Paternalism & Pessimism in Public Health

Public health has had its big moment during the COVID-19 pandemic. The often maligned field has become centre stage for the last 18 months. However, it has become obvious recently that paternalistic and negative attitudes have not only backfired, but become less effective than liberal and optimistic attitudes. In this piece, I refer to the COVID-19 situation in Australia, where 83% of the 12+ population has already had one dose of vaccine, and 64% are fully vaccinated, with millions more to be vaccinated. How did this happen? By countering the paternalist culture in public health.

In New South Wales. 91% of over 12s have one dose, and 77% are fully vaccinated. This is despite the state having huge vaccine hesitant population. The other successes include Australian Capital Territory (home of our capital Canberra), with 97% of over 12s with one dose, and Victoria, with 87% of over 12s with one dose. What do all of these states have in common? They have suffered through months of lockdown due to active COVID-19 outbreaks. They have all promised increased freedoms to fully vaccinated people instead of the more “acceptable” lockdown to zero characteristic of Australian COVID policy.

“Hoist it” graphics made by @Glaven1994 have become a symbol of Australia’s unstoppable vaccination momentum

The biggest success story to me is New South Wales (NSW), who have achieved world-class vaccination rate “in spite” of a Liberal Party Government. However, I would argue that Liberal Party values worked in favour of achieving this high number. Let me explain. Recently, a thread from public health journalist Melissa Sweet criticised the NSW Government approach to ending lockdown and committing to reopening.

• Her first criticism was that the NSW politicians should have focused on cautious messaging through the swiss cheese model. However, this model is not as relevant in a post-vaccination environment. Its creator Ian Mackay recently admitted that catching COVID was inevitable. The model assumes a Zero Covid mentality where everything must be achieved to prevent Covid infection. It also ignores that NSW reopening restrictions are also highly conservative and prioritised to fully vaccinated residents.

• Her thread was marked by a paternalistic attitude to alcohol drinking and going to the pub. Namely, the idea that Australia’s drinking culture is shameful and should not be promoted by politicians. However, this misses the point on several levels: Firstly, Australians love to go to the pub, they love politicians who can relate to themselves, risk is inherent in all aspects of normal life, and the alcohol industry made a lot of money during lockdown taking advantage of lonely and isolated individuals.

• Her other criticism was that the focus on the pubs did not address structural health inequities. Fortunately, decisions from NSW and Federal Health Departments have actually addressed this: they have done a terrific job to counter vaccine hesitancy in vulnerable communities, and now Australia has reliable access to the monoclonal antibody treatment Sotromivab.
• Finally she argued that politicians should not be setting examples that will overwhelm emergency departments; however, vaccinating 90%+ of the adult population is actually an excellent way of achieving this goal.

Another theme that has been countered is the idea that health advice overrules everything. This was perfectly articulated by Waleed Aly on the show Insiders on September 12. He argued that “The politician’s job is not to follow health advice. Their job is to take health advice, consider it, and place it in its proper context”. In essence, he was arguing that the logical consequence of following the health advice means tearing up liberal democracy. Politicians need to step in to consider additional factors. If they don’t, then serious social consequences follow, like large-scale protests of union members in the heart of Melbourne.

The CFMEU protest started as angry union workers, and devolved in to anti-vaxxers doing their own thing

Going back to Sweet’s thread, the NSW Government’s strategy to open the pubs goes completely against the “health advice”, but taps into something deeper: people want their lives back and vaccination is the primary outlet to achieve this. NSW did not achieve 90%+ vaccination because they wanted to protect the vulnerable, or reduce their odds of getting sick (though these help): they were motivated by the individualistic (some say selfish) desire of freedom. Politicians understand this in a way that health experts are oblivious. An example of this attitude was when Virgin Australia promised reduced flight prices for fully vaccinated. Some public health experts criticised this announcement at the time because “vaccinated people can still catch and spread the virus”, and “we aren’t safe until the world is vaccinated”. However, counter to public health paternalism: the focus of promised returned freedoms ends up creating the positive externality of higher vaccination.

