`Just` Behaviors? Understanding the Value of Public Behavior Change to Stem Tide of Pandemic

“It’s just behaviors.”

These three words of clarification from Deborah Birx, MD, the coronavirus response coordinator for the White House Coronavirus Task Force, were offered as part of the revelation on March 31 that between 100,000 and 240,000 Americans were likely to die in the coronavirus pandemic. Her extended statement offers context for the word, “just:”

There’s no magic bullet. There’s no magic vaccine or therapy. It’s just behaviors. Each of our behaviors, translating into something that changes the course of this viral pandemic over the next 30 days.

Like everyone else, I was hoping for a biomedical solution like a vaccine or an antiviral medicine. That might be for another day, and until then, the nation needed to settle for “behaviors.”

While Dr. Birx and Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, certainly extolled the power of social behavior in this situation, there was clearly a sense that this was an inferior solution. This emphasis is understandable considering everyone’s desire for a stronger, medical solution, but the message also fits neatly into cultural expectations. We value biological solutions. We view behavioral solutions as difficult and limited.

The limitations of behavior change

The reality of behavior change, whether the focus is on health behaviors like nutritious eating or on the imperative to maintain distance in a pandemic, is that one must resist an impulse to do something easier, familiar or preferred. Whether motivation is found in logic or some moral imperative, effort is required. One exception is that some healthy and unhealthy behaviors can become socially contagious.

Behavior change is not like a cure. People would rather take a pill that eliminates their appetite rather than choose foods wisely. Medicines work efficiently and effectively, while having to keep six feet away from others for fear they carry a virus seems imperfect. People with the highest level of motivation and commitment are left to worry if their behavior and their results are good enough. It is exhausting.

The duration of behavior change can also be problematic. Healthy diets and exercise regimens are never flawless. One must accept good days and bad days. This reasonable attitude is less functional with maintaining distance in a pandemic. The duration of responsible behavior becomes oppressive over time, and this is critical. Everyone could eat well now and then, if that were the only requirement.

Behavior change is rarely the top choice. People would like bad moods and self-defeating habits eliminated. The option of working in therapy to change thoughts, feelings or behaviors for some degree of improvement is not tantalizing. We settle for behavior change when Dr. Birx’s “magic bullet” is not available. This is why people prefer medications to psychotherapy.

The limitations of magic bullets

Magical thinking is a magic bullet that many people employ in hard times. The desire for easy answers or the preference to not change behaviors can be powerful. Like many short-term solutions, it is initially appealing. Our field has dissected magical thinking into many subtypes, but the common result is some unpleasant clash with reality. Did this apply to the college students infected on spring break vacations?

People pursue magic bullets in the face of evidence that there is no magic. Many people spend years trying multiple medications before giving psychotherapy a try. While this may have started rationally, the desire for a magic bullet can drift into irrationality over time. Dr. Birx structured her comments to the public knowing that people wanted to stubbornly hold out for a medicine that was not arriving.

Magic bullets are often just bullets. While bullets can be deadly, magic bullets are deadly in fantastical ways. Many medications available today ameliorate but do not cure. This disappointment leads some to not adhere to the best available treatment. Other people might stick with a mediocre, pseudo-magical remedy when better alternatives exist. Note, for example, that pills are not the best sleep aids.

Our belief in magic bullets is a cultural set-up for discontent. Belief in the wonders of science is warranted and it cultivates a sense of optimism. Belief that science can remove all troubling or unpleasant aspects of life is understandable. Yet it is bound to disappoint. Pandemics makes us wonder how long earthly forces and human realities can defy scientific advancement. Is there a time limit?

Improving the message on ‘just behaviors’

Human behavior is a powerful force in the world, and there are many dramatic and inspiring examples of people changing behavior. There is no need to apologize if the best path forward is behavioral. Many people struggle through great discomfort in psychotherapy to change behavior and enjoy enduring results. Dr. Birx could have accentuated the positive. Our behavior will save tens of thousands of lives.

Acknowledge the ambivalence associated with behavior change. Communication is diminished but not eliminated with distancing. The pain of distancing will be more extreme and unusual than most would expect. The joy of saving lives and ultimately eradicating the virus will be great. Social distancing will require social support, and we should reinforce one another as we persist on this path.

When dealing with changes that can’t be readily seen, celebrate and memorialize it in positive ways. People change in therapy without a clear visual representation of that change. You can’t see the heroic events during a pandemic – people not getting sick due to distancing – but you can use language and pictures to make it real. We should find a compelling, less violent metaphor to replace the bullet.

Our role in public health

The pandemic has taught us that Americans don’t really understand public health, but it seems here to stay. Public health includes a prominent behavioral component, and yet we always need to find ways to energize participants. Remember that behavior has long been central to public health campaigns, from a focus on safe sex to those on the dangers of smoking and the use of seat belts.

The private healthcare system in our country should model itself on public health through a focus on health promotion and disease prevention in the primary care setting. Behavior change is key to promoting health and preventing disease, and our field can lead the way when it comes to changing an unhealthy lifestyle or bending a pandemic’s curve. Let’s give behavior change a little respect.

We have a bigger role to play than discussing an increase in symptoms of anxiety during the pandemic. Few will easily return to pre-pandemic behavior once the distancing ends. Behavior change experts will be needed within public health and primary care settings to craft practical behavioral goals and motivational messages. The season for health promotion and disease prevention is always with us.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.