The SARS CoV-2 is a recent virus that is making its way through the human population currently. The resulting disease experienced by some people is COVID-19. The underlying family from which SARS CoV-2 emerged is a coronavirus. Contrary to that to which many people refer, coronavirus is not a single virus, nor novel. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
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Coronaviruses are a large family of viruses which may cause illness in animals or humans. In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS)[fn1].
The occurrence of the SARS CoV-2 outbreak is relatively small. The overall burden of influenza for the 2017-2018 season in the United States alone was an estimated 45 million influenza illnesses, 21 million influenza-associated medical visits, 810,000 influenza-related hospitalizations, and 61,000 influenza-associated deaths[fn2].
But just as Influenza comes and goes seasonally other coronaviruses, rhinoviruses and parainfluenza viruses have periodic outbreaks. In the last 40 years, Ebola has surfaced in almost 25 separate and deadly outbreaks, often after long spells in which it has apparently lain dormant[fn3].
SARS was unheard of before 2003. But it affected more than 8,000 people, killing about one in ten of them, causing fear and panic across the world, and inflicting enormous economic damage, especially in Asian countries[fn3].
The Ebola epidemic in West Africa (Guinea, Liberia, and Sierra Leone) in 2014 was unlike the previous 24 localized outbreaks observed since 1976. Instead of being restricted geographically, this one seriously affected three African countries and spread to six other countries in three continents, and sparked alarm worldwide[fn3].
In 2018 it was predicted with a high degree of certainty, that when the next viral outbreak comes, there will be “(a) an initial delay in recognising it; (b) a serious impact on travel and trade; (c) a public reaction that includes anxiety, or even panic and confusion, and (d) this will be aided and abetted by media coverage. The fear generated by the emergence of a previously-unknown infection may be greatly out of proportion to its real public health impact.”[fn3].
But even with this foreknowledge in hand the response to the less virulent SARS CoV-2 some 16 years after the first outbreak has followed the predictions made by the World Health Organization (WHO). There was an initial delay in recognising it. There has been a serious impact on travel and trade. The public reaction includes anxiety, panic and confusion. This public response has been aided and abetted by media coverage. Finally, the fear generated by the emergence of this infection has been greatly out of proportion to its real public health impact.
We are not without historical data by which a rational response could be formulated to address the SARS CoV-2 virus. The influenza pandemic of 2009 reached all continents in less than nine weeks. That is a similar timeline to this current viral pandemic. That influenza outbreak provides good guidance for the life-span of the SARS CoV-2.
Irrational Response
As predicted by the WHO the response has been irrational and far from proportional to the risk. Many irresponsible people are strictly implementing or following quarantine procedures. Businesses are being ordered closed without regard to the risk of transmission based upon business models or practices.
However, this direct-threat response ignores the collateral consequences. One who is knowledgeable about pathogen life spans is aware that the final phase of a pathogen pandemic is reduced transmission when human-to-human transmission decreases because of acquired population immunity. That is, as the people who first contracted and passed the ailment recover they can no longer pass it and those interactions are no longer a threat[fn3]. Thus, it is important early on for people to get and recover from the ailment so that it does not linger in the population thereby allowing a mutation to spread and reinfect those who have recovered.
The far greater concern that I have about the collateral consequences is the psychological impact. While focus on physical well-being during this time of a statistically insignificant rise in mortality risk is prominent the lack of attention to mental health is problematic.
It is collateral consequences or secondary impact that is often ignored or not recognized which can do more harm than prevented by the primary action. This is something I discussed with numerous legislators and judges in regards to protective orders used to separate children from parents. Although they understood my point they were quite cognizant that they depend on election results to maintain their position and a typical response was something like, “Stuart, you know the public isn’t intelligent enough to understand that.”[en1]. This time I think it may be the officials who don’t understand the consequences of a quarantine.
Over the course of a lifetime, nearly half of all Americans will meet the criteria for a mental health disorder[fn4]. Mental illness is now the leading cause of disability in the United States[fn5]. Yet, armed with this knowledge public health officials and, of greater note, politicians along with media outlets are deliberately exacerbating adverse mental conditions or susceptibilities in the general population.
Particularly I will assess the potential for the saturation of SARS CoV-2 attention and the resulting panic and isolation to induce anxiety and loneliness and the effects of these on the immune system and overall health of individuals.
