Fear, explanation and action – the psychosocial response to emerging infections

In December 2019, pneumonia caused by a novel coronavirus (Covid-19) emerged in Wuhan, the capital of Hubei Province in the People’s Republic of China. The population of the city is just over 11 million people and it is the largest city in central China and is a key transportation and industrial hub. Coronaviruses originate in animals and are usually not transmissible to humans. However, as in the cases of Severe Acute Respiratory Syndrome (SARS) in 2003 and Middle Eastern Respiratory Syndrome (MERS) in 2002, they can mutate and become transmissible from animals to humans and then from human to human. Many of the first cases in Wuhan worked or frequently shopped at the seafood wholesale market in the city.

At the time of writing we are eight weeks into the 2019-nCov (Covid-19) outbreak in China and 24 other countries, and the World Health Organization (WHO) Sitrep: 23 (13 February 2020) indicates that there have been 60,000 confirmed cases worldwide and 1370 deaths. The mortality rate appears to be 2% (but the denominator remains unclear). The steep rise in cases this week (13,332) is largely a result of a revised definition being used by the Chinese authorities, which now includes clinically diagnosed as well as laboratory confirmed cases (World Health Organization, 2020). This change in diagnostic criteria will enable the Chinese to treat the population more quickly, as admission to hospital was dependent upon a laboratory confirmed diagnosis. The largest cluster outside China (218 cases) is on the Diamond Princess cruise ship, which sailed from Hong Kong to Yokohama. Sadly, Dr Li, the clinician who first alerted colleagues to the fact that he had seen seven patients with SARS-like symptoms on 30 December 2019, died of the infection on 7 February 2020, nearly four weeks after having been admitted to hospital.

Many of you will have spent the past several weeks following the course of the outbreak and ensuring that your trusts are prepared for any potential or confirmed cases, while knowing that the situation is fluid and changing on a daily basis. This editorial reflects on some aspects of the media and government response to the Covid-19 and draws on studies that focus on how we respond to and create public health and media messages around emerging and known infections.

A seminal text on the sociology of epidemic infectious disease is the work of Philip Strong in “Epidemic psychology: A model” (Strong, 1990). Written against the context of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), Strong explored how society, since the period of the Black Death, responded to new infections. He describes how epidemics “can potentially create. . .the war of all against all” (Strong, 1990: 249) creating an existential threat to the human race. While large outbreaks of novel disease often present serious threats to global public health and the world economy, they also engender almost immediate “fear, panic, stigma, moralising and calls to action” (Strong, 1990: 249); these responses form the model’s three types of inter-related psychosocial epidemic, which may spread to almost everyone in society. Wald (2008) discusses the outbreak narrative of scientists, the media and fiction as being a formulaic plot that starts with the identification of a new infection, follows its global transmission and ends with the epidemiological activity that results in its containment. The language we use and the images that are used to portray the development of novel infections feed the psychosocial epidemics described by Strong (1990).

The epidemic of fear (Strong 1990: 253) has a number of linked concepts; because we are afraid of the emerging infection, we also become suspicious of those around us as they may be the person who passes on the infection. Early in an epidemic, scientists are often unsure of the means by which the infection is transmitted, causing us anxiety; is it through human contact, the environment, food, breathing, coughing and sneezing? The fear and uncertainty that is generated in the early stages of an epidemic caused by a novel organism/strain results in a degree of irrationality. Stigmatisation of those who have the disease and those identified as the main carrier groups swiftly follows. Wald (2008) discusses the labels that society attaches to individuals who are unfortunate enough to be the first or in the early cases of a novel infection. The media narrative surrounding new infections feeds our fear. It nearly always invokes the vocabulary of human conflict; we wage war against killer viruses and bacteria, battle indomitably against the invisible threat of infection and we quarantine people in camps, often stigmatising particular individuals or groups as the initiators of the threat. Headlines invoke the super-spreader or patient zero to create convenient scapegoats. In a recent study Ophir (2018) studied over 5000 articles from US newspapers that covered the H1N1, Ebola and Zika epidemics. He identified three key themes that typified media coverage: a social theme focusing on social and economic disruption, a scientific theme focusing on medical and health risks and the efforts to limit the spread of infection and finally the pandemic theme focusing on the government/global response. What the study noted was that these themes were almost always silos of information, with little effort to provide the public with a comprehensive perspective of the disease and its impact. In particular they lacked information about what people could do as individuals to limit their exposure to the infection.

