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Coming to you LIVE from the American Public Health Association’s annual conference in Denver, Colorado, we’re talking about how even talk about public health. We’ll talk to Dr. John Douglas, Director of Colorado’s largest health department about what he’s learned about how we talk about public health in a polarized moment and how it’s shaped his work and the future of his health department. Then we speak with messaging guru Anat Shenker-Osorio about what’s working—and what’s not—in messaging around masks and vaccines.

Transcript

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Dr. Abdul El-Sayed: The FDA and CDC approved boosters of the Moderna and J&J vaccines, endorsing a mix and match strategy in the process. Scientists are closely watching a new mutation of the Delta variant that is spreading in the UK. Surgeons treated a patient with a replacement kidney grown in the genetically altered pig, and it worked. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. We’ve got a special show in store for you today. We’re live from the American Public Health Association’s annual conference. Recorded Sunday night in Denver, Colorado, today’s show was the America Dissected’s first foray into the live scene. And let me say, it was a blast. It was a pleasure to meet some of you in person. Oh, and don’t worry, we took all the precautions an audience of public health experts would be expected to take: masks and vaccines were required. I talked to two leading experts for this event. First, there was Dr. John Douglas from the Tri-County Health Department in Colorado. We talked about the challenges local public health officials have faced during the pandemic and how politics have gotten in the way of public health messaging. After that, I sat down with Anat Shenker-Osorio, a leading message researcher and host of the podcast “Words to Win By”. Anat broke down for us the ways public health messaging has fallen flat sometimes, and we took turns dissecting some PSAs of today and old.  I hope you enjoy the show.

[announcer] Please welcome the executive director of the American Public Health Association, Dr. Georges Benjamin.

Dr. Georges Benjamin: Well, thank you, everyone. Listen, I’m really excited about this, having this podcast here today. You know, we really want to, you know, think about what’s really happening, and the America Dissected Podcast is a really great way for us to have this very important conversation. And as you know, we’ve been dealing with a lot of misinformation, which I define as people just sharing the wrong stuff, and disinformation, which I define as people sharing the wrong stuff on purpose, quite often for nefarious purpose. And the fact that public health, I’m sorry to say, is all about policy. And if it’s all about policy, it’s all about politics. Doesn’t mean that you have to be partisan, but you have to understand that there is something called political science, it’s the art of convincing people that your way is the right way. And so we’re going to have this, I think, an amazing conversation tonight. Our host and moderator is a public health practitioner. He is very skilled. Some of you may know he actually ran for office once, but I just think this is an amazing opportunity for us to really kind of hear and give some concepts about what’s going on. So without further ado, I’m going to exit the stage and we’ll all be bringing up our moderator and our panel. Thank you.

[announcer] And now your host, Dr. Abdul El-Sayed.

Dr. Abdul El-Sayed: Hi everybody! Welcome to the show! I want to start with just a single question: who here believes in public health. [cheers] Who here wishes everybody else believed in public health like we do. [cheers] That’s what we’re going to talk about here today, we’ve got an amazing show lined up for you. We’re going to hear from somebody whose real world work focuses on improving the lives of people. But he’s found that the politics of this moment, the challenges that all of us as public health professionals have faced messaging through a deeply challenging political moment that that’s gotten in the way. And he’s going to share his experience with us. And then we’re going to hear from somebody who’s a cognitive linguist, a messaging guru, somebody who spent time thinking about testing hypotheses about how we talk to people and how that frames the conversations we then get to have. Because that’s really important right now. And I’ll tell you a little bit about the story of the show, why we started this podcast America Dissected. I started my career as an academic epidemiologist. My job was to understand how we know what we know, thinking about causal inference—and I don’t mean to take you back to your first year in epidemiology. And I found myself writing more and more about less and less, to fewer and fewer people. And I realized that the thing that got me into public health was the public part. That we do work in our communities, in our societies, to improve access to a long, healthy life, and so one thing led to another and I found myself in this position of rebuilding Detroit’s health department as its health director. Now that health department had been shut down by the same racism that caused the Flint water crisis just 50 miles north, a policy that took away the right to self-determination for people in our city. They shut down 185-year old health department in a city with a higher infant mortality rate than my father’s native Egypt. A city where our children face threefold the probability of being hospitalized for asthma than the state average. In a city where the lead prevalence was higher than it was in Flint at the height of the water crisis. My job was to rebuild it. I’ll tell you what, all the causal inference in the world couldn’t really help me do that. Now, I had no clue what I was doing, I’ll be honest with you, trying to rebuild a department in a post-bankruptcy city. And on my third week of work, I got to meet this little boy who was the fourth child of a 21-year old mom, he met his father maybe four times in his life because his dad’s in jail. But this boy, he had this incredible confidence. I couldn’t help but contrast that confidence with the circumstances in which he was growing up. Now, this kid I don’t know if you’ve ever met a three-year old, you know you never knew before, but most of the time they don’t just come up to you and shake your hand, right? They bury their face in their parent the minute they make eye contact and realize that you’re an adult they don’t know. The kid didn’t do that. Walked right up to me, shook my hand, gave me a big hug, walked back to his mom. I realized this kid’s either the most confident or the most rational three-year old ever my life. But this boy taught me more about public health than I’d learned in all of my academic experience combined, because if nothing else, public health is about justifying the confidence that any three-year old should have in the life that she or he is going to lead. So we rebuilt our department around kids. We wanted to break down the barriers that kids in our city had to learning and earning, like you’d want for any kid anywhere. Took on one of the biggest petroleum refineries in the state, forced them to reduce their emissions because they were increasing their sulfur dioxide emissions in a part of our state that was already in what the EPA calls “non-attainment” meaning there was already too much sulfur dioxide in the air and they had the audacity to apply to increase it. Forced them to invest $10 million of their own money to reduce their emissions when they had wanted to increase them. After Flint, we had every school, daycare, and head start tested for letting the water, knowing that our kids spent most of their day—our most vulnerable people—most of the day, most of the year in those buildings. We made sure that every kid had a free pair of glasses delivered at school within two weeks of a vision test. But here’s the thing, every single one of those challenges that I took on, every single one that we as a collective, as a department took on, almost always led us to the door of a politician. And here’s the thing, those doors, as much as you think they ought to, they don’t automatically open when you’re advocating for the life of a three-year old. And so in 2017, I resigned my role and decided to run for governor, partly because nobody told me not to, which was kind of crazy. But here’s the thing I believe that public health shouldn’t just be the organizing principle behind a health department, it ought to be the organizing principle behind our politics entirely. You agree with me? [applause] I ran my race and I lost. And in the time honored tradition of every 21st century political candidate who loses a campaign, I started a podcast. But honestly, when I’d come to politics, I came to politics through policy. I had thought that if you had the right policy, that if you were talking about and animating your policy with equity, with integrity, with a focus on that three-year old boy, the people would vote for you. But here’s what I learned: politics is less about policy than it is about culture. Politics exists to translate our culture into our policy. And if we don’t value the life of that three-year old boy, we’re not going to put together policy that values the life of that three-year old boy. Now, the question becomes, how do you shape culture? And in my travels across the state of Michigan, nearly every one of the 83 counties, talking to people who couldn’t pronounce my name, let alone believe that I speak English without an accent, I came to appreciate that in the end, the culture that drives our politics comes down to two questions: who are we, and who do we want to be? Who are we? And who do we want to be? And right now, we’re not having a coherent conversation about either of those questions. There are vastly different visions for who we are and who we want to be. And so the hope in this podcast actually brings me back to the thing I started my career doing: how do we know what we know? But even more importantly, how do we tell people what we know? Because in the end, our profession has often taken our expertise for granted. We assume that because we have letters behind our name and that we speak with public health and we do this a lot, that people are going to listen to what we have to say. And then we ran into the buzzsaw of the intersection between American politics and a hell of a big pandemic. And I think it ought to have woken up. So the conversation we’re going to have to date is about how we talk about what we know, how do we engage with people who don’t necessarily agree with the precepts that bring us to this work in the first place? How do we engage them on their principles and bring them back to ours? What are the consequences if we fail as a collective to do that? And how do we prevent ourselves from doing that in the first place? Now a lot of us are looking, hopefully, to the end of this pandemic, as we say in my tradition, Insha’Allah. But it doesn’t end here. The work that we must do has to engage with the lessons of this moment. So that’s what I’m hoping we can do with today’s show. So let’s get right to it. My first guest today is Dr. John Douglas. He’s the executive director of the Tri-County Health Department. He’s an infectious disease doctor who previously led STI Control for Denver Public Health. His department has faced some of the most serious challenges to public health authority, and one of the counties voted to leave over it. He’ll share his experience and what he’s learned. Please welcome Dr. John Douglas to the show! [applause]

