Tom Geraghty

Critical Review: Freckleton, I, Q.C., 2020. COVID-19: Fear, quackery, false representations and the law. International Journal of Law and Psychiatry, 72, p.101611.

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

In this paper, Ian Freckleton Q.C. argues that depictions of previous epidemics and pandemics in religious texts, literature and television, as well as fictional depictions in books, film and video games, heighten and exacerbate fears related to the Covid-19 pandemic. He also suggests that this state of heightened fear and anxiety can cause people, particularly laypeople, to be more vulnerable to exploitation by ‘quackery’, or “the promotion of unsubstantiated methods that lack a scientifically plausible rationale” (Barrett, 2009). 

To conclude, the author posits three key recommendations to combat this problem.

1. Provision of calm, “medico-scientifically, evidence-based” information to the public about effective treatments, and warnings about ineffective ones.
2. ‘Cease and desist’ warnings against those promoting unproven treatments or making exaggerated claims. 
3. Robust, well-publicised and assertive legal action against those who sell unproven and/or harmful treatments or prophylactics against Covid-19.

The paper begins with a vivid description from poet Ieuan Gethin of his 1349 experience of the plague, which killed him later that year (Alchemipedia, 2009). This sets an emotive tone which continues throughout the paper. The focus of the paper then is largely on the fear caused by the emergence of a pandemic-causing disease, particularly that felt by lay people who may not be able to “exercise medico-scientific discernment”. Arguably, Freckleton’s stance is a privileged one; he appears to adopt a deficit mindset, which considers lay people deficient in their ability to make rational decisions about their own health. He positions the emotionality and ignorance of lay people in stark contrast with the cool rationalism of the scientific ‘experts’. 

Freckleton’s lack of empathy with the ‘deficit lay people’ creates something of an irony in his failure to acknowledge the barriers they may face in accessing scientific information. The journal this paper was published in costs $35.95 to access, unless you happen to have access through an academic institution. An alternative would be to publish in an “Open Access” journal, which would have bolstered his stance by making sure members of the public are able to access it. Furthermore the language of the paper itself seems at times deliberately inaccessible. For example “The diathesis stress model is useful in this context. It postulates that if the combination of predisposition and stressor exceed a threshold, this can result in the development of pathology” (p. 4).  Even for those used to reading academic texts, the language is opaque. When asserting that lay people are more easily swayed by scams and quackery, it might have been illuminating for Freckleton to reflect on why people consume and trust information that they can access easily.

Another trap Freckleton seems to fall into is that of assuming causality. He spends two pages listing pandemics and diseases in ancient history, theology, literature and film, using this to assert that “a variety of influences can combine to generate high levels of fear and anxiety,” (pp.4). Whilst this may be true, no causal relationship between these influences in literature, films or video games and the lived experiences of those during Covid-19 is demonstrated or referenced.

Freckleton’s conclusions are similarly problematic. His first conclusion assumes that the provision of calm, “medico-scientific, evidence-based” information to the public about effective treatments, and warnings about ineffective ones, will result in reduced harm. However, no evidence is offered in this paper that communicating “medico-scientific” information would have any effect on the likelihood of people being able to discern a proven treatment from an unproven one. It is well documented that it can require much greater effort to refute falsehoods and misrepresentation than to create them, a phenomenon known as Brandolini’s Principle, or “The Bullshit Asymmetry Principle” (Williamson, 2016); it is easy, for example, to claim a teapot exists on the surface of Mars, but it would require much effort, including missions to Mars and accurate teapot-detection equipment to refute such a claim. Brandolini’s principle is highly relevant to claims of Covid-19 miracle treatments, and as shown by Vijaykumar (2021), combating these claims is not as simple as providing evidence-based information to the public. In some demographics, a “backfire” effect has also been shown, where “corrective” evidence-based information strengthens beliefs in falsehoods (Lewandowsky et al, 2012).  Provision of “medico-scientific, evidence-based” information to people can solidify the belief in unproven treatments via confirmation bias (Nickerson, 1998). The same confirmation bias, created by an “epistemic vacuum” left by a distrust in modern science, the pharmaceutical industry, or western medicine, can lead people to believe that the “evidence based” information is the falsehood, strengthening a belief in false or unproven claims (Pierre, 2020).

