This past winter’s “tripledemic” – the convergence of flu, Covid-19, and RSV – is a case study on how community failure to adopt proven hygiene interventions is holding us back. The fact that hospital occupancy surged during an anticipated respiratory disease season shows that current hygiene research and communication is failing to create widespread, habitual hygiene behavior changes to curb preventable surges.
Consider the 2020-21 flu season. The CDC attributed its dramatically fewer illnesses, hospitalizations, and deaths compared to previous years to Covid-19 mitigation measures such as wearing face masks, hand washing, and social distancing.
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One would think Americans who now know how to prevent respiratory disease spread would take measures to do so. After all, the flu comes every year, and Covid-19 is joining it at endemic status.
Yet they don’t.
The challenge here isn’t just with the specificity of our science (though that is part of it). It’s also with how we present it in ways that turn practices adopted in a moment of urgency into long-term habits.
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In December 2021, the most comprehensive study on mask wearing and Covid-19 transmission in Bangladesh pointed to masks’ effectiveness. The science and the methodology were strong: Mask materials were cross-randomized, as were interventions in households and villages. The study was conducted among a specific population in the winter of 2020-2021 and had clear endpoints.
Why wasn’t it convincing enough? An October 2022 Lancet Commission report revealed that opposition to Covid-19 masking reflected, among many factors, low confidence in and inconsistency of government guidance, extensive misinformation and disinformation proliferating on social media, and a lack of adequate behavioral-change interventions. Government guidance was enacted to keep the public safe, but with growing skepticism of authority in times in and out of crisis, the decision to wear a mask was left to individual perceived risk of illness, and, in some cases, risk of mortality. To mask or not to mask against Covid-19 became a decision based on emotion and perception rather than a decision backed by indisputable science.
The January 2023 Cochrane review “Physical interventions to interrupt or reduce the spread of respiratory viruses” created even more confusion. This meta-analysis of masking research purported that we don’t have enough evidence that masks prevent respiratory virus transmission, including Covid-19. But poor science underpinned the findings. Randomized controlled trials (RTCs) in which people wore masks some of the time and continuously were mixed together. The review’s methodology aggregated analyses of mask behavior in health care and community settings – even though there might be implicit social pressure to wear a mask in the former and to forgo a mask in the latter, especially in social settings. Some studies involved self-reporting on mask usage, even though self-reporting is not necessarily reliable.
Many academics and policymakers have pointed out the Cochrane review’s faults. Dr. Tom Frieden, former CDC Director and NYC Department of Health and Mental Hygiene Commissioner, flagged the Cochrane review’s “glaring weaknesses” and shared a robust CDC review of mask efficacy as a counterpoint. Yale Economist Ahmed Mushfiq Mobarak noted that the Cochrane review didn’t effectively address many of the behavioral science questions around mask use, pointing out that more research is needed on the effectiveness of enforced mask mandates versus behavioral change through habit formation.
To say that the Cochrane review conclusively proves that masking doesn’t work, as the New York Times opinion piece by Zeynep Tufekci does, flagrantly disregards the conclusions of the study which express the uncertainty about the effects of masking, as well as the need for “large, well designed RCTs addressing the effectiveness of these interventions.” Jason Abaluck, a Yale economist who contributed to the landmark 2021 Bangladesh masking study has explicitly refuted this line of thinking, arguing that rather than answering if masking reduces Covid-19, if anything, the Cochrane review begs the question, “Do mask distribution and information reduce Covid-19?”
It’s clear that public trust has eroded. Social media is sending mixed messages. And now a scientific review with a shaky methodology has further muddied the waters. Covid-19 wasn’t the first pandemic, and it won’t be the last – and we need to be better prepared for what’s next.
Catalyzing long-term habit formation
Hygiene is humanity’s response to living together in communities. It’s built into religious texts and cultural practices that carry the authority of “belonging.” So how can we create not only short-term hygienic behavior change, but long-term habit formation across the heterogeneous and individualistic U.S.? There is no easy way to change American ideals, but we can appeal to them.
We need to better understand the economic effectiveness of specific hygiene interventions in specific situations, so government officials have more incentives to promote them. We can’t yet show that consistent handwashing is economically beneficial, much less how masking stands to reduce the economic burden of Covid-19-related hospitalizations, or, more broadly, productivity lost to illness during flu season. This is not because these are unknowable things, but rather because the data does not exist.
The 2021 flu season demonstrates that throwing the proverbial kitchen sink at disease mitigation works in the management of infectious diseases, but such interventions are neither scalable nor sustainable. We need investments in peer-reviewed health and economic research, conducted in high-income countries as well as in low- and middle-income countries, to understand exactly what changes when we change very specific factors, and the cost-benefit analysis of making those changes in specific locations. What keeps employees from catching each other’s colds when they’re hot desking in hybrid workplaces? What are the most cost-effective ways to keep the flu from rampaging through an elementary school? How do we measure and explain ROI in a way that is trusted, and not dismissed as “hygiene theater”?
We also need widespread dissemination of that scalable, neutral, credible data so policymakers can leverage it to create change. Press conferences and infographics are important tools, but without unassailable evidence backing them up, the proliferation of misinformation and attacks on guidance will only continue. Public health officials need to be able to say, “mask up for safety, with this type of mask, in these situations, until this particular metric changes,” with the same authority they can now say – after a preponderance of evidence that repelled even the tobacco lobby – “smoking kills.”
The way forward
It has been more than three years since the World Health Organization declared Covid-19 a Public Health Emergency of International Concern (PHEIC). The fall out and loss of life was enough to get people to sing “Happy Birthday” while they washed their hands, cough into their sleeves, and wear masks as short-term and pandemic-centric habits.
But these aren’t Covid-19 precautions. They shouldn’t be considered emergency actions. This is health. These should be habits. Viruses aren’t going away – we call some of them “seasonal,” after all.
To improve public health outcomes, not only at the local and national level, but also globally, we need to invest in hygiene research and those who seek to solve hygiene-related issues. We need to facilitate partnerships across the government, NGOs, and private sectors. We need to foster long-term habit formation that leads to more resilient societies and economies, for this pandemic, for those to come, and to pivot away from the acceptance that “you’re eventually going to catch it,” because when we know and act better, you shouldn’t have to.
Photo: FabrikaCr, Getty Images
David Wheeler is acting executive director of the Reckitt Global Hygiene Institute (RGHI), an independent nonprofit bridging epidemiology, public health, and behavioral insights to generate high-quality scientific research that improves hygienic practices and saves lives.
David is a global leader in developing and executing investments in R&D, clinical science, and analytics to drive highly successful transformations in healthcare. This work has included delivering results across Johnson & Johnson Medical Devices and Medtronic’s Surgical Solutions businesses, as well as working with startup organizations as a consultant earlier in his career. He has consistently delivered development strategies and organizational designs, enabling the successful integration of new procedures and technologies into patient care, resulting in improved outcomes. As a result of his efforts, better, safer care is available to patients worldwide.
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