by Steven Hatch
Indeed, this CBS article serves as a decent template for what media stories about health should be. Anyone unfamiliar with the kerfuffle over HPV vaccination would read the article and conclude that it was, at least, safe, and at most, safe and effective. Moreover, the reader would be aware that there is a database that tracks adverse events from vaccination, but that most of these adverse events are minor. It never mentions deaths reported in the VAERS system because such reports cannot be trusted to indicate that the death is attributable to the vaccine, because that isn’t what VAERS is designed to do. The five minutes it takes to read the CBS news piece was considerably more valuable to an uneducated consumer than the thirty minutes that were devoted to the topic on Katie.
A mildly chastened Couric issued a not-quite-apology the following week in an online editorial for the Huffington Post. In the editorial, she acknowledged that she might have been more careful in exploring the subject. “Following the show . . . there was criticism that the program was too anti-vaccine and anti-science, and in retrospect, some of that criticism was valid,” she wrote. This had the appearance of contrition, but like everything else attached to the Katie HPV episode, it was mere show, not least because essentially all of the criticism levied at her following the show was valid. After backtracking for a few paragraphs with almost mea culpas, she plunged back into the pseudoscience that got her into trouble in the first place, even invoking the very VAERS data that serves as a primary weapon in the antivax arsenal of misrepresentation.
Couric, in fact, was so untroubled by the whole dustup that she let the video segment that was the object of much of the criticism stand on the Katie website. Because this would be a strange action to take for someone who was earnest in trying to create a more “balanced” picture of the safety of HPV vaccines, it is hard not to conclude that Couric was trying to have her cake and eat it, too, by pacifying critics with theoretical apologies at the Huffington Post website while simultaneously perpetuating the anti-intellectual claims on her own. “IS THE HPV VACCINE SAFE?” her web page asked in large all-caps lettering. The logic implicit in asking such a question is that the answer is in doubt, because if it really was a remarkably safe vaccine, it wouldn’t make any sense to ask the question at all. During the remainder of Katie’s TV run, none of this was retracted or even altered. The Katie website did include the CDC recommendations, as well as the segment where Dr. Marshall “defends” the vaccine, but by leaving all the misdirection to stand at her website, Couric effectively conceded that she had no real interest in doing anything other than pandering on this topic.*
The final Katie episode aired on June 9, 2014. The show’s website, as I complete revisions in mid-2015, is no longer available on a basic Internet search. Clips of this Katie episode are still available on YouTube as of June 2015, and in Orac’s blog posts on the matter, the links for which can be found in the bibliography.
Fear, by the Numbers
The Katie “HPV Controversy” episode is only a highly egregious instance of a broader motif at work in health-care coverage. If the story of a single person is carefully selected and really does highlight some kind of broader trend in medicine, then of course such an illness narrative is a powerful tool; when a narrative is pulled out of context and thrust on a frequently distracted public, as exemplified by the guests on Katie, there is a potential for real harm. Yet one doesn’t have to watch a poorly executed half-hour segment bordering on propaganda to get a distorted view of the real threats one faces and what one should do about it. All one has do to is watch the nightly health segments on television or look at their online equivalents.
Death, of course, is scary, and in a world of 7 billion people there is always someone dying somewhere of something particularly scary. Infectious disease doctors and epidemiologists have a website known as ProMED that takes advantage of the instantaneous worldwide communication provided by the Internet, and it is used to monitor various worldwide outbreaks at any given moment in time so that appropriate public health resources can be brought to bear to contain serious outbreaks. Dozens of reports of deaths at the hands of the witches’ brew of the world’s microorganisms come filtering in every day: brucellosis, avian influenza, Rocky Mountain spotted fever, Hantavirus, dengue, and a host of other maladies make routine appearances on the ProMED list. Reading it, especially for the first time, requires a certain steeliness of spirit. If you knew all of the ways you could die from exotic infections on a daily basis, you’d stay in bed all day with the sheets over your head and only come out for an occasional cup of soup.
