For some, the odious new normal is yet another malign child of the pandemic. It is the dustpan where the armies of the new normal faithful are swept into obedience, each faithful soldier but a speck of dust swirling in the maelstrom, carried along by the madness of crowds. Each one wears the badge of compliance, a mask: some gaily embroidered and tightly fitted, like a wired brassiere, others black, as if to signal ask not for whom the bell tolls, and yet more the ragged remains of a soiled and stained surgical mask, left dangling from ear or wrist. At the other end of town, covid marshals scan smart phones as visitors to the exhibition centre show their digital covid papers to confirm a recent negative lateral flow test. Never mind the negative test result is meaningless and pointless, because the test has too low a sensitivity to be useful as an enabling test, the exhibition visitors comply, because it is part of the new normal, as is the hand sanitizer semaphore as they go in and out of the store next door. The new normal is a never ending stream of badges, totems, rituals and voodoo that rolls past day in day out, with never an end in sight.
This new normal may seem very new, and the behaviours it requires in the face of covid are new, but the public health dogma behind the new normal is anything but new. For almost half a century, the majority of public health specialists have been in thrall to a dogma that has electrified them, as if animated by Victor Frankenstein’s mysterious spark. The ideas originated on the continent, but were unleashed on the English speaking medical world in the 1980s by Professor Geoffrey Rose, an epidemiologist of international repute who published papers with alarming titles that nonetheless thrilled public health doctors. The first seminal paper was Sick Individuals and Sick Populations, first published in 1985, and present on the public health best-seller list ever since. For those who didn’t get the message first time, Rose followed up in 1990 with the even starker, more alarmist The Population Mean Predicts The Number of Deviant Individuals. No wonder public health doctors thrilled: all those sickos and deviants to get their teeth into. Other key works by Rose with less alarming titles include Strategy Of Prevention: Lessons from Cardiovascular Disease, published in 1981, and The Strategy of Preventive Medicine, published in 1993.
The core idea at the heart of all these works goes by the rather less headline-grabbing title of the single distribution theory of disease. The central proposal couldn’t be simpler: for most major risk factors and diseases of public health importance, everyone in the population belongs to one all embracing group, and so there is but one distribution, or spread, from top to bottom for the disease, for the entire population. It means, taking alcohol consumption as an example, there aren’t separate groups, perhaps teetotallers, moderate drinkers, and heavy drinkers, with each group behaving in it’s own way; instead, there is just one all encompassing distribution, with teetotallers on the left, most moderate drinkers a little left of centre in the middle, and a long rat’s tail heavy drinkers stretching way off into the distant right.
At this stage, the theory is just descriptive, a way of describing the distribution of health related factors. But, if it is true, it has one very important practical implication. Because distributions are cohesive, and defined by numerical parameters, it means that if you move one part of the distribution up or down the scale, then the whole of the distribution will move in the same direction. It is as if there is a quantum entanglement between everyone in the population: each knows what the others are doing, and reacts accordingly: Einstein’s spooky action at a distance. This is what Rose is getting at with ‘the population mean predicts the number of deviant individuals’. If — Heaven help us — moderate drinkers start to drink more, then the population mean will move to the right, pushing ever more individuals into deviance. Equally, and this is what thrills the public health doctors, the theory predicts that if you can move the population mean to the left, by reducing what moderate drinkers consume, then a number of the deviants will be will be drawn back towards moderation, and the total number of deviants will decline.
The idea that there is some sort of quantum entanglement between teetotallers, moderate drinkers and heavy drinkers is of course bunkum. Instead of one single distribution, there are at least three — the teetotallers, the moderate drinkers, and the heavy drinkers — and unless the individual concerned happens to be a health fascist, then none care much how much alcohol the others consume. But the single distribution theory is so pervasive that just about all public health policy on alcohol is based on it. The first safe alcohol consumption limits, published by a committee of the great and the good in 1987, assumed a single distribution for alcohol consumption, and set weekly limits that target moderate drinkers just as much as heavy drinkers: 21 units for men, and 14 units for women. Even more remarkably, not only did these limits lack a sound basis in distribution theory, they also lacked any basis in epidemiological evidence. The great and the good had no idea what level of alcohol consumption was or was not safe, and so they just, as Dr Richard Smith, a member of the 1987 committee, and since editor of the BMJ, has revealed on more than one occasion, pulled the numbers out of thin air, on the grounds that they seemed like a good idea at the time. As Clive James might have said, to base national guidelines on alcohol consumption on epidemiological evidence that doesn’t exist, piled on a theory made of quicksand — truly this is the work of the righteous in public health.
The same faults apply to minimum unit pricing (MUP, muppetry) for alcohol. Again, the policy is based on the quicksand of the single distribution theory, and so an assumption that everyone in the population has the same sensitivity to changes in the price of alcohol, and adjusts their consumption accordingly. But what evidence there is suggests the opposite: the price elasticity of demand for alcohol — an economic measure of how consumption varies according to price, with larger negative elasticity values meaning greater reductions in consumption as prices increase — varies greatly depending on consumption. Moderate drinkers are the most elastic, while heavy drinkers are the most inelastic, with some perhaps approaching zero elasticity: they consume alcohol, whatever the price. The consequence is that minimum unit pricing for alcohol backfires. Moderate drinkers, those at lowest risk of harm from alcohol, are targeted, while the heavy drinkers, the intended target, are largely untouched. MUP fails, fundamentally, because there is no single distribution of alcohol consumption.
Just about every widespread population level public health policy for risk factors in place or under consideration today is underpinned by the single distribution theory. The sugar tax, obesity policy, control of blood pressure and statination, the policy of putting all adults on a statin, are all grounded on the single distribution theory. The common theme is that, rather than target those at greatest risk — an approach which Rose calls the “High Risk” (sic) strategy — Rose advocates a mass strategy, which targets the entire population. His earlier papers, though they propose radical changes in prebentative medicine, are restrained in their approach, with full regard for the delicacies of mass interventions on the population at large, many of whose members stand to gain no benefit, only harm, from the intervention. But as time passed by, Rose’s ideas got the better of him, and started to mutate into something much grander, and indeed sinister. By 1993, in his Strategies of Preventative Medicine, Rose was emboldened enough to write (emphasis added):
“The population strategy of prevention seeks a shifting of the whole risk factor distribution in a favourable direction. It faces the formidable difficulty of needing to change the majority, which means redefining what is to be regarded as normal.”
And there we see it for the first time: the conception of the public health concept of the New Normal. The old normal was no longer satisfactory, instead, it had to be redefined, into a New Normal. Rose was ahead of his time, but he sowed the seeds, and by the mid-noughties, the phrase new normal had started its inexorable rise. By the time the pandemic arrived, it was already firmly embedded in public health thinking, making it natural for public health specialists to adopt a new normal approach to pandemic management, because ‘redefining what is to be regarded as normal’ had become part of public health’s mantra, even part of its DNA. And so it came to pass that, instead of targeting those at greatest risk, we had imposed on us a new normal: all had to wear masks, be subject to mass screening, and sign up, regardless of individual risk, to all the other badges, totems, rituals and voodoo of the population wide pandemic response. It may look like a new normal, but it is a decades old idea, and what’s more, it’s an old idea that has not stood the test of time well.