Confronting

Health
Misinformation
The U.S. Surgeon General’s Advisory on
Building a Healthy Information Environment

2021

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 1
I am urging all Americans to help slow the
spread of health misinformation during
the COVID-19 pandemic and beyond.
Health misinformation is a serious threat
to public health. It can cause confusion,
sow mistrust, harm people’s health, and
undermine public health efforts. Limiting
the spread of health misinformation is
a moral and civic imperative that will
require a whole-of-society effort.

Vivek H. Murthy, M.D., M.B.A.

Vice Admiral, U.S. Public Health Service
Surgeon General of the United States
Table of Contents

BACKGROUND 4
WE CAN TAKE ACTION 6
What Individuals, Families, and Communities Can Do 8
What Educators and Educational Institutions Can Do 9
What Health Professionals and Health Organizations Can Do 10
What Journalists and Media Organizations Can Do 11
What Technology Platforms Can Do 12
What Researchers and Research Institutions Can Do 13
What Funders and Foundations Can Do 14
What Governments Can Do 15

WHERE WE GO FROM HERE 16

REFERENCES 17

ABOUT THE ADVISORY

A Surgeon General’s Advisory is a public statement that calls the American people’s attention
to a public health issue and provides recommendations for how that issue should be addressed.
Advisories are reserved for significant public health challenges that need the American people’s
immediate awareness. For additional background, visit SurgeonGeneral.gov.

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 3
BACKGROUND
During the COVID-19 pandemic, people have been exposed to a great deal of information: news, public
health guidance, fact sheets, infographics, research, opinions, rumors, myths, falsehoods, and more. The
World Health Organization and the United Nations have characterized this unprecedented spread of
information as an “infodemic.”1

While information has helped people stay safe throughout the pandemic, it has at times led to confusion.
For example, scientific knowledge about COVID-19 has evolved rapidly over the past year, sometimes
leading to changes in public health recommendations. Updating assessments and recommendations based
on new evidence is an essential part of the scientific process, and further changes are to be expected as we
continue learning more about COVID-19.2 But without sufficient communication that provides clarity
and context, many people have had trouble figuring out what to believe, which sources to trust, and how
to keep up with changing knowledge and guidance.3, 4, 5

Amid all this information, many people have also been exposed to health misinformation: information
that is false, inaccurate, or misleading according to the best available evidence at the time.6, 7, 8 *
Misinformation has caused confusion and led people to decline COVID-19 vaccines, reject public health
measures such as masking and physical distancing, and use unproven treatments.5, 9, 10 For example,
a recent study showed that even brief exposure to COVID-19 vaccine misinformation made people
less likely to want a COVID-19 vaccine.11 Misinformation has also led to harassment of and violence
against public health workers, health professionals, airline staff, and other frontline workers tasked with
communicating evolving public health measures.12, 13

Misinformation can sometimes be spread intentionally to serve a malicious purpose, such as to trick people
into believing something for financial gain or political advantage. This is usually called “disinformation.”14, 15
But many people who share misinformation aren’t trying to misinform. Instead, they may be raising a
concern, making sense of conflicting information, or seeking answers to honest questions.16

Health misinformation is not a recent phenomenon. In the late 1990s, a poorly designed study, later
retracted, falsely claimed that the measles, mumps, rubella (MMR) vaccine causes autism.17 Even after
the retraction, the claim gained some traction and contributed to lower immunization rates over the next
twenty years.18 Just since 2017, we have seen measles outbreaks in Washington State, Minnesota, New York
City, and other areas.19, 20, 21 Health misinformation is also a global problem. In South Africa, for example,
“AIDS denialism”—a false belief denying that HIV causes AIDS—was adopted at the highest levels of
the national government, reducing access to effective treatment and contributing to more than 330,000
deaths between 2000 and 2005.22 Health misinformation has also reduced the willingness of people to
seek effective treatment for cancer, heart disease, and other conditions.1, 23, 24, 25

* This advisory focuses on health information specifically, not other kinds of misinformation. Defining misinformation is a challenging task,
and any definition has limitations. See References for further discussion of the definition used in this Advisory, including the benchmark
of ‘best available evidence at the time.’