Anxiety and depression
Studies have found what may be apparent to lay observers which is an association between exposure to televised trauma and anxiety among children and adolescents[fn6, 7]. For my depressive or anxious clients I recommend that they abstain from general news reporting. Clients following this advice have consistently reported elevated mood and reductions in anxiety. Reduction of anxiety is not the end goal though. While anxiety may be discomforting it is the effect on the immune system which is important to understand during times of viral contagion.
The study of the relationship between mental states and the immune system is known as "psychoneuroimmunology". In the early 1980s, psychologist Janice Kiecolt-Glaser, PhD, and immunologist Ronald Glaser, PhD, of the Ohio State University College of Medicine, were intrigued by animal studies that linked stress and infection. From 1982 through 1992, these pioneer researchers studied medical students. Among other things, they found that the students' immunity went down every year under the simple stress of the three-day exam period. Test takers had fewer natural killer cells, which fight tumors and viral infections. From there the field of psychoneuroimmunology burst onto the scene and psychological researchers conducted hundreds of studies. The results were clear.
Anxiety can trigger a person’s flight-or-fight stress response and release a flood of neurotransmitters and hormones into the system. This prepares the body to respond appropriately to an intense threatening, whether imagined or actual, situation. The immune system may even experience a brief boost. During periods of occasional stress the body returns to normal functioning when the immediate stressor passes.
However, exposure to repeated stressors or protracted stressful events can lead to the condition of general anxiety where the body never gets the signal to return to normal functioning. This can weaken the immune system which increases susceptibility to viral infections and frequent illnesses.
Protracted general anxiety can also lead to depression. Although some mediational variables have been tested, the mechanism through which anxiety might affect later depression is currently unknown in naturalistic settings. One variable which may explain the naturalistic longitudinal relationship between anxiety and depression is avoidance[fn8]. In response to the discomfort caused by anxiety, persons experiencing anxiety may limit their exposure to these perceived threats (avoid) to reduce their levels of discomfort.
In the case of the SARS CoV-2 virus it is the carriers (other people) who are perceived as the threat. Thus, those people experiencing anxiety as a result of the constant attention given to this virus will avoid interacting with other people. While avoiding the potential threat -- people -- may mediate the negative potential of the virus it comes at the expense of the positive benefits of social interaction[fn9].
People who are socially isolated or quarantined also miss out on positive events of daily life or nature. One recent study found a significant relationship between earlier anxiety and the later onset of depression in a naturalistic setting[fn10]. As previously stated, it is avoidance which leads to depression and in the matter of SARS CoV-2 it is the avoidance of people, or social isolation, which is detrimental to health.
Social Isolation
The most recent U.S. census data show that more than a quarter of the population lives alone—the highest rate ever recorded[fn11]. This may be why nearly half of adults report they sometimes or always feel alone[fn12]. This feeling of loneliness, or not connected to community or humanity at-large, is not social isolation but can lead to it. While loneliness is a state-of-mind, social isolation is an objectively perceived physical state. Likewise, social-isolation can lead to loneliness[fn13].
There are two bases for these outcomes. The first, loneliness, can lead to social isolation because the subjective feeling that one is alone may cause the person to limit social contacts and withdraw from social interactions. The other, social isolation, can lead to loneliness because the objective experience of being alone can logically lead to one feeling alone.
Naturally, there is often an overlap between the two states. Similarly, for those who don’t feel lonely or are not socially isolated many still feel that their relationships are not meaningful.
One meta-study found that lack of social connection heightens health risks as much as smoking 15 cigarettes a day or having an alcohol use disorder, and increases health risks twice as much as obesity[fn14]. It is significant to note that there was no difference found between measures of objective and subjective social isolation. That is, whether one was objectively isolated or well connected but felt isolated made no difference on health outcomes. That is the crux of the matter when individuals are quarantined.
It has been speculated since the time of the telegraph that as communication technology advanced that those who employ it regularly would suffer ill effects from lack of face-to-face contact. Yet, others contend that social media provides individuals with greater social connections. However, it is the quality of the social connection such as whether it provides bonding or bridging social capital that is relevant to affective outcomes[fn15]. Although persons who are quarantined may be able to use social media and technology in general to maintain social contact, those forms of mediated communication are comparably less fulfilling of social contact needs[fn16]. As previously stated, this lack of perceived connection has an adverse outcome on the immunity system.
