become known to the public in an unpolluted science communication environment.
The science communication environment, I explain in the paper, consists of the sum total of processes and conventions generative of the cues that normally guide diverse individuals align their behavior with the best available evidence.
The HBV vaccine, like every universal childhood immunization before it, traveled safely through these processes and conventions to the destination of overwhelming public confidence. The vaccine was considered and approved for inclusion in state universal-immunization schedules by non-political public health agencies that have been delegated this expert task by state legislatures. The vast majority of parents thus had occasion to learn of the vaccine for the first time when their consent to administer it was sought from their pediatricians, individuals they had selected b/c they trusted them, who advised the vaccine was safe and a useful addition to the array of prophylactic practices that keep children healthy. Just as important, regardless of who they were—republican or democrat, devout evangelical or atheist or agonistic—all were afforded ample evidence that parents just like them were getting their kids vaccinated for HBV (Kahan 2013).
The decision to follow suit was a no brainer!
In contrast, parents and other citizens learned about the HPV vaccine in what I characterized as a polluted science communication environment. A polluted science communication environment is one in which some risk or fact has become entangled in antagonistic social meanings that transform them into badges of membership in and loyalty to opposing cultural groups. In those conditions, the same cues that normally guide diverse citizens into convergence on the best available evidence—including what others in their situation are doing and saying-- instead drive them apart.
That’s what happened with the HPV vaccine. To try to establish a dominant position in the market before the approval of a competing HPV vaccine manufactured by its rival Smith-Glaxo Smithkline, Merck--manufacturer of the Gardasil, the HPV shot approved by the FDA in 2006--orchestrated a nationwide campaign to add the vaccine to the state, mandatory school-enrollment schedules by statutes enacted by state legislatures.
What was normally a nonpolitical decision—the updating the of state school-enrollment immunization lists—necessarily became hyper-politicized. People first learned of the vaccine not from their pediatricians but from Fox News, MSNBC, and other political news outlets, who hyped the repressive-in-your-face-religious right vs. the cosmopolitan, communism-of-women-and-children-left showdown on the “STD shot for school girls,” a framing facilitated by Merck’s decision to seek fast-track FDA approval of a girl’s only shot as part of its market-driven plan to sidestep the slower, less politicized approval process.
The result was the entanglement of the HPV vaccine in the sort of antagonistic meanings productive of the most debilitating of all known science-communication pathologies—identity-protective cognition (Kahan 2013).
3. Sarah Gollust and her collaborators (2010, 2013, 2014, 2015) have done a lot of outstanding work to identify and quantify the indicators of this entanglement and its disruptive impact on how ordinary members of the public ordinarily recognize valid science..
The CCP research group did a study on this too back in 2007, just as the process that resulted in this disaster began to unfold. In it we tried to model how different “science communication environments”—unpolluted and polluted—could affect engagement with information on the vaccine’s risks and benefits.
The study (Kahan, Braman, Cohen, Gastil & Slovic 2010) examined how cultural cognition could shape perceptions of the HPV vaccine. Cultural cognition refers to the tendency of people, in effect, to conform their own perceptions of risk and like facts to the ones that predominate among others who share their cultural identities.
We measured individuals cultural identities with two orthogonal attitudinal scales, hierarchy-egalitarianism and individualism-communitarianism, which can be viewed as forming four types of cultural “affinity groups.”
Next, we exposed them to competing arguments on the balance of risks and benefits of the HPV vaccine from fictional “public health experts.” The experts were ones we had determined in separate pretests would be tacitly identified by the experimental subjects as having the cultural identifies featured by the cultural cognition worldview scheme.
By crossing the two arguments with the four advocates, we had had 12 HPV “expert-argument matchups.” To assess their impact, we modeled how the proximity of the subjects’ actual cultural outlooks to the experts' tacitly perceived ones affected subjects’ HPV-vaccine risk perceptions.
Our goal in simultaneously manipulating the array of experts and arguments, on the one hand, and the proximity of the experts' cultural outlooks to the subjects', on th the other, was to simulate the impact of learning about the vaccine under conditions that would themselves vary in how readily they suggested the presence or absence of division of opinion between subjects’ own cultural groups and a rival one.
The simulation suggested that the impact was yuuuuuuuugely consequential.
We knew, again from pretesting, that subjects with particular identities had modest predispositions to form one or another impression of the safety and efficacy of the vaccine.
But under the condition least likely to suggest group conflict—the one in which subjects saw an alignment of culturally identifiable experts and arguments contrary to the one they would have expected to see if the issue were in fact dividing groups consistent with subjects’ own predispositions—polarization essentially disappeared.
