Book excerpt: Telling the Truth
Welcome to Plugging the Gap (my email newsletter about Covid-19 and its economics). In case you don’t know me, I’m an economist and professor at the University of Toronto. I have written lots of books including, most recently, on Covid-19. You can follow me on Twitter (@joshgans) or subscribe to this email newsletter here.
A preview
Tomorrow the updated version of my book, The Pandemic Information Gap: The Brutal Economics of COVID-19 will be published by MIT Press. Today I thought I would offer you a preview with one of the new chapters from the book.
In case you would like to purchase the whole book, here are some links to help you find some outlets.
And now the Chapter (references and endnotes excluded).
This is one I fell for. In early March, I told my colleagues, with a passion, that it was stupid to wear a face mask when traveling. This was an opinion I had come to having read government statements and media reports. This was also the clear statement from the US Surgeon General:
Seriously people—STOP BUYING MASKS!
They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!
The clearest of these was from the World Health Organization (WHO), which recommended that masks be worn only by those who were sick. Even by late March, this was their line:
There is no specific evidence to suggest that the wearing of masks by the mass population has any potential benefit. In fact, there’s some evidence to suggest the opposite in the misuse of wearing a mask properly or fitting it properly. (Mike Ryan, Executive Director of WHO health emergencies program)
The rationale was that only certain masks (such as the N95) could protect the wearer from the coronavirus, which was small enough that it would pass through surgical or cloth masks. There was a shortage of all masks, and, thus, the limited supply needed to be preserved for healthcare workers. That made sense to me. If the masks weren’t necessary, then what you didn’t want was people hoarding them for no good reason. When I passed mask wearers on the street, I thought that they were selfish morons.
Things, however, did not add up. In East Asian countries where mask wearing when sick was considered socially responsible, the outbreak seemed to be more contained. While one could point to other explanations, it did stand out that Taiwan, Hong Kong, South Korea, and Japan all seemed to be doing better without harsh social distancing rules in place and widespread mask use (with a daily growth rate of infections of 10 percent rather than 18 percent elsewhere). Moreover, given that asymptomatic people might be infectious and past and increasing evidence that mask wearing did prevent the spread of the virus from the wearer to others, there was a likely mechanism that supported widespread mask wearing as a public health policy. Economists estimated that every additional mask wearer might contribute $3,000 to $6,000 in public health benefits. In many countries, the advice changed to recommend (e.g., in the United States just five weeks after the statements referenced earlier) and, in some cases, to require the wearing of masks. Airlines signaled that mask wearing would be mandated. My family, however, having heeded earlier advice, did not have any masks, and, by that time, they were hard to come by.
We, the public, were played. And we were played by those whom we were supposed to trust implicitly because of their expertise. And I played a role in trying to spread that advice to my colleagues, who ignored me and bought some masks just in case (including an extra one or two for me).
Let’s unpack this. Was there a mask shortage? Yes, there was. Should healthcare workers be prioritized to receive those masks? Yes, they should. Did surgical and cloth masks completely protect the wearer? They did not. Thus, technically, no one had lied to the public on that basis. But health officials did have a goal, which was to prevent people buying up masks. And some, like Mike Ryan of the WHO and Jerome Adams, the US Surgeon General, as evidenced in the statements above, chose to get to that goal by telling people that masks had no health value. That last step was the falsehood. Masks did not necessarily protect the wearer but could be very useful in protecting others from the wearer. A better policy message would have been to prioritize healthcare workers for existing masks, and to ensure the creation of new masks to help curtail the spread of the virus outside the home.[x]
The problem with the misinformation is that it cut off, or at least made very difficult, the second goal of mask wearing to protect others. First of all, by saying for a month and a half that masks were of no value, market forces could not come into play. Making acceptable cloth masks is within the scope of the economy, especially with otherwise idle resources, but that didn’t happen right away. Second, people do not want to wear masks. A good way to motivate them is if there is some value for them as protection. As it turns out, while they are not 100 percent effective, there is some protective value to wearing a mask. That information, however, is now distorted and not necessarily persuasive. Third, the more protective masks, such as the N95, can have valves that filter air coming in but not air coming out, which means that they won’t perform a socially beneficial function. In other words, you want people to wear masks potentially less protective of them than of others. Finally, in order to get people to wear masks for social reasons—to prevent the spread to others—you likely cannot rely on soft persuasion but, instead, need to have more strictly enforced policies. This is more expensive and also fosters discontent. Although, as the Czech Republic demonstrates, a mandate early enough did have positive effects. As we face a situation where masks will need to be worn for a year or two, distrust is a constraint that likely would really undermine public health pushes.
