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By Michele Cleary

As we begin July 2020, the United States continues to battle rampant COVID-19 spread. While many countries within Asia and Western Europe have tamped down their COVID-19 hot spots, infections continue to roar across the United States with many states setting new case records daily.

Maricopa County, Arizona—home to Phoenix, the capital city of 4.5 million people—currently reports nearly 3000 new cases a day, eclipsing that of the boroughs of New York City, even on their worst days.^1,2

“This is not bad luck,” declared Arizona Public Health Association Executive Director, Will Humble. “The public policy that we developed and that was used at the end of the stay-at-home order really set in an honor system,” he said. “And an honor system isn’t adequate to direct the kind of human behavior that we need to slow down the spread of this virus.”³

This article examines how human behavior is complicating COVID-19 containment efforts (mask wearing, social distancing). Behavioral economists Kevin Volpp, MD, PhD, and Doug Hough, PhD, shared their perspectives on citizen choices to comply with COVID-19 mitigation and how culture leads to significantly different experiences during this pandemic.

Revelers and Revelations From the Lake of the Ozarks

In the United States, COVID-19’s early wrath targeted large metropolitan centers, especially New York City, while most states experienced only minimal infection rates. This inconsistent COVID-19 experience led many state leaders to disparage the economic costs that accompanied the COVID-19 shutdown. Eager to return their states to pre-COVID-19 operations, these leaders have supported a more casual approach to (if not full disregard of) virus control initiatives. Many of these states enthusiastically opened businesses and recreational sites as highlighted in the now infamous images of Lake of the Ozarks, Missouri, from May 2020.

Kevin Volpp, MD, PhD, Director of the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania in Philadelphia, found these scenes upsetting, yet understandable. “I think that people tend to make decisions based on how they feel as opposed to any deliberate cognitive process,” said Volpp. “People aren’t very good at weighing future costs versus immediate gratification.”

Volpp continued, “I think what we’re seeing is that there are some subsets of the population who, when asked, are making a rational calculation—that the benefit of wearing a mask outweighs the downside, the risks, the costs. They will continue to socially distance pretty reliably. But a lot of the population won’t.”

He suspects that these Lake of the Ozarks partygoers view any potential harm from the virus as probabilistic, that it is in the future. “There’s no guarantee it will happen. And people are not very good at estimating probabilities to begin with.” Volpp added that the limited available data resulted in many viewing their risk to contract the virus to be largely intangible. “I think that all conspired to make it more likely that people would engage in risky behavior.”

Individuals’ Inability to Assess Risk

Douglas Hough, PhD, associate scientist at Johns Hopkins University in Baltimore, Maryland, agreed that many people are having an emotion-driven response to COVID-19 restrictions, fueled by the need for immediate gratification. “People are not calculating bodies,” he said. “They’re not doing cost-benefit analysis, looking at the discounted present value of future earnings. They’re just feeling that they’ve sacrificed. ’I’ve been at home for 8 weeks and nothing has happened.’”

Hough noted that citizens often struggle with applying statistics to their own lives. “We’re asking people to assess their own risk for COVID-19 or other diseases.” In his view, people often view “low risk” as “no risk” despite someone usually being in the numerator. “They’ll just round up or round down to zero and say it’s practically zero,” he continued. “Do they do the math? No. Instead they think, ‘No, it’s not going to be me.’”

Variable Distribution of Risk

Hough identified the variable distribution of virus risk as reinforcing many people’s underassessment of their own risk. Until recently, COVID-19 cases were largely concentrated in a few geographic centers in the United States and globally. Even in these hot spots, those most severely affected were predominantly persons from older age cohorts (over age 65). Under these conditions, Hough argued that salience becomes very attenuated. People see their risk as minimal when no one in their social circle has experienced infection. “They say that they don’t work at a chicken processing plant, don’t know anybody who does,” stated Hough.

However, Hough continued that people need to understand that they do not necessarily need such proximity to be at risk. “You don’t have to know somebody who does. You just need to know someone who knows somebody who was in the store next to somebody whose family member works at the processing plant,” he said.

In Hough’s view, contact tracing could have different short- and long-term effects. “My sense is that when someone is informed that she has been in contact with someone who has been diagnosed with COVID-19, the salience of the disease will be heightened and behavior will be more circumscribed.” Hough warned of noncompliant behaviors if that person learns that her test comes back negative. “She will feel invincible (after all, she came close to the disease but did not succumb), moral hazard will take over, and she will begin to take more risks (less social distancing, less wearing of a face mask). A negative test result may be perceived as a ‘free pass’ from the disease.”

