Containing COVID-19 involves finding measures people can live with sustainably
One of the difficulties of enforcing compliance to COVID-19 isolation rules and testing is that people may not comply if the consequences are steep (e.g. due to financial difficulty). For someone with the sniffles right now, getting tested for COVID-19 is a high stakes game. Containment measures may mean that you are forced into self-isolation - and who wants that? That doesn't mean we shouldn't have isolation rules - just that they need to be rules people can sustainably follow, and we need to incentivise compliance.
Self-isolation means taking practical steps (e.g. working from home) to avoid being in contact with other people as much as possible. In New Zealand (NZ) isolation rules state that you must self-isolate for 14 days in the following circumstances:
Close contact with a confirmed or probable case.
Awaiting a test result under alert levels three and four.
Living in the same household as a close contact who is symptomatic.
Some version of self-isolation rules is in place across many countries worldwide. World Health Organisation (WHO) guidelines suggest patients must isolate for ten days after symptom onset, plus at least three additional days without symptoms. Asymptomatic cases must isolate for ten days following a positive test. The guidelines are obviously sensible in terms of the evidence, but implementation is tough.
Rules that are too strict or not people-friendly risk compromising compliance
Data on compliance with self-isolation is still developing, but a recent study from the United Kingdom (UK) with approximately 32,000 people found that of those who have experienced COVID-19 symptoms in the last seven days, just 18.2% said they had not left home since. That is very low. There are many reasons why, such as not knowing the Government guidance or to visit the shops or pharmacies. These results can't necessarily be generalised to other countries as there are many factors influencing compliance, but they are an interesting insight.
If you are someone with COVID-like symptoms right now, getting tested is not that appealing, particularly if those symptoms are mild. Sure there is a chance you will have a negative test and all will be well. But with a positive test, you face the possibility of 14 days of isolation. That could be enough to put people off getting tested in the first place. Better to ignore it if you are just feeling a little off right? That's why fines for breaching isolation are stupid. If people face fines for breaching isolation, the incentive to get tested is reduced. There needs to be the right balance of carrot and stick.
Creating and enforcing isolation rules that are overly strict or unworkable for people could lead to a perverse incentive to not comply. Low compliance due to overly strict measures can compromise efforts to reduce transmission in the first place.
Isolation and testing measures need to be designed to encourage compliance
Isolation and testing are critical to stopping transmission of COVID-19. Governments need to be aware of peoples' ability to comply with isolation and testing, and design measures to suit. If compliance is low, perhaps the rules need to adapt to suit peoples' needs. That could mean several things:
Encouraging compliance by making self-isolation easier for example by providing food, income support, cleaning, childcare or entertainment services to those who are in self-isolation to make it feel less of a burden.
Incentivise increased testing for example by giving people the time off work to get tested or a financial reward.
Relaxing the rules where there is still low risk to make it easier for people to comply for example by making the self-isolation less strict by allowing people outside the home at certain times of day when it is less crowded. I suspect this option would only be exercised after considering the other two above.
It is wishful thinking to believe that the reduced-transmission benefit of self-isolation and testing compliance is enough to make an individual comply. Remember, isolation rules could be in place for several years depending on how long it takes for a vaccine to become widely available. People need to be able to live with the rules for a long time. Call it being people-friendly.
There is of course a limit on the extent to which isolation and testing can be people-friendly. Measures still need to contain the disease.
Evidence is developing for the potential for financial incentives to encourage compliance
The UK study cited earlier found that providing financial reimbursement could improve compliance with isolation, testing and tracing. These findings are supported by an Israeli study of 563 respondents that found compliance with quarantine rules increased to 94% from 57% when people were compensated. That's a meaningful jump. Incentives of this nature could even pay for themselves if they allow governments to maintain more 'open' economies in the face of COVID-19.
Of course, there is more to compliance than financial reward and the strictness of rules. To an extent, compliance comes back to faith in a nation's leadership. If we are confident that lockdown measures can mean a return to normality compliance is more probable.
Also while the focus of this article has been on isolation, rules regarding business operations fit in a similar bucket. If people's livelihoods are compromised they are less likely to comply with rules around keeping their businesses shut.
Finding the right balance is tough. On the one hand, self-isolation protects population health. On the other, it takes a big toll, and if isolation rules are too strict or don't fit with people's needs, then the rules are less likely to be complied with. The balance needs to be tailored to the needs of the population with appropriate incentives to comply. Each country will have a different answer.
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