Dr. Abdul El-Sayed: So, John, if I can call you John.

Dr. John Douglas: Absolutely.

Dr. Abdul El-Sayed: All right. Can you tell us what was the moment that got you interested in public health?

Dr. John Douglas: My background is I trained in internal medicine, infectious diseases. I thought I was going to be a lab guy. I studied herpes viruses in the laboratory. I actually discovered I was not terribly good in the laboratory and then begin to think about larger questions that this one virus impacted the population, it led me to think about other infectious diseases in the population and all of a sudden a not-great lab guy thought public health is a pretty good path.

Dr. Abdul El-Sayed: So you found the public in public health too.

Dr. John Douglas: I found the public in public health. Exactly.

Dr. Abdul El-Sayed: So, you know, now your storied career has led you to become the commissioner of the state’s largest health department. Can you tell us about your community and how many people you serve and what the makeup of these three counties you serve looks like?

Dr. John Douglas: Sure. So three counties just to the north, east and south of here, Adams, Arapahoe and Douglas counties. Together, they comprise about a million and a half people. They’re actually quite diverse. Adams County is the lowest income of the three counties. It’s got the largest population of color. It’s about 40% Hispanic, about 5% African-American, maybe 10% Asian. Arapaho in the Middle has the majority of one of Colorado’s largest cities, Aurora. Aurora is one of the most diverse cities in the country. It’s a city of about 400,000 people. Very high immigrant and refugee population, estimated that something like 160 languages spoken across the city. Arapahoe County, in and of itself, is maybe 20% Hispanic and 10% African-American. And then to the south is Douglas County, and Douglas is the best off of the three counties in terms of wealth and health. It’s been ranked in the recent U.S. News and World Report rankings system is either the healthiest or the second healthiest county in the country. So we have racial diversity, we have economic diversity and we also have political diversity, speaking of politics. So our county to the North, Adams County is relatively bluer, our one of the middle Arapahoe is a little more purple, and Douglas tends to trend red.

Dr. Abdul El-Sayed: So you got the whole microcosm of America right in your, Tri-counties.

Dr. John Douglas: I got the whole microcosm there, and it’s probably worth pointing out that we not only have urban and suburban areas, but we have a fair amount of rural areas as well, which brings another dimension into it.

Dr. Abdul El-Sayed: So take us back to the before times. All right? Back when we were going to weddings and singing at the top of our lungs without a mask on, and had you seen the fault lines starting to build at that time? Like if you trace it back and you go back in history, when you tried to institute public policy, of course, without the harsh limelight of the pandemic on it, did you see some of the fault lines of trying to improve and engage in public policy for public health and the ways that some of the diversity of your community would flummoxed that?

