When ‘Just do it’ doesn’t work in public health

Communication is an essential component of public health. While there is considerable clout behind its regulatory powers, much work in public health involves education and persuasion. Compliance with safety advisories is often difficult. Without trust, you can forget it.

An epidemic is “a moment of truth between communities, health officials and the overall system of government,” according to one physician who has worked on public health crises throughout the world. Most Americans trust scientific experts in their assessments, yet they stubbornly disregard following their advice, especially when that advice is delivered arrogantly.

Dr. Ranu Dhillon, a public health physician at Harvard University who worked on the Ebola crisis in Guinea, says public health communication should accept “shades of gray.”  Dr. Dhillon suggests that in their desire to be authoritative, public health experts have eroded trust by not accurately communicating uncertainty and by being stubborn about correcting the record when our understanding evolved.

In the case of the coronavirus pandemic, the situation evolved almost daily, and with-it public health recommendations – and politics. Initially, masking wasn’t required, in fact, it was dissuaded to protect the supply for essential workers. But as the asymptomatic transmission of the disease because evident, masking became highly recommended. Many Americans asked why, while others openly rebelled against the advice, along with other public health orders.

Health Affairs recently published a blog about lessons learned by the 1918 influenza epidemic: Masking doesn’t work unless the masks are constructed and worn correctly and part of a comprehensive social distancing strategy  (https://www.healthaffairs.org/do/10.1377/hblog20200508.769108/full/). The basic components of the strategy include:

1. The primary purpose of wearing a mask is not to prevent a healthy person from getting sick, but rather to prevent people already infected from contaminating others through casual contact. Recent research is beginning to validate that masks also protect the wearer.
2. Masks must be worn correctly and consistently, fully covering the nose and mouth, with enough layers to prevent the spread of droplets.
3. Wearing masks is a “collective declaration that a serious disease requires that the behavior of the entire population must change”.
4. Perhaps most relevant to the current dilemma in the United States, countries that prize individual expression and personal rights must anticipate resistance to these measures.  whether they are exhortatory or legal. In 1918, many were arrested for not masking when simply ordered to do so. Wearing masks means accepting that community welfare supersedes individual preferences.
5. Masks combined with other forms of social distancing has proven effective.

The Nike adage “Just Do It” doesn’t always apply to public health, at least not with the stubborn minority of people who would rather not “do it”. The degree to which one can be persuaded that it’s the right thing to do, or that it’s socially popular, or that there would be some sort of reward, generally predicates success.

People may have a high degree of trust in Dr. Anthony Fauci, yet they will still prefer not to wear their masks. It’s a confounding communication challenge that changes from one public health crisis to another. But it must be addressed with no less vigor and attention to detail than contact tracing or data analysis.

Dennis Archambault is vice president of Public Affairs for Authority Health.