But as a matter of statistics, you aren’t going to die from these infections, and the reason ProMED is an important tool for doctors looking at disease patterns but not for ordinary people living their lives is because there is an absolute lack of context with respect to these reports. The steady stream of death that flicks across the ProMED page does not ruin the lives of the professionals reviewing that data because they traffic in such matters on a daily basis and can read these reports with the much-needed context already hardwired into their brains. Yet mainstream media news reports of rare deaths from unusual viruses and bacteria almost never are accompanied by such context to help laypeople make sense of it. The consequence of that lack of context is fear, and because of that fear people overestimate remote threats and vastly underestimate real ones.
As I write this book in 2014, there is a low rumble about a nasty infection that has been given the tongue-swallowing name of Middle Eastern respiratory syndrome coronavirus—MERS-CoV, or just MERS.* From its discovery in 2012 to the early months of 2014, MERS has killed about sixty people. A lot of press has been devoted to MERS, and many of these reports have dutifully noted that it bears a close relationship to another notorious virus, SARS, which had captured the world’s attention in 2003 as part of a global outbreak that killed as many as eight hundred people, perhaps more. SARS became part of an elite group of viruses that are well known to laypeople despite being remarkably rare. In addition to SARS, people who have only a passing knowledge of health topics are aware of avian influenza, the Marburg virus, Eastern equine encephalitis, and probably the all-time scary virus champ, Ebola—whose notoriety likely not only derives from its high mortality rate, but from the fact that it comes from deep within sub-Saharan Africa, a region over which people from developed nations still have considerable anxiety and guilt.†
I wrote most of this chapter in the spring of 2014, before the largest Ebola outbreak in history had truly erupted and dominated world health news stories. I am willing to wager that MERS has largely been forgotten by most people who expressed deep reservations about allowing flights from Saudi Arabia to enter US airspace only a few months ago. And I finish the revisions on this chapter as the Ebola epidemic is winding down (but not yet extinguished) in summer 2015 while MERS has erupted in Southeast Asia and is once again dominating health news headlines. So I leave these bookend footnotes in place because who knows what will be the Terrifying Virus of early 2016.
Could MERS become a real-life Andromeda strain? Yes, it’s certainly possible. Of all the scary viruses that have become objects of media fixation in the past few decades, only SARS has all the necessary ingredients to cripple the health infrastructure of every country on earth: it is lethal, it moves quickly, and it is airborne, easily passed from person to person and therefore able to outstrip even the best quarantine procedures.* MERS exhibits the same basic biological features as SARS and indeed is a member of the same phylogenetic group, the Coronaviruses, so it’s plausible to assume that it could wreak havoc on civilization.
For instance, Ebola and Marburg, which are passed through blood and other body fluids, have thus far not developed into lethal airborne mutants. The Ebola Reston virus is airborne but lethal only to nonhuman primates. It was the subject of Richard Preston’s bestseller The Hot Zone and formed the basis of the movie Outbreak, starring Dustin Hoffman. Although it was not “news” by any literal definition, movies such as Outbreak and
their nonfiction counterparts like The Hot Zone become the narrative backdrop against which real outbreak stories such as the current MERS-CoV reports are interpreted by laypeople, or even specialists for that matter.
Yet one could just as easily endlessly fret over equally catastrophic threats to the world. We could include monthly news stories about how close we periodically come to nuclear annihilation (or at least what would happen if a rogue political group got hold of just one); we could publish stories of asteroid strikes, noting that, had some been just a little bigger and in a more metropolitan area, hundreds of thousands of lives might have been threatened. These are very real dangers that we face, but they are equally difficult to quantify. The media obsession with magnifying these threats on a constant basis leads to what Marc Siegel, a physician and writer, has dubbed “the epidemic of fear.”†
The irony of Siegel’s professional life is that he serves as a senior medical contributor at Fox News, given that Fox has arguably done more than any other powerful media outlet at exploiting fear.
