Health Promotion International, Vol. 28, No. 1, 2013, pp. 43-50
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The version below does not incorporate some changes in the final published article.
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Campaigners on public health issues face a number of dilemmas when tactical choices in public debating involve uncomfortable mixtures of benefits and costs. Key dilemmas for campaigners are whether to acknowledge weaknesses in their own position, whether to advocate research to address claims by opponents, whether to acknowledge vested interests on their own side, whether to debate with opponents, whether to launch attacks on opposition individuals and groups, and whether to criticise extreme behaviour by those on their own side. Drawing on literature on scientific controversies, these dilemmas are outlined, with illustrations from the Australian vaccination debate.
Dilemmas in health campaigning warrant attention because choices made can affect both the success of policy initiatives and the image of professions, sometimes with trade-offs between these. However, dilemmas have been neglected because most studies of health controversies give little attention to campaigning tactics.
Campaigners can choose options that seem to maximise the likelihood of winning in the short term. However, options for short-term advantage may establish a precedent for approaches to campaigning that undermine commitment to free and open debate, to possible long-term disadvantage.
Keywords: Health controversies; Campaigning; Dilemmas; Debating; Vaccination
There are innumerable public health controversies, for example over AIDS, alcohol, fluoridation, genetic modification, microwaves, nuclear power, obesity, stem cells and vaccination. Some of these controversies are incredibly bitter and may seem never-ending. For example, the fluoridation controversy has been going strong in English-speaking countries since the 1950s (Freeze and Lehr, 2009). Public health advocates have much to gain by entering debates but can find them frustrating and sometimes distressing.
Health controversies are a subset of the wider category of scientific and technological controversies, about which there is a considerable literature (Engelhardt and Caplan, 1987; Kleinman et al. , 2005, 2008, 2010; Nelkin, 1979). Research on controversies suggests why they can be so intractable: evidence, no matter how apparently definitive, can always be challenged through questioning of assumptions and methods, which means that evidence on its own is never enough to close debates. Furthermore, public controversies also involve social, ethical and political differences that cannot be resolved by science.
Another complication is the presence of vested interests, typically corporate, government or professional groups with a financial or reputational stake in a particular outcome. Vested interests can use their powerful resources to thwart consensus, discourage opposition, or enforce a dominant viewpoint (Boffey, 1975; Michaels, 2008; Orestes and Conway, 2010; Primack and von Hippel, 1974).
Research on scientific controversies can be classified into four approaches: positivist, group politics, constructivist and social structural (Martin and Richards, 1995). Social scientists using a positivist approach assume that scientific orthodoxy is correct and typically analyse social reasons for opposition. Those using a group politics approach focus on the activities of citizens' groups, government bodies, corporations and other actors in a political marketplace (Nelkin, 1979). The social structural approach uses concepts such as class, patriarchy, the state and professions to analyse players and alignments in controversies. The constructivist approach, drawing on the sociology of scientific knowledge (Barnes, 1974; Bloor, 1976; Mulkay, 1979), involves examining the social construction of knowledge claims on both sides of a debate. Some debates so analysed are largely between scientists (Collins, 1985; Pinch, 1986); others involve governments, corporations and citizens (Martin, 1991; Richards, 1991). Actor-network theory (Callon, Law and Rip, 1988; Latour, 1987) is a constructivist approach that problematises social structure and the human-technology distinction, but has seldom been applied to public health controversies.
Constructivist approaches help explain the intractability of controversies: resolution of disagreements is inevitably a political and social process, not just a matter of identifying "the truth" and implementing it. However, even using a positivist approach, it is possible to understand that controversies can involve different beliefs about nature overlaid with social factors (Mazur, 1981), so reaching a resolution is not a straightforward matter.
Although social science approaches are valuable for understanding controversy dynamics, they give surprisingly little guidance for campaigners. For example, when partisans cite evidence in support of their views, a positivist might decide whether the evidence is correct (i.e., in accordance with dominant views), but this does not say how to respond to the partisans, except to support or oppose them. A constructivist might analyse the social influences on the creation and deployment of the evidence, but this does not provide any way to evaluate courses of action. For public health campaigners, controversy studies can offer background insights but seldom much practical direction.