Failure to build and maintain perceived social capital places one at great risk for physical ailments. The subjective sense, perception, is the key component to the wellness effects of social connection. Controlling subjective assessments of affective stimulus is difficult, at best, for most people. Hence, the prescriptive use of cognitive behavioural therapy (CBT) in mediating moods. It’s adjusting the perception of the glass as half-empty or half-full.
An anecdote from my early adulthood provides an example. When I was in prison I was often provided lodging in a private suite with room service three times a day. It was also referred to as “the hole” or, officially, the “segregation unit”. During all of my stays there I refused to come out for “rec time” or speak to the hacks or other inmates. Yet, I felt a strong sense of social connection during those times. I simply knew I would step right back into my regular place in the social order following my respite.
So, during times of reduced objective social connection it is important to have a subjective sense of social connection or the risks to physical health will exceed that of the physical ailment being avoided.
Assessing the risks
Whether to live in an urban or suburban environment involves a calculation of risks. Likewise, to live in a traditional home or a cave under layers of rock when contemplating death by meteorite involves a calculation of risks. Humans do poorly at evaluating risks!
One way in which humans do poorly at measuring risks involves base rates. If a doctor evaluates a patient and indicates a 30% risk for developing lung cancer in the next five years the patient may assume a lower risk because he is not a smoker, thereby ignoring recommendations for this high risk assessment. The fallacy here is that the evaluator has already considered tobacco use in the risk assessment. That’s an easy one to see. But other ways in which humans fail to accurately assess risks are more subtle.
Fear exaggerates perceived risks. In the appraisal of dangers, those who are fearful of the situation produce pessimistic estimates and make risk-averse choices[fn17]. A person who is afraid of heights may perceive the risk of professionally assisted skydiving or bungee jumping as far greater than driving to work regularly. This is especially true if the person has recently heard news accounts of a skydiver’s death during a jump.
But why would a person perceive the risk of death from skydiving -- 1 in 500,000 -- as much greater than the risk of using the roadways where the lifetime probability of dying is 1 in 106?[fn18] One would have to skydive nearly 5,000 times to reach the same rate of death as using the roadways. This miscalculation of risk comes from two logical fallacies; the Salience Bias and Availability Bias.
The Salience Bias is the tendency to focus on items that are more prominent or emotionally striking and ignore those that are unremarkable, even though this difference is often irrelevant by objective standards. The thought of helplessly plummeting to Earth and being smashed like a pancake has greater emotional resonance than getting in a car and driving along jamming to the latest tunes which may lead to lying in a hospital ICU with a ruptured liver, multiple broken bones and a spreading infection which results in death a week later. One has more immediate emotional punch than the other.
The availability bias is the human tendency to think that examples of things that come readily to mind are more representative than is actually the case. The risk of injury from a shooting in a school is far less than being struck by a vehicle. But when school shootings fill news space and social media postings the risk appears escalated.
The current situation with the SARS CoV-2 virus provides a good example of the Base Rate Fallacy. The base rate fallacy, also called base rate neglect or base rate bias, is another cognitive fallacy. If presented with related base rate information and specific information the mind tends to ignore the former and focus on the latter.
Here is a beautiful example of base rate neglect. After sipping champagne one evening from a freshly opened bottle let it remain open overnight. But first hang a stainless steel spoon handle in the bottle. Would you be surprised that by using that spoon trick the champagne still retains its bubbly in the morning? You shouldn’t be. The base rate for champagne to lose its carbonation is on a continuum terminating in three to five days after opening and is temperature dependent.
To assess the risk from a viral outbreak one should first determine a base rate for contracting a viral infection in any given year. In the United States Influenza would establish a good comparative base for SARS CoV-2. Although it is not inclusive of all viral contagions it is the most prolific, tracked, aerosol transmission pulmonary infection. In recent years there have been around 30,000,000 cases and 40,000 related deaths per year in the United States[fn19].
Using Influenza as a base one can then see that the resulting infection from SARS CoV-2, COVID-19, currently has an infection prevalence of less than 1% and a mortality rate of around 4%. Or said another way -- you’re 100+ times more likely to catch the flu and 25 times more likely to die from the flu contagion.
