During disease outbreaks, community anxiety can rise and mass quarantine is likely to raise that substantially
The emergence of a novel form of coronavirus (2019-nCoV) in Wuhan is creating a confused and rapidly evolving situation, accompanied by “the usual, frenzied response to epidemics.” As ever in the early stages of a major incident, facts are unclear. How many people have caught the disease? What is the fatality rate? What is the incubation period? How far has it spread? And inevitably “how worried should we be?”
The imposition by the Chinese authorities of travel restrictions into, out of, and within Wuhan and an expanding number of other cities has surprised many. The move has left over 20 million people caught within a modern form of quarantine. How well these measures will work in containing the spread of disease remains to be seen. Even attempts to completely close national borders may do little more than delay an epidemic by two or three weeks. Regardless of whether it succeeds in controlling the outbreak, the widespread lockdown will inevitably have a psychological effect. Not surprisingly the UK media are already reporting a substantial psychological impact of both the outbreak and the response. Residents are said to be comparing the situation to “the end of the world,” hospitals are “overwhelmed” and there are concerns about food shortages. “Panic in Wuhan” is a common refrain.
We must be careful of reading too much into this. Journalists regularly assume panic based on little if any evidence and in our experience, the further away a reporter is from an incident, the more likely they are to claim panic. Yet words have power. Portraying public responses as nothing more than panic can lead policymakers to conclude that people should be controlled for their own wellbeing, or that information that might worsen the situation should be withheld. It can also deter us from understanding the more important factors underlying changes in behaviour, such as inaccurate risk perceptions and beliefs about how best to protect oneself.
But while history reminds us that outright panic is unlikely, fear seems more certain as a consequence of mass quarantine. Anxiety within Wuhan is to be expected even without quarantine. During disease outbreaks, community anxiety can rise following the first death, increased media reporting and an escalating number of new cases. Mass quarantine is likely to raise that substantially, for multiple reasons.
First, the measure has significant signal value, indicating that authorities believe the situation to be severe and liable to worsen.
Second, the imposition of the measure primarily for the benefit of others outside of the affected cities reduces trust and reassurance for those within the cordon—the belief that authorities are acting in my best interests.
Third, quarantine is by definition associated with perceived loss of control and a sense of being trapped, which will be heightened if families have become separated.
Fourth, the impact of the rumour mill must not be underestimated. The desire for facts will escalate and an absence of clear messages will increase fear and push people to seek information from less reliable sources. For some, the cumulative effect of these impacts may be severe. While it is difficult to extrapolate from home- or hospital-based isolation to city-wide measures, the experience of the Taipei Municipal Hoping Hospital during the SARS outbreak bears consideration. After cases of SARS were identified among the staff and patients, all staff, patients, and visitors were suddenly and forcibly restricted to the building for a two-week quarantine period. In their account of the chaos that followed, Barbisch and colleagues describe how the confinement “caused a sense of collective hysteria, driving the staff to desperate measures.”
Elevated anxiety may also have knock-on implications for other health measures. While reports of hospitals in Wuhan being overwhelmed might reflect high levels of disease activity, in previous incidents the large majority of patients who attended hospital were found not to have the disease in question. Surges of such low risk patients, who still are often unhelpfully and inaccurately referred to as the “worried well,” are often precipitated by high levels of anxiety, leading patients to identify, catastrophise, and seek help for symptoms that might otherwise have prompted little concern, and leading clinicians to refer to patients to hospital at the first sign of a mild symptom developing.
And yet, while anxiety among people subjected to quarantine is troubling, perhaps the most pernicious effect is on how those outside the cordon come to view those on the inside. Stigma can be rampant. Previous incidents have seen residents of affected areas socially shunned, discriminated against in the workplace and their property attacked. Unless active steps are taken to prevent this, the official imposition of a cordon may aggravate such effects. Vigilante-imposed isolation can follow or even run ahead of official quarantine.
Longer term effects are also possible. The potential exists for anger over official reactions, exacerbated by the impact of the outbreak on some sections of the economy, to set in train social disruption that might linger for years.
Ever since the plague of Justinian, imposed quarantine has rightly remained part of our public health arsenal. But as with every medical intervention, there are side effects that must be weighed in the balance and alternatives that must be considered. Voluntary quarantine, for example, may be associated with good compliance and less psychological impact, particularly when explained well and promoted as altruistic. Whether the uncertain epidemiological benefits of this new form of mandatory mass quarantine outweigh the uncertain psychological costs is a judgement that should not be made lightly.
G James Rubin, Reader in the Psychology of Emerging Health Risks, King’s College London
Simon Wessely, Regius Professor of Psychiatry, King’s College London
Funding statement: Rubin and Wessely are affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King’s College London in partnership with Public Health England (PHE), in collaboration with the University of East Anglia and Newcastle University [@EPR_HPRU]. Rubin is also supported by the UK Public Health Rapid Support team, funded by the United Kingdom Department of Health and Social Care. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or Public Health England.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.