The ineluctable role of persuasion

On the importance of working to convince rather than compel.

“A quarantine officer cannot just introduce restrictions and rely on the threat of military force to implement them; he must also seek to persuade people to adhere to those restrictions of their own volition.” 

This passage is from Nights of Plague, the novel I am reading now, by Orhan Pamuk, one of Turkey’s most decorated contemporary writers. The novel is about the arrival of a plague to a religiously and culturally divided island in the Ottoman Empire in 1900. Nights of Plague contains much that is relevant for how we think about pandemics, the societies they strike, and the public health authorities tasked with addressing them. The passage above speaks to something that we arguably do not talk about enough in our conversations about how to encourage compliance with public health best practices in both normal times and in times of crisis: the value of persuasion. In the last Healthiest Goldfish, I wrote about the value of performance, about how the roles we play can help us to better support the health of the public. Persuasion is a natural extension of this conversation about how our public presentation can best serve our work. Some thoughts, then, on the importance of persuasion and the steps we can take to become more persuasive as a field.  

There are several reasons why we might overlook the importance of persuasion. Public health is moved by moral and empiric arguments. By the time a given measure rises to the level of a public health recommendation, it is generally supported by a strong basis of data and moral urgency. When we call for addressing the inequities that create racial health gaps, for example, we do so based on ample empiric data as well as on an awareness of the historic injustice that creates these gaps. Any recommendations that emerge from this intellectual and emotional context can seem so self-evidently correct to us that we may not consider that it might be necessary to persuade the public to accept them. Indeed, it can seem to us that to engage in persuasion around issues of such consequence can be, on some level, to make a concession to the forces that created these health gaps in the first place.

Further distancing us from the inclination to persuade is the institutional and statutory force public health has accumulated over the years, allowing us to compel where we might otherwise have tried to convince. There is much that is bad for the health of the public that is also currently illegal, simplifying the task of encouraging public compliance. We know, for example, that wearing a seatbelt decreases risk of injury and death in car accidents, that curtailing a company’s capacity to pollute can support health in communities, and that well-functioning sanitation infrastructure can prevent the spread of disease. As a result, there are now laws on the books which help to ensure that these factors will remain aligned with healthier outcomes. While persuasion can help facilitate compliance, the threat of legal sanctions serves as a powerful deterrent for anyone thinking about disregarding such rules. Compounding the legal force of public health measures is the increasing power our field has enjoyed within institutions in recent years, notably our alignment with progressive political power. While I have argued that, in the long-term, our increasingly explicit alignment with the policy priorities of one political party is a net negative for public health, politicizing our recommendations and narrowing the scope of our appeal, in the short-term it has undoubtably given us more immediate influence within the political institutions that wield power in American life.

The combination of data, statutory force, and institutional power has meant that, to the extent that we engage in persuasion, it is often an afterthought. What has come to matter most in the current paradigm is what we can legislate, the gains we make in the policy space. But is this the best direction for our efforts to take? Certainly, rules are important, and a central goal of public health should remain the shaping of good policy. But as any lawmaker could tell us, shaping policy is just part of the broader task of working in the public space to create a better world. Just as fundamental is the work of persuasion, of marshaling public opinion so that rules, when implemented, will stick even when no one is watching to enforce them. It is because we are persuaded it is the right thing to do that we do not run red lights, that we do not carelessly litter, that we wash our hands thoroughly when no one is watching. This reality is reflected in the Pamuk quote. It is not enough to simply introduce restrictions and rely on the threat of coercion to ensure compliance. We also need to persuade populations to follow these rules.

The challenge of persuasion has been vividly present in the challenge of advancing effective policies around masking during COVID-19. Masking has long been a contentious topic, with much debate over the efficacy of masking and the role of public policy in enforcing mask mandates. There has been much recent commotion generated by a Cochrane analysis that found in its own summary “uncertainty about the effects of face masks.” At core, it appears that masks’ ability to prevent the spread of COVID-19 depends, in part, on the kinds of masks being worn and the willingness of populations to consistently wear them. And while there seems little question that an individual can better protect themselves by wearing a mask, the data on the efficacy of masking at the population level remains mixed. So, is population-level masking a viable strategy to reduce spread of infectious disease? Well…it depends, and centrally it depends on whether or not most are willing to wear masks, i.e., on the adoption of the intervention. Certainly, early in the pandemic it looked like a national mask mandate was a prudent step for us to take as we worked to learn more about the disease and prevent its spread, which is why I, along with colleagues, advocated for one. However, the more we learn about masking the clearer it is that the effectiveness of masks depends on public compliance, which can be difficult to enforce and which, in the long-term, requires a persuaded public. It is this persuasion that we often neglected to invest in during the height of the pandemic, allowing instead the issue of masking to be subsumed into the broader social and cultural arguments around how best to manage a crisis that were raging at the time.

