Can Fear Be Good Medicine?

In the late 1980s, the Partnership for a Drug-Free America launched a pretty famous public service announcement. I was a kid at the time, but I still remember it. Maybe you do, too.

P.S.A.: This is your brain. This is drugs. This is your brain on drugs. Any questions?

The message was: doing drugs will fry your brain, just like that sizzling egg in the pan. The informational content was pretty crude, but the point wasn’t to convey information. The point was to inspire fear.

FAIRCHILD: You are using emotion in a way that helps people understand in their gut — helps them translate facts and data into something that’s personally meaningful.

That’s Amy Fairchild, Dean of the College of Public Health at The Ohio State University. She’s an historian and an ethicist, and she’s done a lot of work on using fear to get people to make better decisions about their health. Fear is tricky. It’s powerful, but it’s also subjective. What scares me in terms of my health may not scare you. We don’t want to take advantage of people’s fears or use fear to create stigma about a group or a disease. And yet — sometimes fear is the only appropriate response.

FAIRCHILD: Imagine a case in which you see somebody swimming in the ocean with a shark. You wouldn’t simply just say to them: “There’s a shark approaching. It’s now 500 feet away. There’s a shark rapidly approaching. It’s now 250 feet away. There’s a shark approaching. It’s now 10 feet away.” You would say, “Get the heck out of the water! There’s a shark coming. Swim, swim, swim!”

From the Freakonomics Radio Network, this is Freakonomics, M.D.

I’m Bapu Jena. I’m an economist and I’m also a medical doctor. Each episode, I dissect an interesting question at the sweet spot between health and economics.

Today on the show: Fear can drive us to make necessary changes to improve our health — or it can scare us away from going to see a doctor in the first place. Fear can catalyze — and it can paralyze. So, how can we use fear to make people healthier?

FAIRCHILD: The more fear you use, the bigger the effect that you have.

And what do we do when fear doesn’t seem to work?

WORSHAM: It seems intuitive but oftentimes people surprise us with their behavior.

SATPUTE: I think certainly in our culture, fear has a privileged place.

That’s Ajay Satpute. He’s an Assistant Professor in the Department of Psychology at Northeastern University.

SATPUTE: My research focuses on the neural and psychological basis of fear and other emotions. So, it’s often assumed that fear is one thing, a single psychological state that has like a dedicated brain circuit or mechanism that kind of works like a light switch. When that brain circuit is on, we feel fear. When that brain circuit is off, we don’t. Instead, it seems like fear is a category of mental states that are very diverse in terms of their features.

As part of his research, Ajay actually studies brain imaging data to understand what’s going on in our heads when we experience certain emotions. It turns out that acute fear — like of a predator — affects the body in a fundamentally different way than fear of heights, for example. Or an existential fear, like climate change. In that way, fear isn’t singular. It is, however, necessary.

SATPUTE: Fear plays a very important functional role in preventing us from doing things that might otherwise cause us harm. There are many situations that are ambiguous in terms of what’s right or wrong. And what fear can do is bias the kinds of information that we end up paying attention to and highlighting as being important for decision-making.

FAIRCHILD: There’s no exact definition of what a fear-based campaign is.

That’s Amy Fairchild again.

FAIRCHILD: But I would say it is something that tries, through emotion, to convey a sense of vulnerability to disease. A sense of vulnerability to death. Maybe it’s a sense of vulnerability to a kind of loss. Maybe it’s loss of beauty. Maybe it’s loss of your social status: You’re not going to have friends anymore because you have bad breath, or because you have venereal disease, or because you smoke. Disgust is certainly one of the common methods that we see used in fear-based campaigns. You know, um, oozing, bloody hearts, seeping intestines, things crawling all over you, and in you, and out you, that kind of make you have this visceral “yuck” reaction. Humor can be part of it. there are fear-based campaigns that have been quite funny, but they still kind of give you that “ugh” sort of reaction, and maybe make you want to get a little bit queasy. Conveying some anxiety is part of fear-based campaigns because you need to internalize that risk.

