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\title{A Tale of Two Pandemics: COVID-19 and Misinformation}



\author[1]{Richard Stein}%
\author[2]{Oana Ometa}%
\author[3]{Sarah Pachtman}%
\author[4]{Adi Katz}%
\author[5]{Mircea Ionut Popitiu}%
\author[6]{Robert Brotherton}%
\affil[1]{New York University Tandon School of Engineering}%
\affil[2]{Babes-Bolyai University}%
\affil[3]{Long Island Jewish Medical Center Northwell Health Cancer Institute}%
\affil[4]{Lenox Hill Hospital}%
\affil[5]{University of Medicine and Pharmacy Victor Babes Timisoara}%
\affil[6]{Barnard College, Columbia University}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\par\null

Conspiracy theories, omnipresent in traditional and modern societies
{[}1{]}, span demographic strata and political differences {[}2{]} and
have fascinated people for ages {[}3{]}. While many conspiracy theories
are harmless and may even be entertaining, the ones related to medical
and public health topics can be particularly dangerous for the
individual and collective well-being {[}3{]}. This second category
includes misinformation and conspiracy theories related to COVID-19,
which is likely one the most significant pandemics of our lifetime.
Compounding the challenges that it opened for the economy, social and
political sciences, and biomedical, translational, and clinical
research, COVID-19 also propelled discussions about conspiracy theories
and media health literacy to the forefront of public health in ways that
were nearly impossible to predict.

Situations of crisis, fear, and uncertainty increase the likelihood of
conspiratorial thinking {[}4{]}. A key difference between COVID-19 and
the 1918 flu pandemic, which is sometimes used as a reference, is that a
highly interconnected world, to a great extent on social media, is
setting the stage for distributing information and misinformation about
COVID-19 {[}5{]}. In the short time since the beginning of the pandemic,
the number of COVID-19-related conspiracy theories increased and
propagated on social media. According to some metrics, online
sensationalist and conspiratorial sites and articles generate more user
engagement than more reputable sources such as the World Health
Organization and the US Centers for Disease Control and Prevention
{[}6{]} or mainstream news media such as the BBC and New York Times
{[}7{]}.

An important way in which misinformation related to COVID-19 differs
from misinformation that impacts other health-related topics is its
multi-layered nature, in the sense that it concomitantly targets
multiple facets of the pandemic. These include misinformation and
conspiracies casting doubt on the very existence of the virus,
minimizing the value of long-proven preventive strategies, and
questioning the safety, efficacy, and potential ulterior motives of a
vaccine that is not even available yet, and not sure it will ever be. In
the wake of COVID-19, \emph{an ocean of misinformation} {[}8{]} that
spans all these domains has accumulated faster than for many other
health-related topics. As a result, mutually incompatible and
contradictory conspiracy theories were sometimes being endorsed and
circulated together {[}9{]}. Misinformation and disinformation during
the pandemic contributed to the demonization of health care workers
{[}10{]}. As patients avoided hospitals or had difficulties making
appointments in the wake of the pandemic, they experienced delays in
accessing healthcare for various medical conditions {[}11-14{]}. An
increased mortality from acute heart disease was reported in several
countries {[}15{]}. In this context, ambiguous messages about the
pandemic endanger the delivery of healthcare in virtually all clinical
areas and can place patients at a heightened risk of complications.

Some conspiratorial claims include assertions that COVID-19 is a hoax,
arguments that the virus was created artificially {[}16, 17{]} and
spread on purpose {[}18{]} as a bioweapon {[}19{]}, or allegations that
governments are using the emergency situation to pursue their
anti-democratic goals {[}20{]}. As early as in January 2020, social
media stories contained claims that 5G technologies either caused or
accelerated the spread of the pandemic {[}21, 22{]}. Other conspiracies
argued that people in power are taking advantage of the pandemic as a
plan to inject microchip quantum-dot spy software and monitor people
{[}8{]}. Videos or articles perpetuating these theories were viewed by
millions of people on social media platforms. Another conspiracy theory,
circulating in several languages, claimed that the swab test reaches the
back of the nasopharynx and damages the blood brain barrier, and urged
people to refuse testing {[}23, 24{]}. Yet another conspiracy theory,
spread thousands of times on social media, claimed that testing itself
infects people with the coronavirus and urged them to refuse testing
{[}23{]}.

