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In Pandemic, Green Doesn't Mean 'Go.' How Did Public Health Guidance Get So Muddled?

A mid-April sign in Philadelphia reminds passersby that current social distancing measures are for their own good.
Cory Clark/ NurPhoto via Getty Images
A mid-April sign in Philadelphia reminds passersby that current social distancing measures are for their own good.

When Marquita Burnett heard Philadelphia was moving to the "green" phase of reopening, she was confused. First of all, she was pretty sure the city had already earned the green label from Pennsylvania's governor (it had). The next thing she knew, the city was scaling backon plans it had made to allow some businesses to reopen (namely, indoor dining and gyms). But it was still calling that phase "restricted green."

"I feel like it's been back and forth – the mayor says one thing, the governor says another. So who do you really listen to?" asks Burnett, a 32-year-old teacher's assistant.

Looking for something to do with her 6-year-old son at the end of June, Burnett saw a mayoral announcement that libraries could open in the new, modified "green" phase. But people who worked at the library were posting on Twitter that they were notopen.

"The lines are very blurred," says Burnett. "Are we completely in the green, or not?"

When the coronavirus shutdown was ordered in March, the message was straightforward and simple: Stay at home and don't leave the house except to perform essential work or shop at essential businesses. However hard those restrictions were to stomach, they were clear.

Skip ahead four months. As businesses started to reopen, mixed messages started raining down from every level of government, making what's permissible and safe feel like a matter of interpretation.

Absent any overarching or consistent national messaging, elected officials are left to come up with localized rules. These rules often contradict one another, presenting a false choice between personal freedoms and protecting one's health. The upshot is that individuals are constantly forced to assess risk on their own and make decisions about actions that have serious safety and moral implications.

Drowning in color-coded confusion

Pennsylvania's reopening plan is structured like a stoplight, with "red," "yellow" and "green" phases. The guidance is built around two main factors: the amount of virus circulating in the community and the degree to which the economy is open.

"In the beginning, we had a plan where there was pretty tight linkage between level of viral transmission and reopening activities," says Susan Coffin, a pediatric infectious disease specialist who has helped create the pandemic response plan for Children's Hospital of Philadelphia.

But over time, she says, the reopening system began to falter. The color-coded phases remained a good indicator for which businesses were opening up, but it stopped reflecting the ongoing viral risk, as the number of new cases ebbed and flowed. That divergence has resulted in confusion, she says.

By late July, Philadelphia found itself – at least officially – in a phase called "modified, restricted green." Gyms were allowed to reopen. Indoor dining remained off-limits.

"Now, we are seeing what might sound like a contradictory message," Coffin says, "Yes, we are reopening, but, no, we don't want you to stop behaving as though there is virus in our community."

In neighboring New Jersey, by contrast, the phased reopeningtakes a more fine-grained, incremental approach. There is no overall color scheme. Instead, each phase offers not only a broad overview of what will change, but also industry-by-industry specifics of which restrictions will be lifted and when.

For his part, Philadelphia Health Commissioner Thomas Farley says he wished people could have ignored Pennsylvania's color coding altogether.

"The governor came up with this high-level plan with these three different colors, but clearly Philadelphia is unique," Farley told reporters at a June 30 press conference, during which he announced the city would pause before entering the full green phase.

"So we're calling it 'green,' but I would rather have people focus less on the color and more on what activities are allowed and not allowed."

Part of the issue is that as the science continued to evolve, so did the recommendations. Masks, for example, were explicitly discouraged for the general public, at first. This was partly because supplies were limited, but also because scientists didn't think the SARS-CoV-2 virus could be easily transmitted via "airborne" aerosolized particles, at least outside hospital settings. But once masks became more available, and more research emerged supporting their use, masks were back in full force.

Though health departments do their best to keep up with the research — and to explain why the recommendations change and when they do — it can be hard to keep track. And it doesn't help when politicians explicitly and vociferously contradict the science-backed recommendations.

"We can't be out there, [with] the secretary of health telling you to wear a mask and your local elected official is telling you, 'Don't wear a mask. You'll be fine,'" says April Hutcheson, communications director for Pennsylvania Department of Health. "It makes the job more challenging."

But there is some messaging health departments cancontrol. Pennsylvania had laid out what many interpreted to be specific metrics for assessing how well a community was doing. The measures looked at testing capacity, contact tracing resources and infection rates in nursing home. To move on to a less-restrictive phase, each county would have to reach a specific benchmark, by a certain date, on the number of new confirmed in that county.

In May, many counties in the southeastern part of the state didn't meet those benchmarks, but transitioned to the next phase, anyway. Gov. Tom Wolf later said the metrics were not hard targets but would be considered with other "subjective information" provided by health officials to determine each county's overall risk.

Then all counties in Pennsylvania moved from red to yellow in early June. Weeks later, case counts began to creep up again.

Proving the transition was rushed and therefore caused the spike may never be possible. But setting that aside, the experience probably contributed to more distrust in government, says Ellen Peters, who runs the Media Center for Science Communication Research at the University of Oregon.

"It gives people inconsistent information, so you're being told, 'Eh, that didn't happen, but we're going to go ahead and do it anyway,' " says Peters, whose own county in Oregon failed to meet its benchmarks, but moved into a new phase anyway. "And so people are left with 'Well, the guidelines don't matter, then. If they don't matter, what else can I not trust that this city or state entity is telling me?' "

Research has shown that when people are stuck at an impasse, they are more likely to just opt for doing what they want to.

How safe is safe?

Health departments in cities and at the state level have come to rely heavily on regular news briefings, where they advise residents which activities are safe and how to do them safely. But asking people to constantly evaluate what they consider safe is a tall order.

