Psychological dimensions and implications of the novel coronavirus outbreak 2019-nCoV

There is a lot to think about when considering the impacts on individuals and communities affected both directly and indirectly and for those concerned about the spread.

I want to look at some cognitive biases that might alter how we perceive the risk of the coronavirus, and how susceptible we might be to it, and how we might over-react, under-react, and how we can change or calibrate our reactions.

But, let’s start with some background:

Many epidemiological experts are predicting a sharp increase in the number of people infected with the Wuhan coronavirus. Though based on the limited information that is currently available, it seems as though the coronavirus has already undergone at least 4 generations of spread, meaning that the virus is already likely to be circulating beyond family members and health care workers who’ve been in close contact. Combined with new information that large numbers of people could be walking around with no symptoms, spreading the virus to anyone who comes in close contact, all this means that containing the spread of the virus is looking very difficult. Some models predict a very challenging start to February: further outbreaks in other Chinese cities, more infections exported abroad, and an explosion of cases in Wuhan.

It’s important however to maintain a sense of perspective. Concerning how infectious this new coronavirus is, one estimate of the number of people one person can infect – known as the virus’s reproduction number is between 1.4 and 4.0, according to two different research groups and WHO officials’ comments. Compare this with SARS, which was between 2 and 5, and measles – the most contagious disease known to humans, which is 12 to 18.

Let’s also compare that with influenza, where we may see quite a few false positives for testing for the coronavirus in the northern hemisphere at the moment: The pandemic (H1N1) 2009 influenza virus has a R0 of 1.2 to 1.6. The 1918 pandemic influenza virus is estimated to be 1.8, and Seasonal influenza is estimated to usually be about 1.3.

Of course, what we don’t know about the current coronavirus outbreak is the fatality rate, or how secondary infections of complications will unfold, or how it affect people who may already be vulnerable to the effects of the infection.

Cognitive biases and emotion

But we humans don’t tend to process information rationally at these times. We are fallible, and can be highly influenced by how events are reported to us, through imagery of people walking around in facemarks, crowded hospital corridors with no staff, and through numbers that increase rapidly, confusing us as to the scale and rate of increase.

Let me talk about 2 particular cognitive biases that can influence how we may perceive risk of susceptibility to the coronavirus outbreak.

The Availability heuristic – this is the tendency to overestimate the likelihood of events with greater ‘availability’ in memory, which can be influenced by how recent the memories are, or how unusual or emotionally charged they may be. So, lots of emotionally charged images and commentary on TV is likely to make the memory of the event more available to us – we tend to remember events that are linked to emotion more readily. Therefore, it’s going to make us more likely to recall the event, and precipitate either an approach or avoid reaction, depending on how prepared we feel, and how well we think we may be at dealing with the challenge ahead – which is called self-efficacy. We see this when we think about how to deal with living in an earthquake zone. Some people can take a fatalistic approach and think to themselves, well, its going to kill me no matter what I do, and they can tend to take very few preparation measures. However, for those who are more open to receiving messages that emphasise that little actions can make their chances of survival so much greater, such as having a store of water and food (if they can afford it), and securing items that may fall and injure them, they will have a greater sense of agency and feeling that what they can do can make a difference to their chances of coming out of an earthquake relatively unscathed. Of course, the best way to get this information is from a trusted source, preferably from someone, or an organisation that you have known for a while – which is why disinformation, or exaggeration is such a problem when it comes to preparing to deal with risks like these.

The second bias I want to talk about is Anchoring or focalism – the tendency to rely too heavily, or ‘anchor’, on a past reference or on one trait or piece of information when making decisions. Because many people have been subject to much talk and discussion about measles outbreaks, we could anchor or thoughts and beliefs on transmissibility on the rates seen with measles. However, what we have seen already is that the transmission rate looks to be much lower than that. However, unless are given the chance to attend to and process this information and to consider its implications, fear is likely to spread, meaning that we feel far more vulnerable than we actually are. That’s not to say that we shouldn’t be taking precautions, we most certainly sure. But if we are not careful, we are not unnecessarily stoking and ramping up fears in the community.

