Dr. Anthony Robbins © Mark Morelli

Can we explain smallpox vaccination to Americans and to the world?
by Anthony Robbins, M.D.

The Advisory Committee for Immunization Practices has wisely chosen to recommend a cautious approach to using the new and unlicensed smallpox vaccine that may soon become available. The nation's public health officials still face many unresolved questions. Not the least of the problems is how our governments—federal, state and local—should explain the issues to the public and respond to public concerns.

Vaccination programs, like most public health efforts, require great public cooperation and participation to be effective. Indeed, public health programs have, with carefully developed communications strategies, usually succeeded in garnering public trust, cooperation and participation. Mostly, Americans cooperate with public health officials and programs, although exceptions to this rule, including the recent reluctance of soldiers to accept the anthrax vaccine, should make us cautious.

These are difficult times because the needed public trust is certainly low. We in the public health community didn't perform well in response to the anthrax releases. If you have any doubt, ask the postal workers. Public trust is the key ingredient for success and constitutes one broad measure of the effectiveness of communications.

Trust depends on the public understanding what and how actions will protect people. In our case, the public will need to understand the important distinction between protecting individuals with the vaccine versus using the vaccine in the population to stop the spread of disease by reducing the number of susceptible individuals and thus the chance of transmission. Our actions should not be in conflict with public understanding or lead to suspicion that we have unrelated political motives. Where there is trust, the public can tolerate both new development and ambiguity.

Perhaps most importantly, to be effective, we must not adopt reassurance as an objective. Elected officials often demand that we, as public health officials, reassure the public. In truth, the public is comforted only by knowing that its public health officials are more concerned about and alert to threats to the public health than are individual citizens. Public health officials—and this applies directly to those who plan, organize and operate a smallpox vaccination program—are never trusted if they are perceived as offering reassurance rather than vigilance and protection.

As a corollary, I would note that secrecy is also counterproductive and destroys trust. What we know, the public should be able to know. Many citizens may choose to trust our word and follow our advice, but others will want more information. Experience teaches us that it should not be withheld.

Simplification carries risks. Clear and understandable explanations are indispensable. It helps to be able to explain complex and difficult ideas, but experience teaches us that simplification must not be or even appear to be a way to withhold information. With every useful simplification, we must demonstrate a willingness to expand and explain in greater depth and complexity. This is one reason it often behooves us to use a knowledgeable person as a spokesperson, provided he or she can master understandable simplification as well as complexity. Grasping the needs and desires of an audience is no mean talent.

Finally, there is a dilemma for which I have no simple answer, only a caution. Despite our efforts to build policy on science, there is one domain where politics, not science, seems destined to prevail. Clearly, if smallpox poses a serious risk to Americans, it is in the nature of the virus and how it might spread in our world that it poses similar risks to everyone on earth. Yet our country is caught in this war imagery. Our focus on protecting Americans may be seen in a very different light by the other 6 billion people on the planet. We Americans are loved for our spirit and generosity, but also feared. Colleagues around the world have often reminded me that we are the only country that has ever used nuclear weapons on civilian populations—and quite deliberately, over the objections of many scientists, including Albert Einstein.

I do not have a communications plan to explain our war strategy, yet this strategy, as it incorporates smallpox vaccination, seems likely to trigger distrust. We may engender the same kind of distrust that we saw after our early response to the AIDS epidemic. Remember how many people believed we had invented HIV in our military laboratories? A vaccination strategy focused entirely on Americans seems likely to provoke, among many people around the world, similar mistrust of our motives and fears of genocide.

Dr. Anthony Robbins is professor and chairman of family medicine and community health at Tufts University School of Medicine. This article is based on a talk Robbins gave to a special Institute of Medicine meeting on smallpox vaccination policy on June 15.