Pandemic Shaming Doesn’t Work Says Harvard Epidemiologist

CHRISTIANE AMANPOUR: Now, let’s look at a different aspect of the public health response with Harvard University epidemiologist, Julia Marcus. Here she is talking to our Hari Sreenivasan about how we can mitigate the risk of COVID in a sustainable way.

HARI SREENIVASAN: Christiane, thanks. Dr. Julia Marcus, thanks for joining us. First, I want to ask you about a series of articles that you wrote for at “The Atlantic.” And one of those first ones was a very simple idea, risk is not binary. Explain that.

JULIA MARCUS, INFECTIOUS DISEASE EPIDEMIOLOGIST, HARVARD UNIVERSITY: Yes, the risk is a continuum. And I think at the time when I wrote the article, which is back in May, it felt like we were stuck in this binary discussion about whether we were going to stay locked down forever or go back to business as usual. And of course, neither of those options was really feasible and there is a lot in between. And I wanted to draw attention to the in between area and really start to help people think about risk as a probability rather than, you know, this dichotomy.

SREENIVASAN: Because it’s easier for people to kind of grasp that dichotomy, it seems that anything in between seems like a compromise that one or both sides won’t accept, right? I mean, the people who are concerned for their health says, well, there is a risk. And look, we have nearly 500,000 Americans dead from this. So, we’ve got to take precautions. And then you’ve got folks on the other side who are like, well, this isn’t that relevant to me or my immediate community.

MARCUS: Right. And I think that as is often the case, the truth is somewhere in between, and you are right, that nobody is going to be happy with any particular approach, but I think we need to accept that, yes, this is a huge problem that we need to address and we need to take on as many risk mitigation strategies as we can, but we also need to think about what the tradeoffs are for each of those. And there are always tradeoffs. You know, we could potentially eliminate risks in some scenario where humans could remain completely isolated for some time, but that’s just not possible. So, what is it that we can do that’s realistic and is going to be sustainable for the long-term, which as it’s turned out, this really has become quite a long-term situation.

SREENIVASAN: Because as we have seen, isolation comes with several hidden costs.

MARCUS: That is right. There are costs of isolation, there are also people who continue to go to work. And we need to think about, you know, who are the people who we can pay to stay home. And for those who we can’t, because society needs to continue to function to some extent, how do we protect those people? So, you know, assuming that we can eliminate the risks kind of ignores some the ways that society needs to continue to function, that humans have to interact to some extent for us to continue to survive. And then, yes, there are mental health costs of isolation as well, and for — especially for, you know, elderly people who are isolated in nursing homes, you know, there are a lot of different scenarios that we can think of where there really are some large costs to maintaining safety over some — you know, some semblance of well-being.

SREENIVASAN: So, how do we reduce it? I mean, if we can’t get to zero, how do we minimize it knowing that some people are going to have to take risks because of the jobs they do, the roles they play in society or even their own families?

MARCUS: I think what can help is really focusing on where risks really are. And I don’t know if we have always done that during the pandemic. I think we’ve gotten distracted by the things that really visible, like the people being outdoors without masks, you know, people gathering in the parks. But actually, most of the risk is indoors and most of it is happening in the workplaces and in people’s crowded households. And so, how do you make those situations safer? How do we ensure that people have safe places to isolate away from their crowded households? How do we ensure that people can stay home from work when they’re sick and make sure that people are able to afford to do the things that we are asking them to do to reduce risks?

SREENIVASAN: What is the role of politics and policy and government? Because in some ways, I feel like the onus has been put on the individuals where there are definitely systemic and structural things that only collective organizations like communities and governments can perform.

MARCUS: I think there has been a lot of emphasis during the pandemic on personal responsibility, which, of course, is important especially in an infectious disease epidemic where risk affects not just you, but the people around you. But there is a lot more that needs to be addressed here to make progress. It is not just, you know, if everybody wore a mask for four weeks, the virus would go away, and that is the kind of the messaging we were hearing months ago. It’s — but people continue to have to go to work when they are sick, because they can’t afford to stay home. It’s that people having to wear it to isolate. And so, everybody in their household, including the older generation gets infected as well. And these are problems that have not been addressed. There was an emergency paid sick leave measure that applied to only about half the workforce and has expired, you know. So, we haven’t really taken the steps that we need to, to really address what is driving risk and those structural factors, in particular, which I think is so obvious in terms of who has been affected by the pandemic, in terms of not just caseload and mortality, and it is worldwide. I mean, the working and living conditions being associated with these outcomes is a worldwide phenomenon. So, policies can solve those problems, individuals cannot.

