To mask or not to mask? Is that the question?

The debate about wearing masks during the COVID-19 pandemic has fluctuated, but there now seems to be consensus that it is safer for the public to wear masks to avoid or at least reduce community transmission.

Credit – Unsplash

Whilst most community members are prepared to do so, there has been some highly publicised resistance to mask wearing. But is mask wearing and other issues relating to social distancing simply a symptom of a deeper question about the mutual obligations inherent in our social contract and the roles and responsibilities of the public in the management of their own health?

The concept of a social contract is not new, harking back at least to Rousseau in 1762 https://philpapers.org/rec/BERRPG-2 , but perhaps the mutual obligations on both sides of the contract have not come into such stark relief in Australia as they have done in 2020. In relation to public health, the need for a social contract has been highlighted through the experience of COVID 19. Is it time to rethink how we define health, focusing perhaps on health systems, rather than health services, and recognising as potentially outdated the concepts of health providers and consumers?

When we think back on the way that society in general has evolved since the 1960s, it is evident that we have moved away from the interconnectedness of people and systems in what was described as the counterculture by Gregory Bateson in 1972 https://stream.syscoi.com/2019/04/08/gregory-bateson-and-the-counter-culture/, and we have moved towards a far more individualistic ideology. This belief that the individual is in control of their own destiny is found in political movements such as “trickle-down economics”, in phenomena such as self-help books and even at the extreme, in beliefs such as prosperity theology.

This has meant that the major focus has been on the individual’s ability to control and manage their environment and their personal success has been seen as a measure of that control and management. In tandem, both sides of governments have to some extent withdrawn from social and welfare support, underpinned by a recurrently individualistic ideological theme. The concepts of rugged individualism and capitalism have almost been used interchangeably, and even Barack Obama in 2017 reluctantly acknowledged that “rugged individualism” was probably in America’s DNA https://obamawhitehouse.archives.gov/blog/2011/12/06/president-obama-america-we-are-greater-together. Most Western cultures have embraced similar ideologies over that time.

Enter COVID 19 and the scene seems to be set for a rethink, as the pandemic has revealed the weaknesses in our social fabric. The rise of the “precariat” class was identified by Guy Standing in the UK in 2014 as “the most deprived British class of all with low levels of economic, cultural and social capital” https://greattransition.org/publication/precariat-transformative-class. There can be no doubt they have also been made visible here in Australia during the lockdowns for COVID and their aftermaths. It has become abundantly clear that strong financial supports are needed for our increasingly casualised workforce to stop them from going to work when infected.

Yet these casual workers would probably have argued that they have to survive and have learnt from experience that no-one else is likely to help them if they don’t help themselves. It has become clear that the cost and availability of childcare is a major factor in enabling our essential services to continue, yet the cost of childcare plays out hardest on those essential service deliverers who are poorly paid. In short, it has become evident that in this time of crisis we are indeed interconnected – that to stop the spread of the virus we have to recognise, to quote our PM Scott Morrison, that “we are all in this together”.

But some of the tenets of our more prosperous pre-COVID society create problems for our togetherness. “Rugged individualism” and the notion of the “sovereign citizen” have been seen to raise contentious issues when it comes to mask wearing, social distancing, social isolation and other public health measures. We now need the public to be ‘responsible’, we want them to recognise our interconnectedness – and more: we want them to be proactive in their management of themselves and their loved ones in society.

Arguably, when public health strategies are the most important line of defence against a virus for which we have no cure, then the public and our communities cease to be “consumers” of health care. In reality, the public themselves become the “purveyors” of health practices and we health care professionals are relegated in the main to the last line of defence, caring for those who become infected. This is not to underestimate the need for good science and evidence to inform public health behaviours – an ongoing fundamental role for health care professionals.

How do we shift our social rhetoric in terms of these health care practices? We have certainly had a significant movement towards a focus on consumers of health care in Standard 2 of the latest edition of the Australian Commission for Safety and Quality in Health Care Standards –“Partnering with consumers” https://www.safetyandquality.gov.au/standards/nsqhs-standards/partnering-consumers-standard. But I would argue the terminology of health care “consumers” and “providers” simply doesn’t work for “Health Care in the Time of COVID”. The partnership element of Standard 2 is absolutely correct, but what we need for public health practices is for the community to recognise their interconnectedness and to be in the driving seat for the creation of safe new public health systems.

We need them to be the creators of safe health systems. In turn, the community needs to have faith in us as health care professionals and to believe and respect the changing evidence-based advice that we provide to them. Most importantly, if the community is to be supported to manage its own public health, the people in the community need to feel secure that state and federal governments will not abandon them to their individual survival strategies into the future. Perhaps it is time for a major rethink of public responsibility in health care practices – co-production of health care https://www.cambridge.org/core/journals/primary-health-care-research-and-development/article/celebrating-connecting-with-communities-coproduction-in-global-primary-health-care/895FE0F462EA3235CD7A1E11571F7198/core-reader, rather than consumption. [end]

Mary Chiarella Am Professor Emerita
Susan Wakil School of Nursing and Midwifery
The University of Sydney
Adjunct Professor, University of South Australia
101, Currie Street, Adelaide, SA 5001

Let us never consider ourselves “finished nurses” – we must be learning all our lives. Florence Nightingale

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Mary’s career spans 40 years both in the United Kingdom and Australia. Mary is Professor Emerita, Susan Wakil School of Nursing at the University of Sydney. In 2003/04 she was the Chief Nursing Officer, NSW Health Department and prior to that was the Foundation Professor of Nursing in Corrections Health, with the University of Technology, Sydney.
Mary is a Board member of Northern Sydney LHD and chairs their Health Care Quality Committee. She also serves on the Health Ethics Advisory Panel to the NSW Minister for Health and the Clinical Governance Advisory Committee to Healthdirect Australia.

Mary was awarded an AM for significant contributions to nursing and midwifery education and healthcare standards in June 2019.

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