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 4
In recent years, the rapidly changing information environment has made it easier for misinformation to
spread at unprecedented speed and scale, especially on social media and online retail sites, as well as via
search engines.26, 27 Misinformation tends to spread quickly on these platforms for several reasons.

First, misinformation is often framed in a sensational and emotional manner that can connect viscerally,
distort memory, align with cognitive biases, and heighten psychological responses such as anxiety.28, 29, 30
People can feel a sense of urgency to react to and share emotionally charged misinformation with others,
enabling it to spread quickly and go “viral.”24, 31

In recent years, the rapidly changing information

environment has made it easier for misinformation
to spread at unprecedented speed and scale.

Second, product features built into technology platforms have contributed to the spread of
misinformation. For example, social media platforms incentivize people to share content to get likes,
comments, and other positive signals of engagement.32 These features help connect and inform people
but reward engagement rather than accuracy, allowing emotionally charged misinformation to spread
more easily than emotionally neutral content.33 One study found that false news stories were 70 percent
more likely to be shared on social media than true stories.31

Third, algorithms that determine what users see online often prioritize content based on its popularity
or similarity to previously seen content. As a result, a user exposed to misinformation once could see
more and more of it over time, further reinforcing one’s misunderstanding.34 Some websites also combine
different kinds of information, such as news, ads, and posts from users, into a single feed, which can leave
consumers confused about the underlying source of any given piece of content.35

The growing number of places people go to for information—such as smaller outlets and online forums—
has also made misinformation harder to find and correct.36 And, although media outlets can help inform
and educate consumers, they can sometimes inadvertently amplify false or misleading narratives.37, 38

Misinformation also thrives in the absence of easily accessible, credible information.39, 40 When people look for
information online and see limited or contradictory search results, they may be left confused or misinformed.

More broadly, misinformation tends to flourish in environments of significant societal division,

animosity, and distrust. For example, distrust of the health care system due to experiences with racism
and other inequities may make it easier for misinformation to spread in some communities.41 Growing
polarization, including in the political sphere, may also contribute to the spread of misinformation.42, 43

Additional research is needed to better understand how people are exposed to and affected by
misinformation and how this may vary across subpopulations based on factors such as race, ethnicity,
socioeconomic status, education, age, sexual orientation, gender identity, cultural and religious practices,
hobbies and interests, and personal networks.44

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 5
WE CAN TAKE ACTION
Because it pollutes our information environment, misinformation is harmful to individual and public
health. Together, we have the power to build a healthier information environment. Just as we have all
benefited from efforts to improve air and water quality, we can all benefit from taking steps to improve the
quality of health information we consume. Limiting the prevalence and impact of misinformation will help
all of us make more informed decisions about our health and the health of our loved ones and communities.

Together, we have the power to build a

healthier information environment.

During the COVID-19 pandemic, there have been significant efforts to address health misinformation.
Here are just a few examples:

Trusted community members, such as health professionals, faith leaders, and

educators, have spoken directly to their communities to address COVID-19-related
questions (e.g., in town halls, community meetings, via social and traditional media)

Researchers have identified leading sources of COVID-19 misinformation, including

misinformation “super-spreaders” 45

Media organizations have devoted more resources to identify and debunk

misinformation about COVID-19 46, 47

Some technology platforms have improved efforts to monitor and address

misinformation by reducing the distribution of false or misleading posts and
directing users to health information from credible sources 48, 49, 50

Governments have increased their efforts to disseminate clear public health

information in partnership with trusted messengers 51

But there is much more to be done, and each of us has a role to play. Before posting or sharing an item
on social media, for example, we can take a moment to verify whether the information is accurate and
whether the original source is trustworthy. If we're not sure, we can choose not to share. When talking
to friends and family who have misperceptions, we can ask questions to understand their concerns, listen
with empathy, and offer guidance on finding sources of accurate information.52, 53, 54, 55, 56

It will take more than individual efforts, however, to address health misinformation. The threat of
misinformation raises important questions we must answer together: How do we curb the spread of

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 6
harmful misinformation while safeguarding user privacy and free expression? What kinds of measures
should technology platforms, media entities, and other groups adopt to address misinformation? What
role is appropriate for the government to play? How can local communities ensure that information
being exchanged—online and offline—is reliable and trustworthy? How can we help family and friends
who may have been exposed to harmful misinformation?

