Lessons Forgotten: Smoking, Seat Belts and Masks

The history of public health is littered with examples of the tension between scientific advances and discoveries and cultural norms and beliefs rooted in individualism. For example, many of the public health laws that we now take for granted were not always in place and were not always socially acceptable. In fact, many of these laws were challenged on the grounds of personal liberty and counter arguments designed to confuse the issue and muddy the science.

As a medical doctor and public health expert who trains future physicians on the importance of the relationship between medicine and public health, I can consider several instructive historical parallels to shed light on our current challenges in following the best scientific guidelines to stop the spread of COVID-19.

Do you remember the time when it was normal for people to smoke in public?  We would routinely go out to eat or visit with friends at a dance club or bar and find our clothes reeking of smoke when we came home. I would always separate out my clothes and leave them outside to air out before washing them so as not to fill the house with the smell of smoke. Do you also remember that it was not easy to ban smoking in restaurants and bars? A cursory review of the news at the time reveals extensive public debate about the rights of smokers and the flawed science. The dangers of secondhand smoking were initially not widely accepted even after the science was overwhelming.  Instead, we had nearly endless debates about why banning smoking in public was an attack on personal liberties

Fast forward 30 years later and we are in the midst of a global pandemic where science is now telling us that not wearing a mask presents a clear and present danger to everyone. And yet, people are resistant to masks, sadly more so in my home state of Arizona than anywhere else in the country. Mask resistance is not new, it was even present during the 1918 Influenza pandemic.

Understanding how something that is culturally difficult to accept can become socially acceptable based on lessons learned from the history of public health is critical and timely. Our efforts to educate and advocate for the place of science in dictating public policies and lifestyles depend on our not forgetting these important lessons. Beyond the public ban on smoking, the history of tobacco use itself provides even further lessons that we must not forget. The fall in tobacco use came not only from educational campaigns and an established scientific proof of their harm to human health. It came in large part due to economics. Taxes on tobacco products resulted in the largest decline in smoking rates . While many other factors were involved, the financial incentives to do the right thing learned in combating big tobacco cannot be forgotten or understated in our current approaches to expand mask use.

As learned in the case of smoking, cultural norms and conflicting values often lag behind science. In addition to scientific testimony on the best evidence, financial incentives and laws are catalysts that nudge us in the right direction. Public health has always faced a number of challenges in implementing its guidelines. Great advances have historically benefited greatly from laws and financial incentives in the form of taxes or fines. With masks, the best way to implement this life-saving practice is to enact laws, not simply guidelines or advice. We need real laws with real consequences. Just like smoking in public or drinking and driving have real consequences for those caught in the act, so must we enact similar laws with penalties for not wearing masks in public. The history of seatbelts is another example of a norm that was initially argued against and now is taken without question.

COVID-19 is not going anywhere.  The summer heat has not destroyed it.  It will continue to take lives, disrupt our way of life and expose the unpleasant realities of our society including long standing health inequities from structural systemic racism. In this and other aspects of our world, lifting the veil to reveal the worst in us will hopefully be a driver to bring out the best in us with lasting reform and transformation in our hearts and in our institutions. Beyond that, let us also not forget the lessons of the past. Instead, let us remember how science evolves within societies and how culture can be changed with the right incentives for the sake of public health.  As difficult as it may be, we cannot afford to forget and foolishly repeat the mistakes of the past. Now more than ever, our very lives depend on remembering forgotten lessons.

Dr. Shad (Farshad Fani Marvasti, MD, MPH) is a Stanford-trained physician, Integrative Medicine Doctor medical educator, clinical researcher, and author. He is proactively engaged in creating solutions to promote health and prevent the chronic diseases of our time.

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