Analysing the public debate about lockdown: Having adult conversations means admitting that things are more complicated than they seem.

My specialty is policy ethics, so I’m interested in the public debate concerning what lockdown measures we should ease. Various UK political leaders have said they want an “adult conversation” about the best ways to ease the lockdown.[1] It strikes me that we are some way off from having any such conversation, but public health people could play a crucial role in making it happen.

I have analysed some online debates about lockdown measures in the UK.[2] There is an interesting thread running through these debates concerning just how serious Covid-19 is, eg what the actual number of deaths is and how seriously we should treat that number of deaths compared with other causes of mortality. Many contributors distrust government statistics on this question.

Mistrustful contributors split two ways. Group 1 are conspiracy theorists. They think the government is hiding deaths, eg:

The true number is nearer 50,000 dead [not 20,000], but government aren’t counting.[3]

Group 2 consists of those who think the government is exaggerating actual and projected deaths (so this is broadly an anti-lockdown group). Group 2 is the riskier group from a public health point of view. At the time of writing, 9,000 UK citizens have been fined for breaching lockdown rules.[4] Some of these breaches will be the result of Group 2-type scepticism about the rules. In fact, a survey from Kings College London suggests that 9% of the population are resistant to the lockdown. 58% of this group think “too much fuss is being made about the risk of coronavirus” and just 49% of this group are following lockdown rules completely or nearly all the time.[5]

In other parts of the world, resistance has turned to protest. There have been anti-lockdown protests in the USA, Berlin, Vienna, Paris, Tel Aviv, and Southern Russia.[6] Even the UK is not immune.[7]

So, I will focus on Group 2. My purpose is to diagnose why people might think government is overplaying the numbers. I will then compare it with debates the public has had about healthy eating messages, where a similar Group 2 exists. My conclusion is that, to regain the trust of Group 2, public health messages need to be more nuanced. When there are two sides to a public health question, public health people need to acknowledge this.

To summarise the comments from the debate about lockdown measures, Group 2’s comments can be grouped into four broad themes: scepticism about the science; accusations of scaremongering; balancing costs and benefits of lockdown measures; and natural human resilience.

The first theme is scepticism about the science. For example, people say that Covid-19 has not caused as many deaths as have been reported:

COMMENTS:

“Many deaths are reported Covid which while detected was no more causative than a driving licence”[8]

“Testing positive for Covid-19 and dying does not mean it killed you. We could just as well be reporting “dark haired deaths, or deaths with teeth”. The only true indicator is year-on-year respiratory mortality.”

“[deaths] are “with” and not “of” Covid-19. There is a difference.”[9]

“I wonder if, as is apparently happening in the USA, deaths from other causes are falling as Covid-19 deaths are rising? But that would mean death rate is being inflated wouldn’t it?”[10]

“so we are to be under house arrest until there is a vaccine. The same people who told us 500,000 were going to die from Covid-19 tell us we need a vaccine first. oh by the way how many died from BSE — not 150,000 as predicted by same adviser, try 250”[11]

“certain scientific advisers get the figures drastically wrong over and over again, but yet still have their advice accepted and acted up on. foot and mouth outbreak 2001; BSE, 2005; Swine Flu, 2008/09, to name 3 biggies.”[12]

“Last month’s prediction was 260,000 deaths. The more data the better the prediction.”[13]

The second theme is an explanation of the government’s supposedly selective use of figures: the government is scaremongering. In order to minimise deaths going forward, the government will tell us anything to scare us into living more healthily. To this end, either they’re exaggerating the number of deaths, or exaggerating how bad this number of deaths is — when in fact, it’s no worse than seasonal flu and therefore doesn’t deserve the attention it’s getting.

COMMENTS:

“Propaganda. Propaganda, Propaganda. This is deaths of the average flu season.”[14]

“We are being fed a story they want us to believe. Its not gone but it’s much better than Govt imply. Flatten the curve..”[15]

“The temporary corona hospitals of the US military near New York are „largely empty“ so far. Hospitalization rate in New York overestimated by a factor of seven. US study concludes the new corona virus has spread much further than originally assumed, but causes no or only mild symptoms in most people, so that the lethality rate could be as low as 0.1%, which is roughly equivalent to seasonal flu.”[16]

“It was only a few weeks ago when we were being told the death toll would be in the millions. And now we have these new field hospitals lying empty and the number of dead no worse than those that would die of flu in any given year.”[17]

“Last year, 10 million fell ill from TB and 1.5 million died. Coronavirus pails into insignificance against this dataset.”