No critique of actions like this should be judged without considering the counterfactual—What should have been done, especially given that there were real issues of the supply of medical-grade masks? Sociologist Zeynep Tufekci, who has studied misinformation, believed that telling the nuanced and unvarnished truth would be superior:
If anything, a call for people who hoarded masks to donate some of them to their local medical workers would probably work better than telling people that they don’t need them or that they won’t manage to make them work. “Look, more masks would be great. We are doing our best to ramp up production. Till then, if our medical workers fall ill, we will all be worse off. Please donate any excess—maybe more than two weeks’ worth per person—to your hospital” sounds corny, but it’s the truth. Two weeks is a reasonable standard because the C.D.C. and the W.H.O. still recommend wearing masks if you’re taking care of someone with a milder illness self-isolating at home, something that will increasingly be necessary as hospitals get overwhelmed.
This, she argues, would have appealed to people’s altruism, and had the officials communicated that truth it would have been done while they still possessed default trust. This could have been supplemented by other information, such as the app the Taiwanese government made available that showed people the stocks of masks available in nearby stores. Doing this would have avoided causing a leak in what epidemiologist Carl Bergstrom called the “reservoir of trust” that many health experts start out with. Moreover, with respect to the potential scarce supply, if masks had been seen as important, this statement could have allowed a more proactive and obvious move to manufacture these for the entire population, something which Taiwan moved to do at the onset of the crisis.
Given this clear example, this chapter will examine, in more detail, the value of trust in managing crises like COVID-19 and how misinformation can not only undermine that trust but also cause actions that are not in the interests of good public health management. How can leaders be persuasive at times like this while at the same time not stoking behaviors whereby citizens are moved to pursue their private interests above what is socially desirable (such as personal hoarding of masks)? Here is where the pandemic information problem morphs beyond what the key decision makers know to what is generally known and understood. As we will see later in this chapter, perhaps there are circumstances when misinformation can be justified, although we’ll come to understand why this particular obfuscation ultimately does not serve the greater good.
The Art of Persuasion
The issue with communication is that it causes the recipients to act in a certain way. If you do not want people to panic in a crowded theater, you do not call out “fire” whether there is a fire or not as it could create a panic. This poses an issue. You want people to clear out of a theater if there is, in fact, a fire but not in a way that causes more damage or is counterproductive. What you would like is for people to file out in an orderly way. If your only choices are to shout “fire” or not, you may not be able to achieve that by just telling the truth. If your message is always the truth, then when there is actually a fire, people will run for the door and not otherwise. On the other hand, suppose that, if there is a fire you let people know, but, sometimes, even if there isn’t one, you say there is a fire. If people understand this rule, then even when there is a fire and you let people know, some people won’t be so sure and will not be as quick to leave their seats. The trick will be to ensure they eventually leave. You could be forgiven for thinking whether people would really shout “fire” when there isn’t one. But then consider how often smoke detectors go off or fire alarms are activated even when there is no smoke. And then consider how quickly you reacted. The point is that having a little doubt about the seriousness of the situation in this case can get people to have a more relaxed exit but hopefully not cause people to ignore it entirely. Managing exit when panic is possible requires some nuanced messaging.
Notice this all works because there are times you believe that you are not being told accurate information. But it also is necessary because people will act in their own interests even when such actions have a negative impact on others. In the case of the theater, your desire to rush to the door impedes others and vice versa. In other words, if it was just you in the theater, there would be value to transparent truth-telling, but because it is you and others, there is value to obfuscation to get everyone to behave better. Not surprisingly, in a pandemic, what communication impacts is not only your own beliefs and actions but those of others. Experts might see as their best option, in certain situations, to sometimes obscure the unvarnished truth.
Which brings me back to masks. Masks have a theater-fire aspect in that when there is a pandemic, we want people to wear them but not to hoard them—the equivalent of leaving the theater in an orderly fashion—even if they find it costly to do so—that is, they would rather flee. Thus, if your goal is to stop people from rushing to hoard masks, then even if there is a pandemic, you want to downplay the need to wear masks, as the WHO Executive Director and US Surgeon General did. If the only messages you can effectively send is whether there is a pandemic or not, then you might sometimes say there is no pandemic when there actually is one.
