Practical Steps for Combatting COVID Misinformation: Adam Beckman & Kyla Fullenwider, Office of the U.S. Surgeon General

Shiv Gaglani: Hi, I'm Shiv Gaglani. As we all know, disinformation about mask use, social distancing, vaccines, and various treatments for COVID-19 has become a harmful pandemic of its own. In fact, previous Raise the Line guests, including Chelsea Clinton and Dr. Ashish Jha, described health misinformation as one of the biggest challenges of our time. If you're wondering what the federal government is doing about it, we have some answers for you today from two experts who work with U.S. Surgeon General Dr. Vivek Murthy, who has described health misinformation as an urgent threat to public health. 

I'm very pleased to welcome Adam Beckman and Kyla Fullenwider, both senior-level advisors to Dr. Murthy, who will lead us through the Surgeon General's response in this critically important area. So, Adam and Kyla, thanks so much for taking the time to be with us today. 

Adam Beckman: Thank you for having us. We're really glad to be here, Shiv. 

Kyla Fullenwider: Thanks, Shiv. Nice to meet you.

Shiv: Good to meet you guys, too. I'd like to start first with learning more about your very impressive backgrounds and what brought you to your current role with the Office of the Surgeon General. Perhaps we can start getting some career highlights from you, Kyla.

Kyla: Sure. Now, I should caveat this by saying I didn't have a background in public health when I started working with the Surgeon General's office. Believe it or not, my last job was helping to head up the 2020 census. I had a bit of a different hat on, but my work around misinformation really started there because as far back as 2016, we were actually seeing early indications that misinformation and disinformation campaigns were going to be a big issue in the 2020 census. And so, as Chief Innovation Officer at the Census Bureau, I brought in some experts and some folks to help guide us on that. I then continued my work on that at the Harvard Kennedy School, once I left the Bureau. 

At some point, I think a few people started to realize a lot of the work that we were doing on misinformation issues around "Get Out the Count" and the census actually were very applicable around vaccination and efforts there. It's a little bit of a long-winded answer to your question, but I think -- like so many of us in the last couple of years -- I found myself working in public health by necessity. Really, I'm thrilled with the team that I get to work with at the Office of the Surgeon General, including Adam! 

Shiv: Well, that's awesome. That's a great background. I actually didn't realize the census connection, which seems very applicable. Adam, how about yourself? Before we got started on the show, I know you mentioned that you were a medical student on leave to work with the Surgeon General and doing your MBA, and had actually used Osmosis during med school. 

Adam: That's right, Shiv. Like you said, I was in medical training and as you know well, so much of that experience is about being with patients who are vulnerable and experiencing something frustrating or outright awful. Those issues often are resulting from structural problems around them. During training, my classmates and I, we constantly have these feelings of needing to be working with patients and also, there's so much we need to be doing about the systems around us. 

When COVID hit last March, we got pulled off of the wards and there was essentially an explosion of efforts to try and be helpful. Classmates, and former colleagues from when I had worked in D.C., started working on language to try to help think about what Congress should be doing right away. There were all sorts of grassroots efforts to get personal protective equipment to hospitals and clinics that needed it. I got wrapped up in some of that work and ultimately, when the opportunity to come work with Dr. Murthy in the Office of the Surgeon General came, I took that leap and left school. 

I'll just say that I knew a little bit, maybe, about what I was getting into from the outside of government perspective...fact sheets and policies and technicalities. I knew a lot less about the experience of the people we would be working with. Let me just say that if you have that chance, you may find a second family and a group of people that are just a joy to work with. So, it has been a special opportunity to work with Kyla, to work with Dr. Murthy, to work with the whole office. 

Shiv: Tell us a bit more about what the Office of the Surgeon General actually does.

Adam: Absolutely. Our current Surgeon General, Dr. Vivek Murthy -- who served as the 19th Surgeon General and is currently serving as the 21st Surgeon General -- he essentially wears three hats. The first is the immediate Office of the Surgeon General. Think of this like part of the office you are probably most familiar with -- Surgeon General's reports and advisories. In the past, those have been landmark public health statements and documents around HIV/AIDS, or on Tobacco. During this administration, Dr. Murthy and the Office have put out major pieces around health misinformation, and around youth mental health. 