It may be that Freckleton is suggesting that evidence-based information needs to be presented to the public before they see misleading information. This would align with other studies which show that once people are exposed to misinformation, such as conspiracy theories, evidence refuting them is ineffective, whilst being presented with evidence prior to exposure can “inoculate” against those beliefs (Jolley and Douglas, 2017). However, the practicality of this is questionable, given that even pre-social media, “a lie can run round the world before the truth has got its boots on.” (Pratchett, 2000). In the age of the internet, false news spreads faster still (Vosoughi et al, 2018). To get in front of false news, with true, appropriate and accessible evidence in order to combat falsehoods would be challenging at best.

Freckleton accuses “laypeople” of being unable to apply proper scientific discernment, failing to recognise his own confirmation bias in the assumption that people, including himself, make objective judgements grounded upon evidence-based information. A single positive research paper for homeopathy can convince someone of its effectiveness, whilst thousands of papers showing otherwise will be ignored (Chirumbolo, 2013). Ironically, Freckleton’s conclusion that “evidence based information will result in people making the correct decisions” is not evidence based at all.

Freckleton’s second conclusion assumes that cease and desist warnings against those promoting unproven treatments or making exaggerated claims will result in decreased harm. Most worryingly, he fails to differentiate between claims made as a result of intentional deception for monetary gain, claims that well-intentioned are largely harmless such as the use of vitamin supplements, and folk medicine recommendations where no money changes hands. Folk medicine, it is important to note, is not “quackery” (Barrett, 2009), and whilst folk treatments may be unproven, they can be founded on solid evidential grounds, such as the potential for Clove (Syzygium aromaticum L.) in treatment of Covid-19 (Vicidomini et al, 2021). The “medico-scientific” approach to health in the West and the increased distancing of the health system from the patients it serves has contributed to the expansion of folk medicine (Bakx, 1991). It would be inappropriate and counterproductive to include folk medicine in the realm of quackery.

Freckleton’s failure to differentiate between malicious intent such as those marketing bleach as “Miracle Mineral Solution” and well-intentioned modern, homeopathic or folk remedies belies his own bias. At one end of the spectrum, bleach is sold as a treatment that “can rid the body of Covid-19” (Mark Grenon in his letter to Donald Trump, in Pilkington, 2020), and at the other end, Ayurvedic practitioners suggest drinking warm water, moving (“yogasana”), breathing (“pranayama”) and meditating. It should be fair to say that one end of the spectrum warrants legal action, and the other end is at worst a harmless way to spend time. Where the line should be drawn is surely a question worthy of consideration, and Freckleton fails to recognise this nuance. 

Freckleton’s third conclusion implies that robust, well-publicised and assertive legal action against those who sell unproven and/or harmful treatments for Covid-19 will reduce harm. Here it is worth noting Freckleton’s position as a practitioner of law; arguably this conclusion is a case of ‘a hammer looking for a nail.’ His narrative is sound – he shows that in early pandemics, unscrupulous quacks would take advantage of the desperate in order to make money from treatments they knew would not work. He also explains that as society has progressed, so too have the legal mechanisms by which these charlatans and quacks are prevented from exploiting the vulnerable. Fines have been issued in Australia to firms selling “Miracle Mineral Solution” as a treatment for Covid-19, and thus courts successfully protect consumers from the actions of unscrupulous and unethical businesses. However, he has not proven, nor shown any correlation that would suggest such a conclusion, that increased legal action would be an effective measure. Indeed, it is possible that stronger legal action may only strengthen the resolve of those who believe conspiracy theories and do not trust the motivations of ‘big pharma’ or western medicine. 

