The first time I watched the Grim Reaper ad campaign from 1987, I was an adult, and I had been warned. Nevertheless, it was incredibly distressing. My family, friends and colleagues who grew up in Australia and watched it as children have never forgotten it, even though it was shown on TV for no more than three weeks.
Though it won awards in the advertising world for its unforgettability, the positive impact of the ad from a public health point of view is thought to be minimal. Australia did have an exceptional response to the HIV/AIDS campaign – but this has been credited to significant bipartisan support for HIV/AIDS prevention and sustained Federal funding for service delivery at a state and community level. These successful programs were characterised by explicit engagement with affected communities and responses directed to local needs.
When I studied for my Master of Public Health degree, these programs were held up as an example of a gold standard public health response that markedly altered the trajectory of the HIV/AIDS epidemic in Australia. The Grim Reaper ad, on the other hand, was taught as something that caused harm from its portrayal of the disease and contribution to the stigmatisation of particularly gay men.
The new ad against COVID-19 has some parallels to the Grim Reaper campaign. It has been introduced with no warning and contains alarming and potentially inaccurate footage of a sick patient struggling to breathe in their hospital bed. It suddenly appeared on television screens and social media feeds as case numbers in New South Wales continue to rise. Clearly it is designed to shock and produce fear, presumably with the hope that this will motivate people to stay at home and get vaccinated.
Among the things that are surprising about the ad, it is an unexpected lurch from the previous rhetoric that vaccination is ‘not a race’ to presenting a pressing urgency that we all get vaccinated as soon as possible lest we die. That vaccination is not yet available to many, including quite possibly the patient portrayed in the ad, embarrassingly seems to not have been considered.
There are a number of other criticisms to be made. Firstly, it is distressing and disrespectful to the medical community to suggest that a patient would be left to suffer in this way. Kate Gregorevic is a geriatrician who took care of many elderly patients with COVID-19 during the wave of infections in Melbourne last year. She has previously written about the many things healthcare workers did to support sick patients, from holding hands and smiling with their eyes, to providing medications to help with shortness of breath and other supportive measures. I know that watching this ad, many healthcare workers have been disappointed by this depiction of a patient alone, fearful, and distressed. This is not the care that they worked so hard, risking their own lives, to deliver, or will give in the future.
Secondly, it is incredibly distressing and disrespectful to the many families who have lost loved ones to COVID-19 to assault them with imagery that suggests that this is how their loved ones spent their final days and hours, and that this is how they died. Not only have many Australians lost family members in Australia, but many more Australians have lost family members overseas. Even where borders were not a barrier, infection prevention and control meant that many people could not be with loved ones in hospital, and their final moments are left to imagination. The makers of this ad have clearly misunderstood how common this trauma and grief really is, despite the fact that a third of Australians were born overseas where the effects of the pandemic have been so much more widespread and tragic.
It also disrespects the trauma of those who have had and recovered from infection, while also suggesting that patients who become infected are somehow at fault by leaving their home or for not already being vaccinated – despite the fact that a significant number of Australians are essential workers who cannot work from home and/or cannot yet access vaccination for a variety of reasons.
Moving away from potential harms, there is then a question as to whether fear-based public health campaigns are effective. Dr Gregorevic now spends significant time counselling patients who are eligible for the vaccine but have not yet booked to have it. She has a profound understanding of why people might continue to be hesitant to be vaccinated. In her experience, she tells me that what people are looking for in these conversations is hope.
This is something that other governments seem to have understood. Singaporean ads feature music, dancing and promises of what the world will look like with high vaccination rates. In France, similarly, their ads show a progressive opening up of society as more and more people are vaccinated. The UK has produced comedic ads featuring celebrities that provide scientific reassurance along with laughs. Even the beer manufacturer, Heineken, has produced an ad full of joy.
Public health practitioners and clinicians understand that fear is a poor motivator of behaviour change. At best it is very short term, at worst people are too clever to fall for threats. Good clinical practice, whether at an individual or population level engages people, is honest, and is targeted to their individuals needs and concerns.
Fear and shock campaigns can have a role – as we have seen with graphic anti-smoking ads or the famous road safety ads of the aftermath of road traffic accident – but it is important to remember that these ads did not exist in isolation. Taxation of tobacco and, to a lesser extent, plain packaging had a greater impact than graphic images on cigarette packages and TV ads on reducing smoking rates. Decreased speed limits, increased safety features in vehicles, black spot targeting, and a suite of other road safety interventions have done more to improve road safety than shocking ads of injuries.
This is not to say that ads can’t be useful. Condoman, developed by Aboriginal and Torres Strait Islander people for sexual health education in their own community, was highly successful and still in use decades later. The Australian HIV/AIDS response ultimately had different ads for people living in different Australian communities, after targeted local research identified the key concerns and motivators of each group of people. Though the Grim Reaper is the one most Australians remember, it was not the one that led to behaviour change or a turn in the epidemic.
Similarly, it is likely that multiple strategies and a variety of ads will be needed to address vaccine hesitancy and complacency in different demographic groups in Australia, along with a greater understanding of how to increase vaccination rates – arguably starting with having enough vaccines in the country and utilising other proportional public health measures to limit the spread of disease in the interim.
What is likely is that this ad will not be an effective one and should be pulled before it causes further harm.