With few COVID-19 restrictions, personal responsibility takes center stage in the pandemic response

In this Nov. 16, 2020, file photo, a runner passed by a window displaying portraits of people wearing face coverings to help prevent the spread of the coronavirus in Lewiston, Maine.Robert F. Bukaty/Associated Press

Coronavirus cases are reaching record highs. Hospitals are overflowing in several parts of the country. In Massachusetts, some elective surgeries are again on hold.

But as the final weeks of 2020 begin to mirror the grim, early weeks of the pandemic, the stay-at-home advisories, shelter-in-place orders, and strict industry regulations that helped flatten the curve in the spring are almost nowhere to be found. Instead, public officials around the country are pursuing another approach to managing the virus’s spread: a plea for personal responsibility.

State leaders, Governor Charlie Baker chief among them, are increasingly calling on individuals to do the right thing — avoid high-risk settings, cancel holiday and travel plans, and limit their social circles — without handing down formal guidelines to enforce such behaviors.

Public health experts said this course of action ignores the structural nature of public health and fails to account for the confusion many ordinary people feel over how to do their part and stay safe.

“Yes, people have to take responsibility for their decisions, but you have to give people an environment in which the decisions that are good for them aren’t so hard,” said Dr. Mary Bassett, director of the FXB Center for Health and Human Rights at Harvard University. “It’s part of public health to use regulatory measures and they are sometimes necessary.”

Massachusetts has reported an average of more than 3,000 cases per day in December — putting a state that for months ranked among the lowest-risk in the country closer to the middle of the pack. Several states that saw staggering summer spikes in COVID-19 transmission, including Texas, Florida, and Georgia, have had lower new cases per capita than Massachusetts over the past week.

Over the weekend, pressure mounted for Baker to take more aggressive action on COVID-19, with disease specialists and Boston-area mayors urging the state to consider targeted closures of some nonessential activities.

The state is currently under a stay-at-home advisory that went into effect on Nov. 6, but so far, Baker has resisted recent calls to tighten restrictions. At a news conference Monday, he repeatedly declined to answer questions about whether the state will impose a more stringent stay-at-home advisory or limit activities such as indoor dining.

But as he has many times before, Baker appealed to residents not to have parties or gatherings.

“I talked to several mayors over the weekend who are frustrated with me and frustrated generally,” Baker said. “But to a person, they all said that they see in their communities, all the time, people engaging in risky activity that we have all been talking about as the sort of thing that you should seek to avoid. . . . Some of them even talked about their own neighbors who have gatherings.”

A focus on personal responsibility while maintaining relatively lax restrictions sends a mixed message about whether people need to change their behaviors, said Helen Jenkins, a Boston University epidemiologist.

“You get this conflict between trying to encourage people to act differently, and yet, by keeping lots of nonessential activities open, you’re telling them that they’re perfectly fine to do, and there will be zero risk, which is not the truth,” Jenkins said. “I find that difficult because it is placing all the responsibility on individuals.”

Jenkins and others said there is a role for ordinary people to play in the pandemic response. She urged people to remember the sacrifices they made in March and April, and to the extent they are able, return to the level of caution they practiced then.

But Jenkins said that people pick up on discrepancies in public health messaging, such as rules that allow group dining in restaurants but discourage families and friends from gathering for a meal at home. These mixed signals can confuse and frustrate the public, she said, and ultimately put the state at risk for more infections and tougher restrictions — including economy-wide lockdowns — down the line.

“We’ve seen in the spring and we’ve seen in Europe that the longer you delay harsher restrictions, the longer they end up having them go on for, and the more people end up dying as a result,” Jenkins said.

Besides questioning the effectiveness of framing public health in terms of personal responsibility, experts also pointed to a moral pitfall: framing COVID-19 transmission as a choice overlooks the structural inequalities that put some people more at risk than others.

Many people working low-wage jobs must choose between the risk of COVID-19 exposure to pay their bills or staying safe at home but going without income.

“I think policy makers need to realize that we do not have good choices because there is no social safety net here,” said Marlene Kim, a professor of economics at the University of Massachusetts Boston who studies how policies affect the working poor.

Yet to be seen are the long-term implications of the growing inequities, especially for people of color and women who hold a disproportionate share of low-wage jobs in sectors like food service, personal care, sanitation, and child care, Kim said.

Neglecting to focus on structural causes for coronavirus transmission absolves leaders of their responsibility to protect public health, said Shawnita Sealy-Jefferson, a social epidemiologist at Ohio State University. That is particularly true in a pandemic that has disproportionately affected people of color, both economically and in terms of illness and death, she said.

“In this moment, the focus on personal responsibility is a form of gaslighting, and it’s violent,” she said. “What we are seeing is the manifestation of the lack of public health infrastructure in this country, and leadership.”

Bassett, who before coming to Harvard was New York City’s health commissioner, said, “People with resources almost always have more latitude in their choices and are better able to protect themselves.”

“To chalk it all up to personal responsibility is unfair for people who encounter environments over which they don’t have much control,” she said. “If they live in a crowded apartment, if they have to take public transit to their jobs, if they work in a workplace which isn’t enabling them to socially distance — that’s not a personal choice.”

Experts agreed that there are undoubtedly actions that individual people can take to make their communities safer — wear masks, maintain social distancing, avoid gathering indoors for any amount of time with people outside your own household.

And those who are able to work from home or otherwise limit outside activities should be especially focused on helping stop the spread, lowering the risk for those who cannot avoid exposing themselves.

“All of that is good advice,” Bassett said. “The question is, what will it take for people to be able to follow it.”

Clarification: This story has been updated to make clear that Massachusetts was under a stay-at-home advisory in the spring and that a new advisory took effect Nov. 6.