Fear-based campaigns have appeared throughout history. During World War Two, they were used to scare people — particularly young American soldiers — about venereal disease.

FAIRCHILD: You see all of these images of the prostitute, the sex worker, depicted as this sort of voluptuous woman, maybe with a hood that’s hiding her skeletal face. Uh, and the idea is to convey a threat. She may look nice. She may look pure, but she’s going to convey something to you — healthy young American man — that’s going to sap your strength and your health. And it also meant that it would sap our national strength, and our national wellbeing, and it became a patriotic cause.

Fear-based appeals can be very effective. In 2015, Amy published a study looking at the use of fear in public health campaigns in New York City. She found that anti-smoking messages had a dramatic impact.

FAIRCHILD: So, in New York City, for example, you see the decline in smoking rates begin to stall. And that’s when New York City decides: “We’re going to go with some hard-hitting, fear-based campaigns.” They used a campaign that had been used in Massachusetts called Rinaldo. And it was a man living with a permanent tracheotomy. And one of the themes of this was: you can’t go back. Once you have suffered the consequences of cancer because of smoking, you can’t go back. Your life is never going to be the same again. And then a couple of years later, they begin to push this notion about cigarettes eating your life away. And that’s when you begin to see these really graphic images of clogged-up arteries of hearts that were struggling to beat. Of limbs and lungs that had been eaten away by cancer. And those campaigns were quite effective in reducing consumption of cigarettes. They were quite effective in increasing calls to the New York City 311 line. And certainly they were getting calls from people saying, “These images disgusted me. These images scared my kids.” But, if being scared is what makes somebody take action, the view was: then this is an effective campaign.

Amy’s study also looked at another fear-based campaign.

FAIRCHILD: It was around 2010. The New York City Department of Health launched the “It’s never just H.I.V.” campaign. And they were responding to seeing rates of H.I.V. infection among young gay men of color beginning to rise. So, this subgroup within New York City was not seeing H.I.V. infection and AIDS incidents go down. They were seeing it going up. And they had focus groups with some members of this community. And they decided we need to scare people.e

The “It’s Never Just H.I.V.” campaign was meant to communicate that contracting the virus also puts people at risk for a lot of other health problems.

 FAIRCHLID: So, it’s anal cancer, it’s dementia, it’s osteoporosis. And they would show images of gay men — these young gay men of color — looking confused and ashamed, not quite being willing to look at the camera. And it sparked this huge backlash amongst groups like the Gay Men’s Health Crisis and other long-standing activists, arguing that you’re not just conveying to these men what’s in their self-interest. You are building on, and you are enhancing, and you are legitimizing stigma amongst this group.

One of the primary arguments against using fear in public health — is stigma. Because sometimes, generating fear about a disease ends up targeting the people who have that disease.

FAIRCHILD: In the context of the AIDS epidemic, one of the things that happens is that people start to equate fear with stigma. So, it’s not just that a fear-based campaign is going to make you afraid. It’s going to stigmatize those very groups that you’re trying to reach. Those groups that have been made vulnerable by disease, that had been made vulnerable by poverty, that had been made vulnerable because of gender, and the ways that gay people were stigmatized, and excluded. And so, fear, in the context of AIDS, becomes a big, big no-no.

As an ethicist, Amy also thinks a lot about when, and how, fear can, and should be, used appropriately. For example, it’s generally not considered acceptable to make people afraid by lying to them; or as with H.I.V. and AIDS, to create stigma. Like so much in public health, it’s a balancing act.

FAIRCHILD: So, if, in fact, through fear, we are increasing the harms to, say, people who are obese, or who are gay, or who are smokers, then we would argue that fear-based campaigns are actually doing more harm than good.

And yet, these campaigns — when done well — can often work.

FAIRCHILD: The evidence on fear-based campaigns has demonstrated pretty conclusively that, in fact they do work to change behavior. That they don’t typically backfire. That the more fear you use, the bigger the effect that you have.

