Post by Nadica (She/Her) on Aug 22, 2024 22:43:03 GMT
Why do People Stop Masking After They Get Covid…and How Should These Changes Inform Our Own? - Published Aug 22, 2024
Lately, I’ve been seeing a lot of posts on social media that ask “why do people who were masking suddenly stop after having covid?”
This is definitely “a thing” – one that I’ve seen occur among many of own previously “covid cautious” friends and extended family members after they’ve been infected for the first time. The phenomenon isn’t restricted to mask wearing, either: I have a friend who lives in a very large and crowded urban area who had been masking consistently for four years. Recently, she was down with the virus for the first time. After she recovered, she kept masking, but she also started visiting the city’s perennially crowded restaurants – something she had avoided doing since those establishments temporarily shuttered in 2020.
Why does this sort of “giving up” after infection occur? Well, fundamentally, recidivism has to do with how people assess both a health risk and its associated risk reduction activities. So to begin, let’s do a quick review of the processes that shape people’s health judgments and behaviors regardless of whether or not they’ve experienced a threat directly:
First, people often assess personal health risks and mitigation strategies based on a whole host of factors that may have little or nothing to do with the threat itself, including what they’re being asked to do to mitigate the threat (for example, how easy or hard those behaviors are to do, and how well they think they can do them); how they feel about those activities; what other folks they know (or know of) think about risk mitigation, and how those other folks are behaving. If people believe that a risk prevention activity or strategy isn’t likely to keep the threat at bay; if they think the (financial, social, or other) costs of engaging in risk reduction are too high; or they think they just can’t do the risk-reducing behavior for some reason, they aren’t likely to try or to keep trying.
But two other big factors in health risk assessment and prevention (which together are called risk judgments) have to do with the threat itself. The first of these factors is people’s perceptions of how likely it is that a negative event (like an infection) will happen to them, specifically – that is, the perceived event probability, which is often based on the person’s perceived susceptibility to the health threat. The second factor is their perceptions of the threat’s severity – for example, what people believe will happen to them as a result of experiencing the health-related event.
At this point in the pandemic, people’s perceptions of “personal vulnerability” to infection with SARS-CoV-2 may be the same as they were previously, or may even have increased over time due to personal experience with infections; once you’ve been through an event, it becomes harder to think that you never could. But a perception of vulnerability going forward isn’t a given, because many people assume that prior infection or vaccination compliance means they’re now immune, to some degree; in such cases, people may perceive their vulnerability to getting infected as being lower than it once was, even if they’re engaging in more risk activity than they were in previous years. (This is why messaging about waning immunity is so important.)
What is likely to have decreased is people’s perceptions of severity. To some degree, this is due just to the passage of time: when people become alarmed about a new threat (like a novel virus) yet do not experience the most feared outcomes (like sudden disability or death) over a stretch of time, perceptions of both event probability and risk severity tend to wane; this is reflected in the attitude that “if it hasn’t happened yet, it’s not going to.” To some degree, these perceptual changes can be adaptive, because maintaining a state of hypervigilance over long periods can itself have negative health effects, and because viewing a threat as less concerning than one used to allows folks to re-engage with things they may really need to do but had put on hold (like dealing with a dental issue, which many folks waited on in 2020). But ironically, the tendency to relax over time means that the things many folks do daily (like driving or riding in cars) tend to be perceived as less risky than those we do less frequently (like flying in planes), even when people “know” that those more frequently taken risks are also statistically more likely to result in harm.
One example of people “habituating” to a health risk from the world of viruses is influenza. Seasonal flu is an illness that affects hundreds of millions of people globally every year, with millions of severe cases and (according to the WHO), 290,000 to 650,000 acute respiratory deaths annually. (Not all flu-related deaths are acute, of course; for example, the actor Harry Anderson suffered strokes from a flu infection in 2018, eventually dying from one three months later.) Yet most people in industrialized nations don’t give much thought to avoiding the flu, in significant part because we’ve all grown up with it in the background of our daily lives. In the US, fewer than half of us tend to get our annual flu shot (especially if we’re young and without particular risk factors that make us more aware of the threat), even though flu vaccination is an annual one-off intervention that’s pretty easy for most folks to do. And far less of the population engages in more ongoing risk-reduction for flu; for example, before the covid pandemic, some high-risk people wore masks during flu season (I was one of them, depending on the flu strain), but doing so never would have occurred to most.