"What does it mean to be careful right now? I don't think that's actually a meaningful instruction," says Tess Wilkinson-Ryan, a professor of law and psychology at the University of Pennsylvania.

"The level of care we are asking of individuals is really high — we would never ask this in normal life."

At the start of the pandemic, what it meant to be safe was easier to grasp, says Wilkinson-Ryan. Concepts like "flattening the curve" gave people new language they needed to understand the broader reasoning behind shutting down the economy. They felt like they were doing something by doing nothing — it created a behavioral norm. In this new era of partial or "paused" reopenings, the norm has disappeared — leaving many people unsure how to keep themselves and others safe.

Wilkinson-Ryan faced her own safety dilemma about six weeks into a period of strict stay-at-home orders in Philadelphia. Her husband, Caleb Furnas, went out to walk the dog; the leash got tangled around his ankle and he fell back and hit his head. Furnas told her what had happened, and she asked him, half-jokingly, who the president was. "He said, deadpan, 'George Bush,' " she recalls. "And he wasn't joking."

Wilkinson-Ryan spent the next few hours frantically trying to determine how severe her husband's concussion might be and trying to decide whether she should take him to an emergency room that mightbe overwhelmed with contagious coronavirus patients, and pose its own health risks.

Luckily, she was able to reach a friend who is a pediatrician. The friend advised her to take Furnas to the hospital. During triage, he was sent to a wing designated for non-COVID patients. He's home now and doing fine.

While grateful that she had a friend with expertise to call upon, Wilkinson-Ryan knows not everyone has that kind of resource. And she still longed for more clear-cut rules to serve as a guide in moments of crisis like that one.

Making their own decisions

Without those clear rules, Wilkinson-Ryan, Marquita Burnett and countless others have been left on their own to make critical decisions. They might combine various inputs to reach a decision, such as the emerging science around the virus (if they're aware of it), the advice of people they know and trust, and their own values and priorities.

Caleb Furnas tripped over the dog leash and sustained a concussion while strict stay-at-home orders were in effect in Pennsylvania. His wife, Tess Wilkinson-Ryan, says she was so confused by the mixed messages from various public officials that she didn't know whether to take him to the hospital or not.
/ Tess Wilkinson-Ryan
Tess Wilkinson-Ryan
Caleb Furnas tripped over the dog leash and sustained a concussion while strict stay-at-home orders were in effect in Pennsylvania. His wife, Tess Wilkinson-Ryan, says she was so confused by the mixed messages from various public officials that she didn't know whether to take him to the hospital or not.

Burnett, for instance, has decided that during the pandemic she can take her son to get his hair cut outside, on the barber's front porch. The barber always wore a mask and took the virus seriously, so when the barbershop reopened, she felt comfortable taking her son there.

But she's not comfortable with many of their other typical summer activities, like going to the zoo, amusement parks or outdoor restaurants. If she can't predict how a crowd of strangers will act, she's not taking the risk.

But that's how Burnett figured it out. It's easy to imagine someone else, confronted with the same choices, coming to the opposite decisions: skipping the close contact of the haircut, but hitting the zoo because it's outside.

"It's sort of like asking everyone to decide their own speed limit based on, like, the make and model of their car," says Wilkinson-Ryan, or telling them: "Think about who you're gonna drive with, think about the importance of your destination. Good luck!"

Because one person's idea of "careful" in a pandemic is different from another's, she says, the most helpful instructions are those that are clear and specific: designating maximum capacities in public spaces; using marks on the ground to denote 6 feet of distance; issuing specific instructions for people on how often they should go grocery shopping.

Otherwise, people are likely to come to different conclusions based on the same information, which in turn, leads to public shaming. And that has its own risks.

"When someone gets angry, they shut down to new information. They react and simply do what they want to do," says Ellen Peters of the University of Oregon. "I could see where you could get much worse health behaviors from shaming other people."

Peters pointed to photographs of people on beaches, which then were circulated online and used to publicly shame the beachgoers. The perspective of some of the photos, though, may have made beaches look more crowded than they were. "Maybe in reality, people are pretty far apart," she says, "and they're outdoors."

Wilkinson-Ryan explain that shaming can occur naturally, when there's a lack of cultural norms in a new and changing environment.

When people are overburdened with decisions, shaming also provides a cognitive shortcut.

"It's easy and salient to think about what people in my neighborhood are doing wrong," says Wilkinson-Ryan. "They're sitting at the park, they're playing, they're touching each other. That's an availability bias: It comes easily to mind because it's part of my everyday life. You tend to place blame on the causes that come to mind quickly and easily."

But when people spend a lot of energy blaming or shaming their neighbors, it distracts from another goal: holding state legislatures, Congress and the president accountable for managing the pandemic.

Other countries managed to avoid these issues to some degree because they had coordinated federal responses. National messaging meant there was no need to deputize hundreds of local health officials to distribute hyperlocal and often conflicting messages.

"It really is kind of ridiculous, that idea of asking all of these people to come up with their own experts and their own way of guiding behavior in the states or cities, rather than having theexperts in the country come together and decide what is the best guidance for all of us and having the politicians stick with that," says Peters.

To streamline her own decision-making, Peters says, she adopted a approach that she calls the "What Would Anthony Fauci Do?" approach. Fauci is the government's infectious disease expert.

But that's just her. When everyone chooses their own way to navigate — whether that's by map, polestar, dowsing stick or gut instinct — people are bound to crash into one another.

This story comes from NPR's reporting partnership with WHYY and Kaiser Health News.

Copyright 2020 WHYY. To see more, visit WHYY.

Nina Feldman