In summary, whilst the author has provided in-depth context on representations of pandemics in different media, and posited potentially useful suggestions to combat irrational fear and harm from “quackery”, it’s clear that Freckleton is observing through the lens of his practice of law. Given this, it is no surprise he came to the conclusions that he did, however none have been shown to have any significant evidential basis in this paper, a point that is ironic, given the author’s belief that providing “medico-scientifically, evidence-based” information to the public will help people make more rational decisions.

 

References

 

Alchemipedia, 2009. Jeuan Gethin (Welsh Poet) d. 1349 Bubonic Plague. Alchemipedia.blogspot.com. Available at: http://alchemipedia.blogspot.com/2009/11/jeuan-gethin-welsh-poet-d-1349-bubonic.html (Accessed: 2 June 2021).

 

Bakx, K., 1991. The ‘eclipse’of folk medicine in western society. Sociology of Health & Illness, 13(1), pp.20-38.

 

Barrett, S., 2009. “Quackery: how should it be defined?”. quackwatch.org. Available at: https://quackwatch.org/related/quackdef/ (Accessed: 2 June 2021).

 

Chirumbolo, S., 2013. Homeopathy: bias, mis-interpretation and other. Journal of Medicine and the Person, 11(1), pp.37-44.

 

Jolley, D. and Douglas, K.M., 2017. Prevention is better than cure: Addressing anti‐vaccine conspiracy theories. Journal of Applied Social Psychology, 47(8), pp.459-469.

 

Lewandowsky, S., Ecker, U.K., Seifert, C.M., Schwarz, N. and Cook, J., 2012. Misinformation and its correction: Continued influence and successful debiasing. Psychological science in the public interest, 13(3), pp.106-131.

 

Nickerson, R.S., 1998. Confirmation bias: A ubiquitous phenomenon in many guises. Review of general psychology, 2(2), pp.175-220.

 

Pierre, J.M., 2020. Mistrust and misinformation: A two-component, socio-epistemic model of belief in conspiracy theories. Journal of Social and Political Psychology, 8(2), pp.617-641.

 

Pilkington, E., 2020. Revealed: Leader of group peddling bleach as coronavirus ‘cure’ wrote to trump this week. The Guardian. https://www.theguardian.com/world/2020/apr/24/revealed-leader-group-peddling-bleach-cure-lobbied-trumpcoronavirus. (Accessed: 7 June 2021).

 

Pratchett, T., 2013. The truth (Vol. 25). Random House. ISBN 0-385-60102-6

 

Vicidomini, C., Roviello, V. and Roviello, G.N., 2021. Molecular Basis of the Therapeutical Potential of Clove (Syzygium aromaticum L.) and Clues to Its Anti-COVID-19 Utility. Molecules, 26(7), p.1880.

 

Vijaykumar, S., Jin, Y., Rogerson, D., Lu, X., Sharma, S., Maughan, A., Fadel, B., de Oliveira Costa, M.S., Pagliari, C. and Morris, D., 2021. How shades of truth and age affect responses to COVID-19 (Mis) information: randomized survey experiment among WhatsApp users in UK and Brazil. Humanities and Social Sciences Communications, 8(1), pp.1-12.

 

Vosoughi, S., Roy, D. and Aral, S., 2018. The spread of true and false news online. Science, 359(6380), pp.1146-1151.

 

Williamson, P., 2016. Take the time and effort to correct misinformation. Nature News, 540(7632), p.171.

