We sat and watched the Chinese government implement its draconian measures on the Wuhan, Hubei province and the rest of the country. We saw leaks of photos and videos capturing these harrowing times. Healthcare workers strained to meet the needs of the surge of patients admitted to hospitals that were constructed to meet the emergent need. Somehow, most of us thought that it wasn’t coming to our cities.
Little by little, the cases trickled in to other countries, first the countries neighboring China, then sporadic cases in Europe, Canada, Australia and the United States, all with ties of travel from the epicenter of the outbreak. Suddenly, there was a huge spike in cases in Italy, Iran and South Korea. Images and stories being transmitted from the heaviest hit zones in Italy were not encouraging and showed a system in major strain. Cases started getting confirmed in the United States, with more than 13,700 cases reported as of March 19th. A surge in cases seems imminent.
Beginning on March 12th, the United States began to issue recommendations for social distancing under consultation with the CDC. This was under intense scrutiny of the US government and the CDC’s reactive approach, including the lack of testing availability and the strict guideline for whom was considered at risk for COVID-19. Suddenly, schools were canceled until the end of April, all meetings and events were canceled, the remaining seasons of NBA and NHL and March madness were canceled, popular destinations, such as Disneyland, were closed, and families were asked to stay home. Even employers asked workers to convert to home-based work, conduct teleconferencing, or, for the unlucky ones, to not work at all. Just over the last few days, many restaurants have shifted over to take-out only.
The supermarkets were raided for essential materials and groceries. Toilet paper (for unclear reasons!) and alcohol hand sanitizers were the first to go. Longer lines, first at the cash register, then in front of stores on opening hours, are sending a signal of people in crisis mode. The dramatic drop of the stock market over the last month, a total of more than 9,000 points, leaves little doubt that we are entering uncharted territory. Since when can a virus infect the market! All of this was caused by a black swan event, all from something that isn’t visible.
Captain of the Men of Death: The Makings of a Global Disaster
We are relatively desensitized to the horrors of zombie apocalypse themes in movies and literature. Though, when it comes to the unseen enemy that is a viral infection, our sympathetic nervous system responds sharply. The fight, flight or freeze instinct overtakes our decisions. What is different in the case of a viral outbreak, however, is that we do not see a lion or bear coming for us – or a zombie for that matter. And we can’t fight it head on in one instance or even run away from it. The scary thing is that when we are actively in this mode, our stress hormones trigger physical changes that lead to tunnel vision and not logical conclusions or judgements.
The information is freely available on social media, the news media, youtube videos, and all around the internet. We have access to personal photos, putting a name to the face of death. It is a response to these signals that makes someone go out and buy provisions for three to six months, buy every roll of toilet paper that remains on a shelf in their local COSTCO or order n-95 masks to put on and protect themselves from an unseen enemy – even though it makes them feel even more panicked! Multiple people are doing the same, because sensing other people’s survival responses is programmed in our brain. We owe our amygdala for processing fear signals and designating a reponse and our anterior cingulate cortex for sensing a collective fear. There is one thing that is more infectious that COVID-19 right now and it’s fear.
This COVID-19 outbreak satisfies several ingredients of a destabilizing event, which propagate fear even before it makes its way into the community. The fear incites actions for self-preservation and cripples the fabric of society.
The virus is an unknown, unseen enemy
For me, there was no greater fear in my childhood than the fear of the dark. As a child, I held my breath as I quickly ran to turn the light switches on. Instantly, I was ready to take a breath and defend myself with an immediate boost in courage. At some point, this matured into a “fear of the unknown.” I think it stands to reason that COVID-19 is as unknown and unseen as they come.
A coronavirus is about 100 nanometers in size – just to give you some perspective, you would need to put 10,000 viruses grouped together for it to be visible to most people (1mm). Yet, when someone is infected, they can spread it easily when they cough, sneeze laugh or talk. They may cough in their hands and greet you, or touch something that you touch – which gets into your mouth, nose or eyes. Since a cough may contain as many as 3,000 respiratory droplets measuring 10 to 100 microns, we could be blasted with hundreds of thousands of viruses if we are a passerby. On average, a typical person may touch their face more than 20 times an hour, with about 50% of the time being mucosal surfaces. Most people don’t even realize they are doing it. Unless your spouse gets ill and passes it to you, most of us really don’t even know when and where we catch an infection.
