Shall we slow down the virus, or speed up the people?

Taking off the proverbial mask and putting on a real one.

 By Regan Duff

(Acknowledgments: Dr. Niki Harre, Varun Bhardwarj, Dr. Sophie Febery & Francesco Bolstad) 

Gearing up the public health system is an important prerequisite to managing the present health crisis, but may not be enough to ensure long-term population health and well-being. To go beyond just keeping the virus at bay, I propose a more participatory approach that builds trust, enables positive behaviour and ultimately contributes to the long-term resilience of the public health system. 

Living ‘with’ or ‘without’ the virus!

In response to the threat posed by SARS-CoV-2, New Zealand has implemented some of the strictest quarantine restrictions in the world. Kiwis can surely take stock in their achievements. However, as the recent bungle at the border highlights, there is still ground to believe that we have merely slowed down the virus, especially with winter looming and the increased likelihood of community transmission (Sajadi, et al. 2020). Further, due to the increasing inevitability of a second wave, finding new ways of co-existing with the virus, needs to be an all hands on deck approach. I argue here that it is through exploring the relationship the virus has with the social, that we must collectively find innovative ways of acting and being in the post-covid world. 

Research into the development of social norms suggests that individual and collective behaviour continually evolves, however, not all resulting norms are desirable, and in order to obtain a desirable one, a sustained collective action needs to be encouraged (Ostrom, 2000; Cialdini et al. 1991). An evolutionary approach to social norms acknowledges the need for creating the right conditions under which collective norms can evolve. In line with this approach, I argue here that in order to increase the probability of a desirable outcome, central individuals [such as politicians or media personalities] play a crucial role in the emergence of prosocial behavior within social networks (Ková?ík, 2012). The Christchurch terror attack is one such example, where our Prime Minister was able to bring about a sense of solidarity through the symbolic act of embracing the Muslim headscarf, and in turn signal to the world that “us Kiwis we’re better than that.” 

Overcoming the hubris of success

Although New Zealand’s effort so far to stamp out the virus is admirable, we must not allow the hubris of success to get between us and our long-term resilience. Given that a second wave is increasingly more likely, ideas of living ‘without’ the virus are now almost fantastical. Unless we learn to live “with” the virus, New Zealand’s cosmopolitan future is under serious threat. At the very least, the lockdown cast some much needed light on the benefits of preserving the public good even when it comes into conflict with basic personal liberties. The concept of “Public Health”, as a fundamental human right, is now embedded in the hearts and minds of everyday New Zealanders. Anecdotal evidence would suggest that our government also acknowledges the unique opportunity that COVID-19 for fostering in a nationwide ethic of solidarity and kindness.

Despite the noble stance of our government, historian Carlo Ginzburg has chronicled that during outbreaks of disease, a society will often look for a scapegoat on which fears, hatreds and tension of all kinds [can] be discharged (as cited in Cohn, 2012). However, this is not the only historical precedent. We know that during the Spanish flu of 1918, communities all around the world were able to come together and heal the hurt caused by preceding social tensions and anxieties, contextualised by the first world war (Cohn, 2012). 

Including social dynamics in the public health process

Because both individuals and groups learn exceptionally fast in times of public health crisis, with “armchair epidemiology” having recently trended on Twitter, more of the general public is now increasingly familiar with some of the complex language used by epidemiologists. Examples include terms such as asymptomatic shredding, non-pharmaceutical interventions (NPIs), and the basic reproduction rate (R0). Therefore, insofar as it constitutes a collective response to a global crisis situation, the science of epidemiology offers more promise to human flourishing than is captured by the narrative of simply preventing disease. Because of its multidisciplinary nature, epidemiologists have not always been able to agree on the most pressing determinants of population health. Although ‘multiple causality’ is generally accepted, there are still epidemiological camps that prefer to take a more biologic, unidirectional approach (MacMahon, et al., 1960; Susser, 1985). This functionally fixated approach does not account for a complex digital world where peripheral factors such as social contagion can both help and hinder traditional medical interventions. 

To pave the way for long-term population health and well-being, I propose a psychosocial approach (Cassel, 1964; Cassel, 1976; Syme, 1983) to the web of causation in public health. Such an approach acknowledges that social dynamics constitute a critical and often under-acknowledged aspect to the theory and practice of epidemiology (Krieger, 1994; Kriger et al., 1993; Krieger et al., 2008). Here, I assume that the distinction between a reactionary stance to public health and a more meaningful one lies in how individuals and groups are included as an integral part of the solution. To give effect to the possibility of a more meaningful response, Nancy Krieger and her colleagues have succinctly coined the image of an eco-social epidemiology which views the agency and accountability of individuals as a critical element of population health and well-being. Such an image allows individuals to be rightly perceived as an integral part of society and yet still affords people their individuality (Krieger, 1994). 

