Wilner and Holton Respond

We thank Modell et al. for their informative and insightful letter. This discussion could not be more timely at this moment, as we find ourselves nearing three years of a health “infodemic,” while Elon Musk’s very recent takeover of Twitter poses significant challenges to the health not only of that particular platform but also of the larger information ecosystem.

Modell et al. are right to point out that social media platforms such as Pinterest can be used to disseminate information to facilitate earlier detection and treatment. They are also correct that much messaging about cancer advances a sort of generalized awareness that seems less likely to actually enhance health outcomes. In our study, 619 of 797 Pinterest posts (78%) did not make factual claims about how to prevent or treat breast cancer.¹ Most of these instead offered inspirational messages or promotions for pink ribbon‒themed products. We also agree with the authors that using community-specific influencers could be key to social media‒based public health promotion, given not only distrust of health institutions among minoritized groups but also how health topics have become increasingly politicized.²

Indeed, public health professionals face numerous challenges in using social media for health promotion. The past three years have shown as much. While many in public health performed admirably getting out messages about COVID-19, too often messaging was inconsistent or best practices known from the research literature were not followed.³ Now, Musk’s large-scale layoffs of thousands, including content moderators and the company’s internal watchdog team, coupled with the mogul’s evident disregard for truth, threaten to make Twitter a place where misinformation overwhelms any attempts at health promotion.^4,5 This could lead to knock-on effects as misinformation migrates from Twitter to other platforms and to mass media publications.

We are intrigued by the authors’ suggestion of coalition-based and community-advisory social media regulation and wish to suggest a complementary approach that one of us (Wilner) has been involved in. The Center for Media Engagement at the University of Texas at Austin, together with the National Conference on Citizenship, consulted with more than 100 technologists, scholars, and other experts; spent two years researching literature; and conducted 10 citizen focus groups to come up with Civic Signals, a set of principles that we suggest social media should follow for a flourishing public sphere—in much the same way that public squares and parks follow design principles.⁶ We received backing for our Civic Signals from our survey of more than 20 000 individuals in 20 countries, which found that people prioritized different principles on different platforms. Our expert-reviewed white papers explain how these principles could be translated into action. These can be found at https://newpublic.org/signals.

We remain optimistic that public health professionals can be among the forces shaping social media for good, and, similar to Modell et al., we feel the changes will need to be sweeping, systemic, and scientific.