Updated: Dec 1, 2021
As frequent visitors to this blog know, one of our goals is to demonstrate how to apply key principles based on the rich history of behavioral research to deepen our understanding of daily interactions, be it our relationships with others, or to inform our analysis of local, national, and global issues. Indeed, we want to encourage every citizen to use behavioral science as a trusted shared bedrock for a rational and coherent process to understand our collective challenges and make decisions that will lead to more enduring positive changes. Sadly, we recently passed 730,000 deaths in the U.S. from COVID-19, more than any other country. What insights does using our behavioral science lens provide to better understand the past 20 months.
…hospital workers continue to experience the daily trauma of death at much higher rates than experienced prior to the pandemic.
For many of us we are thankful we have returned to “close to normal” life despite the pandemic continuing here and abroad. For others, changes in employment, re-balancing family and work responsibilities, and the added stress of navigating these new times continues to be daunting. And for a few, like my girlfriend who is a critical care nurse on a Step-down ICU, our front-line workers continue to bear the significant brunt of our collective behaviors, and disagreements as to how to address the reality of this new viral threat. My girlfriend, like most critical care nurses, serves in 12+ hour shifts (more like 14+ hours when factoring in paperwork, commute times,…). Due to shortages in the field, made worse by a lack of coordinated response, she and other hospital workers continue to be asked to do more with less. They continue to have limited access to PPEs, therefore requiring them to re-use masks and gowns, and work shifts with less-than-optimal staff to patient ratios. Her and her colleagues continue to experience the daily trauma of death at much higher rates than experienced prior to the pandemic. They interact with grieving loved ones who have limited access to their family members. At other times, the hospital staff are the last humans to meaningfully interact with a patient who dies from COVID-19.
She, and her hospital colleagues signed up for a challenging and demanding career that even before COVID-19 had high rates of staff burn-out and turn-over. Increasingly however, she and her colleagues have had to contend with an added infuriating facet of reality: (1) simple precautions by all citizens early on could have prevented countless deaths and suffering (and afforded our economy less impact), and (2) for many months the vast majority of deaths have been preventable. As reported in the New York Times, Deborah Birx, former Coordinator of the White House Coronavirus Task Force testified to a House Select Subcommittee on the Coronavirus Crisis that it is likely 30-40% of deaths that followed the initial phase of the pandemic could have been avoided with better adherence to mask mandates, social distancing and testing for COVID-19. As recently reported by National Public Radio, the Center for Disease Control used well-designed research studies to conclude: unvaccinated individuals are 5 times more likely to get infected, 10 times more likely to need hospitalizations, and 11 times more likely to die than vaccinated individuals. My girlfriend's experience supports these findings as the vast majority of patients admitted to her hospital are unvaccinated, and many report they regret their reluctance to get the vaccine. As with any vaccine, break-through cases and side effect complications were predicted and do occur, but at such low rates as to clearly show mask wearing and getting vaccinated saves lives, and must be part of a coherent response to the shared goal of all people returning to a “normal” pre-pandemic lifestyle. So what insight can a behavioral lens offer us to understand why different individuals are behaving in vastly different ways?
… we would always choose the doctor who chose to wash their hands and wear a mask over one who refused to wear a mask, wouldn’t we?
An analysis of the differential response to COVID-19 and solutions for such, demonstrates much of the behavioral work we do. As return readers will surely guess we will start at Step 1 of the 5-Step Competing Schedules model of understanding and addressing behavioral change: Define and Teach. For many of us the pandemic was defined by identification of a new virus that spreads easily between individuals and has a much higher rate of serious illness and death than what we encounter with most prior known corona viruses. When we learned that masks could protect us, but also importantly protect others, we gladly embraced established medical protocols for preventing this dangerous virus from being transmitted from person-to-person. By simply wearing a mask, and social distancing we could drastically reduce our chances of contracting the virus, as well as reduce the chance a loved one, or a fellow citizen who we share air with from contracting the virus. For many, it was clearly a medical and public health issue requiring a medical and public health response. As such we donned our masks and wondered why others may find such minimal requirements so egregious. Just like if we were given a choice between doctors who would perform a surgery on our daughter, son, or spouse--we would always choose the doctor who chose to wash their hands and wear a mask over one who refused to wear a mask-- wouldn’t we? Why? Because the basics of virus transmission and prevention are understood, and universally accepted and embraced. Likewise, those that defined this as a public health crisis understood then, and still understand---viruses left to spread unmitigated are given time to mutate. Through the process of natural selection invariably, eventually, they will become stronger and more resistant to our responses.