The second hat he wears is as a Vice Admiral in the United States Public Health Service Commission Corps. So, the reason he wears that uniform is because he is part of a uniform service that he leads, made up of thousands of public health officers and clinicians that are serving public health emergencies around the country. That could mean issues related to public health on the border; it could be serving in the Bureau of Prisons; working on COVID vaccinations; or helping staff hospitals that are strained on capacity. 

The third hat, in this administration, is that Dr. Murthy -- along with Dr. Fauci and Dr. Walensky, the director of the CDC -- serve as three key medical advisors to the White House COVID response.

Shiv: Wow. That’s a lot of work. Three different, very important hats all in one person, one office. So, it's been a very interesting time, obviously over the last two years. We knew misinformation has been an issue for as long as people have existed. People have always traded wrong information and snake oil cures and things like that. But really, in the last couple of years there has been an explosion. 

So, can you set the stage for us here and maybe define how big a problem misinformation is at the moment and how it's impacting public health? Maybe we can start with you, Adam, and then go over to you Kyla.

Adam: Well, I'll kick it to Kyla in a moment because I think she does a really nice job of setting some of the key pieces here. But the important thing to know is when we came into the Office, we were in the middle of the COVID pandemic and we were trying to get organized, get a federal response going under this administration. It was very clear from early on that health misinformation was starting to, and was going to, cost a lot of people their lives. Let me turn it to Kyla just for a moment to talk through some of the scope of what we were noticing.

Kyla: Sure. Shiv, to your point, we actually called this out as an advisory. Of course, health misinformation has always been an issue. It's not new. What is new is the speed, scale and sophistication with which health misinformation is now spreading, and has been spreading during the COVID-19 pandemic. To Adam's point, I think a lot of people sort of knew anecdotally that this was a problem and we were still waiting on good data to really help us understand the scale of the problem. But very recently, there has been some data coming out that starts to map the scale that we're talking about. 

For example, Kaiser just published a study in November that basically showed that almost 80% of the public either believes COVID misinformation or is unsure about COVID misinformation. That essentially means, at this point, it's ubiquitous. It's widespread. Similarly, in terms of actual cost, the Johns Hopkins Center for Health Security came out with a study that estimated that COVID misinformation is costing the U.S. somewhere between $50 million and $300 million each day -- which of course is a big range -- but it's a first attempt, I think, to start to put a number to that. 

That, of course, is really not even describing the most important part here, which is that COVID misinformation is costing lives, right? Adam can speak to that piece. But I think, at this point, we're almost 800,000 lives lost in this pandemic and we know that a sizable portion of those deaths were preventable. So, there are a lot of costs. It's clearly widespread and ubiquitous at this point. And so, the scale question, in short, is that it is a big problem in the U.S. 

Shiv: Wow. That's an incredible scale. I wasn't familiar with the report about the cost being $50 to $300 million a day here in the U.S., which is just mind-boggling. So, in November, the Surgeon General's office released a Community Toolkit to help individuals combat misinformation among people they encounter in their daily lives, and we all have been part of that -- whether it's your patients or just your neighbor or someone you encounter at a restaurant. 

What's the thinking behind this community toolkit approach? Can you share specific steps that our audience -- many of whom are already clinicians or will be clinicians -- or just the general public, can take to do their part in the fight? 

Adam: Shiv, that's right. We released a Community Toolkit related to health misinformation just a couple of weeks ago. But, let's just step back even further. This summer, Dr. Murthy released his first Surgeon General's Advisory of his tenure and that was also on this topic of health misinformation. Those advisories are reserved for urgent public health threats. Dr. Murthy called for a whole society approach to address this issue and really called for action from a number of different stakeholders -- individuals, technology platforms, educators, health professionals, journalists, funders, and government. 

Those recommendations, which we can make sure you and your audience have access to, I think are novel for the urgency with which we needed people to act this summer and have continued to need to see that action. Since that advisory, we've seen a number of different actors come forward and take steps in the right direction, but we felt that we also needed to give people a concrete toolkit to help individuals and to help community leaders and trusted messengers that are so critical for addressing health misinformation to be able to speak about this and equip their communities more effectively.

Kyla: Shiv, to your question around the toolkit, as we rolled out the advisory this summer we were talking to communities and talking to health care providers and talking directly to people. What we kept hearing again and again, was that this is a real issue that people are dealing with in real-time and don't have a lot of resources around. So, it's not just this sort of academic abstract concept. It is literally a kitchen table and clinic room issue. And so, we wanted to provide a set of resources that we felt were truly accessible for anyone. We even talked to high school teachers in the process to make sure that the content would be accessible for a high school audience. 