Emerging community-led responses to public health 

As the masking debacle illustrates, the process through which multiple interventions scale up to benefit population outcomes is not as straightforward as health authorities would like it to be. As the disparity of successful interventions around the world illustrates, achieving full compliance on any one intervention does not guarantee the desired population level outcomes. Therefore, it's important that individuals and collective groups are invited to become an integral part of the public health process. I acknowledge that present day institutional designs can present a formidable challenge, however, I believe that the award winning work of Nobel Laureate Ellinor Ostrom may hold some of the answers. Ostrom’s body of work looks at decentralised ways in which the public can manage a ‘common pool’ of resources, and illustrates that by incorporating an adaptive/participative institutional design, communities can more effectively govern themselves. More importantly, they do this not through top-down enforcement, but through the creation, adoption and championing of the most appropriate social norms. Hence, to stay one step ahead of this virus, I argue for an urgent push towards a more organic, decentralised emergence of prosocial cues, behaviours and community-led sanctions within the public health space. 

Putting on a real mask for public health 

For the sake of brevity, I focus here on the web of causation in the ongoing debacle around masking here in New Zealand. As one of the more contentious interventions deployed in response to COVID-19, the simple facemask has found itself at the heart of the current US culture war. This division appears to be all the more deeply entrenched given that government officials including the current US president are refusing to wear a mask in public. It is argued here that if leaders from around the world were to put forward “the mask” as a symbol of universal solidarity, which when fervently embraced signals to the wider public the importance of masks and their role in saving lives. In the event that COVID-19 community transmission were to reappear here in NZ, a more participatory institutional design framework would be better equipped to leverage the social network effects already in play around the world (Gino, Ayal and Ariely, 2009). For example, in East Asia, community-led sanctions successfully signalled the importance of wearing a mask and the consequences of not. Furthermore, because East-Asia is becoming increasingly digitally enabled, the success of interventions there illustrates how community-led sanctions emerge and scale up through loosely coupled social networks. A stark illustration is provided by the case of South Korea who was able to achieve 99% mask uptake before any legislation was in place (Yonhap, 2020). 

Leveraging moral responses to public health crises

I have argued thus far that when it comes to COVID-19, complex social dynamics are in play and social norms emerge quickly to effect behavioural change (Neaigus et al. 1994; Ostrom, 1994; 2000; Schultz et al., 2018). If successful, the pro-social behaviour that emerges around mask uptake, will be framed in the language of ‘protecting innocent others’ and an opportunity to feel a “sense of solidarity with the rest of humanity. My intention is not to moralise the masking debacle in New Zealand. It is not a moral failure of individuals if the New Zealand public fails to wear masks. In support of this argument, Harre (2011) highlights that in order to achieve sustainable outcomes, not everyone needs to be driven by moral concerns such as protecting innocent others. However, a moral framing at the institutional level is more likely to prevent a masked version of the tragedy of the commons. Therefore, I argue that by incorporating a more participatory institutional framework, a norm seeking public health system can act to override individual differences in cooperation. 

Overcoming (non)cooperation barriers in public health 

Here, in the final section of this blog, I end by proposing three key social-psychological mechanisms which help to overcome the barriers people face when contributing to public health: happiness, solidarity and kindness. This section of the blog draws heavily on the social-psychological framework provided by leading community psychologist Niki Harre (2011) within the context of the masking debacle here in New Zealand. 

• Happiness

First, I assert that even during a global health crisis, people are essentially happiness seekers. This suggests that when introducing public health measures, communicating with the public in a way that maximises opportunity for positive emotion provides the benefits of enhanced creativity, openness to change, and cooperation. For example, the Czech Republic #Masks4all movement put ‘having fun’ at the centre of their grassroots #masks4all campaign. Through engaging social media personalities in the co-creation of upbeat catchy songs, the republic was able to solve their masking supply chain issues in a matter of days. 

• Solidarity

Second, people are social beings and learn by observing and imitating others. This suggests that the examples we set through our own actions greatly influence macro level phenomena such as public health. For example, the simple act of wearing a mask doesn’t just contribute to individual level outcomes, it also acts as a behavioural trace of our intention to contribute to the health of society at large. To leverage this mechanism of solidarity at both the national and global levels, government officials here in New Zealand should be encouraged to don a mask in public to signal to our international fraternity that New Zealand is an empathetic partner in solving the ongoing challenges humanity faces.

• Kindness

Finally, people inherently want to do good, and moral considerations greatly influence emotions. For public health institutions in New Zealand, this means that framing messages to the public in moral terms can positively contribute to population level health outcomes. This illustrates the role of institutional design in creating the conditions for the emergence of desirable social norms. For example, when the need to wear a mask in public is presented in terms of the negative public health consequences of not doing so, or what Rappopport (2000) calls ‘tales of terror’, people tend to experience emotions such as shame, guilt and anger. On the contrary, when moral issues are framed in positive terms, or as a ‘tale or joy’, people find it easier to contribute meaningfully. In practical terms, we know that New Zealanders have in the past responded to positive messaging by Prime Minister Jacinda Ardern, for example, the ‘stand at dawn’ Anzac celebration during lockdown. In the case of COVID-19, officials must let go of some control by giving the public permission to adopt the new norm and make it their own. Therefore, in order to provide the conditions with the best chance of public buy-in, influential individuals can begin by framing the stories they tell in a morally uplifting tone while at the same time ensuring that they too are modelling pro-social behavior.

