community voice

With the alarming growth of COVID-19 cases, our state’s media and leadership have obsessively focused on the public’s “bad behavior.”

All summer, we have read stories about people breaking quarantine and gathering in large groups. In many of these articles, experts and non-experts alike out those who went to work while sick or speculate on whether or not the infected person was wearing a mask when around others.

In nearly every daily news digest from the COVID-19 Joint Information Center, the public is reminded to take personal responsibility. They are shamed for their lack of regard for others: Governor Ige had strong words for people who have let their guard down contributing to the surge in cases.

All state leaders echo the personal responsibility rhetoric, using a public relations strategy that is known as framing. They directly attribute spikes and surges to a misbehaving public, one that is unable to take responsibility for its actions.

Here are a couple of examples.

A top public health official said, “As long as individuals in our communities fail to accept personal responsibility for the spread of COVID-19, we are unfortunately going to see continued days of triple digit numbers.”

Or, from our governor: “It’s clear that many across the state has relaxed their commitment in fighting against this COVID-19 infection … We have to take action to embrace the personal responsibility, to do what we can to slow the spread of COVID-19 in our community.”

Our major media outlets reinforce these sentiments, as demonstrated by a July 8 editorial in the Honolulu Star-Advertiser entitled, “Bad time to let down our guard.” Or more recently, in an Aug. 10 article in Civil Beat that asks, “So how badly are people behaving?”

Should we expect anything different? A story about an office where workers diligently wear their masks and sit 6 feet apart is hardly click-bait.

Nor are perhaps the more important questions about that office: Did the employer provide enough hand sanitizer? Is there sufficient ventilation? Do the workers have sick leave if they get ill? Are they paid enough to take time off?

Responsibility Rhetoric

While there is certainly evidence of poor decision-making, and we must all do our part, blaming the public for the current crisis obfuscates the responsibility of state and local leadership.

If the public is to blame for the current surge in infections, then our leadership is no longer responsible. It is an evasion technique that avoids asking hard questions, making hard choices, and more than anything, it avoids accountability.

Blaming the public allows for inaction on contributing factors to the spread of infection. These include limited access to health care for certain groups and for those that have lost their jobs, the lack of sick leave for many, insufficient wages to match the astronomical cost of living, and overcrowded housing that disproportionately affects our highest risk groups.

The use of personal responsibility rhetoric is one that the tobacco industry mastered in the early 1980s. As evidence mounted that Big Tobacco was responsible for the deaths of millions, it needed a public relations strategy that shifted blame elsewhere.

Through some trial and error, Big Tobacco realized that framing a public health crisis around personal responsibility was highly effective at reducing public outrage and in minimizing litigation. The tactic is so successful that it continues to be used by many other industries and interests to avoid accountability for public harms (e.g., gambling, firearms, etc.).

In the past month, Governor Ige reiterated the importance of personal responsibility at nearly every daily press briefing. Nearly all mass media venues have parroted this language, as have all the most prominent elected and appointed leaders involved in the response to COVID-19.

To be fair, our state leadership is not alone in using this framing. The rhetoric of personal responsibility is also coming from the federal government.

For example, here is a transcript from the Centers for Disease Control and Prevention: “We owe it to our nation’s children to take personal responsibility to do everything we can to lower the levels of COVID-19.”

Knowing the occupants of our executive branch, should we really be surprised that the federal government is applying techniques learned from Big Tobacco to defer responsibility for the crisis?

Punitive Action

If a badly behaving public is responsible for out-of-control infections, then a natural extension of this logic is to punish the public when it misbehaves. The criminalization of previously normal and healthy behaviors, such as walking on the beach or in a park, reflect this logic.

Our state is currently using police and other security personnel to enforce restrictions on a variety of behaviors for which such actions would have been unimaginable six months ago. What’s more, it is unclear if the targeted behaviors currently pose a risk to public safety.

