Revisiting the Fear-Apathy Cycle in Global Health in Light of COVID-19

27 May 2020, 1004 EDT

This is a guest post from Ashley Fox, an Assistant Professor of Public Administration and Policy at Rockefeller College of Public Affairs and Policy, University at Albany, SUNY.  who researches the politics of health policy and population health.  She can be found on Twitter @ashfoxly.

Since the novel Coronavirus, Covid-19, was discovered in Wuhan, China in late December 2019, it has spread to nearly every country on the globe, culminating in more than 5.5 million confirmed cases and nearly 350,000 deaths (and counting). Moreover, the epicenter of the outbreak has now migrated from Southeast Asia and the Pacific Rim to Western Europe and the United States and increasingly now Latin America.

The draconian social distancing measures utilized to bring China’s outbreak under control that many speculated would not be possible to use effectively in the West are now being undertaken under the threat of a health system tsunami. Moreover, the global economy is in a complete tailspin threatening to tack on a global economic crisis to what is already a public health crisis. 

It is now painfully clear that the world collectively underestimated this pathogen and its pandemic potential and that, once again, our containment efforts have been reactive rather than proactive, with deadly consequences. How did an emergent pathogen with a (likely?) 1% case fatality rate manage to bring civilization to its knees in a matter of months? What happened to the lessons learned from SARS, MERS, Ebola, and other recent pandemics that had resulted in promising reforms to pandemic preparedness?

Following the Ebola pandemic of 2014, the now late Andrew Price-Smith (whose passing, unfortunately, we were unable to commemorate at ISA this year) came out with the concept of the Fear-Apathy Cycle with coauthor Jackson Porecca to explain the recurring deficient responses of the global community to infectious disease outbreaks.

The global community, according to Price-Smith and Porecca (2016), oscillates between moments of panic in the midst of an outbreak, leading potentially to excessively draconian and undemocratic reactions, followed by long periods of total inaction thereby hampering the most critical aspect of epidemic responses – early and preemptive actions to prevent an outbreak from becoming widespread. This cycle repeats with frightening accuracy due to cognitive biases that affect our decision-making processes.

This post takes up the mantle laid down by Price-Smith & Porecca (2016) to “explore the theoretical ramifications of political psychology and the Fear/Apathy Cycle for the conduct of global health governance.”  Sadly, it seems that COVID-19 is, for the most part, yet another data point reinforcing the notion that we were not pandemically prepared and have not learned the lessons from the past.

So how did we get here? Could this have been avoided? Will COVID-19 be the straw that breaks the Fear-Apathy Cycle’s back, or not?

Updating the Fear-Apathy Cycle in light of COVID-19

The Fear-Apathy Cycle builds on insights from behavioral economics and cognitive psychology that aim to explain the mismatch between the actual extent of a threat and the amount of attention it receives.

Price-Smith & Porecca attribute the Fear-Apathy Cycle largely to two principle cognitive biases – the availability heuristic and probability neglect. The availability heuristic refers to the tendency to overestimate the likelihood of events with greater “availability” in memory. In this case, policymakers may compare COVID-19 to recent outbreaks that we ultimately were able to get under control.

For instance, SARS and MERS, both “sister” coronaviruses, which, in spite of being incredibly deadly proved harder to spread and were ultimately contained, at least for now. SARS, which stands for Severe Acute Respiratory Syndrome, killed nearly 800 people around the world after it emerged in 2002 in China. MERS or Middle Eastern Respiratory Syndrome killed a comparable number of people to SARS after emerged in Saudi Arabia in 2012.  

Or swine flu (H1N1), which ultimately became endemic and produced far fewer deaths than predicted despite the dire warnings of the WHO and global health agencies. The memory of these recent diseases with pandemic potential that were nonetheless contained or were billed as an “overreaction” in our collective memory may have given a false sense of security that COVID-19 would turn out the same.

