COMMENTARY: Strange COVID-19 bedfellows: gnawing anxiety and under-reaction

Editor's Note: This commentary was published on Mar 11 on psandman.com and has been slightly adapted here with permission.

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The other day, a new neighbor overheard us complaining about how slowly western governments were imposing drastic social distancing to help slow the spread of COVID-19. He entered the conversation, saying, "It's not as if life as we know it is ending." He seemed a little anxious as he said it, contradicting his words.

He was wrong, of course. Life as we know it is ending for now, and the sooner people's mental understanding of this catches up with their gut understanding, the sooner people will demand and support stronger government responses.

In recent days, several other friends have expressed a lot of anxiety to us about this pandemic coronavirus, but then mentioned almost in passing that they were taking a trip to Florida next week to visit grandchildren, or going into New York City by train for a dinner date, or excited about a planned week in Hawaii, or attending a business meeting in Michigan. They mostly dropped these trips into the conversation without connecting them to the COVID-19 discussion.

We think their anxiety about COVID-19 was in one place and their cognitive understanding of COVID-19 was in another.

So we want to talk about these strange COVID-19 bedfellows: gnawing anxiety and under-reaction.

People you know are probably experiencing exactly this contradiction as we confront the COVID-19 pandemic together:

  • On the one hand, they feel a gnawing anxiety in the pit of their stomachs that just won't go away.
  • On the other hand, they haven't changed their daily lives much yet, or even planned much for the life changes that they sort-of suspect are just around the corner.

This is true of many people we know, including people who have spent decades preparing professionally for this unprecedented moment.

What's going on? And what can be done about it? Here is a tentative answer.

  1. Just about everybody is feeling the anxiety—perhaps even the naysayers like Marc Siegel, MD, whose anxiety leaks out around his scoffing.

  2. Just about everybody wonders if they're overreacting—except the "preppers" who have been predicting this moment for years.

  3. As a result of #1 and #2, just about everybody is a bit frozen in place with self-doubt.

  4. The self-doubt and the frozen-in-place feeling are exacerbated by conflicting messages from government and the media.

  5. They're also exacerbated by our totally understandable fear of being mocked as alarmist. And by public officials who seem to want us to have no feelings whatsoever about this crisis.

  6. The not-very-satisfying solution: We have to bear it all—not just the pandemic itself, not just the anxiety, but also the self-doubt, the mixed messages, and the fear of being mocked. In spite of it all, we have to do what we can to protect ourselves and get ready, and to help our loved ones, neighbors, and communities protect themselves and get ready. And officials have to do what they can to help.

Gut-vs-brain battle

We relatively normal people are caught in a battle between our gut and our brain.

Our gut "knows" that we're almost certainly facing a pandemic severe enough to disrupt our normal lives.

If we were 100% rational, our brain would know it too. "Star Trek's" Mr. Spock would find the evidence persuasive that the COVID-19 threat is bad and rapidly getting worse. Mr. Spock would instantly understand COVID-19's short doubling time—why one week nothing much was happening in northern Italy and a week later it was as if a Category 5 hurricane had hit them. Sure, the pandemic might fizzle; the virus might mutate into a milder strain; a miracle cure might get invented overnight; the world could get lucky. But those are long shots. The vast majority of experts now expect at least a few very bad months, and maybe a couple of very bad years.

The experts aren't certain, of course. Still, we can't think of any reputable expert who believes the imminent COVID-19 risk is so low that it's not worth serious immediate efforts to start protecting ourselves and start preparing for much worse to come.

But we're not 100% rational. Part of our brain just can't help slightly doubting the wisdom of extreme pandemic precautions. This part of our brain has second thoughts when scoffers look at us as though we're nuts. We don't want to be wrong about the looming disaster (even though we pray some miracle will stop the pandemic), but we also don't want to be seen as weirdos. We start to understand the loneliness and alienation that Cassandra and Chicken Little must have felt.

 (Jody just said to Peter: "It feels like we're writing this and performing it at the same time.")