“One of the challenges for us in this country has been to try to balance individual freedoms, which we hold so dear, with pandemic control.”

 

Taking Risks for Social Justice

Yet this year, risky social gatherings have not been limited to bars and beaches. While partygoers gathered in spots like Lake of the Ozarks, millions of protesters gathered in hundreds of towns and cities around the world to protest systemic racism and police brutality in response to the death of George Floyd in Minneapolis, Minnesota. While these protests did violate social distancing recommendations, Volpp saw the risk calculation somewhat differently.

“I think a lot of people weighing benefits and risks are deciding they need to participate in these protests because it’s a moment in history that hasn’t come along very often to really try to change the system. And I think a lot of people feel a deep need to be part of that and to try to contribute to it. And that in essence weighs on the benefit side of the equation.”

The Weight of Social Networks

Regardless of whether people are gathering to protest or to socialize, the individual decision-making calculus of social participation is heavily influenced by one’s community. “People are very powerfully influenced by what others in their social networks do,” Volpp said. “I think in both cases you have, for very different reasons, people influencing each other’s actions in ways that make a certain course of action, much more likely than it otherwise might be.”

Failing to Protect the Social Good

Volpp views noncompliance with social distancing and mask-wearing risks as rife with negative externalities—one’s choice not to social distance or not to wear a mask imposes costs on others. He likened this behavior to that of chemical factories spewing soot in the air. “The chemical factories should have to cover the cost of that.” In the same vein, in public health epidemic situations, we need to have stronger enforcement of actions that impose harm on others.

To achieve meaningful success over the virus, citizens must act together and comply with basic initiatives. The common good can result only from millions of conscious choices.

Echoes of de Tocqueville

To Hough, the need to protect the common good is echoed in Alexis de Tocqueville’s Democracy in America. Said Hough, “We are very independent, yet we are perfectly willing to help our neighbor. Government, not so much, but our country, very much so.” He continued, “This is part of who we are. I think it’s definitely an American trait.”

However, Volpp highlighted the inherent difficulties in this American approach when applied to public health. “One of the challenges for us in this country has been to try to balance individual freedoms, which we hold so dear, with pandemic control.” He continued, “I think the pandemic is largely winning. As you see the number of cases continuing to shoot well past a hundred thousand in the United States with no sign of letting up, we haven’t as a society really been able to figure out how to balance this.”

The Ladder of Interventions

To change human behavior and bring US infection rates under control like other similar nations, Volpp proposed a ladder of behavioral intervention options. Options on the bottom would be gentle nudges, such as informing citizens that COVID is dangerous to their health. “That in itself probably doesn’t accomplish very much, but it’s also very nonintrusive.” Higher up the ladder would be more effective, but also more constraining approaches. “You can use some type of social norming intervention. You could think about positive incentives or rewards. You could think about penalties, financial penalties.” At the top would be ways of changing choice architecture and defaults. “The most effective approach clearly, and you see this in terms of epidemic control in places like China, is to just eliminate choice altogether.”

The Carrot or the Stick

Volpp shared his doubts that the United States has the appetite to enforce effective COVID-19 measures or penalize people who will not wear masks. “I’m not very optimistic about that. I feel like we’re not going to be as successful at controlling the epidemic.” He expects most Americans view heavy-handed measures to be “nonstarters.” “In various parts of the country, we’re trying to restrict choice by having people work from home where possible, but increasingly, I think the balance is shifting where this was more like an opt-out kind of default.”

Regarding the workplace, Volpp stated, “I would say it’s shifted from a restriction or elimination of choice where most workplaces required you to do it to now. I think increasingly, people get the option of going back to work and that’s likely to make endemic control less effective. It’s all a balancing act. We may go back and forth, you know, up and down this ladder, in essence, depending on how things go.”

China, Volpp noted, has achieved some success by imposing highly restrictive measures. However, wide acceptance of less restrictive COVID-19 measures in China, such as mask wearing, may also stem from its recent experience with SARS.

For the United States, Volpp proposes a more targeted approach of restrictions. “I think this is a situation where sticks are much more effective than carrots. The vast majority of people will hopefully comply with what they’re being asked to do. And so it makes more sense to penalize the relatively small proportion of people who are not complying than reward the vast majority of people who are complying. That would not be a very efficient use of resources.”

Personalizing Infection Risks

Hough proposed adherence tools that personalize the disease and its risks—a mass customization of messaging. “Public health has demonstrated that you’ve got to make the case almost on a one-on-one basis. Finding ways of explaining to different kinds of people who have different pressures, different reasons, why they’re not adherent, why they’re not taking the drugs, why they’re not getting vaccinated, and finding ways of identifying those people and getting the target.”

