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.


  1. dearieme Reply

    With cases like this it’s always tricky – should we call them Stalinist or Nazi? I suspect that “totalitarian” would do though that doesn’t catch the puritan flavour to it.

    Maybe “Rosian” should be adopted for a policy that is simultaneously totalitarian, puritan, malevolent, stupid, and generally anti-human. What a fine way to memorialise that barbarian.

    Declaration of interest: I am a light drinker, ten units a week tops. This evening’s drink was a glass of Amontillado.

    Question: there are good no-alcohol beers available these days. Is anyone yet campaigning against them on the grounds that they’ll prove to be a “gateway drug”?

  2. DevonshireDozer Reply

    A beautifully written, informative and yet depressing piece. It has not helped my mood of almost overwhelming despair.

    Some days ago, I had a surreal experience when picking up repeat prescriptions from my GP practice/health centre. Its effect is still with me.

    Because covid, I was not allowed into the building. Instead, I had to queue up in the open air. The queue shuffled towards a top-hinged window, behind which sat a dispenser person. When it came to my turn, I announced my name as loudly as I could to the nosebag wearing window minder. She mumbled something, but I couldn’t make it out because of the muffling effect of her face-wear. As I moved closer to hear better, she slammed the window shut, recoiled and emitted further mumbling noises – but now even more muffled and with additional high pitched squeaks. The dispenser person pointed at a sign stuck up in an adjacent window, then slid a disposable mask towards me through the smallest possible gap she had opened under the window.

    Apparently ‘customers’ are now obliged to wear a paper mask whilst standing in the open air (actually in a steady breeze), in order to have a package handed out to them through a tiny gap under the window. Any questioning of this nonsense, according to another sign, brings a risk of the questioner being labelled ‘aggressive’ or ‘abusive’. I was neither, but did manage to elicit the response that they weren’t her rules. Rather, they were imposed by Dr Voldemort (name changed), a senior GP in the practice.

    The medical profession has a long and dark history of antipathy towards real science. I had hoped that those days were over, but apparently they are not. Dr Voldemort is probably around 60ish – old enough to know better. If he is insisting on this farcical behaviour I can only imagine that there must be a new bonus scheme in operation. Surely . . . he can’t believe in it . . . can he? Whatever the reason, I’ve lost all faith in him as a doctor.

    I now have a state of mind similar, I guess, to that which Semmelweiss must have had in 1865. I don’t know how much longer I can put up with this insanity.

  3. dr-no Reply

    dearieme – the answer to your question about low alcohol beers being seen as gateway drugs is yes. There are plenty of hand wringers and bed wetters out there, deploring these evil drinks that lure kiddos into a life of alcoholic depravity, and encourage recovering alcoholic to fall off the wagon. More sherry, vicar? Or should that be glue, another dangerous gateway drug:

    DevonshireDozer – it is depressing, profoundly so, and is yet another example of the medical profession sleepwalking into coercive healthism, but it needs to be said, because it is only by recognising what has and is happening that we can start to counter it. Maybe a triumph of hope over experience, but it still needs to be said – All that is necessary for evil to triumph etc etc. It is in recognising the depressing nature of what is going on that we find hope. Dr No will leave it at that. less he start sounding like Margaret Thatcher quoting St Francis of Assisi.

    One of the more toxic consequences of the new normal is that it gives licence and legitimacy to all the Sgt Peppers (Bond, not Beetles) and ARP Warden Hodges out there. Your Dr Voldemort is no different. GPs – by no means all, but certainly many – are especially prone to be not so much anti-science as a-science, as in the absence of science. And some of them, when the find they have new-found powers of control, relish them, and vent a lifetime of pent up resentment by making other people’s lives a misery.

    Dr No recently came up against an absurd non-covid regulation: he could only fill two cans, or a total of 30 litres, of diesel at a garage. He had three 10L cans, and so fell foul of the two cans rule. So he filled two of them, drove round the block, and then filled the third. The petty rule did its little bit to add to pollution and traffic congestion, and Dr No drove away feeling very smug.

  4. Tom Welsh Reply

    “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”.

    There is one theory that accounts for this quite neatly. At least some people are punished! (Whether they have done anything wrong or not – better still if they haven’t).

    Since March 2020 I find myself more and more often quoting H.L. Mencken’s definition:

    “Puritanism: The haunting fear that someone, somewhere, may be happy”.

    There seems to be an immense amount of latent sadism in humanity.

  5. Tom Welsh Reply

    It seems obvious to me that, rather than being any kind of fallen angel, human beings are apes who have made some progress – very unevenly, with far greater success in technology than in ethics or even common sense.

    Anyone who studies the behaviour of apes, such as chimps, is immediately confronted by the behaviour of dominant apes. Every troop has one apex ape who dominates all the others. Without undue anthropomorphism one may call this ape “the leader”. (Indeed, rather than anthropomorphism it rather a case of humans actually being apes and therefore naturally acting like other apes).

    The behaviour of dominant apes is truly shocking from a moral point of view. They are supremely un-PC. It seems to be a duty of the post never to go for more than a minute or two without attacking, biting, urinating or defecating on, or otherwise impressing on all the others who is boss. (Apex males also mate with many females, because they can – and because this impresses on the other males, more than anything else, who is boss).