Be Responsible
There is no best universal approach to managing risks. Every person has a different constellation of factors which affect her or his susceptibility to any harm be it pathogenic or behavioural. Each person has the responsibility to manage his or her risks. This should be done in consideration of a social obligation to not do harm or do least when facing a harm continuum. As explained herein social isolation likely does harm either to self or others. Therefore, each person must exercise responsibility to weigh the risk of harm to self or others from cutting off face-to-face social interactions when confronted with a presumption for quarantine during a time of pandemic.
Individuals also have the responsibility to control their access to media. Parents should do so for children. Anxiety disorders are the most common psychiatric condition in youth. It is especially troubling that the rates of any anxiety disorder in children is now over 30% and ever increasing[fn20]. Global or general anxiety is not related to any acute incident but, rather, a general feeling of foreboding -- such as there is a virus ravaging humanity and civilization is likely to end. These children are the candidates for suicide. Adults, particularly the media and other profiteers, are potentially worrying children to death.
When modifying behaviour to accommodate a risk make a logical assessment. While it may be best for some people to quarantine themselves there are risks for adverse outcomes associated with social isolation. Likewise, although it is not best to ignore all reporting on an issue one should be selective in obtaining information so as to reduce sensationalism and the adverse health consequences of that sensory input. The vast majority of news I receive about SARS CoV-2 comes from WHO and the US CDC.
As Positive News founder Sean Dagan Wood said in a 2014 TED talk, “A more positive form of journalism will not only benefit our well-being; it will engage us in society, and it will help catalyze potential solutions to the problems that we face.”[fn21]
We have an obligation to each other as a society -- a social contract -- which requires us to establish laws for orderly conduct, to provide for the general welfare of each other, and to protect our individual and collective rights to pursue and live our lives. Therefore, as with any assessment of risks, we must consider the social contract. While we have no obligation to mitigate another’s susceptibility to risk we should model behaviours that reduce risks -- to lead by example. This is the primary way in which learning takes place early in life. Babies and young children learn by what we model to them. Specific to the threat of a contagion would be demonstrating proper eating habits, sufficient exercise, weight management, limiting airborne and contact contaminants, engaging in meaningful face-to-face relationships, and maintaining a positive attitude. All attributes which facilitate healthful immune system functioning.
End notes
[1] In addressing the topic of false allegations of domestic violence, sexual abuse or other offenses as means by which to obtain protect orders and gain strategic advantage in child custody cases I discussed possible solutions with legislators and judges. They ranged from elevating the standard of proof to criminal charges for unsubstantiated allegations.
One judge told me, “When these women come into my court and try to pull that **** I tell them you better have some proof or I’ll throw your *** in jail for perjury.” She was quite adamant that she was not going to allow patently false allegations to be used to manipulate custody cases.
But all seemed to agree that it is better to issue 999 bogus protective orders and one which is legitimate than not issue those 1000 and have someone get killed. This was true even knowing of the psychological harm to the children from being deprived of access to a parent -- who may be the more emotionally sound and supportive parent -- and the disruption to their routine.
That’s because the immediate death of one of the parties is more salient to the general public than the numerous children who end up sexually abused, having substance abuse issues, plagued by anxiety, or suffer any of other numerous ill effects from that lack of parental contact. Simply put they know that the general public is too stupid to see these secondary harms and thus would boot a judge or legislator out of office for “allowing someone to get killed.”
Footnotes
[1] Coronaviruses. NIH: National Institute of Allergy and Infectious Diseases. [Cited 2020 March 23] Available at: https://www.niaid.nih.gov/diseases-conditions/coronaviruses
[2] US CDC [Cited 2020 March 24] Estimated Influenza Illnesses, Medical visits, Hospitalizations, and Deaths in the United States — 2017–2018 influenza season. Available at: https://www.cdc.gov/flu/about/burden/2017-2018.htm
[3] World Health Organization; 2018 [Cited 2020 March 24] Managing epidemics: key facts about major deadly diseases ISBN 978-92-4-156553-0. Available at: https://www.who.int/emergencies/diseases/managing-epidemics-interactive.pdf
[4] Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE Arch Gen Psychiatry. 2005 Jun; 62(6):593-602.
