The Accountability Gap: Who Pays When Public Health Gets It Wrong?

The CDC's EVALI communication failure of 2019—conflating nicotine vaping with illicit THC cartridges, failing to distinguish between products with dramatically different risk profiles, creating a durable public misperception that persists years later—has never been formally acknowledged by the agency, never been investigated by an independent body, and never resulted in any compensation to the smokers who, influenced by the CDC's messaging, continued to smoke because they believed—incorrectly—that vaping was as dangerous as smoking. **No one was held accountable. No one paid anything. The smokers who died because they were systematically misinformed about the most important health decision they could make are not even recognized as victims of the communication failure that contributed to their deaths. The accountability gap—the absence of any mechanism for holding public health institutions responsible for the harm caused by their communications—is a structural injustice that the field has never confronted.**

**The accountability gap is not unique to tobacco.** Public health agencies make errors across domains—dietary guidelines that prove incorrect, screening recommendations that cause overdiagnosis, pandemic responses that cause avoidable harm. The errors are inevitable—public health operates under uncertainty, and some recommendations will always turn out to be wrong. What is not inevitable is the absence of accountability. **When a pharmaceutical company's product causes harm, the company faces litigation, regulatory penalties, and reputational damage. When a public health agency's recommendation causes harm, the agency faces none of these consequences. The asymmetry is structural—and it creates an incentive for public health agencies to err on the side of over-warning, because the costs of over-warning are borne by the public while the costs of under-warning are borne by the agency.**

**The accountability mechanisms that exist are inadequate.** Scientific peer review can correct errors in the evidence base, but it operates on a timescale of years and cannot address the real-time harm caused by communication failures. Legislative oversight can hold agencies accountable for egregious failures, but it is politically driven and rarely addresses the systematic biases that produce routine harm. Internal review processes can improve agency performance, but they are conducted by the same people whose work is being reviewed. **None of these mechanisms addresses the fundamental asymmetry: the public bears the costs of agency errors, and the agency bears none of the consequences.**

**What would accountability look like?** Independent review bodies—modeled on the National Transportation Safety Board, which investigates transportation accidents without regulatory or industry conflicts—could investigate public health communication failures and issue public findings. Compensation mechanisms—perhaps funded by a portion of the tobacco tax revenues that currently flow to general government spending—could provide restitution to smokers who can demonstrate harm from systematic misinformation. And institutional reforms—including whistleblower protections, transparency requirements, and external oversight of agency communications—could reduce the likelihood of future failures. **The accountability gap is not a technical problem. It's a power problem—and addressing it requires redistributing power from the institutions that make errors to the public that bears their consequences.**

**💬 Do you think public health agencies should be held accountable when their communications cause harm—or is the uncertainty of public health an adequate defense? Have you ever been misled by a public health message in ways that affected your behavior?**