Dr. John Douglas: Yeah, and it was very apparent on a number of occasions. I’ll give you one example. We had a bill before the legislature trying to expand sex education. Not done very well in our schools. We had just finished a very detailed analysis of hotspots of teen pregnancy in the community. We followed up on that with some focus groups of parents and kids in the community. The number one request we got from these communities, which happened to be in our northernmost counties, was the sex-ed is terrible. It’s not well organized, it’s being taught by gym teachers, and number one. And number two, our parents don’t know much about what’s happening now. We can’t talk to our parents about sex. Fast forward to a bill. I was asked to testify. We had just heard this community input. It was a no brainer that I should stand up and share our information, not realizing the very strong reaction I was going to get in one of our counties. And that was an early, I’d say fault line. There are others like that, but that was a particularly poignant one.

Dr. Abdul El-Sayed: Hmm. And how did you respond at the time? I can imagine that that can be, as having been in your shoes before, that can rattle you. What was your initial response, and then how did you process that through your department?

Dr. John Douglas: The, it was rattling. It was rattling in part because one of the three counties that was unhappy with that said, we’re not pleased with your speaking on this issue, maybe we need to form our own health department. We had a lot of staff that work in all three counties, and we tried to remind them that we represent counties for whom this is very important. We also developed with our Board of Health a clearer policy with them, so they would be less blindsided about communication like this. That was probably a mistake that I made in the beginning. But I don’t think we completely settled it. I think it was the sense that we thought and some of our residents thought this topic was quite important and other parts of the counties were less, less happy with that. That was pre-pandemic, though, that was a fracture line.

Dr. Abdul El-Sayed: Yeah, I mean, so in comes this pandemic. Tell us about the first three months. And we all lived through that, it’s sort of one of these things that if you lived through it, you’re never going to forget. But how did it feel being in the cockpit of this extremely diverse public health department that’s already got some fractures in it? And trying to manage the onslaught of both new information, and the fact that we were trying to interpret the science in real time and changing our public policy goals through that, but then the onslaught of mis- and disinformation. How did that feel? And what were your initial thoughts going in about what that might mean for your department?

Dr. John Douglas: Well, we certainly didn’t think at the beginning that this would end up being a the ultimate fracture, which it actually did turn out to be. We thought, oh my gosh, we have the public health challenge of the century. We’ve got to get everybody in our department focused on this. We pretty much pulled everybody from all programs into COVID response. We also thought it would be frankly self-explanatory that although we didn’t initially experience the sort of impact that Western Europe did, it was, you know, northern Italy became a metaphor, New York City became a metaphor. And surely everyone should understand how we all need to work together. And I’d say that goodwill lasted for maybe three weeks. We put our first stay at home lockdown order in place after three weeks of cases in Colorado, and we got initially support from all three counties. That support lasted for about two days. And at that point, we began to get lots of pushback, lots of anger, lots of all the things that people have experienced all over the country: hate mail, epithets—the kindest one I got my wife made me a T-shirt about this, s being an unelected bureaucrat, but there were others, much, much, much less kinder than that—we had vandalism in our offices, we had protests in front of our offices. So the goodwill, at least for public health, didn’t last very long. And some of the old fracture lines of maybe we should leave and form our health department, came out pretty fast.

Dr. Abdul El-Sayed: You’re trying to manage this once-in-a-lifetime, hopefully, pandemic. You’re trying to keep your department together. How did you think about trying to engage with the folks in Douglas County who were opposing your leadership? What was the nature of your engagement, and did you find that anything at all worked?

Dr. John Douglas: You know, I think the notion at the beginning when it was, you know, we were all rattled by how rapidly the pandemic spread in other places was this really is an-all-hands-on-deck. This is like pandemic influenza 100 years ago. We’ve all got to get together. And I think that worked, you know, for a couple of weeks of sort of rallying elected officials. Things were closed, we had librarians say, can we help you with contact tracing? We don’t know how to do it, but we’d like to learn. So I think we had a fair amount of willingness and support and we were, you know, I often quoted Dr. Fauci, I’d done clinical trials with NIH at one point and I don’t know Tony that well, but I trust him, and I would cite him and I thought, well, that’s the gospel. And that worked for maybe four or five, six weeks. And then as Dr. Benjamin just talked about mis-, and then, of course, disinformation began to become more and more prominent. I didn’t realize how many people across our counties were really epidemiologist in training, because we had analytics happening left, right and center, and often coming to different conclusions than we did. So it pretty quickly moved into a much more fractious situation.

Dr. Abdul El-Sayed: There’s nothing like those Twitter-trained epidemiologists, I tell ya. They know everything about going viral. In this moment, I mean, you trained for all the right reasons. You came up in the public health community. You’re in this position of leading a department in THE public health moment. And yet you’re facing the onslaught of just frank abuse and pushback from people, founded in myths and disinformation. You know, if you sort of think about this, what must have gone differently? What would have had to go differently for us not to have seen what we saw, for your department not to have split over this?

Dr. John Douglas: Well, you know, it’s an easy trope to say that during the first year of the pandemic, our national leadership was not optimal. And I think that’s true. But the president—

Dr. Abdul El-Sayed: That’s kind.

Dr. John Douglas: President Trump didn’t create the discord. I mean, he certainly accentuated it. But that discord was out there. And I think that one of our challenges was understanding, perhaps not understanding sufficiently, different values in different parts of our county, counties. I think we had a lot of common values, but this business that we’re hearing over mask mandates now, “you’re taking away my freedom, don’t tread on me” was something that I just didn’t adequately digest and appreciate that, whether it was a deeply felt value or simply a tag line that people latched on to, it became really very powerful.

Dr. Abdul El-Sayed: Were there any moments where you tried to turn that message against you detractors to say, look, you know, the values of honor and duty and freedom also come with deep and profound responsibility. And one of the ironies to me is always the notion that oftentimes the same political tradition that is now delivering a lot of this pushback is also the tradition that talks about personal responsibility and talks about duty and talks about honor. And I wonder if there was any effort to try and turn that back on and to say, Look, we’re going to try and message this in your own words and in your own ideals.

