Category: health

Listening, Gay Marriage and Lessons for Changing Minds

A pro-gay marriage rally in Sacramento in 2008. A recent study showed that engaging opponents to gay marriage in a dialogue about the issue was effective in changing minds. Photo by Kelly B. Huston. Used under Creative Commons license.
By Michael Kuczkowski

Years ago, I was part of a team that was hired to help a pharmaceutical company explain to America why its industry was a good thing.

This was not an easy task, obviously. The pharmaceutical industry has a weak reputation overall, despite delivering many innovations that improve the health of people around the world. A big chunk of the problem is rooted in costs: People believe health care is a right, yet prescription medications cost money, sometimes a lot of money. With ever-changing insurance co-pays, drug classes and deductibles, individuals increasingly bear the brunt of those costs. Which is tough.

It was, however, a fight I could feel good about. The industry was taking a lot of criticism for things that I didn’t think actually were bad things. And there were lots of ways in which the pharmaceutical industry was (and is) hugely valuable. The prescription drugs these companies produced often saved lives, and certainly extended the lives of many, many people. It didn’t make sense to me that the industry was being demonized as much as it was.

The client in question had amassed mountains of compelling economic and policy arguments – all of which I think have merit – about the value of the innovative pharmaceutical industry. (I know this remains a controversial question in many quarters, but that’s an argument for another time.)

What became clear early in the engagement was that the leaders of this company felt strongly that if only they could get people to understand these facts – very credible analysis by respectable academics – then people would come to love the pharmaceutical industry, and the industry’s reputational problems would go away.

Unfortunately, that belief was unrealistic. Few things are as emotionally charged as health care, and it’s the emotional vector of rising health care costs, rooted in very real experiences, that shapes people’s opinion of industry. (There are other factors too, but this is the single biggest driver.)

We came up with a three-part framework for dialogue.

Understanding: You have to start by listening and acknowledging facts that no one can really dispute: health care is expensive, more and more people are bearing the direct costs of health care, people are suffering, the system is maddeningly complex and changing in ways that are painful to the average American. Expressing empathy for what people were going through in their battles with the health care system is critical. And it’s not hard. Listen to people’s stories. Tell them you understand their frustration. And recognize that their frustration is real.

Facts: Use the facts, if you must, to illustrate the value the industry brings to people and the health care system. Innovation saves lives, and no other industry invests as much of their revenue in research and development as pharma does. For example, while new drugs are costly, they also reduce other types of health care spending, often by a significant margin (the linked study showed that new drugs increased pharmaceutical spending by $18 per person, but reduced other types of health care spending by $129 per person. That’s a big-picture “good thing” that most people don’t know about, and could be useful in reframing their thoughts about the value of the industry.)

Future: Focus on a future where more people have access to medicines, medicines cure more diseases and prolong life, and the cost burden borne by individuals is more aligned with the things that support prevention and interventions that delay disease progression. After all, it is possible to change policy around health care financing to support things, like regular doctor visits, disease management and access to medicines, that can keep people healthy and reduce their individual cost burden. We just have to fight for it.

So there it is. U-F-F. UFF. Unlikely to win a Cannes Lion for best mnemonic device, but more effective than trying to give the entire U.S. population an advanced degree in health economics.

UFF didn’t go very far, ultimately. We tried it, and we trained people on it, but a leadership change prompted a shift in the overall approach. None of which, in hindsight, worked out very well.

Still, I was reminded of it recently while listening to a podcast from This American Life titled “The Incredible Rarity of Changing Your Mind.”

A big chunk of this program examined the experience of a group of people who canvassed voters last year about California’s Prop 8. You may have read about this based on a study published in February in Science magazine: Researchers studied an effort by canvassers to persuade voters to change their minds from neutral or opposed to gay marriage, to supportive of gay marriage. The canvassers, many of whom were gay, were actually incredibly successful in getting people to change their minds. Follow-up research showed that people’s changed minds stayed changed for up to a year. Both the degree of changed minds and the length of the effects were a surprise to experts.

The reporting on this focused on the aspect of the findings that I just emphasized: Gay canvassers were more effective at changing minds on the issue of gay marriage than straight ones, statistically speaking. In other words, the messenger matters. (And in communications, we know this is true.)

But there was more to it than that. It turns out that the approach the canvassers adopted matters too.

First, they listened. Rather than making some compelling argument about fairness or the rights of individuals, canvassers got the voters they were interviewing to talk about their own personal experiences with gay people or marriage. And, they talked about whether being gay was a choice or a genetic predisposition. Ultimately, the discussions led somewhere. Like, wouldn’t you want the gay people you know to enjoy all the benefits of marriage?

As I’m describing this, the second point is pretty obvious: It’s an emotional conversation. We’re not talking about facts. There were no data points about how many gay people can’t visit their partners in the hospital because they don’t get spousal recognition, or how many people are denied health care because they don’t have coverage from their lover’s health plan. Which would be valid arguments to make, of course. Instead, the conversations focused on what it felt like to know someone who was gay, to feel what they must feel, to miss out on the things a heterosexual married couple naturally enjoy by dint of being married.