 

I have been struck by the differential impact of Covid-19 on different communities. Black people in the UK are 4 times more likely to die from Covid-19 as white people, and when taking other socio-demographic factors into account, the risk of a Covid-19 related death for black people is still 1.9 times greater than white people (White and Nafilyan, 2020). The effect is not just restricted to the UK; the same effect has been seen in the USA, where predominantly black counties suffered significantly higher Covid-19 infection rates and deaths (Millett et al, 2020)

 

These statistics are alarming. From a biomedical perspective, the risk for black people who have contracted Covid-19 is nearly twice as great, whilst structural racism, socio-economic  disadvantages and other social determinants mean black people are more likely to contract the disease in the first place. Black people in the US are significantly less likely to trust physicians (Armstrong et al, 2007), are more likely to exhibit vaccine hesitancy (Razai et al, 2021), and are more likely to work in “essential” jobs, or roles that require in-person interaction that cannot be done from home (Dyer, 2020). The typical low pay of these types of roles mean that workers are less able to take time off, or practice protective measures such as isolating at home (Public Health England, 2020), and this impacts not just black communities but all those people in lower paid, “essential” and in-person jobs. 

 

The Covid-19 pandemic had disproportionate impacts on low-income families (Bitler et al, 2020), of which the results will be felt for years, possibly for generations. Even before the pandemic, life expectancy was stalling and inequalities were worsening in England (Taylor-Robinson, 2019), and the Covid-19 pandemic only served to amplify these inequities. Children, especially those living in low-income families have suffered significantly, with evidence showing that the pandemic caused low-income families’ expenditures to increase, whilst expenditures of higher income families decreased.

 

For many children living in poverty or in low-income families, schools are not just a place to learn, but to eat healthily. School closures meant that for many of these children, it wasn’t just their education that has been put on hold, but their nutrition too, which will only serve to widen the existing gaps in food security and learning (Van Lancker and Parolin, 2020).

 

There are efforts to redress these inequalities that have been growing over the past decade, and exacerbated by the Covid-19 pandemic. In “Build Back Fairer”, the Covid-19 Marmot Review, community approaches to health are recommended in an approach “based on the principles of social justice” (Marmot et al, 2020), in order to reverse these growing inequalities. Proposed measures include increasing funding for public health alongside an expanded focus on the social determinants of health, recognising that poverty, deprivation, employment, ethnicity, social class and culture strongly influence health and our individual perception of it.

 

 

References:

 

Armstrong, K., Ravenell, K.L., McMurphy, S. and Putt, M., 2007. Racial/ethnic differences in physician distrust in the United States. American journal of public health, 97(7), pp.1283-1289.

 

Bitler, M., Hoynes, H.W. and Schanzenbach, D.W., 2020. The social safety net in the wake of COVID-19. National Bureau of Economic Research. (No. w27796).

 

Dyer, O., 2020. Covid-19: Black people and other minorities are hardest hit in US. BMJ, p. m1483. doi: 10.1136/bmj.m1483.

 

Marmot, M., Allen, J., Goldblatt, P., Herd, E. and Morrison, J., 2020. Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London: Institute of Health Equity.

 

Millett, G.A., Jones, A.T., Benkeser, D., Baral, S., Mercer, L., Beyrer, C., Honermann, B., Lankiewicz, E., Mena, L., Crowley, J.S. and Sherwood, J., 2020. Assessing differential impacts of COVID-19 on black communities. Annals of epidemiology, 47, pp.37-44.

 

Public Health England, 2020. COVID-19: understanding the impact on BAME communities. Available at: https://www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities (Accessed: 11 May 2021).

 

Razai, M.S., Osama, T., McKechnie, D.G. and Majeed, A., 2021. Covid-19 vaccine hesitancy among ethnic minority groups. BMJ, p. n513. doi: 10.1136/bmj.n513.

 

Taylor-Robinson, D., Barr, B. and Whitehead, M., 2019. Stalling life expectancy and rising inequalities in England. The Lancet, 394(10216), pp.2238-2239.

 

Van Lancker, W. and Parolin, Z., 2020. COVID-19, school closures, and child poverty: a social crisis in the making. The Lancet Public Health, 5(5), pp.e243-e244.

 

White, C. and Nafilyan, V., 2020. Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 15 May 2020. Office for National Statistics.

 

Whitehead, M., Taylor-Robinson, D. and Barr, B., 2021. Poverty, health, and covid-19. BMJ; 372:n376