We also know that just participating in health risk behavior is sometimes associated with lower perceptions of the likelihood of negative outcomes. “Wait, what?” I hear you asking. But it’s true; people who do various risky things may view those activities as less risky than the folks who abstain do. One reason is that, when people intend to engage in risk behavior (whatever their motivation), they often then “adjust their perceptions of risk down” as a way of reducing cognitive dissonance and justifying their choices. Some studies show that general perceptions of population-level risk might not change (so, for example, folks who are socializing without a mask may still know that covid is “out there” and can kill and disable people), but perceptions about one’s own behavior and expected outcomes get rosier.
So habituation and cognitive dissonance are part of the story. But what about all the people who presumably knew that mask wearing and other forms of covid risk mitigation were important for them personally (because, after all, they were doing it), yet suddenly stopped once they’d had an encounter with the virus? Wouldn’t that personal experience make them even more committed to avoiding another infection?
The answer is: not necessarily. To some unknown degree, people may be dropping their masks after recovery from infection with SARS-CoV-2 simply because the thing they were trying to accomplish (“never getting covid”) is now off the table, and in that all-or-nothing way of thinking in which people are so often inclined to engage, they feel they’re no longer playing the same game – so they don’t feel the need to play at all. This pattern of response contributes to recidivism within a whole host of health risk reduction realms, from weight management to the abstinence from alcohol and illicit drugs. (Unfortunately, messages from the covid cautious community that people must engage in consistent risk avoidance all the time, without allowing for relapse, don’t help this situation.)
Even when people develop long-term health issues after an experience like a covid infection, they may convince themselves that “the damage is already done,” so why keep avoiding the threat? With both covid and other health threats, folks often don’t fully grasp that one experience of a threat doesn’t mean there’s no benefit to avoiding subsequent encounters; I used to see this in my own research with HIV+ men, who sometimes failed to recognize the benefit of avoiding new exposures to additional strains of that virus – including drug resistant ones. Another, especially vivid picture of this kind of thinking, which was embodied by the character played by Andy Garcia in the film Dead Again, is of smokers who develop cancer; receive tracheostomies; and then continue to smoke through the stoma hole. As Garcia’s character asks, “I’m dying; what the f** is the difference?”
But mostly, the cessation of masking (and re-commitment to restaurant dining, and all the rest) once people experience a covid infection likely has to do with changes to the perception of disease severity discussed above. Some of this change is undoubtedly due to the fact that folks with a recent infection under their belt (just like everyone else) have been told by trusted authorities and the media that covid is now more mild than it was, which most people take to mean “not a threat.” The absence of morgue trucks parked outside hospitals, and the absence of accessible statistics about hospitalizations and deaths, both lend credence to that narrative. The perception of a threat as something you need to avoid is a necessary precondition to wanting to ameliorate that threat; why would people avoid doing an enjoyable activity that they don’t view as “too dangerous,” or put themselves out to sidestep exposure to a virus they think is “just a cold?”
Additionally, when people have been engaging in risk reduction behavior (like masking) yet still experience the outcome they were trying to avoid (like a covid infection), this often leads to a perception that the mitigation behavior is itself ineffective (so what’s the point in continuing to do it?) and a sense of helplessness or fatalism (because “everyone’s going to keep getting it, anyway”). Both compromise people’s intentions to avoid risk activity. Even when people were infected simply because they weren’t engaging in an intervention consistently or effectively, (say, they removed their mask in a high-risk situation, or they were wearing just a “baggy blue” when an N95 would have been appropriate) or because there were extenuating circumstances (say, their exposure took place during an unusually high risk-situation like a Taylor Swift concert, where they were masked but the air was laden with the breath of tens of thousands of unmasked people), folks may be likely to start viewing an intervention like masking as globally ineffective. So they abandon it, rather than recognizing that, although no intervention is fool-proof, a “harm reduction” approach to masking when you can is better than adopting an all-or-nothing attitude that leads to giving up.