One reason fear might work has to do with salience, which is when something becomes noticeable, prominent, or important to you. Salience can motivate behavioral change. Here’s Ajay Satpute again.

SATPUTE: What fear can do is make salient whichever attitudes and beliefs you think matter for that choice, So, for example, when it comes to getting vaccinated for individuals who already believe that getting vaccinated is a good way to prevent something really bad from happening, fear can help motivate them to go do that. But for individuals who instead make salient information about how a vaccine might have a side effect in really small proportion of people, fear can make salient the possibility that they or their children might have a really adverse reaction.

So, speaking of vaccines: can fear motivate people to get vaccinated? A colleague and I wondered about this ourselves recently.

WORSHAM: You would think that if you knew how bad something could be that you, as a parent, would want to make sure that your child avoided that bad thing.

When we come back, we’ll look at what happens when fear doesn’t seem to work. I’m Bapu Jena, and this is Freakonomics, MD.

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WORSHAM: Over the last couple of years, I’ve unfortunately had to think about COVID-19 a lot.

That’s my friend and colleague, Dr. Chris Worsham.

WORSHAM: I’m a pulmonologist and intensive care doctor at Mass General Hospital in Boston and a public health researcher at Harvard medical school. My research has focused on the healthcare system, looking at what makes it tick, what makes it break? What makes it work well? What makes it not work well?

When it comes to swaying people on important health decisions — fear works, and the more the better, as Amy Fairchild of Ohio State told us before the break. And with problems that exist on a mass scale — that seems to be true. But a few months, ago Chris and I were thinking about how an individual’s experience with a certain disease — like, say, COVID-19 — might affect their desire to protect themselves, or a loved one, from the same disease.

WORSHAM: One thing that was coming up in the hospital was, we would have patients who were really, really sick. Sometimes they would be patients who had not been vaccinated. And these days that tends to be the majority of patients who are really sick in the hospital. And from time to time, these really sick patients would have visits from family members and maybe their entire family hadn’t been vaccinated yet. And sometimes they would see how sick these patients got and might rethink their decision not to be vaccinated.

It was the middle of 2021, a few months after COVID vaccines had been approved and were starting to be widely distributed throughout the country. And yet, a lot of people were choosing not to get a COVID vaccine. Chris and I wondered what might be motivating people to get vaccinated against COVID — and also, what might be stopping them. So, we decided to look at another vaccine for hints.

WORSHAM: We ended up studying the H.P.V. vaccine because we felt like it could tell us a lot about vaccine behaviors in general.

H.P.V. stands for human papilloma virus. It has a few different strains, and some of those strains have been linked to cervical cancer, and to certain head and neck cancers. H.P.V. is spread through close skin-to-skin contact, primarily in the genital and oral areas. It’s the most common sexually transmitted infection in the U.S. Aside from being a widespread virus with an available vaccine, H.P.V. actually bears little resemblance to the virus that causes COVID. But there is some common ground.

WORSHAM: We thought that the decisions surrounding should I get vaccinated or not, are more comparable between any two vaccines than the disease itself. And so, we wanted to focus on the decision-making process.

Also, compared to other vaccines, the H.P.V. vaccine hasn’t been around that long. It was introduced in the U.S. in 2006. The CDC recommends children receive two doses of the vaccine, six months apart, starting at around age 11. Unlike other childhood vaccines, it’s not mandatory. And as a result, uptake has struggled: for example, in 2020, just under 60 percent of adolescents were up to date with their H.P.V. vaccination. Research has shown, though, that it’s really good at preventing the diseases that H.P.V. can cause — specifically, cancer, and even more specifically: cervical cancer.

So, both the H.P.V. and COVID vaccines are available, safe, effective — and difficult to convince some people to get. The number of eligible people in the U.S. who are fully vaccinated against COVID is currently around 70 percent. But there’s another thing about the H.P.V. vaccine that has caused hesitation.