The downstream effect of medical panic is that, because we can’t really do anything at all to prevent a cataclysm like a MERS pandemic, we become more passive about the kind of actual threats that can be found in our everyday existence. “Influenza” is a word, when it is shorn of its terror-inducing modifiers “avian” or “swine,” that people often assume is the equivalent of a bad cold. Yet influenza is a killer: since 1976, when the CDC began systematically tallying influenza mortality, the estimated number of annual deaths from the flu has ranged from about 3,000 to 50,000, with a typical year resulting in about 25,000 deaths. One can actually do something to prevent influenza in the form of getting the annual flu vaccine. The flu vaccine doesn’t provide 100 percent protection (estimates hover in the 60 percent range), but it is effective and unquestionably prevents morbidity and mortality. Yet our national vaccination rate among adults runs about 40–45 percent. The only good news is that nearly two-thirds of adults most at risk for the worst ravages of influenza, those over sixty-five, are vaccinated annually; the very bad news is that among equally at-risk “near-seniors” in the fifty to sixty-four age range, fewer than half get vaccinated. Given that the only effective action one can take in the face of the rare but lethal MERS agent is to buy Depends undergarments and pee one’s pants, it seems a waste not to get a vaccination for something that can legitimately be prevented.
The overemphasis on reporting rare and scary diseases also has the effect of inuring the public to the real threats that we face every day. A death toll of 25,000 from influenza in one year is big, but it doesn’t hold a candle to the true killers in an industrialized country like the United States. In any given year for the past generation or so, about 2.5 million people die. One of every four of those deaths is due to heart disease. When similar diseases such as diabetes and strokes are taken into account, about one in three Americans dies from such pathology. Although the causes of these diseases are multifactorial, the science is well established that a low-fat, low-calorie diet, along with routine, vigorous exercise, have a dramatic effect on lowering the incidence of vascular disease. Would you like a news story about an epidemic? Would there be nonstop coverage if a new virus killed even a fraction of the percentage of people who die from cardiovascular disease in one year?
Yet this is an epidemic. Call it a virus, too—the “too much fat, not enough exercise virus” if you wish. But a casual observer of the news would be forgiven for failing to appreciate the gravity of the danger, that signal being buried in the noise of reports of frightening but trivial threats.
Indeed, it is even possible that some people might conclude that exercise itself could be dangerous, taking a bad problem and making it even worse. In the summer of 2013—at the precise time of year when people should be maximally motivated to get outside and put their muscles to aerobic activity—the New York Times published an article about a health study of Swedish cross-country skiers with the remarkable headline “Can You Get Too Much Exercise?” The article went on to describe a study indicating that these Swedish marvels of aerobic activity, who participated in an annual fifty-six-mile cross-country ski event, were slightly more likely to be hospitalized if they participated in more of these races. It was, in fact, a very small effect. Moreover, the comparison group wasn’t a cohort of people who sat around munching Cheetos or their Swedish equivalent while living a sedentary life; it was the other racers themselves, making exercise-versus-lack-of-exercise comparisons useless.
Normally an excellent source of news for health issues, the Times tried to be a little too cute by asking this question and by reporting on the results, even with a fairly long, detailed discussion that followed the explanation of the study. Because one would normally assume that the answer to the question Can you get too much exercise? would be no, people who perused the Health section’s titles without diving into the particulars might be forgiven for concluding that exercise wasn’t all that it was cracked up to be. Perhaps for Swedes pushing themselves to the absolute limit of endurance, that could be true, but, for the rest of us, there is simply no question that we exercise far too little. That mainstream media health news does not treat cardiovascular disease as the single most important, most lethal, and yes, scariest epidemic of our time is evidence of the skewed perceptions of what constitutes danger in our lives. Can you be certain that you will die of a heart attack? No, but you can be as certain as one can that if you eat and laze yourself into diabetes, you stand a much higher risk of it than if you exercise and lay off the megaburrito specials with large fries washed down with thirty-ounce sodas.