In addition to these biases, theoretical work on information cascades and herding behaviour suggests that in situations of uncertain or obscure information (such as the early stages of a disease outbreak), people may rationally look to the behaviour of others as a source of information. This process can lead large numbers of people to the same incorrect conclusions and unhelpful decisions. People don’t tend to get panicky about seasonal flu because its an old risk. If anything complacency is more the issue here.

It seems reasonably likely that under the conditions of high uncertainty, poor information, rapid change and emotional stress that exist during an infectious disease outbreak, individuals could arrive at significantly biased subjective assessments on key factual issues, at least for a time. This could lead to an over-estimation of the infection risk and to making less than optimal decisions regarding preventative actions, such as not complying with quarantine restrictions, fleeing, or quitting their jobs prematurely (e.g. in the health sector), for fear of exposure to infection.

Communication is critical

Public opinion surveys taken during SARS suggest that people at times held excessively high perceptions of the risk of becoming infected with SARS, or if infected, of dying of the disease. However, other survey evidence also indicates that people are constantly trying to update and improve their subjective probability estimates.

All of this means that the role of information and communication in public health policy and response becomes pivotal. Accurate and timely information needs to be released through official sources to help reduce unwarranted panic and emotional distress and to help people form more realistic probability assessments of subjective risk.

In the early stages of a limited disease outbreak, there may be considerable uncertainty as to whether it will turn into an epidemic or merely disappear. Authorities may often adopt a ‘wait and see’ approach, especially if an official announcement may trigger the kinds of severe trade and travel restrictions that were imposed on India during the 1994 Surat plague outbreak.

We also have unofficial information sources competing for eyeballs, and spread in a viral manner using social media platforms. It’s going to be really difficult for public health information sources to respond to these – excuse the pun – completely different viral challenges.

Different kinds of events produce different kinds of reactions 

Disease outbreaks can be characterised as developing with forewarning rather than sudden impact – this gives us some time to prepare although information about this has emerged in a very time compressed way which has left people appearing to be scrambling to respond. So, this kind of an event trajectory leaves less time for plans to be executed, and more anticipatory anxiety about imagined futures with a high degree of uncertainty at the moment.

We also have to ensure supplies are in place and able to be replenished, and to keep remembering that staff load and cumulative impact of working in a highly stressful environment starts to take its toll remarkably quickly. The belief that you are working for an altruistic purpose does seem to have a protective effect from the worst of the impacts for staff, but it’s not complete protection – don’t take this for granted – burnout and leaving the profession when its all over is a real risk.

Issues of community cohesiveness

Now let me be clear that I am not claiming by any means to be an expert on Chinese culture, or the psychology of disasters in China. Its a completely different political and cultural system to ones that I am familiar with. Nevertheless, what I offer here is some general principles which could be drawn upon to understand some of the dynamics that might be at play currently at a community level in China, and how this might play out.

What I am talking about particularly here is the fracturing and rupturing of community cohesiveness. Inter-regional and international transport has been severely restricted in China. There are reports of communities and towns making their own barriers, reportedly trying to keep people who have originated from Wuhan out. In this was we can see how stigma and discrimination take root and spreads through communities, poisoning relationships that before hand we perfectly fine.

We have also seen how health workers who work in situations like this can be shunned and stigmatised by their own communities for fear of transmitting and infection they maybe they picked up at work. And this stigma may also be extended to their family members, such as their children being treated differently at school. Or ostracised by their peers, or worse still, their teachers. We have certainly seen this in New Zealand, and it was reported in Singapore and Hong Kong during the SARS outbreak too.

But with fracturing between communities and travel restrictions meaning that families who are meant to be together in this holiday period, where it may be the only time in the year that they get together, means that the social capital that would usually exist to help people get through something like this is somewhat eroded. People can feel lonely, and isolated, with little sense of when things may return back to normal. Further than that, they may also experience stigma and ostracism if they are isolated outside their home community.

The impact of secondary stressors may be bigger than the virus impact itself

Secondary stressors are circumstances, events or policies that are indirectly related to or are a consequence of an emergency event, which result in emotional strain among affected individuals and make it more difficult for them to return to what is perceived as normality. Examples of secondary stressors include ongoing financial strain, conflict in families and couple relationships, job insecurity and/or loss.