Of course, this assumption is inaccurate for several reasons that demonstrate the problem of relying on cognitive shortcuts for decision-making. For one, it ignores the fact that significant effort went into containing SARS and MERS. They did not become pandemic, at least in part, due to active efforts being undertaken to contain them as well as other characteristics that slow their spread.  And in the case of the swine flu, recent evidence shows that its toll may have actually been underestimated

These examples also illustrate the bias known as probability neglect. Probability neglect concerns either under- or over-estimating the likelihood that a worst-case scenario will occur. This can lead to either an excessively aggressive response or an apathetic response. This idea draws on Sunstein’s concept of “misfearing” – the tendency to either over- and under-estimate potential risks based on cognitive shortcuts.

Already with COVID-19, as social distancing measures enter their second month in some locales and have begun producing fewer deaths than models had predicted we can see probability neglect in the direction of underestimating potential risks starting to creep back in to the US response. The already optimistic projections of 100,000 to 240,000 COVID-19 related deaths with strict social distancing measures were initially revised downward by the Institute for Health Metrics and Evaluation to closer to 60,415 deaths in the period until August 4 (just below the leading cause of death in the US- heart disease).

This contributed to President Trump and many state governors suggesting that it might be possible to open the economy up sooner than initially projected in spite of experts warning against such optimism. The models have quickly adjusted upwards to 135,000 Americans in response to account for the premature easing of restrictions – the pace of the fear-apathy cycle repeating with increasing intensity.

We can also see decision-makers and the public around the globe currently oscillating between these two extremes either underrating the possible threat of total health system collapse and the need for the wide-spread social-distancing measures (e.g., Bolsanaro in Brazil, Ortega in Nicaragua, and Lukashenko in Belarus, among others) or instituting the most severe form of social distancing without planning for how it might work in practice (e.g., Modi in India).

At the individual-level, we see this oscillation with some individuals panic shopping and prepping for an end-of-days collapse of society (the fear response) while others dismissing the threat as a hoax or overreaction (the apathetic response). At the international organization level, the WHO has also oscillated between apathy and fear – delaying declaring COVID-19 a pandemic until after it was widely believed to be so by the public at large, while later citing statistics that put the Case-Fatality Rate at an excessively high level at 3.4% (a simplistic computation of total known COVID-19 deaths over total known COVID-19 infections), which is unlikely to be the case.

While hindsight is 20-20, to experts in global health, there is little that is surprising in the COVID-19 outbreak. In fact, just such an outbreak of a zoonosis has been eerily portended in popular media (e.g., Unseen Enemy; Spill-over), the entertainment industry (viewership of the 2014 film Contagion has skyrocketed) and among experts, as well as the likely political, social and economic consequences  as illustrated by this Tweet thread by Clare Wenham:

Why was the world not prepared? Why does this disease seem so prone to misfearing?

Disease Characteristics and Misfearing: Coronavirus as the Perfect Storm

Every disease has both a natural history and a social history. Natural history refers to biological and microbial characteristics of a disease- how it is spread, its reproductive rate, its etiology. Early in an outbreak of emergent pathogen, the natural history of a disease is not well known and therefore the exact probability of virulence, transmissibility, and potential for genetic mutability are essentially unknown. 

As Price-Smith and Porreca note: “The inability to accurately estimate probability contributes to uncertainty, and then to fear. This often results in the widespread use of the availability heuristic in combination with probability neglect to generate a bi-modal response, one of denial and apathy, or of fear and overreaction.” As we learn more about the natural history of the virus, we can more accurately and scientifically make predictions, but in the absence of information we may alternate between responses that are either unnecessarily draconian (such as quarantining people with HIV in sanitoriums as was done early in Cuba’s AIDS response) or lulling people into thinking that more invasive precautions are unnecessary – like whether wearing a mask is necessary or what constitutes a “safe” distance between people.

