Tuesday, April 7, 2020

The psychology of pandemics: fear - rationalization - action

The social consequences of microbial epidemics can result in temporary collapse of societal order. Three phases typically occur: fear – rationalization – action. Civilized behavior, pain-stakingly learned over millennia, is easily cast aside, resulting in selfishness, persecution, stigmatization, avoidance and segregation. Fortunately, at least in the past, things have returned to normal quite rapidly, after the epidemic disappears. Existential threats such as pandemics can also generate positive consequences such as speedy clinical trials

Smallpox, malaria, cholera, tuberculosis, typhoid, the black plague, yellow fever, influenza, HIV, Ebola, Zika and corona viruses. Microbial pests are nothing new to humankind. Societal reaction has also stayed the same. According to Philip Strong (1990), a microbial epidemic results in the psychological plagues of fear, panic, suspicion and stigma. This initial phase is followed by explanation and rationalization. The third phase is characterized by action. 

The psychological consequences of epidemics are strikingly similar to the actual epidemic. In our current age when information is available ubiquitously, without any delay or filter, fear and panic spread even faster than the microbe. Fear leads to stigmatization, avoidance and segregation, all of which have already been seen with corona.

The second psychological phase, the explanation for the pandemic, appears straight-forward once the causative microbe has been identified. However, there are many things which remain unclear in the current corona pandemic. How contagious is the virus and for how long? Can symptom-free people spread the virus? What is the death rate? How many people die with corona instead of because of corona? Why does the virus seem to spread more in some countries than others? Will there be second, third and fourth waves like with the Spanish flu? 

All kinds of explanations and theories are abundant. Many people are unable to decide how they rate the importance of the pandemic and which restrictions on our freedoms they consider acceptable. How much economic punishment and social problems can be tolerated to fight or delay the epidemic?
Unbelievers and pandemia cynics can suddenly become messianic, rushing out to warn and convert others. 

Rationalization can have a metaphysical aspect. Who is to blame? God? People from some country? Society? 

All kinds of moralization is also seen. Initially, China was blamed. Then, Europe was blamed. Smokers deserve some blame if they get the disease? Old and ill people are to blame because they burden health care?

The third phase, action, was initiated with different speed in different countries. In some East Asian countries, rigorous action was taken rapidly, resulting in fast control of the first wave of the pandemic. In many Western countries, the virus was able to spread more widely before countermeasures were implemented. Many political leaders displayed plenty of initial self-deception. Also, the degree of the measures taken varied. For example, geographical quarantine, closing of schools, restaurants and services varied between countries. 

Just like corona is able to infect almost anyone, also the psychological consequences – fear, explanation, action – have been seen in all levels of society. Anyone can panic, then rationalize and then call for action. Terror and irrational behavior can occur despite a person’s education or experience.  

Why do epidemics cause so much anxiety
Why is corona feared much more than cancer or cardiovascular diseases, which kill up to 10 and 20 million people every year, respectively? One obvious reason is contagiousness - no one can feel safe. However, seasonal influenza kills hundreds of thousands each year, and in bad years the death toll goes up to millions. As of 6 Apr 2020, corona has killed about 70 000 people in the first 5 months of the pandemic, and some of these deaths might have been with corona instead of due to corona.

Admittedly, the corona death toll is still on the increase and we don’t know yet how high it will rise. Nevertheless, keeping in mind that 160 000 people die each day from different causes, and corona currently causes about 3% of these deaths, mortality alone does not seem to explain the magnitude of anxiety seen.  

Another reason is that the newer the disease, the bigger the fear, and the more dramatic the call for action. With new diseases there can also be a feeling of helplessness, as there are no vaccines or proven drugs. 

In an amazing contrast, underlining how we become tolerized to older threats, each year hundreds of thousands of doses of influenza vaccine go unused. Even among risk groups the coverage of influenza vaccination is frequently less than 50%, depending on the country. Well known killers such as smoking and alcohol use are allowed in most countries. Consumption of red meat, fat and sugar is allowed despite known increases in risks of cancer and cardiovascular diseases.  

Contributing to anxiety about new diseases, there is the media-propelled fear of the unknown. The disease has spread rapidly; how many people will eventually die? Will health care systems be able to cope? At what price? In developed countries, health care has already been under increasing pressure because of aging populations. Which diseases will be de-prioritized to deal with corona?  

Positive aspects
Are there any good sides to a pandemic like corona? It is part of human psychology to think that whatever doesn’t kill us makes us stronger. That something good will arise from something bad. Perhaps globalization and unnecessary travel will be reduced, resulting in benefits to the environment? Perhaps people and systems will be more aware of infectious agents and try to avoid spreading them? Microbe awareness is the only way to reduce the frequency of future pandemics and infectious diseases in general. Otherwise, problems caused by microbes will just keep on increasing, because the population of the world is still going up and the amount of travelling has also grown constantly. The more contacts between people from different regions, the more fertile ground for microbes to spread.

We have already seen some positive aspects developing. Increased caring has emerged in many people. Neighbors have started helping each other. Teddy bears line windows. Citizens are collecting money to buy new respirators for the local hospital. 

From a scientific and medical perspective, perhaps the most striking phenomenon has been the extremely rapid initiation of clinical trials with both new and old corona drugs and vaccines. This is in sharp contrast to the usual pace of clinical trials. It can take years to set up clinical trials in oncology, despite the huge unmet clinical need in most metastatic types of cancer (Hemminki 2015). In many metastatic tumors, the death risk is nearly 100%, which is much higher than with corona.

The psychological consequences of pandemics are fear, rationalization and action. The newer the disease, the more profound these reactions are. Despite improvements in medicine and hygiene over centuries, psychological reactions to epidemics have remained unchanged. Threat of contagion generates a psychological flight-or-fight response, often bringing out the worst in humankind, underlining evolutionarily conserved survival mechanisms. 

Akseli Hemminki, MD, PhD, eMBA
Professor of Oncology


Hemminki A. Crossing the Valley of Death with Advanced Therapy. Published by Nomerta, Turku, Finland, 2015. Available at http://www.nomerta.net and several e-book stores globally

Philip Strong. Epidemic psychology: a model. Sociol Health Illness 1990. Vol 12; No 3: 249-259. Free on the web.