WORSHAM: When the H.P.V. vaccine first came out, there were some fears that if children were protected against H.P.V. that they might feel emboldened to engage in higher risk sexual activity. So, if kids feel protected against some of the adverse outcomes of sexual activity, then they might be more likely to engage in higher risk activities. And this was a fear that was debunked. But despite it being debunked in multiple studies, that fear still persists.

In fact, one of those studies that debunked this theory was done — by me and some colleagues at the University of Southern California. In a 2015 study published in JAMA Internal Medicine we found there was no link between H.P.V. vaccination in adolescents and increased sexual promiscuity. And yet, as Chris pointed out, that fear lingers. As do other fears related to vaccines, like side effects. And so, we wondered if there might be a group of people for whom the fear of not getting the H.P.V. vaccine would outweigh everything else.

WORSHAM: We wanted to see whether children whose mothers had had cervical cancer, or a cervical cancer scare were more likely to vaccinate their children against H.P.V.

In other words — would having cervical cancer, a disease strongly linked to H.P.V., scare these moms into getting their kids vaccinated? To start, we looked at a large insurance database.

 WORSHAM: So, we found about 750,000 kids whose parents were on an employer sponsored health insurance program. And that meant that we had information about the kids, but we also had information about their parents, and in particular, their mothers.

We divided these 750 thousand kids into three groups. The first group was children whose mothers had been diagnosed with cervical cancer. There were about one thousand kids there. The second group was children whose moms had undergone a biopsy to check for cervical cancer, but were not ultimately diagnosed with it. So, they’d had a cervical cancer scare. This made up around 38 thousand kids. For the remaining 700 thousand or so children, we presumed their mothers had not had any serious cervical issues.

WORSHAM: We broke up the kids by these different groups. We were expecting to see that mothers who had had cervical cancer would be more likely to vaccinate their children against H.P.V. But we were surprised to see that there were actually no differences between these groups when it came to getting their children either the first or the second H.P.V. vaccine that they’re supposed to get. So, mothers who had had cervical cancer were not more likely to get their children vaccinated against H.P.V. And the mothers who had had cervical cancer scares were not more likely to vaccinate their children against H.P.V., compared to mothers who had neither.

Our findings were published in JAMA Network Open in December of 2021. They suggested, to us, that fear derived from a personal experience with a disease did not seem to make people more likely to safely protect their kids from that same disease. So, why not?

WORSHAM: Yeah, so that was, that was the question we were faced with because it kind of goes against intuition. You would think that if you knew how bad something could be — like cervical cancer, and we had a good vaccine against cervical cancer that you, as a parent, would want to make sure that your child avoided that bad thing. Then it comes down to: why wouldn’t you do this? What is motivating your decision to vaccinate your child? And so, that brought us back to thinking about, well, what causes people not to vaccinate in general?

A lot of factors can drive people to get a vaccine or take a treatment for a disease, and certainly fear plays a role. Maybe not enough of a role, though.

WORSHAM: And so, that led us to think, “Well, maybe there are other factors that are stronger motivators for vaccination decisions than intimate familiarity with the bad outcomes that the vaccines are trying to prevent. Maybe your general trust in the healthcare system, trust in your doctor, your general attitudes towards whether or not vaccines are even necessary — maybe those are stronger than any personal experience might contribute to your decision of whether or not to vaccinate yourself or your child.”

And something else that can drive — and stoke — fear is misinformation.

WORSHAM: If I tell you not to think about elephants, the first thing you’re going to think about is elephants. So, even if we debunk all of the conspiracy theories or misinformation that’s put out there, those things have been said. And the debunking isn’t necessarily going to reach everybody. I could have the world’s best study debunking conspiracy theories about any vaccine, but if that person doesn’t trust me — doesn’t trust the process that we use to generate evidence — it’s going to be really hard to use that research to motivate their health behaviors.

FAIRCHILD: I think that’s one of the things that makes this era particularly hard for public health officials

That’s Amy Fairchild again.