The natural history of diseases then interact with a diseases’ social history – factors including the risk groups that are most afflicted, how visibly the disease manifests and debilitates, which determine the social reactions to the disease in terms of disgust, stigma, and locus of control- i.e., the degree to which a disease is viewed as voluntarily versus involuntarily acquired. This “social construction of risk” in turn affects what types of policy responses are deemed acceptable. 

For instance, HIV is conceived of very differently than Hepatitis C even though both are blood-borne illnesses due to the early groups it was detected in – gay men in the case of HIV. This reputation has remained quite sticky. Its social history has been shaped by its mode of transmission through acts often deemed “immoral” and “voluntary”- i.e., sexual transmission, injection drug use. Moreover, its natural history has made it hard to contain and eradicate. Though its transmission requires highly intimate contact and therefore is not as “communicable” as other infectious illnesses, its long latency period (the fact that one can appear healthy while infected for an extended period) has allowed index cases to unknowingly transmit the disease in an efficient manner that has allowed the disease to become endemic and resistant to eradication in part owing to the fact that there is still no vaccine.

COVID-19, by contrast, appears to be nimble enough to spread rapidly but not deadly enough to burn out easily. It produces just enough morbidity and mortality to overwhelm our health systems, but also kills through complications that are more familiar such as pneumonia, which render it less frightening than Ebola or diseases that kill and debilitate in a more gruesome or less familiar manner. Mortality from COVID-19 is clustered in older adults and those with preexisting conditions, the symptoms it generates are similar to the flu (a disease whose risk is already severely underestimated by most) and as many as one in four cases may produce mild to no symptoms. Given these characteristics, probability neglect in the direction of under-fearing is understandable. Older adults and people with compromised immune systems are already more at risk of death and severe morbidity, making it easy for the median person to believe they are not at risk.

Perhaps most importantly of all, healthy children are seemingly largely unaffected by COVID-19, though they are believed to be disease carriers and the Kawasaki-like complications that are appearing in some children are now thought to be a reaction to the Coronavirus. If COVID-19 killed in the same bi-modal way as seasonal flu (affecting young and old most profoundly) but at the higher case-fatality rate we are experiencing, the degree of panic and fear would likely be ratcheted up several notches. For instance, Zika galvanized a high degree of public engagement in spite of the fact that the microcephaly cluster observed in Brazil has not replicated elsewhere, arguably because of the target group that it impacted (i.e., innocent unborn children).

The disease characteristics of the Coronavirus arguably place the disease at an uncomfortable mid-point between fear and apathy. It is just deadly enough that it requires a concerted and large-scale reaction to mitigate and contain, but its features are familiar enough that it lends itself easily to an underestimation of its potential deadliness and disruption.

Only time will likely tell if the extent and duration of the extreme social distancing measures we are taking are ultimately warranted, but in the absence of full information, the precautionary principle (essentially, better safe than sorry) has been a long-held ethical principal of public health. Butas the strictures of social distancing become too much to bear and complacency sets in, measures may be removed too soon, leading to a sharp upsurge in cases, hospital overcrowding, followed by renewed fear, and the cycle may begin anew.

However, disease responses come with risks of their own. It is therefore worthwhile to take stock of the risks of both under- and over-reaction and its implications for the Fear-Apathy Cycle in global health.

Weighing Risk: Economic, Social and Political Costs in the Fear-Apathy Cycle

While so far most people seem to be peacefully respecting the cordon sanitaires imposed around the world with surprisingly few reports of extreme or violent acts of social resistance (though this is rapidly evolving in the US and elsewhere), a number of commentators have raised concern about not allowing the “cure to be worse than the disease.”

Many world leaders (and state governors in the US context) initially resisted the call to action to impose strict social distancing measures that are certain to lead to mass economic disruption, though many eventually came around to accepting them, at least temporarily. Leaders are now being advised to continue the measures for long enough to reduce the likelihood of flare-ups and scale-up their capacity to do widespread testing and contact tracing in spite the strong cross-pressures to resume economic activity. Already, we are seeing the cracks in this consensus. Social resistance to the lock-downs is building across the US as protests spread across the country, though the majority of the public (80% by some estimates) supports lock-downs and fears re-opening too soon.