Finally and perhaps most important, when people engage in risk activity and come out the other side “unscathed” (or think they have), perceptions of risk and associated intentions to engage in activity like masking may be especially likely to take a hit. Emotionally, “getting away with it” (which the majority of people believe they do, with any one infection, whether that means avoiding hospitalization or avoiding long-term health issues) provides positive reinforcement for engaging in health risk behavior, as well as a sense of invulnerability. (For some, engaging in risk behavior even provides a “buzz” that is itself reinforcing!) Cognitively, navigating an infection without experiencing unacceptably adverse consequences (or without realizing you did, at the time) provides people with concrete information about what to expect from the virus; this allows them to conclude that getting infected is an acceptable thing to keep doing.
Even if a person is aware of new research studies and statistics such as hospitalization/mortality numbers – which isn’t likely, these days – such population-level information is often perceived as much more abstract and much less relevant to a person’s own situation than their lived experience is. If you’ve ever looked askance at a friend who is doing something patently unsafe and been told “don’t worry, I’ve done this before,” that’s an instance of this sort of reasoning. This phenomenon occurs with regard to behaviors we do all the time; one example is of folks who think it’s safe to use their phones – or to unwrap their fast food order, or to turn around to yell at their kids – while driving. It also affects decisions we make about much more rare events, as when people stay in their homes after receiving evacuation orders, because they’ve “done this for years.” Having ridden out a storm successfully (whether it’s a literal or metaphorical one) reinforces the idea that all storms can be successfully ridden out.
Together, all of these factors can combine to foster an “illusion of invulnerability.” As psychologist Neil Weinstein once wrote, “the lesson we learn about most hazards is that they do not happen to us.” And when people are provided with mitigation guidance that they later deem to have been unnecessary, that further contributes to an unwillingness to follow that guidance again. One example from outside the world of covid is that of homeowners in Florida or the Carolinas who ignore evacuation messaging and tell newscasters it’s because “we left once, but it turned out we could have just stayed where we were, so now we just do that.” This sort of situation is directly analogous to the decision-making of folks who were told they needed to wear masks; did so (whether well or poorly, consistently or inconsistently); had a covid infection; recovered; feel fine; and so, conclude that that covid mitigation isn’t worth the trouble.
Early in the pandemic, people didn’t know what to expect of SARS-CoV-2. The threat was new, ambiguous, and hard for people to assess because they had no prior experience from which to draw. They were shocked by all the deaths being described on TV and social media, and were given concrete instructions to stay home and mask up. But for most people, personal experiences with infection (as well as policy changes) have altered that risk assessment. When their own acute infection is asymptomatic or mild (as most acute infections are, regardless of what may happen later) and people perceive no lasting damage (whether or not there was some), that can lead folks to believe that covid is actually no big deal, and so, lead them to conclude that interventions aren’t worth their perceived costs. This kind of thinking is especially likely when there’s a time lag between a health risk exposure and development of subsequent negative outcomes; we see it with smokers who later develop lung cancer or heart disease, and with heavy drinkers who develop cirrhosis. In early HIV intervention, we saw it all the time among people who had unprotected sex and were later surprised to learn they had HIV, because (since the consequence didn’t follow immediately from the precipitating behavior), they really felt like they’d been dodging the bullet.
So how can we deal with this reality?
