In the late 1970s and early ‘80s, a mysterious illness spread through America’s overlooked communities, mainly affecting intravenous drug users and homosexual 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 like 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 society’s fringes, at least initially.
By the time the government and public fully grasped the threat in 1986—following Dr. C. Everett Koop’s “Surgeon General’s Report on AIDS”—tens of thousands of Americans had already died.
Looking back on this and other public health crises, it’s clear that medical science alone isn’t enough to save lives. To prevent similar tragedies, public health leaders and elected officials must first understand the role denial plays in people’s perception of medical threats. They must then develop effective strategies to overcome it.
The Psychological Basis For Denial
Denial is a powerful, usually unconscious defense mechanism that shields individuals from uncomfortable or distressing realities. By repressing 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 daily life. With little protection against illnesses like smallpox, tuberculosis or plague, people would have been immobilized by fear if not for the ability to repress 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 detrimental consequences.
For example, more than 46 million Americans use tobacco products, despite their links to cancer, heart disease and respiratory illness. Similarly, tens of millions of people refuse vaccinations, disregarding scientific consensus and exposing themselves—and their communities—to preventable diseases. Denial extends to cancer screenings, as well. Surveys show that 50% of women over 40 skip their annual mammograms, and 23% have never had one. Meanwhile, about 30% of adults between 50 and 75 are not up to date on colorectal cancer screenings, and 20% have never been screened.
These examples demonstrate how denial leads individuals to make choices that jeopardize their health, even when life-saving interventions are readily available.
A Pattern of Denial: How Inaction Fuels Public Health Crises
When individual denial scales up to the collective level, it fuels 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 the stigma surrounding affected populations made it easier for the broader public to deny the severity of the crisis. Even within at-risk populations, the lengthy 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 take PrEP (Pre-Exposure Prophylaxis), a medication that is 99% effective in preventing the disease.
Chronic diseases like hypertension and diabetes mirror 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 healthcare costs.
Whether the issue is an infectious disease or a chronic illness, denial causes harm. It allows medical problems to take root, it delays care and it leads to tens of thousands 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 illustrate how denial hampers 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 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 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 devastation had passed. More than 1 million American lives were lost, and the economic and social consequences continue today.
Mpox presents the most recent example of this troubling pattern. On August 14, the World Health Organization declared mpox a global health emergency after identifying rapid spread of the Clade 1b variant across several African nations. This strain is significantly more lethal than previous variants, having already caused over 500 deaths in the Democratic Republic of Congo, primarily among women and children under 15. Unlike earlier outbreaks associated mainly 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 fallen 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. Already, cases have appeared in Sweden and Thailand, and the U.S. may soon follow.
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 nearly-all chronic diseases demonstrate 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 clear focus. Simply warning people about the dangers isn’t enough.
Strong leadership is crucial in breaking through this subconscious barrier.
Lessons To Learn, Actions To Take
Dr. C. Everett Koop’s public health campaign on AIDS in the 1980s demonstrated how clear, consistent messaging can shift public perception and drive 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 imagery of blackened lungs—leading to a significant decline in smoking rates.
Unfortunately, government agencies often fall short, hampered by bureaucratic delays and overly cautious communications.
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 for their agencies. People, in turn, distrust and fail to heed the recommendations.
Early in the COVID-19 pandemic, and more recently with mpox, officials hesitated to admit how little they knew about the emerging crises. Their reluctance further eroded public trust in government agencies. In reality, people are more capable of handling the truth than they’re 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 increasing 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 actual risk.