Dr. John Douglas: Yeah, no, that’s a really good question. And yes, we certainly did try to do that. I mean, so when we got through the initial lockdown and the next controversy was mask wearing and we tried to first promote mask wearing as being a, you know, everybody out here wearing masks. How hard is it to do? It’s something one can do to take responsibility to protect other people. And we tried—that personal responsibility is actually an official value of this particular county—and so we, we tried that. And I think for some individuals, it resonated. For many it it didn’t. We also promoted the idea of vaccine freedom. So when the vaccines came along, this is absolutely the best way to move back more closely to the life you had it, to exercise responsibility to protect other people, and to promote the welfare of your community. So I think we looked at those phrases, those values, and I think for some people we were successful and for others, a lot less so.

Dr. Abdul El-Sayed: There was a very public fight over whether or not the health department would stay together and ultimately the commissioners from Douglas County voted to secede from the union. I wonder, in in the process of that. How did that debate take shape and was it one of those things that once the politics got involved, it was over? Or was it, was there an opportunity for intervention? And if so, what was it?

Dr. John Douglas: Yeah, that’s a really good question. I mean, this began in July 2020. We did have a mask mandate put into place. The county, Douglas County immediately reacted and said, we have other people outside our counties making decisions for us. We’re giving you notice. In Colorado, a district health department requires a one year notice to leave. We spent two or three months right in the middle of the pandemic saying this is absolutely the worst thing to happen. What can we do to come up with a compromise? We came up with what we thought was a reasonable compromise of letting each county have the option of opting out of any public health order. That was at a point in time that our governor was quite active in issuing public health orders. We thought we could sort of fly beneath the radar of, in some ways, giving away this particular public health tool to the counties. Fast forward six, seven, eight months, our governor’s tired of issuing executive orders. Anything that’s going to happen if something bad gets worse is going to have to come at the local level. That’s something bad was Delta. Delta in Colorado like it did everywhere in the U.S., really reversed things. We had to remove that opt out provision, and that potential remedy ended up not being satisfactory.

Dr. Abdul El-Sayed: You know, you’re highlighting the way that having, trying to manage the politics of this actually either interfered with, hastened or slowed or might have prevented some of the things that you might have done as early as you might have done them to interfere, to intervene on Delta. How, what is your advice to public health professionals and to folks thinking about even engaging their family on some of these questions from your own experience about, you know, what we trade off when when we try and engage or even placate or even give away some of the authorities that are so critical to improving public health?

Dr. John Douglas: Well, one thing I’ve learned is that I think at the root of a lot of this stuff is mistrust, profound mistrust. And I think whether one fails to talk the right language or whether one fails to appreciate values in given organizations, if you don’t interpret those correctly—I think I missed it, frankly, in some of the conversations I had, I let that mistrust grow. The second thing I would say is while I’ve tried to take responsibility for what’s happened, there are big forces out there and I think mistrust is actually infected, really, all of our counties, all of whom are hunkering down after a 73-year experiment in having a regional three-county health department. So we now—breaking news— as of five days ago, have a second county who’s decided they wish to leave as well. So we’re working forward with that one. But I think what was going on there is we the second county, Adams County, don’t really trust being in a relationship. Public health is secondary to the politics of the situation. So I would, I guess I would say to you, to my family, to my staff: trust is huge. Listening, trying to understand where, when seeds of mistrust are coming up, and then in some ways, trying to decide how long you can keep listening and when you need to act. And that’s what we ended up having to decide to do with this sort of final mask issue that arose. We imposed a mask mandate in schools because we were so concerned that they would not be able to stay in session.

Dr. Abdul El-Sayed: Yeah, I really appreciate that advice. And I wonder, you know, because this is not over. The pandemic, hopefully the pandemic era of COVID-19 will come to a close and we’ll be more in this endemic era, and there is a lot that public health will need to reckon with as we do the work of building trust. Because of course, trust is slowly built but easily lost. What can we do in terms of building trust with the folks with whom we may have lost trust, for reasons that are frankly outside of our control? Because I think for a lot of folks, the pushback is like, well, you don’t trust us—not my fault, you should be wearing a mask, you should be getting vaccinated. But the problem is that our job is to show up for people, even if they don’t necessarily want to show up for themselves. And what can we do to be building that trust?

Dr. John Douglas: So this is really, I think, the question of the day. And it’s the question of the day, whether you’re talking about public health, whether you’re talking about the national economy, whether you’re talking about the existential crisis of climate change—how do we regain that? I think we need to find ways of identifying common values. We tried very hard, by the way, with our school mask mandate of saying: doesn’t everybody get the fact that getting our kids educated makes sense, that we all want to maybe make a small sacrifice to do that? That wasn’t particularly successful, but I do think that search for finding common values, sometimes it takes different language to understand and explain those values, but I think that’s number one. Number two is, I think, not giving up on this notion of a common good. I think we, you know, you talked about the founding of this country. We were founded in some ways—the term common good doesn’t show up in the declaration, but it’s written in there. That’s a key principle. And to the extent that we can endeavor to figure out what is the common good, what do people understand as the common good? And to try to promote that. The third thing I would say is that we’ve spent a lot of time in public health trying to find spokespeople in our more marginalized communities. I’d give our department maybe a C-plus on that. I think we’re a lot better post-COVID or at least mid-COVID, close to post, I hope, than we were pre-COVID. We we talked community engagement, but I don’t think we practiced that as effectively as we should have. And that really ought to be part of preparedness for—I hate to tell you—the next pandemic, which is going to occur sometime. But I think we also failed to develop that sort of engagement with some of our more conservative community members. It was pretty easy to say, look, I’ve got it figured out, just trust me. And I think we probably didn’t, in a in a pretty diverse set of three counties, reach out broadly enough for the whole spectrum of voices and concerns.