In many LMICs, lock-downs are causing social unrest where authoritarian regimes are using the pandemic as cover to implement harsh policies and grab power. In Hungary, Prime Minister Viktor Orbán used COVID-19 as a pretext to enact a law that suspends elections and gives him the authority to rule indefinitely. In Kenya, police have killed at least 12 people in the course of enforcing a dusk-to-dawn curfew, which is likely contributing to excess mortality by discouraging seeking emergency medical care. Even in the US, election boards are contemplating cancelling primaries and elections (with New York State being the first to do so) and commentators are speculating what continued social distancing measures might mean for the 2020 Presidential election in the US.

While there are serious risks to under-fearing, Price-Smith & Porecca also warn of “social cascades” whereby the fear expressed by others may amplify and rapidly transmit even if false or exaggerated. This is similar to the bandwagon effect whereby the rate of uptake of beliefs, ideas, fads and trends increases the more that they have already been adopted by others. Adoption of measures in one institution, jurisdiction or country creates pressure for taking similar measures elsewhere under fear of being accused of negligence.  Policymakers feel pressure from their opponents who reproach inaction.

While many of the more extreme actions may be justified, in the absence of full information, some measures may prove later to be unnecessarily reactionary. In the US we already see a politicization of the response occurring with infighting among governors of Red and Blue states leading to responses being crafted for political reasons often against the judgement of public health authorities and “disease doubters” emerging along political lines. But public health experts may also recommend the most risk-averse alternative from a health standpoint, disregarding or underestimating the social, political and economic costs of the pandemic.

Prophetically, Price-Smith & Porecca (2016) and other scholars of global health security warned that “epidemic disease could produce a range of negative externalities that could undermine state capacity, and radiate across nations to generate considerable political, social, and economic instability.”  As this pandemic continues to unfold, there will likely come a point of reckoning where these externalities from social distancing need to be reassessed and weighed against the continued health risks from COVID-19. This raises uncomfortable moral questions regarding the “value” of a human life (especially at older ages). But there are also health harms associated with economic downturns as well as the disruption of ordinary health care services. During the Ebola pandemic in West Africa, as many people died of non Ebola-related causes as Ebola itself. Flattening the curve will make the health system more able to cope and buy time, but will also deepen and prolong the magnitude of the economic downturn and its political and social ramifications.

Already we are seeing the side-effects of a reallocation of resources towards COVID-19 and emerging effects of the economic downturn. A recent study on the indirect effects of COVID-19 on maternal and child mortality in LMICs estimated that as many as 1 million additional children and 50,000 more mothers could die in the next six months alone due to disruptions in MNCH services. These estimates are for the direct effects of reduced health care availability but as economies and growth rates slow down, declining rates of poverty reduction will undoubtedly slow the rate of improvement in health conditions around the globe setting progress back, which could mean as many as 500 million people falling into abject poverty. This will be compounded by looming food shortages.  Food shortages are expected to result from a number of factors including the sudden loss in income for millions already living on the margins around the globe, the collapse in oil prices, shortages of hard currency due to reductions in tourism, and overseas workers ceasing remittances among others.

A truly rational and evidence-based accounting would attempt to put a price tag/health toll on all of the externalities generated by the response and weigh them against more and less stringent counter-measures. But with evolving information availability, there are limits to our abilities to process and update information in real time. This, in turn, contributes to the Fear-Apathy cycle as we alternate between fear of the virus and fear of the cure.