As I think about it, a key reason why we have neglected persuasion is the sheer speed at which we have amassed the capacity to circumvent it in favor of brute political or institutional force. In the past, public health had to rely on persuasion because its access to other forms of power was limited. In recent years, however, we have, in large part because of the COVID-19 crisis, found ourselves in possession of the power that makes persuasion seem less necessary. This happened quickly, with little time for reflection. In this post-war moment, we now have a chance to pause, to reflect, and to ask ourselves whether it is really sustainable or desirable for our influence to rely primarily on power rather than persuasion. The goals of public health are radical, transformative. Beyond advancing any single policy or shoring up any given institution, we aim to shape a healthier world. It is with this in mind that, as I see it, for public health to achieve this goal in the long-term, it needs the support of broad majorities to enact durable change. This will take persuasion.   

How then, can we do a better job of persuading the public?

We need to get better at communicating the “whys” of our recommendations rather than just the “whats.”

In an article about the uses of persuasion vs. coercion, K. C. Cole wrote “Persuasion requires understanding. Coercion requires only power.” To effectively persuade, we must help the public understand the reasons behind what we ask it to do. Even if we are not able to fully convey all the details—the complicated data that often underlie our recommendations—the simple act of trying to explain ourselves can stand as a good faith effort to engage with, rather than coerce, the public. The more we are seen attempting to engage, the likelier it is that the public will recognize that public health is not a faceless monolith trying to bend people to its will but is, instead, a collection of individuals doing their best to help others. I realize that there is an element of radicalism to this in suggesting that most people are reasonable most of the time and subject to appeals to their understanding rather than to their baser, less-rational instincts. Deepening polarization and the political and cultural shifts of recent years have made it possible for many on one side of the partisan divide to feel those on the other are not subject to rational argument. In attempting to explain ourselves to all people—not just those who share our worldview—we are implicitly rejecting this caricature, placing our bets on our common humanity and the rationality that, at our best, defines it.

We need to put ourselves in a position to be credible.

Whether or not a piece of advice is followed does not just depend on its empiric basis, or even on whether it is the right action to take. It also depends on the person giving it—on their credibility and their relationship with the person or people being advised. Imagine getting an identical piece of good advice first from your parents and then from someone who you feel has cheated you in the past. It is likely you would follow the advice from your parents and think twice about doing so when it came from someone you do not see as credible. We in public health have a responsibility to make sure that we are seen as credible by the populations we serve. This means applying a high standard of rigor to our recommendations so that they are always seen to be supported by a foundation of reasoned analysis. It also means working to avoid the appearance of partisan bias or of taking actions motivated by anything other than the pursuit of the public good. At the heart of these efforts should be the aspiration of clarity in all our communications and consistency in our commitment to data.

We need to be unimpeachable in our promotion of rules that are defensible, sensible, and reasonable. 

It is far easier to persuade someone that they should take a medicine when they are sick than it is to persuade them that the sky is green. In the first case, what is being called for is sensible, reasonable, and backed up by data. In the second, what is being argued for is patently absurd. We should not be in the business of arguing for absurdities. We should instead take pains to find ourselves always on the side of rules that are defensible, sensible, and reasonable. Such rules have the benefit of being better suited to the process of persuasion, by allowing us to appeal to the better, more rational angels of the public’s nature. It is, of course, possible to convince people of absurdities—recent years have presented many examples of this. But the process by which this is done is rarely that of reasoned persuasion. Instead, it is accomplished through demagogy or the exercise of raw, coercive power of the type encountered by Winston Smith in 1984. We should not lend our credibility to attempts to convince the public that up is down or that 2 + 2 = 5. Instead, we should engage in a constant process of self-evaluation, to ensure that we stand always on the side of the just application of rules that make sense.    

People need to like us.

This may seem obvious, but it is difficult to persuade anyone of anything when the people we would persuade do not like us. Perhaps it is occasionally possible to do so in times of fear, when the conditions of crisis make whoever seems to speak with authority the most persuasive by default, but in normal times being liked is a precondition to being persuasive. For this reason, we need to be likeable by being truthful, credible, and willing to embrace an ethos of joy. I have written previously about how public health can tip into scolding, moralizing, and how it can become so focused on the rhetoric of injury and disease that it forgets to address the core function of health—which is to enable a rich, full, happy life. I have also written about the value of restraint and the danger of facing diminishing returns when our actions alienate the public. If we lean into trying to compel when we should persuade, we risk being tuned out by the populations we serve. We need to focus on the elements of our message that emphasize joy, towards the goal of being the kinds of people that others are willing to be persuaded by.  

All of us in academic public health are tasked with giving our students the tools they need to be effective public health practitioners. I cannot help but feel that in addition to the basics of research and practice, the art of persuasion should be a core skill each public health professional learns early in their career, towards shaping a field that is maximally effective. By prioritizing persuasion over the use of power, we can help ensure this moment yields healthy populations that are disposed to work with us rather than against us. 

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Also this week.

I had the honor of speaking with Noam Chomsky, one of the leading progressive thinkers of the past century, as part of Boston University School of Public Health's new Public Health Conversations Starters series. Watch our recent discussion here.