The third thing was how artfully the canvassers brought the voters to their own realizations. They would weave in the fact that they were gay at just the right moment. Or, even just wait while the voter connect some key dots. (One interviewee, a widower whom the broadcast named “Mustang Man,” completely flipped his stance in the course of the interview with a canvasser, because he reflected on the powerful love he’d had with his wife: “I would hope that they would find the happiness that I had with my wife. If you could have that kind of relationship with your partner or the other sex, I would say you’re a very lucky person. Because I know I had it. But yeah, that’s what I would wish on them. That they’d be as happy as I was with mine.”) It was subtle but impactful, holding a kind of mirror of reality up to people’s faces.

And that’s how the interactions worked. Canvassers asked voters whether they were likely to vote for gay marriage before and after the discussion, and many of them were more likely at the end of the conversation. By statistically significant margins. And, the opinion change held for a year in many cases.

There are incredibly powerful lessons in here for communicators.

Firstly, if you want to change minds, you have to start by listening. This is huge. It’s almost the opposite of the job, right? I’m a communicator, therefore I should talk all the time. But, we know that understanding where people are is critical to helping them adopt a new opinion or behavior.

Second, you can’t change someone else’s mind for them. This seems obvious, but the process has to be owned by the person who is changing their mind. Facts are not going to help you (oh, how I wish I could travel back in time and tell my mid-30s self and pharma industry clients this truth). In fact, studies show that if people with a certain opinion are confronted with facts that show they are wrong, those people are more likely to become even more entrenched in their mistaken beliefs than before. (This is known as the “backfire effect”) But, you can lead someone to reframe their thinking on an issue, and it can even happen quickly. (This is where I’d go back and change the middle “F” in the UFF framework above to say, try to find ways to help the person you’re talking with connect their own dots about an issue, rather than laying a white paper on them.)

Finally, and most importantly, the emotional aspect of these arguments is incredibly significant. People feel hurt, anger, joy, outrage, frustration, anxiety and all kinds of other emotions about their experiences. Mounting factual arguments against a wall of emotions is a waste of time and energy. It’s not going to change minds.

But minds can be changed. The human mind can learn and evolve and take up new opinions over time.

This has huge implications. It suggests that organizational change efforts should think not just about who occupies the newest boxes on an org chart, but also about the emotional state of people across an organization.

It reinforces the vital importance of research in understanding how people view issues.

It shows how important it is to listen, be flexible and adapt in the face of unanticipated data.

And, it shows that communications can be incredibly effective – but that it’s also very resource intensive. Changing minds on the gay marriage question wasn’t going to happen from exposure to a few 30-second ad spots. It was going to take a dialogue, and an artful one at that.

But that’s okay. Because the issues on which we need to change minds – racism, police brutality, gender equality and even the divisive issue of health care– are important issues. They’re worth the time. Because on those and many other issues, every opinion counts.

The Persistence of Lies

Dr. Schreiber of San Augustine giving a typhoid innoculation at a rural school, San Augustine County, Texas. April, 1943. Photo by John Vachon.

By Mike Kuczkowski

I live in Marin County, Calif., just north of San Francisco via the Golden Gate Bridge. It is one of the most strikingly beautiful places I’ve ever seen, and I’ve seen a lot of beautiful places. With a median income of $94,347, Marin ranks 13th in the nation in per capita household income[i]. Most people—actually 54.6 percent of those over 25—are college graduates. In short, it’s an affluent and well-educated place.

Yet, Marin is also an epicenter of the anti-vaccination movement. More than six percent of the incoming kindergartners in our public schools have a “personal belief exemption,” which means they don’t have to be immunized against diseases like measles, mumps and whooping cough. (At one local school, the rate is 61 percent.) That’s the highest rate in the Bay Area, one of the highest in the state. By contrast, the entire state of Mississippi, which has a much more stringent policy around medical exemptions, allowed just 17 of the state’s 45,000 kindergartners to not be vaccinated.

With more than 100 confirmed cases of measles, a disease we had nearly eradicated 15 years ago, there’s now a great debate about why we allow people to opt out of immunizations. In Marin, the father of a 6-year-old boy with leukemia and a suppressed immune system due to his treatments, has made national news by asking public health officials to bar unvaccinated kids from his son’s school. It’s the only way, he says, to protect him son from a potentially deadly infection.

The issue of personal belief exemptions, vaccination science and perceived links to autism, which persist despite a complete lack of scientific basis, illustrate just how persistent myths can become, and how hard it can be to change minds. For marketing and communications professionals, it serves as a reminder of how vital it is to continually reinforce even the most straightforward messages and infuse them with humanity and relevance.

First, let’s examine the science. In 1998, the British Journal The Lancet published a groundbreaking study by a British doctor and researcher named Andrew Wakefield, who claimed he had found a link between the measles, mumps, rubella (M.M.R.) vaccine and the onset of autism. Wakefield’s research, which took an in-depth look at 12 autistic children, prompted a sharp decline in the vaccination rate in the United Kingdom and the United States. For many parents of autistic children, the study offered an explanation for a painful and as-yet unexplained phenomenon.