    One huge difference between chimps and humans is that humans have a variety of rules, laws and morals that forbid overt violence. Thus human societies tend to have not one, but many interlocking pecking orders. X is senior to Y; but Y is more articulate, more handsome, and plays the violin. Etc. Much, if not most drama consists essentially of observing how these clashing dominance hierarchies play out.

    A situation such as “Covid” has brought about gives great scope for the repressed dominance in many people to emerge and do a bit of biting, urinating and defecating on others. It’s instructive to see how eagerly each tiny opportunity is seized upon and exploited to the full. Sad, but instructive.

    • Tish Farrell Reply

      Wearing my somewhat holey old prehistorian-anthropologist hats, Tom, I believe I’m agreeing with you, though it’s a most dispiriting conclusion to come to. Some days I ruminate on the notion that back in our hunter-gatherer era we might have been more civilised, in that to survive at all we had to have a firm grip on reality, and this further involved inter-personal relations on the hoof, much sharing, reciprocating and negotiation largely uncluttered by dogma, hierarchical posturing, or any of the other attitude-mongering that seems to turn us into idiots. I do also wonder if those of us who appear to be awake might be the lost descendants of Neanderthal people who apparently had quite good brains. Or it may be that I too am losing a grip on reality. Drat and double drat.

  6. Tish Farrell Reply

    Thank you, Dr. No, for this most illuminating essay. It explains much, though as others have said, it’s bloody depressing. I have this silly notion that medicine is about healing which to me requires observant exchanges between practitioner and patient to get to the bottom of things. Ah well.

  7. Mister Odwin Reply

    Speaking of behaviors on a continuum:
    The late Daniel Patrick Moynihan (Senator,Academic) described something very similar in a piece from 1993 titled “Defining Deviancy Down” > In which he posited that there is a quanta of deviant behaviors that are tolerated/discouraged on a sliding scale by society. I believe this is also known as ‘The Slippery Slope’

  8. dr-no Reply

    Mister Odwin – certainly an interesting paper – a pdf of a reprint of the original can be found here. Perhaps what it describes is more a sort of social homeostasis, in which what it is to be deviant is adjusted to keep the number of deviants reasonably constant (the saintly monks example – they add new forms of deviancy, to keep the number of deviants constant).

    Moynihan gives three examples of what he considers to be modes of redefining deviancy. The first is altruistic – a genuine desire to ‘do good’, even if the results backfire. The example of deinstitutionalisation he gives is what we here in the UK (we did pretty much the same thing) would call Care in the Community. On paper this is a good thing, but in practice there are more and bigger cracks in the community floor than in the hospital floor, and patients all too often fall through them. It is also a bit worrying to hear President Kennedy quoted as saying the whole idea is “a wholesome and a constructive social adjustment” because it is the sort of thing the Chinese say when they are about to lock up ethnic minorities and ‘re-educate’ them to more wholesome and constructive ways. Dr No is not persuaded by this example: just moving mental health patients from institutional care to (non-)care in the community doesn’t redefine them. They are still mentally ill, but in a different place.

    The second mode, which Moyniham calls opportunistic, is interesting. He puts this rather well as being motivated not by the desire to do good (the altruistic mode), but to do well, that is, it is the perpetrators prosper by being opportunistic: “In this pattern, a growth in deviancy makes possible a transfer of resources, including prestige, to those who control the deviant population. This control would be jeopardized if any serious effort were made to reduce the deviancy in question.” But who are the deviants? The mask wearers etc (who are the real deviants), or those who oppose masks etc (who want to carry on the old normal)?

    Moynihan’s third mode is normalising, the process of becoming numb to outrage. He uses the example of becoming numb to violent crime, but today in the context of covid it might be becoming numb to the outrages of the control measures, and their widespread, pervasive and persistent harmful effects. Those who accept the new normal have become numb to the harmful effects.

    All in all an interesting article, but perhaps not quite as succinct as it might be. But the final paragraph is clear enough, especially in it’s final word:

    “As noted earlier, Durkheim states that there is “nothing desirable” about pain. Surely what he meant was that there is nothing pleasurable. Pain, even so, is an indispensable warning signal. But societies under stress, much like individuals, will turn to pain killers of various kinds that end up concealing real damage. There is surely nothing desirable about this. If our analysis wins general acceptance, if, for example, more of us came to share Judge Torres’s genuine alarm at “the trivialization of the lunatic crime rate” in his city (and mine), we might surprise ourselves how well we respond to the manifest decline of the American civic order. Might.”

    Might face masks for those who advocate and wear them be the “pain killers of various kinds that end up concealing real damage”?

  9. H+W+Tsudnim Reply

    Good stuff! Unfortunately politicians and managers go to Public Health doctors for advice rather than any other branch of medicine (or failing that, the BMA but that’s another story). The name “Public Health specialist” implies great knowledge.
    (P.S. on a tragic note, when Hamlet, Laertes, Gertie and Polonius died the other night it was clearly because they were not wearing masks, unlike 2/3 of the audience.)

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