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Why can't people just stay home during Covid-19?

It's so fricking obvious. 

Staying home and limiting interaction with others reduces the chance of getting the coronavirus and passing it to our loved ones. 

Everyone has the power to do one simple thing that would save their own lives. That would lessen the burden on te healthcare system. So why can't people do it?

You might be surprised that such behaviour isn't unfamiliar to many of us. I would bet that you and I have not been so different from these "Covidiots" at varying points of time in our lives. Times when, cognitively, we know what is the right thing to do. That not doing the right thing will cost us, cause harm to ourselves and those around us. And yet we don't do it. 
 

This ranges from minor to major. Have you ever, for example:​​

  • Said something you knew you shouldn't have to a family member or a good friend?

  • Waited several hours and refreshing fervently for the daily cases update, without which you are unable to go to sleep. Even though it makes absolutely no difference whether you knew figure that night or the next morning. 

Got angered by what someone said on social media, spoiling your own day, as well as those around you?

Avoided or delayed going for a health check-up?

Had unprotected sex with multiple partners?

Got into a dangerous position to take a better photo for social media?

Driven without a seatbelt, drunk, or while texting? The number of people killed per month in road accidents is about the same number as those who lost their lives to Covid-19? And this persists even though there are stiff penalties. 

Smoke or over-ate to the point of obesity (even doctors) - which combines for about 30% of deaths?

Or the crème de la crème - going out for a political walkabout even when your own boss has told everyone else not to? Even though you are a doctor? Oh, oh, it's just to tell others to wear masks. (psst.. he's wearing white). That's ok then.

If many of us are guilty of some of the above, then we do share some commonalities with people who flout stay-home rules. It is worth examining the underlying reasons behind such behaviour, which consequently also helps us understand how this behaviour can be changed. What are these reasons?

1) We overvalue the short-term and under-value the long-term.

There's no end of good examples for this. But let's go through 2 particularly relevant examples. 

 

Some of you might be familiar with Dan Ariely, the behavioural scientist. Ariely contracted Hepatitis C about 20 years ago. Left untreated, patients with Hepatitis C would eventually suffer from liver cirrhosis (basically the complete wearing out of the liver), with a real possibility of death. At that time, medical treatment was not as advanced; the drug for Hepatitis C was Interferon, which had massive side-effects - headaches, nausea, vomiting, shivering, lasting for almost a day. And it was not a one-off;  Interferon had to be injected 3 times a week, over many months. 

But surely people can bear the horrible side-effects knowing that it would save their lives? After all, what's more important than... living? As it turns out, no. Ariely was the only patient in his batch who managed to finish the entire course of Interferon. Even at the risk of dying, people couldn't bear the short-term pain of the drug's side effects.

 

So did Ariely possess extraordinary willpower to be able to finish the course despite the painful side-effects? Again, no! It was not willpower. Ariely was a big fan of movies, though he typically had no time to watch them. After being diagnosed with Hepatitis C, Ariely would go and rent a movie on the days he had to inject himself. An hour before injection, he would start playing the movie. In other words, he "reward substituted". Obviously, the real reward of him regularly taking medication was that he would stay alive and healthy. It's just that the reward seems so far away, while the pain was so immediate. So Ariely introduced (i.e. substituted) a more immediate reward - being able to enjoy a movie. 

Second example: Stroke medication (Warfarin) greatly reduces the risk of a second stroke. Yet, up to 35% of people did not take their medication regularly and on time. Again there is the same problem. The benefit or reward is not immediate. But getting to the reward is troublesome. Indeed there has been much research done on how to convince people to take medication that is good for them. Psychologists Kevin Volpp and George Loewenstein from CMU came up with an interesting solution. Each time a patient completed a dose on time, they would be entered into a lottery, where there was a random and equal chance of winning a prize.
(There are some biological intricacies behind this. We are often told that dopamine is a reward neurotransmitter. You eat chocolate, your brain releases dopamine, you feel good. This is, of course, not how dopamine works. Dopamine spikes up in anticipation of a random reward, which is why casinos, lottery, and social media is so addictive. But the main point here is that a random lottery is an excellent choice for a reward).

 

A few learning points:
A) The immediacy of reward or pain is weighed very heavily. We often base decisions on the immediate, even though we know it has bigger long term consequences. 

B) This, as with many brain functions, happens subconsciously. 
C) We often obsess over people doing the right thing for the right reasons. People should stay home because it is obviously the rational and responsible thing to do. Yet the example of Ariely and the lottery patients show otherwise. People only took action not o save their own lives, but to get that immediate reward. In other words, they did the right thing for the "wrong" reasons. The question w have to ask ourselves is, does it matter in this instance?

 

2) Optimism Bias

The optimism bias is one of many cognitive biases we have, that affects our assessment and judgement of things.

There are 2 parts to optimism bias. The first and the more obvious: we are optimistic about how things would turn out for us, and we are optimistic about ourselves compared to others. Plenty of research on this. But you probably have experienced many real-life examples:

 

  • As teachers would attest, most parents fervently believe that their child is special and the best child there is. 