The problem was, the paper wasn’t true. Other researchers who tried to duplicate Wakefield’s results – a key tenet of the scientific method – were unsuccessful. New claims emerged that Wakefield had an undisclosed financial conflict of interest. Eventually, his co-authors backed away from the article’s claims. Since Wakefield’s initial publication, more than a dozen studies including millions of children showed no link between autism and the M.M.R vaccine. In 2010, The Lancet took the rare step of retracting Wakefield’s article. Two years later, British medical authorities stripped him of his license.

That’s as emphatic a “correction” as one will ever see in a peer-reviewed journal, yet many people still don’t know that that study has been thoroughly discredited.

There is another strand of thought that ties autism to a preservative called thimerosal, which has a form of mercury in it that has been suspected of having a role in autism. No connection has ever been proved, and thimerosal is no longer used in most vaccines (an exception being the flu vaccine).

In sum, there is no credible scientific argument against vaccinations. The evidence in support of vaccinations is robust. The lone article that suggested a link has been retracted. End of story.

Yet, it’s not. The genie is out of the bottle. In 2008, nearly one in four Americans said that because vaccinations may cause autism, it would be safer not to have children vaccinated at all. Nineteen percent more said they were not sure. A recent poll by the Pew Research Center showed that 30 percent of Americans say parents should be able to decide not to vaccinate their children.

This issue of choice is a very slippery one. A key precept of mass immunization is that if most members of a community are immunized, outbreaks of a disease are more likely to be contained. By allowing people to opt out of vaccines, the risk that more people will get sick goes up significantly. As policy decisions go, choice sounds appealing, but it also carries risks.

How can there be a clear scientific consensus that vaccines are not harmful, and yet 43 percent of Americans say they either believe vaccines cause autism, or are unsure? I’d suggest there are at least three major factors at play.

First, autism is a scourge, and we don’t know what causes it. It is probably one of the most emotional and fear-laden issues a parent faces – am I potentially exposing my child to harm? The early symptoms of autism tend to emerge at around the same time as children are being vaccinated. Parents may perceive a connection, even if it is merely a coincidence, and they become believers. In the absence of an answer, lots of lay hypotheses take hold. Yet this is precisely why we need science. As recently as the 19th century, people believed that diseases such as cholera were spread through miasma, or bad air, which explained why epidemics centered on poor areas with unhygienic conditions. Germ theory gave us a better explanation. (See Steven Johnson’s The Ghost Map for a riveting account of this transition.)

Second, many people today distrust the government. And while most Americans acknowledge that science has made the world better, they still distrust scientists on key issues, like climate change, pesticides, and even the theory of evolution. As a result, when the American Academy of Pediatrics and the Institutes of Medicine dismiss studies, it’s like white noise.

Third, and perhaps most concerning, people don’t understand science and scientific language in particular. It would seem, from a distance, that science is all about proving things. Electricity lights bulbs. Heart attacks cause death. But in reality, most scientific inquiry is very cautious in its assertions, and very incremental in assembling a body of knowledge. When researchers appropriately list limitations or caveats on their findings, it can seem like they doubt their conclusions. Yet that’s not really what’s going on. If you look at the Institute of Medicine’s most recent study on the adverse effects of vaccines, there is some risk that your eyes will glaze over. (“(E)vidence favors rejection of five vaccine-adverse event relationships, including MMR vaccine and autism…”)

What should we do about all of this?

The first thing leaders and communicators need to do is have the courage to engage unfriendly audiences. We should hear the opponents of vaccines out, but we should also continue to talk about the science.

The second thing we need to do is stick to a singular message and deliver it everywhere. Communications research shows that people need to hear a message 5-7 times before they believe it, and more often if they don’t trust the messenger. That means there should be a significant, sustained campaign to reinforce the benefits and address concerns about vaccines.

But we have tools to do that. We can use social media to respond to people who continue to tout bad science as a basis for anti-vaccine arguments. If we work at it – and use clear, accessible language – we can increase awareness that there is no scientific basis for many of the anti-vaccine movement’s claims.

The third thing we can do – and I think this would be a huge opportunity for the pharmaceutical industry – is trot out real scientists to communicate in clear language their expert perspective on these issues. Utterly unqualified people are standing up and speaking out in favor of a vaccine-autism link, with no credible evidence behind them. Where are the bench scientists, the safety and risk management analysts, the medical leaders of pharmaceutical companies who have a stake in helping the public understand that these vaccines are safe. (Note I did not say, where are pharma’s CEO’s; the reputation of the industry is such that the business leaders are not trusted. Scientific expertise, however, is still valued.)

We can change policies, mirroring more of what Mississippi has done and less of what California has done, to make exemptions harder to obtain. But I think the starting point is a clear, loud, science-based communications effort to help people understand the facts – and the very real risks – about this issue.

[i] Based on data obtained from the US Census Small Area Income and Poverty Estimates, 2013, here.