Dr. Abdul El-Sayed: I really appreciate both the note of optimism and hope that’s implicit in what you shared. And also, you know, bringing our attention back to equity, because oftentimes so much of these conversations can be dominated by the people with the loudest voices, right? It’s no coincidence that Douglas County was the first to leave, and they also happened to be the highest income county who, because they were being forced to take, to reckon with the public good now, had to be, to engage with the inconvenience of government power being wielded against them. And for so many of the other communities within the other two counties, public power and state power are wielded against them all the time in far more burdensome ways, in very dangerous ways, in murderous ways. And I really appreciate you bringing that back. On a final note, I just want to ask you, you know, personally what, you’ve come through a really challenging 18 months—all of us have—but you come through a really challenging 18 months. What gives you hope right now?

Dr. John Douglas: You know, I think what gives me hope is, a couple of things: one, we have the great privilege of being engaged in one of the noblest of professions, and when things look really dark and they aren’t going our way and the pandemic is getting worse and there are protesters outside of our homes, keeping that in mind is really huge. I think the second thing that gives me hope is that one of the things that anthropologists tells us characterizes the human species, for all the damage we have done and are doing, is the ability to work together. And I think if we can figure out ways of channeling that aspect of our species, that’s when issues of all kinds, particularly public health issues, I think can be can be dealt with.

Dr. Abdul El-Sayed: Dr. John Douglas, we really, really appreciate your leadership, and joining us on the show. Again, one more round of applause for for Dr. Douglas.

Dr. John Douglas: Thank you very much.

Dr. Abdul El-Sayed, narrating: We’ll be back for more from our live show after this break.

[ad break]

Dr. Abdul El-Sayed, narrating: And we’re back.

Dr. Abdul El-Sayed: I’d like to introduce our next guest. Anat Shenker-Osorio is a public messaging guru. She’s the principal at ASO Communications, as well as the Race-Class Narrative Project. She’s the host of the podcast “Words to Win By,” and if you haven’t listened to the first season, I highly recommend it. In fact, they’ve got a second season coming up in November. A really, really incredible podcast about how we talk about what we know and how we persuade others to see it our way. She’s also the author of the book “Don’t Buy It: The Trouble with Talking Nonsense About the Economy.” And if we can give a big, warm APHA welcome to our next guest, Anat Shenker-Osorio. [applause] Anat, thank you so much for being here.

Anat Shenker-Osorio: Thanks for having me. I’m the only non-medical health person here, but I feel very well taken care of.

Dr. Abdul El-Sayed: We also, we also had a shoe-off and Anat definitely won. She’s got foxes on her shoes.

Anat Shenker-Osorio: Yeah, I won. I don’t know if you can see, but I won.

Dr. Abdul El-Sayed: Public messaging is all in the shoes. Anat, you spent your career advising public officials, both here and abroad. What do public officials usually get wrong about the public?

Anat Shenker-Osorio: How long do we have? So many things. She first and foremost is that we shouldn’t be taking our policy out in public. It is unseemly. Your policy should not be your message, you should be speaking about what the outcome of your policy is. But in terms of what that means for what people don’t understand about the public, it’s that almost all of political behavior and belief is actually driven by identity. It is, people are not rational actors and so the hope that we would be able to speak to them and to move them through some sort of triangulation toward sort of their best interests, that’s pretty far-fetched.

Dr. Abdul El-Sayed: So now with that, and I talked earlier about the belief that, you know, politics starts from policy and how wrong—

Anat Shenker-Osorio: Yeah, that’s fun. Yeah.

Dr. Abdul El-Sayed: And at the same time, the people you want making policy, you want them to be in the weeds on the policy. What do we have to do to address the fact that we so systematically, right, our, believe in the policy and the logistics of the policy and the logic of the policy, and what do we do to get our policymakers out of this? Like what kind of intervention do we need—obviously, there’s a reason you’re here—but what kind of intervention do we need?

Anat Shenker-Osorio: Well, first of all, I’m going to go out on a limb here, and I’m going to make a big claim without evidence. You ready? That lawmakers are people. Yeah.

Dr. Abdul El-Sayed: There’s no evidence to substantiate that.

Anat Shenker-Osorio: I know! There’s none, but I’m making it anyway. And what I mean by that claim, is that just like all other human beings, all of us only know what we think that we think. So we believe ourselves to be reasonable people who are guided by the facts before us—some of us even more than others—when in fact almost all of thought is unconscious. And so a more accurate way to understand the way we come to judgments is: I’ll see it when I believe it. Not the other way around. And so as far as what you’re saying, I think a big part of the problem is that people don’t understand that strategic communications has a very specific purpose. There are lots of reasons to say things to people. There are journalistic reasons. There are academic reasons. There are public health reasons. There are you-hanging-out-with-your-medical-provider reasons? But vix a vix strategic communications, broadcast communications, things that we are saying to a lot of people at once, there are only two purposes. One, what do I need this person to believe, and what do I need them to do? And if you do not have a theory of change around what it is you are saying to people, then you have no business saying it to them in the form of political communication. The name of the game is: what do I need you to do upon hearing this?

Dr. Abdul El-Sayed: And one of the things that you really well establish in your work is the notion that oftentimes the things we think people think, the things that we think are going to get them to believe a thing or to do a thing, are the same things that would get us to believe a thing and do a thing. And can you talk about how that attitude may not have served us so well in this pandemic?

Anat Shenker-Osorio: Yeah, I mean, let’s take a very well established fact, probably one you know well, which is that talking about vaccine refusal increases vaccine refusal. So social proof is real. This is the middle school theory of messaging, this is where people do the thing they think people like them do. And so we know that when we continue to transmit this message—wearing masks is very controversial, look at all these people who are real mad about masks! Now I’m going to tweet about them some more and give them some more time. These vaccines, people hate them! They’re very upset about them! I’m going to do 37,000 stories about how much people hate that! And also, I’m going to talk about it a lot because it makes me really mad. And by the way, it makes me really mad. HOWEVER, if it is your job to actually make people do the thing that you need them to do, then this “I just need to tell people what’s happening and not, we just need to tell people the truth.” I’m like, you do that on your own time. That’s not what you’re doing here. So talking, I mean, that is probably the biggest one. That we actually engendered a larger problem for ourselves by reaffirming this idea that this is a popular and socially-sanctioned idea, that it is socially sanctioned to be against vaccines, because we kept showing that people are.