Addressing health misinformation will require a whole-of-society effort. We can start by focusing on the
following areas of action:

Equip Americans with the tools to identify misinformation, make informed

choices about what information they share, and address health misinformation in
their communities, in partnership with trusted local leaders

Expand research that deepens our understanding of health misinformation,

including how it spreads and evolves; how and why it impacts people; who is most
susceptible; and which strategies are most effective in addressing it

Implement product design and policy changes on technology platforms to slow

the spread of misinformation

Invest in longer-term efforts to build resilience against health misinformation,

such as media, science, digital, data, and health literacy programs and training for
health practitioners, journalists, librarians, and others

Convene federal, state, local, territorial, tribal, private, nonprofit, and research
partners to explore the impact of health misinformation, identify best practices
to prevent and address it, issue recommendations, and find common ground on
difficult questions, including appropriate legal and regulatory measures that address
health misinformation while protecting user privacy and freedom of expression

Addressing health misinformation will require

a whole-of-society effort.

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 7
WE CAN TAKE ACTION

What Individuals, Families,

and Communities Can Do
Learn how to identify and avoid sharing Address health misinformation in your
health misinformation. When many of us share community. Work with schools, community
misinformation, we don’t do it intentionally: We groups such as churches and parent-teacher
are trying to inform others and don’t realize the associations, and trusted leaders such as educators
information is false. Social media feeds, blogs, and health care professionals to develop local
forums, and group chats allow people to follow strategies against misinformation. For example,
a range of people, news outlets, and official invite local health professionals to schools or to
sources. But not every post on social media can faith congregations to talk about COVID-19
be considered reliable. And misinformation can vaccine facts.
flourish in group texts or email threads among
friends and family. Verify accuracy of information
by checking with trustworthy and credible
sources. If you’re not sure, don’t share. When many of us share
Engage with your friends and family on the
misinformation, we don’t do it
problem of health misinformation. If someone intentionally: We are trying to
you care about has a misperception, you might be
able to make inroads with them by first seeking
inform others and don’t realize
to understand instead of passing judgment. Try the information is false...
new ways of engaging: Listen with empathy,
If you’re not sure, don’t share.
establish common ground, ask questions,
provide alternative explanations and sources of
information, stay calm, and don’t expect success
from one conversation.

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 8
WE CAN TAKE ACTION

What Educators and

Educational Institutions Can Do
Strengthen and scale the use of evidence-based Establish quality metrics to assess progress in
educational programs that build resilience information literacy. While there is substantial
to misinformation. Media, science, digital, media and information literacy work being
data, and health literacy programs should be carried out across the United States, there is
implemented across all educational settings, a need for more consistent and empirically
including elementary, secondary, post-secondary evaluated educational materials and practices.
and community settings. In addition to teaching
people how to be more discerning about the
credibility of news and other content, educators
should cover a broader set of topics, such as Media, science, digital, data,
information overload, internet infrastructure
(e.g., IP addresses, metadata), the challenges of
and health literacy programs
content moderation, the impact of algorithms should be implemented across
on digital outputs, algorithmic bias, artifcial
intelligence (AI)-generated misinformation (e.g.,
all educational settings.
deepfakes), visual verifcation skills, and how
to talk to friends and family who are sharing
misinformation.