But what if, absent information to the contrary, people did not want to wear masks? (This is reasonable because, if they wanted to wear them all of the time, this whole communication problem wouldn’t exist.) This means that, in order to persuade people to wear masks when it is definitely socially beneficial to do so, we need to sometimes tell them to wear masks when that is not the case—that is, when the experts believe that an outbreak is not as serious. In this situation, if the experts say the pandemic is not serious, people will definitely not wear a mask. But if they say that it is serious, people may not be sure, but this raises the probability they think it is serious by just enough so that they choose to wear a mask rather than take the risk.
Hopefully you can see the issue here compared with the situation we found ourselves in for COVID-19. With COVID-19, experts told the public that the situation was not serious enough for them to wear masks in order to discourage mask wearing. As the public was not predisposed to wear or buy masks, this was a clear signal for them not to do that. Thus, they did not wear them. But when the experts switched course and said it was actually serious enough, then people were not sure what to believe. The experts had not learned any new information but had decided that they wanted to encourage rather than discourage mask wearing. As a result of this about-face, however, the authorities are going to struggle to convince people to wear masks. If people are reluctant to wear masks, you want to tell them not to wear masks only when they clearly should not wear masks and be encouraging otherwise. Instead, health officials in the United States initially presented a clear picture that mask wearing conferred no health benefits. This undermined their ability to later persuade an otherwise reluctant population to action.
When people do not trust the information they are receiving, they will adjust their behavior. Sometimes that can work well. But if the signal is completely distorted, then you lose the power to persuade. As Tufekci wrote:
providing top-down guidance with such obvious contradictions backfires exactly because lack of trust is what fuels hoarding and misinformation. It used to be said that back in the Soviet Union, if there was a line, you first got in line and then figured out what the line was for—people knew that there were going to be shortages and that the authorities often lied, so they hoarded. And when people feel as though they may not be getting the full truth from the authorities, snake-oil sellers and price gougers have an easier time.
Thus, it is not simply guidance on masks that becomes a problem but guidance on other things. It prevents the authorities from being persuasive when they need to be and also when they need to simply provide people with information to help them navigate the crisis.
If your ability to be persuasive breaks down, the only alternative to get people to undertake the actions you want is to use authority. As already noted, this is likely to be used with respect to the wearing of face masks in many places. However, if people do not believe in the rationale behind wearing face masks, this means resources will need to be devoted to enforcement to ensure compliance. Put simply, even if you are using authority to ensure an outcome, being persuasive can be useful as it makes compliance cheaper.[xx]
Wearing face masks is a somewhat straightforward policy which masks (!) the benefits from being persuasive. If economies are going to be partially reopened with a less extreme form of social distancing, this will work well if individuals understand the risks associated with physical interactions more clearly. What you don’t want, for instance, is for people to be told it is unsafe to leave their homes under any circumstances. The following is from economist Emily Oster:
For about two months now, Americans have been told the same thing over and over again by public-health officials and influencers everywhere: Stay home to stop the spread of the coronavirus.
The message is true. If we all stay hermetically sealed in our homes for long enough, the virus will die out; if we don’t, it will linger. But framing the message in such a stark way may inadvertently encourage people to make worse choices. A less extreme, more nuanced, set of recommendations may get more traction—perhaps a public-health equivalent of “Reduce, reuse, recycle.” Something like “Stay close to home, keep your distance, wash your hands,” but catchier.…
Stark messaging may also discourage people from taking reasonable precautions. Public-health officials tell people to wash their hands and wear masks. But because the above-the-fold message is “Just stay home,” people may struggle to understand the purpose of these other pieces of advice. If the only truly safe thing to do is stay home, then how should I think about the mask suggestion? Is it a futile gesture, like putting a Band-Aid on a gunshot wound?
Instead, you want to ensure that the public understands the virus and give them ways of assessing risks to take appropriate actions, for instance, who to avoid, what places might lead to the virus spreading, why hand washing matters, and so on.
This type of change in behavior has happened before. During the AIDS epidemic, new patterns of protection needed to be adopted to prevent sexual transmission of the underlying HIV virus. There was no real scope to use authority in this situation, and, instead, it was only through awareness of risks that people could be persuaded to change their behavior. In other words, when individual circumstances matter and there is a need for individual effort as a part of health interventions, then there is no substitute for persuasion. Thus, it is critically important that when risks are communicated, especially when those risks are changing as new information comes to light, that individuals remain cautious and that authorities preserve their reservoir of trust so that when they tell people to feel safe, people do.
Controlling Infodemics
A trusted source for information serves another critical function: it can prevent bad information from filling the vacuum. When there is a high degree of uncertainty, another aspect of the information problem is that misinformation can spread through society like—and this is no accidental naming—a virus. This situation has been given a name: Infodemics.
