“Information disorder is a crisis that exacerbates all other crises. When bad information becomes as prevalent, persuasive, and persistent as good information, it creates a chain reaction of harm.” (Commission on Information Disorder, 2021, p. 1) There is no better demonstration of this chain reaction than the harm that is being inflicted across the globe by the COVID-19 infodemic. The term infodemic may be new for some readers.

Introduction

In 2003, the term Infodemic was coined by journalist and political scientist David Rothkopf in a Washington Post column to describe a blend of information and epidemic. (Merriam-Webster, 2022). In his column, written well before COVID-19, he defines infodemic as: “A few facts, mixed with fear, speculation and rumor, amplified and relayed swiftly worldwide by modern information technologies, have affected national and international economies, politics and even security in ways that are utterly disproportionate with the root realities.” (Rothkopf, 2003, p. 1 ).

Since that time several other definitions have been published all of which contain the same general concepts. For example, the World Health Organization (WHO) defines infodemic as “too much information including false or misleading information in digital and physical environments during a disease outbreak. It causes confusion and risk-taking behaviours that can harm health.” (WHO, 2022, p. 1 para 1) But it took a pandemic in the middle of political crosswinds (Niburski, 2020) to make an infodemic a public health challenge threatening the health of all peoples worldwide. As of January 2022, 136 countries joined together to endorse a Cross-Regional Statement on “Infodemic” in the Context of COVID-19 calling for a commitment to creating a healthy information environment at the national, regional, and global levels (United States Mission to the United Nations, 2020).

Impact of the Problem

In dealing with the COVID-19 health crisis, the spread of the “infodemic” is as dangerous to human health and security as the pandemic itself. (United States Mission to the United Nations, 2020). There have been several studies attempting to understand the damaging impact of the COVID-19 infodemic. For example, Zhang, et. al. (2021) who studied the multiplex network through which both COVID-19 and its related information has spread concluded that freely spreading dis- or mis-information, especially via online and/or mobile social media, might be a major contributor to the fast spreading of COVID-19 around the world.

While there are several resources with statistics related to mortality and morbidity, various issues, such as a lack of testing, raise questions about the reliability of these numbers. Many believe the numbers are underreported. The reality is that the actual number of people from infants to elderly who have died, suffered permanent disability, or just survived a horrendous illness because of the infodemic is unable to be known. This does not mean that the extent of the damage for individuals, families, and communities is not well recognized. It just means we do not have statistics to measure just how damaging the infodemic continues to be. One indication is the number of deaths that could have been prevented if misinformation about the lifesaving vaccines had not influenced so many. Sometimes a picture, as illustrated in the figure, can be worth a thousand words.

Figure.

Average Weekly Deaths for 25 U.S. Jurisdictions from October 3 to November 29, 2021

[View full size]

(Johnson et al., 2022)

Health Professionals Who are Contributing to the Pandemic

For several years the Gallop Poll (Saad, 2022) has demonstrated that nurses, followed by medical doctors, are the most trusted professionals in the United States. This information makes the following quote even more frightening: “We face the COVID-19 pandemic as well as a pandemic of misinformation. Some of the most potent and damaging lies during this crisis have been created or propagated by medical professionals –including doctors and nurses.” (Physicians for Human Rights [PHR], 2021, p. 1 para 4).

One indication of how widespread and dangerous the problem has become is documented in the Federation of State Medical Boards (FSMB) 2021 annual survey of state boards of medicine:

• 67% of boards experienced an increase in complaints related to the dissemination of false or misleading information
• 26% of boards published statements about the dissemination of false or misleading information
• 21% of boards have taken a disciplinary action against a licensee. (FSMB, 2021b)

Table 1 includes links to several examples of nurses and other health providers whose active sharing of misinformation are significant enough to have been published in recognized news sources.

Table 1.