Educate students and the public on

common tactics used by those who spread
misinformation online. Recent research
suggests that teaching people how to spot
these tactics can reduce people's willingness
to share misinformation.57 Examples of
misinformation tactics used by those who deny
scientifc consensus on health issues include
presenting unqualifed people as experts;
misleading consumers with logical fallacies;
setting impossible expectations for scientifc
research; cherry-picking data or anecdotes; and
introducing conspiracy theories.58

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 9
WE CAN TAKE ACTION

What Health Professionals and

Health Organizations Can Do
Proactively engage with patients and the Partner with community groups and other
public on health misinformation. Doctors, local organizations to prevent and address
nurses, and other clinicians are highly trusted health misinformation. For example, hospital
and can be effective in addressing health systems can work with community members
misinformation.59 If you are a clinician, take the to develop localized public health messages.
time to understand each patient’s knowledge, Associations and other health organizations
beliefs, and values. Listen with empathy, should offer trainings for clinicians on how to
and when possible, correct misinformation address misinformation in ways that account for
in personalized ways. When addressing patients’ diverse needs, concerns, backgrounds,
health concerns, consider using less technical and experiences.
language that is accessible to all patients. Find
opportunities to promote patient health literacy
on a regular basis.
Associations and other health
Use technology and media platforms to share
accurate health information with the public.
organizations should offer
For example, professional associations can equip trainings for clinicians on how
their members to serve as subject matter experts
for journalists and effectively communicate peer-
to address misinformation in
reviewed research and expert opinions online. ways that account for patients’
diverse needs, concerns,
backgrounds, and experiences.

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 10
WE CAN TAKE ACTION

What Journalists and

Media Organizations Can Do
Train journalists, editors, and others to include strong caveats where appropriate, seek
recognize, correct, and avoid amplifying out expert opinions, and provide readers with
misinformation. Media organizations should context.
develop in-house training programs and partner
with journalism schools, nonprofits, technology Use a broader range of credible sources—
platforms, and others to democratize access to particularly local sources. Research shows
high-quality training for all media outlets. us that people have varying levels of trust in
different types of people and institutions.4 In
Proactively address the public’s questions. addition to relying on federal and state public
When something is new—such as a vaccine— health authorities as sources, build relationships
people will understandably have questions. By with local health professionals and local trusted,
anticipating and proactively answering those credible health organizations.
questions, media organizations and journalists can
help get ahead of misinformation and increase the Consider headlines and images that inform
public’s health and information literacy. rather than shock or provoke. Headlines are
often what audiences will see and remember.
Provide the public with context to avoid If a headline is designed to fact-check a rumor,
skewing their perceptions about ongoing where possible, lead with the truth instead of
debates on health topics. For example, when simply repeating details of the rumor. Images
discussing conflicting views on an issue, give are often shared on social media alongside
readers a sense of where the scientific community headlines and can be easily manipulated and used
stands and how strong the available evidence is out of context. Picture desk and social media
for different views. Consider questions like: How editors should consider how provocative and
much disagreement is there among experts? Is a medically inaccurate imagery can be a vehicle for
given explanation plausible even if it is unlikely? misinformation.60
If evidence is not equally strong on all sides of an
issue, avoid presenting it as such.

Carefully review information in preprints. Give readers a sense of where

Preprints are research papers published online
before peer review. They can provide scientists
the scientific community
and the public with useful information, especially stands and how strong the
in rapidly evolving situations such as a pandemic.
However, because preprints have not been
available evidence is for
independently reviewed, reporters should be different views.
careful about describing findings from preprints
as conclusive. If reporting on such findings,