Well, telling people that they’re likely to experience dire consequences from acute infection isn’t often going to be persuasive, both because that usually isn’t true (most people don’t die from acute infection, or even become hospitalized) and because people can think of a great many examples of folks they know who caught covid and didn’t die – including themselves. (That’s the availability heuristic, which I’ve discussed before.) In those situations, people are simply likely to assume the messenger isn’t a credible source of information. Even reminding people of the risks of long covid is typically likely to fall on deaf ears, at this point, because of perceived invulnerability and optimism bias issues – as noted above, when a message asks people to prioritize a theoretical risk over actual experience, it’s often ignored. My personal opinion is that, given where we are right now, the best approach we can take is one of harm reduction, which emphasizes lessening risky or harmful behaviors and increasing health-protective ones, rather than looking to achieve, in one dramatic leap, a perfect world in which everyone abstains from risky behavior all of the time. Some important questions are therefore: Who are the people most at risk? What are the most important settings in which to work to increase infection control measures? What policies do we need to fight for, and against? How can we meet people where they currently are? And what are the obstacles to doing that?
Risk reduction messaging needs to adapt based on what people’s beliefs and attitudes are at the moment; the strategies and message that people were receptive to early on are not the same as those they may be receptive to now. This is a different time – not because we aren’t still living through a pandemic, but because public perceptions and public policy have both shifted dramatically. To create compliance, we need to take into account the misunderstandings and biases that people – even those folks who are not inherently anti-mask or anti-vax – have now embraced and carry with them. We must understand the foundations of people’s risk behavior and current views of risk reduction if we are to build on that base.
For example, risk perceptions fluctuate; many people who don’t generally mask may be willing to return to masking during specific surge periods, but one obstacle is that there is poor public awareness of when the threat is highest. The reluctance of some media outlets to get out in front of surges (rather than mentioning them in passing once the horse is out of the barn) is a contributing factor, but there are others that are far less obvious. For instance, when well-meaning people convey to friends or social media followers that community transmission is at a high level all the time, this may make it harder for unmasked-but-mask-receptive folks to know when community transmission has really hit a level at which they, personally, would be willing to mask. Over time, believing that credible information about these surge events is unknowable, those folks may simply tune out and stop engaging with surge alerts. (I’ve seen this happen with a very kind, decent friend who always respects the mitigation needs of others who explicitly inform her of those needs, but who has been infected multiple times because she hasn’t known when it’s most important to protect herself.)
The beliefs and behaviors being “deconstructed” in this particular essay aren’t those of folks who were calling life-saving vaccines “fascism” or having mask burning parties, early on. They reflect the psychology of well-intentioned people who have often tried to do the right things, but who don’t understand the full risks of new and repeated covid infections. Yes, the cause of this disconnect is due in part to government institutions having poorly conveyed those risks (and sometimes having actively sought to limit, or even restrict, effective risk reduction activity, rather than to promote it). But it’s also simply because people think, feel and behave as people are generally “wont to do” about a wide variety of health risks – not just SARS-CoV-2. For example, thousands of people in the US are injured or die each year in home fires or from falling off of furniture. But firefighters tend to be far more aware than the rest of the public is of how burning candles and leaving the kitchen with food cooking on the stove can significantly increase house fire risks. ER doctors are more aware than other folks are of how frequently people are injured by falling off of the chairs they’ve stood on to reach something. Likewise, covid-cautious people can be hyper-aware of risk behavior that they’ve been sensitized to, without appreciating that humans in modern society often feel safe with regard to many sorts of risk activity that they engage in as a matter of course.
In general, I’m not a huge fan of the expression “don’t let the perfect be the enemy of the good,” because I tend to believe that most people could be doing better at most things, most of the time, than they are; I am, by nature, an optimizer. But I also think we need to recognize the psychological forces that have both led people to abandon covid mitigations and which keep them from taking up those risk-reducing behaviors again – and we should look to deal with those dynamics while appreciating that they are deeply ingrained aspects of the human condition. No matter how frustrated, angry or upset folks are that so many people, including their previously masking friends, have “moved on,” we need to tailor current strategies to engage with people about risk reduction on the battlefields on which we currently find ourselves, if we hope to win those battles, let alone to prevail in the larger war on public health.
