I could see his future and in it was illness and suffering. I told him the rituals to prevent his forthcoming suffering. Small doable steps. But he did not believe me.
A month back, a few days before the lockdown, I went out grocery shopping. The shopkeeper retuned from a loo-break, rinsed his hands with water and started servicing my order. I requested that he wash his hands with soap. And this simple, reasonable request quickly escalated when he patronisingly smiled and responded, “my hands are clean, I just washed them”. Appalled, I explained the germ theory. He quipped back, I can’t see germs! Exasperated, I talked about microns, viruses and microscopes. He mocked me for my English education. I told him about diseases, including the pre-recorded messages before phone calls on Corona virus. He said, only those who are afraid will get it. Finally I insisted that I buy him a soap to wash his hands. He responded that he had one in the shop but he doesn’t need to use it.
With the Corona virus threat and repeated precautionary advisories of hand-washing on every conceivable medium, the program officers in WASH (Water, Sanitation and Hygiene) programs had surely never seen such a massive campaign for hand washing. And yet, the man across the counter did not change his behaviour! It puzzled me to see the lack of efficacy of such a large, aggressive, incessant campaign for this urban, semi-educated merchant.
We believe!
The problem was not his knowledge, it was his belief. As sentient beings we need beliefs as an anchor for our sanity — to somehow explain the unknown, bizarre universe around us. Thousands of years earlier, when we did not have the advancements in science that we take for granted now, people explained the unexplained through stories and tales — of Gods and supreme powers; of fairies and demons; of heaven and hell. These stories passed through generations; twisted, turned and evolved — to finally take the form of faith and religion. It is what we believe in! We always have. This is why we celebrate Christmas, fast during Navratras (Hindu religious period), enjoy Eid. But frankly, like germs, none of us have really seen God. Strangely, while we have seen neither, we don’t believe in one and are ready to kill for the other.
For more than two decades, health communication specialists (now referred to as SBCC- social and behaviour change communication) have applied numerous strategies, spent billions of dollars, worked on hundreds of programs to make hand-washing a habit for all- often unsuccessfully! The lack of efficacy of these initiatives is not due to the lack of quality, talent or enterprise. It’s simply because there are two systems of thinking (for those zealous behavioural scientists- this is not System 1 and System 2) and we are still trying to decipher how to lock one into another. We have been missing a piece of the puzzle and I just found it!
The Faith-Science Maxim (The two systems of belief)
There are ancient Norse stories about roaring thunders and heavy rains revolved around Gods being angry. We can find references, or rather caricatures, of some of these miraculous Gods in the ‘Avengers’ series as Thor, Loki and Thenos. In India, the sun, the moon and stars have been worshiped for millennia. Norwegians and Indians, both polytheistic civilizations, believed in Gods representing thunder, animals, rivers, birth, growth, death, war, trickery, time and many more. And over time, civilizations created stories and folklore to explain the periodic flooding of Nile, the miracle of birth, the mystery of death, the hope for victory in war — passed on from village to village and generation to generation. As sentient beings, we have always wanted control of (or at least, an ability to affect) our destiny. And so came the priests and the rituals. And just like that, we started believing that if we do a certain set of actions in an exact fashion at a specific time, we can hope to get a vaguely positive consequence. We followed these blindly. Because we believe without question. And religion was born with priests closest to the Gods. The fuel religion works on is unquestioning faith. And asking for proof is blasphemy!
Science has always been in the crosshairs of religion. It’s because the two work on very different and incompatible operating systems. While religion works on ‘faith and belief’, science works on ‘evidence and exploration’. Scientific thinking demands reason, evidence, deductions. It works on maths, equations and theories. It discards old and births new. It revises and upgrades knowledge; it alters old theories and accepts new ones. It works on cause and effect.
Because these systems are so different in what they can conceive and imagine, what we find plausible through the prism of our chosen belief system (science or faith) is equally different. And therefore while one may find it hard to believe in God of thunder or war, other may find hard to believe in the germ-theory. — both things invisible to the eye. There are those, therefore, who do not believe in vaccination or the water cycle or climate change. For them, it could be God’s will, their sins or destiny.
Education, especially that of science- even at the most rudimentary high school level — trained us in the art of enquiry. It taught us to challenge and demand evidence. But mostly it gave us the courage to reject or accept ideas based on evidence rather than blind faith. Due to this training, we can believe in black holes, viruses and dark matter, — even if we have not seen them with our own eyes. Simply because someone has used logic, math and science to provide proof. Education converted us from the belief system of ‘faith’ to belief system of ‘science’.
As public health experts we try hard to explain the scientific theories (our beliefs) to those who are non-believers. And when our ‘scientific’ arguments go against their (religious or normative) beliefs, we hit a brick wall. This is compounded by anchoring bias and confirmation bias. (for the uninitiated- anchoring bias is when people rely too much on pre-existing information or the first information they find to make their decisions. Confirmation bias is when people focus and favour information that confirms their previously existing beliefs). In a community where most follow religious and cultural beliefs, conversion towards science becomes difficult because of these biases, even for the most receptive. Dirt is visible. That is an anchoring bias. Diseases are caused by evil spirit. That is an anchoring bias. And when a sick person gets better after a common flu (or in their understanding get better due to a ritual told by a quack), it causes confirmation bias. This self-perpetuating cycle of beliefs and biases at a community level turns to norms. And norms can be very persuasive for ‘acceptable behaviours’ and very discouraging for ‘unacceptable behaviours’.