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 11
WE CAN TAKE ACTION

What Technology
Platforms Can Do
Assess the benefits and harms of products Evaluate the effectiveness of internal policies
and platforms and take responsibility for and practices in addressing misinformation
addressing the harms. In particular, make and be transparent with findings. Publish
meaningful long-term investments to address standardized measures of how often users are
misinformation, including product changes. exposed to misinformation and through what
Redesign recommendation algorithms to avoid channels, what kinds of misinformation are most
amplifying misinformation, build in “frictions”— prevalent, and what share of misinformation is
such as suggestions and warnings—to reduce the addressed in a timely manner. Communicate why
sharing of misinformation, and make it easier for certain content is flagged, removed, downranked,
users to report misinformation. or left alone. Work to understand potential
unintended consequences of content moderation,
Give researchers access to useful data to such as migration of users to less-moderated
properly analyze the spread and impact of platforms.
misinformation. Researchers need data on
what people see and hear, not just what they Proactively address information deficits. An
engage with, and what content is moderated information deficit occurs when there is high
(e.g., labeled, removed, downranked), including public interest in a topic but limited quality
data on automated accounts that spread information available. Provide information
misinformation. To protect user privacy, data can from trusted and credible sources to prevent
be anonymized and provided with user consent. misconceptions from taking hold.40

Strengthen the monitoring of misinformation. Amplify communications from trusted

Platforms should increase staffing of multilingual messengers and subject matter experts.
content moderation teams and improve the For example, work with health and medical
effectiveness of machine learning algorithms professionals to reach target audiences. Direct
in languages other than English since non- users to a broader range of credible sources,
English-language misinformation continues including community organizations. It can be
to proliferate.61 Platforms should also address particularly helpful to connect people to local
misinformation in live streams, which are more trusted leaders who provide accurate information.
difficult to moderate due to their temporary
nature and use of audio and video. Prioritize protecting health professionals,
journalists, and others from online
Prioritize early detection of misinformation harassment, including harassment resulting from
"super-spreaders" and repeat offenders. Impose people believing in misinformation.
clear consequences for accounts that repeatedly
violate platform policies.

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 12
WE CAN TAKE ACTION

What Researchers and

research institutions Can Do
Strengthen the monitoring of health questions, Evaluate the effectiveness of strategies
concerns, and misinformation. Focus on a and policies to prevent and address health
broader range of content and platforms, as misinformation. For example, can flagging
well as on information flow across platforms. certain content as misinformation have
For example, examine image- and video-based unintended consequences? Is it possible to build
content and content in multiple languages. To resilience to misinformation through inoculation
address existing research limitations, expand data methods such as “prebunking”? (Debunking
collection methods (e.g., recruit social media involves correcting misinformation once
users to voluntarily share data). someone has been exposed to it. Prebunking,
or preemptively debunking, involves warning
Assess the impact of health misinformation. people about misinformation they might come
There is an urgent need to comprehensively across so they will be less likely to believe it when
quantify the harms of health misinformation. exposed.)57
For example, how and under what conditions
does misinformation affect beliefs, behaviors,
and health outcomes? What is the role of
emotion, cognition, and identity in causing There is an urgent need to
misinformation to “stick”? What is the cost to
society if misinformation is left unchecked?
comprehensively quantify
the harms of health
Prioritize understanding how people are
exposed to and affected by misinformation,
misinformation.
and how this may vary for different
subpopulations. Tailor interventions to the
needs of specific populations. Invite community
members to participate in research design.

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 13
WE CAN TAKE ACTION

What Funders and

Foundations Can Do
Move with urgency toward coordinated, at- Incentivize coordination across grantees to
scale investment to tackle misinformation. maximize reach, avoid duplication, and bring
Assess funding portfolios to ensure meaningful, together a diversity of expertise. For example,
multi-year commitments to promising research encourage coordination around monitoring
and programs. health misinformation across multiple languages.

Invest in quantifying the harms of

misinformation and identifying evidence-
based interventions. Focus on areas facing Assess funding portfolios to
private and public funding gaps. Examples
could include independent and local journalism,
ensure meaningful, multi-year
accountability mechanisms for platforms, and commitments to promising
community-based health literacy programs.
research and programs.
Provide training and resources for grantees
working in communities disproportionately
affected by misinformation (e.g., areas with
lower vaccine confidence).

