In South Africa, we have faced challenges concerning health-related behaviour change before. Not least among these challenges has been HIV. Mistakes were made in our response, but we learned from them and that learning is critical now. We learned that information is not enough, and that it is a mistake to see young people as part of the problem and not part of the solution.
HIV is relatively simple to protect against – don’t have unprotected sex. Yet, despite campaign after campaign many people have continued to have unprotected sex, putting themselves at risk of HIV infection, and for some, getting infected as a result.
While for many people the provision of accurate and clear information on health risk and ways to protect against it is enough, for others it is not. Just think of all the people who continue to smoke. The interesting thing about smokers is if you ask them what the health risks of smoking are, they typically overestimate them. But if you ask them what the risks are for them, they underestimate them. They have the information but are convinced that while smoking is bad, the bad things won’t happen to them!
People have an amazing capacity to deny risk. I would hazard a guess that almost everyone, if not everyone, has done something risky, not because they carefully weighed the pros and cons, but because they convinced themselves that they would be fine. It is not rational, but it is the way we function in the world – without such denial, we might all be hiding out at home for fear of a million risks that going out would elevate. The problems come when that denial of risks ends up putting you in significant danger. And in the current context, putting you and everyone else in significant danger.
Think now of the young people celebrating spring break in the US or young and old in pubs in London or breaking lockdowns in Italy. Are they uncaring callous people? Or have they somehow convinced themselves that it will be fine and that their actions will not harm themselves or others? I often catch myself trying to find arguments that prop up my hope that everything will be okay. We don’t know where this pandemic is going. There is a long list of reasons to think that the situation in South Africa may be worse than elsewhere in the world: weak healthcare infrastructure, high rates of untreated HIV and latent TB, crowded public transport and informal settlements and a highly mobile and interconnected population.
There are also reasons why it may not be so bad: early intervention, higher average temperatures may help, as well as humidity in some regions and lower average age of the population. I find comfort in the reasons that it may not be so bad; I want to believe them. I find myself looking for scientific papers which argue that weather like ours will help, and am disappointed when I find arguments to the contrary. I have to push myself to acknowledge the many factors which elevate our risk. Human nature is to try and feel safe, not to be safe.
So are we lost? Will those prone to deny risk do so and put us all in danger? Possibly, but not necessarily. If we repeat the errors of our HIV response and focus too much on simply providing information, we will have problems. Such an approach is not only likely to be ineffective, but also dehumanising. It would fail to acknowledge the complexity of people’s thinking and self-management. It casts them as computers, simply processing information. Not as people balancing multiple motives and stresses to manage as best they can. Sometimes it is hard to acknowledge a risk, denial in such circumstances feels like the only way.
We need to provide information. Indeed, information on Covid-19 should have been seen, at this time, as a basic right. But we have to think about multiple framings, presenting the same information in different ways that speak to the different ways in which people are thinking about the issue. We need to appreciate that some people will need more convincing, some will be actively resistant to the information (for example if compliance will cost them their livelihood), some will be despairing and fatalistic and need motivating, some will respond to gloomy projections, others to a call to be responsible.
Government is already giving information in the “protect yourself and your family” frame. To some extent, they are pushing the “be a good citizen” frame. What else do we need? For a start, I would argue that we need more of the second frame. We need to argue to people that these measures are necessary and we must all do our part, regardless of how you think it will affect you or your family. You must do it to be civic, to be a contributing member of society, not because of the risks you face. But this may speak more to what I value than to what will work and I fear that it will not be enough. We need to be more creative and we need to involve more people, not just experts, in the discussion as a few cannot understand how everyone else thinks.
This brings me to how we think about, and engage with young people. Currently, around the world, young people are being seen as a problem. They are less likely to abide by the advice and regulations, and as they are at lower risk of serious illness, are seen as uncaring and selfish. Through the HIV epidemic we have seen that it is easy to cast young people in this light, and we have seen that it does not help. Is there not a better way to think about young people at this time? This is a crisis, and in times of crisis we must draw on the resources we have. The young people of South Africa are perhaps our greatest resource. There is no other group with the energy, creativity and the understanding of multiple different contexts than these members of our society. And they are more connected and interlinked than the rest of us.
The president and minister of health must acknowledge that the experts alone will not be able to understand how to promote safer behaviours. Our leaders must directly ask young people to figure this problem out, to mobilise them. They can help us formulate the multiple frames needed. This could be done through social media or through encouraging family members or contributing to the design of campaigns – I am sure that if there are answers to be had, it is from this group that they will come, and it is through this group that they will be carried forward. I hope we ask them, and I hope we remember their help once this is done, and do more for them in the future.
I have taken some monumentally stupid risks in my life, despite knowing them to be monumentally risky at the time. But every time I was convinced I would be fine, and most of the time I was right, and many of these risks paid off. I am (almost) convinced that I will be fine during this pandemic. But I place a high value on civic behaviour, and so I am doing all that is asked of me. That is the frame that works for me. I don’t know how many others my frame will work for. Others have their own stories. They must find their own frames. Or perhaps someone who understands them can find one for them.
But everyone needs a story that works, to bring them to safer behaviour. One that recognises their challenges, that recognises their humanity, its depth and frailty. This is not a time to ignore the complexity of human nature. If we do that, we will lose touch with each other, and we will lose this fight. DM