Caveats and Silence
What I’ve tried to demonstrate thus far are three major mechanisms by which the media obscures the importance of this simple health advice, and each of these mechanisms is related to either discounting or overemphasizing uncertainty, often doing so through inappropriate anecdotes. The case of the Berlin patient demonstrates a situation in which there is too much certainty of a new therapy’s promise; the vast majority of experimental therapies of the kind that Timothy Ray Brown endured never pan out, and, by not attaching this critical qualification, news consumers (especially casual ones) overestimate the genuine promise of cutting-edge medicine. The Katie HPV vaccine debacle is an instance of portraying medicine as being far more uncertain than it really is, using a single person’s story to trump a large amount of data that all points toward the benefits of a given therapy, all the while hiding behind the fig leaf of logic that one can’t prove a negative. And the stories about the respiratory virus known MERS display how the media can lead people to do what former President Bush called “misunderestimation” in this case of the real risks that we face in life.
There is a fourth path by which uncertainty gets warped in far too many media articles. This relates to the language used by journalists when they describe medical research, and the impression that can be created by such language. For instance, perhaps the two most pernicious phrases in medical journalism are “researchers have found” and “doctors have discovered.” Those words “found” and “discovered” give the impression that whatever they found or discovered was unassailably, incontrovertibly there, like a new species of Amazonian bird or a new set of hominid bones unearthed in Olduvai Gorge. They imply that physicians and human researchers are looking at the world exactly as it exists. A more precise analogy is that we are looking at the world through cracked, warped, and foggy glass: there is some external reality out there, but getting at that reality is sometimes difficult, and all of our speculations should be regarded with skepticism.
How do articles utilize the wrong language, besides applying these two blanket phrases? In many cases, the wrong language is simply no language at all. By failing to mention caveats to research—and all research has caveats—too many of the health news stories create misperceptions among their readers. Medical scientific research is, in fact, a daily exercise in uncertainty. Investigators make their living by staring
at streaked gels, trying to divine whether those streaks indicate an underlying reality. Bench research routinely leads scientists into blind alleys, and clinical research often is accompanied by about-faces where one study will show something to be beneficial, only to have that study contradicted by a trial a year or two later. This portrayal of smart people walking around laboratories with large question marks above their heads is often absent in health reporting. Every new paper that a medical center trumpets with a press release is accompanied by the aura of inevitable certainty, researchers being portrayed as a Bringers of Truth to the world rather than people who think they might be on to something, with a partial shrug of the shoulder.
Gary Schwitzer, as a website devoted to his work notes, has specialized in health-care journalism involving radio, television, and the Internet in a career spanning four decades. Perhaps more than any other person in the United States, Gary thinks about the lack of caveats in health news reporting, the silent gaps in health stories that lead people to the wrong conclusions about the current state of health care. He should be as famous as Sanjay Gupta; instead, he is little known outside a small group of health-care professionals and media types. He is the embodiment of media skepticism, coming at his work from an insider’s perspective, arguing about what could be instead of what currently is, and doing so by knowing intimately what changes really are possible and offering concrete solutions for doing so.
In 2006, Schwitzer founded HealthNewsReview.org, a website devoted to, as it says, “improving the dialogue about health care by helping consumers critically analyze claims about health care interventions and by promoting the principles of shared decision-making reinforced by accurate, balanced, and complete information about the tradeoffs involved in health care decisions.” Led by Schwitzer, HealthNewsReview pooled the talents of nearly thirty health-care professionals ranging from doctors and researchers to writers and reporters and was designed with one basic idea in mind: grade health news stories from one to five stars based on overall quality. The reviewers analyze news stories focusing on ten principal qualities, among them whether it quantifies benefits, explains harms and quantifies those as well, reviews the quality of the evidence, and establishes the novelty of the idea on which the report is based. In a way, those categories can be thought of as an elaboration of the question How certain can we be that what the story claims to be saying really is true?