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 14
WE CAN TAKE ACTION

What Governments Can Do

Convene federal, state, local, territorial, tribal, Increase resources and technical assistance to
private, nonprofit, and research partners to state and local public health agencies to help
explore the impact of health misinformation, them better address questions, concerns, and
identify best practices to prevent and address misinformation. For example, support the creation
it, issue recommendations, and find common of teams within public health agencies that can
ground on difficult questions, including identify local misinformation patterns and train
appropriate legal and regulatory measures that public health misinformation and infodemic
address health misinformation while protecting researchers. Work with local and state health
user privacy and freedom of expression. leaders and associations to address ongoing needs.

Increase investment in research on Expand efforts to build long-term resilience

misinformation. For example, more research to misinformation. For example, promote
is needed to better define misinformation, educational programs that help people
document and process its harms, and identify distinguish evidence-based information from
best practices for preventing and addressing opinion and personal stories.
misinformation across mediums and diverse
communities.

Continue to modernize public health Deploy new messaging and

communications. Work to understand
Americans’ health questions, concerns, and
community engagement
perceptions, especially for hard-to-reach strategies, including
populations. Deploy new messaging and
community engagement strategies, including
partnerships with trusted
partnerships with trusted messengers. Proactively messengers. Proactively and
and rapidly release accurate, easy-to-understand
rapidly release accurate,
health information in online and in-person
settings. Invest in fact-checking and rumor easy-to-understand health
control mechanisms where appropriate.62 information in online and
in-person settings.

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 15
Where We Go From Here

We are all still learning how to navigate

this new information environment.
But we know enough to be sure that
misinformation is an urgent threat, and
that we can and must confront it together.

During the COVID-19 pandemic, health misinformation has sowed confusion, reduced trust in public
health measures, and hindered efforts to get Americans vaccinated. And misinformation hasn’t just
harmed our physical health—it has also divided our families, friends, and communities.

While health misinformation has always been a problem, today it spreads at unprecedented speed and
scale. We are all still learning how to navigate this new information environment. But we know enough
to be sure that misinformation is an urgent threat, and that we can and must confront it together.

The only way to address health misinformation is to recognize that all of us, in every sector of society,
have a responsibility to act. Every single person can do their part to confront misinformation. But it’s not
just an individual responsibility. We need institutions to recognize that this issue is their moral and civic
responsibility, too, and that they are accountable.

We have the power to shape our information environment, but we must use that power together. Only
then can we work toward a healthier information environment—one that empowers us to build a
healthier, kinder, and more connected world.

Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 16
References
* Note: Defining “misinformation” is a challenging task, and any definition has limitations. One
key issue is whether there can be an objective benchmark for whether something qualifies as
misinformation. Some researchers argue that for something to be considered misinformation,
it has to go against “scientific consensus” (e.g., Chou, Gaysynsky, & Cappella (2020)). Others
consider misinformation to be information that is contrary to the “best available evidence” (e.g.,
Johns Hopkins Center for Health Security (2021)). Both approaches recognize that what counts
as misinformation can change over time with new evidence and scientific consensus. This Advisory
prefers the “best available evidence” benchmark since claims can be highly misleading and harmful
even if the science on an issue isn’t yet settled. At the same time, it is important to be careful
and avoid conflating controversial or unorthodox claims with misinformation. Transparency,
humility, and a commitment to open scientific inquiry are critical. A second key issue is whether
misinformation should include not only false information but also misleading information. This
Advisory includes misleading claims in the definition. Consider an anecdote about someone
experiencing a rare side effect after a routine surgery. The specific anecdote may be true but hide the
fact that the side effect is very rare and treatable. By misinforming people about the benefits and risks
of the surgery, the anecdote can be highly misleading and harmful to public health. Going forward,
there is a need for further alignment on a shared definition of misinformation. However, we can
meaningfully improve the health information environment even without a consensus definition of
misinformation. For further discussion on definitions, see Vraga & Bode (2020).

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2 Branswell, H. (2021, April 21). We know a lot about Covid-19. Experts have many more questions.
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