COVID-19 (SARS-2-CoV) emerged likely from an animal reservoir, a bat, or perhaps an intermediate reservoir, such as a pangolin. The genomic sequence appears similar to the bat lineage coronavirus. It is not exactly the same, because it changed when it jumped species. This is a spillover event, where a completely novel coronavirus was capable of infecting humans and causing human to human transmission. We cannot look back at this specific virus SARS-2-CoV to gain an understanding. We can only look back to the research on SARS and begin to apply some of the research questions on this distinct coronavirus. We have no vaccine. We have no treatment. We have only uncertainty.
On a hopeful note, the only current method of visualizing this threat is testing. Imagine throwing powder on the Invisible Man. For a moment, the predator can be seen, its movement can be controlled, and people can be protected. This is the power of testing. The test has to be abundant, inexpensive and sensitive to allow for maximal benefit. Restricting testing to only those with severe disease has a very limited role in curtailing an outbreak. Testing those with symptoms is like turning on a light and making the invisible – visible, allowing fine-tuning of containment and quarantine strategies in order to protect those at high-risk of infection (healthcare workers) and those at high-risk of complications (elderly, those with chronic diseases, those immunocompromised).
2. This virus is deadly but not too deadly.
As of March 20th, there have been more than 245, 000 confirmed cases of COVID-19 worldwide (and likely many more untested). 10, 046 people lost their lives because of this virus. When we hear of these deaths, the easiest way we can understand it is by thinking of our own mortality. We do not dare to fathom this number of deaths, as 10,046 separate individuals plucked away from their lives, leaving a hole in the fabric of their family systems. Each of us asks “Will I survive this disease, if I get it?”
We have diseases such as the yearly pandemic influenza that don’t seem to trigger national fear. Most people who get infected will feel sick for a few days and improve without complications. Not to mention, we have a vaccine for it that works about 40-60%, usually in causing a milder disease or in protecting from infection. We don’t always think of influenza as that serious, and certainly not as serious as COVID-19, right?
Each year, the Global Influenza Mortality project (GLaMOR) estimates that from 294,000 to 518,000 people die of influenza-associated respiratory deaths worldwide. More than two-thirds of the deaths are in those older than 67 years old. We don’t tune in to the influenza outbreak daily news by youtube personalities like Dr. Campbell and go through the body counts, failures and recommendations for each country. We don’t get the sensationalized reports. Our sympathetic nervous system doesn’t alarm. Some people don’t even get the vaccine.
We have diseases that are very deadly, like Ebola, which trigger fear but not a fight or flight response from afar. These infections may not even spread outside of the countries in which the outbreaks began. They are harder to transmit, tend to kill off people faster than they can be transmitted, and are usually easier to contain. In the global village that is the world, ebola cases did get diagnosed in other countries, including Italy, Spain, the UK and the USA. These were mostly imported cases, meaning from a person who left the outbreak site and arrived into another country with the disease. In the wake of the 2014-2016 Ebola outbreak in West Africa, it was estimated that 28,652 were infected and 11,325 died because of this infection, a case fatality rate (CFR) of approximately 40%. We feel for the losses, even feel fear, but still our sympathetic nervous system didn’t alarm to an action.
COVID-19 seems to trigger an amygdala reaction. After all, it is at a “sweet-spot” for a virus: no one is immune to this infection; it causes a certain amount of more serious cases; it spreads as easily as the flu; and it can be lethal. Photos taken from the outbreak site Wuhan show police donned in the highest level of personal protective equipment (PPE) with masks, bodysuits and respirators, impervious to the respiratory droplets carrying COVID-19. We hear of the deaths being reported daily and the amount of cases being reported, like a malignancy out of control.
We hear of it on the news as a “deadly virus,” but is it really that lethal? We have learned from South Korea that with more available testing there was a lower CFR and in China there was a greater surge of cases and a higher CFR, which exhausted their health system. We attempt to try to explain these differences. Is this because the virus changed from L for to an S form, and that the L form was more aggressive – after looking only at 103 genomes of SARS-CoV-2!!?
Did the testing cause less deaths or just reveal that the virus was less deadly? Perhaps both. The case fatality rate was 2-4.0 % in Wuhan at the start of the outbreak, where testing was just becoming available. Only the most severe cases were tested; many milder cases were not tested. It was 0.25-0.6% in South Korea, where everyone who had symptoms was tested. The South Korea government spearheaded a massive campaign, a “war on COVID-19”, that prioritized screening and identification of cases. The testing probably also had a role in taragetting quarantine measures to protect the higher risk populations.