Lately, I’ve been seeing a lot of posts on social media that ask “why do people who were masking suddenly stop after having covid?”
This is definitely “a thing” – one that I’ve seen occur among many of own previously “covid cautious” friends and extended family members after they’ve been infected for the first time. The phenomenon isn’t restricted to mask wearing, either: I have a friend who lives in a very large and crowded urban area who had been masking consistently for four years. Recently, she was down with the virus for the first time. After she recovered, she kept masking, but she also started visiting the city’s perennially crowded restaurants – something she had avoided doing since those establishments temporarily shuttered in 2020.
Why does this sort of “giving up” after infection occur? Well, fundamentally, recidivism has to do with how people assess both a health risk and its associated risk reduction activities. So to begin, let’s do a quick review of the processes that shape people’s health judgments and behaviors regardless of whether or not they’ve experienced a threat directly:
First, people often assess personal health risks and mitigation strategies based on a whole host of factors that may have little or nothing to do with the threat itself, including what they’re being asked to do to mitigate the threat (for example, how easy or hard those behaviors are to do, and how well they think they can do them); how they feel about those activities; what other folks they know (or know of) think about risk mitigation, and how those other folks are behaving. If people believe that a risk prevention activity or strategy isn’t likely to keep the threat at bay; if they think the (financial, social, or other) costs of engaging in risk reduction are too high; or they think they just can’t do the risk-reducing behavior for some reason, they aren’t likely to try or to keep trying.
But two other big factors in health risk assessment and prevention (which together are called risk judgments) have to do with the threat itself. The first of these factors is people’s perceptions of how likely it is that a negative event (like an infection) will happen to them, specifically – that is, the perceived event probability, which is often based on the person’s perceived susceptibility to the health threat. The second factor is their perceptions of the threat’s severity – for example, what people believe will happen to them as a result of experiencing the health-related event.
At this point in the pandemic, people’s perceptions of “personal vulnerability” to infection with SARS-CoV-2 may be the same as they were previously, or may even have increased over time due to personal experience with infections; once you’ve been through an event, it becomes harder to think that you never could. But a perception of vulnerability going forward isn’t a given, because many people assume that prior infection or vaccination compliance means they’re now immune, to some degree; in such cases, people may perceive their vulnerability to getting infected as being lower than it once was, even if they’re engaging in more risk activity than they were in previous years. (This is why messaging about waning immunity is so important.)
What is likely to have decreased is people’s perceptions of severity. To some degree, this is due just to the passage of time: when people become alarmed about a new threat (like a novel virus) yet do not experience the most feared outcomes (like sudden disability or death) over a stretch of time, perceptions of both event probability and risk severity tend to wane; this is reflected in the attitude that “if it hasn’t happened yet, it’s not going to.” To some degree, these perceptual changes can be adaptive, because maintaining a state of hypervigilance over long periods can itself have negative health effects, and because viewing a threat as less concerning than one used to allows folks to re-engage with things they may really need to do but had put on hold (like dealing with a dental issue, which many folks waited on in 2020). But ironically, the tendency to relax over time means that the things many folks do daily (like driving or riding in cars) tend to be perceived as less risky than those we do less frequently (like flying in planes), even when people “know” that those more frequently taken risks are also statistically more likely to result in harm.
One example of people “habituating” to a health risk from the world of viruses is influenza. Seasonal flu is an illness that affects hundreds of millions of people globally every year, with millions of severe cases and (according to the WHO), 290,000 to 650,000 acute respiratory deaths annually. (Not all flu-related deaths are acute, of course; for example, the actor Harry Anderson suffered strokes from a flu infection in 2018, eventually dying from one three months later.) Yet most people in industrialized nations don’t give much thought to avoiding the flu, in significant part because we’ve all grown up with it in the background of our daily lives. In the US, fewer than half of us tend to get our annual flu shot (especially if we’re young and without particular risk factors that make us more aware of the threat), even though flu vaccination is an annual one-off intervention that’s pretty easy for most folks to do. And far less of the population engages in more ongoing risk-reduction for flu; for example, before the covid pandemic, some high-risk people wore masks during flu season (I was one of them, depending on the flu strain), but doing so never would have occurred to most.