In this case, policies designed to contain the outbreak may have larger social and psychological consequences than the virus itself – at least at this stage. China’s approach is perhaps quite different, rebalancing the needs of the many against the needs of the few using a different algorithm or set of decision principles than we might see elsewhere in the world. That’s neither a good or a bad thing, but it does bring about a different set of consequences perhaps. And we also know that the effects of disaster s on the already disenfranchised gets magnified in times of emergency – we can predict that those that have less of a voice or influence may also not do so well in this emergency too.

There may be far-reaching economic consequences too

All this fear and uncertainty takes a toll on our ability to cope with an unknown threat. This toll fall upon a community that is actively dealing with the direct impact of the virus, or indirectly dealing with the impacts of policies implemented to try to contain the virus. For example, the Chinese Government’s decision to limit the ability of citizens to leave the country on tour groups means that countries and regions that have economic ties to this Chinese tourism trade will feel the impacts, sometimes acutely. This then has flow-on social impacts upon those affected communities also. This is how the impact of the outbreak doesn’t just follow lines of physical transmission: attempts to deal with the outbreak also have psychological and social impacts far beyond the origin of the coronavirus.

But this can also have other negative consequences …

Dealing with stigmatisation and racism

Here in New Zealand, Queenstown Lakes Mayor Jim Boult said he’d been advised about “anti-visitor sentiment” prompted by coronavirus concerns.

“It is understandable to have concern about this unfolding health issue, but it will never be acceptable to descend to racism and xenophobia.

“We must all unite to demonstrate zero tolerance in regard to any such behaviour … This is a time to show a bit of humanity and kindness to our visitors.”

Unfortunately, our communities will have to remain vigilant to respond to such sentiment with appropriate measures. It’s highly unlikely that anyone traveled deliberately with the intention of spreading the virus. UK schools are on alert to deal with stigmatisation of Chinese students.

Quarantine impacts

There will be a Cabinet meeting today here in New Zealand and over further days to discuss powers of quarantine – but this has implications too. What we are seeing in terms of restriction of movement in China is unprecedented.

Quarantine doesn’t come without risks. I wrote a paper back in 2009 published in the NZ Medical Journal outlining some of the psychosocial challenges involved in quarantine, including, how many patients experienced social stigmatisation and loss of anonymity and many described the emotional strain of quarantine and isolation.

Parents had to confront changes in normal roles and routines, creating stress for entire families. Most found it difficult to explain the situation to their children without provoking more fear. Healthcare workers felt a duty to protect their children from being taunted or stigmatised by association. Spouses were physically isolated, for example, partners slept in separate rooms and were subjected to further pressure as they assumed responsibilities involving the outside world, such as school runs and shopping, as well as normal routine activities.

In addition to the physical isolation, healthcare workers experienced isolation and stigma as a result of their exposure to SARS. Although most workers rationalised this as a lack of understanding about the illness or the risks involved, all described feeling angry and hurt. Even after the outbreak had been contained and individuals’ quarantine had ended, workers remained acutely aware of others’ reactions. To avoid the negative response, one worker even denied being a healthcare worker from the affected region.

How to support workers? 

For those healthcare professionals or other front-line staff working in dangerous conditions, accessible and timely referral paths should be developed for the few who may require mental health services. For example, a confidential telephone support line set up by staff with knowledge and training to be made available for those staff members in quarantine. Just the knowledge that support is available may suffice for many resilient staff members. There is also an opportunity for leadership by example where service-managers advocate and use peer-support. Issues regarding stigma for health workers or front-line staff involved in quarantine responses are understandable and are likely to subside only when public information and role modelling by authorities at all levels are improved.

We know from the Canterbury earthquakes experience here in NZ that many workers didn’t present for help until much later than necessary for fear of being labeled as not resilient enough, and perhaps being taken out of their substantive roles. It’s really important to find ways to support staff to come forwards for help, as this outbreak possibly ramps up. The legacy of previous outbreaks is that staff were sometimes left so mentally scarred by the experience that they left the sector and their professions entirely – and we can’t afford for that kind of turnover and loss of skill to happen. So we need to prepare that support now.

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