The ironic consequence of religiously following the “health advice” is reduced buy-in to public health measures. This contrast is most obvious when comparing NSW and Victoria from the turning point of mid-August. NSW focused on the carrot of reopening the economy at 70% to drive up vaccination rates despite widespread criticism from the media and public health experts. Meanwhile, Victoria under the advice of Brett Sutton and the support of media and public health experts focused on doing whatever possible to bring Victoria to zero cases. The classic example of this contrast was NSW promising eased restrictions once a vaccine target was achieved (in the form of outdoor picnics) versus the closing of playgrounds in Victoria. While the closing of playgrounds made logical sense from an infection control perspective (after all, you can’t deny that outdoor transmission exists), it assumed that the public would have 100% compliance. In reality, this measure was the breaking point for lockdown compliance and led to perverse incentives like people secretly visiting people in homes.

While the Victorian Left has been eager to blame the Murdoch Media for the polarised attitude to public health, the attitude of the Victorian government has been fairly negative and unempathetic to non-COVID concerns. Victoria’s press conferences having a continued theme of pessimism, which has been contrasted by optimism at NSW press conferences. Examples of this include Andrews’ inconsistent messaging about vaccine supply, the hostile attitude towards vaccine hesitancy in construction workers, and the focus on long-COVID and sick COVID patients. However, it’s worth noting that all of this subscribes to Sweet’s argument that politicians need to continually remind the public to take precautions and solidarity to their vulnerable and at-risk colleagues e.g. health care workers, disabled, Indigenous.

To date, it still seems like Sutton is committed to Zero Covid, and this is evident by his close ties to the Burnet Institute and Twitter endorsements of Eric Ding and Zoe Hyde. Fortunately, it seems that Andrews has realised that it’s politically impossible to maintain lockdown as per Sutton’s health advice: Victorian compliance has worsened and worsened as cases refuse to peak. This was most obvious with the opening of crowds to the Melbourne Cup in November, and the recent (as of today) announcement that fully vaccinated people would be allowed home visits once the 70% full vaccination threshold is met.

The “Dingster” has been a constant figure influencing health advice across the world.

A tertiary example of the problems with paternalism and despair has been my home state of Queensland. Despite the state following all the rules prescribed by the public health orthodoxy it has a serious problem: not enough Queenslanders want to be vaccinated. I argue that this problem is multi-faceted but all linked by a reliance of paternalistic attitudes to public health.

• Chief Health Officer Jeanette Young trashing the AstraZeneca vaccine because of risks in a Zero Covid environment. Technically, she was correct, but she has helped fuel anti-vaccination sentiment across the country due to not considering the heightened health risks of unvaccinated young people from the Delta variant. Queensland has also been incredibly reliant on the Pfizer vaccine, meaning that it is more sensitive to supply shocks than elsewhere.
• The Premier Annastacia Palaszczuk being very reluctant to reopen the Queensland border. It’s possible that this attitude is a personal belief in Zero Covid, but it might also a fear that any level of COVID would overwhelm Queensland’s poorly resourced hospitals. This has led to the contruction of a quarantine facility called Wellcamp, near Toowoomba, which does not make sense in a highly vaccinated population, but makes perfect sense as a counter to “living with COVID”. Recently attitude this has also led to some sensationalist statements, like 70 deaths per day from reopening, or disparaging anybody who wants to travel outside of the state.

“Why would you want to go to India?”

Both of these factors display correct public health attitudes but miss the big picture: as long as Queenslanders are not threatened by “living with COVID”, they do not see the rush in getting vaccinated. Despite some “interesting” choices to get Queenslanders vaccinated like Bunnings, and a poem about roller skates, there is not enough demand to get Queensland to its goal of 90% full vaccination. Queensland’s over-reliance on paternalism means it faces serious trouble: face overwhelmed hospitals, or sacrifice its tourism industry.

In summary, I believe that paternalistic and pessimistic approaches to public health don’t work in practice. The most effective long-run approach is to promote optimism and treat the public like adults.