We also know that just participating in health risk behavior is sometimes associated with lower perceptions of the likelihood of negative outcomes. “Wait, what?” I hear you asking. But it’s true; people who do various risky things may view those activities as less risky than the folks who abstain do. One reason is that, when people intend to engage in risk behavior (whatever their motivation), they often then “adjust their perceptions of risk down” as a way of reducing cognitive dissonance and justifying their choices. Some studies show that general perceptions of population-level risk might not change (so, for example, folks who are socializing without a mask may still know that covid is “out there” and can kill and disable people), but perceptions about one’s own behavior and expected outcomes get rosier.
So habituation and cognitive dissonance are part of the story. But what about all the people who presumably knew that mask wearing and other forms of covid risk mitigation were important for them personally (because, after all, they were doing it), yet suddenly stopped once they’d had an encounter with the virus? Wouldn’t that personal experience make them even more committed to avoiding another infection?
The answer is: not necessarily. To some unknown degree, people may be dropping their masks after recovery from infection with SARS-CoV-2 simply because the thing they were trying to accomplish (“never getting covid”) is now off the table, and in that all-or-nothing way of thinking in which people are so often inclined to engage, they feel they’re no longer playing the same game – so they don’t feel the need to play at all. This pattern of response contributes to recidivism within a whole host of health risk reduction realms, from weight management to the abstinence from alcohol and illicit drugs. (Unfortunately, messages from the covid cautious community that people must engage in consistent risk avoidance all the time, without allowing for relapse, don’t help this situation.)
Even when people develop long-term health issues after an experience like a covid infection, they may convince themselves that “the damage is already done,” so why keep avoiding the threat? With both covid and other health threats, folks often don’t fully grasp that one experience of a threat doesn’t mean there’s no benefit to avoiding subsequent encounters; I used to see this in my own research with HIV+ men, who sometimes failed to recognize the benefit of avoiding new exposures to additional strains of that virus – including drug resistant ones. Another, especially vivid picture of this kind of thinking, which was embodied by the character played by Andy Garcia in the film Dead Again, is of smokers who develop cancer; receive tracheostomies; and then continue to smoke through the stoma hole. As Garcia’s character asks, “I’m dying; what the f** is the difference?”
But mostly, the cessation of masking (and re-commitment to restaurant dining, and all the rest) once people experience a covid infection likely has to do with changes to the perception of disease severity discussed above. Some of this change is undoubtedly due to the fact that folks with a recent infection under their belt (just like everyone else) have been told by trusted authorities and the media that covid is now more mild than it was, which most people take to mean “not a threat.” The absence of morgue trucks parked outside hospitals, and the absence of accessible statistics about hospitalizations and deaths, both lend credence to that narrative. The perception of a threat as something you need to avoid is a necessary precondition to wanting to ameliorate that threat; why would people avoid doing an enjoyable activity that they don’t view as “too dangerous,” or put themselves out to sidestep exposure to a virus they think is “just a cold?”
Additionally, when people have been engaging in risk reduction behavior (like masking) yet still experience the outcome they were trying to avoid (like a covid infection), this often leads to a perception that the mitigation behavior is itself ineffective (so what’s the point in continuing to do it?) and a sense of helplessness or fatalism (because “everyone’s going to keep getting it, anyway”). Both compromise people’s intentions to avoid risk activity. Even when people were infected simply because they weren’t engaging in an intervention consistently or effectively, (say, they removed their mask in a high-risk situation, or they were wearing just a “baggy blue” when an N95 would have been appropriate) or because there were extenuating circumstances (say, their exposure took place during an unusually high risk-situation like a Taylor Swift concert, where they were masked but the air was laden with the breath of tens of thousands of unmasked people), folks may be likely to start viewing an intervention like masking as globally ineffective. So they abandon it, rather than recognizing that, although no intervention is fool-proof, a “harm reduction” approach to masking when you can is better than adopting an all-or-nothing attitude that leads to giving up.