Examples of Nurses and Other Health Professionals Spreading Misinformation

Headline	URL
Oregon Nurse is placed on leave over TikTok Video Mocking Masks	https://www.nytimes.com/2020/11/30/us/oregon-nurse-tiktok-mask.html
Coffey County Health Department nurses decline to give the COVID-19 vaccine	https://www.wibw.com/2021/01/13/coffey-county-health-department-nurses-decline-to-give-the-covid-vaccine/
Houston doctor suspended from hospital for spreading COVID-19 misinformation	https://www.theguardian.com/world/2021/nov/15/houston-doctor-suspended-hospital-spreading-covid-misinformation
Alabama nurse fired after TikToks with COVID-19 misinformation, racism go viral	https://www.beckershospitalreview.com/nursing/alabama-nurse-fired-after-tiktoks-with-covid-19-misinformation-racism-go-viral.html
Hospital Employee Out of Job After Posting TikTok Comparing Vaccine Mandate to Holocaust	https://www.newsweek.com/hospital-employee-out-job-after-posting-tiktok-comparing-vaccine-mandate-holocaust-1622122

In March 2021, the Center for Countering Digital Hate (CCDH), a not-for-profit NGO, released a report titled The Disinformation Dozen, identifying twelve anti-vaxxers who play leading roles in spreading digital misinformation about COVID-19 vaccines. They reported that an analysis of anti-vaccine content that was shared or posted on Facebook and Twitter between February 1^st and March 16, 2021 demonstrated that 65 percent of the posted anti-vaccine content on these sites can be attributable to the twelve individuals making up the “Disinformation Dozen” (CCDH, 2021).

Six of these 12 individuals can be considered healthcare providers. The six are listed in Table 2. This table includes their medical credentials, the state where each is or were licensed and a site to verify their current license. On some of these sites board disciplinary action can also be found.

Table 2.

Health Professionals Included in the “Disinformation Dozen”

Name	State	Verification Site
Joseph Michael Mercola, DO	Florida – maybe It is interesting to note the FDA used a Florida address to correspondence with this individual. A copy of this letter can be seen at https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/mercolacom-llc-607133-02182021	https://online-dfpr.micropact.com/lookup/ licenselookup.aspx lists the state where he is licensed as Florida. However, I was unable to find his name in Florida Dept of Health web site for verification of physician’s license located at https://mqa-internet.doh.state.fl.us/ MQASearchServices/Home
Sherri Tenpenny, DO	Ohio	https://elicense.ohio.gov/ oh_verifylicense
Rashid Buttar, DO	North Carolina	https://portal.ncmedboard.org/ Verification/search.aspx
Kelly Brogan, MD	Previously licensed in New York however, no current verification of a state license to practice medicine could be found	The web site below is provided to demonstrate she is currently using the MD credential https://www.kellybroganmd.com/
Christiane Northrup, MD	Maine License withdrawn/terminated by licensee	https://www.pfr.maine.gov/ ALMSOnline/ALMSQuery/ SearchIndividual.aspx
Ben Tapper, DC	Nebraska	https://www.nebraska.gov/ LISSearch/search.cgi

While the Disinformation Dozen demonstrates the effectiveness of social media sites in creating a healthcare lead infodemic, social media is not the only avenue for healthcare providers to broadcast disinformation. For example, Senator Rand Paul from Kentucky and Dr. Mehmet Oz, a candidate in Pennsylvania’s Republican primary for Senate, are well recognized physicians known for sharing COVID-19 misinformation. (Watkins & Tobin, 2020; Bort, 2021; Cathey, 2021; Shi, 2021; Caplan, 2022). Both physicians are currently licensed in good standing to practice medicine. Dr. Paul is licensed in Kentucky and Dr. Oz is licensed in New York. Because of their notoriety, their comments are reported across many of the better-known news organizations.

While the activities of individual healthcare providers are shocking, even more shocking is the development of coalitions or organizations of healthcare professionals focused on producing, and in some cases selling, false and misleading information. One such well recognized group is the Frontline Doctors (https://americasfrontlinedoctors.org/). The group “originated as a right-wing political organization, and since its founding has consistently spread medical misinformation” (Bergengruen, 2021, p. 1 para 4). The group was founded by Dr. Simone Gold, a physician who was arrested during the Jan. 6 attack on the U.S. Capitol (Bergengruen, 2021). Gold is currently licensed as a physician in California. The information can be verified at https://search.dca.ca.gov/. The page verifying her license lists 12 different “Public Record Actions,” however no information about the actions is included. For example, the second action reads as follows: COURT ORDER (NO INFORMATION TO MEET THE CRITERIA FOR POSTING).

