On Teaching Public Health

Organizations have done such a bad job of explaining Covid to the public over the last almost four years, that it will be difficult to ever get mitigations back in place. 

Research director with a PhD in education, Dr. Sean Mullen said incredulously, 

"They said herd immunity would work. Then hybrid immunity. What's next? They should just come out and say it: Hocus-Pocus, Hail Mary Hypothetical Immunity. Seems we've been banking on magical thinking, prayers, and theories rather than results. Hallucination immunity. Might as well be dreaming."

When asked why health care professionals aren't masking he explained why he thinks people in general stopped:

"1. People can't stick to things, period. Research on any health behaviour and it's over 50% stop within three to six months. People can't even take their blood pressure meds regularly after a heart attack!!
2. Survivor bias and other logical fallacies. Everyone knows people who've been infected over one time (most of the living had the experience). Survivors had 'mild symptoms.' Must not be that bad, right? It's just 'other people' (with XYZ) who are 'vulnerable.'
3. Mainstream media silence and propagation of misinformation. It impacts culture. If people aren't talking about it on TV, why would they discuss it while on break? Then media picks up on a controversial study, like the Cochrane review that no one interpreted correctly (and the hidden agenda). Note that no one is talking about the recent RCT showing efficacy of masking or the horrifying data showing neural cell fusion or autoimmune effects (just two examples). 
4. Why should the average clinician stay on top of scientific papers (especially when it's not covered in media or is downplayed by 'experts')? They didn't pre-pandemic; why would they now?
5. Normative peer pressure. Nearly everyone succumbs to the majority of peers.
6. Low relevant health literacy (ignorance). There aren't really any experts on this virus. It's novel. It keeps evolving. You'd be surprised how little medical trainees learn about areas outside their specialty area, but they certainly aren't trained in all the areas you need to keep up with this. 

I could keep going, but there are layers to this disaster onion. 

Ok, a couple more: Perceived inability to breathe. Perception that one cannot communicate with something on their mouth. Perception that masking is only to appease others and that it is ineffective. Ego / vanity."  

One commenter added that "the time lapse from going to a super spreader event, or even the grocery store unmasked and the start of symptoms also has a huge part to play. If someone walked out of the large indoor festival and got hit by that covid lightening bolt right away..." Exactly. We need to see the effects of the virus directly. I know a woman who has been surrounded by cases, but never seems to have it, so considers herself somehow immune to it, so won't take any precautions. Meanwhile, she's quite possibly an asymptomatic carrier, like Typhoid Mary, giving it to everyone around her. Because she feels no adverse effects, she mistakenly believes there aren't any. That asymptomatic spread is a big part of the problem. Seeing is believing.

The list reminded me of  Dan Ariely's experience described in Predictably Irrational. He tells the story of having hepatitis C, and having to inject himself with interferon, which has horrible immediate side effects including overwhelming nausea and vomiting. Every other day for weeks, he would gather all his favourite things to reward himself with to override the punishing side effects of the drugs. He saved movies he wanted to see and only allowed himself to watch them after his shot. At the end of weeks of self-administered doses, his doctor told him he's never seen anyone else complete the series before! It's just too hard! So it's clear what's needed to maintain a difficult behaviour: lots and lots of rewards associated with the behaviour. We need images of punishers in our heads if we don't do the behaviour -- he reminded himself that not doing the shots meant a lifetime of problems -- and we need rewards for doing the behaviours. Basic operant conditioning.

We went in the other direction: humiliation, pointing and laughing or random threatening abuse in the streets, and social ostracization for people who continue to wear masks. We could have set up rewards to keep it going, but politicians decided to follow the noisiest supporters instead of actually leading the way through this mess. So it really is amazing that anyone still wears a mask. It's an incredible act of courage.

I have no problems sticking with it for a few reasons. I was affected very early on when I watched a video of a woman who almost died in the hospital, but managed to survive. She told a harrowing story of basically drowning in her own mucus for weeks in a crowded ward with people dying around her daily, with no family allowed in to see her, experiencing a near-constant sense of suffocation until it gradually started to clear. Then stories of Long Covid started coming in, of it sounding a lot like ME/CFS and people needing a family member to help them go to the bathroom. Two of my biggest fears were triggered by these stories: suffocation and my children having to give up their own lives to take care of me. 

From 2021

It's like old-school driver's training videos. I came of age when seatbelts were new, and we were shown gruesome images of a person buried head-first in the asphalt after being thrown through the front windshield of a car that hit a post, so I wear a seatbelt 100% of the time now! Early PSAs about the harms of Covid could have done wonders to prevent the spread and mutation of the virus, but public health was too worried about scaring people that they downplayed the harm to a lethal extent. 

I don't need to do something rewarding every time I wear a mask because it's not a painful thing to do, not like taking interferon. Others might need to set something up for themselves on the daily. But anytime I falter, whenever I'm starting to be convinced by friends that I'm really weird and that it may be a problem that I'm still so "into" all this Covid stuff, I seek out one of the several groups of people online who are also into it all. They're my cheering section that keeps me on track, and that support is absolutely indispensable. The big long term reward is that I haven't been sick for years and years. I biked two 60 km trips this week without much effort, and some people who have had Covid are wiped out from doing groceries. It's hugely rewarding to still be healthy, and I can't imagine doing anything to jeopardize that. No restaurant or concert experience or the comfortable luxury of sipping tea during class is worth the possibility of never again being able to go for a bike ride or throw a canoe on my shoulders for another solo trek around the lake. 

And it's unfortunate that we couldn't do enough soon enough to prevent more illness, but we were scrambling when it all started. I feel like we mainly did our best at the beginning, although I'll never get over forcing students to stay inside for "morning nutrition break" even on beautiful days and even when they went home from school at flippin' lunchtime! But then we gave up everything way too soon, ditching masks before we had clean air. We didn't explain, clearly and definitively, research around airborne transmission, mask effectiveness, CR boxes, waning vaccinations, and the real longterm effects of the virus, which behaves nothing like a cold. Imagine if our Premier put out clear pamphlets about these five things to every household, then supported public health in creating PSAs to further explain them with a few necessarily graphic images behind a warning, and then we just went about our days with masks on whenever the monitors just inside each building showed CO2 over 500 ppm, ensuring clean air in all public spaces, and so much less Covid, RSV, colds, and flu. Imagine if public health's first priority actually was the health of the public.

That's still possible. It's just far more difficult to do now.

Some people are complaining about mask fatigue and vaccine fatigue (despite fewer than 6% of people having had a shot in the last six months). Others are shooting that narrative down with times people did step up to do something difficult for a really long time: People literally hid whole families from the Nazis for years - risking their lives doing the hiding, or tolerating being hidden by living behind walls and in attics and under the porch - for years, but people can't mask? The difference there is that there were repercussion - swift and dramatic - to leaving a hiding place when persecuted. There are no repercussions to not wearing a mask. In fact, it's celebrated that you finally joined the masses in no longer worrying about this virus that doesn't really exist. 

We need to turn around the operant conditioning that has effectively trained so many people to refuse to wear a mask. We need people to be reminded of how serious the repercussions are if they're sick, all the Long Covid stories, particularly about people who were young and healthy, not to get people in a panic, but to make it clear this should be a very real concern and it's preventable. And we need media to celebrate masks and clean air. We need TV shows with popular characters wearing masks when inside public buildings, bitching to each other about the air being so dirty in so-and-so's apartment that they have to have sex in a mask! And we could do all that! We've made huge changes to public behaviour before: getting victory gardens planted or saving bits of string and tin foil. It's also possible to get people wearing masks whenever the air's not clean. 

That is, if we actually want to stop the spread.