Kevin Koehler, Leiden University & Jonah Schulhofer-Wohl, Leiden University
During the global COVID-19 pandemic, governments around the world have implemented various forms of non-pharmaceutical interventions (NPIs), including lockdowns, mask mandates, curfews, the closure of business, schools, or places of worship, and more. One factor in physicians’ and governments’ decision making about which measures to implement has been anticipated rates of compliance. Compliance, in turn, affects the extent to which these measures impact rates of infection and deaths. What, however, explains varying levels of compliance with public health measures?
There is a large and rapidly expanding literature on the determinants of NPI compliance which has pointed to a range of psychological, social, and political drivers of (non-)compliance. Research has in particular identified trust in government (Bargain and Aminjonov 2020b; Han et al. 2021; Lalot et al. 2020; Pagliaro et al. 2021; Pak, McBryde, and Adegboye 2021; Travaglino and Moon 2021; L. Wright, Steptoe, and Fancourt 2021) and institutions (Badman et al. 2021; Caplanova, Sivak, and Szakadatova 2021) as important political drivers of compliance, suggesting that people comply with containment measures if they trust the authorities that mandated them. At the same time, studies have also shown that partisanship and ideology (Becher et al. 2021; Clinton et al. 2021; Gadarian, Goodman, and Pepinsky 2021; Goldstein and Wiedemann 2021; Ramos et al. 2020, Stroebe et al. 2021) can be major causes of non-compliance as well. This suggests that in the context of politicized public health policies, what matters is who people trust, rather than trust as such (Goldstein and Wiedemann 2021).
We build on this literature and develop a theoretical argument for when we would expect trust in authorities to support non-compliance, rather than compliance. This argument starts from the notion that NPIs are public goods in the context of an ongoing pandemic. Whether or not political leaders have incentives to provide such public goods depends on the size of their winning coalition (Bueno de Mesquita et al. 2005; Morrow et al. 2008). The smaller the winning coalition, the weaker the incentives to supply public health goods in the form of NPIs (Koehler and Schulhofer-Wohl 2022a). Rather than investing in public health, such leaders are likely to downplay the extent of the threat. We suggest that this is not only a rhetorical device, but can actually lead to lower compliance among supporters of such governments. We provide illustrations of this argument from different cases of NPI compliance in the Middle East and North Africa (MENA).
This paper proceeds as follows. In the next section we review the existing literature on NPI compliance, focusing in particular on political drivers, and develop our theoretical argument. We then turn to compliance in the MENA to provide illustrative evidence for this mechanism.
The Politics of NPI Compliance
Research on NPI compliance is a growth industry spanning different disciplines from public health to psychology and political science. Without claiming to be exhaustive, we can roughly distinguish between different sets of factors. On the psychological level, scholars have found effects of (perceived) risk status (Atchison et al. 2021; Plohl and Musil 2021; Yıldırım, Geçer, and Akgül 2021), belief in the effectiveness of protective measures (Clark et al. 2020; Jørgensen, Bor, and Petersen 2021), belief in conspiracy theories (Soveri et al. 2021), (mis)trust in science (Brzezinski et al. 2020; Pagliaro et al. 2021; Plohl and Musil 2021), and moral relativism (Forsyth 2020), for example. On the social level, non-compliance was found to be associated with low generalized trust (Nivette et al. 2021), low income (Atchison et al. 2021; Bargain and Aminjonov 2020a; Mamelund, Dimka, and Bakkeli 2021; A. L. Wright et al. 2020; Yechezkel et al. 2021) and minority status (Atchison et al. 2021), while social connections with affected communities was found to increase compliance (Charoenwong, Kwan, and Pursiainen 2020). On the political level, research has uncovered effects of partisanship and ideology (Becher et al. 2021; Clinton et al. 2021; Gadarian, Goodman, and Pepinsky 2021; Goldstein and Wiedemann 2021; Ramos et al. 2020), and in particular of trust in government (Bargain and Aminjonov 2020b; Han et al. 2021; Lalot et al. 2020; Pagliaro et al. 2021; Pak, McBryde, and Adegboye 2021; Travaglino and Moon 2021; L. Wright, Steptoe, and Fancourt 2021) and institutions (Badman et al. 2021; Caplanova, Sivak, and Szakadatova 2021).
