Are scare tactics off the table for public health campaigns targeting HIV?

Beginning in 2005, the New York City Department of Health and Mental Hygiene mounted fear-based campaigns around smoking and obesity that were largely embraced by the public, with largely positive feedback to the Department. But in 2010, the fear-based "It's Never Just HIV" campaign targeting young men of color who have sex with men erupted into a firestorm of controversy with the sharpest criticism from those who viewed themselves as socially vulnerable. The experience has lasting consequences for public health campaigns around HIV, argue authors Amy L. Fairchild, PhD, Ronald Bayer, PhD, and James Colgrove, PhD, professors of Sociomedical Sciences. "Although the Department of Health has continued with its fear-based obesity and tobacco efforts, as of 2015 the hard-hitting approach seems to have been shelved for HIV," they write.

During this period smoking declined precipitously and some data suggests that childhood obesity may have turned a corner, but HIV infections in young men of color who have sex with men continue to rise. It is difficult to measure to what extent these successes and failures can be attributed to fear-based campaigns, in part, because the campaigns were accompanied by other interventions like a cigarette tax and the distribution of free condoms. The authors note that scientific studies of fear-based campaigns around the world draw mixed conclusions: some reject the approach; others conclude that "the stronger the fear appeal the better."

180 on Fear

For generations of health educators, public health campaigns around health issues emphasized positive messages and highlighted healthy behaviors; the use of fear in was seen as counterproductive. Beginning in the early 2000s, in the face of increased marketing by tobacco companies and stalled smoking cessation rates, New York City Health Commissioner Thomas Frieden, today director of the Centers for Disease Control and Prevention, embraced hard-hitting tactics employing fear and graphic imagery.

A 2006 Health Department campaign titled "Cigarettes Are Eating You Alive," featured posters and television spots with close-ups of a diseased heart, lung, mouth, teeth, and throat. Similar imagery was printed on matchbooks distributed at cigarette retailers. Health department officials reported immediate, marked declines in smoking. And public reaction was mainly positive: one observer at the time commented about the ads, "They are disgusting, horrible, and distasteful; and they helped."

Fear-based campaigns were attractive because they were seen as neither as restrictive as bans nor as burdensome as high taxes. They were also politically palatable, the authors write, because smoking had become "denormalized" as deviant or antisocial and its use concentrated among low-income groups. "Fear was a socially acceptable response to smoking," the authors write. "This would not hold true in the case of either obesity or HIV."

Thomas Farley, who succeeding Frieden as Health Commissioner, expanded the fear-based tactics to obesity prevention with efforts like the 2009 viral video, "Man Drinking Fat," which showed a white man attempting to drink semi-congealed fat poured from a can of soda. A 2013 campaign against sports drinks featuring African-American and Hispanic men and women was seen by some as stigmatizing.

Controversy

In 2010, Health Department concluded they needed to apply fear-based techniques to HIV. "Longstanding efforts using humor or affirmation--known as 'sex positive' approaches--had failed to reduce HIV incidence among young men who had sex with men, especially among blacks and Latinos," the authors write. Focus groups with black and Latino men reinforced the notion that a hard-hitting tactics were needed. Before launching the campaign, the Department reviewed the initiative with opinion leaders in the affected community.

"It's Never Just HIV" evoked a horror movie style, interposing images of young gay men who "glance fearfully (even shamefully) at the camera," intercut with grizzly depictions of osteoporosis, dementia, and anal cancer. Controversy erupted soon after the campaign launched. Critics like Francisco Rogue of Gay Men's Health Crisis argued, "It really paints this picture of gay men as these sort of disease-ridden vessels." Others like HIV/AIDS activist Larry Kramer condoned the fear-based messaging, saying, "This ad is honest and true and scary, all of which it should be." Mainstream media were uncritical of the campaign, which ran in subways and on television for a month, exceeding its original budget.

Controversy returned several years later when the Human Resources Administration released a campaign against teen pregnancy that many felt stigmatized young mothers. While Mayor Michael Bloomberg defended the effort, arguing that it was "past time" for a "value neutral" approach, the Department of Health stated that stigma was not "an effective way to communicate these issues."

Political Calculation

"Relying on fear is risky business," the authors write. For the Health Department, the lesson was that "the use of fear could not be measured simply in terms of efficacy. Behavioral achievements came with a political price. Some saw stigma as a "health promotion profanity."

Yet, as consequence of New York City's experience with fear tactics, the approach remains in the public health toolbox today. "It is no longer possible to assert that fear-based efforts can never serve the interests of public health," the authors write.

"There's a reason we see public health turning to fear. We live in a culture that bombards people with incentives to consume products that are clearly unhealthy. It is a duty of public health to sound a meaningful warning," says Dr. Fairchild. "You can't fight unhealthy seductions with abstract odds and probabilities. It's like trying to put out a fire with a water pistol," adds Dr. Bayer.