The matter of masks
Beating Covid requires behavioural change. But that’s not going to come from coercion; the government needs to inspire compliance through grassroots organisation
President Cyril Ramaphosa likes to remind us that Covid-19 is caused by a virus, but spread by human contact and behaviour. It is, indeed, important to acknowledge that the spread of the disease will be determined by the choices we make and how we behave.
But it is troubling how often the government has relied on fear, fines and brute force to force behavioural change. For example, hundreds of thousands of arrests were made in an attempt to enforce social distancing and stay-at-home policies. It is easy to interpret this as both a sad reflection of our broken society and of our lack of trust in the government. But it should be acknowledged that, at least in the initial phases of the pandemic, there was substantial urgency and peril, and it was understandable that the government resorted to command-and-control strategies and high-stakes penalties.
Many experts now say that the coronavirus is likely to remain a threat until 2022 — which means we need a change of strategy.
Behavioural change and social norms cannot be legislated or established by decree; they are promoted, encouraged and nurtured through grassroots partnerships with local champions. This has been true of the HIV/Aids epidemic and it is true of the current pandemic.
In the recent National Income Dynamics Survey: Coronavirus Rapid Mobile Response Survey (Nids-Cram), we found only half (53%) of the more than 7,000 respondents wore masks.
Studies have shown that for masks to have an effect on infections and the trajectory of the disease, at least eight in 10 people would need to wear them.
One can also argue that widespread compliance with mask-wearing is even more important where, as in much of SA, dense neighbourhoods make it difficult to avoid close contact. But we found that only 35% of respondents complied with both mask-wearing and either avoiding any contact with people, or avoiding close contact.
On Sunday the government said it was responding to low compliance by making it mandatory to wear a mask in public places; enforcement has now become the responsibility of employers, shop owners, managers and public transport operators.
The concern, however, is that this may do more harm than good. Given the high burden already borne by shop owners and facility managers, it may result in superficial compliance. For instance, shop owners or operators may keep a number of "communal" masks at hand for those who don’t comply, but then recycle these through the day. That would be not only unhelpful, but actively harmful.
The fundamental challenge is to motivate people to behave responsibly for the benefit of others: the elderly are the most likely to die from the virus, but prime-age adults are more likely to be infected. This problem is likely to grow, as we encounter an increasing number of first-hand stories of successful recoveries that counter the fearful narratives we read in the media. The panic will subside and the fears will fade.
For this reason, it’s important to invest in community-based initiatives, with local champions to establish social norms and an understanding of the importance of social solidarity. We need less fear and coercion, and more inspiration and hope; more bottom-up engagement, fewer top-down orders.
Fear can be counterproductive, discouraging people from seeking care. Administrative data has already shown decreases in primary health-care utilisation, such as antenatal care visits, vaccinations, HIV check-ups and TB tests. The government has reported a 50% reduction in TB tests carried out, and a 30% decline in measles vaccinations.
In an SMS survey of more than 3,000 new mothers and pregnant women who rely on the public sector for health care, we found that one in four had missed vaccinations and one in 10 of those who need antiretroviral treatment reported running out.
Both groups overwhelmingly cited coronavirus fears as the reason for missed clinic visits. Such fears are higher in poor and vulnerable communities.
The government’s continued reliance on regulation is concerning and may reflect a disconnect with the communities it represents and governs. It is clear that change is required to enhance the government’s community responsiveness and engagement — but that may be an uphill battle.
During the lockdown, it has been encouraging to see some inspired and strong leadership from Ramaphosa. At his best, he gave us not only a reason to believe that he will lead us through this storm, but also vision of a shared future beyond this pandemic.
Such a vision of hope is what we need to propel SA forward. To sustain the strength and resilience that’s required, we need a vision of how we will repair relationships of trust and respect to create more functional and responsive systems. To navigate the coming calamities and challenges, we need to turn away from fear and subjugation, and foster change in the name of hope.
*Burger is a professor of economics at Stellenbosch University. For more information on the Nids-Cram survey, visit http://www.cramsurvey.org
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