Low-Hanging Fruit of Masks in COVID-19: What Went Wrong?
In one of their greatest feats, their book titled Poor Economics (2011), the Nobel Memorial Prize in Economics awardees Esther Duflo and Abhijit Banerjee unveil astounding truths about behavior and decision making under poverty.
The chapter titled ‘Low-Hanging Fruit for Better (Global) Health?’ stands out, especially in the present context of COVID-19. The authors express how “health is an area of great progress yet great frustration”.
There are simple, cheap and effective methods to secure individual health, yet few people (the poor) seem to practice them.
Since the beginning of the pandemic, global as well as national organizations and governments have bombarded citizens with guidelines to practice similar methods that are cheap and effective, namely, wearing masks, sanitizing hands and maintaining appropriate distances in public.
However, these practices lapse long before they become social habits. Why is it so?
The possible answers to this question are several, and all in line with the reasoning provided by Duflo’s and Banerjee’s much celebrated book. Not only does this show the universality of personal belief and lack of knowledge, but also that the rich, without pre-placed nudges, are very much like the poor.
As suggested by the title of this piece, only the use of masks to prevent contraction of the coronavirus has been focused on. Vaccinations could have made for a hotter topic, but that shall be reserved for another time.
To Mask or Not to Mask?
Various levels of seriousness and styles in wearing face masks have been seen during the pandemic. Bizarre ways to fashion masks around faces have surfaced due to supposed discomfort that comes from wearing them correctly. Often a mask has been styled as a pocket square in shirts with occasional flaunting on the chin. But the mask would seldom be worn in a way that fulfilled its true purpose.
This description is not a singular observation, but a common site in a country like India.
In some economies, masks were worn in public long before the coronavirus arrived (e.g., Japan and South Korea) and there are enough studies that point towards their efficacy during COVID-19.
It is safe to say that masks qualify as what the economists had termed as ‘low-hanging fruits’- they are cheap, they are accessible and they are surely effective. Wearing masks would ensure the safety of both, private and social health.
Despite such a promising nature, a study found out that only 44% of the Indian population wore a mask in 2020.
Presently, masks are the unpicked fruits of healthcare science.
Medicine and Rigid Beliefs
Duflo and Banerjee discuss the lack of belief in an oral rehydrating solution (ORS) as a means to cure diarrhea in the city of Udaipur. Government nurses express their frustration over mothers wanting more complex fixes like antibiotics and drip.
Undoubtedly, there is a similar sentiment towards masks. The understanding of how a mask works is missing and to many, it makes little sense how a piece of cloth could filter out a microscopic virus.
There might also be some bias against cheap fixes like ORS and face masks. Perhaps it is not that people do not care about their health, but that they do not perceive inexpensive methods like the aforementioned as particularly effective. Rigid, and possibly faulty, ill-informed beliefs reduce people’s incentives to use these methods.
Medicine, healthcare and biology at large are quite specialized fields of knowledge. It is not easy for anyone and everyone to be well-informed. The economists had also pointed out that only limited biology is taught in high school, which is then forgotten over the course of life. So, it comes as little surprise when people outside of science display a lack of understanding in such matters.
COVID-19: A Self-limiting Infection?
Another excellent observation was made in the book and perhaps, it presents us with the most plausible explanation in the case of masks.
This might actually be a subset of the discussion above, but it is concerned with a specific characteristic of the coronavirus infection.
Several common diseases and infections are self-limiting in nature, i.e., with great certainty, they will leave the human body after some time. During periods of illness, most of us try to use fixes like taking antibiotics, steam, visiting the doctor who would then prescribe some medication or simply, doing nothing about it. Due to the self-limiting nature of these infections, our bodies may recover without any apparent damage.
COVID-19 has been self-limiting in several cases- people have been termed as ‘asymptomatic’; many of us have experienced cold and flu like symptoms without any severe effects, and some of us have even recovered despite severe effects.
The economists observed that when our notions of what cured the disease seem appropriate in curing self-limiting diseases, we start to believe that our methods were, in fact, scientifically correct. The self-limiting nature and a largely harmless experience with the infection reinforces the idea that the virus is benign and consequently, the fear associated with it as well as the incentive to wear a mask reduces.
Prevention vs Cure
Human beings are often myopic in their decision making. We have always had to remind ourselves through proverbs that prevention is better than cure. Cure stops suffering whereas prevention is aimed at keeping the suffering at bay in the first place. Yet, we find it hard to practice prevention because prevention is a health insurance of sorts. It is an active effort undertaken regularly to avoid the suffering. But when the perceived chances of suffering are low, an individual may underinsure.
The benefits of prevention are not understood well either. It is hard to understand the goodness of masks because they do not cure COVID-19 as such. They simply help prevent it. People may even feel cheated if they contract the infection despite wearing a mask.
Therefore, combining our rigid beliefs about medicine, risk of infection and its severity, we might not be tempted to undertake adequate effort to protect and cover ourselves daily.
The Rich, the Poor and the Coronavirus
Poor Economics makes an important judgement about the perception of healthcare and the poor.
It is easy to think that the negligence of the poor is what leads them to make sub-optimal, ill-informed decisions about their health when clearly, they can do much better with fairly simple technologies.
However, the rich have great privilege in that they do not actively undertake preventive measures to live a safe and healthy life at each step. There are invisible nudges already provided to them that do the job.
As put very well by the economists, the non-poor population lives in houses where clean water runs in taps, so they naturally don’t need to remember to add Chlorine to water every day. Children get immunized and go to schools where others are immunized as well because schools mandate immunization for admission. We get fresh food from trustworthy sources and have good drainage systems in our apartments, whose workings even we do not know. These are just a few examples.
Nudges are so deeply embedded in our lives that even the notorious anti-mask protestors of the US and Europe who cried paternalism have failed to see how they benefit from it daily.
The coronavirus is a respiratory infection which means that it does not differentiate between the lungs of the rich and the poor. Additionally, preventive measures under COVID-19 require people to actively ensure their safety by purchasing masks and wearing them. There is less scope for invisible nudges to do this for them (at least that is the case so far).
It is amusing that once this line of privilege between the rich and the poor vanishes, we are all likely to behave similarly, with negligence, irrespective of our income class and education.
“It is true that we who are not poor are somewhat better educated and informed, but the difference is small because, in the end, we actually know very little, and almost surely less than we imagine.”
— Poor Economics
Duflo and Banerjee also discover that even the poor are willing to allocate huge amounts of resources to curing illnesses (medicines, hospitalization, surgeries, etc.). Willingness to spend on health reveals motivation to secure health.
Perhaps it is not that we do not care about our bodies and health, but that we do not know how to.
To reap the benefits of such low-hanging fruits, we first need to believe in the presence of these benefits. Had people really understood them, they would have invested in the cheap science of masks, at least after constant bombardment from the World Health Organization. Underestimating benefits and holding rigid beliefs act as the enemy of global health in such times.