The role of health behaviour (our diet, physical activity, sleep, smoking, substance use, and so on) in public health practice needs special attention during an epidemic. The challenge is that the onus of altering health behaviour lies with the individuals who often don’t have the option of changing their livelihood. We see this during this pandemic. This demonstrates the failure of public health in internalising the knowledge about the social origins of human behaviour. Let’s examine four aspects of our response to COVID-19.
Identifying ‘at risk’ sections
The real skill of public health professionals during an epidemic is to identify those social groups which can be at greater risk to disease at any given point of time. The screening of those groups becomes efficient when the high-risk groups are identified and targeted for systematic surveillance to prevent potential spread of a disease. In other words, the real skill of public health surveillance is to pick up those who are at risk from a general population, even before they know that they are at risk. To know whether any group is at risk or not is possible only if we have a deep understanding of the society and its people and their livelihood-related behaviour of which health behaviour forms a part.
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It is this classic public health act of identifying an ‘at risk’ population that calls for an anthropological understanding of human lives for which understanding risky health behaviour becomes inevitable. Laboratory tests only categorise the population as ‘positive’ and ‘negative’. These can be matched with those with risky health behaviour and non-risky health behaviour. These categories are further linked to their livelihood characteristics and are crucial for effective public health action. Any attempt to over-emphasise laboratory tests during an epidemic without capturing the health behaviour of people is actually putting the cart before the horse. This is what happens when very little is known about people, their occupation and health behaviour.
Another related but crucial aspect of health behaviour is the significant linkage it has with the prevention of an epidemic. The primary purpose of public health action during an epidemic is to prevent the spread of a disease in the community. When laboratory tests that are meant for clinical practice become the starting point, and when guidelines state that only those with symptoms be tested, this does not help prevent the spread of the disease. This is because testing is done among those who already have symptoms and who have the potential to transmit the disease to others by the time test results are available. The overreliance on laboratory tests not only means that we lose the opportunity to detect those who are possibly at high risk of transmission but also the opportunity to look for high risk behaviour among people. In other words, the approach to tackle COVID-19 allows, by design, silent transmission of the disease within populations.
Capacity to modify behaviour
The third important aspect is the the role of health awareness in health behaviour. Many who are at risk find it difficult to modify their health behaviour despite being aware that they are at risk. People are aware that taking precautions like wearing masks, hand washing and maintaining physical distancing can prevent transmission of the disease. Yet we hear of politicians, celebrities, healthcare workers and those travelling in public transport testing positive for COVID-19. This implies that there is a limit to an individual’s capacity to modify his behaviour and sustain that behaviour without altering his living and working condition.
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Related to this is the fact that if there is success in controlling an epidemic, the credit goes to science and institutions and the government, whereas if there is a failure to control the epidemic, the blame is placed on the people. There is a failure to understand that health behaviour is only a subset of human behaviour and is closely linked to a person’s living and working conditions. Behavourial change takes place when society is organised in such a way that there is no option to engage in risky/ unhealthy behaviour by virtue of one’s occupation or social position. Right now, those who can afford to modify their life conditions without affecting their livelihood are the ones who are mostly able to keep away from the risk of COVID-19.
Finally, it is important to examine ways by which States/ governments intervene to ensure that people follow a certain health behaviour. Most States invoked the Epidemic Diseases Act of 1897 and some gave the police the responsibility to ensure that people follow certain health behaviour. What is the expectation of public health professionals about people’s health behaviour during epidemics? Can we expect people to recognise the potential risks on their own and keep away from those risks? Disease control models focus on modifying individual risk factors. The role of public health in this case gets largely confined to ‘preaching’ with very little scope for action. The second approach has been to create fear of punishment as the basis of behavioural change. The police is given the responsibility to fine people when they violate rules. This has serious ethical implications, especially for those who cannot afford certain health behavioural practices. What history teaches us is that those health behavioural practices that are ‘natural’ and linked to living and working conditions are more acceptable and sustainable and are followed by people voluntarily. The task of public health professionals is to understand those health behavioural practices and the relationship of those practices with social structures and institutions. Anything short of this commitment in public health will ultimately result in putting the onus on the people to adopt ‘self-control’ which is the same as ‘preaching’, where there is little scope for action.
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For real change
Health behaviour plays a critical role in deciding the success of any public health intervention. The potential of health behaviour to transform the direction of any crisis is immense. The real change in health behaviour is possible only when there is acknowledgement of its societal roots and there are efforts to alter it at multiple levels. Instead, putting the onus of changing or modifying health behaviour onto individuals will only result in ‘victim blaming’ and create distrust between people and those responsible for epidemic control.
Mathew George is Professor, Centre for Public Health, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai. The views expressed are personal