The use of face masks has become a passionately debated topic {[}25,
26{]}, even though many studies support their benefit against SARS-CoV,
SARS-CoV-2, MERS-CoV, {[}27, 28{]}, flu, and seasonal coronaviruses
{[}29{]}. Some people wearing masks have faced alienation or
discrimination {[}30{]}. Claims on social media that the virus crosses
the masks, and therefore the mask is useless, have been circulating
together with claims that the virus persists on the surface of the mask
and wearing a mask would, therefore, infect people, or that the mask
could ``activate the virus'' {[}31{]}. Other social media claims include
warnings that masks may cause fungal or bacterial pneumonia {[}32{]} or
oxygen deprivation and carbon dioxide poisoning {[}33{]}, an especially
worrisome complication for children and pregnant women, despite evidence
that no differences exist in heart rate and oxygen saturation between
pregnant and non-pregnant women wearing N95 respirators for a short
period of time {[}34{]}.

Most recently, warnings on social media advised people of the dangers of
having their temperature checked upon entering closed spaces, based on
the false claim that infrared light damages their pineal gland, when in
reality infrared thermometers detect radiation emitted by the body
{[}35, 36{]}. Other pseudoscientific claims advanced unproven therapies,
including homeopathic arsenic-based products or colloidal silver
solutions {[}22{]}, advocated for prophylactic vitamin megadoses
{[}37{]}, promoted vitamin C and garlic as miracle remedies {[}38{]},
and recommended ginger, hot pepper, and lemon to limit the impact of the
pandemic {[}39{]}.

A vaccine is highly anticipated but not yet available, and it is
uncertain which of the several vaccines that are currently pursued will
succeed, if any. As of late July 2020, \textasciitilde{}200 vaccine
candidates were under active development and 15 were in human clinical
trials {[}40{]}. Prior to the widespread use of social media and
crowdsourcing to obtain medical information and advice, the spread of
infectious disease outbreaks was usually limited to confined geographic
locations; now, the availability of misinformation widens the footprint
of its harm. Vaccine-related misinformation on social media is rampant.
In late April 2020, a false story that circulated claimed that one of
the first volunteers in the UK during a COVID-19 vaccine trial died from
complications {[}41{]}. Another conspiracy theory claimed that the
vaccine will be used to establish a global surveillance network
{[}42{]}. Additionally, various social media posts are already providing
advice on how to avoid the vaccine. A WebMD poll in late July 2020 found
that if a COVID-19 vaccine was available, fewer than one-third of the
respondents would take it in the first 90 days, and fewer than one-half
of the people would take it in the first year {[}43{]}.

Each of these conspiracy theories may be destructive in itself. While it
is challenging to demonstrate the direct influence of any given
conspiracy theory on an individual's behavior, there are some suggestive
trends. In the wake of the misinformation linking 5G technologies to the
pandemic, attacks were perpetrated against telecommunication masts on
several continents, and engineers were subjected to verbal and physical
abuse {[}44{]}. Between April 2-6, 2020, it was estimated that at least
20 phone masts were damaged in the UK. This included a hospital in
Birmingham, UK, whose phone mast was set on fire {[}21{]}. There are
previous examples to illustrate the heavy price of denial and
misinformation in the wake of an infectious disease crisis. During the
HIV/AIDS pandemic, claims that the virus does not exist or that it does
not cause AIDS were incredibly harmful {[}38{]}. When the South African
government, in its widely criticized denialist approach {[}45{]},
withheld lifesaving drugs and promoted non-tested alternative solutions
instead {[}46{]}, the public health damage was incalculable and
estimated to have claimed \textgreater{}330,000 lives {[}47-49{]}.

Anti-vaccination rhetoric and conspiracies are not new. They existed
since Edward Jenner's time, when some rumors claimed that vaccination
will make people grow horns {[}50, 51{]}. The themes have been
strikingly similar across time, and include distrust of the medical
establishment or governments mandating vaccination; revulsion at the
idea of introducing unknown substances into the body; accusations that
the ingredients are harmful; or suspicion that the real motives behind
vaccines are to make people sick or to control the population. Like many
conspiracy theories, some worries over history have been rooted in a
kernel of truth. Such examples include the Tuskegee Syphilis Study,
where the government and the medical establishment have abused their
power at the cost of people's health {[}52-54{]}; the rare cases when
contaminated vaccines caused harm {[}55-57{]}; or instances when
vaccination was used as a cover for intelligence operations {[}58{]}.
During the Zika virus epidemic, some of the conspiracy theories claimed
that the disease was caused by vaccines, and an Australian
anti-vaccination Facebook group emphasized that the vaccine used to
prevent diphtheria, tetanus, and pertussis in pregnant women was
introduced in Brazil only months before the Zika outbreak {[}59-61{]}.
This makes it understandable, to a certain extent, why some people
continue to view vaccines with suspicion.

