The deficit model originated in the 1970s in conversations about public attitudes toward science and technology, with the idea that an adequately informed public would become more welcoming of science. Journalists were enthusiastic early adopters. It didn’t take long to notice it wasn’t reliably producing results. Both scientists and journalists recognized that the public’s attitude is not influenced solely by knowledge but also by personal beliefs, religion, culture, and community. And yet, despite that recognition showing up in the literature decades ago, the model persists, especially in policy design. Scientists are trained in rational choice theory, which assumes people make decisions by evaluating costs and benefits, and many carry that assumption directly into their public health practice, expecting the public to behave accordingly. The National Academies pushed back on this directly, noting that people make decisions based on a variety of factors, rarely on science alone, and I could not agree more.
A flawed framework can still produce results, though, and the deficit model did, because the environment it operated in didn’t give skepticism much room to breathe.
Think about what the information environment looked like before the internet, before social media, before your phone could surface seventeen competing explanations for any health claim within seconds. If your doctor told you something, or Walter Cronkite reported it, or the sciencey-sounding pamphlet in the waiting room said it, that was largely it. The scarcity of information sources gave authority figures disproportionate influence by default. You didn’t go home and find a community of people who disagreed, only to be validated by an algorithm designed to keep them engaged.
Institutional trust was also high. People largely believed the CDC, the AMA, and the government were acting in good faith — not perfectly, but in good faith. The deficit model assumes the problem is a knowledge gap, and that framing only functions if people trust whoever is trying to fill it.
I’d also argue that “back then,” the stakes felt shared. Polio is a good example — parents had watched it paralyze and kill children for years. The iron lung didn’t leave room for doubt; they were desperate for a solution. That’s a very different communication challenge than what we face now.
So yes, the old way worked — sort of, sometimes, for certain audiences. But it worked because it operated within a trust infrastructure that made people receptive. The information was almost incidental.
Smoking might be a more instructive example, and honestly, the first one that came to my mind when the reporter asked. The public health campaign against smoking was one of the most successful behavior change efforts of the 20th century. Smoking rates peaked at around 42% of adults in 1964 (the year of the first Surgeon General’s report), and decades of communication, policy, taxation, and denormalization have driven that number down to around 11% today.
But look at who is still smoking. Not people who haven’t encountered the message… they have heard it thousands of times. What remains is a population with deeply entrenched habits (and addiction, of course), significant structural barriers, and real reasons to distrust the institutions delivering the message. The approach that moved us from 42% to 11% is not going to get us much further. The tool worked on the people it could reach. When that pool shrank, we were left with a harder-to-reach group — and we are still there. I’d argue that the harder-to-reach pool is Olympic-sized now, not specifically for smoking, but for the entirety of public health guidance.
Another thorn in public health’s side is that we are not operating on a level playing field. There are well-funded, organized interests actively working to convince people that public health experts are shills, that we don’t care about them, and that our recommendations serve pharmaceutical companies or government agendas rather than the people we’re here to help. This is a documented, deliberate strategy, and it is working. The shill accusation is particularly effective because it doesn’t require disproving our evidence; it just requires casting doubt on our motives. Once someone believes you’re bought and paid for, no amount of data moves them. Which is one more reason why leading with connection and transparency matters now more than ever.
Every time I open my social media, I see very well-meaning people sharing the same messages. Vaccines work. Vaccines save lives. Vaccines are safe and effective. I am not disputing any of that — but are those messages actually moving anyone? Based on what lands in my inbox, I don’t think so. People don’t just want the ‘what’ anymore. They want the ‘why.’ They want to be let in on the process, given the nuance, and treated like adults who can handle complexity. And they can handle it. Most people are far more capable of engaging with complicated, layered information than we give them credit for — they just need someone to walk them through it rather than hand them a bumper sticker.
The masking debate is a good illustration. As I explored in a recent piece on masking, the evidence that masks reduce transmission is extremely strong, but the decision of whether to wear one involves far more than transmission risk. People weigh comfort, social signaling, trust in the institutions recommending them, and their own sense of autonomy. The pushback I received from public health colleagues for saying so reflects how deeply rational choice theory runs in the field. The idea that decisions involve more than data can feel like heresy even from the inside. If we have a hard time accepting that within public health, the deficit model stays baked into our approach even when we think we’ve moved past it. And that shapes both what we say and who we think we’re talking to.
Share this article
If your reaction to that is: public health skeptics are trolls who will never be convinced anyway — I’d push back, gently but firmly. They are not all trolls. And even those who are skeptical in good faith won’t get there on the back of canned messages we’ve been recycling for decades.
I know some people balk at what sounds like kumbaya language — “meet them where they are,” “bridge-building.” I get it. But I don’t say those things because I’m the Mr. Rogers of public health, though I wouldn’t mind that at all. I say them because I care about the bottom line: getting people to do the things that we know, based on really good evidence, will be good for them, their families, their communities, and all of us.
In the talk, I acknowledged something that I felt needed to be said explicitly– that so many of us are exhausted, scared, demoralized, angry, and frustrated in ways that are completely understandable. And that exhaustion bleeds into our tone. Exasperation creeps in, and people on the receiving end can feel that edge even through a screen. There may be some value in that (for us)– catharsis, a rallying cry for people already in your corner. But if the goal is to reach people who are not already nodding along, that tone isn’t getting us there. If anything, it confirms the story they’ve already been told about us.
It also tends to collapse into a data dump. A few months ago, I came home from the hospital, and a childhood acquaintance (I gave him the pseudonym ‘Trent’) messaged me to say that vaccines had probably caused the symptoms I was experiencing (not the back-to-back viral infections I had just hobbled through). I wrote a whole piece about it, but the short version is: I, someone who teaches connection before correction for a living, aggressively data-dumped. Because when you’re exhausted and feel accused of dishonesty or ignorance, the data dump is what feels controllable. In that moment, I was not compassionate or curious about Trent’s experience; I just wanted to prove him “wrong.” (That cuts both ways: if you make a person feel like you think they’re ignorant, they won’t be compassionate or curious or open to what you have to say, either.)
It won’t work. I promise you that.
So, what does the alternative look like? Skip the canned messages. Connect first on a human level. Don’t lead with judgment or shame. Explain why the consensus is what it is, not just what it is. Walk through the evidence without skipping the nuance — the public can handle it and wants it. And be responsive: let the questions and pushback you receive actually inform what you put out next.
None of this is revolutionary. Most of it is just treating people like people. And yes, I say all of this as someone who has received death threats and harassment for this work. It is easier said than done. But repeating the same messages to people who have already tuned them out is not a strategy; it is just noise that they will tune out.
The honest answer to the reporter’s question (that the old way worked when the conditions were right) strengthens the case for changing course, not weakens it. We’re not abandoning something that worked. We’re finally understanding why it worked, and building something that doesn’t require conditions we no longer have.
Jess Steier is a public health scientist dedicated to bridging the gap between complex scientific evidence and public understanding. Jess is the Founder of Unbiased Science, CEO of Vital Statistics Consulting, and Executive Director of The Science Literacy Lab (a 501c3 non-profit organization). Follow Jess on Substack @drjessicasteier
A version of this article was originally posted at Unbiased Science and has been reposted here with permission. Any reposting should credit the original author and provide links to both the GLP and the original article. Find Unbiased Science on X @unbiasedscipod