The third theme is about balance. The government is not taking a balanced view of the cost and benefits of lockdown. This helps explain the government’s excessive concern about death rates.

COMMENTS:

“The “cure” is worse than the disease.”[18]]

“Prof on select committee says we may end up with 40k deaths. That’s 0.06% of population. This will have cost probably close on £1 Trillion, financial ruin for tens of thousands, many businesses gone to the wall, poverty for possibly millions, thousands of suicides, mental health probs for many, underfunding of services for generations to come, big tax increases for millions.”[19]

“How many younger cancer patients are being denied treatment while the NHS experiment with PPE and end of life resuscitations?”

“For the stats to have any credibility we need to see deaths from the Corona virus compared to deaths from the Flu virus in a bar chart side by side. If we don’t get to see a direct comparison it can only be concluded that once the Government had set us on a course to trash lives / economy they needed the stats to support their misjudged action.”[20]

The fourth theme is about natural resilience. These posts say that humanity can fend off the virus via herd immunity. These contributors don’t have a lot of faith in science. (This argument obviously has implications for the third theme regarding costs and benefits).

COMMENTS:

“the sooner this country realises that the lockdown may kill many more people than Covid will, the sooner we can get back to normal, get the jobs back, get the infections going and maybe then a herd immunity can be established and we can learn to live with Covid in our systems”[21]

“If a vaccine is found and proven to give long term protection, but before Edward Jenner’s rather amazing discovery people got on with life and just lived with it which we may well have to.”[22]

I will now draw a parallel with debates about other public health messages — specifically, healthy eating messages. The following comments are all taken from an online debate about a study that questioned the orthodox assumption that people could improve their health by cutting down on red or processed meat.[23] This prompted a general debate about healthy eating advice.

Again, the first prominent theme is scepticism about the science:

COMMENTS:

“Meat bad. Meat good. Wine bad. Wine good. Vegetables bad. Vegetables good. Yadda, Yadda, Yadda! Pssst. I have an idea, eat what you like in moderation and stuff the ‘research’”

“Experts — if you don’t like what they say, find another!”

“Don’t we just love “experts”. You cannot both be right of course but never mind, easy pickings for another nanny BBC web-page health item.”

“All these food fads are made up. Weak correlations with no cause. Media are suckers for it.”

The second theme says that government is scaremongering. Again, we see this in the debate about healthy eating advice:

COMMENTS:

“Too much scaremongering in the mainstream media if you ask me.”

“you cannot say that red meat causes cancer , just that there is a risk associated with it, (which may be due to cofounders like body fat). The same is true for alcohol and hence we now have ridiculous guidelines of 14 units per week based on no real evidence at all.”

The third theme is about lack of balance on the part of authority figures. This theme is prominent in debates about healthy eating advice. Contributors say that public health advisors talk as if as if the only thing that matters is optimising health. Contributors object that actually, other things matter too. One can accept some risks for sake of a good life.

COMMENTS:

“So either live a miserable, boring, safe life and live to a hundred. Or enjoy life and everything it has to offer and live to eighty. I know which one I’d prefer.”

“I never change my diet when told to do so. As a rule — if you preach I don’t listen. Fed up of this climate change, vegetarianism, veganism.”

“You will take my bacon sandwich from my cold and lifeless hand.”

The fourth theme is about natural resilience, which we see again in the debate about healthy eating advice.

COMMENTS:

“Thousands of years of omnivorous evolution are dangerous to mess with.”