Dr. Abdul El-Sayed: And one of the things that also is so frustrating about this is that we have gotten really focused on parsing out who doesn’t want to get vaccinated, which signals to all the people like those people who don’t want to get vaccinated, that those people are not getting vaccinated. And so, you know, you talked about the idea of identity. Can you talk about the role that politics has taken in shaping identity in this particular moment?

Anat Shenker-Osorio: Yeah. So politics has always been about identity. That’s not a new thing. And all that has happened is that in this day and age—and I’m thrilled that you all heard from Heather McGhee, who was a friend and colleague, we actually worked together on the Race-Class Narrative Project. So if you listen to her, you know that the stoking, specifically, of racialized identity in this country has been part and parcel of our politics, arguably since our founding, and most certainly since Richard Nixon and Lee Atwater. So this idea that there is no faster route to an “us” than the [unclear] of a them. And so where this has taken us now in this day and age, is that for some people, it is core to their identity to reject expertise, to reject what they are told by others because it is part of this belief system that: I know what’s right for my own self and my family and I make decisions based—do you like my voice? I do the voice very well, I get to do it a lot. So when that is happening, we need to understand—I mean, we need to understand so many things—but one of the things that we need to understand is that we need to create the permission architecture. This is what we call in messaging, the “permission architecture” what we call in psychology, to allow people to reckon with the fact that they’ve been wrong. Now we don’t require that they say that out loud because God forbid that will never happen. But we have to recognize that unless there is a way to save face, then people cannot come back around to what we need out of them. And that is true of the politically-motivated people who are refusing vaccines, but it’s also true to a certain degree of the people in our, the targeted communities who are rightly and understandably hesitant because high government hasn’t been that great to them, so why should they trust government?

Dr. Abdul El-Sayed: Yeah. On that note, you know, one of the biggest predictors of being unvaccinated is being uninsured. And so there’s a whole question about like, all right, so you all have been denied me health care for decades and this is the one piece of health care you now want to give me? It says something. The other point that I really appreciate you making is, you know, we in public health really put a prime on being quote unquote “rational,” very evidence driven. And we sometimes think that the way the world works is that when we present someone with an elegant empirical argument, that they will be like, wow, thank you for showing me the light. And it turns out that never happens. It doesn’t happen in my whole family, it’s not going to happen in public. And so in some respects, it’s like we need to give people the rationalization, which is to say what is it about what you are thinking and what is the thing that made you be right, not what made me be right? Where have we done that well, and where have we not done that well?

Anat Shenker-Osorio: Yeah. So let’s take a really concrete example. One of the tools that we have at our disposal is, for example, using a journey story. In marriage equality, many of you will know this well, some of the most effective messaging that was utilized was the older white man with his wife saying, you know, all my life, I’m a good Christian and all my life I knew that marriage was between a man and a woman, and that’s what I believed, and that’s what my church taught me. And then we had our kids and we had our Emily, and Emily, she just grew up dif—you know, whatever he’s saying, right? And then he says, and now I understand that I want my daughter to be able to have the marriage and the love and the family the same as my son. And so what you do is you take the archetype of the person that you were trying to move and you have them narrate their own journey story without actually explicitly saying, I changed my mind. Because that’s too high a bar. You basically just hint at that so people can watch it. So that’s one. Another really concrete example is where you activate, as your previous guest just said, you activate their own values and there are multiple ways that we do that. One of those ways is freedom. Freedom is one of the core values that we have associated with the United States when we asked people across demographic groups, geographic, etc., the core value that rises to the top, whatever race, age, etc. is freedom. And so there is a freedom-based argument to make about vaccines. There might be one to make about masks. I could construe it. And so we do that. Let me give you one more and then I’ll stop. The fight around the minimum wage. We were told for a very long time that the way that we need to fight about the minimum wage is we need to make practical arguments being the adults in the room and providing rational, empirically sound evidence from economists, because then people will care. Right? Because that’s why the 1% is not letting the people who make all of the money have more money, it’s because they didn’t read a white paper. That’s the trouble. So instead of belaboring the “we should raise wages because then people will be customers in our stores and they’ll be able to afford the basics,” once we flip the frame and started having a “Fight for 15” all across this country—shout out to organizers— and started saying “people who work for a living ought to earn a living.” Once we started claiming the moral high ground instead of attempting to have a practical argument, that’s when we started to see movement. [applause]

Dr. Abdul El-Sayed: I want to actually look into some of the history of public health interventions and public health messaging, some better than others. And so let’s start with this, you know, for those who were alive in the ’80s, you will likely appreciate this next, this next shout out. It’s the “Don’t be a dummy campaign” for seatbelts. Let’s take a look:

[PSA] Thanks to these air bags here, this job is now a piece of cake—but Vince—yeah, I’ll tell you something partner, I just much stick around a few more years—but Vince—no more dashboard de jour or Vince on the glass—But Vince—Look out!—[yelling, crash]—Even with air bags, Vince, you still got to remember to buckle your safety belt—Now you tell me—you could learn a lot from a dummy, buckle your safety belt.

Dr. Abdul El-Sayed: You can learn a lot from a dummy. So tell us a, did this work? And b, why or why not?

Anat Shenker-Osorio: Yeah. So I hate to give away the store, but I knew you were going to show this. I’m wearing my dynasty outfit because of this ’80s ad. I knew this was going to happen. So let’s see. Do you know your history? Did this work? Did “you learn a lot from a dummy work”? Did it alter seatbelt behavior? [makes buzzer noise] No. It was a total failure. It was a total failure.

Dr. Abdul El-Sayed: It was a great video game.