The resources that are in the toolkit are very interactive. We tried to minimize the text and lean more heavily on infographics and visualizations. We even have a cartoon strip in the toolkit. But there's a section in the second half of the toolkit that I would really draw your listener’s attention to. That's the second practice that we have in there, and the title of that section is called "How to Talk About Health Misinformation with Your Family, Friends and Community." 

Many of your listeners probably already know this through some of their training in medical school, but we essentially map out current evidence-based best practices for having some of those really tough conversations. Essentially, those include starting just by listening -- which sounds really obvious but sometimes it's not. That often means not fact-checking people right out of the gate because that doesn't always work. In fact, sometimes it can backfire. We tell people to really empathize and really try to ask questions to understand where folks are coming from. And then at some point, if you have an opportunity to point to actual credible sources, perhaps steer them away from some of the social media information that they might be getting, but really refraining from being judgmental as you're pointing towards those credible sources. 

Then, of course, not shaming. As Dr. Murthy says, shame doesn't usually work. I think it's really clear that publicly shaming people -- whether on social media or even at the family dinner table -- isn't an effective means of engaging people. Then, finally, using inclusive language. So, using terms like "we" and "I" to the extent that you can point to your own experiences, whether with other family members or whatnot, that can be helpful as well. But again, I will point folks to that resource because it is really great and something that we put a lot of thought into. 

Shiv: That's really great and actionable and we will be sure to distribute that toolkit along with the episode. A lot of our audience I'm sure have already seen it, but those who haven't should absolutely read it. You're also speaking to our heart, Kyla, with regards to reducing text, leaning on visualization, making it fun and engaging…that's kind of our schtick at Osmosis. 

Kyla: I should add, actually, on that note, we worked with a group of behavioral scientists out of the federal government called The Office of Evaluation Sciences. Their entire role is to work on making things behaviorally designed. They were very, very critical in helping us to make this document as accessible as possible. It's always helpful to have a team of behavioral scientist looking at anything you're producing!

Shiv: That's awesome. It's really good to hear that it's grounded in evidence-based practice in terms of teaching because, ultimately, that's what we're trying to do. We're trying to teach the public and teach our patients on what to do. So, you mentioned social media companies. We've had several guests from the social media companies on our podcast, including KX Jin, who runs Facebook Health, and Dr. Garth Graham who runs YouTube Health -- and they're very close partner of ours. We've done a lot of work with YouTube Health to distribute correct information about vaccines and social distancing and those kinds of topics. 

What are some of the details you could share with us regarding how the Surgeon General's Office has communicated with the social media companies? Any positive developments that you can share with us? Because I know that's the source of a lot of this misinformation. 

Adam: It is. The advisory that we put out this summer has a section on what technology platforms can do. I'll note that it's one of the multiple different sections. We call on a number of different stakeholders because we really believe, yes, social media and technology platforms have a key role to play here, but they are not the only ones. Shiv, the beauty of the internet is it allows people to be connected. It allows people to be informed. We think that technology platforms can do this even better. 

There is a massive challenge, we all know it, related to misinformation here, and there's a whole bunch of different things that Dr. Murthy and the Office have called for to be done. These include sharing data with researchers, being more transparent about what works and what doesn't when talking about how do we prevent people from seeing information that is obviously false and potentially harmful. It includes monitoring misinformation more closely, helping preempt it, taking action against super spreaders of misinformation -- individuals or accounts that are deliberately out there to harm or cause problems. 

Then, on the proactive side -- like Kyla was speaking to -- amplifying trusted messengers. There's so much work happening -- whether it's with your organization or health professionals, commissions, students around the country -- that are just trying to get the right information out. COVID is confusing. There are so many different moments where people have questions where it's not black and white. There's nuance. One of the big answers is to make it easier to find a local physician who is saying the truth and trying to get people information in a timely, accurate way. Kyla, what else would you add to that call to action? 

Kyla: Yeah. I think that two of the most important recommendations or points specifically around the technology platforms that came out of the advisory, were fundamentally about increasing transparency on the platforms. The fact of the matter is we just don't know what's happening on these platforms because there isn't independent research happening at scale to really understand the true impact and the true harms of health misinformation and how that might be impacting health decisions, among other things. And so, Dr. Murthy has been very clear about calling on the platforms to increase their transparency and work with the public interest research community so that we can really better understand what is happening. Ultimately, that's the fundamental first step before we can start addressing this issue systemically. 

