Vulnerability and resilience to mis- and disiformation during an emergency

I was asked today to give a talk discussing vulnerability to mis- and disinformation and how to build resilience to the information disorder for preparedness and prevention. Thank you Elisabeth Wilhelm for your thoughtful comments.

There are several things to consider here:

• If we do not systematically and holistically address the questions, concerns and information voids in communities of focus and vulnerable populations, we do so at our own peril. Without addressing them, any attempts on responding to mis- or disinformation will fall flat.
• The message and the medium are both important when responding to the infodemic. Debunking a piece of misinformation or pumping out health information will not have desired effects without us also addressing the vulnerability patterns in our systems and structures that perpetuate ineffective infodemic response.
• Health misinformation becomes disinformation because narratives shift and can be hijacked. This happens when public health concerns expressed by individuals are hijacked by values-based meta narratives that are intentionally spread to achieve an agenda and do harm to systems.

An infodemic during a health emergency

The infodemic describes the phenomenon of populations seeking, receiving and acting on information during a health emergency. The digital information ecosystem is intertwined with social dynamics and health behaviors, and it swirls information of different quality, misinformation, disinformation, outdated information; people are experiencing confusion, information overload, and frustration over inability to follow recommended guidance or have access to recommended health services, while the science continues generating new evidence and reshapes the emergency response by health authorities.

Drawing analogies between dark patterns in UX/UI design to vulnerability patterns in health systems

Dark patterns are concepts from human centered design and “designed environment” practices of how the information ecosystem affects user behavior and results in people being vulnerable to digital information flows and information and context bias. Examples of these are content moderation policies on social media platforms, algorithmic content promotion, and accessibility and design of user interfaces of information sharing platforms

In public health, we need a similar view of our systems and structures – how are public health systems and structures propagating own vulnerabilities and weaknesses because we have blind spots to how we keep failing to address the infodemic and therefore the response is getting weaker in the population behavior and adherence to guidance.

When there is misalignment between what populations need and what the health system provides we create a systematic vulnerability

When there is a misalignment between population needs and health system actions, individual reactions and behaviors ladder up to population behaviors that can be detected by various data sources within and outside the health system – which can be adverse health outcomes. For example:

(i) historical mistrust of government and health systems in specific populations that go unaddressed or unresolved perpetuates low adherence of PHSM during the COVID-19 pandemic and otehr outbreaks (think of Zika, polio and ebola currently);

(ii) continued assumption that population will adhere to new guidance even if it is confusing or impractical to people to implement in their day-to-day lives;

(iii) continued assumption that repeating of what worked in last wave of COVID-19 surge in the country or specific populations will work again in the next surge or in the next outbreak, without contextualizing people's current lived experiences;

(iv) the overwhelming focus on messaging about vaccines during the beginning of the COVID-19 pandemic backfired because it reduced awareness of COVID-19 treatments which later became even more important in the time of omicron when breakthrough infections were more common and are concerning people. Similarly, we spent two years telling populations that COVID-19 is not the flu and it is more dangerous, but we are now close to declaring the pandemic over and are starting to advise people to go get the flu shot without any explanation of the changes in epidemiological situation or risk.

This misalignment continuously challenges the effectiveness of the pandemic response measures and can become a self-reinforcing cycle that can worsen the infodemic. Most public health efforts are unilateral and do not incorporate feedback loops to understand population response to health interventions. A vulnerability pattern emerges when the same structures or processes are in place to address reoccurring infodemic challenges, even though they have failed in the past. A vulnerability pattern is a series of failures that recur and/or are not addressed through leading to specific issues that continue to perpetuate. Continuing to repeat this vulnerability pattern can make the infodemic worse and further erode trust of the populations in the health system, health system staff and recommended health interventions.

Vulnerability patterns in emergency response and public engagement erode trust

Every failure of delivery of interventions, services and guidance in a people-centered way subtracts from the pool of trust, confidence and willingness of people to listen and adhere to what health authorities are recommending. Some examples include:

(i) utilizing the military to administer mass vaccinations among populations that do not trust the military which can instead spur conspiracy theories;

(ii) issuing confusing guidance that is not appropriate for specific populations, such as people who are immunocompromised or pregnant;

(iii) slow content updates through digital channels from health authorities that do not address most common questions and concerns;

(iv) late removal of outdated content on health authority web sites that propagates confusion and conspiracy thinking in the populations;

(v) leveraging spokespeople and influencers that are not trusted medical voices and who tend to change their positions related to medical information over time, which can backfire.

This created a situation where the science was improving COVID-19 epidemic management tools and evidence, but they have become less and less effective because their design and delivery were optimized with infodemic insights and interventions. Communicating unsettled and evolving science has repeatedly been demonstrated to be challenging for most countries, especially in an increasingly digital world we live in.

Infodemic insights analysis can identify strategies to promote prevention and resilience patterns instead

Since the beginning of the COVID-19 pandemic, infodemic management has brought together a variety of innovations across the health and other sectors and across of society, which had organically emerged and evolved in the recognition that the existing emergency response, health systems and society were not meeting certain needs of populations. Such structural and systemic failures, when coalescing, give rise to patterns of vulnerability that restrict the ability of individuals to enact health behaviors and also restrict health systems from responding effectively. Identifying vulnerability patterns in our systems and structures would allow for the development of matching prevention and resilience patterns, which can then be implemented through health-in-all policies and utilized in both emergencies and in routine health service delivery.

When questions, concerns and information voids are ovecome by misinformation narratives, this is fertile ground for disinformation attacks

If we dont' address questions, concerns and information voids expressed by populations, and analyze the narratives and mid/disinformation circulating in the communities of focus, we are opening the door for health misinformation to dominate the conversation, which can easily be hijacked by value-based messaging in disinformation.

I provide here an example of how narratives if left unadressed, morph from one to the other form:

• A community expresses confusion about why a foreign-made vaccine is recommended to them, expressing preference for locally made vaccines.
• Concerns gain momentum, becoming misinformation that foreign vaccine supplies were chosen due to hidden financial motives by leadership
• Negative sentiment and misinformation about vaccine origin is amplified with disinformation narratives undermining trust in government and becomes a talking point by a political candidate

Values-based?messaging can be extremely difficult to counter by the health system. For example, during the pandemic, resistance to PHSM was recast as medical freedom which became the reason for anti-lockdown protests in many countries.

Once information swirls in this third box on the right, health is just a vehicle among other topics that can be used by disinformation promoters to exploit a value or emotion (anger, dissatisfaction, etc).

Key takeaways

• Infodemics are complex phenomena, especially when multiple occur simultaneously, requiring multi-level interventions to effectively address them.
• Infodemics will only become more frequent and remain a public health threat during emergencies, especially as more of the world comes online.
• Intersectoral and crossdisciplinary collaboration is needed to overcome systems, practice and cultural silos that perpetuate vulnerability patterns.
• Addressing and mitigating infodemics requires a whole-of-society approach, because what health systems can do is still limited.
• Risk assessment and scalar judgements are critical to determining an appropriately scaled response.
• It is cheaper to build trust than to try and repair it during an emergency. Nip potential for mis- and disinformation spread by building bridges and trust with communities during “peacetime.”
• Check for vulnerability patterns near you. Reconsider what makes people, health systems and society vulnerable to infodemics and proactively address them.