Where in contrast they saw the alignment most suggestive of such conflict—the one in which an expert with their identity took “their side’s” position and one with opposing identity “the other side’s”—polarization dramatically escalated relative to the level predicted by the subjects’ predispositions alone.
These two points on the continua reflect a pristine and a polluted science communication environment, respectively. The first was the environment in which American parents learned of the HBV vaccine; the latter the one in which they learned of the proposal to add the HPV vaccine to the schedule of mandatory school-enrollment immunizations.
4. Likely this condition could have been avoided. Lots of physicians and others were worried that the manner in which the HPV vaccine was being introduced to the public risked generating a political controversy (Kahan 2013).
But the question now is whether anyone is going to learn from this experience and from research on it, including our study and the penetrating set by Gollust and her collaborators.
The answer, I think, will depend largely on whether members of the public health establishment avoid the mistake of “ignoring the denominator”—the relatively large number of cases in which the public doesn’t polarize but rather converge on the best available scientific evidence. Frankly, I think many of the proposals on how to over come the continuing public ambivalence on the HPV vaccine reflect exactly that mistake.
One prominent proposal is to conduct a large-scale social marketing campaign promoting the vaccine. Thrusting the HPV vaccine back into the limelight in this way would risk exciting the very sorts of sensibilities—and more importantly reigniting the same sort of interest group activity —that bred the initial conflict. Indeed, this idea sounds more or less like a proposal to take out of mothballs the very advertisements that Merck bankrolled during its disastrous campaign to secure legislative mandates.
Just look at the denominator!
There wasn’t any social marketing campaign on HBV vaccine, just as there wasn’t any on the myriad other science issues—from medical x-rays to nanotechnology—on which diverse members of the public now have aligned their behavior appropriately by science.
The mechanism, moreover, in those cases hasn't been the public's reflective processing of detailed bits of medical or other scientific information. It has been their attention to the cue emitted by the words and behavior of others who have evinced their confidence by words and deeds showing that they have confidence in the underlying science.
An unpolluted science communication environment is not bustiling with broadcast messages. On the contrary, it comprises a host of persitent low key signals that assure that people that doing things that rely on what is in fact the best available evidence is mundane, banal normal.
The question is how to promote this sort of normality to people's engagement with the HPV vaccine.
I’ll give you a hint on the answer.
The one state, Rhode Island, that has adopted an HPV-vaccine school-enrollment mandate in the years since the initial political firestorm over this proposal abated did so without particular fanfare—by resort to the nonpolitical administrative process that is actually the norm for updating state mandatory vaccination regimes.
Parents in RI aren't now learning about the HPV vaccine from media reports on a contested legislative mandate for an STD shot for their pre-teen children; they didn’t learn about it from a weird and very likely counterproductive (Nyhan et al. 2014) social marketing campaign.
Rather they are getting the information in the normal way—from talking to their pediatricians about it at the same time they discuss other immunizations that their children are required to get, and from seeing that other parents just like them, after having done the same, are making decisions to get their kids vaccinated for HPV—just as they are making the decision (at rates well over 90%) to do the same for HBV, MMR and all the other childhood diseases from which their kids and lots of others too are protected by universal immunizations.
It's a no brainer!
It's no big deal.
Gollust, S.E. & Cappella, J.N. Understanding public resistance to messages about health disparities. Journal of health communication 19, 493-510 (2014).
Gollust, S.E., Attanasio, L., Dempsey, A., Benson, A.M. & Fowler, E.F. Political and News Media Factors Shaping Public Awareness of the HPV Vaccine. Women's Health Issues 23, e143-e151 (2013).
Gollust, S.E., Dempsey, A.F., Lantz, P.M., Ubel, P.A. & Fowler, E.F. Controversy undermines support for state mandates on the human papillomavirus vaccine. Health Affair 29, 2041-2046 (2010).
Gollust, S.E., LoRusso, S.M., Nagler, R.H. & Fowler, E.F. Understanding the role of the news media in HPV vaccine uptake in the United States: Synthesis and commentary. Human vaccines & immunotherapeutics, 1-5 (2015).
Kahan, D., Braman, D., Cohen, G., Gastil, J. & Slovic, P. Who Fears the HPV Vaccine, Who Doesn’t, and Why? An Experimental Study of the Mechanisms of Cultural Cognition. Law Human Behav 34, 501-516 (2010).
Nyhan, B., Reifler, J., Richey, S. & Freed, G.L. Effective messages in vaccine promotion: A Randomized Trial. Pediatrics 133, e835-e842 (2014).