Finally and perhaps most important, when people engage in risk activity and come out the other side “unscathed” (or think they have), perceptions of risk and associated intentions to engage in activity like masking may be especially likely to take a hit. Emotionally, “getting away with it” (which the majority of people believe they do, with any one infection, whether that means avoiding hospitalization or avoiding long-term health issues) provides positive reinforcement for engaging in health risk behavior, as well as a sense of invulnerability. (For some, engaging in risk behavior even provides a “buzz” that is itself reinforcing!) Cognitively, navigating an infection without experiencing unacceptably adverse consequences (or without realizing you did, at the time) provides people with concrete information about what to expect from the virus; this allows them to conclude that getting infected is an acceptable thing to keep doing.
Even if a person is aware of new research studies and statistics such as hospitalization/mortality numbers – which isn’t likely, these days – such population-level information is often perceived as much more abstract and much less relevant to a person’s own situation than their lived experience is. If you’ve ever looked askance at a friend who is doing something patently unsafe and been told “don’t worry, I’ve done this before,” that’s an instance of this sort of reasoning. This phenomenon occurs with regard to behaviors we do all the time; one example is of folks who think it’s safe to use their phones – or to unwrap their fast food order, or to turn around to yell at their kids – while driving. It also affects decisions we make about much more rare events, as when people stay in their homes after receiving evacuation orders, because they’ve “done this for years.” Having ridden out a storm successfully (whether it’s a literal or metaphorical one) reinforces the idea that all storms can be successfully ridden out.
Together, all of these factors can combine to foster an “illusion of invulnerability.” As psychologist Neil Weinstein once wrote, “the lesson we learn about most hazards is that they do not happen to us.” And when people are provided with mitigation guidance that they later deem to have been unnecessary, that further contributes to an unwillingness to follow that guidance again. One example from outside the world of covid is that of homeowners in Florida or the Carolinas who ignore evacuation messaging and tell newscasters it’s because “we left once, but it turned out we could have just stayed where we were, so now we just do that.” This sort of situation is directly analogous to the decision-making of folks who were told they needed to wear masks; did so (whether well or poorly, consistently or inconsistently); had a covid infection; recovered; feel fine; and so, conclude that that covid mitigation isn’t worth the trouble.
Early in the pandemic, people didn’t know what to expect of SARS-CoV-2. The threat was new, ambiguous, and hard for people to assess because they had no prior experience from which to draw. They were shocked by all the deaths being described on TV and social media, and were given concrete instructions to stay home and mask up. But for most people, personal experiences with infection (as well as policy changes) have altered that risk assessment. When their own acute infection is asymptomatic or mild (as most acute infections are, regardless of what may happen later) and people perceive no lasting damage (whether or not there was some), that can lead folks to believe that covid is actually no big deal, and so, lead them to conclude that interventions aren’t worth their perceived costs. This kind of thinking is especially likely when there’s a time lag between a health risk exposure and development of subsequent negative outcomes; we see it with smokers who later develop lung cancer or heart disease, and with heavy drinkers who develop cirrhosis. In early HIV intervention, we saw it all the time among people who had unprotected sex and were later surprised to learn they had HIV, because (since the consequence didn’t follow immediately from the precipitating behavior), they really felt like they’d been dodging the bullet.
So how can we deal with this reality?