A paradox in the vaccination debate seems to be the fact that even
though vaccines have well-known and widely-reported adverse effects
{[}62-64{]}, most conspiratorial discussions focus on false claims about
adverse effects that were never linked to vaccines, while the actual
adverse effects, that scientists and regulators are attempting to
address and avoid, are rarely discussed, if ever. What makes the
COVID-19 vaccine refusal so different is that the debates are directed
against a vaccine that was not even manufactured yet. Amidst these
multiple layers of misinformation and conspiratorial discourse, the
potential for damage is unpredictable, poignant, and difficult to
manage, and the challenges associated with bringing the pandemic under
control adopt a new, amplified, and more acute perspective.

On the bright side, overall, social media harbors a larger volume of
accurate information than misinformation {[}65{]}. The sobering news is
that misinformation seems to be more popular {[}65{]}, become more
prevalent over time {[}66{]}, and spread faster, farther, and deeper
{[}67, 68{]}---though whether this is true of health emergencies is less
clear {[}69{]}. Several studies found that COVID-19 conspiracy beliefs
negatively correlate with COVID-19 health-protective behaviors {[}70,
71{]}, and individuals who support COVID-19 conspiracy theories are less
likely to accept the advice of public health experts {[}72{]}.

Even though social media made it easier to disseminate misinformation,
it is not clear to what extent it causes more people to believe in them.
Surveys of public opinion around conspiratorial beliefs, particularly
during an ongoing global event such as the current pandemic, should be
interpreted with caution. The responses to such surveys depend on the
questions asked. As noted, conspiracy theories often make a multitude of
specific, sometimes mutually contradictory claims; COVID-19 conspiracy
theories are no exception. As a result, it is difficult for a single
survey to cover all variants of any given conspiracy theory. While
research suggests that endorsement of one conspiracy theory predicts the
endorsement of others, general conspiratorial ideation has been found to
be relatively weakly predictive of general conspiracy claims about
COVID-19, and even more weakly predictive of a plethora of specific
claims {[}71{]}. Even more basic aspects of survey design such as the
wording of available response options can have a substantial influence
on responses {[}73{]}. The extent to which such surveys over- or
underestimate true engagement with conspiracy theories is therefore
unknown. It must also be noted that misinformation constitutes only a
small fraction of people's news consumption, and that news consumption
itself is only a small fraction of people's overall information diet
{[}74{]}. The nuances of public opinion around conspiracy claims should
receive increased attention in the years to come, as they have the
potential to directly impact public health.

Even though initial surveys indicate that many people would hesitate to
adopt a coronavirus vaccine, it is important not to over-extrapolate, as
responses to hypothetical questions may reflect many unstated
assumptions and variables. However, the link merits increased focus over
the coming months and years. We also need to recognize that hesitancy
does not necessarily suggest that someone is a conspiracy theorist, or
that they won't actually seek vaccination should it become a reality
with demonstrated safety and efficacy. A lot remains to be understood
about people's attitudes towards vaccines, and we should support this
topic to further develop in the years to come.

As we are exploring the best way forward during the COVID-19 pandemic,
an ongoing challenge and a critical task will be to understand how to
limit the rapid spread of misinformation, for which the term
``infodemic'' was coined to reflect its amplitude and extent
{[}75-77{]}. Prompt, effective, and targeted interventions that seek to
delegitimize misinformation emerge as an important strategy to reduce
its impact. It was suggested that social media users should take
advantage of the mechanisms available to report misinformation on the
respective platforms {[}21{]}. More extensive efforts need to be
dedicated to advance and promote media and social media literacy, and to
interrogate the impact of misinformation, disinformation, and
conspiratorial thinking on the different facets of this pandemic and of
other public health emergencies. For sure, the road ahead will be long
and tortuous.

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