FAIRCHILD: Because, on the one hand, they are needing to convey legitimate harms of COVID-19, and they’re needing to combat not just misinformation, but disinformation — deliberate attempts to create a sense of fear about vaccines that work, therapies that work, prevention measures that work.

As Amy explains, no public health measure exists in a vacuum. No one approach — like fear — can work alone, nor should it.

FAIRCHILD: You have to think about public health in terms of layers. If we’re going to imagine fear as one of the tools in the public health arsenal, it would be a mistake to assume that it’s this magic bullet.

Fear can work, and has worked, to influence people’s decisions about their health — but it doesn’t always. It’s not a one-size-fits-all, or a one-size-scares-all approach. During the COVID-19 pandemic, we’ve been trying to figure out — in real time, amid awful circumstances — how to persuade people to protect themselves, and others, from a dangerous virus. It hasn’t been easy, but at every juncture, we’ve tried to learn from this experience. And for Chris and me, looking at a different virus, like H.P.V., helped frame how we might want to think about using fear — or not using it — going forward.

WORSHAM: We were going through these results in the middle of the COVID-19 pandemic, and we were turning on the news and you saw these reports of emergency doctors, I.C.U. doctors, trying to clue everybody in to how bad coronavirus could be, we thought, “Well, maybe that’s actually not convincing people.” Maybe for a handful of patients, a family member getting sick with COVID-19 is enough to convince them to get vaccinated. But is showing people how scary and deadly and devastating COVID-19 infection can be — is that going to motivate them to get vaccinated? Maybe not. It seems intuitive but oftentimes people surprise us with their behavior.

I think if we’ve learned anything over the last two-plus years of a pandemic — it’s that Chris’s observation is an understatement.

Anyway — that’s it for today’s show. I want to thank my guests — Amy Fairchild, Ajay Satpute, and Chris Worsham. If you liked hearing from Chris, check out an earlier episode he was on called, “Why Are Kids With Summer Birthdays More Likely to Get the Flu?” Also: don’t forget to leave a review for Freakonomics, MD wherever you get your podcasts. And send us your thoughts or questions! We’re at bapu@freakonomics.com.

Coming up next week: I’ll chat with Pfizer CEO Albert Bourla about his new book “Moonshot,” and about a lot of other things too. We’ll hear the dramatic tale of bringing the world a first-of-its-kind mRNA vaccine — when it was desperately needed.

BOURLA: My scientists came and said, “Let’s try mRNA.” I challenged the decision and I said, “Are you kidding me? You want to put, in a pandemic, all our bets into a technology that never delivered the product? Why don’t we go with something else?”

And find out what Albert thinks we can expect from his company, and others like it, as we enter what feels like a new period of innovation in medicine.

 BOURLA: Reputation is something that you are earning in drops, but you can lose in buckets.

Don’t miss me and Pfizer CEO Albert Bourla — next week on Freakonomics, MD. Also — we’re going to try something new. We get a lot of emails from listeners, full of provocative questions. In a few weeks, I’m going to do my best to answer some of them on the air. So, if you’ve got something you’ve always wanted to ask me, send a voice memo to bapu@freakonomics.com. Make sure to record somewhere quiet, and please keep your thoughts to under a minute. Thanks for listening.

Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. All our shows are produced by Stitcher and Renbud Radio. This episode was produced by Julie Kanfer and mixed by Eleanor Osborne. Our staff also includes Alison Craiglow, Greg Rippin, Gabriel Roth, Rebecca Lee Douglas, Morgan Levey, Zack Lapinski, Ryan Kelley, Jasmin Klinger, Emma Tyrrell, Lyric Bowditch, Jacob Clemente, Alina Kulman, and Stephen Dubner. Original music composed by Luis Guerra. To find a transcript, links to research, and a newsletter sign up, go to Freakonomics.com. If you like this show, or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.

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WORSHAM: One of the things that happens when you do a lot of work with Bapu is he finds ways to get you interested in things you hadn’t necessarily thought about before.