[5] National Institute of Mental Health. Bethesda (MD): NIMH; 2015. [cited 2020 March 26]. U.S. leading categories of diseases/disorders [Internet] Available from: http://www.nimh.nih.gov/health/statistics/disability/us-leading-categories-of-diseases-disorders.shtml
[6] Busso, D. S., McLaughlin, K. A., & Sheridan, M.A. (2014). Media exposure and sympathetic nervous system reactivity predict PTSD symptoms after the Boston Marathon bombings. Depression and Anxiety,31, 551–558.
[7] Pfefferbaum, B., Nixon, S. J., Tivis, R. D., Doughty, D. E., Pynoos, R. S., Gurwitch, R. H., & Foy, D. W.(2001). Television exposure in children after a terrorist incident. Psychiatry, 64, 202–211.
[8] Behavioral avoidance mediates the relationship between anxiety and depressive symptoms among social anxiety disorder patients. Moitra E, Herbert JD, Forman EM, J Anxiety Disord. 2008 Oct; 22(7):1205-13.
[9] Why do people with anxiety disorders become depressed? A prospective-longitudinal community study. Wittchen HU, Kessler RC, Pfister H, Lieb M. Acta Psychiatr Scand Suppl. 2000; (406):14-23.
[10] Avoidance mediates the relationship between anxiety and depression over a decade later. Nicholas C. Jacobson* and Michelle G. Newman. J Anxiety Disord. 2014 Jun; 28(5): 437–445. [cited 2020 March 27] Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4957550/
[11] In 2019 the rate of single member households was 28.4%. United States Census Bureau [2019] One-Person Households on the Rise. [cited 2020 March 27] Available at https://www.census.gov/library/visualizations/2019/comm/one-person-households.html
[12] 46% of respondents report feeling lonely all or some of the time. CIGNA 2018 U.S. LONELINESS INDEX. The State of Loneliness In America. [cited 2020 March 27] Available at https://www.cigna.com/assets/docs/newsroom/loneliness-survey-2018-updated-fact-sheet.pdf
[13] Myeloid differentiation architecture of leukocyte transcriptome dynamics in perceived social isolation. Steven W. Cole, John P. Capitanio, Katie Chun, Jesusa M. G. Arevalo, Jeffrey Ma, and John T. Cacioppo. PNAS December 8, 2015 112 (49) 15142-15147; first published November 23, 2015. [Cited 2020 March 27] Available at: https://www.pnas.org/content/112/49/15142
[14] Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review. Julianne Holt-Lunstad, Timothy B. Smith, Mark Baker. First Published March 11, 2015. [cited 2020 March 28] Available at: https://journals.sagepub.com/doi/10.1177/1745691614568352
[15] A meta-analysis of social capital and health: a case for needed research. Gilbert KL, Quinn
SC, Goodman RM, Butler J, Wallace J - J Health Psychol. 2013 Nov; 18(11):1385-99.
[16] Comparing the happiness effects of real and on-line friends. Helliwell JF, Huang H - PLoS One. 2013; 8(9):e72754.
[17] Lerner, J.S., & Keltner, D. (2000). Beyond valence: Toward a model of emo-
tion-specific influences on judgment and choice. Cognition and Emotion, 14, 473-493.
[18] Lifetime odds of death for selected causes, United States, 2018. [cited 2020 March 28] Available at: https://injuryfacts.nsc.org/all-injuries/preventable-death-overview/odds-of-dying/
[19] US CDC [Cited 2020 March 28] Disease Burden of Influenza. Available at: https://www.cdc.gov/flu/about/burden/2017-2018.htm
[20] Anxiety Disorders in Children and Adolescents: New Findings. 2019 February 25, Karen Dineen Wagner, MD, PhD [Cited 2020 March 29] Available at: https://www.psychiatrictimes.com/child-adolescent-psychiatry/anxiety-disorders-children-and-adolescents-new-findings
[21] The positive future of journalism | Seán Dagan Wood | TEDxSussexUniversity
2014 September 15. [Obtained 2020 March 29] Available at https://www.youtube.com/watch?v=zPy0xnymGR0
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Monday, March 30, 2020
Coronaviruses, SARS CoV-2, Covid 19, and a Social Responsibility
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