When the very existence itself of the virus was questioned…people behaved much differently.
But for some, COVID-19 was defined not as an immediate and significant medical and public safety threat, but rather one less important than economic concerns. Political and conspiratorial angles with little to no sustaining evidence were allowed to propagate (to this day), and those who consumed such, behaved much differently. For some what was occurring was entirely a hoax, or at its core a ruse by corrupted individuals to take advantage of a situation for their own nefarious goals. Let’s be clear when one defines COVID-19 this way, it makes sense to question, and resist (and hopefully use critical thinking skills to collect data, and make a rational decision as to the merits of such claims). Masks, while annoying at worst, became seen, or their absence as an expression of political belief, affiliation, or honoring American bed-rock principles. A 3-inch piece of cloth was defined by many as equivalent to the oppressive tax and colonization rules our forefathers fought to liberate themselves from. Even more egregiously wrong and falsely equivalent, comparisons to forcing Jews in Europe to wear a Star of David by Nazis was made. As such those that chose to emphasize personal choice and freedom (very important topics for sure) increasingly refused social distancing guidelines and to wear a mask when around others, be it on a plane, at a store, in a restaurant or on the sidewalk.
As the first step in the 5-Step Competing Schedules model emphasizes--how we define a problem or goals, be it personal ones or for the collective good, will have a large impact on everything else that follows.
One has to wonder though, similar to the example earlier of the doctor choosing not to wear a mask prior to operating on your loved one, would these individuals who defined this as personal choice continue to visit a dental hygienist who wanted to demonstrate the importance of freedom to our way of life by providing their services mask free? What if we knew the hygienist might have recently been exposed to the flu virus? Or perhaps the hantavirus? Indeed, when I have asked individuals this hypothetical example, almost invariably people have said: (1) they would never accept a hygienist choosing not wear a mask, and (2) that they should have the right to not be exposed to that hygienist. And since we understand much about virus transmission (and accept there are some things we don’t yet fully understand, so best be careful), we might require hygienists at this point to wear a mask, for it is a small loss of personal choice for the benefit of others. I am all for our country’s origin story, the adherence to our self-identifying as “Maverick-y”, and American, "toughness", but we are talking about a 3-inch piece of cloth. Certainly, tyranny and persecution comparisons do not hold up to honest critical thinking. As the first step in the 5-Step Competing Schedules model emphasizes--how we define a problem or goals, be it personal ones or for the collective good, will have a large impact on everything else that follows.
We see adults, similar to a child tantrum, fall on the floor and refuse to move, tear at a mask with their teeth and growl like an animal, grab items that are not theirs, urinate on the floor, or even strike another person…their behavioral pattern follows what we know and understand about behavioral escalations.
We have all seen videos of, and possibly witnessed first-hand individuals refusing to wear a mask in public. Interestingly we almost always see they have clearly understood the requirements of the context, yet are, “choosing” not to. We also see that these are examples of well-understood behavioral escalations, and as such they invariably follow a predictable pattern. A person quickly enters a heightened state of agitation and becomes increasingly unwilling and more important un-able to meaningfully consider or rationally interact with others. We see adults, similar to a child tantrum, fall on the floor and refuse to move, tear at a mask with their teeth and growl like an animal, grab items that are not theirs, urinate on the floor, or even strike another person. But don’t misunderstand the purpose of the comparison—I am not suggesting these are immature people, these are adults. Rather, their behavioral pattern follows what we know and understand about behavioral escalations. We are all capable of, and likely at least a few times in our lives, to have engaged in a tantrum to try to get our needs met and to express ourselves. We also hopefully have learned more adaptive skills to express our feelings and to engage with others in mature discourse.