Well, telling people that they’re likely to experience dire consequences from acute infection isn’t often going to be persuasive, both because that usually isn’t true (most people don’t die from acute infection, or even become hospitalized) and because people can think of a great many examples of folks they know who caught covid and didn’t die – including themselves. (That’s the availability heuristic, which I’ve discussed before.) In those situations, people are simply likely to assume the messenger isn’t a credible source of information. Even reminding people of the risks of long covid is typically likely to fall on deaf ears, at this point, because of perceived invulnerability and optimism bias issues – as noted above, when a message asks people to prioritize a theoretical risk over actual experience, it’s often ignored. My personal opinion is that, given where we are right now, the best approach we can take is one of harm reduction, which emphasizes lessening risky or harmful behaviors and increasing health-protective ones, rather than looking to achieve, in one dramatic leap, a perfect world in which everyone abstains from risky behavior all of the time. Some important questions are therefore: Who are the people most at risk? What are the most important settings in which to work to increase infection control measures? What policies do we need to fight for, and against? How can we meet people where they currently are? And what are the obstacles to doing that?
Risk reduction messaging needs to adapt based on what people’s beliefs and attitudes are at the moment; the strategies and message that people were receptive to early on are not the same as those they may be receptive to now. This is a different time – not because we aren’t still living through a pandemic, but because public perceptions and public policy have both shifted dramatically. To create compliance, we need to take into account the misunderstandings and biases that people – even those folks who are not inherently anti-mask or anti-vax – have now embraced and carry with them. We must understand the foundations of people’s risk behavior and current views of risk reduction if we are to build on that base.
For example, risk perceptions fluctuate; many people who don’t generally mask may be willing to return to masking during specific surge periods, but one obstacle is that there is poor public awareness of when the threat is highest. The reluctance of some media outlets to get out in front of surges (rather than mentioning them in passing once the horse is out of the barn) is a contributing factor, but there are others that are far less obvious. For instance, when well-meaning people convey to friends or social media followers that community transmission is at a high level all the time, this may make it harder for unmasked-but-mask-receptive folks to know when community transmission has really hit a level at which they, personally, would be willing to mask. Over time, believing that credible information about these surge events is unknowable, those folks may simply tune out and stop engaging with surge alerts. (I’ve seen this happen with a very kind, decent friend who always respects the mitigation needs of others who explicitly inform her of those needs, but who has been infected multiple times because she hasn’t known when it’s most important to protect herself.)
The beliefs and behaviors being “deconstructed” in this particular essay aren’t those of folks who were calling life-saving vaccines “fascism” or having mask burning parties, early on. They reflect the psychology of well-intentioned people who have often tried to do the right things, but who don’t understand the full risks of new and repeated covid infections. Yes, the cause of this disconnect is due in part to government institutions having poorly conveyed those risks (and sometimes having actively sought to limit, or even restrict, effective risk reduction activity, rather than to promote it). But it’s also simply because people think, feel and behave as people are generally “wont to do” about a wide variety of health risks – not just SARS-CoV-2. For example, thousands of people in the US are injured or die each year in home fires or from falling off of furniture. But firefighters tend to be far more aware than the rest of the public is of how burning candles and leaving the kitchen with food cooking on the stove can significantly increase house fire risks. ER doctors are more aware than other folks are of how frequently people are injured by falling off of the chairs they’ve stood on to reach something. Likewise, covid-cautious people can be hyper-aware of risk behavior that they’ve been sensitized to, without appreciating that humans in modern society often feel safe with regard to many sorts of risk activity that they engage in as a matter of course.
In general, I’m not a huge fan of the expression “don’t let the perfect be the enemy of the good,” because I tend to believe that most people could be doing better at most things, most of the time, than they are; I am, by nature, an optimizer. But I also think we need to recognize the psychological forces that have both led people to abandon covid mitigations and which keep them from taking up those risk-reducing behaviors again – and we should look to deal with those dynamics while appreciating that they are deeply ingrained aspects of the human condition. No matter how frustrated, angry or upset folks are that so many people, including their previously masking friends, have “moved on,” we need to tailor current strategies to engage with people about risk reduction on the battlefields on which we currently find ourselves, if we hope to win those battles, let alone to prevail in the larger war on public health.