How to deal with people who ignore COVID safety

COVID-19 cases are up around the country, even in places that had low rates over the summer. In response, many states have increased restrictions and emphasized the need to prevent transmission. People are not listening.

Families continue to make Thanksgiving plans. Large gatherings are continuing despite the warnings. This is happening outside of the United States, as well. There's a phrase for this: "pandemic fatigue." People are tired of changing their behavior because of the coronavirus.

None of this should be surprising. People are often reluctant to do things they might find unpleasant to improve their health. The American government spends millions of dollars every year to educate the public about a healthy diet, for example. And yet most of this advice is ignored.

In my own work, I find little evidence of people changing their diet despite getting a diagnosis of diabetes. The same pattern occurs with infectious diseases. Even at the peak of the HIV epidemic, before widespread treatments were available, data from several countries in sub-Saharan Africa showed limited reductions in risky sexual behavior.

It is even more difficult to get people to make changes for the health of others. One of the reasons we struggle to get full cooperation with vaccinations for flu or childhood illnesses is that the benefits are mostly to public health. Childhood vaccination resistance can be overcome, but mostly when it is linked to school attendance, as California's recent experience in improving vaccination rates for measles has shown. When we have to rely on individuals to make good private decisions for the sake of public health, behavior change is elusive.

Stemming the spread of COVID-19 requires exactly this — a change in private behavior. The virus is being spread in informal settings like parties, sleepovers, dinners in people's homes. The spread has accelerated in recent weeks, as colder weather has moved more social gatherings indoors.

When the problem is private spread, many public health levers are no longer useful. City and state officials can lower restaurant capacity, but that won't matter if people are getting takeout and gathering with acquaintances elsewhere.

Other countries have managed this better. South Korea, for example, has much higher compliance with masking and other social distancing guidelines. But that is not all; testing, contact-tracing and other public health infrastructure have proved to be just as important.

Consider the case of South Korean nightclubs. After several infected people visited five big nightclubs over a short period, government officials used cellphone location data, credit card records and visitor lists to identify about 5,500 people who may have been contacts, of which about 1,200 were closely monitored. An additional 57,000 people who were in the area were encouraged to get tested for the coronavirus.

This could be considered a public health failure (perhaps these potential infections could have been avoided if nightclubs had been closed), but the incident didn't lead to uncontrolled spread. In more recent outbreaks in China, the government has tested millions of people in a short period to limit spread. Even in the U.S., some institutions that are now considered COVID-19 successes — such as elite universities or professional basketball teams — have accomplished this by using comprehensive testing, monitoring and isolation.

Americans need to start thinking about how to control the pandemic under the assumption that people are not necessarily going to listen. Testing is a key component of this. What if, for Thanksgiving, in addition to telling people not to see their families, we also emphasized getting a test before and after traveling and isolating until results were available?

We should still ask people to keep gatherings small, and reinforce the recommendation to avoid traveling, but we need to recognize that not everyone will listen. Testing is a useful backup.

This realization puts renewed focus on the need for a better testing system. Imagine what Thanksgiving might look like if we had cheap, rapid at-home testing kits. Our families could test every day, and catch cases fast. Tests aren't perfect (as the White House Rose Garden outbreak showed), but rapid, widely available testing would make things safer. This technology should be part of the first line in our viral response, and it needs more investment.

The alternatives are more extreme lockdowns and punitive measures to stop large gatherings.

As with so many other health behaviors, we cannot expect solutions based solely on individual behavior change. Pandemic fatigue is real, and we need to find more realistic solutions.