TUESDAY, 20 OCTOBER 2020“Stay Home. Protect the NHS. Save Lives.”
Emblazoned in block capitals against a bright yellow backdrop, these words were everywhere in the early days of the coronavirus pandemic. From billboards and buses, TV screens, and pop-up ads, the British population was instructed on how to protect themselves and others from infection. Comparisons to the Second World War and invocations of 'wartime spirit' abounded.
Whilst often attributable to the general tendency of the British media to reach for the Blitz in times of national crisis, there is an underlying truth to these wartime comparisons. Whilst the beginnings of a movement towards greater government responsibility for health had been growing throughout the late 19th century, with the Public Health Acts of 1848 and 1875 establishing a role for local government in sanitation and vaccination, the mass media public health campaign was born in the trenches of the Western Front.
With the introduction of conscription, the poor health of much of the British population was revealed to a previously disinterested ruling class. Whilst the poor health of working class people has been recognised during the 19th century, this became a far more pressing governmental concern when the success of wartime ventures hinged on the physical capabilities of conscripted private soldiers. This concern for the physical health of military recruits, combined with the proliferation of wartime propaganda, created the ideal conditions for the birth of the mass media health campaign. The Ministry of Information was founded in 1917, followed by the Ministry of Health in 1919. Early campaigns focused on the health of soldiers directly, but these expanded to the home front, with rising food shortages and an oddly ubiquitous belief that the British drinking habit was damaging wartime productivity.
Posters (available in a centenary archive collected by Public Health England) appealed directly to nationalist sentiments. “YES – COMPLETE VICTORY IF YOU EAT LESS BREAD,” promises one, whilst another features a quote from Lloyd George: 'We are fighting Germany, Austria and drink, and, as far as I can see, the greatest of these three foes is drink'. 'Don't take alcoholic drinks on MONDAYS,' pleads a third. All demonstrate the firm belief of propagandists that patriotism was the primary motivation for people to change health behaviours.
The end of the War brought further challenges to public health, with the outbreak of the 1918-1919 'Spanish' influenza pandemic. Approximately 228,000 people died in Britain alone, and 50 million worldwide. In the absence of effective treatments, poster campaigns focused on minimising transmission, often with continuing undertones of wartime patriotism. The period saw the first use in the US of a slogan still popular in respiratory hygiene campaigns today: 'Coughs and sneezes spread diseases'.
This formula is so effective in its rhyming simplicity that it has persisted across time and national borders, from British posters during the Second World War to the beginnings of the 2020 pandemic. When asked in early March whether the UK government had a grip on the virus, Jacob Rees-Mogg replied that 'coughs and sneezes spread diseases, keep it in your handkerchief' (which people he imagines still use a handkerchief is anyone's guess). Notably, he chose to leave out the original second half of the slogan: '…diseases, as deadly as poison gas shells.'
The 1920s and 30s saw the cessation of wartime propaganda, and a reduction in the urgency of mass-media health campaigns. Some bizarre examples remain, including a 1920s newspaper ad featuring a figure surrounded by flames, with the message “Thou shalt not catch cold.” Unsurprisingly, government public health propaganda once more became ubiquitous with the start of the Second World War. Food shortages and rationing were primary concerns, as well as the prevention of infectious disease. The tone of the slogans is patrician, patriotic, and generally factual, though with occasional forays into rampant scaremongering. Posters featuring capering vegetables Potato Pete and Doctor Carrot cheerily proclaiming their protective properties contrast sharply with those reading “Diphtheria costs lives. Immunisation costs nothing,” complete with a clawed hand poised to grab the head of a screaming child.
The foundation of the NHS in 1948 fully formalised population health as the responsibility of the state. Public education campaigns therefore continued in full force even in peacetime, accelerated by breakthroughs such as the linking of smoking to lung cancer in 1954, and by the interventionist stance of the post-war welfare state. From the late 1960s, the British government also adopted techniques from commercial advertising for the first time.
These influences are clear in early anti-obesity campaigns, designed to play on individual insecurities, growing consumerism and the changing morals of the Sexual Revolution. 'Do you hold your breath when a man looks at you?' asks the slogan beneath two glum pictures of a woman in a high-waist bikini. A cheerful shopaholic sits on a hoard of hats and handbags as the poster announces 'More Money - More Fun - If You Don't Smoke.'
This jolly consumer era of health messaging did not last. Examples from the late 1970s, 80s and 90s are bleak, in subject, colour and tone. This tonal shift reached its epitome with the government's 1986 HIV/AIDS awareness campaign. In the televised adverts, a volcano erupts against a dark screen as a clipped voice intones warnings of “a danger that is a threat to us all”; a deadly disease with no known cure. A tombstone topples to the sound of single bell tolling, and the slogan “AIDS: Don't Die of Ignorance” appears on screen. Even today, the videos are terrifying.
Opinions differ on the efficacy of this campaign. Whilst certainly memorable, many question the utility of such fear-mongering. Davis and Lohm, in their book Pandemics, Publics and Narratives, write that the 'Don't Die of Ignorance' campaign exemplified a shift to “risk individualism.” Positioning individual “ignorance” as a crucial determining factor in people's health ignores long-standing dynamics of poverty and social marginalisation that restrict access to evidence-based healthcare. Meanwhile the campaigns emphasised the threat to the population at large, despite the fact that AIDS affected certain demographics in significant ways and others much more minimally. This had the effect of “deepening for some the notion that HIV was a disease of the 'other',” contributing to heightened stigma.
So how did we get to today? The ghosts of past mass media health campaigns are clearly visible in 2020's pandemic sloganeering. The power of rhetorical devices — be it rhyme, monosyllables or the eternal tricolon — remains. The contrasting efficacy of a message conveying general fear ('Stay Alert') with one conveying a simple action ('Stay Home') can be seen in the early success of the 'coughs and sneezes' slogan compared with the complex legacy of Don't Die of Ignorance. Appeals to patriotic spirit continue, although the NHS, rather than the Armed Forces, is now the acceptable face of British nationalism.
Finally, the fundamental question remains of how much a slogan exhorting individual behavioural changes can really do to tackle the root causes of ill-health. The choices people can make are frequently constrained, by poverty, occupation or marginalised identities. Now is the time for a new era of public health, which recognises that above a certain threshold, people do not die of ignorance. Communicating information can only do so much to change behaviours. Instead, we must create the environments, both physical and political, in which meaningful changes can be enacted.
Jess Knight is a 4th year medical student at Trinity Hall