Public health advocates might prefer a process involving respectful discussion leading to evidence-based policy-making, but on many issues the reality is quite different. Tactics used in controversies can include censorship, deception, false claims, abusive comment and suppression of dissent (Deyo et al. , 1997; Kuehn, 2004; Moran, 1998). Some controversies are so polarised and vicious that anyone who, seeking rationality and balance, advocates a middle position may come under attack from one side or the other.
Most research on controversies addresses the issues being disputed, especially scientific, ethical and public health dimensions. The small body of work on how to wage controversies is mostly pragmatic, being based on experience with advocacy rather than drawing on theoretical frameworks. Simon Chapman, in one of the few comprehensive treatments of campaigning strategy, notes that public health advocacy has been neglected even within public health (Chapman, 2007: 29). Because of the relative neglect of campaigning, a number of difficult decisions encountered by campaigners are seldom discussed openly.
How should campaigning methods be evaluated? There is no standard set of criteria, indeed very little discussion of evaluation: evidence-based campaigning remains to be developed. One approach is to assess effectiveness in achieving outcomes, but even this is problematical. Effectiveness could be assessed on the basis of media impact, changes in opinions, increased participation in campaigning, decreased campaigning by opponents, changes in imagery, policy change or changes in behaviour, any one of which is difficult to measure and correlate with campaigning methods. Another approach is to examine the ethics of campaigning options, for example in terms of their compatibility with the goal of public deliberation or free speech.
Campaigning is further complicated by the array of options available for intervention to promote public health, including communication (as researched in the field called public understanding of science), government regulation, designing the decision-making context (Thaler and Sunstein, 2009), and market mechanisms. Anti-smoking campaigning can involve messages to citizens, government controls over advertising, and taxes, among other options. Campaigning can be directed towards citizens, scientists, the medical profession, politicians and public servants, among others. Coalitions can be built between different constituencies to make a campaign more effective. There is also the question of goals, for example whether to prevent disease or foster positive health.
These issues are all important in the wider context of health campaigning. Here, the focus is on a particular aspect within this broader picture, namely public disputation on highly contentious issues, typically when citizen campaigners challenge orthodox scientific views, resulting in public claims and counter-claims. The aim here is to outline some of the dilemmas encountered in such circumstances.
A dilemma occurs when there is a choice between two or more options, each containing a mixture of benefits and costs. Typically, there are two options, each of which has different sorts of benefits and costs that cannot be readily predicted or compared. Dilemmas often point to choices that reflect underlying and unarticulated values.
One important feature of health controversies that affects the existence and evaluation of campaigning methods is the role of vested interests. In some controversies, public health campaigners are on the opposite side to powerful vested interests. The canonical example of this configuration is smoking. In other controversies, vested interests are on the same side as public health campaigners: their opposition is largely composed of citizen volunteers, as in the fluoridation controversy. Here, I use an example fitting in the latter configuration - vaccination - because some of the dilemmas are more acute for proponents.
In the following sections, I describe a series of dilemmas, spelling out options and likely benefits and costs. Possible counter-tactics are mentioned: these give an indication of limits to effectiveness, and also include an ethical dimension because methods considered unethical can be challenged on that basis. I give a few examples, especially from the vaccination controversy in Australia.
I selected the dilemmas discussed here based on my studies of a large number of public controversies, including informal conversations with prominent as well as lower-profile campaigners. Because campaigning dilemmas are seldom discussed openly, it is possible to give only a limited number of references to published literature. A key aim of this paper is to make these dilemmas explicit so they can be given the scrutiny they deserve.
Every position has both strong and weak points. A common approach in campaigning is to emphasise strong points and ignore or gloss over weak points. Is it wise to admit weaknesses?
Supporters of vaccination emphasise the large benefits from being vaccinated, notably a reduction in disease, including associated deaths and disabilities. They also emphasise the social benefits, due to herd immunity, from high levels of vaccination (Andre et al., 2008). That is straightforward. But is it wise to mention that a small number of individuals will have adverse reactions, including death and permanent disability?