Also, I would say the second piece is around moral responsibility for these platforms to assess the benefits and harms of their products and, ultimately, taking responsibility for addressing those harms. That's something that we lay out in the advisory. Dr. Murthy has talked about it. So, I think to the extent that the platforms can tackle those two things -- first and foremost, product changes, adding frictions, etcetera are important. But those are, from my perspective, the two really fundamental issues right now. 

Shiv: That's a really good point. It actually preempts my next question which was, we've talked about misinformation using some of the same language that we've talked about COVID itself, right? Super spreaders, contagious...those kinds of topics. I'm curious, in your opinion, has there been any evidence that COVID misinformation also spreads to misinformation about other health topics, whether it's vaccines in general, misinformation about nutrition, all these other areas? You mentioned, Kyla, social media companies. I know earlier this year we learned about the reports internally at Facebook regarding knowledge around the effect on mental health that Instagram is having on teenage women. So, any evidence or anything you can point to about COVID misinformation becoming misinformation in other aspects of public health?

Kyla: I can jump in here. I have not seen any evidence. Again, this space is still pretty early days. I will say that there are a lot of researchers monitoring that very question and this idea of COVID misinformation metastasizing, to use the same jargon, around other topics and reaching into more mainstream groups. I think we will know a lot more about that later in the year as some of that data starts to come in. It's a hard thing to study at scale, but it's something that I'll definitely be paying attention to.

Adam: Shiv, I'm so glad you brought this up because this past week, Dr. Murthy issued his second advisory of his tenure -- The Surgeon General's Advisory on Youth Mental Health. That advisory also lays out a number of different roles for different stakeholders. As you know, and as many folks know, we had a challenge with youth mental health in this country before the pandemic, and COVID has only made that more complicated and widespread. 

One of the findings that is noted in the report is that during the pandemic, the time teenagers spent in front of screens for activities not related to school more than doubled, from 3.8 to 7.7 hours per day. And while, as Kyla was alluding to, the research is still evolving on this topic, there's reason to be worried about a number like that and there's a lot more that we need to know and understand about the relationship between social media interaction and time on these tech platforms and the mental health of children in this country. 

Shiv: Wow. That's another jarring statistic, just like the $50 to $300 million a day for misinformation. Seven-point-seven hours a day on screens is just atrocious, it seems. One of the things that I think makes health misinformation so difficult is that health information itself is so dynamic. One of the reasons we even left med school to create Osmosis was to start adopting some of the tools that tech companies had used to engage their audiences, as well as keep them updated. 

One of my favorite features is LinkedIn where it will say, "Someone you know in your network has changed their job. Why don't you congratulate them?" So, it dynamically pushes out content to you based on how your network is changing. One of the core, killer features we put on Osmosis in the first place is when we update a video or a question, everyone who's ever seen that video or question gets an update notification saying, "Something you once knew has changed." For example, the guidelines for hypertension changed…they went from 130 to 140. 

COVID has been changing all the time. That's part of the issue. And the nuance required is high for even highly-educated people to understand that this is a dynamic space and we don't know all the answers. So, it's a challenge to then make that something accessible to the public to understand...that things are going to change. There's going to be new variants. There's going to be new vaccines that do and don't work. I think that's one of the greatest challenges. 

That's more of a comment, but I want to put it out there in case you have any response to that inherent issue about health information that makes it so easy to propagate mistrust and misinformation. 

Adam: I think it just speaks to, yes, there's a role for the federal government and yes, there's a role for the Office of the Surgeon General here, but there's a role here for clinicians, for health professionals, for people in communities. That's why we've spent a lot of time working with individuals like that -- whether it is doctors and nurses, or whether it's faith leaders and store owners -- because it's a confusing time and people in confusing moments get information from sources they trust, and oftentimes that's people that you know well. 

The toolkit lays out a lot of these principles about empathy and listening that, for your audience, will sound really familiar. It's the same type of principles that textbooks teach related to end-of-life conversations or conversations around smoking cessation...about listening first, judgment free. 