State officials appear unable to provide epidemiological evidence to justify many of the restrictions. The lack of evidence of major outdoor transmission events, especially when juxtaposed against other known sources of outbreaks, threatens the perceived legitimacy of these restrictions.

Crucial consideration of the fairness and proportionality of the punishments for our misdeeds is lacking. Bad behaviors, such as hiking, walking in a park, and going to the beach, are all now subject to criminal misdemeanor charges that can result in a fine up to $5,000 and/or a year in jail. In other words, members of the public who engage in these behaviors are subject to the same punishments (actually, in many cases, less) as those who committed a DUI, assault, or minor drug crime.

A Cautionary Tale

Personal responsibility rhetoric is effective until it is not. In the face of public demand for greater accountability brought on, in part, by whistleblowers leaking evidence of the deliberate misleading of the public, Big Tobacco became vulnerable to a flood of litigation in the late 1990 and early 2000s.

The public relations strategy of Big Tobacco ultimately failed because the public can only take personal responsibility for their behaviors when they are empowered to do so.

For combating COVID-19, this means doing much more than giving daily press briefings and public safety announcements. People need clear messages, articulated in ways and languages they understand and across media platforms they actually use. They need support to follow the messages.

As we are learning, not everyone can access masks and other personal protective equipment. And, many people do not have or cannot afford to take sick leave.

For those with low incomes and no sick leave, the choice is often between paying for food and rent or staying at home when sick. Asking people to change “their bad behaviors” under such circumstances not only lacks empathy, but is almost certainly doomed to fail. Other actions are thus needed, including in this case, policy change to provide sick leave to our most vulnerable.

A Final Warning

The engagement of police in public health is risky business. As articulated in this excellent commentary, the use of police to enforce measures perceived as illegitimate fundamentally damages the relationships among the state, police, and public. This, in turn, can generate disorder and damage the foundations of democracy.

When done well, police can be successfully engaged in outbreak control, but their application needs to be targeted and information driven. The United Kingdom, for example, is using an approach built on the concepts of “engage, explain, encourage” and “enforce” only when necessary. It is an approach that seeks to build public cooperation, which is a necessary prerequisite to managing the virus.

COVID-19 restrictions will have to be applied to varying degrees for months to come. We need a maximum of public goodwill and cooperation.

Unfortunately, our response is eroding these fundamentals. At the end of the day, the question really begs asking, who is it again that is behaving badly?

About the Author

Catherine Pirkle is an associate professor in the Office of Public Health Studies at the University of Hawaii Manoa. She is a global health researcher and life-course epidemiologist who has done work in sub-Saharan Africa, Latin America, and the Canadian Arctic. She is also a lead investigator for the Health Hawaii Initiative Evaluation Team, which works in close collaboration with the Hawaii Department of Health.

Originally posted at Civil Beat

This week, the Legislature is convening to make critical spending decisions for the future of our state. Most of these decisions will dictate how we address our local COVID-19 outbreak.

I offer here the perspective of someone who has worked for over 15 years in some of the most severely resource-constrained settings in the world. They’re based on my professional experiences working on another global pandemic — HIV/AIDS.

I began my career at a unique historical moment in which global funds to address HIV/AIDS went from almost non-existent to spectacularly abundant. This happened in 2003 and coincided with President Bush’s State of the Union speech in which he simultaneously announced intentions to go to war with Iraq and a $15-billion-dollar relief package to address HIV/AIDS.

The decade to follow was a remarkable time for research and action, as well as for critical reflection about our responses.

I present three considerations from my work on HIV/AIDS that may provide lessons for moving forward with our responses to COVID-19.

The first consideration is “Know your epidemic, know your response.”

This slogan was led by UNAIDS, the United Nations agency responsible for strategic direction in the global response against HIV/AIDS. The slogan recognized that there is no single HIV epidemic, but instead many diverse ones that reflect the unique social, demographic, economic, and health system characteristics of the places where they occur.