The advantage of sticking to positives and not admitting shortcomings is that the message is much more powerful. "Vaccines are safe" is far more reassuring than "Vaccines are nearly always safe." "Vaccines are safe" is also clear and uncomplicated and hence far easier to sell. Furthermore, any admission of weakness is likely to be seized upon by opponents and trumpeted far and wide.
The disadvantage of not admitting weaknesses is that any evidence of risks, if taken seriously, potentially undermines the strong position and thereby the credibility of advocates. Just a few adverse reactions to vaccination may be enough to undermine unqualified claims that "Vaccines are safe" and make some individuals, for example parents who believe their children have suffered adverse reactions, lose faith in medical authorities. Not admitting weakness is thus open to the counter-tactic of challenging a position based on a few counter-examples.
Admitting weakness can be interpreted a sign of strength, indicating a belief that the case, even with full disclosure, is strong. Furthermore, acknowledging weak points, while providing responses to them, is a type of "argumentative inoculation," preparing people to be more resistant to counter-arguments (Pfau et al., 2007).
On the other hand, advocates who admit weaknesses in their side's position may come under attack from other advocates. Professor Peter Collignon, a supporter of vaccination, was quoted as receiving "a lot of pressure" due to his cautionary comments about Australia's flu vaccination programme (Bita, 2011).
Critics of the dominant epistemological position - the position supported by an overwhelming majority of experts in the field - often claim that research is not conclusive. They might point to weaknesses in studies or to contrary findings and insist that further research is needed. Critics of vaccination say, for example, that better data are needed on adverse reactions, claiming that many of these are unfairly dismissed as anecdotal. They also say that more research is needed to explain the increase in auto-immune disorders, and that vaccinations could be contributing to the increase (Habakus and Holland, 2011; Wolfe et al., 2002).
Supporters of the dominant position often say that the existing research base is more than sufficient to conclusively support their stand. Sticking with this claim has the advantage of not admitting weakness. It also can have an economic justification: unnecessary research is avoided.
The disadvantage of rejecting calls for more research is that the critics have a continual source of complaint. When critics have little capacity to undertake their own research - at least research requiring substantial funding - they can portray the defenders of orthodoxy as stonewalling in the face of legitimate doubt.
As mentioned earlier, new evidence hardly ever resolves a scientific controversy, because the findings can be challenged and because there are non-scientific factors underlying the dispute. Nevertheless, new evidence can be a powerful campaigning tool: the evidence on its own is not the key, but rather its role in mobilising supporters, neutralising some challengers and winning over uncommitted third parties.
One option that might thwart opponents more effectively would be to invite some of them to be participants in the research or in monitoring research protocols. If critics have a personal stake in the research, it is much harder for them to disown the findings. If the findings vindicate orthodoxy, as expected, then the participating critics may be neutralised or, if they persist with their claims, discredited. However, if the findings are ambiguous or even support the critics, then the orthodox position is weakened. If critics are never brought on board, or if they are not provided data for their own studies, they can claim the reason is fear of the results.
For those who advocate further research to address claims by critics, there is an additional hurdle: employers and funding bodies may be unreceptive, on the grounds that such research would be unproductive scientifically and thus a waste of money. Those who openly accept the value of more research, but who are unable to deliver, may give even more fuel to opponents.
If public health campaigners are supported by powerful groups with stakes in measures being advocated, should campaigners acknowledge the potential influence of these groups and, if so, how? It is common to attack the role of vested interests on the other side, so it can be predicted that opponents will claim that corporations, government departments, religious or professional groups, if they fund research or profit from policies, are a source of bias or worse (Kassirer, 2005; Krimsky, 2003).
In the vaccination debate, critics point to the role of pharmaceutical companies that produce vaccines, suggesting that corporate influence, for example through sponsoring research, leads to the unwarranted adoption of new vaccines and the continued use of unnecessary ones. Pharmaceutical industry funding - for example of research, conferences and journals - is claimed to create a conflict of interest for scientific researchers and policy makers.
The most common way to deal with vested interests on one's own side is not to mention them, relying on the belief held by scientists that they are objective, so it doesn't matter if corporations offer research funding and perks. However, this stance leaves the stage open for opponents to exaggerate the role of vested interests.