When individuals are not trained in civics, conflict resolution, or effective communication, and are largely disenfranchised--all while given access to powerful echo chambers that allow ideas to be left unchallenged-- it is predictable to see adults behaving in many of the ways we now are forced to accept as, “normal”.
Similar to a child’s tantrum these individuals are losing their mental grounding, and as their ability to use rational thinking skills erodes, their undesirable behavior will intensify. The needs of others and safety to themselves are not considered and it is not likely to have a positive outcome for themselves or others. Escalations follow a predictable sequence, and we know how to plan for, and address the known stages individuals who are behaviorally escalated will go through (See our TEMPER—ED(TM) curriculum, training and material to learn more about understanding, preventing, and effectively addressing behavioral escalations). We also know how we might do a better job of ensuring all citizens understand effective communication and how to respectfully share their voice to the collective discussion of shared issues. When individuals are not trained in civics, conflict resolution, or effective communication, and are largely disenfranchised--all while given access to powerful echo chambers that allow ideas to be left unchallenged-- it is predictable to see adults behaving in many of the ways we now are forced to accept as, “normal”.
We all should be better informed with the research behind our medicines, and about what we choose to expose ourselves to—be it a vaccine, an over-the-counter medicine we take without thinking, the technology we increasingly surround ourselves with, or the food and water we consume.
In fact, the power to define is so powerful that our own prior experience and decisions and attitudes can be relegated and dismissed. Let’s be clear wearing a mask IS very different than getting a vaccine shot. Being injected with something is inherently more intrusive and potentially harmful then wearing a mask. But how many against “forced” mask mandates and vaccines freely got vaccines in school, to serve in the military, for participation in extracurricular activities, to travel abroad, or to maintain employment prior to 2020? How much research did they do before exposing themselves to such risk? Don’t get me wrong--we all should be better informed with the research behind our medicines, and about what we choose to expose ourselves to—be it a vaccine, an over-the-counter medicine we take without thinking, the technology we increasingly surround ourselves with, or the food and water we consume. But why all of a sudden do many mask and vaccine opponents purport concern about the amount of and quality of medical research behind a drug? Are these individuals informing themselves to be good consumers of scientific research? Are they relying on information sources who clearly understand the process of medicine development and scientific inquiry? There certainly seems to be a high correlation between sources of information and beliefs about effective interventions.
The power to define is seen again though as individuals are willing to trust singers, actors, businessmen’s statements as to effectiveness of medicines more than those who have dedicated their lives to the pursuit of these endeavors.
As my girlfriend has increasingly been experiencing, individuals who reject the scientific research behind the COVID-19 vaccines have determined that their understanding of medicine is greater than doctors and researchers. They instead demand (and in some cases sue to ensure) their loved ones be administered hydroxychloroquine and ivermectin. Weren’t these drugs developed, researched by the same organizations and professionals who they have determined are not to be trusted? The power to define is seen again though as individuals are willing to trust singers, actors, businessmen's statements as to effectiveness of medicines more than those who have dedicated their lives to the pursuit of these endeavors. Indeed, information found on the internet and social media from unknown sources has become as trusted, and, at times, even more trusted by some than from our public institutions.
Monoclonal antibodies are an effective REACTIVE intervention, they are administered AFTER contracting the virus…[They] do nothing to stop the transmission to others.
