Why is it so difficult to contain the spread of COVID-19? This question has been discussed and written about almost ad nauseum. Permit me, nonetheless, to add my perspective.
While, theoretically, there are many ways in which the virus can spread such as through contaminated surfaces or infected sewage, it appears that the only significant manner is through intimate person-to-person contact. This means that most of the over 50 million people worldwide who have contracted COVID-19 were each infected by another person through close contact that allowed the virus to pass from one to the other. How could this be?
Since the basic methods of preventing viral spread are appropriate hand washing, social distancing, mask wearing and avoidance of large gatherings, especially indoors, it becomes apparent that tens of millions of people simply have not adhered to these fundamental tenets. In each of these individual cases, there was an incident in which the shared behavior of at least two people facilitated viral transmission. With regard to the transmitter – the person who passed on the virus – this was at least a second occurrence of unprotected behavior, the first being when that person contracted the virus from someone else; now, with this second occurrence, they spread the infection further. The fact that this was not a one-time event suggests an overall pattern of inadequate protective behavior on the part of the transmitter such that he or she may well have communicated the virus to others, too. Since almost everyone is capable of taking adequate precautions, the prodigious spread of the infection is due mainly to millions of peoples’ failure to take personal responsibility for their behavior.
There was a similar problem initially with the HIV/AIDS epidemic: While the mode of transmission and the behavioral changes required are different, aside from transmission through blood transfusions, here, too, we were and are dealing with an incurable viral infection that spreads through personal contact and behavior. For a while the spread of HIV/AIDS appeared to be out of control. This situation began to improve only when a sufficient number of potential contacts assumed responsibility and changed their personal behavior – and then, in due course, drugs were developed that reduced viral load. It is this combination of behavioral change, together with partially effective medication, that eventually led to epidemiological control of the spread of AIDS.
Why are so many people not taking personal responsibility, while others are?
- Overall difficulty in changing basic behavior: Under normal circumstances, social intimacy is such a positive fundamental component of human behavior on both a personal and professional level that it is difficult and counter-intuitive to deliberately and consistently refrain from the kind of socializing that leads to viral spread. If any change is difficult, introducing unfamiliar and unnatural changes into our day-to-day conduct is particularly formidable.
- Infringement of personal autonomy and sovereignty: No one likes to have their behavior restricted. This is especially true of actions such as social distancing and mask wearing, which would typically be considered to belong exclusively to the personal realm. In broad general terms, Asians have nevertheless adapted cooperatively, which, as a corollary, is why their countries have achieved better control; in Western countries along with in Israel, partial cooperation has been associated with some measure of control, and, in contrast, since many Americans have resisted change, it is not surprising that COVID-19 is now running amok in the U.S. Mask wearing and social distancing, from the president down to the ordinary citizen, are inconsistent and controversial, giving rise to countless unsafe one-to-one personal encounters. As the infection rate increases, so, too, do the absolute numbers of hapless very ill people who will either die from the disease or end up with long term COVID-related complications.
- Many do not take the threat of COVID-19 seriously enough to change their behavior effectively. If they only know of people who are asymptomatic or who have contracted the disease and recovered, or if they do not personally know of an infected individual, they may mistakenly believe that the danger of dying or becoming ill has been exaggerated. For a realistic appreciation of the risk of dying from COVID-19, we should look at the case fatality rate, which exemplifies how the severity of the disease is misconstrued. The case fatality rate is the percentage of infected people who die from the disease. A ballpark figure is about 3%, i.e., out of 100 people testing positive for the virus (only) about 3 will go on to die from it. This percentage is higher in older sicker individuals and even lower among the young and healthy. Consequently, my presumption is that because this number appears low, many healthy people along with asymptomatic carriers do not appreciate the dangers of the virus sufficiently to consistently change their behavior. Unfortunately, the truth is that even if 3% sounds low, and even if in certain situations the case fatality rate is still lower, this preventable situation is catastrophic for those patients and families who are afflicted. Furthermore, when multiplied by millions of people, these so-called low numbers become highly significant. Were the potential transmitters and recipients to modify their behavior to ensure that they neither contracted nor spread the virus, they would be part of the solution; without adequate change their conduct is part of the problem.
Paradoxically, both nursing homes, which have a high case fatality rate, and even hospital wards with infected COVID-19 patients have a low rate of spread. Why is this so? For the most part, because staff take personal responsibility for making the essential behavioral change. Once the dangers and pattern of viral spread were understood, high risk institutions adopted stringent personal regulations; staff members cooperated and, on the whole, took personal responsibility for complying with them. In these setups there is a joint commitment of all involved to rigorously comply.
I term one-to-one interaction between people an example of micro-behavior; government intervention, on the other hand, is an example of macro-behavior.
Governments cannot directly control how people behave when they are together; at most, they can limit contacts between people. That is why many government policies the world over has been shown to be insufficient to contain viral spread. In free Western countries, only extreme policies have been successful – lock-downs. When people are prevented from encountering one another, the micro-risk becomes zero and consequently the virus cannot spread. Lock-downs, however, cannot be sustained indefinitely. Once governments relax their restrictions and permit selective contact between people, along with efficacy of the chosen policy and the personal example set by leading government and national figures, continuing success depends on the and the degree to which the public cooperate and change their behavior. For both private citizens and those in positions of authority, taking personal responsibility and behaving consistently in a safe manner is then an essential prerequisite for success.
Hopefully, a successful vaccine may well be just around the corner. However, even though Pfizer and Moderna have reported an initial 95% success, we do not yet have enough information to know how effective vaccine implementation will be or when it will be available on a large scale. Flu vaccines, for example, even after decades of development, are only about 40-60% effective in preventing viral transmission, and we still see extensive illness and death from influenza every year. In addition, some people may refuse to take the vaccine further lowering its efficacy. Therefore, in my view, even when COVID-19 vaccines becomes available, it is unrealistic and misleadingly optimistic to view them as a potential panacea for the immediate future. At best, vaccine usage will become one of several factors contributing to viral control. For now, and probably even after the vaccine is employed, personal responsibility will still play a vital role in preventing one-to-one viral spread.
The blunt message of this blog is that only by each individual taking personal responsibility and behaving consistently in a safe manner can we wrest control of viral spread. Metaphorically, we should all regard ourselves as the fictional Dutch boy who saved his country from flooding by plugging a dyke with his finger. Each of us should strive to be part of the solution rather than part of the problem. Micro one to one transmission must be arrested. This is the painful reality that obliges each of us to accept and comply with – rather than resist – the necessary change. The sooner we all adopt this approach, the less need there will be for further oppressive government restrictions, and the less havoc the virus will wreak in our lives.
Thank you Carol S., for help with the editing.