Another approach is to acknowledge and defend the role of corporations or other vested interests, for example by saying that research is peer reviewed and that all conflicts of interest are declared. This can partially counter the claims of opponents, but has the disadvantage of allowing the role of vested interests to be on the table.
Yet another approach is to acknowledge the potential for bias due to vested interests and to leave campaigning to those who are least tainted, for example to scientists who have never received corporate funding or to citizen activists without careers at stake. However, this can be difficult to achieve when most key players have connections with vested interests.
Challengers to the dominant position often seek to promote public debate. They welcome opportunities for public meetings or for-and-against forums on radio, television, newspapers and blogs. The question for those supporting the dominant position is whether to join such debates.
The advantage is the opportunity to present one's position and to counter the claims of critics, ideally to show that the critics' position is weak, flawed or unethical. However, there is an associated disadvantage: joining a debate signals that critics exist and gives them an opportunity to present their viewpoint. Defenders of the dominant view sometimes say, "There is no debate," by which they mean that critics have so little credibility that they should be ignored. From this perspective, joining a debate grants the critics unwarranted credibility, namely that they have a viewpoint that needs to be taken seriously.
This line of thinking leads to the position of refusing to debate. Leading scientists sometimes refuse to speak if a representative of the opposing side is also invited. Refusing to debate can serve to marginalise and implicitly denigrate critics, but it has a cost: it can seem arrogant. Critics can claim that authorities are afraid to debate because they might lose, and members of the public, having heard this claim from the critics, might think the same.
This dilemma is seldom discussed openly. An exception is in the fluoridation debate: some pro-fluoridation commentators have recommended against debating but acknowledged the disadvantages of this stance (Martin, 1991: 60-64).
When leading figures refuse to debate, there is another risk: others on the same side might agree to debate and perform poorly. Seldom can leaders in a field dictate behaviour by all partisans. Yet another problem is that when leaders seldom debate, they do not develop debating skills, whereas key critics obtain a lot of practice in local forums. Engaging in a debate is disastrous if one is not prepared with skills for public performance as well as knowledge of the topic.
There is no easy resolution to this dilemma. A pragmatic resolution is to only debate when refusing to debate becomes a serious liability by damaging the credibility of the authorities. This will involve a sensitive assessment of the likely counter-tactics to a refusal to debate, as well as impacts on uncommitted audiences. A more principled approach, based on a commitment to public education and discussion, is to engage in debates, and to build up the capacity of a much larger number of committed supporters to be effective debaters (Leask and McIntyre, 2003).
Is it wise to mount a direct attack on opponents, seeking to discredit them and muzzle their ability to campaign? There are many possible dimensions to attack, including making abusive comments, spreading rumours, making false claims, making threats, suing for defamation, seeking deregistration, blocking research funding, seeking dismissals, calling in police, and physical assault.
Attacks can weaken the willingness and capacity of opponents to campaign. Some opponents may be scared away merely by abusive language; others may be frightened by defamation actions or death threats, and reduce their involvement. Scientists may choose to research other areas, or be blocked from planned studies. Organisations may collapse due to loss of members or funds.
Campaigners may justify attacking on the grounds that opponents are threatening valuable public health efforts, leading to loss of life, or that opponents are themselves using unsavoury techniques. However, the issue here is not so much whether actions can be ethically justified but whether they are effective.
The Australian Vaccination Network (AVN), a citizens' group critical of conventional vaccination policy, advocates informed choice by parents. The AVN is similar in orientation to other vaccine-critical groups (Hobson-West, 2007). In 2009, a pro-vaccination group, Stop the Australian Vaccination Network (SAVN), was set up, with the stated goal of shutting down the AVN. SAVN and others hostile to the AVN have used a range of techniques, including making unsupported claims about the AVN believing in a global conspiracy to implant mind control chips, making derogatory comments about AVN members, making dozens of complaints to government bodies such as the Health Care Complaints Commission, and posting online the names and contact details of advertisers in the AVN's magazine Living Wisdom (inviting harassment) (Dorey, 2011). These activities have scared some AVN members, discouraging them from participation.
The disadvantage of attacking is that it can be perceived as illegitimate, especially as a threat to free speech and open debate. Another disadvantage is that some opponents may be provoked into greater efforts. Attacking can damage the image of attackers: instead of being seen as honest and open advocates of public health, they may be perceived as heavy-handed censors who are afraid to rely on the good judgement of members of the public.
