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Denial is a powerful, usually unconscious defense mechanism that protects individuals from… … [+]
In the late 1970s and early 1980s, a mysterious disease spread through America’s overlooked communities, primarily affecting intravenous drug users and gay men.
The disease, which caused a sudden and devastating collapse of the immune system, was unlike anything doctors had seen before. Patients arrived at hospitals with rare infections such as Kaposi’s sarcoma and fungal pneumonia.
But despite the rising number of cases, public health officials remained silent for years. Few Americans saw it as a national emergency, especially because the disease, at least initially, seemed confined to the fringes of society.
By the time the government and public fully understood the threat in 1986 – following Dr. C. Everett Koops “Report of the Surgeon General on AIDS”—tens of thousands of Americans had already died.
Looking back on this and other public health crises, it is clear that medical science alone is not enough to save lives. To prevent similar tragedies, public health leaders and elected officials must first understand the role denial plays in people’s perceptions of medical threats. They must then develop effective strategies to overcome this problem.
The psychological basis for denial
Denial is a powerful, usually unconscious defense mechanism that protects individuals from uncomfortable or disturbing realities. By suppressing objective facts or experiences – especially those that evoke fear or anxiety – people can maintain a sense of stability in the face of overwhelming threats.
Historically, denial has been essential to everyday life. With little protection against diseases like smallpox, tuberculosis, or the plague, people would be immobilized by fear if they did not have the ability to suppress reality. Denial, mixed with superstition, took the place of facts, allowing society to function despite the ever-present risks of death and disability.
Today, even with tremendous advances in medical knowledge and technology, denial continues to influence individual behavior with deleterious consequences.
More than, for example 46 million Americans use tobacco productsdespite their links to cancer, heart disease and respiratory diseases. Likewise, tens of millions of people are refusing vaccinations, ignoring scientific consensus and exposing themselves – and their communities – to preventable diseases. Denial also extends to cancer research. Studies show that 50% of women over 40 skip their annual mammogram, and 23% have never had one. Meanwhile, about 30% of adults aged 50 to 75 are unaware of colorectal cancer screenings, and 20% have never been screened.
These examples show how denial leads people to make choices that endanger their health, even when life-saving interventions are readily available.
A pattern of denial: How inaction fuels public health crises
When individual denial spreads to the collective level, it leads to widespread inaction and worsens public health crises. Throughout modern medical history, Americans have repeatedly underestimated or dismissed emerging health threats until the consequences became impossible to ignore.
Early warnings of the HIV/AIDS epidemic were largely ignored, as stigma surrounding affected populations made it easier for the broader public to deny the severity of the crisis. Even within at-risk populations, the long delay between infection and symptoms created a false sense of security, leading to risky behavior. This collective denial allowed the virus to spread unchecked, resulting in millions of deaths worldwide and a public health problem that continues to this day in the United States.
Even now, forty years after the virus was identified, only 36% of the 1.2 million Americans at high risk for HIV are taking PrEP (Pre-Exposure Prophylaxis), a drug that is 99% effective at preventing the disease .
Chronic diseases such as high blood pressure and diabetes reflect this pattern of denial. The long gap between early signs and life-threatening complications – such as heart attack, stroke and kidney failure – causes people to underestimate the risks and neglect preventive care. This inaction increases morbidity, mortality and healthcare costs.
Whether it’s an infectious disease or a chronic illness, denial causes damage. It allows medical problems to take root, delays care, and leads to tens of thousands of preventable deaths every year.
The invisible parallels: COVID-19 and Mpox
Our nation’s responses to COVID-19 and MPox (formerly known as monkeypox) similarly illustrate how denial hinders effective management of public health emergencies.
In March 2020, as COVID-19 began to spread, millions of Americans dismissed it as just another winter virus, no worse than the flu. Even as deaths rose exponentially, elected officials and much of the public failed to recognize the growing threat. Critical containment measures – such as travel restrictions, widespread testing and social distancing – were postponed. This collective denial, fueled by misinformation and political ideology, allowed the virus to take root across the country.
By the time the severity of the pandemic was undeniable, hospitals and health care systems were overwhelmed. The chance to prevent widespread destruction had passed. More than 1 million American lives were lost, and the economic and social consequences continue to this day.
Mpox presents the latest example of this disturbing pattern. On August 14, the World Health Organization declared mpox a global public health emergency after identifying the rapid spread of the Clade 1b variant across several African countries. This strain is significantly more deadly than previous variants and has caused more than 500 deaths in the Democratic Republic of Congo, mainly among women and children under 15 years of age. Unlike previous outbreaks that were primarily linked to same-sex transmission, Clade 1b spreads through both heterosexual contact and close family interactions, expanding its reach and putting everyone at risk.
Despite these alarming developments, awareness and concern about MPox in the United States remains low. International aid has been limited and vaccination efforts have lagged far behind the growing threat. As a result, by the time the WHO issued its emergency declaration, only 65,000 vaccine doses had been distributed across Africa, where more than 10 million people are at risk. Cases have already appeared in Sweden and Thailand, and the US could soon follow suit.
Even with the added danger of the new variant and the proven efficacy of the JYNNEOS vaccine, only one in four high-risk individuals in the United States has been vaccinated against MPOX.
Our slow and delayed response to Covid-19, MPox, HIV/AIDS and almost all chronic diseases reveals the prevalence of denial, the lives it continues to claim and the urgent need to address this hidden defense mechanism. The best way to overcome denial – both individually and collectively – is to clearly highlight the risks. Simply warning people of the dangers is not enough.
Strong leadership is crucial to breaking through this unconscious barrier.
Lessons to learn, actions to take
Dr. C. Everett Koop’s public health campaign against AIDS in the 1980s showed how clear, consistent messages can change public perception and lead to action. Similarly, former Surgeon General Luther L. Terry’s seminal 1964 report on smoking informed the public about the dangers of tobacco. His report spurred subsequent efforts, including higher taxes on tobacco products, restrictions on smoking in public places and health campaigns using vivid images of blackened lungs – leading to a significant drop in smoking rates.
Unfortunately, government agencies often fall short, hampered by bureaucratic delays and overly cautious communication.
Officials tend to wait until all details are certain, avoid acknowledging uncertainties and seek consensus among committee members before recommending actions. Instead of being transparent, they focus on delivering the least risky advice to their agencies. People, in turn, distrust the recommendations and do not heed them.
Early in the COVID-19 pandemic, and more recently at mpox, officials were reluctant to admit how little they knew about the emerging crises. Their reluctance has further eroded public trust in government agencies. In reality, people are better able to deal with the truth than is often assumed. When they have access to all the facts, they usually make the right decisions for themselves and their families. Ironically, if public health officials focused on educating people about the risks and benefits of different options—rather than issuing guidelines—more people would listen and more lives would be saved.
With viral threats on the rise and chronic diseases on the rise, now is the time for public health leaders and elected officials to change tactics. Americans want and deserve the facts: what scientists know, what remains unclear, and the best estimates of true risk.