On May 28, 2021, the Centers for Disease Control and Prevention (CDC) issued new Interim Public Health Recommendations for Vaccinated People, essentially giving a green light to fully vaccinated people to resume activities without wearing a mask or physically distancing. This guidance surprised nearly everyone, coming just a few weeks after the CDC director had noted that she had a sense of “impending doom” as she was watching the pandemic unfold. It reflected a dramatic pivot point in the US handling of the pandemic, an implicit shift away from community responsibility for Covid-19 transmission, towards individual responsibility. It suggested, essentially, that the onus was on those who remained unvaccinated to take precautions because the vaccinated could drop their effort to protect others.
Leaving aside arguments over whether this was the correct move based on the science, we saw this as an expression of the CDC’s appraisal of what regulation the country could—and could not—bear, and an acknowledgement that after a year of Covid-19 restrictions, the country was at the end of its pandemic tolerance.
The last 18 months of Covid-19 has tested us all. The hardships experienced were, of course, quite variable in scale; nothing compares to the pain and grief of losing loved ones. And yet, it was the sum total of all the pandemic-era experiences and losses that shaped the landscape of population behavior during Covid-19, and directly or indirectly, set the stage for what we collectively were willing to do to mitigate the spread of the virus.
Any population-wide effort to control disease, whether we acknowledge it explicitly or not, requires the willingness of populations to acquiesce to new rules and regulations, whether these are enforced by the power of law, or by emergent social norms. So, for example, rules against smoking indoors only become changes in smoking patterns if, indeed, people do not smoke indoors. Similarly, we wear seat belts because of a combination of laws that mandate it, and social norms that make seatbelt non-use unacceptable. And although we may back up these rules with incentives and disincentives, the abject failure of prohibition against alcohol use in the US a century ago showed that the establishment of rules of behavior that influence the public’s health requires the consent of populations, and that there are limits to the public’s tolerance of these rules.
The need for general public agreement has had implications during the time of Covid-19. Despite visible political arguments about mask wearing, the public was enormously tolerant of policies that encouraged us all to stay home, not to travel, and to limit our interactions for many months. Emerging data showed that the majority of the reduced mobility in the population was voluntary, preceding the implementation of regulations that mandated shutdown of business and public services, reflecting a general consensus that the limitation of movement was, at the time, a good idea. And yet, the limits of our tolerance began to show in 2021. As vaccines became widely available in the spring of 2021, one could sense—and indeed see—the slow dissolution of public will. Many states dropped post-vaccine guidance leading to the CDC’s change in its guidance.
We have learned that the public’s tolerance for restrictions and actions to promote our collective health is not infinite. And that puts pressure, appropriately perhaps, on those who are making the rules to use the best available evidence, but to do so in a way that takes into account what may need to be tolerable over prolonged periods. We should avoid unnecessary rules and focus on ones that are core and essential, so as not to try the public’s patience. Because in cases like pandemics, our collective tolerance of the rules of engagement is literally a matter of life and death.
Michael Stein & Sandro Galea
As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.