Anat Shenker-Osorio: It was a great video game, and a total failure. Do you know what did work to alter seatbelt behavior in this country? “Click it or ticket.” “Buckle your safety belt, you can learn a lot from a dummy” went on for a very long time, and some of us are old enough to remember that we used to not wear seatbelts in cars. At least in the backseat. In the backseat you were allowed, the back seat, it was cool.

Dr. Abdul El-Sayed: I’m seeing a lot of nodding from the audience. It’s really concerning.

Anat Shenker-Osorio: Yeah, I mean, they’re, there are in the dark, so they think they can’t see us, we can’t see them admitting it. So, what is going on in that ad is the exact same failure that we have in a lot of our vaccine messaging, which is that fear-based messaging doesn’t work. Fear-based messaging is largely ineffective. There are places that it works, but both in this case and in the vaccine case, it has been, in my opinion—while in the seatbelt case it has been in affirmed disaster because “click it or ticket” turned things right around—and I would tell you that having requirements, that is also what’s going to turn it around. Because that’s what “click it or ticket” is. It’s, you’re going to get a ticket, there’s going to be consequences. So fear-based messaging, which we have had a lot of in this pandemic, basically what you’re doing is you are asking people to unconsciously weigh two different fears: a fear that they are having peddled to them constantly and continuously on Fox News, among other sources, about this purportedly very dangerous and scary vaccine. And from our side, you’re gonna die! You’re going to get sick and you’re going to have, you know, you’re going to be in the emergency room and you’re not going to be able to breathe. So what’s going on for people is they’re making a calculus between a 100% certainty, if I put this shot, if I put this liquid inside of my body, that is a 100% certainty that I will have it in my body. And how scary is that? Versus a fear that we are relying upon that they have told themselves is really not that likely that they will actually get COVID and that they will actually get sick. In a battle of fear against fear, the left never wins, because the right is always scarier than we are. And so instead, what people do is they’re like, I don’t want to listen to any of that, I’m simply going to tune it out, because I am not interested in it. So that does not work. And it didn’t work then.

Dr. Abdul El-Sayed: And, you know, and it’s fascinating, because in public health, we talk about the, you know, the prevention paradox all the time, which is a different version on the same issue. Which is to say you go up to a principal and you say, I would like you to increase my budget. And they say, OK, well, what are you going to give me for that? Well, I’m going to save lives. They’re like, well, which lives, when, from what? And you’re like, I don’t know, some lives, from something, someday. And we all know that that’s kind of why we continue to get nothing in the political space, right? Because we cannot define what the risk actually is. And so when you think about this, when we’re messaging the fear, right, that you ought to fear COVID-19, there’s a plausibly deniable risk of disease. Nobody thinks that they’re going to be the one who gets COVID. And so we’re going to lose, right, which is exactly the point here. And we talk about this all the time in abstract, but sometimes we don’t apply it to our messaging.

Anat Shenker-Osorio: Well, it’s two-fold, and I’ll try to be fast. It’s both the plausible deniability, the sort of self-soothing that people do that it’s not going to be me or I’m not going to get that sick. And it’s the, then I’m just not going to listen to you.

Dr. Abdul El-Sayed: I want to now step forward to our current campaigns about COVID, so here’s a clip from the CDC:

[CDC ad] I got my COVID-19 vaccination and here’s why: this isn’t about gimmicks or sentiment or what commercial I like this, is about facts. COVID-19 vaccines are safe and effective. Millions of doses have already been given in the United States, and these vaccines have the most intensive safety monitoring in US history. When you need more information, use a reliable source like the CDC website, and get the facts.

Anat Shenker-Osorio: [laughs]

Dr. Abdul El-Sayed: Anat break this, break this one down for us.

Anat Shenker-Osorio: Yeah. OK, so here’s the thing: if people were listening to the CDC, then they’d be listening to the CDC. So whoever that was aimed at, I mean, that’s just like a Russian nesting doll of nothing. Because if you believed that, then you would have already believed that, in which case you didn’t need to see that, because you’re already, we’re good. So the issue with that, I mean, first of all, it begins with the negation, right? This is not about, this is not about, which is no different than Nixon saying that he’s not a crook, which, by the way, tells us he is. So we shouldn’t be engaged in negation just as a rhetorical device. And I mean, there’s some good stuff there, or at least she wasn’t trying to scare the crap out of people. So that’s good. She looked kind of like average person. She wasn’t like all medicalized. I guess that’s good. But the main problem actually with that ad is that 80% of people stop watching ads that they register as political within the first second. So most of the trouble with most of our ads is that we wear on our sleeve the fact that I’m going to talk to you about a political issue. And that doesn’t work, because it is no different than when your romantic partner says to you, we need to talk. And then you’re like [ugh]. And that’s what’s going on. So effective ads, effective political ads—and you can kid yourself all you want, this calls for political ads—need to sort of sneak the broccoli into the mac and cheese as my colleague, Maya Bordeaux phrases it. They need to not telegraph the fact that they’re about to talk to you about a political issue or a health issue.

Dr. Abdul El-Sayed: And I hear a lot of people in your mind saying, but this is not about politics, it’s about public health, except for the folks who don’t see that as obvious, think this is about politics. And we don’t do us ourselves a service so long as we keep talking about this like it’s not about politics. Because in their frame of reference, this is about politics, and we have to recognize that frame, right? Because we forget that every time we open our mouths and go: this is not political, but let me tell you something that’s been deeply politicized by almost everybody you talk to. And I want to move to one last ad. This one you found from Up To Us and Frameshift.

[Ad clip] There’s a lot out there that you don’t trust—right, hard pass—but you do trust your doctor—and they say the vaccine is safe and it works—so if you’re considering getting vaccinated, trust the facts.

Dr. Abdul El-Sayed: So what do you like about this one? What don’t you like about this one?