The missing piece- Ability to conceive
I am not to imply that people who are religious or work on normative belief are irrational. On the contrary, we are all rational being — at least at most levels — and experts in understanding the cause and effect doctrine. If a child falls and cries, irrespective of one’s belief system, we understand that the child fell, got hurt and consequently is crying. If a person cuts himself, applies Dettol and the bleeding stops, one comprehends that Dettol will stop the bleeding. So if both systems depend on establishing cause and effect relationships, why are the two systems different?
The true test of whether one follows the scientific system or normative system comes in our understanding of cause and effect relationship between things that we cannot see. We cannot see black holes. However, scientists have recently taken pictures, carried out calculations, observed the movement of galaxies through high powered telescopes to establish that they very much exist. Because I believe in science, I believe in blackholes. Now try explaining this to a person who believes in Rain-Gods!
Where cause and effect is invisible, those who do not understand the scientific paradigm, almost always go with faith. It is because what you cannot conceive you cannot believe and what you cannot believe you would not act upon.
The development sector has struggled with promoting appropriate complimentary feeding (including feeding of eggs) for children who are 6 months or older. But the baby is small, has barely got any teeth, no one can see the size of the stomach and it is simply unintuitive that a six month old can digest eggs. So, science be damned, I will believe in what I see and what I have known for long (anchoring bias). And what I see is small baby who does not have teeth, cannot digest foods such as eggs and no one sane would feed her that.
We have seen similar problems with vaccination. When a child is sick, mothers try home remedies and visit the health centres for medication. Because the cause is illness and the effect of medication is a cured happy child, mothers believe that illness can be cured by medicine because the cause and effect is visible. But, to explain — that we will inject microorganisms into the body of your child — that may lead to fever for a couple of days; but would create antibodies; that would in-turn protect your child from a disease that you may not be aware of, is simply abstract. We are giving scientific reasoning to a mother who believes in religious and cultural norms. She falls back towards her comfort-zone and avoids anything to do with fever or crying baby or injections. By God’s grace, her baby is healthy and happy today. And that’s all that matters. What she sees, she believes.
Similar struggles have been faced to create compliance for IFA (Iron Folic Acid tablets) among pregnant women. A 180 day regimen of one tablet a day is prescribed to prevent maternal anaemia (and potentially prevent puerperal sepsis, low birth weight, and preterm birth among many other complications). But, ‘pills are for sick people’. Pregnancy is not considered sickness. And, critically, iron in blood is invisible, blood cells are invisible, anaemia is invisible. The cause and effect relationship is both unclear and invisible.
So the lecture of the health worker about anaemia, birth weight, preterm labour, placenta previa, premature rupture of membrane, cardiac arrest, and haemorrhage, lowered resistance to infection, poor cognitive development and reduced work capacity — simply does not stick. And with good reason — the women cannot imagine and believe the unknown, unseen vague benefits that the health worker is talking about. What she does experience are the immediate side- effects of IFA pills — constipation and stomach discomfort! And that cause-effect is visible and clear and leads to discontinuation.
The Possible Solution
The clash of the two systems — the scientific and the normative — has led to incremental behaviour change for an exponential investment. And it is, therefore, worthwhile that we focus on the audience to evaluate what they can comprehend, conceive and critically, imagine. Because what they cannot imagine or believe in, they will not do. None of us will. As dev. sector specialist (with lofty degrees of MPH and PhDs) we work through the ‘scientific cause and effect’ lens. But the messages are received by the ‘conceive and believe cause and effect’ lens.
So there are three core solutions that we need to consider:
1. Make cause and effect visible. In Ethiopia, while working on Alive and Thrive, a project funded by Bill and Melinda Gates Foundation, we were trying to convince mothers to give thicker gruel to 7-month old children. While the message was clear — thick gruel has higher nutrition value and will make your child healthy and strong — it clashed with the traditional wisdom that such young children cannot consume thick foods. The invisible cause and effect was not a good motivator. However, our insights showed that watery gruel made children cry often, which disturbs the mother every hour. We therefore, changed our messaging to — If you feed thick gruel, your child will cry less often, you will need to prepare meals less often and you can focus on other chores. This message could be tested by the mother. The cause and effect relationship was visible. And it worked.
2. Create Rituals: Rituals are often seen as black magic by the scientists. Because they are not based on scientific evidence and the results promised are vague. But the community believes in ritual because the actions are very specific (which makes the ritual seem credible) and results hinge on your own perfect execution, which shifts the onus of action on you. A great example of how a ritual can be created is: Provide 80 IFA tablets in white colour and the remaining in red colour. Ask women to put a bindi (dot sticker) after each IFA tablet they consume. Explain the details of the ritual — You cannot start the black ones until you finish the red ones. And the child is not protected unless you complete the red ones. This will dramatically increase the compliance of IFA consumption (which in some Indian states is as low as 10–20%).
3. Use anchoring and confirmation biases: Imagine trying to explain what an email is to person who has no concept of a traditional postal mail. Anchoring allows people to contextualize new ideas within the frame of their existing knowledge. In India, the most successful programs (polio eradication and universal immunization) used anchoring by positioning vaccines as ‘tika’ (the black mark put on a child to protect her from evil spirits. Similarly, use of confirmation bias gets the following response — “you are telling me what I already believe in”. This leads to less resistance and higher uptake of behaviours proposed.
Creative solutions that demonstrate benefits here and now, simple doable actions that confer with current beliefs and easy to enjoy messaging that can be conceived may be the way to go!