“Every thing in moderation. Back in the day when we were “hunter gatherers “ we would not have survived without meat. If we all had to live off nuts, we would have starved to death. Through the millenniums our bodies have adapted to meat as a source of protein, but that does not mean you have to eat a “BigMac” everyday”

So we see that broadly similar arguments are seen in debates about two very different public health issues, the coronavirus pandemic and healthy eating. Tentatively, I claim that the recurrence of these arguments in different debates suggests that these considerations are not debate-specific. Someone who is sceptical about public health data in one domain will be similarly sceptical in other domains. I suggest that such individuals rely on a caricature of what government and public health people are like. Group 2 people expect public health people to be excessively concerned to reduce deaths, and not concerned enough about other considerations. In consequence, Group 2 people expect that advice from public health people will not be balanced. Public health people will be exclusively concerned with maximising people’s health and will ignore other considerations. Public health people can therefore be expected to present a distorted picture of the data. For example, if there is uncertainty about pandemic death statistics, public health people will present figures at the top end of the range of uncertainty. If a study is published showing that wine is unhealthy, public health people will endorse it and promote it vigorously; but if a study is published suggesting that wine has health benefits, public health people will emphasise that the data is unclear and that drinking wine is risky.

Admittedly these reactions come from just one subgroup of the population. But it’s an important subgroup in terms of achieving compliance, since it consists of people who are sceptical about the policies they’re being asked to follow.

If public health people do indeed sometimes emphasise data that support their messages over other data, the above analysis suggests this is a risky strategy — even if we grant for the sake of argument that health is the only thing that matters. First, this strategy will reduce people’s trust in authority figures, such that their advice is less likely to be heard. For example, their data won’t be trusted. Second, it reinforces a sort of ivory tower stereotype: people will think that authority figures don’t understand real life and the conflicting considerations that are important to people. And finally, it creates a sense of “us and them”. It means that public health people are seen as finger-wagging teachers, rather than companions on life’s complicated journey.

I will now offer some possible solutions for consideration. Broadly my suggestion is that sometimes, when public health people present data and recommendations, they should aim to undermine the above stereotypes. They can do this in their statements about facts, and in their statements about values.

First, in statements about facts, my suggestion would be to acknowledge the complexity of the evidence. If a study provides evidence that wine is good for you, and public health people think they should emphasise that it might *not* be good for you, then when a study provides evidence that wine is bad for you, shouldn’t public health people equally emphasise that it might *not* be bad for you? This may seem paradoxical. Shouldn’t public health people promote health? But the health promotion aim is currently undermined by the public’s scientific scepticism, as we saw in the above comments. A primary cause of this scepticism is the apparent flip-flopping of scientific opinion. The point to convey is that there is less flip-flopping than might appear. To oversimplify, a new study doesn’t change scientific opinion on a question from yes to no, but from “60% chance of yes” to “55% chance of yes”. Public health press releases and interview comments ought to reflect that, by acknowledging uncertainty *both* in studies that support public health messages as well as in studies that don’t. I would expect that the public and media can be brought to accept such nuanced messages. It won’t be easy, but it’s essential if Group 2 sceptics are ever to trust public health messages.

Similarly with projections of the death rate from coronavirus. It’s easy to get annoyed at people who question the science, and therefore ignore them. But this is a big mistake, as we saw before Covid-19, in the case of anti-vaxxers. Largely ignored in their specialist forums, they built a powerful movement.

So, in response to such sceptics, the first question is: What numbers should we present to the public, eg what number of projected Covid-19 deaths? To address Group 2 concerns, the uncertainties should be openly acknowledged. There may be fewer deaths than projected (or more, of course). But then, show that proposed policies are justified even given that uncertainty. For example, address the comparisons with seasonal flu. Some sceptics said the number of coronavirus deaths might only be of the same order of magnitude as seasonal flu deaths. In response, we could have granted that point, and yet still argued that certain lockdown measures were justified. These were “new” deaths which could be avoided with a one-off sacrifice. If we can avoid them, we should.

Just as important, I suggest public health people could be proactive in engaging with sceptics and defending the science. For example, issuing separate press releases addressing Group 2 doubts about the numbers. Contributing posts to discussion forums, including the general discussions which take place on the mainstream news channels, as well as discussions among activists on the more specialist forums.

The second domain concerns the values that public health people convey in their recommendations. Here again, I suggest the key is to acknowledge complexity. Health is not the only consideration in deciding what to do about health risks. Even if drinking wine reduces someone’s life expectancy, that doesn’t always mean they shouldn’t drink wine. If the audience realises that public health people can see both sides of questions about how to live, they might listen.

