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Amazon is under pressure from Democrats in Congress over how its algorithms promote hoax COVID-19 cures, including the livestock dewormer ivermectin, as well as anti-vaccination claims and other medical misinformation.

Rep. Adam Schiff of California and Sen. Elizabeth Warren of Massachusetts sent letters this week to CEO Andy Jassy pressing for information on Amazon's misinformation policies and what the company is doing to stop its systems from recommending books and other products linked to falsehoods about the pandemic and vaccines.

"Amazon is directly profiting from the sensationalism of anti-vaccine misinformation, while these conspiracy theories continue to directly contribute to COVID-19 deaths," Schiff wrote.

Warren accused the e-commerce giant of being "either unwilling or unable to modify its business practices to prevent the spread of falsehoods or the sale of inappropriate products."

Scrutiny of Big Tech is expanding beyond social media

Amazon largely has escaped the intense scrutiny that social media platforms including Facebook, YouTube and Twitter have come under during the pandemic over how they deal with health misinformation.

But that appears to be changing following a series of investigations in recent months from academics and journalists.

They have shown Amazon's algorithms promote books with false anti-vaccination claims and COVID-19 conspiracy theories, and have found people are easily able to evade rules against promoting false cures in product reviews, such as for the anti-parasite drug ivermectin. (The U.S. Food and Drug Administration has warned against taking formulations of ivermectin meant for animals.)

COVID-19 searches turn up conspiracy theories

Warren's letter said when her staff conducted its own searches on Amazon for terms including "COVID-19" and "vaccine," it found the top result was a book by Joseph Mercola, a Florida physician who has long promoted debunked claims about vaccines.

Other results for "COVID-19" or "COVID 19 vaccine" on Amazon included books touting ivermectin and claiming COVID-19 vaccines were "making people sick and killing them," Warren wrote.

Mercola's book, which Amazon labels as a "best seller," appeared on Thursday as the top result when NPR searched Amazon for "COVID-19" and as the third result for "vaccine."

"Collectively, this is an astonishing sample of misinformation that appeared in only a few potential searches relating to COVID-19," Warren wrote to Amazon.

How bad actors game Amazon listings

Renée DiResta, who studies misinformation at the Stanford Internet Observatory, said Amazon's systems can be gamed by bad actors because Amazon allows authors to categorize their own books.

"If you write a book about cancer and argue juice cures cancer, you can categorize your book as a cancer book, and it can end up No. 1 in Amazon's oncology section," she said.

Another area of concern is what Amazon recommends to shoppers based on what other people have bought. "The recommender system doesn't have an awareness of what the content is," DiResta said. "It just understands that people searching for certain terms buy certain products. Amazon's business is to sell products."

Where does Amazon draw the line?

Both Warren and Schiff want Amazon to give more detail about where it draws the line on misinformation and conspiracy theories and how it enforces those rules.

Schiff said he was particularly concerned that Amazon's content guidelines do not spell out its policies on vaccine misinformation.

In response to a letter he sent in 2019 asking about Amazon's policies on anti-vaccination claims, the company told him it "provide[s] our customers with access to a variety of viewpoints," Schiff wrote.

"This cannot possibly justify the sale of false information that directly endangers your customers," he wrote in this week's letter.

In a statement, Amazon spokesperson Tina Pelkey said: "We are constantly evaluating the books we list to ensure they comply with our content guidelines, and as an additional service to customers, at the top of relevant search results pages we link to the CDC advice on COVID and protection measures."

Activists want more transparency from tech, too

The focus on Amazon is overdue, said Imran Ahmed, chief executive of the Center for Countering Digital Hate, a group that tracks COVID-19 misinformation online.

"It's the same story we've seen across Big Tech," he told NPR. "If we had more transparency, we'd be able to hold them to account. Because right now they hide behind the opacity of just saying that they are free speech platforms, when in fact we know their algorithms, their enforcement, the rules and their advertising economics show that they're not free speech platforms."

Editor's note: Amazon is among NPR's financial supporters.