Denial is a powerful, usually unconscious defense mechanism that protects individuals … [+]
In the late 1970s and early 80s, a mysterious disease spread 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 growing 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 became fully aware of the threat in 1986—after Dr. C. Everett KoopSurgeon General’s Report 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 that denial plays in people’s perception of medical threats. Then they have to develop effective strategies to overcome it.
The psychological basis for denial
Denial is a powerful, usually unconscious defense mechanism that protects individuals from uncomfortable or painful realities. By suppressing objective events or experiences—especially those that cause fear or anxiety—people can maintain a sense of stability in the face of overwhelming threats.
Historically, denial has been vital to everyday life. With little protection from diseases like smallpox, tuberculosis, or the plague, people would have been 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 risks of death and disability.
Today, even with tremendous advances in medical knowledge and technology, denial continues to affect individual behavior with detrimental consequences.
For example, more than 46 million Americans use tobacco productsdespite their association with cancer, heart disease and respiratory disease. Likewise, tens of millions of people refuse vaccinations, disregarding the scientific consensus and exposing themselves—and their communities—to preventable diseases. The denial extends to cancer screenings. Research shows that 50% of women over 40 skip their annual mammograms and 23% have never had one. Meanwhile, about 30% of adults between the ages of 50 and 75 are unaware of colon cancer screenings, and 20% have never been screened.
These examples demonstrate how denial leads people to make choices that put their health at risk, even when life-saving interventions are readily available.
A pattern of denial: How inaction fuels public health crises
When individual denial escalates to the collective level, it fuels 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 easy for the general public to deny the seriousness of the crisis. Even in at-risk populations, the long delay between infection and symptoms created a false sense of security, leading to risky behaviors. This collective denial allowed the virus to spread unchecked, resulting in millions of deaths worldwide and a public health challenge that persists in the United States today.
Even now, four decades after the virus was identified, only 36% of the 1.2 million Americans at high risk for HIV receive 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 wide 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 inactivity 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.
The Unseen Parallels: COVID-19 And Mpox
Our nation’s responses to COVID-19 and mpox (formerly known as monkeypox) similarly demonstrate how denial impedes effective management of public health emergencies.
By 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 mounted 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. Over 1 million Americans perished, and the economic and social consequences continue today.
Mpox presents the latest example of this troubling pattern. On August 14, the World Health Organization declared mpox a global health emergency after detecting the rapid spread of the Clade 1b variant in several African nations. This strain is significantly deadlier than previous variants, having already caused more than 500 deaths in the Democratic Republic of Congo, mostly among women and children under 15. close family interactions, increasing its impact and putting everyone at risk.
Despite these alarming developments, awareness and concern about mpox remains low in the United States. International aid is limited and vaccination efforts have lagged behind the growing threat. As a result, by the time WHO issued the emergency declaration, only 65,000 doses of 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 added risk of the new variant and the proven effectiveness of the JYNNEOS vaccine, only one in four high-risk people 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 demonstrates how widespread denial is, the lives it continues to claim and the urgency to address this hidden defense mechanism. The best way to overcome denial—both individually and collectively—is to clearly focus the risks. Simply warning people of the dangers is not enough.
Strong leadership is vital to overcoming this subconscious barrier.
Lessons to be learned, Actions to be taken
The campaign of Dr. C. Everett Koop on AIDS public health in the 1980s showed how clear, consistent messages can change public perception and lead to action. Similarly, former Surgeon General Luther L. Terry’s landmark 1964 report on smoking educated 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 significant reductions in smoking rates.
Unfortunately, government services often fall behind, hampered by bureaucratic delays and overly cautious communications.
Officials tend to wait until all the details are certain, avoid acknowledging uncertainties, and seek consensus among committee members before recommending action. Instead of being transparent, they focus on providing the least risky advice for their services. People, in turn, do not trust and do not follow 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 eroded public confidence in government services. In fact, 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 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 tack. Americans want and deserve the facts: what scientists know, what remains unclear, and the best estimates of the real risk.