As such, no singular prevention or treatment solution exists. This lesson equally applies to our current COVID-19 outbreak.

“Know your epidemic, know your response” is a reminder that successfully combatting a disease requires nuanced insights into the people infected and affected, including broader community expectations around behavior. Most human health conditions, including those caused by infectious organisms, are rooted in people’s behaviors. People’s behaviors are constrained by social structures.

Social structures broadly describe how we organize our society and the institutions that govern our actions. Our economic and political systems are examples.

Public policies also reflect these, including how we fund health services, who has access to those services, and which services we deem most important. Social structures also manifest in how we define groups — race, sex, occupation — and how we treat those groups, including the options that are available to them to protect their health. Not everyone is treated equally, nor have the same options available to them.

Waiting For A Vaccine

This brings me to the second consideration, biomedicalization.

At varying moments over the past four decades of addressing the HIV pandemic, there were intense debates about who should be “at the table” to address the problem. At times, the epidemic was viewed as “a medical problem best addressed by purely technical, biomedical solutions whose management should be left to biomedical professionals and scientists.” This is biomedicalization. Such a response searches for singular solutions — such as a wonder drug or vaccine — to solve a complex problem that cannot be parsed out from the complicated ways people behave and interact, and the inequalities between people.

This is no different from now. All of us, including myself, are hoping for a silver bullet solution like a vaccine. There are no guarantees one will be developed. In the meantime, we must address the ongoing pandemic. Diagnostic tests and case-tracing are critical tools to effectively address outbreaks across the globe, but they are insufficient. A purely biomedical response to the disease will fail, because it doesn’t consider the people and communities in which disease transmission happens. It ignores the behaviors, and social structures, that facilitate or prevent viral transmission.

This brings me to my final consideration — vertical approaches.

When we biomedicalize a response to a given health condition, like COVID-19, our actions and funding tend to concentrate exclusively on that condition and a set of limited technical solutions to resolve it. This is a vertical approach. While vertical approaches make sense, especially when resources are scarce, they often do not work as intended.

The problem is that most deadly diseases, including COVID-19, are efficient at reaching the vulnerable members in our society. The much higher rates of infection, hospitalization, and death among underserved and marginalized racial/ethnic minorities in the US exemplifies this point. Vertical approaches are incapable of addressing the complex factors that place certain groups at higher risk than others.

The other issue with vertical approaches is the challenge associated with implementing them within health systems and public health networks. Neither function well vertically. When we throw all our money and effort into addressing a singular disease, we risk creating duplicate systems that compete with each other.

After President Bush’s State of the Union speech in 2003, large sums of money went to vertical, heavily biomedical approaches. In general, this new windfall could not be used to build capacity within already fragile health systems.

The result was a fracturing of the existing health system. For example, staff who once treated critical medical issues like malaria or worked in delivery care took better paying jobs working on HIV/AIDS.

Bolster Resources

Governmental agencies limped along with sparse budgets, while newly created HIV/AIDS units flourished. But, these new units could not be sustained without external infusions of money. Because of this, they often lacked independence to make decisions pertinent to their communities and funds frequently flowed in inexplicable ways driven by external donors unfamiliar with the local context. In other words, “Know your epidemic, know your response” was ignored.

We can learn from the considerations above. For example, to properly know our epidemic, we need to identify and target the unique social vulnerabilities that place certain groups in our state — for example Filipinos and Pacific Islanders — at higher risk than others. To do so means avoiding an exclusively biomedical response, part of which requires a diversity of perspectives, including from social scientists and community leaders, to guide the response.

Finally, there are risks to vertical approaches that seek to bolster resources for a singular health condition while failing to support the broader system in which these approaches are implemented. To successfully combat this disease, we should limit our dependence on unsustainable external funds that create siloed, vertical programs, with a limited number of technical fixes, rather than reinforce the whole system.

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