Honestly, as we're having this conversation, I'm just thinking back to an experience we had a couple of weeks ago where the Surgeon General had a conversation with an individual who had chosen, for many months, not to get vaccinated. He spent about 45 minutes talking with Dr. Murthy -- asking questions about myths he had heard, curiosities he had, and concerns. The next day, he called Dr. Murthy and said, "I've decided to go get vaccinated. And not only that, I've gone ahead and shared this conversation with dozens of people in my life who are also having that same concern." It's easy to get cynical. It's easy to lose faith in the hyper-polarized environment we're in. But what the evidence tells us, and what we've seen anecdotally over and over again, is that one of the best ways for addressing all of this is through those individual interactions, through those smaller-scale, intimate connections. 

Kyla: Yes. It is such a great and really critical point, Shiv. I'll just add to what Adam said. We have essentially watched the scientific process happen in real time and in ways that often happen behind closed doors or have a much longer process. So, I think for so many people watching recommendations change or the evidence evolve has been unsettling, frankly. 

I think what we have learned during the pandemic, and perhaps it can be something that we take forward, is that health communication has to change, right? Information, as I say, now moves at the speed of memes and so you really don't have the luxury of top-down communication channels in the way that we might have before. I think that's something we're all grappling with right now and I hope at this time next year, if we talk again, we'll have better answers on how to address that. But I feel empathy for all of us, and especially for clinicians and public health communicators who have really been on the front lines of this. Thanks for that point. I think it's a really important one. 

Shiv: I'd love to talk again in a year. This is a fascinating and really interesting conversation. I'm aware of your time, so I just have a quick last one or two questions. Obviously, our audience consists primarily of current and future health care professionals. Adam, you're going to go back and finish medical school at some point -- I've always intended to -- and maybe make your parents proud like I hope to one day, but I'm curious, what advice would you give to your classmates? Both for you, Adam and Kyla. What advice would you give to current and future health care professionals about meeting the challenges of this moment and beyond?

Adam: Shiv, first of all, I'm sure you have already made your parents proud and they are listening to every podcast episode that you do. (laughs) 

Shiv: (laughs)

Adam: There's so much that health professionals and trainees can do, and we center a lot of our work with these individuals and organizations. One that I just want to hone in on for this conversation is around education curricula. During my time in medical school, it often felt like the curriculum was changing while we were learning it. That was a function of professors and leaders that were receptive to that feedback, and students who are really vocal and clear about what we wanted to learn about. For instance, “Where's our education on racism as a public health and a medical issue?” I think health misinformation is one of these topics. 

We've just gone through a pandemic that has put this to the center. We now need to build the medical curricula around that. That could take a number of different forms, but I think hearing from students and seeing professors and schools step forward and show us what that could look like is really important because it's not obvious, and the problems that we have now, I fear, are likely to grow more. We will get past this pandemic, but the challenges of how we communicate about public health, how we communicate about science as a society when information that is false is traveling quickly and it's hard to decipher...that suddenly is a major role for health professionals to be playing now and going forward. 

Shiv: Kyla, any advice you'd like to provide?

Kyla: I guess I would just say that I certainly never imagined that I would be working on pandemic response this year, and yet it's been one of the most rewarding and deeply gratifying professional experiences of my life. Had I just stayed the course and stayed in my lane, then I probably wouldn't be here doing this work. 

And so, my advice would be -- and I say this to my students -- it's a lot easier to take risks when you're younger. It's a lot easier to do the startup when you're in your 20s than when you're in your 40s -- and I say this as one who's in their 40s (laughs). I would just encourage folks -- if they're feeling called or compelled to do something but it may not be strictly in their lane or may not strictly be on the path that they had imagined for themselves -- to give it some extra thought and consideration because it could end up being a very rewarding and deeply meaningful experience that will just add to that path. So, I'll just finish with that. 

Shiv: That's great advice. And for sure, very consistent with some of the things we've heard from other highly accomplished people who are helping combat this pandemic. Any final words from you guys... anything you wish I had asked you about that I haven't that you'd like to leave with our audience?

Kyla: Yes. We mentioned a few resources on this call, and so I just want to point out that anyone can go and download both the advisory and the toolkit that we mentioned at surgeongeneral.gov/healthmisinformation. 

Shiv: That's awesome. We'll be sure to link to that as well. Adam and Kyla, this has been a wonderful conversation. Thanks so much for taking the time to be with us on the Raise the Line podcast. 

Adam: Thank you, Shiv.

Kyla: Thanks so much. 

Shiv: And with that, I'm Shiv Gaglani. Thank you for checking out today's show and remember to do your part to flatten the curve and raise the line. We're all in this together. Take care.