SREENIVASAN: How much of this comes down to how we message or how we communicate this? Because, in the beginning, it seemed is like fear was one of the driving tools trying to communicate this, but there seems to be a diminishing marginal turn to how long we can stay afraid.

MARCUS: Yes. I think fear is a bit fraught in terms of a public health messaging strategy. I think it can have an impact of people’s behavior, but I think it does tend to be short-term and it can come with some costs as well. And I think, as you’re saying, we really did have a massive shift in behavior, that first month to two months when the stay-at-home orders rolled out in March, in April. But that level of fear and massive behavior change cannot be sustained indefinitely. And I do want to recognize that, in fact, people have continued to, you know, change their behavior over time, but that people also have to continue to live their lives to some extent. And public health messaging, I think, does better when it comes from a place of compassion and giving people as much information as they need to empower them so that they can make, you know, informed decisions in their everyday lives. That said, public health messaging, when it is good, it is necessary, but it is not sufficient. You actually have to give people the resources they need to take the steps that you want them to.

SREENIVASAN: You know, very quickly after that first month or so, people, when they saw (INAUDIBLE) behavior, whether it’s parties in spring break in Florida, et cetera, there seemed to be a shift where it’s almost a shaming, a moral nature that crept into how we perceived behaviors by other people.

MARCUS: Yes. And of course, there is a moral nature to this, as we’ve talked about, you know, the risk isn’t just to yourself, it’s to other people and that does bring in a layer of morality and ethics. But I think what — when we think about what works as public health messaging and what works in terms of, you know, the way that the public interacts with each other, shaming does not tend have the effects that we want it to have, and we have seen this in other areas of health. I work on HIV prevention, but we also see it in substance abuse and other areas of health where when you shame people, you tend to drive them away from public health effort, and we are seeing that now with the people who are afraid to get tested because they don’t want to be judged, they don’t want to tell people that they have been exposed or that they may have exposed somebody else. And you can see how that start to breakdown to public health efforts, especially the contact tracing. And so, what works better is really trying to recognize why people are taking risks. And sometimes the things that we’re shaming people for are really not very risky like hanging out in the beach, sometimes they are quite risky like having a big indoor party. But the goal is to reduce infections and maximize health. Let’s ask why are people having a party and what can we do to help them meet their needs in a safer way. And the need is not to have a party, the need is to stay socially active. So, how do we encourage that? Do we create spaces outdoors where people can gather more safely and encourage them to gather there? I think really thinking creatively about how we can address what it is that’s driving that behavior will be more productive than shaming a behavioral result (ph).

SREENIVASAN: We must have evidence over time through different campaigns that just saying, don’t do it, just saying, no, doesn’t work.

MARCUS: Yes, the just say no approach has been a failure in many areas of health. And I think we can think of a few, teen pregnancy, substance use, HIV prevention, it just doesn’t work. And the reason it doesn’t work is that people have reasons why they take risks. And the just say no approach assumes that people can eliminate risks and it ignored the concept of people’s lives and the other aspects of health that may be sacrificed when they don’t take those risks. So, let’s take teen pregnancy for a minute. If we tell teens just say no, what’s going to happen is that some of them are going to have sex and they’re not going to have the tools that they need to reduce risks when they do. So, in fact, we have missed an opportunity to give the people information and tools that they need to reduce the risks when some of them do inevitably take those risks. And we also ignored the context that drives people’s risks and people’s decision-making, and sometimes that context include structural factors that are out of their control, and that’s very much the case during the COVID pandemic and certainly with HIV as well, that, you know, working and living conditions are some of the main drivers of risk. And when we think about risk as being driven by individual choices, we miss that context and we miss opportunities to help people reduce them.

SREENIVASAN: So, what have we learned them from, say, for example, your work with HIV/aids and the prep pills? What have we learned from that that we can apply to behavioral modification or encouragement in this case?