The knots in our stomachs are telling us unambiguously that we need to keep working on precautions and preparedness, that we haven't done enough. But our heads are ambivalent. We can't help wondering if we're overreacting. Our guts are sure. Our brains aren't, yet. And it only worsens our self-doubt and embarrassment when someone on television or in our inner circle says we're being foolish or hysterical or panicky.

Hitting the public health sweet spot

Public health officials need to speak to our pandemic fears—the knots in our stomachs—and also to our self-doubt and embarrassment. We need their help to bear the fear and self-doubt and embarrassment, just as we need their help to bear the pandemic itself. (See sidebar below.)

What would their help look like? In a nutshell: validation and empathy for all that we are feeling. That's easy for us to say, but not so easy for officials to do. But it is doable. We will close this article with a collection of inspiring examples.

Paradoxically, part of why it's so hard for public health officials (and politicians) to validate and empathize with our fear, self-doubt, and embarrassment is their own fear, self-doubt, and embarrassment. Imagine not just having to decide what precautions to take for yourself and your family, but also what precautions to take, recommend, and mandate for a whole city, state, or country. Just like us, officials have knots in their stomachs. Just like us, they're not sure what the right course of action is. Just like us, they're afraid of coming under attack for overreacting—not just for being foolish, hysterical, and panicky, but also for ruining the stock market, depleting the world's supply of toilet paper, and forcing people to cancel weddings and church services and sports events.

Our guts are right. Our brains are behind the curve. Caught in our fear, self-doubt, and embarrassment, we do half-hearted pandemic preparedness. The same is true of our officials. They too are torn between the intuition that they're not doing enough and the embarrassed fear that they might be doing too much. We suspect this accounts for their halfway or grossly belated containment and mitigation measures.

If only officials could tell us that they are feeling what we are feeling. They are. We're sure they are. If they could say so, we might be able to help each other overcome our ambivalence and focus on facing the COVID-19 pandemic head-on, together. But saying so is a challenge.

From preppers to deniers

Dedicated long-term preppers may fear the COVID-19 pandemic like the rest of us, but they are immune to pandemic self-doubt and embarrassment. This is the moment they've been planning for and warning about for years. They feel validated—not glad that the pandemic has come; not glad that they're going to have the last laugh at their friends and neighbors who laughed at them—but validated nonetheless.

Extremist preppers, survivalists, may be worried mostly about defending their stockpiles. For the more communitarian preppers who intend to help their neighbors as best they can, our only advice is to try to cut back on the temptation to say, "I told you so." (We are fighting that ourselves, not always successfully!) Message to the Old Guard: Be kind to newbies—even when their efforts strike you as half-hearted and half-baked, even when they make newbie mistakes, even when they don't appreciate how far ahead of the curve you are.

On the other extreme are the pandemic deniers—especially professional over-reassurance TV docs like Dr. Drew (Drew Pinsky, MD) and Dr. Marc Siegel—but pretty much anyone who tries to tell you that COVID-19 is less serious than an ordinary flu season.

We suspect that these types are mostly reactants. "Reactance" is a term of art for the tendency to aggressively underestimate a new risk, and to disdainfully ridicule those who are more concerned than the reactant individual deems appropriate. We think reactance is often a defense mechanism. People who can't bear their own feelings project those feelings onto others, or recognize them in others, and then ridicule those others for having the feelings the reactants are suppressing in themselves. When government officials imagine that the public is panicking, for example, we think they are often projecting their own panicky feelings.

In extreme cases, frightened officials may project their panicky feelings to the point where they decide that the public's fear is a bigger problem than the spreading disease itself. We worry that this might be the case for WHO Director-General Tedros Adhanom Ghebreyesus, PhD, who on Feb 28 said, "Our greatest enemy right now is not the #coronavirus itself. It's fear, rumours and stigma." Surely on Feb 28 global complacency about COVID-19 was demonstrably a bigger problem than fear, rumors, and stigma.

So spare a moment to sympathize with Drs. Drew, Siegel, and Tedros. They may be having more trouble than others at bearing their pandemic fears.