  • While 1 in 3 people in developed countries gets cancer at some point in life, most people rater their chance of getting cancer much lower.

  • When asked to rate ourselves on some measure, say driving, most drivers rate themselves in the top half.
     

Yadda yadda. I think most of us have no problems with this.

The second part to the optimism bias is that we are only optimistic for ourselves but not others. In research by Tali Sharot of UCL, 75% of Brits were optimistic about the future of their families (but of course, since we all have special kids). But only 30% of Brits think that families, in general, are doing better than several generations before. Even though by almost every measure, the latter is factually true, people didn't think so. 
 

Just like those of us who drink-drive, and smoke, and over-eat, those who flout circuit breakers are likely to be more optimistic about themselves - they believe they will not get the virus, or if they do get it, they will be fine. 

 

3) Habits​

Again, a familiar but very powerful force. People find it difficult 

What wouldn't work?

  • Information is not useful. Posting "Stay Home" on social media or recording "Stay Home" videos are not likely to work, because people already know they should stay home, they just don't do it. If information has any chance of needs to be visceral, evoking emotions which spark wiring to jolt in our brains. But this might  An extreme example Remember the gruesome images of lung cancer on cigarette boxes? That has some effect,

  • Instead of fining people $300 for violation of social distancing, one alternative would b

Why whip a mule when you can make it do what you want by offering it a sugar cube?

This ranges from minor to major. Have you ever, for example:​​

Said something you knew you shouldn't have to a family member or a good friend?

Waited several hours while refreshing fervently for the daily cases update, without which you are unable go to sleep, even though it makes absolutely no difference whether you knew figure that night or the next morning. 

Got angered by what someone said on social media, spoiling your own day, as well as those around you?

Avoided or delayed going for a health check-up?

Had unprotected sex with multiple partners?

Got into a dangerous position to take a better photo for social media?

Driven without a seatbelt, drunk, or while texting? The number of people killed per month in road accidents is about the same number as those who lost their lives to Covid-19? And this persists even though there are stiff penalties. 

Smoke or over-ate to the point of obesity (even doctors) - which combines for about 30% of deaths?

Or the crème de la crème - going out for a political walkabout even when your own boss has told everyone else not to? Even though you are a doctor? Oh, oh, it's just to tell others to wear masks. (psst.. he's wearing white). That's ok then.


If many of us are guilty of some of the above, then we do share commonalities with people who flout stay-home rules. It is worth examining the reasons behind such behaviour. Consequently, it also helps us understand how this behaviour can be changed.

 

What are these reasons?

1) We overvalue the short-term and under-value the long-term.

There's no end of good examples for this. But let's go through 2 particularly relevant examples. 

 

Some of you might be familiar with Dan Ariely, the behavioural scientist. Ariely contracted Hepatitis C about 20 years ago. Left untreated, patients with Hepatitis C would eventually suffer from liver cirrhosis (basically the complete wearing out of the liver), with a real possibility of death. At that time, the treatment for Hepatitis C was the drug Interferon, which had massive side-effects - headaches, nausea, vomiting, shivering, lasting for almost a day. And it was not a one-off;  Interferon had to be injected 3 times a week, over many months. 

But surely people can bear the horrible side-effects knowing that it would save their lives? After all, what's more important than... living? As it turns out, no. Ariely was the only patient in his batch who managed to finish the entire course of Interferon.

 

Even at the risk of dying, people couldn't bear the short-term pain of the drug's side effects.

 

So did Ariely possess extraordinary willpower to be able to finish the course despite the painful side-effects? Again, no. It was not willpower. Ariely was a big fan of movies, though he typically had no time to watch them. After being diagnosed with Hepatitis C, Ariely would go and rent a movie on the days he had to inject himself. An hour before injection, he would start playing the movie. In other words, he "reward substituted". Obviously, the real reward of him regularly taking medication was that he would stay alive and healthy. It's just that the reward seems so far away, while the pain was immediate. So Ariely introduced (i.e. substituted) a more immediate reward - being able to enjoy a movie. 

Second example: Stroke medication (Warfarin) greatly reduces the risk of a second stroke. Yet, up to 35% of people did not take their medication regularly. Again there is the same problem - the benefit or reward is not immediate. But getting to the reward is troublesome. Indeed there has been much research done on how to convince people to take medication that save their lives. Psychologists Kevin Volpp and George Loewenstein from CMU came up with an interesting solution. Each time a patient completed a dose on time, they would be entered into a lottery, where there was a random and equal chance of winning a prize.


(There are some neurobiological intricacies behind this. We are often told that dopamine is a reward neurotransmitter. You eat chocolate, your brain releases dopamine, you feel good. This is, of course, not how dopamine works. Dopamine spikes up in anticipation of a random reward, i.e. you feel good before anything actually happens. This is why casinos, lottery, and social media is so addictive. But the neurobiology rabbit holes goes much, much deeper. So for now, the main point here is that a random lottery is an excellent choice for a reward).


2) Optimism Bias

The optimism bias is one of many cognitive biases we have, that affects our assessment and judgement of things.