The website for this organization is a great example of saying all the right things with all the wrong meanings. For example, the following quote is taken from the Mission Statement on the web site: “We The People with independent information from the world’s top experts in medicine and law, so you can be empowered with facts, protect your health, and ..” (Gold, nd). How could anyone disagree unless, of course, those same “top experts” are spreading misinformation and selling unsafe “cures”. However, there is one redeeming use for the site. This website is an excellent resource for teaching healthcare professionals and students how to recognize a dangerous website where their patients may be looking for health information and care.

The Nursing and Medical Professions Respond

Both the nursing and medical professions have responded to this challenge presented by the pandemic with policies and procedures to discipline nurses and physicians who participate in spreading dangerous misinformation. The National Council of State Boards of Nursing (NCSBN) policy statement is available on their website (NCBSN, 2021). When you click on the site note, there is a range of professional nursing organizations who have endorsed this statement. The FSMB also released a statement, available on their website (FSMB, 2021a).

Furthermore, several boards that certify physicians within their specialties have warned their members that board-certified physicians who engage spreading misinformation about the COVID-19 put their certification at risk. (American Boards of Family Medicine, Internal Medicine, and Pediatrics, 2021). In addition, to these efforts both NCSBN and FSMB joined with the National Association of Boards of Pharmacy (NABP) to issue a joint statement (2020) on inappropriate prescribing and dispensing of medications.

Determining where and how state boards of practice are enforcing these policies is difficult. Maine Public Radio reported in January 2022 that Lisa Robin, chief advocacy officer with the FSMB stated that more than 20% of state boards have taken disciplinary action against physicians for COVID-related issues (Miller, 2022). This is consistent with the FSMB survey discussed earlier. Two weeks later an article posted on Politico also citing the FSMB reported that medical boards have sanctioned eight physicians since January 2021 for spreading coronavirus-related misinformation (Tahir, 2022). Eight is certainly less than 20% of all state medical boards. The variation in these numbers may simply result from the wide variation in reporting policies and procedures of the different state medical boards (FSMB, 2021a).

Other health related agencies and associations have also attempted to meet the challenge of healthcare providers creating or contributing to an infodemic. One common approach is to provide healthcare professionals with information and resources for dealing with the pandemic. A number of these resources can be found in Table 3.

Table 3.

Resources for Dealing with the COVID-19 Infodemic

Health Related Association or Agency	URL
CDC: How to Address COVID-19 Vaccine Misinformation	https://www.cdc.gov/vaccines/covid-19/health-departments/addressing-vaccine-misinformation.html
DHHS: How to Address COVID-19 Vaccine Misconceptions	https://wecandothis.hhs.gov/outreach-tools/addressing-covid-19-vaccine-misconceptions
NLM: Panel Presentation: Addressing the Infodemic Online	https://www.youtube.com/watch?v=AKRg87a-qQk
PAHO: Understanding the infodemic and misinformation	https://iris.paho.org/bitstream/handle/10665.2/52052/Factsheet-infodemic_eng.pdf
UN tackles ‘infodemic’ of misinformation and cybercrime in COVID-19 crisis	https://www.un.org/en/un-coronavirus-communications-team/un-tackling-%E2%80%98infodemic%E2%80%99-misinformation-and-cybercrime-covid-19
UNESCO: DISINFODEMIC: Deciphering COVID-19 disinformation	https://en.unesco.org/covid19/disinfodemic/brief1
WHO: Infodemic	https://www.who.int/health-topics/infodemic#tab=tab_1

 
Challenges for Health Professionals

Today the question on the table for all health professionals is: Can the health professions using the current infrastructure of professional organizations and state licensing boards still police or regulate themselves and protect the public? Certainly, the public expects health professionals to regulate themselves. Nine in 10 Americans say doctors who intentionally spread misinformation about COVID-19 should be held accountable, according to the de Beaumont Foundation (2021). But to meet this challenge state boards must effectively deal with both external and internal forces.