Now some individuals who are still wary of vaccines state that the technology is new, and more data is needed before they would trust the vaccines. That is an understandable and somewhat rational position. The mRNA technology behind the Moderna and Pfizer vaccines is newer than the technology used to create the vaccines most of us were exposed to as a child. However, mRNA technology research started more than a decade ago and as a result was largely why these two highly effective vaccines, that contain NO actual virus (a vast improvement over past technology), were able to be developed so quickly. Monoclonal antibodies, also a more recent medical advancement, has been championed by many of the same individuals who claimed medical approaches are to be avoided. Monoclonal antibody approaches are as far as I know not much more researched than the mRNA approaches behind the vaccines, but they do differ in one fundamental important way. Monoclonal antibodies are an effective REACTIVE intervention, they are administered AFTER contracting the virus. Masks and a vaccine are PROACTIVE steps one can make—masks being the least intrusive, and having no potential of any lasting physical or emotional harm. Importantly however from a public health perspective, monoclonal antibody interventions do nothing to stop the transmission to others. Here we see two important key behavioral principles we cover in most of our trainings: (1) Humans tend to choose behaviors that require less effort, and (2) we often choose more immediate small reinforcers over delayed long term reinforcers. Preventative measures require more planning and diligence than reactive ones. Prevention appears superficially to take more effort upfront to teach, prompt, and reinforce a desired behavior than to only reactively respond to errors an individual makes. Many individuals, especially the young, report that there is only a small chance that they would get the virus, and if they did-- the effects would likely be minimal--so why should they inconvenience themselves and take a risk (no matter how small) for complications. While the risk is indeed greater for those with underlying conditions, and are older, the risk for the young is not zero. One has to wonder if the symptoms of COVID-19 were more extreme and visceral, for example like bleeding from orifices, would one’s willingness for more preventative measures been easier to swallow, and would there be a greater willingness to accept a small risk in getting a shot.
We also see some errors in approach to public policy that have had predictable negative outcomes.
We also see some errors in approach to public policy that have had predictable negative outcomes. First, the idea of promoting vaccine adherence through the use of “incentive programs” shows how difficult true reinforcement systems are to get right, and how the best of intentions, when implemented poorly, can change reinforcement to bribery. We reinforce behaviors, but bribe individuals. Many states flooded with federal dollars decided to “motivate” individuals to get the vaccine through lottery style systems where they could win sizable dollar amounts, sporting event tickets, and other highly “reinforcing” items. Across states these were found to be highly variable in terms of effectiveness. We often saw those states that chose high value reinforcers, but with small odds were less effective than ones who chose reinforcers that were more immediate (i.e. tickets to upcoming games), and likely (greater likelihood of winning). Importantly these efforts tended to draw in those who had not yet received a vaccine for less articulated and deeply held beliefs. So they were effective up to a point. But they also were seen by many as manipulative (i.e. coercive) and that aversive quality prevented some from buying-in.
…using punishment or the threat of punishment rarely supports the adoption and/or sustained use of desired behavior…[Rather] engage in sound rational dialogue and consensus building.
What is also evident is coercing an already reluctant group may have poor outcomes and unintended side effects. There does seem to be stronger and more widespread reluctance and adversarial relationships between public workers and state/local leadership over vaccine mandates when the essential step of dialogue was not emphasized. As elegantly explained in the must read, Coercion and Its Fallout by one of our behavioral science founders, Murray Sidman, using punishment or the threat of punishment rarely supports the adoption and/or sustained use of desired behavior. Rather than an adversarial and threatening approach that uses punishment as a motivator, we instead must we take the time necessary to approach individuals respectfully. We must, when negotiating, engage in sound rational dialogue and consensus building, even when confronted with highly emotionally-charged individuals. Empathetic listening and calm sharing of clear information from trusted sources to counter fears, and misinformation can go a long way in building trust. The CDC’s website now has some wonderful examples of how to clearly communicate information that addresses concerns and informs. This type of messaging was critically missing early on as more coherent and honest communication from our highest leadership at the start of the pandemic was absent at best, and at worst systematically counter-programmed. Nonetheless the importance of quality definition and teaching to public policy is evident for our future challenges.
One thing is clear…we need to do a better job of defining and teaching all citizens how to conduct oneself in civil discourse and disagreements, how to critically think and consume information...How to participate and respond to our collective challenges...
One thing is clear across many of the individuals who don’t want to wear a mask or refuse to get vaccinated. In their explanations for their hesitancy, when asked, they rarely speak of the implications of their choice on others. While I do not have hard data on this, I have been listening very closely to media reports and when I speak directly to those that have chosen not to mask, socially distance, or get vaccinated (including my own extended family). I certainly hear the words, “us”, “others” and “responsibility” more from those that have embraced the medical and public health definition than those choosing to opt-out. We are much more likely to at the very least hear expressions of sensitivity to the needs of others in their decision making. As a firm believer that we must all do better to think critically, for ourselves, and embrace a scientific sceptic approach, I am not suggesting blind allegiance to, “group think” is a good thing. Just the opposite. But we do need to have a common language, a common playbook for the ills that we all are exposed to. So then might it make sense, as we look toward the future to return to Step 1 of the model: Define & Teach. Do we need to define what it means to be a citizen? With so much other conflict and discord in our society, is this experience, one more data point that clearly shows we need to do a better job of defining and teaching all citizens how to conduct oneself in civil discourse and disagreements, how to critically think and consume information? How to participate and respond to our collective challenges be it global warming, ensuring equity, or how to prepare and respond to the next inevitable pandemic?