Similarly, consider Chris Whitty’s 22 April announcement that social restrictions would be needed for the rest of 2020. He said the question to ask is: “What is the best balance of measures that gives us the best public health outcome?”.[24] But Group 2 will respond that even if public health is the most important consideration, it’s not the only consideration. Policy-makers should also take account of people’s freedom; jobs; and other contributors to human welfare. Sometimes, that may justify acceptance of a slightly higher death rate, just as it justifies allowing people to drive cars.[25]

Some public health people might object that they’re only scientists, so it’s not their job to make the trade-off decisions on behalf of individuals or government. But if this is right, they ought to avoid recommendations about what to do, and instead just present data and projections for the different options. To the extent they go beyond the data and make recommendations, to that extent I suggest they need to nuance their messages to reflect the complexities in the data or the applicable values.

Having said that, my specialty is the ethics of health policy. I’m not a social scientist, and I offer the above only as tentative hypotheses about the impact of alternative strategies. So finally, I will focus on the ethics. The question is what to do when the scientific data are ambiguous as to the real state of play, and when conflicting values might undercut public health messages. Let’s grant that sometimes, for the sake of influencing the public to act healthily, it’s necessary for public health communications to be simplistic. It’s necessary to skate over uncertainty in the data, and to avoid mentioning legitimate considerations that might push against the public health message. Well, even if this is necessary, I suggest it’s ethically less than ideal. It treats people as less than adults.

Perhaps some people end up in Group 2 precisely because they recognise that some public health communications are tendentiously simplified. Group 2 people will see this as a highly objectionable attempt to undermine their freedom of choice. They want to make choices based on full information and awareness of the relevant values. Analogously, suppose I love red wine but my spouse wants me to stop. She therefore tells me that a recent study has shown that red wine drinkers have a lower life expectancy. I stop, thereby missing out on some pleasurable moments. Six months later, I discover that at the very time she told me this, my wife was aware of another study showing that drinking red wine lengthens your life. I would have grounds for complaint. Perhaps the public has somewhat similar grounds for complaint when public health people put more weight on “anti-wine” studies than “pro-wine” studies.

Ideally, we need to avoid prompting such concerns. This is not just for the sake of bringing Group 2 on board but also because communicating openly and honestly is the right thing to do. It would be better for adult conversations if public health people trusted their audience to take a balanced reading of the data, and to take a balanced view of the considerations that determine how they should live.

So, if there is doubt about the impact an open and honest message will have, such that a simplistic message is tempting, I suggest giving people the benefit of the doubt: acknowledge ambiguity and uncertainty in the data and in the question of what to do about it.

REFERENCES

BBC. 2019. Is red meat back on the menu? (30 September 2019). https://www.bbc.co.uk/news/health-49877237 Accessed 28 April 2020.

BBC. 2020a. Coronavirus: Significant social distancing needed ‘until vaccine found’. (16 April 2020). https://www.bbc.co.uk/news/uk-52308201 Accessed 28 April 2020.

BBC. 2020b. Coronavirus: Warning over daily death figures (7 April 2020). https://www.bbc.co.uk/news/health-52167016 Accessed 28 April 2020.

BBC. 2020c. Coronavirus: Boris Johnson says this is moment of maximum risk (27 April 2020). https://www.bbc.co.uk/news/uk-52439348 Accessed 28 April 2020.

BBC. 2020d. Coronavirus: When will we know if the UK lockdown is working? (6 April 2020). https://www.bbc.co.uk/news/health-52133054 Accessed 28 April 2020.

BBC. 2020e. Coronavirus: ‘Stay at home’ plea as Easter holiday starts (3 April 2020). https://www.bbc.co.uk/news/uk-england-52150388 Accessed 28 April 2020.

BBC. 2020f. Coronavirus: Why are there doubts over contact-tracing apps? (20 April 2020). https://www.bbc.co.uk/news/technology-52353720 Accessed 28 April 2020.