From an external perspective state boards are subject to political pressure. In every state, licensing boards exist within the structure of the state government. As a result, they can be manipulated by politicians to the point that they are ineffective. Manipulation can occur in several ways. First, there is direct political pressure. The Tennessee Board of Medical Examiners voted to remove from its website their policy for discipling doctors who spread COVID-19 misinformation. This decision was made after a Republican lawmaker threatened to dissolve the board. This would not have been the first state board this lawmaker had dissolved (Wade, 2021).

Second, state boards can be manipulated and controlled by legislation. As of January 2022, 11 state legislatures across the United States introduced bills that limit medical licensing boards from acting against professionals who prescribe hydroxychloroquine and ivermectin. In North Dakota and Tennessee, it is already the law (Goba, 2022). Third, state boards can be controlled through budgeting processes. Just cutting the budget can make it impossible to hire adequate staff as well as obtain other needed resources. This approach can be very effective to limit what a state board can accomplish.

Even if state boards were not subject to political pressure, they would still be challenged to deal with the current pandemic. Many of the policies, procedures, and cultural behaviors of the professionals within healthcare, and in turn the professional organization and state boards, precede today’s digital world. The de Beaumont Foundation (2021) identified three characteristics of state boards making them ineffective in controlling the pandemic:

• State boards have significant discretion on what complaints they will investigate; limited accountability, because a decision to close a complaint has created no public record; and no transparency, because most of the investigation remains confidential once completed.
• State medical boards do not have capacity for proactive monitoring and can only react when presented with a complaint.
• The process to investigate complaints takes months and even years. By the time a decision is reached the damage is already done.

In addition to the characteristics identified by the de Beaumont Foundation (2021) other factors challenge state boards of practice. The professionals who serve on state boards have usually volunteered their time and expertise, suggesting concerns such as:

• Serving on a state board of practice can take a significant time commitment. With the onset of the pandemic many of these professionals are struggling to meet their responsibilities in their primary place of employment.
• Professionals serve on these boards for several reasons, including serving the profession and expanding their professional network. Being in the middle of an ugly political battle can be very uncomfortable and these professionals may seek to avoid the confrontation rather than dealing directly with political problems.

Conclusion

The long-term impact of the COVID-19 infodemic is yet to be known and questions remain. For example: can we as health professionals create organizations and agencies that are proactive, flexible, and fast enough to protect the public from this infodemic in today’s digital world. Can the professions regulate themselves and protect the public? If yes, how will that be done? These and other concerns will require thoughtful consideration to mitigate damage done by the false and misleading information so easily spread during these challenging times.

Author

Ramona Nelson, PhD, BC-RN
Email: ramonanelson@verizon.net

Dr. Nelson holds a baccalaureate degree in nursing from Duquesne University, and master’s degrees in both nursing and information science, as well as a PhD in education, from the University of Pittsburgh. Prior to her current position as President of her own consulting company, she was Professor and Chair of the Department of Nursing at Slippery Rock University in Pennsylvania. In the early 1980’s, one of Dr. Nelson’s employee benefits, while teaching at the University of Pittsburgh, was the opportunity to take university courses for only $5.00 a credit. After taking courses in computer assisted instruction and theory for information science, she recognized these tools (computers) just might be somewhat useful at the bedside and in the classroom. She has been exploring and discovering just how useful they can be ever since.

Dr. Nelson’s more recent research and publications focus on the specialty area of health informatics. Health Informatics: An Interprofessional Approach (2014), co-authored with Nancy Staggers, received the first place American Journal of Nursing Book of the Year award for Information Technology/Informatics. The second edition (2018) continues today as a primary textbook in the field of health informatics. Based on her contributions to nursing and health informatics she has been inducted into both the American Academy of Nursing and the first group of fellows in the National League for Nursing Academy of Nursing Education. She has also been recognized as a pioneer within the discipline by the American Medical Informatics Association. Her goal in serving as Editor of OJIN’s Informatics Column is to open a discussion about how we as nurses in the inter-professional world of healthcare can maximize the advantages and manage the challenges that computerization brings to our practice.

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