Urgent need to focus on thoughts, not just behaviors

Dr. Akanksha Rathi Maheshwari

With gradual unlocking, it is incredibly common to witness public behaviours which pose immense risk of spread of contagion, which has a potential to turn into a disaster. In spite of oft repeated appeal for need of personal preventive measures by policy makers and public health authorities, we are coming across a blatant breach of such measures. Even after impressing upon people the need for more stringent infection prevention measures in the unlock period than during lockdown, public leniency can be observed on a day to day basis.

It is not uncommon these days to behold careless behaviours related to masking, social distancing, hand hygiene and spitting in public places; all essential steps to prevent spread of droplet borne contagious disease. Improper masking behaviours (not wearing masks, pulling mask below to uncover nose, mask lying around the neck, pulling mask down to talk, to name a few), lack of social distancing (though truly impractical in a few instances) and neglect of hand hygiene, are more often the rule rather than exception. Step out outdoors and you don't have to go far to realise that most people don't follow safe practices. Pent up energy of lockdown is turning few of them into free radicles ready to damage public health!

While we are right in being critical of such attitudes, it is more important to decipher thoughts and beliefs behind these attitudes and resultant behaviours. Such behaviours can be due to multiple reasons: wishful thinking, intolerance to long-drawn lockdown, ignorance regarding the science behind proper masking and hand hygiene, and irrational thoughts leading to irresponsible behaviours. Some of these thoughts are: it is better to have this infection once and for all so that we will develop immunity to it, anyway we all are going to have it someday, 80% of those who get infected have a mild or no disease. Such trivialisation can be disastrous for the individual himself and the population at large, and truly eviscerates safety. There is a need to impress upon people that such irrational thoughts are based on hypotheses and hypotheses are not scientific evidence. Let us delve into scientific evidence or the lack of it behind such thoughts.

Those who think we will develop immunity once we are infected should note that present scientific knowledge is not sure if, once infected, one is protected against reinfection. There are instances where presence of antibodies makes the next episode of the same disease more detrimental as seen in the case of dengue fever. Also, science is not sure how long the immunity will last. The other prevailing belief among many is that we all will be infected some day or the other, then why not have it now. Having a novel infection earlier than later has its own disadvantages. Science has learned many things about treating this infection in the last few months which has made the treatment more effective. Doctors will learn more as time goes by. The same belief can lead to overwhelming of health care facilities and will beat the very aim of flattening the curve. Moreover, we might get the vaccine in the future, which would help us avoid the disease. Another irrational thought that all of us will get infected sooner or later is not correct as enough herd immunity to stop the spread of the disease is

likely to develop once 42-66% of population is infected. Hence 34-58% of population may never have it and you may be the one who is spared for ever.

Another fallacious thought is that 80% of those who get the infection will have mild or no disease. True, 80% will have no danger to life but what about remaining 20%? You don't know who will be in those 20% for sure and these have serious health implications and 3-4% may lose their life. There is another twist here. Scientific evidence indicates that few of those who had mild or no disease can go on to develop extremely morbid or life-threatening late-onset or long-term complications. Such complications are seen not only in adults (lung, heart, brain damage) but also in children (Kawasaki-like disease).

Apart from all the dangers to self, people with risky behaviours who go on to develop mild or no disease can transmit infection to those people with old age or comorbidities, in family, friends and community, for whom it would be catastrophic, and for no fault of their own! It is criminal, remotely akin to homicide (in fact it is criminal, if intentional, under section 271 of IPC).

We have to understand that self and external regulation are less effective in making behavioural changes. Campaigns directed towards only changing behaviours are likely to be futile. Irrational thoughts are the most reliable extinguisher of safe behaviours. Behavioural science emphasises that focussing on thoughts behind the behaviours is a more effective, impactful and long-lasting solution for behavioural change. If we target the thoughts underlying these risky behaviours, like in the most effective therapeutic intervention in behavioural sciences called CBT (Cognitive Behavioural Therapy), we can bring out a permanent & sea change in behaviour of people and improve the ability to advocate for oneself. Focussing on thoughts, and not just behaviours would surely optimise the measurable impact of campaigns on behaviour change.

We have to warn people of a potential disaster from these risky behaviours. We will be damned and rightly so, if we don't realise that over alarming is far more forgivable in times of present crisis than over reassuring. To sum it up, I would strongly recommend targeting the underlying irrational thoughts if we are to have successful behaviour change campaigns.

Dr. Akanksha Rathi Maheshwari, MD, DNB, MRCP (London)
Consultant Psychiatrist, Bombay Hospital, Mumbai

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