... short-term thinking can trap individuals into failing to consider and choose options that require more effort upfront, or those that require delayed reinforcement.
Regardless of your political leanings, or how you view the pandemic and public responses, some things are clear. We must define what it is we are talking about for that will guide our process of designing an intervention. We must also recognize that, often being reactive requires less effort, and less perceived risk in the short run. This short-term thinking can trap individuals into failing to consider and choose options that require more effort upfront, or those that require delayed reinforcement. To do nothing requires no effort, and can often be seen as the best option when the perceived threat is low in terms of probability and when the severity of outcomes is not readily seen.
Consider the driving behaviors of wearing a seat belt and speeding. Some drivers “choose” not to wear a seat belt, despite the fact that in the event of an accident there is a greater probability of injury as a result of failing to wear a seat belt. What accounts for this reality? First, to put on a seat belt requires more effort than not. In addition, some have driven in the past without wearing a seat belt, and there was no accident or other negative outcome. Their experience is that more likely than not, when they drive without a seat belt, they will remain injury free. The potential negative consequence of injury is more abstract and distant in time from when they entered the car and had the option of putting on a seat belt. The same goes for speeding. Despite speeding being the main contributor to fatalities on our roads, many still “choose” daily to speed. The reinforcers for speeding are more immediate than the reinforcers for driving the speed limit. For that driver, since the probability of any potential future negative consequences are low their intensity and severity are minimized. We see the same variables when considering why some of our friends, neighbors, and family members continue to not be vaccinated.
Often times our best choice must consider how short- and long-term choices differ, not only for ourselves, but those we love, and those we simply share the air we breathe in, and public spaces we all rely on.
Rather than make value judgements, we may better understand motivations by using a behavioral lens. Much like the driving behavior examples, we can understand why some are choosing not to be vaccinated. First, choosing to not be vaccinated requires less effort. Second, despite little to no evidence of any potential harm they believe they are reducing their risk from any unforeseen harm by getting the vaccine. The very real threat to themselves (and others through their inaction) is perceived to be a lower risk, or one of insufficient intensity to motivate them.
This short-term thinking can trap individuals into failing to consider and choose options that require more effort upfront, or those that require delayed reinforcement. To do nothing requires no effort and can often be seen as the best option when the perceived threat is low in terms of probability and when the severity of outcomes is not readily seen. For some people the potential benefit not only for themselves, but also others may be a more abstract option than the choice in the here-and-now to do nothing. If you don’t see death daily from COVID-19 it is far easier to dismiss it, then if you see and hear daily the horrific results of inaction, or failing to proactively protect oneself and others. Often times our best choice must consider how short- and long-term choices differ, not only for ourselves, but those we love, and those we simply share the air we breathe in, and public spaces we all rely on.
Please thank, or better yet support in some sincere way those on the front line of this current battle. This pandemic is NOT over. They, like our soldiers, endure the effects of the choices of what we expose our country to, and they allow the vast majority of us to live our lives largely unaffected. The lack of clarity as to definition, approaches and our country’s embracing personal choice over collective good creates their daily reality. When defined as a medical issue people behave in ways to protect themselves, those they love, and those they don’t know. When we embrace this choice to define, “success” as not only in the interest of ourselves, but the collective good we maturely delay our gratification in the short run, and have a greater positive impact. Choosing to behave in this way would allow us ALL to return more quickly to the flawed, yet more agreeable-to-all pre-COVID, “reality”. I think that is something we would all agree we would like to do.
Sidman, M. (1989). Coercion and its fallout, Boston: Authors Cooperative, Inc.