When the threat of covid became apparent in the spring of 2020 hard won public health principles were overthrown in favour of gesture based public health policy built around non-pharmaceutical interventions (NPIs). We began to experience the pandemic as spectacle.
The history of modern pandemics is the story of a learning process. Panic led to broad and often ineffective measures. Over time the lesson was the need for specific forms of protection that could be shown to work and which involved less, rather than more, collateral damage.
But in the spring of 2020 the big gestures came back – lockdowns, school closures, border controls, mass handwashing, masking and so on. To ask for evidence that these worked, to propose scientific trials, was to become an evil pantomime villain – no different from those who believed that covid was a hoax.
What mattered was our willingness to support what might work. We exchanged a commitment to evidence-based medicine for declarations of our moral and political fibre and faith.
Gestures versus evidence
Medical advance is about what works in practice – not in theory. That is why randomised control trials are so important but only a handful have been done for NPIs. (1)
Imagine, for example, that you can show that in a lab that a specific type of mask protects both the wearer and any person close by. Does that mean that any mask worn by any person in normal circumstances will have the same effect? Of course not. People wear masks of different materials; reuse single use masks. They wear masks in the wrong way in the wrong places. Who knows what the result is? And this is without knowing whether a perverse result of wearing masks maybe that behaviour changes in negative ways.
But mask wearing is ‘socially desirable’.
When asked if they still wore masks in the summer of 2021 95% of people told a UK ONS survey that they did despite the obvious evidence to the contrary.
Moreover, even if it was shown that mask wearing had some impact in practice, unless we did trials of the other interventions too we still would not know which was the best thing or things to do.
But woe betide anyone who has dared to say show me convincing proof of what works.
Gesture Public Health and Human Rights
The gesture spectacle sweeps all before it. Most non pharmaceutical interventions have involved limitations on what, prior to the spring of 2020, were seen as basic human rights. I am less interested here in the rights of adults who can defy the gestures than those whose circumstances make them victims.
Think of those who have effectively become voiceless – the direct and indirect prisoners of the NPIs. These include migrants and asylum seekers. They include locked down prisoners in jails. They include those living out their last years in care homes; the sick in hospitals; the young; the disabled; the vulnerable and so on. All of them have been subject to measures ‘for their own good’ decided on and imposed by others.
If rights conflict some may need to be sacrificed. But who has heard this discussion? Where are the attempts to set the balance? The various organisations that have fought for the rights of the voiceless have been swept aside by the gesture.
Gesture Policies and Misdirection
Public health as gesture has led to the lack of any discussion of alternatives.
Take the question of care homes. At the start of the pandemic these were rightly seen as ‘petri dishes’. Large numbers died there. In the UK grouping 400,000 old people together in homes run for profit on shoe string budgets with low paid staff in buildings not designed to minimise infection was a recipe for things to go wrong. But what has changed in the year and a half other than a better supply of protective equipment? In fact, in some respects the crisis has worsened the economics of these homes and their staffing situations.
Gesture policies have let governments like that in the UK off the hook. Find a real problem and you can be pretty sure that public health as spectacle has side-lined discussion of change for the better.
Vaccination as Gesture Politics
Now the big gesture is coerced vaccination, several times over, for everyone under the sun in the rich world while those who need it most in the poor world get the left overs.
Vaccination is crucial to dealing with covid. But all vaccination involves some risk. And vaccination too always provokes resistance. It is too easy to put this down to some weird transatlantic conspiracy of Trump and Brexit loving reactionaries.
A significant part of vaccine ‘hesitancy’ comes from more marginalised groups. The reason for their doubts is that have been and are the main victims of state led authority and injustice – including medical injustice. Yet instead of having a conservation about this and accepting that 100% is neither possible or necessary, cheered on by the gesture left, some countries are opting for compulsion and vaccine passports– others, like the UK, for indirect compulsion.
Gestures backfire. Those vulnerable UK care homes, for example, are staffed by the poor and BAME groups (67% in London) who have most reason to be suspicious. Because nothing else much has been done to solve the infection problem, the UK government demands that they all be vaccinated or lose their jobs. How many care home workers will vote with their feet is unclear? But if they do who would blame them for choosing to quit or go to Amazon for £13-50 an hour?
Ill thought-out gestures always create ‘blowback’. Many more examples will be uncovered as the pandemic diminishes. The question will then be why we preferred gestures and public health by spectacle to a search for evidence of what might work and genuine reforms that could really reduce long term risk.
(1) Most epidemiology is based on the search for links between variables. Do smokers get more lung cancer than non smokers. The trouble is that that these observational studies can be less persuasive than we think because of confounding factors – things that confuse the link. In a randomised control trial, groups are matched as closely as possible to minimise the differences. For an example of how this should work see the Bangladesh mask study.