The crude CFR is likely closer to the lower end (0.25%), which is similar to a few of the more severe seasonal flu outbreaks that we have had. All of the research coming out of Wuhan, showing age-adjusted CFR and range of presentations (82% mild, 15% severe and 3% critical) was tainted by the testing delays and not accounting for all of the cases. One support of this is that outside of Wuhan, the case fatality rate jumped down to 0.8% from 4% – and even these areas were undertested; and even if the WHO thinks otherwise. It is still impactful, but would these lower rates generate fear?
The tendency is to take these numbers and plug yourself into the equation. What is my risk that I could die and that I would leave my husband or wife and children without a parent? Let’s play Russian Roulette: If I gave you a gun with a barrell that could fit 400 bullets and I placed one bullet in it, rolled the barrell, closed it, and then gave it to you to pull, would you be really scared that you would shoot yourself?
That is likely the crude CFR. If we adjust it to age and other health conditions if present, the CFR now is lower than that rate for most people and for some people it is higher and still support that the majority of people are going to be fine through this. Does that invoke the same fear? Most likely not. Though fear probably doesn’t come as much from the case fatality rates as it does from the mass media storm (as it did with Ebola).
3. The virus cannot be walled out. It flourishes on social interactions and is stopped by distancing.
A virus has no brain and has no motive or conscience. It just is. Yet, it can change the world. This lifeless force uses cellular mechanisms to generate copies. These copies infect adjacent cells and generate more copies. A person develops a disease and has coughs, sneezes and lots of drainage. The person essentially becomes a vessel – a conductor – delivering the viruses to others. The viruses gain nothing from this, but the bridge for which they may make more copies and infect more cells.
If one infected person spreads viruses to three other people, and these three people spread to nine more, and these nine people spread to twenty-seven more, a little while longer and the a large amount of the population has been infected. If it is a cold, people just keep on keeping on, infecting people and not affecting them. Most people won’t call in for work if they have a minor cold, even if they probably should to protect others from getting their cold.
With COVID-19, there was enough uncertaintly and severity that health systems became strained, and other systems spiraled out of control. We watched builders team up in Wuhan to rapidly build sixteen (!) hospitals to accomodate those sick from COVID-19. We saw the government take strong measures of containment and social distancing, shutting down modes of transportation and enforcing curfews and other measures all for an unseen enemy.
Isolation can be a strong risk factor for anxiety and depression. The rapid changes that are being requested for all of us can take a toll on those already at risk for mental health concerns. The America Psychological Association has an informative page detailing about this concern, including suggestions to cope: limiting news consumption to reliable sources, creating a daily routine, staying virtually connected, maintaining a health lifestyle, and using other strategies such as mindfulness and relaxation exercises.
A paradox: You can’t put a wall around a city to protect it from a virus. It comes in as a Trojan horse. A society has to literally stop the spread by stopping what people do best – interacting with others. Sure, most people aren’t going to die from COVID-19. It isn’t so much about that one person who will likely recover, it is about the fact that this person can be a vessel to transmit an infection to that one elderly person – or maybe a nursing home filled with chronically ill elderly people (Kirkland Life Care Center, 81 infected, 34 deaths!). In order to preserve the fabric of our society, we have to become unglued from each other. As Phillip Picardi succinctly put it, “now our only way out is to come together – by staying apart.
4. The virus is coming to a city near you.
We have watched or listened to hours of news reports, some even more than that. The caseloads continued to increase, with new countries added. All of the sudden, there was a surge of cases in Washington, then New York, then Los Angeles area. Just under a few weeks later, there have been COVID-19 cases in every state and more than 14,000 cases at my last check on March 20, 2020. It seems like there is no stopping it – it is coming to a city near you.
It provokes fear to think that something that originated across the world can find itself to you. Sure it isn’t exactly the same thing that it was when it started. Sure this happens every year with the flu, but we aren’t scared to act then.
The COVID-19 outbreak is an unprecedented period in our history. There are multiple reasons why fear can affect the way we respond to our preparation for this. Measures that have been taken to stop further transmission can fuel separation, isolation and boredom, increasing the risk of mental health disorders and demoralization.
My suggestions toward managing this fear and anxiety include 1) getting plenty of sleep, 2) setting up a routine 3) getting some outdoor time 4) using this time to explore your interests, including crafts, hobbies, music and writing, enjoying the art of home cooked meals, and 5) tapping into technologies such as video calls, social media groups and other outlets.
Remember that this is a group effort. We are physically preventing the virus from spreading to others and potentially putting someone in harm’s way.
After all it really is all of humanity that is under threat during a pandemic -Margaret Chan
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