The epidemic of explanation is situated in the desire to understand historically how God, or currently government, could have allowed a new disease to emerge. Who is to blame? Why were we not alerted sooner? What in our well-ordered global infrastructure failed? Emerging diseases, according to Strong (1990), disrupt our intellectual ability to decide whether a new infection or outbreak is significant or insignificant. In reality this means the public are bombarded with often conflicting opinions and theories about how the infection has emerged and spread and what its effects might be. In some instances, the interpretation of the origins and impact of the infection result in moral judgements based on religious or cultural beliefs. In the early period of HIV/AIDS moral judgements focused on sexual morality and substance misuse; the emergence of SARS was blamed on primitive farming practices in Guangzhou: “Pigs, ducks, chickens and people live cheek by jowl on the district’s primitive farms. . .” (Kalb, 2003).

The third epidemic, the need for action, leads to a range of national government and global responses. These often infringe on individual rights and freedoms and disrupt the normal rhythm of trade, travel and everyday activity in the interests of the greater good and the spectre of halting the emerging epidemic in its tracks. The requirement to do something and quickly requires a shift of much needed resources in economies and health systems. While interventions such as closing public and manufacturing spaces, banning travel and quarantining individuals and regions in affected countries may provide a short term fix, in the long term they may create social unrest and distrust; in Sierra Leone during the 2014–2016 Ebola epidemic the quarantining of large areas of the country resulted in hardship due to reduction in income and lack of food. Images of healthcare and other government workers in full protective equipment may be in contrast to public health messages that indicate that an emerging infection is acquired through a particular route and that basic hygiene measures are all that is required. In the Covid-19 outbreak, the actions of the Chinese government in limiting travel, closing down all public venues and manufacturing and imposing quarantine measures appear to have largely limited the spread of the virus to Wuhan and surrounding areas; but the forcible removal of citizens with suspected infection makes uncomfortable viewing.

The WHO and other public health organisations globally have been efficient at shaping balanced public health messages and have recognised the misinformation that is circulating within the world of social media (SoMe) and taken action with the co-operation of the SoMe companies to try to manage the “Infodemic” that surrounds Covid-19 (Richtel, 2020). Reports suggest that the companies are making concerted efforts to create links to trusted sources of information such as the WHO, making misinformation more difficult to find and in some cases removing information altogether. In the UK our public health organisations have swung into pandemic preparedness mode with advice on screening and diagnosis and self-isolation/quarantine requirements.

What has struck me in researching the content of this editorial is that the model suggested by Strong 30 years ago continues to explain how we respond to novel infections. Governments, the media and the scientific community contribute to an almost inevitable “over-reaction” at the beginning of a new epidemic, but we continue to use language and images that confirm society’s worst fears. As professionals we have the knowledge to challenge and normalise the perceived threat of infection. We need people to take infection seriously and use reasonable measures to prevent it and protect themselves, but we also need to keep a sense of proportion that reduces fear, stigma and scapegoating.

Our public health messages need to be simple but also make links to some of the complexities that infections pose. This requires an awareness of health literacy and an imperative to present data about risk and outcomes in a way that can be understood by a population where 43% of adults have literacy skills lower than Level 2 (national curriculum key stage 2) and 15% have skills equivalent to Entry Level 3 (national curriculum key stage 3) or below (Rowlands et al, 2015). We also know that 43% of people aged between 16 and 65 years find health information too complex and when the information also requires maths skills this rises to 61% (Rowlands et al, 2015). Additionally, the population groups most likely to be affected by an emerging infection include many of those that have disproportionately low or inadequate health literacy in more disadvantaged socioeconomic groups. These include older people, people with long-term health conditions, migrants and people from ethnic minorities and people with disabilities. Finally, in the NHS, where finances and staff are already under huge pressure, there needs to be the ability to take proportionate decisions about the focus, energy and resources that are needed to prepare for emerging infections.