More generally, be kind to the reactants. When they finally get it, try not to say, "We told you so."

Acknowledging the public's range of emotions

And it's not just the anxiety and fear. Sadness and misery are prominent reactions as well. Officials rarely criticize people for those. But they also rarely acknowledge them. Lots of friends and colleagues tell us, "I'm not that worried about getting sick. I just feel terrible about what's going to happen all over the world." We don't think they are in denial about catching COVID-19. We think they are simply far more miserable than afraid about the temporary end of "life as we know it." That's how we feel, too.

While we can sympathize with the feelings behind reactant pandemic denial, it is nonetheless harmful. It exacerbates both our self-doubt and our embarrassment. We may wonder if the deniers are right and our gut feelings are wrong. Even if we're pretty sure that's not the case, we still have to endure the embarrassment of being called foolish or hysterical or panicky. 

 (For more on reactance, see Peter's 2015 Guestbook comment on "How to respond to reactance: an op-ed dissing infectious disease experts as 'prophets of doom.'")

As we write this, a welcome sea change has occurred among many US officials. More have acknowledged community transmission in their cities. They are starting to help their citizens realize that something very upsetting and dangerous is truly happening, or likely to happen soon. They are still behind the curve in the sorts of precautions they are taking, recommending, or mandating; we wish they would say and do today what they already suspect (and their stomachs already know) they will have to say and do next week. But they have come a long way in a short time.

These officials, however, still don't want their publics to be upset. They don't seem to have a category for being "calmly upset," much less "calmly afraid." They certainly don't notice that people are already mostly calm despite their fears, and they don't acknowledge how normal it is to be calmly miserable about the annus horribilis that has begun.

By "calm," too many officials don't seem to mean "bearing our feelings well." They seem to want us to have no feelings. That doesn't make our feelings go away; it just leaves us alone with them and makes us doubt whether we are right to feel them. So officials' demand for "calm" actually gets in the way of the preparedness and precaution-taking that they have finally decided to recommend.

A few officials are beginning to notice that pandemic anxiety is real, unavoidable, and entirely normal and appropriate. They still say insulting things like "There's no need to panic" (when is there ever?), and they still say that the spread of COVID-19 is "concerning," when the right word is at least "alarming" and even better, "frightening."

And they are nowhere close to validating that everyone—including themselves—is fearful about the hard road ahead. It is time for them to do so. And we don't mean that they should say, "We understand that you are afraid." We want them to say, "Most of us are afraid of this pandemic, and sad and anxious, too. But we will get through this together with determination and grit and community spirit. We will rise to the occasion, and take the difficult actions this crisis requires."

What effective messaging looks like

We will end with some real examples of emotionally rich communication by leaders from past crises, as well as one from the current crisis. Partly we want to show you that this can be done well. And partly we want to show you that when it is done well, it doesn't sound strange or weak; it sounds like leadership.

1. Queensland Premier Anna Bligh on Cyclone Yasi

In a 2011 article about Thailand leaders' tendency to under-warn and over-reassure, we compared Thai crisis communication with a spectacularly good example from Queensland, Australia. In February 2011, after weeks of devastating floods, the Australian state of Queensland faced a new threat from Cyclone Yasi. Here is Queensland Premier Anna Bligh talking about that threat, in terms that were human, empathic, no-nonsense, and resilience-inspiring. This is how it sounds when a leader candidly shares her fears about a looming catastrophe, when she makes a bond with her people and shows she expects them to cope with a potential disaster. 

"This is a very, very big storm event.... I think many people will be very frightened by what they're hearing. I don't want to frighten people, or panic them, but all the information I'm getting is that we are facing a potentially very deadly event. We have to make sure everybody knows what's in front of them so they can prepare themselves. [Queensland residents need to] prepare themselves mentally for what I think will be quite frightening to those who experience it....