Taking off the proverbial mask and putting on a real one

In conclusion, I propose that in order to stay ahead of this virus, New Zealand needs to incorporate participatory inclusive institutional designs, that actively leverage pro-social mechanisms. Furthermore, in regards to “the mask”, I see two generic paths we could take as a society as we traverse the new world. 

The well trodden path looks at the negative consequences of our actions and leads us to make unhelpful assumptions about how to keep me and my family safe. The logic goes ‘that we do not need to wear a masks because by not doing so is not harming anyone.’ This dangerously flawed logic which continues to gain momentum in the US sadly underpins the dominant logic of masking debacle. I argue that in essence, continuing on this path as the second wave is already underway is much like playing Russian Roulette with both human lives and the economy up next. 

The path less travelled by, and the one I am suggesting, looks at the positive consequences of our actions and supports the assumption that we should wear a mask, and by doing so, we might instead be saving someone. When we walk this path, we contribute to New Zealand public health through the examples we set in our communities and the signals we send to our team of 5 million. We also contribute to global solidarity through doing our part downunder to help free humanity from the quicksands of the masking debacle.

References:

Cassel, J. (1976). The contribution of the social environment to host resistance: the Fourth Wade Hampton Frost Lecture. American journal of epidemiology, 104(2), 107-123.

Cialdini, R. B., Kallgren, C. A., & Reno, R. R. (1991). A focus theory of normative conduct: A theoretical refinement and reevaluation of the role of norms in human behavior. In Advances in experimental social psychology (Vol. 24, pp. 201-234). Academic Press.

Cohn, S. K. (2012). Pandemics: waves of disease, waves of hate from the Plague of Athens to AIDS. Historical Research, 85(230), 535-555.

Gino, F., Ayal, S., & Ariely, D. (2009). Contagion and differentiation in unethical behavior: The effect of one bad apple on the barrel. Psychological science, 20(3), 393-398.

Harré, N. (2011). Psychology for a better world: strategies to inspire sustainability.[Auckland, NZ: Dept. of Psychology, University of Auckland].

Ková?ík, J., Bra?as-Garza, P., Cobo-Reyes, R., Espinosa, M. P., Jiménez, N., & Ponti, G. (2012). Prosocial norms and degree heterogeneity in social networks. Physica A: Statistical mechanics and its Applications, 391(3), 849-853.

Krieger, N., Rowley, D. L., Herman, A. A., Avery, B., & Phillips, M. T. (1993). Racism, sexism, and social class: implications for studies of health, disease, and well-being. American journal of preventive medicine, 9(6), 82-122.

Krieger, N. (1994). Epidemiology and the web of causation: has anyone seen the spider?. Social science & medicine, 39(7), 887-903.

Krieger, N. (2008). Proximal, distal, and the politics of causation: what’s level got to do with it?. American journal of public health, 98(2), 221-230.

Kuller, L. H. (1991). Epidemiology is the study of “epidemics” and their prevention. American journal of epidemiology, 134(10), 1051-1056.

MacMahon B, Pugh TF, Ipsen J (1960). Epidemiologic methods. Boston: Little, Brown and Company.

Neaigus, A., Friedman, S. R., Curtis, R., Des Jarlais, D. C., Furst, R. T., Jose, B., ... & Wright, J. W. (1994). The relevance of drug injectors' social and risk networks for understanding and preventing HIV infection. Social science & medicine, 38(1), 67-78.

Ostrom, E. (2000). Collective action and the evolution of social norms. Journal of economic perspectives, 14(3), 137-158.

Rappaport, J. (2000). Community narratives: Tales of terror and joy. American journal of community psychology, 28(1), 1-24.

Sajadi, M. M., Habibzadeh, P., Vintzileos, A., Shokouhi, S., Miralles-Wilhelm, F., & Amoroso, A. (2020). Temperature and latitude analysis to predict potential spread and seasonality for COVID-19. Available at SSRN 3550308.

Susser, M. (1985). Epidemiology in the United States after World War II: the evolution of technique. Epidemiologic reviews, 7(1), 147-177.

Schultz, P. W., Nolan, J. M., Cialdini, R. B., Goldstein, N. J., & Griskevicius, V. (2007). The constructive, destructive, and reconstructive power of social norms. Psychological science, 18(5), 429-434.

Syme S. L. (1992). Social determinants of disease. In Maxcy- Rosenau-Last Public Health & Preventive Medicine. 13th edn. (Edited by Last J. M. and Wallace R. W.), pp. 687-700. Appleton & Lange, Norwalk, CT.

Yonhap. Though Outbreak Has Peaked, Masks Becoming Mandatory in Korea. 17 May 2020, www.koreaherald.com/view.php?ud=20200517000260.