This blog was was first posted on 20th May. It was written by Robin Falconer, MPH student at the University of Stirling.

Some context

I am writing this brief article as a Master of Public Health student who, over the last eight weeks since lockdown was imposed, has been experiencing increasing frustration towards the many individuals who just don’t seem to get lockdown and appear to lack any interest in saving their own or other people’s lives. However, pushing aside my personal judgements, I have become increasingly aware of the complexity of human health behaviour which crosses the fields of public health, social sciences and health psychology. I am not a psychologist so do not pretend to be an expert however, I do think it is important that the question must be considered as a member of the public who happens to be studying Public Health academically. The problem is that often, academics try to develop understanding from an external perspective of how we fix such issues and what must be done to get the public to do what we need them to do in order to control this virus. On the other hand, members of the public either willingly decide to follow public health guidance or fight against the government who are apparently only interested in controlling people’s behaviour for a multitude of apparently absurd reasons. This is partly, as the World Health Organisations has pointed out on several occasions, why political interests should not interfere with public health. My reflections cover a point which I feel is crucial – Public Health must relate to the public and not appear to be some distant academic discipline. This means supporting everyone to understand and utilising community leadership and other assets as part of the process.

The greater good – ethics in Public Health

Firstly, it is important to consider the ethical implications of lockdown from a public health perspective. In an ideal world, people would become aware of and immediately take action to minimise risk of harm from public health threats. However, particularly in the Western world, we have become accustomed to freedom to do what we like, within reason, and rely on our government to tell us what to do. Most of us in this generation have not faced such widespread restrictions on our day-to-day lives and this has led to a degree of public resistance. What we must understand is that no one really wants to impose such restrictions unnecessarily. A key ethical principle of Public Health is to use the least coercive means possible unless more restrictive measures are required to protect wider public health. Avoiding restrictive measures relies on everyone having a level of maturity and understanding to make sensible decisions to protect our own health and the health of others. Unlike health behaviours which only influence individual health, in the context of an infectious disease pandemic individual actions affect other people. Our governments should provide direction but may be required to restrict liberty for the greater good.

Why you have so much influence as an individual

Closely linked to the above points, is the importance of understanding the Prevention Paradox which is a concept that was developed by Epidemiologist, Geoffrey Rose in 1981. The concept describes the contradictory situation in which population-wide interventions have little benefit for each individual, and where interventions target high-risk individuals, these have minimal impact on the wider population. The concept is relevant to what has been observed during the current pandemic. Many individuals appear to perceive that their actions (or inactions) will have little significance on everyone else and therefore slight deviations are not really going to affect anyone, right? The truth is, as can be understood from the principles of the Prevention Paradox, that while an individual action may appear unimportant, the cumulative effect is significant and potentially life-threatening. Therefore, as individuals it is important for us to recognise that our influence is significant and that deviations, regardless of how minor they may appear, add up to a significant public health burden when combined with others’.

Skewed risk perception or a genuine dilemma?

The penultimate point relates to the complexity of health behaviours and the dilemmas that many people face when it comes to health. One of the most important elements to consider is that life circumstances are not the same for everyone. Managing my own judgement, which was that most people really have no valid reason not to abide by the lockdown restrictions, I have become increasingly aware of the significant dilemmas that many people face when deciding whether to stay at home or go out. Health inequalities have come to even greater light during this pandemic. Many people have no access to greenspace within walking distance of their home and are restricted to cramped housing conditions. Others experience significant mental health challenges or live alone and are told to avoid all physical social contact. There is no doubt that for some people, an inaccurate perception of risk is a factor or perhaps that there are more perceived downsides than benefits of adhering to restrictions. However, we must realise that for some people it is a genuine dilemma of living a poor quality of life with an uncertain endpoint or facing the risk of coronavirus. Health inequalities are not inevitable and this pandemic disproportionately affects some people in society more than others.

Misinterpretation and confirmation bias

The final reason I propose is that many people are simply confused by the, often, contradictory approaches of governments around the world. The truth is that public health is political and just as everyone else interprets information in their own way, so do politicians. A new pandemic presents challenges, as recently tried and tested interventions are either absent or limited in contemporary Public Health practice. In the end, people seek out information that they feel reinforces their existing viewpoint – this is confirmation bias. To solve this, we must remain open to the fact that scientific evidence evolves over time and that such changes in evidence should not be viewed as a failure of academics to make up their minds. However, Public Health has a role to play in ensuring that the public can make educated health decisions rather than passively following advice from governments and institutions. Afterall, we expect scientists to critically appraise the available evidence so why would we not expect the public to do the same?

Conclusion

Overall, whilst in many senses, lockdown has brought people together through increased community resilience, it has also highlighted divisions in health behaviours and public responses to a pandemic which has never really been experienced to this extent. We must remember that public health is not an academic discipline or a profession which should operate in isolation, creating policies and practices which are disconnected from the realities of people’s lives. Although many may argue that there was little time to prepare for the current pandemic, there are some steep learning curves for everyone moving forward and we must build on this to ensure we are prepared for similar events which are possible and likely to happen again. For Public Health, the learning is in relation to how we ensure the public is a key partner in future decision making and preparedness, not a passive recipient of academic evidence.