 

We stand ready. It's not a task that we expected. We thought we'd borne all that we would be expected to bear in the last five weeks. But it seems that more is to be asked of us. I know cyclones can at the last minute turn off the coast, and I certainly hope this one does. But the Bureau [of Meteorology] advises me in the most serious terms, that all of the modelling right now says this is going to cross our coast."

 

2. North Carolina State Epidemiologist Jeff Engel on SARS

In 2003 when North Carolina had its first case of SARS (severe acute respirator syndrome, also caused by a coronavirus), a reporter asked State Epidemiologist Jeff Engel, MD, if the intense news coverage was likely to cause more hysteria and fear. Engel validated the fear—his own, and that of his community:

"We need to involve our community in all aspects of public health. Certainly a disease like SARS, so new, so frightening, should instill fear. Fear is an appropriate response—for me as a public health physician, for everyone in the community. We need to transfer that fear into positive energy, and keep the facts out in front of hysteria…. I think [the media's] response is appropriate. This is a new disease, it spreads person to person, it can kill, it has a high case-fatality rate. That is newsworthy!"

 

3. CDC Acting Director Richard Besser on 2009 H1N1 flu

At the start of the 2009 "swine flu" pandemic, US Centers for Disease Control and Prevention (CDC) Acting Director Richard Besser, MD, shared his own worries, and warned people that the situation was changing so fast that the CDC's response might be confusing at times:

"Before I talk about the cases and specific actions, I want to recognize some initial guiding concepts. First I want to recognize that people are concerned about this situation. We hear from the public and from others about their concern, and we are worried, as well. Our concern has grown since yesterday in light of what we've learned since then.

 

I want to acknowledge the importance of uncertainty. At the early stages of an outbreak, there's much uncertainty, and probably more than everyone would like. Our guidelines and advice our likely to be interim and fluid, subject to change as we learn more. We're moving quickly to learn as much as possible and working with many local, state and international partners to do so....

 

Because things are changing, because flu viruses are unpredictable and because there will be local adaptation, it's likely that any given moment there will be confusing—or may be confusing or conflicting information available."

 

4. Australian Health Minister Tony Abbott on avian flu

In May 2005, former Australia Health Minister (and later Prime Minister) Tony Abbott made an almost-unnoticed speech about pandemic preparedness, with regard to H5N1 avian influenza. When we analyzed and wrote about Abbott's remarkable speech, we pointed out that "Abbott is worried also about complacency and fatalism—risks far likelier than panic and almost never mentioned in official discourse about avian influenza."

"Not since World War Two have Australians had to cope with very large numbers of premature deaths. Australians are unused to contemplating the possibility of death on a massive scale, especially from 'natural causes.' The competing temptations are 'it won't happen here' complacency, 'there's nothing we can do' fatalism, or 'no precaution is too great' alarmism."

 

5. US Health and Human Services Secretary Michael Leavitt on pandemic preparedness

In 2007, worried about H5N1 avian flu, many officials were pushing for better pandemic preparedness. Health and Human Services Secretary Michael Leavitt famously said:

"Everything you say in advance of a pandemic seems alarmist. Anything you've done after it starts is inadequate."

 

6. Singapore Prime Minister Lee Hsien Loong on COVID-19

In early February 2020, when Singapore found a few coronavirus cases with no known connection to travelers or other cases, Prime Minister Lee Hsien Loong warned his country about what might happen next in terms of the government's response. He was explicit that part of his purpose was to get people ready for potentially alarming developments:

"If the numbers keep growing, at some point we will have to reconsider our strategy. If the virus is widespread, it is futile to try to trace every contact. If we still hospitalise and isolate every suspect case, our hospitals will be overwhelmed. At that point, provided that the fatality rate stays low like flu, we should shift our approach. Encourage those who only have mild symptoms to see their family GP [general practitioner], and rest at home instead of going to the hospital, and let hospitals and healthcare workers focus on the most vulnerable patients—the elderly, young children, and those with medical complications. 

We are not at that point yet. It may or may not happen, but we are thinking ahead and anticipating the next few steps. And I am sharing these possibilities with you, so that we are all mentally prepared for what may come."

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