We are particularly interested in the political drivers of compliance. In this strand of research, two arguments stand out in particular. First, a range of studies have found that trust in authorities increases the likelihood that people will comply with public health mandates. This research has focused on political trust—or trust in government—specifically (Goldstein and Wiedemann 2021), but also on trust in science (Plohl and Musil 2021), and the interaction of different forms of trust (Pagliaro et al. 2021). Such arguments echo a tradition in political science scholarship which has long emphasized the importance of political trust (Almond and Verba 2015; Citrin and Stoker 2018; Zmerli and Meer 2017). Research on earlier epidemics also suggests that political trust improves compliance (Blair, Morse, and Tsai 2017).
Second, research has also found that NPI compliance varies across ideological groups. In the US context, a range of studies find that Republicans are less likely to comply with public health mandates (Clinton et al. 2021; Goldstein and Wiedemann 2021; Stroebe et al. 2021). Similar results were obtained in the case of Brazil, where support for social distancing measures was significantly lower among self-described conservatives (Ramos et al. 2020). Interestingly, comparative studies do not find a similar effect for other countries (Becher et al. 2021), suggesting that ideology only matters if the pandemic becomes politicized (Stroebe et al. 2021). Goldstein and Wiedemann in particular link this phenomenon to political trust, arguing that Republicans in the US have lower levels of trust when in large-scale government interventions, including public health measures. They also find that compliance improved where mandates were issued by co-partisans (Goldstein and Wiedemann 2021).
We suggest that political trust can also have the opposite effect. If political leaders themselves have no incentives to introduce, much less enforce, public health measures, political trust will not bolster compliance. If such leaders additionally give signals that they do not believe in the severity of the situation themselves, compliance with NPIs might even be lower among their supporters than among people with lower levels of trust. In particular, we suggest that there are two plausible causal mechanisms leading to this outcome. First, people might be convinced that strict NPI compliance is neither appropriate nor necessary precisely because they trust in political leaders who downplay the pandemic. Second, low trust individuals might perceive compliance not only as a public health measure, but as a political statement as well. Both mechanisms together lead to differential compliance rates between high- and low-trust individuals, yet opposite to what the conventional understanding of trust and compliance would suggest.
Pandemic Downplaying in the MENA
Evidence of political leaders downplaying the pandemic abounds. Most famously, former US President Trump famously belittled the pandemic on numerous occasions, not only insisting against all evidence that the spread of the virus was under control, but also likening the virus to the common flu. In Brazil, President Bolsonaro has refused to wear a mask and has referred to COVID-19 as ‘the sniffles.’ In the MENA, we do not find such outright denialism. Yet, MENA political leaders employed downplaying as a strategic tool to support their (non)-management of the pandemic.
Downplaying has taken several forms. One particularly frequent phenomenon is the politicization of infection statistics. Guardian journalist Ruth Michaelson, for example, was expelled from Egypt after having reported on simulations later published in the Lancet which estimated infection rates significantly above the official numbers (Koehler and Schulhofer-Wohl 2022a). In Iran, at the outset of the pandemic officials delayed public confirmation that infections were occurring and on the rise, in order to maintain large turnout at mass public events that were politically important to the regime. Also during this period, ‘official media downplayed the severity of the virus’ (Chamlou 2020, 77-78). The Syrian government claimed to have no infections whatsoever when the pandemic started, then published low statistics on the virus’ spread. It also demanded that doctors refrain from reporting new cases and from declaring deaths to have been caused by COVID, coercing them by ‘enforcing the orders with threats of reprisals.’
In Turkey, medical experts were arrested after suggesting that real infection rates were higher than official figures and university administrations investigated scientists who publicly doubted official statistics. The Turkish medical association (TBB) reported that its local branches had recorded more deaths than the aggregate numbers published by the Ministry of Health (Kisa and Kisa 2020, 1010); the mayors of the two largest cities Ankara and Istanbul—both members of the oppositional Republican People’s Party (CHP)—publicly accused the government of downplaying infection figures when Istanbul’s numbers alone almost reached the national aggregate, and Turkey’s Minister of Health Farhettin Koca himself acknowledged that official infection statistics only included symptomatic cases (Kurgan 2021, 164). Later systematic studies based on excess mortality figures confirmed that official figures underestimated the spread of the virus (Musellim et al. 2021). Insisting on lower official case counts and suppressing evidence to the contrary aimed mainly at painting a positive picture of governments’ COVID response. We suggest that it might also have had behavioral consequences among government supporters.
