The UK media have been buzzing this weekend with rumours about a government plan to require people over the age of 70 to self-isolate for a period of at least four months as part of their response to the COVID-19 pandemic. For a few days previously, there has also been a controversy about the alleged influence of social and behavioural scientists on the government’s approach, relative to virologists, modellers and epidemiologists. This is a pointless argument about what counts as ‘real science’ and valid knowledge. However, the self-isolation proposal is a nice indicator of how limited the social science influence actually is – and why it needs to be greater.
To declare an interest, I am a member of two of the expert groups that are advising the UK government – NERVTAG and MEAG, which does not yet have a website. I am not breaching any confidences by saying that the first I knew of these proposals was the media leak. This response is not based on any special knowledge of the details. These are, however, some of the critical points I would, as a sociologist, have made, had I been asked.
In a democratic society, we should be very cautious about allowing the state to encroach on the space for individual decision-making and voluntary actions. This does not mean that states cannot signal preferred choices but that citizens have some freedom to interpret them in the light of their unique knowledge of their own circumstances. Even in a public health crisis, one size does not fit all – and a degree of flexibility may mean better outcomes for everyone. The issues around self-isolation are, for example, quite different in an urban area with a dense availability of public services and a rural community where the 70-somethings are looking after the 90-somethings. Nudge theory has been a focus for media criticism: there are issues about its operationalization but it is founded in a wider historic debate about how best to align individual actions with collective goals.
If the collective goal is to slow disease transmission and divert it from the most vulnerable members of the population, intervention measures must be practical and not fraught with unintended negative consequences. In this case, the ambition informed by modelling work, of eliminating contacts between over 70s and other citizens may not be the best thing to do, compared with encouraging people to make their own risk assessments that minimize contacts – and collateral damage.
There is, though, a first question: who says it is desirable to prevent every death regardless of the cost? My impression is that the loudest voices are coming from young or middle-aged people who have yet to accept that death is a normal part of life. It comes to all of us in good time. A wise person would, of course, prefer to die later rather than sooner, but they might also consider that some deaths are easier to bear than others. It is not for nothing that pneumonia was described as ‘the old man’s friend’ in the days before antibiotics. Contrary to some media coverage, no-one is advocating that any old person is abandoned to die without professional nursing care. However, we should acknowledge that many frail old people might see Covid-19 infection as a relatively peaceful end compared with, say, several years of dementia or some cancers. Government encouragement to discuss this question within families would not be a plan to cull the elderly but respect for their autonomy and their right to make such decisions rather than have others make them on their behalf.
The encouragement of self-isolation also needs to be considered against its negative consequences. Studies from the SARS outbreak point to significant impacts on mental health after quite a short period. Some people become depressed to the point where suicide becomes conceivable. Do not ask people to ban visitors but to consider whether they might come less often for shorter periods of time.
Much of the thinking here reflects the privileged lives of its authors. Advice to use a separate bathroom or sleep in a separate bedroom does not connect with the realities of many poorer people’s lives, especially among the elderly. I could go into a large back garden – a lot of people could not. Activity levels among older people are already considered a serious physical health challenge. How much physical damage will be done by four months incarceration?
The message needs an injection of common sense. If you have a dog, take it out for walks – but don’t stop to hang out with other dog walkers. If you usually walk down to the local convenience store, keep doing that – just pick a quiet time to do it. Maybe the supermarkets could be asked to set aside a morning each week – or a couple of hours every day – when their shelves will be fully stocked and entrance restricted to over 70s and necessary companions. Could the hospitality trade do something similar – seniors’ lunchtimes, for example, which might help with their cashflow while contributing to the mental health and activity levels of the self-isolating?
Many of the frailest elderly are in care homes. It is too easy for a care home just to ban all visitors without thinking of the impact on residents. Care homes must come up with positive alternatives to maintain social contacts. Where residents have capacity, this needs to be discussed with them, not just imposed. Care homes are not prisons and residents have rights. Can homes do more to promote video links – residents may lack technological capacity rather than cognitive capacity? Could outside locations be developed as visitor points, rather like smoking shelters? There is still a risk of transmission in the open air but it is much reduced compared with confined spaces.
We do not need draconian and potentially inhumane interventions to achieve most of the collective goals here, just to consider some fairly basic social and behavioural science questions. Trusting individuals to make their own risk assessments and devise their own solutions is likely to achieve much more than arbitrary and confrontational exercises of state power. Self-isolation must not turn into self-imprisonment.