"In light of the available scientific evidence on vaccines, the question for the media is how to report rare adverse events without distorting the public's perceptions of the true risk." So ask Freed and colleagues writing in this issue of The Journal about the overreporting or misguided reporting of actual or feared reactions to vaccines, reporting that may discourage essential immunizations of children.
The authors call on the media to report responsibly. The question, of course, is "how to report responsibly," and it is not a question for the media alone. It is also one for those who develop, manufacture, promote, and regulate vaccines, including the clinicians who give the doses or the injections.
Do the media sometimes report irresponsibly on vaccines, without perspective? Yes.
Do the media sometimes point out the merits of vaccination, the rarity of adverse events, and the unreliability of scattered cases and anecdotes? The answer is also yes.
The problem is that the impact of a shocking headline or, even more so, the sight of a brain-damaged child on a television screen can overwhelm a thousand written or spoken explanatory words. "To reach the public," explains journalistic observer Stephen Klaidman, "journalists look for concrete, emotional anecdotes to make their stories accessible and compelling." And, as a television producer told another journalist, "The pictures will always win out over the words" (oral communication, Howard Lewis, October 1996).
How can journalists-and television reporters and producers, who are often the greatest sinners for their very impact-do better?
We-I write this as a journalist, who has committed my share of sins-should indeed make the great overall benefit of vaccines, the victory of vaccination over childhood disease, a part and more than a minuscule, offhand part of our reports. We need to ask ourselves: unless there is a true social problem, a true spate of adverse events, not just a rare reaction, is there a story that should be reported? If we do report the rare grim reaction, have we indeed put it in appropriate perspective? Are we also paying enough attention to the number of children who are not being immunized, and to the reasons?
This much said, all of us-scientists, physicians, nurses, and journalists-face not just the problem of vaccine reactions, real or supposed, but also the problem of conveying all risks to the public and helping the public discern the probable truth from the probable trash. We who try to do so are victims of another current social phenomenon, the public's vast mistrust of the political, journalistic, and scientific establishments, based on the fact that the public has so often been told that something is "safe," which it takes to mean completely safe, only to learn otherwise. The public, said John Ahearne, former chairman of the Nuclear Regulatory Commission and chairman of a National Research Council study of risk perception and communication, is understandably "skeptical of technologists who present an argument based on 'trust me, I know best.'" Too often, the experts do not know best.
On almost every issue, we hear flat accusations from one side-"the sky is falling"-and from another side-a flat "it is not." These pendulumlike assertions have made almost everyone confused about a myriad risks: global warming, the ozone layer, chemicals and pesticides, our air, our water, our soil, our health, our medicines, cholesterol, silicone breast implants, food, coffee, tea, and me-you name it. On almost every issue, the public seems to hear one theory today and another tomorrow.
For journalists, doing better is not easy. As Klaidman writes,
Reporting on health risks is rarely simple and straightforward. ... Reporters and editors must grapple with uncertain scientific results that resist interpretation, fundamental assumptions that are hidden, and untested, undisclosed values [and] economic or political goals. ... And [news stories] rarely, if ever, are able to provide the definitive answers that the public is seeking.
We journalists can nonetheless do much.
We can recognize that our much-pursued "balanced reporting"-the "he said, she said" story that quotes all sides-can leave everyone confused. It can be outright deceptive to pretend that all sides are equal in authority or veracity. Where there is controversy about a possible risk, reporters owe it to the public to report which way the wind is blowing, which way there is a consensus or a developing consensus among the best informed, least prejudiced people, those who know the issue and do not have a position to sell.
It can be outright deceptive to pretend that all sides are equal in authority or veracity.
We can learn to test statements of so-called scientific fact by the same rules of evidence that science itself preaches. We can ask a lot of questions: What are your data? What are your numbers? How sure can you be of their accuracy? Did you have enough cases for statistical significance? Are there possible biases or other explanations for the findings? How reliable are your findings? Have results been consistent in most other studies? Who disagrees with you and why? And so on.
We can learn that a single study rarely proves anything and that we must seek out the most credible evidence, the most valid and reliable studies. When a scientist or environmentalist or public advocate or industrialist makes a statement or describes a study that lacks credibility, we journalists are entitled to ask ourselves, "Are we obliged to report every piece of junk, or report it without criticism?" We can point out that some studies are full of holes and that even a Dr Famous can utter things that no one else believes.
We journalists can learn to report with some humility. Some years ago, tongue only partly in cheek, I said there were only two kinds of health and environmental reporting-"new hope" and "no hope." The new hopes and no hopes appear on page one of the daily newspaper and on the network evening news. The in-between stories get buried or ignored. We can unbury them and do so interestingly. We can learn to say that most scientific reports are just that, progress reports, not the last, definitive word, and that the scientists may know more tomorrow.
Medical investigators, authors, and practicing physicians can do much the same, whether in communication with each other or in news conferences or interviews. Those who publicly report their findings can tell us how they meet the statistical tests that good science prescribes. They can tell us about the uncertainty of their findings and the use of probability for some guidance. They must not pretend that their conclusions are written in stone, but rather say, "Here is the best we can offer today, and we hope to do better tomorrow. The pursuit of knowledge is a continuing struggle."
These recommendations contradict the too common argument favoring one course or another: "These are the facts, and if you follow these recommendations, everything will be wonderful." They caution us about saying that vaccines are perfect or near perfect and reporting that any harm is a "rarity" without recognizing that a rarity to a scientist may be a disaster to a child and parents.
I believe we should all refrain from invoking the overused word "safe," whether by the US Food and Drug Administration in describing a medication or by a physician reassuring a patient. Almost nothing is completely safe, and we should officially and individually consider substituting "relatively safe" or "as safe as possible," and indicating, in the best numbers and rates we can muster, the degree of safety or risk.
Similarly, well-intentioned investigators and clinicians should abandon the belief that, if they are completely candid about vaccine risks or possible reactions, they will scare parents and discourage immunizations. Honesty may make selling some ideas, even selling vaccines, more difficult, but it can build trust and prevent future disappointment and disillusionment and the lack of trust that exists today in so much the public hears. The National Research Council committee on risk communication urges candor on all risks and uncertainties, including "data gaps and areas of significant disagreement among experts." The committee also urges advice couched in clear public, not scientific, language as well as respect for an audience's concerns and information about how to cope with any possible problems. In the case of vaccines, this might mean telling parents about when not to vaccinate an ill child or how to respond when there is a reaction.
There is a wise saying: "If you would have public confidence, confide in the public." Any other course may work temporarily, then backfire disastrously.
Reprinted with permission from the December 18, 1996, issue of The Journal of the American Medical Association. Copyright 1996, American Medical Association.
Victor Cohn, retired science writer on the Washington Post, now freelances in Washington. DC.