A second major form of downplaying consisted of the showcasing of highly visible, but largely ineffective public health measures. Disinfecting streets and public places, in particular mosques, was one popular measure which could be observed in different places from Teheran to Cairo, and from Beirut to Ankara and Istanbul. In April 2020, Hizballah invited journalists along as they disinfected streets in southern Beirut. In a highly visible and much-reported move, Egypt tasked the Chemical Warfare Department of their armed forces with disinfecting schools and universities in 2020 and also deployed the military to disinfect major mosques, including al-Azhar and al-Hussain, during Ramadan 2021. In Turkey, such disinfection programs were implemented even though public health experts denied their effectiveness and environmental groups warned against negative environmental consequences. A Turkish company even had plans to export their street disinfection vehicle, despite the fact that the WHO had issued a recommendation against the large-scale disinfection of public places as early as March 2020. Such measures should be seen as an attempt to do what can be done given limited health care capacities. Yet, they are clearly also meant to show that political authorities are in control of the situation. Again, such signals can lead to a decrease in risk perception. The effect is to depress compliance among those who trust the political authorities in question.
It may be difficult to observe the effects of downplaying, posing methodological challenges that studies will need to confront. Existing studies have mainly relied on survey-based measures of self-reported compliance. Experimental approaches have demonstrated, however, that such measures are biased since respondents misreport compliance (Becher et al. 2021; Selb and Munzert 2020). A second type of study uses information on population mobility derived from cellphone location data (Clinton et al. 2021; Pepe et al. 2020). While such studies avoid the problem of self-reported behavior, they are prone to ecological fallacies and cannot differentiate between compliant and non-compliant forms of mobility. Moreover, cellphone mobility data for the MENA does not provide sufficient coverage both within and across countries.
The types of downplaying that we describe above undermine the public’s understanding of three important facets of COVID: its severity as an illness, its present spread within society and the risk of contracting it, and the mechanisms of its transmission. There are many ways in which governments’ policies towards COVID have been politicized that we have not considered in this paper; in the MENA these have included the use of surveillance tools in ways that may erode civil liberties (Israel) and the manipulation of programs like vaccine rollouts to attempt to sabotage political rivals (Tunisia). Downplaying can be considered a form of politicization. However, we distinguish the types of downplaying that we analyzed here from other forms of politicization because the former have first-order effects on the seriousness with which the public treats COVID as a public health threat and complies with government policies designed to bring the pandemic under control and save lives. Other forms of politicization may feed back into such effects, but in a more circuitous and indirect ways.
Moving beyond understanding the effects of downplaying on citizens’ behavior during the pandemic, it may be interesting to consider variation in downplaying across the MENA. Here we have an impressionistic picture of which governments engaged in downplaying and which appear to have refrained from doing so. But more research is needed to map this variation with precision. This can occur along three separate but related tracks: frequency, salience, and unambiguity.
First, how frequently did government officials issue public statements or engage in actions that constituted downplaying? The consequences of downplaying for countries in which officials were regularly and constantly engaging in it might be considerably more severe than those for countries in which it occurred in a very limited manner. Second, regardless of the number of such statements, how important were they, whether in terms of timing, level of official involved, or ability of the message to reach a large public audience? Countries in which even limited instances of downplaying took place at the beginning of the pandemic might see considerably different trajectories of public compliance with public health measures than countries in which this occurred after one or multiple waves of infections. Third, to what degree did statements or actions singularly represent instances of downplaying versus potentially serving an alternative purpose when considered in conjunction with other government actions? Actions like disinfecting the streets are likely to have led the public to misunderstand the transmission mechanisms of COVID or to have provided a false sense of security. But governments that carried out these actions might also have had alternative motivations, like grabbing the attention of the public and demonstrating that a serious public health threat existed. When combined simultaneously with strict measures like lockdowns and requirements to wear masks, actions that might potentially have constituted downplaying could be seen in a different light.
Ultimately, downplaying illustrates an important dynamic with the COVID-19 pandemic, and one that may indeed be common to other public health crises or crises in general. In the pandemic’s early stages, public health officials around the world emphasized that interventions aimed at slowing or stopping the spread of the virus needed to be compatible with human behavioral tendencies. But the effects of downplaying indicate that citizens’ compliance with public health measures can depend on the attitudes of and information provided by politicians and other government officials. In other words, public compliance may be shaped quite heavily by the political realm rather than constituting an exogenous set of behavioral constraints on policy effectiveness. Behavioral tendencies may follow the leader.
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 For example, Hamas’ “prominent disinfection of public spaces” in Gaza, which took place alongside mosque and school closures, as well as quarantine provisions, among other measures. See Jebril (2021).