He noted that this approach requires trusted spokespeople and emotional stories that people identify with as opposed to “just the numbers.” He highlighted the Washington Post’s ongoing stories of COVID-19 victims as an effective way to help people internalize this risk.

Hough also emphasized the value of trusted messengers to relay disease information—trust being a critical component of public compliance with COVID measures. “My sense is that people are looking for somebody they can trust.” He pointed to Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases at the US National Institutes of Health, as an ideal spokesperson. “Here’s a guy who seems to shoot straight not just with data, but he seems to be telling the truth. He doesn’t seem to have an agenda. He seems to really do things in a solid way.”

Yet, Hough warned that the lack of general trust in government authorities—something that has grown in recent decades—makes such efforts challenging.

“We’re paying very dearly for having a more hands-off response, leaving it individual, state-level governments to figure this out without a lot of federal backing.”

Preparing for Future COVID-19 Waves

Looking towards Fall 2020, both Volpp and Hough voiced concern about public exhaustion with COVID-19 measures as we face the likelihood of a worsening pandemic. Volpp lamented that the United States has been mired in a suboptimal situation for much longer than countries that have enacted more restrictive initiatives. He cited countries across Asia and Europe that have opened schools and businesses, where the rate of new cases is lower, while the United States has incurred an enormous human and economic toll. Volpp stated, “We’re paying very dearly for having a more hands-off response, leaving it to individual, state-level governments to figure this out without a lot of federal backing.”

Hough shared similar concerns. He also feared far lower adherence to infection control measures. “People are thinking, ‘Alright, I did my civic duty. I stayed home at that significant personal social cost and nothing happened to me or my family or to many people that I know of. And now you’re telling me to do it again? I don’t buy it.’”

Public Reaction to Vaccination

As we look forward to a possible vaccine, Volpp anticipates people’s COVID-19 experiences resulting in 2 possible responses. “It would make people more conscious of the importance of their health, in disease, thereby making people more adherent to immunization recommendations.” He continued, “The other side of that coin is that a lot of conscientious people who would be getting those vaccines are also very apprehensive about leaving their homes and going to places where there might be a lot of other people. I’m worried that this fall, this winter, that vaccination rates might be much lower because people are reluctant to go to places where they’re worried that they could get exposed to the virus.”

COVID Compliance Today

Many state and federal leaders in the United States are now pressing for the reopening of businesses, schools, and services in hopes of reversing the COVID-related economic slowdown. But while many Americans are done with COVID, the virus is in no way done with them.

The rapid reopening has fueled an enormous surge in new cases with 1 million new cases of the novel coronavirus in just the month of June. The growth in new cases is exceeding that seen this past spring. Parts of Texas, Arizona, California, and Florida are facing zero or minimal capacity in their critical care units.⁴

In Miami, Mayor Francis Suarez shared his concerns about individual compliance with social distancing and mask wearing. “I think the problem that we’re having is the behavior. When we allowed businesses to open, citizens just went out and pretended like this virus didn’t exist.” 

Like many officials within COVID-19 hot spots, Mayor Suarez is struggling to compel citizens to comply with containment measures. The city recently required masks in public, fining those who fail to abide with increasing fines for each citation: first, a warning; the second time, a $50 fine; third time, a $150 fine; and finally, a $500 fine.

“I think the biggest issue right now is making sure that we can address behavior and that our residents understand that we’re in this together,” Suarez stated. “If we don’t pull it together, we’re going to have major issues with our hospital capacity and we’re going to have major issues going forward.” 

References

1. Daily COVID-19 Updates. Maricopa County Public Health. https://content.govdelivery.com/accounts/AZMARIC/bulletins/2939edd. Accessed July 2, 2020.

2. COVID-19: Data, By Borough. New York City Department of Health and Mental Hygiene. https://www1.nyc.gov/site/doh/covid/covid-19-data-boroughs.page. Accessed July 2, 2020.

3. Humble W. Doctors face tough choices, narrowing options on COVID in Arizona. Interviewed by Rachel Maddow. Rachel Maddow Show [Television broadcast]. New York, NY: MSNBC. June 26, 2020.

4. Coronavirus Disease 2019, Cases in the US. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed July 1, 2020.

5. Suarez F. The problem we are having is behavior. Interviewed by P. Alexander. Deadline [Television broadcast]. New York, NY: MSNBC. June 26, 2020.

About the Author

Michele Cleary is a HEOR writer in Minneapolis, MN.