BBC. 2020g. Coronavirus: More than 9,000 fines for lockdown breaches. (30 April 2020). https://www.bbc.co.uk/news/uk-52489943 Accessed 30 April 2020

BBC. 2020h. Coronavirus: The US resistance to a continued lockdown. (27 April 2020) https://www.bbc.co.uk/news/world-us-canada-52417610 Accessed 30 April 2020

BBC. 2020i. Coronavirus: Social restrictions ‘to remain for rest of year’. (22 April 2020). https://www.bbc.co.uk/news/uk-politics-52389285 Accessed 30 April 2020

Crow, D & Waldmeir, P. 2020. US anti-lockdown protests: ‘If you are paranoid about getting sick, just don’t go out’ (22 April 2020) https://www.ft.com/content/15ca3a5f-bc5c-44a3-99a8-c446f6f6881c Accessed 30 April 2020

Marrow, A & Tsvetkova, M. 2020. Hundreds protest in southern Russian against coronavirus curbs. (20 April 2020). https://www.reuters.com/article/us-health-coronavirus-russia-protests-idUSKBN22225B Accessed 30 April 2020

Reuters. 2020. ‘I want my life back’: Germans protest against lockdown. (25 April 2020). https://uk.reuters.com/article/us-health-coronavirus-germany-protests/i-want-my-life-back-germans-protest-against-lockdown-idUKKCN2270RD Accessed 30 April 2020

Rosner, E. 2020. Israelis maintain social distancing while protesting Netanyahu. (20 April 2020). https://nypost.com/2020/04/20/israelis-practice-social-distancing-at-tel-aviv-protest/ Accessed 30 April 2020

Smith, O. 2020. Merkel crisis: Fury erupts across EU as thousands join anti-lockdown protests in Germany. https://www.express.co.uk/news/world/1274054/Merkel-Germany-crisis-anti-lockdown-protests-coronavirus-European-Union. Accessed 28 April 2020

The Basingstoke Gazette. 2020. Basingstoke anti-lockdown protest: What we know so far. https://www.basingstokegazette.co.uk/news/18409220.basingstoke-anti-lockdown-protest-know-far/ Accessed 30 April 2020

The Policy Institute, Kings College London. 2020. The Accepting, the Suffering and the Resisting: the different reactions to life under lockdown. https://www.kcl.ac.uk/policy-institute/assets/Coronavirus-in-the-UK-cluster-analysis.pdf Accessed 30 April 2020

[1] Eg Keir Starmer and Nicola Sturgeon.

[2] I trawled 680 comments from 6 debates, i.e. comments 3131 to 3249 on (BBC, 2020a), comments 1600 to 1717 on (BBC, 2020b), comments 3030 to 3182 on (BBC, 2020c), comments 2191 to 2307 on (BBC, 2020d), comments 1299 to 1407 on (BBC, 2020e), comments 215 to 282 on (BBC, 2020f). I selected comments about epidemiological statistics and policies based on them. Of course, such comments are likely to come from sceptics, i.e. those who question the statistics, or the policies derived from them (including those who think the policies are too soft and those who think they’re too hard). My rationale for this selection was that sceptics are the most useful group for public health practitioners to understand, since they are the most likely to resist public health policies. The comments mainly came from BBC (2020a), BBC (2020c) and BBC (2020e). I grouped the selected comments thematically for analysis, and selected representative comments from each group for this report.

[3] BBC (2020c)

[4] BBC (2020g)

[5] The Policy Institute, Kings College London (2020)

[6] Crow & Waldmeir (2020), Reuters (2020), Smith (2020), Rosner (2020), Marrow & Tsvetkova (2020)

[7] The Basingstoke Gazette (2020)

[8] BBC (2020a)

[9] BBC (2020a)

[10] BBC (2020a)

[11] BBC (2020a)

[12] BBC (2020a)

[13] BBC (2020a)

[14] BBC (2020e)

[15] BBC (2020c)

[16] BBC (2020a)

[17] BBC (2020c)

[18] BBC (2020c)

[19] BBC (2020a)

[20] BBC (2020a)

[21] BBC (2020c)

[22] BBC (2020a)

[23] BBC (2019)

[24] BBC (2020i)

[25] Rick Becker on speed limits, quoted in BBC (2020h)