Purity and danger in pandemic public health

A socio-historical take on fear messaging

Public health strategies to encourage compliance and behaviour change during the pandemic have been criticised for applying behavioural theories like “nudge theory” to induce fear. The Independent Scientific Pandemic Influenza Group on Behaviours (SPI-B) includes several behavioural scientists and has influenced pandemic policy in the UK. Psychologists critical of their peers’ involvement in this have been raising concerns with the British Psychological Society about their complicity in government’s use of covert techniques to inflate perceived threat levels, coerce citizens to change behaviour and ultimately cause long-term psychological harm.

Our view is that the use of covert psychological strategies – that operate below the level of people’s awareness – to ‘nudge’ citizens to conform to a contentious and unprecedented public health policy raises profound ethical questions.

Strategies to induce fear employed by SPI-B have been explicitly based in psychological theory, but is there a place for sociological and anthropological perspectives in the debate?

In ‘Purity and Danger’, anthropologist Mary Douglas argues that dirt and impurities, when out of place, are interpreted as dangerous in many cultures, driving various cultural practices around hygiene including rituals and religious practices. Dirt must be in the right place (outside in nature, for example) to be harmless; otherwise it must be managed and kept separate with boundaries put in place.

Applying this analysis to understanding public health practices, medical sociologist David Armstrong explored the different places in which danger has been located under different public health regimes. Taking a historical view, Armstrong considers quarantine (common from the middle-ages until the 1800s), sanitary science (dominant from the middle of the nineteenth century) and personal hygiene (emerging in the early twentieth century).

Quarantine involved strict policing of spatial boundaries, implying that danger to health was located in geographical places. Sanitary science located danger in nature such that dirt and poisons had to be kept out of the body by strict policing of the body boundary (specifically the skin and all orifices). Under the personal hygiene regime, danger was located in other bodies.  This is illustrated by the popularity of germ theories which emerged around the end of the nineteenth century, giving rise to bacteriology and the hunt for microbes.  With germ theory, public health began to focus on the boundaries between bodies, which became blurred as the potential for a social (interpersonal) space became salient.  Armstrong illustrates how this led to the “fabrication” of individual identity, making it possible for medicine to concern itself with interpersonal relations, individual subjectivity and psychosocial spaces. This is linked to the emergence of new disciplines in psychology, psychoanalysis and social medicine.

Armstrong’s analysis shows how dominant public health regimes might tap into fears linked to locating danger in places, nature or other people and hence implement policing of the associated boundaries. Nevertheless, at any particular time and place, there are usually a variety of health messages, deviating from or explicitly contesting mainstream public health messaging.  Given the right messaging, people could potentially become fearful of health risks located in places, nature or people all at the same time. Where there is limited scientific or medical consensus around new emerging issues (such as a pandemic), there are more opportunities to invoke these fears to gain support for multiple agendas (commercial, political, personal).

 To illustrate, about 100 years ago, tonsils became a focus of public health concern. Surgical operations to remove tonsils and adenoids increased dramatically from around 1910 in both USA and Britain.  This was financially beneficial for the increasingly important field of surgery within medicine. It was supported by ‘focal infection theory’ which characterised tonsils as “portals of infection”; orifices collecting infected matter posing a risk that infection would spread systemically through the blood causing arthritis, rheumatic fever and mental illness. This has much in common with sanitary science: policing body boundaries, paying particular attention to bodily orifices as highly risky sites.  Tonsillectomies, nowadays understood as highly risky and unnecessary for most children, were effectively becoming compulsory in interwar Britain, activating some opposition but gaining compliance from many. The procedure was forced on school children by school medical inspectors via the threat of school expulsion and prosecution of parents.

Around the same time were concerns about the bowels as a site of risk, a store for bacteria that had entered the body, breached the body boundary. This fear underpinned the New Health Society active in the 1920s which advocated elective colectomies. Around the same time, a core practice in bacteriology was testing of faeces and blood for microbes.  Carriers (a new concept to explain bacilli found in persons with no symptoms) were identified from faeces testing – locating danger in people labelled “carriers”.  Anti-vaccinationists, as advocates of sanitary science, recoiled at the practice:

The bacteriologist would like us to believe… that only by an elaborate specialist examination of our sputa, excreta, blood, secretions and discharges of all kinds can an accurate diagnosis of our health be attained… A repulsive example of the lengths to which medical indecency can go reaches us from the Far East… ‘In accordance with quarantine regulations at Japan ports, Nagasaki or Moji, passengers from Shanghai are requested to have a sample of their faeces in readiness before the ship’s arrival at the first port, for technical examination. The ship’s surgeon will attend to this matter.’ (National Anti-Vaccination League. Vaccination Inquirer and Health Review, 1921)

Clashes between mainstream public health and its critics therefore reflect different concerns about where the greatest danger is located and therefore which boundary must be managed. This has played out in the recent pandemic with different groups of experts advocating for or against lockdown, asymptomatic testing, masks and/or vaccinations. Masks cover the facial orifices indicating danger present in the air, leaving and entering the body through the mouth or nose. Washing hands eliminates dirt that we collect when touching dangerous matter outside our body. Locking children out of schools locates danger both in places (schools) and in certain people (children) framed as disease “vectors”.  Closing pubs and restaurants locates danger in certain places (places we eat and drink as opposed to places we buy food and drink).  Asymptomatic testing identifies dangerous carriers who must be quarantined. Vaccines reinforce our body boundaries; or they inject dangerous foreign matter into it.

As Douglas suggests, apparent contradictions may need to be understood in social, cultural and historical contexts.  While there may be seemingly evidence-based justifications for each scenario, it would be hubris to imagine that current theories of disease transmission will not continue to ‘advance’. Current theories of airborne or surface transmission may seem as archaic in 100 years’ time as focal infection theory appears to us now. Yet, historic, contemporary and future health discourses may still include elements that locate risk in places, nature or people even if the precise manifestation will depend on cultural and historical context. These approaches to analysing public health and health behaviour offer an alternative to psychological and behavioural science which is arguably enmeshed on both sides of the debate rather than being in a more objective position to be able to observe and analyse developments.