On some issues, opposition organisations may be the wrong target. Vaccine-critical groups may be less a cause of parental concern than a reflection of parents' experiences of feeling patronised and ill-informed by health providers and hence in need of a place where they can share concerns and experiences (Blume, 2006).
In a social movement, a radical flank is a group that adopts more extreme measures (Haines, 1984). If most organisations in the movement act through lobbying and public education, a group that organises rallies and sit-ins would be a radical flank. In the anti-smoking movement, BUGAUP - the loose alliance of activists that reconfigured billboards advertising cigarettes - could be considered a radical flank.
Radical flanks can be positive or negative, depending on whether they serve to advance the movement. A positive radical flank might change the perception of the issue, making the mainstream seem more acceptable. A negative radical flank can alienate observers and discredit the entire movement. In a movement relying primarily on peaceful protest, a group that uses violence can damage the cause. The anti-abortion movement primarily uses nonviolent methods; those who murder abortion doctors might be classified as a negative radical flank.
The dilemma for mainstream campaigners is whether to criticise or disown radical flanks. Remaining silent implicitly gives legitimacy to radical flanks, whereas criticising their tactics or formally rejecting their approach can position the movement mainstream as separate and presumably more responsible.
SAVN can be considered to be a radical flank within the pro-vaccination movement. SAVN is a positive radical flank to the extent that it damages the capacity of vaccination critics to participate in the debate, but could be a negative if its tactics are seen as extreme and unfair. If other supporters of vaccination do not support SAVN's methods, their dilemma is whether or not to criticise SAVN or otherwise distance their own vaccination advocacy from SAVN's. The dilemma becomes more acute to the extent that SAVN becomes a negative radical flank, namely damages the credibility of the movement. This can occur if parents without a strong view react against SAVN's methods and assume these methods are accepted by mainstream vaccination supporters.
Whether to criticise a radical flank is a special case of a more general dilemma of whether to openly criticise anyone on one's own side. Sometimes prominent campaigners get facts wrong, make unwise statements and behave in ways that undermine the movement. Speaking to the campaigner privately is one option but sometimes does not change a strong-willed person. Questioning the campaigner openly is a serious step, signalling disunity in the movement and damaging the credibility of the campaigner, and is seldom done. The result is that movements often tolerate campaigners who make mistakes and behave in disreputable ways, opening the movement to attack from the other side. This is a special problem for challengers to the orthodox position, who may attract various extremist groups and conspiracy theorists - this certainly applies to vaccination critics (Johnston, 2004) - but can also be a problem for the dominant position.
Campaigning on controversial public health issues is challenging in many ways. Campaigners support measures they believe will improve people's lives and in many cases prevent unnecessary death and suffering, yet they are opposed by others who obstruct and derail these efforts. Opponents may make claims that seem outrageous, indeed dangerous. In choosing how to proceed in this sort of confrontation, many dilemmas can arise, including whether to acknowledge risks, advocate more research, acknowledge vested interests, engage in debate, attack opponents and criticise radical flanks.
Each of these dilemmas involves a choice between different sorts of benefit and risk. For example, acknowledging risks or mistakes associated with one's own position provides material for opponents but can increase credibility through fostering an image of honesty. Refusing to debate denies opponents a platform but can seem arrogant.
There are no simple answers to any of these dilemmas: ethical principles can be used to support each choice and so can pragmatic assessments, namely what will be most effective. There is, though, one theme running through all the dilemmas: a choice between ends and means. If the priority is on winning the debate and preventing the views of opponents from gaining legitimacy or implementation in policy, then it is often best to avoid acknowledging risks, to refuse to debate, and to attack critics (recognising that these options contain risks). On the other hand, a choice to be as open and honest as possible and to treat the opponents as legitimate and sincere leads to preference for acknowledging risks, engaging in debate and treating opponents with respect.
In the short term, it often seems better to hold the line against opponents and to adopt methods that prevent their views from reaching audiences. However, given that many issues are debated for decades, it can be worthwhile considering a longer term strategy based on greater openness and respect.
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