MARCUS: Yes. I think we’ve learned a couple of key things. One is about how we message. And I think what we learned in the aids epidemic, we went from messaging in the early days that was really based in fear and shame to now messaging that’s based in what really matters to people about sex, which is how — you know, when we think about sexual transmission of HIV, people get HIV it in context of something that they are enjoying, that’s about pleasure and intimacy. And now, our messaging really centers that, because we understand that we need to center what matters to people. And secondly, I think equity is a huge lesson that we have learned from HIV epidemic, thinking about the structural factors that drives people’s risks that actually need to be addressed before people can reduce risk. PrEP is, you know, a daily pill to prevent HIV and that’s my main area of research. It’s been around for almost a decade, and we see limited population impact. And there are many reasons why people cannot access it. And that’s the kind of think we need to be thinking about during the COVID pandemic. It’s not just stay home, it’s how do we give people the resources that they need to stay home. And thinking about that, you know, taking that lenses with every single intervention that we are thinking about and ensuring that the highest risk people are able to access those intervention is going to be fastest way to have a population change.

SREENIVASAN: You know, there seem to be parallels here when you’re talking about the PrEP pill and when we’re thinking about the vaccines right now. When those pills first came out, was there concern that people would engage in a more risky behavior because they felt like they now they had an extra shield of protection? I mean, did that play out that way?

MARCUS: I would say that was actually the dominating conversation at the time and this was in 2012, when PrEP was first approved by the FDA. And there was really — you know, rather than a celebratory atmosphere around this amazing biomedical intervention, which by the way is much more effective than condoms in reducing HIV transmission, there was kind of a hesitancy and a lot of hand wringing about how it might create, you know, promote promiscuity and condomless sex and that we were going to see a breakdown of HIV prevention particularly for gay men for — you know, for whom this was going to be a boon after decades of condoms being the main stay of HIV prevention. And I think that has slowed the uptake. And we still see today that some health care providers are reluctant to prescribe PrEP or will not prescribe it because they have concerns about people changing their behavior. And I think we’ve seen some of those themes play out around the vaccines that we know are extremely effective in preventing people from getting get sick from COVID and also, we’re starting to see that they are going to reduce transmission as well to some extent. And so, you know, the — that is something to celebrate, but I think we’ve seen a lot of cautious messaging that may actually deter people inadvertently from getting vaccines.

SREENIVASAN: So, what is an example of positive way to message that’s — that kind of toes the line between forceful and appropriate? How do you get these things across because different people react to different types of data?

MARCUS: Well, just as an example, with the vaccines, in particular, you know, we can think about how we can tell people that their risk of disease is vastly reduced, and that when they are spending time with other people, there is still a possibility that they could carry the virus but — and transmit it, but we know that that is also reduced to some extent as well even as we learn about it. I think one thing that we need to distinguish is between public and private settings. So, for now, until more people are vaccinated, we do need to keep up precautions in public setting including masks and distancing, even vaccinated people and that’s because we can’t really determine in public settings who’s been vaccinated, who is vulnerable. But as more are vaccinated, that will change. And in people personal lives, you know, the questions that we’ve hearing are, I am a grandparent, I’m now vaccinated. Can I hug any grandkids? I think we need to be clear that the risk is vastly reduced of having a bad outcome, particularly, you know, severe disease, hospitalization or death, we really have seen that happen very rarely among people who are vaccinated. But there is a small chance that somebody who is vaccinated could transmit the virus to somebody else. And that’s the thing we can communicate and people can then make decisions accordingly.

SREENIVASAN: It seems like if we pivoted toward the opportunity of what lies ahead if we take these steps versus the costs that are all around us and behind us, I mean, I don’t know, does optimism work better? I mean, if I am saying is, hey, I kind of want to enjoy life again. That is why I want to get this vaccine.

MARCUS: Right. And people have different motivations for getting vaccinated but that is a big one for people like, you know, getting back to some semblance of normalcy, being able to be close to loved ones. And I think, again, going back to that example about PrEP and HIV prevention messaging and how we now know that we need to center what matters to people and use the positive messaging rather than fear and shame, the same kind applies here where I think we recognize what is it that matters to people? Well, you know, there being much lower risk of getting very sick. That matters to people. And also, being able to be closer to other people with lower risk. That matters to people, too. And so, I think including a kind of all of these motivations in our messaging in such a way that people see, OK, this is a tool that is going to get me where I want to be. I think that is going to be an effective approach.

SREENIVASAN: Dr. Julia Marcus, thanks so much for your time.

MARCUS: Thanks for having me.