There are 2 parts to optimism bias. The first and the more obvious: we are optimistic about how things would turn out for us, and we are optimistic about ourselves relative to others. Plenty of research on this. But you probably have experienced many real-life examples:

 

As teachers would attest, most parents fervently believe that their child is special. The best child there is. Kids that you don't know? They are wonderfully ordinary. 

While 1 in 3 people in developed countries gets cancer at some point in life, most people rate their chance of getting cancer much lower than 33%. 

When asked to rate ourselves on some measure - say driving skills or how interesting they thought they were - most people rated themselves in the top half. We can't, of course, all be in the top half.

The second part to the optimism bias is that we are only optimistic about ourselves but not others. In research done by Tali Sharot of UCL, 75% of Brits were optimistic about the future of their families (but of course, since we all have special kids). But only 30% of Brits think that families, in general, are doing better than several generations before. The former is speculative; the latter is fact, by almost every measure.


Just like those of us who drink-drive, and smoke, and over-eat, those who flout circuit breakers are likely to be more optimistic about themselves as compared to others - yes maybe some other person might die from it, but they believe they will not get the virus, or if they do get it, they will be fine. 

There is an environmental factor to this. Because initial signals was that life should go normally as much a possible, and because other people seem to be doing so, all the more some are optimistic about going out during the circuit breaker. 

 

3) Habits​

A familiar but very powerful force. Habits develop to become automatic - you don't need to think about how you are doing something, you are simply able to do it, and do it easily. People find it difficult to break out of ways of life they are used to, and a rapid change is difficult.

There is an additional undercurrent to habits. You develop a habit through repetition, and repetition happens because you think you are doing something that you should be doing. Asking people to do something that directly contrasts with their habits could rrigger additional resistance - they believe that their way of life is being attacked. They might then resolve to find ways and reasons to defend or justify their behaviour, in turn causing them to be even more resolute in believing they are not doing anything wrong.

 

If a boss is used to everyone telling him he is right all the time, he is more likely to flare up at a disagreeing opinon even if it was reasonable. Someone, whose highlight of the day is going down to the void deck to meet up with a few friends, will find safe distancing measures hard to accept. And when people start pointing accusatory fingers, some of these folks might feel they are being attacked and need to defend themselves. Which leads to responses such as "if I die, it is my problem." The reaction is emotional in nature, triggered by the part of your brain that regulates fear, anger, aggression, and anxiety. Activity in this specific brain region increases (in fact, the region itself actually becomes bigger) when people feel stressed. Obviously, Covid-19 is a stressful period.

A few learning points:
A) The immediacy of reward or pain is weighed very heavily in our minds. We often base decisions on the immediate, even though we know it might be contradictory to long-term goals.

B) Additional effects like optimism bias and habits amplify our inclination towards short-term gratification or avoiding immediate pain. 

C) All of these, like many brain functions, happens subconsciously. In other words, inclinations like short-term gratifcation or pain avoidance comes to you whether you like it or not. You can't stop yourself from having these inclination. You can suppress thee inclinations by reasoning out for yourself what is the right thing to do. But this is effortful and difficult. 


This brings us to our final point, what can we do to change behaviour?

 

We often obsess over people doing the right thing for the right reasons. People should stay home because it is obviously the rational and responsible thing to do. Yet the example of Ariely and the stroke patients show otherwise. People took action not to save their own lives, but to get that immediate reward - the movie or the chance to win a lottery. In other words, they did the right thing for the "wrong" reasons. The question to ask is, does it matter why they did something, as long as they did it?

What wouldn't work to change behaviour?

Information is not useful. And there is some irony in this. A lot of us cannot help but post "Stay Home" messages or record"Stay Home" videos. We naturally feel inclined to give people information, to give them the "correct answer". We can't help ourselves. This should hint to you how hard it is to overcome your brain's subconscious tendencies. But if we think about it, how can this possibly be useful? You think smokers really don't know that smoking is harmful to them? And even with visceral and gruesome images of lung cancer on cigarette boxes, the reduction in smoking is still limited. Is your stay home message more powerful than an infected lung? If not, no amount of information is going to change behaviour. 


What is more feasible is to introduce immediate rewards (that same term - reward substitution) or to inject immediate pain, which would subconsciously steer people to the right action.

We have already begun introducing immediate pain. This is the easier option and we are quite good at it. The pain is a fine (a warning is not useful because it is not painful) that people who flout circuit breaker rules have to pay

But what about immediate rewards? At present, there are none. If a few uncles are caught at the void deck and are asked to go home, its to boredom and frustration. People have to just will themselves to stay home, which is very difficult. It would help to introduce activities that can only be done at home, thus making staying home more attractive. 

Imagine if everyday, coinciding with the times you are most likely to leave the house, a message is sent to you with a link to a zoom chat. Your friends are all on the chat, and all you have to do is to click the link. There's now an incentive to stay at home because you know the chat is about to begin. And you would not leave your home at that time because a)there si no wifi and data is expensive, and b)your friends are online. This requires some back-end work. Social and community groups helping to set up programs for the elderly and the less tech-savvy

Folks are roped in to some form of 

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