Anat Shenker-Osorio: OK, so not at all surprising that Frameshift was involved here. Full disclosure, I work with them all the time. Some of my favorite ads that we made in the last cycle, I made with frame shift. So first of all, it begins with humor. That is really important. It doesn’t tell you that it’s about to talk to you about a public health issue or a political issue until you’ve already gotten sucked in. What humor does is it creates what we think of as a mini persuasion window.

Dr. Abdul El-Sayed: Mac and cheese!

Anat Shenker-Osorio: It’s the mac and cheese. So what happens is that when we utilize humor, you know, it’s the basic structure of a joke. You set the joke up and then there was a punch line. And what you’re doing for people is you are providing them a little tiny mini endorphin rush that they got the joke. The getting of a joke is the person coming to the conclusion themselves, rather than you telling them what they’re supposed to think. This is what we call not prescribing behaviors, but allowing people to come to the conclusion, which is much more powerful. So first, it does that. It opens with humor, so it keeps the person watching. Second, it uses a trusted messenger—most people do trust their doctor—and it makes that relationship individualized. It also uses direct address you/your, which is very powerful and important. And then it ends with: trust yourself. So what’s going on in that ad is it’s not saying you should do this! And you should do it now! It’s saying, hey, check this out, ask your doctor, find out about it and if this seems right, you should do this. It’s allowing the person to save face by coming to that conclusion or feeling that they have.

Dr. Abdul El-Sayed: It’s establishing, just like you said, that permission architecture. Right?

Anat Shenker-Osorio: Right.

Dr. Abdul El-Sayed: To say, look, here are the validators you should go to and if they say it’s good, then trust yourself, don’t be dissuaded. I want to just from here as folks think about what they do in their lives, because you’re talking to an audience of public health experts and practitioners—what are a couple of takeaways that they can keep in the back of their minds? What’s your message to folks as they go back and they’re working on these issues in their various agencies and in communities?

Anat Shenker-Osorio: Yeah. So if you forget everything else that happened here today, other than my shoes, say what you’re for, say what you’re for, say what you’re for. I frequently joke that if the left had written the story of David, it would be a biography of Goliath because we like to talk about our opposition all of the time. The more that we talk about all of the forces against us, which is totally reasonable and understandable, the more actually credence we lend them. When we tell people: 97 out of 100 climate scientists, you know, understand that climate change is is created by human activity. People are like, oh, so there’s like 3% doubt. Yeah, who’s that 3%, I want to hear from them. So you want to say what you are for and not what you are fighting against? So what does that sound like? No matter what we look like or where we come from, most of us want to make sure our kids can get and stay well, our parents can be around for as long as possible, our partners can make it through every single day by our side. But today, a handful of politicians want to turn us against each other, spreading lies about what we know about our health, what our trusted doctors have told us, hoping we’ll turn the other way while they deny us the health care all of us need, so they can keep handing kickbacks to their donors. By seeing through their lies and standing with and for each other, we can make this a place where real freedom is for every single one of us. I’m taking my shot, I’m taking my shot at freedom. I’m taking my shot at protecting my family. I’m taking my shot at the community that I live in and that I love, and I’m doing this for me. So you have to know your audience.

Dr. Abdul El-Sayed: Drop the mic!

Anat Shenker-Osorio: But copy-edit it shorter because I just made that up on the spot.

Dr. Abdul El-Sayed: No, that was fantastic. We really appreciate your insights and your perspective. And I know that a lot of folks thinking about these issues will have a different viewpoint on how to think about messaging to folks who don’t necessarily agree that we are the experts and there are several, several randomized trials that demonstrate the safety and efficacy of these vaccines. And with that, please, a big APHA round of applause for our second guest, Anat Shenker-Osorio. [applause]

Dr. Abdul El-Sayed, narrating: I hope you enjoyed that show as much as we did. And I hope we get a chance to do it again. On our way out, I did want to tell you a bit about what I’m watching this week. The CDC and FDA approved Moderna and Johnson & Johnson vaccine boosters for people over 65, people over 50 with certain conditions, and people with high-risk exposure in their work. For Johnson & Johnson, they approved a booster for anyone over 18. Though they recommended that people boost with the same vaccine they took before, they also endorsed a mix and match strategy. That’s particularly salient for people who received J&J. After all, a recent study showed that those who boosted with a second J%J vaccine got a fourfold bump in antibody reactivity. But those who boosted with Pfizer saw a 35-fold bump, and those who boosted with Moderna saw a 76-fold bump. I’m not saying I disagree with the CDC, I’m just saying that if I’d gotten J&J, I’d be looking for some Pfizer or Moderna, stat. Before we go, make sure to stick around. Anat Shenker-Osorio, our guest this week, has a sneak peak of the second season of her podcast, launching next month. On your way out, do me a favor and go to your podcast app and rate and review our show. It goes a long way to getting it to other folks. And if you really like us, go get some drip! Crooked Media store is open. We’ve got our new logo tees and mugs, our Safe and Effective shirts, and our Science Always Wins shirts and dad caps. Oh, and if you haven’t already? Don’t forget to get your flu shot.

Dr. Abdul El-Sayed: America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Olivier Martinez. Veronica Simonetti mixes and masters the show. Production support from Tara Terpstra, Lyra Smith, and Ari Schwartz. The theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard, and me: Dr. Abdul El-Sayed, your host. Thanks for listening.

Anat Shenker-Osorio: The world can certainly feel overwhelming, like right-wing movements are gaining traction, that our only way forward is by conceding to some mythical middle. But as the campaigns you’ll hear about this season prove, there is another way.

[Woman]  It was like beautifully executed.

[Man speaks in Spanish]

Anat Shenker-Osorio: Welcome to Season 2 of Words to Win By. I’m Anat Shenker-Osorio. Join us as we unpack how we can mobilize, persuade, and win, when we say what we’re for, not just what we’re against. Words to Win By premiers November 9th. Listen and follow, wherever you get your podcasts.