Infodemics are sometimes misinformation, such as where a virus initially came from. The 1918 pandemic was referred to as the “Spanish Flu,” which gives people the impression that the virus originated in Spain. There is, in fact, no evidence to suggest that. Instead, the name arose when the flu spread to Spain and the press reported cases including the notable one of King Alfonso XIII. This gave a widespread impression that Spain was the root of the outbreak and had more cases than elsewhere. Today, the practice has become to not name viruses after places, which is why the novel coronavirus has the simple name SARS-CoV-2.
The immediate issue arises when misinformation leads to actions that have detrimental health consequences. In some cases, misinformation causes people to take more health risks than they should. For instance, there are continuing beliefs that there is a link between vaccinations and autism in children. The origin of this particular infodemic came from an otherwise trusted source, an article in The Lancet that found a link between autism and the MMR vaccine. Since autism diagnoses were on the rise, there was uncertainty, and, for many, the vaccination link was plausible. However, the study was flawed (based on just 12 children) and the article was misread as being causal. The lead researcher had also received funding from a conflicted source, and this had not been disclosed. Finally, it turned out the sparse data itself were inaccurate. The Lancet eventually retracted the article, but the damage had been done. The MMR vaccine rate dropped from 90 to 80 percent the year it was published. Measles outbreaks continue to this day despite a large volume of studies showing no link between vaccines and autism.
The same issue has arisen with respect to COVID-19. Different governments and media outlets have conveyed health risks in different ways. One study noted that on the Fox News Network, in February 2020, the Hannity program was dismissive of COVID-19 risks, while the Carlson program, an hour earlier, was not. In January, both had been similar in their dismissal of health risks, and by March the tone of the two programs had once again come closer together to emphasize health risks. In a careful study, but not peer reviewed as of the time of this writing, economists exploited these changes in tone along with differential viewership numbers across the United States for these two programs to see if the different messaging had a health impact. They found that in areas with higher relative viewership of Hannity to Carlson, there were 30 percent more COVID-19 cases on March 14 and 21 percent more deaths on March 28. After mid-March, the relative differences declined. This study complemented other studies that showed different rates of concern for the coronavirus among Republican and Democrat voters in the United States with the plausible explanation being the fact that Republican politicians were more likely to dismiss COVID-19 risks than Democrats. What this shows is that information received by individuals from sources they trust does potentially have an impact on beliefs and, indeed, how they confront health risks.
Both the autism/vaccine and the COVID-19 infodemics show that the outset of the spread of misinformation can well be messages from a source that is trusted by those who initially believe what they are being told. In other words, infodemics spread because, once those messages are demonstrated to be false, they cannot easily be dislodged. This is because they tend to build upon one another. A rumor has a different meaning if you have heard it before—perhaps because it spread unchecked quickly—than if you have not. The latter confers skepticism precisely because it seems implausible that you did not hear it sooner. Sadly, that same skepticism can make it difficult to dislodge misinformation once it has been going around.
What can increase the spread of misinformation is when actions are not simply about personal health risk but cause people to hoard various products they believe they might need to mitigate health risks. This was the concern that officials had with regard to face masks that led to the problems outlined earlier. But in pandemics it also arises with respect to purported treatments or cures. Some of these may simply be dangerous, while others may be innocuous, and the harm is where they are hoarded when their use is required elsewhere. This was the case with the malaria treatment hydroxychloroquine, which was hypothesized to be effective against COVID-19. In the absence of any conclusive evidence of its efficacy, it was used and hoarded, which made supplies scarce for its standard use in treating lupus and arthritis. When there is unresolved uncertainty, individuals can take actions that may well harm others indirectly. Once again, this is where officials having a reservoir of trust can play a key role in mitigating the spread of such information.
Managing the information problem in a pandemic requires not just reducing uncertainty but also ensuring that uncertainty is not falsely resolved.
Key Points
Public officials often try to use stark messaging to convey recommendations to the public and get them to move in a certain direction. However, when the basis for that message turns out to be false, this can make it difficult to change course.
Persuasion requires being very clear when you tell people to refrain from an action they do not want to do (such as wear masks). Otherwise, when you want them to take such actions, they will be harder to convince regarding the underlying risks that motivate the desired outcome.
Authorities have a reservoir of trust that can be drawn down. If this happens, then they may be forced to use authority rather than persuasion to achieve health outcomes.
In the absence of trusted sources of information, people may start to believe falsehoods and spread those falsehoods to one another. This can impede proper health messaging.