Later this week, the wearing of masks in shops and supermarkets will become mandatory in England. The question then will be how quickly the public accepts this new law whether face masks become a social norm could be of vital importance to public health.
The science behind the benefits of mask wearing is pretty solid. Masks principally protect others. You wear them because you dont want to pass on a nasty virus that you may not know you have. Pretty simple. Mathematical models suggest the more people that wear masks, the lower the transmission rate (effective R). And when we look abroad, the evidence supports this contention.
Mask wearing is, without the apparent necessity to enforce laws, almost ubiquitous in China, Japan, and south-east Asia. In a country once called the deferential nation, you might expect this policy would go down with relative ease. But a cursory glance at newspaper articles shows English commentators bristling at the suggestion of mandatory mask wearing. According to the Conservative MP Desmond Swayne, face masks are a monstrous imposition that threaten our fundamental liberties; the New York Times, meanwhile, reports that people in England would rather be sick than embarrassed.
For masks to be effective, people need to conform to wearing them. More than 80 years ago the behavioural psychologist Floyd Allport described what he called the J-curve hypothesis of conforming behaviour. He suggested that when a rule came into effect, almost everyone conformed, but a recalcitrant few resisted the rules with all their might, even to the point of breaking the law. They were usually a very small minority.
Allport looked at how motorists behaviour changed as they approached a crossroads and whether a stop sign was present or absent. Where a stop sign was absent, 17% of drivers stopped, 71% slowed down, and 12% kept going without slowing down. Put in a stop sign, however, and 75% of drivers stopped, 22% slowed a lot, 2% slowed a little, and just 1% didnt change their speed at all.
To achieve good compliance to a rule, Allport suggested, the purpose of it must be understood and the specifics must be crystal clear. The governments prevarications over masks with politicians regularly appearing without masks, and Michael Gove seemingly contradicting the mandatory policy later set out by Boris Johnson may have made this new rule anything but clear.
According to social psychologists, behavioural norms have two dimensions: first, how much a behaviour is exhibited, and second, how much the group approves of that behaviour. Getting people to wear masks requires social approval. The challenge for the government will be increasing social approval of mask wearing and doing it quickly. The medical historians Dorothy and Roy Porter once wrote that the subtle art of the administratively possible was at the heart of enforcing public health policies that threaten individual freedoms. Where this falls short, or where a policy is a matter of urgency, authorities may resort to using the threat of sanctions to quickly shift people towards perceiving something as a social norm which is why police in England will fine people for non-compliance.
We have a complex relationship with rules and public health in Britain. In the 19th century, when vaccination for smallpox was made compulsory, dissenters writing in 1854 declared that such a measure, unspeakably degrades the freeborn citizen, not only depriving him of liberty of choice in a personal matter, but even denying him the possession of reason. Those laws, which George Bernard Shaw later described as nothing short of attempted murder, were eventually repealed early in the 20th century for a number of reasons, including a belief that they were ineffective, that the side effects were worse than the diseases, and they were an assault on liberty. In much of the rest of the world, mandatory vaccination laws remain in place. Britain was, at least then, less deferential than Walter Bagehot might have anticipated.
Britains response to the introduction of mandatory seatbelts was rather more obedient. Those opposing the law argued, among other things, that it would be unenforceable. Proponents countered that the British were a law-abiding people and the measure would be virtually self-enforcing. And this proved to be the case when it was introduced in 1988. The compliance rate remains around 95%.
Americans, by contrast, responded more slowly. After seatbelt laws were introduced in the US at around the same time as the UK, initially only around 50% of Americans complied with them. Nowadays, compliance is around 90%. This same attitude in the US can be seen with the adoption of masks, where disputes have escalated even leading to a fatal shooting.
So, is Britain a land of feisty liberty-seeking individualism, or a deferential state? Perhaps it is neither. Notions of risk, public health, and adherence to norms, whether mandated through law or not, are playing out differently across the globe. Moving from east Asia, across Europe to the US, we can witness a gradient of mask use. In past times we might have viewed this as a gradient of the tradition of individualism, of non-conformity with social norms, of resistance to state authority. In Britain today we might instead see this as an expression of confusion, of a lack of concern for others, of limited social solidarity.
My sense, for what its worth, is that mask wearing will become more prevalent in England, more acceptable, less embarrassing, and will impact on the epidemiology in ways that are difficult to measure. Outliers will persist because full enforcement is too challenging, but they may be too few to matter. But another norm will persist for some time: our collective confusion about government interventions that should have been far clearer from the outset.
Richard Coker is emeritus professor of public health at the London School of Hygiene and Tropical Medicine
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Are the British conformist or libertarian? Our face mask response is telling - The Guardian