Denial is a powerful, usually unconscious defense mechanism that protects individuals … [+]
In the late 1970s and early 80s, a mysterious disease swept through America’s neglected communities, mostly 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 since the disease seemed confined to the fringes of society, at least initially.
By the time the government and the public fully understood the threat in 1986 – after the “Surgeon General’s Report on AIDS” by Dr. C. Everett Koop – tens of thousands of Americans had already died.
Looking at 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 that denial plays in people’s perception of medical threats. They must then develop effective strategies to overcome it.
Psychological basis for denial
Denial is a powerful, usually unconscious defense mechanism that protects individuals from unpleasant or distressing realities. By suppressing objective facts or experiences—especially those that provoke fear or anxiety—people can maintain a sense of stability in the face of overwhelming threats.
Historically, denial was vital to everyday life. With little protection against diseases like smallpox, tuberculosis, or the plague, people would be immobilized by fear if not for the ability to suppress reality. Denial, mixed with superstition, took the place of facts, allowing society to function despite the ever-present dangers of death and disability.
Today, even with tremendous advances in medical knowledge and technology, denial continues to affect individual behavior with harmful consequences.
For example, more than 46 million Americans use tobacco products, despite their links to cancer, heart disease, and respiratory disease. Similarly, tens of millions of people refuse vaccinations, flouting scientific consensus and exposing themselves—and their communities—to preventable diseases. The denial also extends to cancer screenings. Surveys show that 50% of women over 40 skip their annual mammograms and 23% have never had one. Meanwhile, about 30% of adults aged 50 to 75 are not up to date on colorectal cancer screenings and 20% have never been screened.
These examples show how denial drives individuals to make choices that endanger their health, even when life-saving interventions are readily available.
A model of denial: How inaction drives public health crises
When individual denial reaches the collective level, it fosters widespread inaction and exacerbates 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 the stigma surrounding affected populations made it easier for the general 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 challenge that continues today in the United States.
Even now, four decades after the virus was identified, only 36% of the 1.2 million Americans at high risk for HIV take PrEP (Pre-Exposure Prophylaxis), a drug that is 99% effective in preventing the disease.
Chronic diseases such as hypertension 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 – leads people to underestimate the risks and neglect preventive care. This inaction increases morbidity, mortality, and health care costs.
Whether the issue is an infectious disease or a chronic illness, denial causes harm. It allows medical problems to take root, delays care, and leads to tens of thousands of preventable deaths each year.
Invisible parallels: COVID-19 and Mpox
Our nation’s responses to COVID-19 and mpox (formerly known as monkeypox) similarly illustrate how denial impedes effective management of public health emergencies.
Until March 2020, when COVID-19 began to spread, millions of Americans dismissed it as just another winter virus, no worse than the flu. Even as deaths increased 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 delayed. 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 systems were overwhelmed. The opportunity to prevent widespread destruction had passed. More than 1 million American lives were lost, and the economic and social consequences continue today.
Mpox represents the latest example of this troubling pattern. On August 14, the World Health Organization declared mpox a global health emergency after identifying the rapid spread of the Clade 1b variant in several African countries. This strain is significantly deadlier than previous variants, already causing over 500 deaths in the Democratic Republic of Congo, mostly among women and children under 15. Unlike previous outbreaks associated primarily with same-sex transmission, Clade 1b spreads through both heterosexual contact and close family interactions, increasing its reach and putting everyone at risk.
Despite these alarming developments, awareness and concern about mpox remains low in the United States. 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 doses of the vaccine had been distributed across Africa, where more than 10 million people are at risk. Already, cases have appeared in Sweden and Thailand, and the US may soon follow.
Even with the increased risk 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 shows how widespread denial is, 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 bring the risks into sharp focus. Simply warning people of the dangers is not enough.
Strong leadership is essential to overcome this subconscious barrier.
Lessons to Learn, Actions to Take
The campaign of Dr. C. Everett Koop’s public health work on AIDS in the 1980s showed how clear and consistent messages can change public perception and spur action. Similarly, former Surgeon General Luther L. Terry’s landmark 1964 report on smoking educated the public about the dangers of smoking. 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. smoking.
Unfortunately, government agencies often fail, hampered by bureaucratic delays and overly cautious communications.
Officials tend to wait until all the details are certain, avoid admitting uncertainties, and seek consensus among committee members before recommending action. Instead of being transparent, they focus on providing less risky advice to their agencies. People, for their part, do not trust and do not listen to recommendations.
Early in the COVID-19 pandemic, and more recently with mpox, officials were reluctant to admit how little they knew about the emerging crises. Their reluctance further erodes public confidence in government agencies. In reality, people are more capable of handling the truth than they are often given credit for. 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 directives—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 current risk.