The Risks of Overreaction: The Fear-Apathy Cycle and Global Risk Society

That the post-industrial, globalized world should be consumed by risk management was a prediction made by prominent sociologists Ulrich Beck and Anthony Giddens in the 1990s, giving rise to what Beck referred to as “Risk Society.” Risk Society is “an inescapable structural condition of advanced industrialization” according to Beck and “modern society has become a risk society in the sense that it is increasingly occupied with debating, preventing and managing risks that it itself has produced.” Risk Society is argued to have changed the relationship between scientific experts and the public. Beck contends that as a consequence of failure of public institutions to calculate and control manufactured risks, the public has grown more distrustful of this endeavor.

In many respects, COVID-19 is the quintessential disease of the Global Risk Society- produced through a zoonosis likely stemming from human’s increasing encroachment into natural habitats and spreading rapidly across the globe nearly overnight. The negative externalities generated by the response are likewise refracting rapidly across the globe as global supply chains and interconnected economies break down.

But COVID-19 also demonstrates another side effect of the risk society as it pertains to the Fear-Apathy Cycle, which is the risk that risks become meaningless in a world replete with risk. In other words, when everything poses a risk, nothing is a risk. When people are so worn down by alarmism and fear, apathy sets in. The 24-hour media cycle that tends to be biased towards negative outcomes has conditioned us to see fear in every corner of life making it difficult to disentangle risks we should actually pay attention to and risks that are oversold and sensationalized.

As Pinker argues, by focusing on negative stories, media coverage may make heavy news watchers more morose and “miscalibrated” in their risk perception. Mass shootings and terrorist attacks are obvious examples of events that scare many but kill few that are prone to misfearing. Initial reports of Coronavirus appeared overly sensational: the number of cases/deaths were presented in the absence of a denominator or contextual information about how case-fatality rates compare with previous pandemics, which may have inured political leaders and the public to the magnitude of the actual risk.

Of course, risk has always been with us and contemporary society is not more risky than previously, but society is now increasingly preoccupied with the future and its safety according to Giddens. And now we are relying on technical experts and political leaders as their intermediaries to figure out whether the risk posed by the disease outweighs the risks posed by the response.

Moving Forward: Will COVID-19 Break the Fear-Apathy Cycle?

The idea of pandemic preparedness is not new. Just months before the novel Coronavirus was discovered in Wuhan, an independent report from the World Health Organization’s Global Preparedness Monitoring Board was published, which suggested that the world is still unprepared for a pandemic virus particularly highlighting the risk posed by new strains of bird flu and swine flu. In pre-COVID times, these reports could be easily dismissed as alarmist.  In the post-COVID-19 world, will we head the warnings and be better prepared? Or will we quickly slip back into apathy?

As Price-Smith and Porreca remind us: “Humans are shocked out of their apathetic state by epidemics (e.g. Ebola and SARS), and are often overwhelmed by fear (particularly as it is stoked by unscrupulous actors in the media). However, once the contagion has passed it fades quickly in peoples’ memories, the lessons gleaned from past epidemics are quickly forgotten, and investments in global health infrastructure and personnel are fleeting.”

However, there are some reasons for optimism that this unprecedented outbreak might lead to a collective refocusing of energy on prevention of future outbreaks, but there are also reasons for concern.

Economic Impacts Equal to or Exceeding Health Impacts. History suggests that when it comes to health or the economy, the economy often wins as suggested here. However, the severity of the economic impacts of the outbreak make this not purely a health crisis but also an economic crisis. Rather than this being a narrow case of people versus profits (i.e., patents versus patients in the AIDS treatment access movement or Nestlé versus babies in the breastfeeding debate) the fate of the economy hinges on controlling the pandemic so we can resume typical economic activity.

Economists are warning that even without lock-down orders, if people do not feel safe, economic activity will not fully recover. To prevent future economic melt-down, leaders might take prevention more seriously. On the other hand, research suggests that politicians get few political rewards from investing in prevention, but are rewarded for mounting aggressive disaster responses, so cautious optimism is in order. Also, the massive economic disruptions generated by SARS estimated to be between $30-100 billion were not enough to shock the world into better pandemic preparedness.

Infecting and Affecting the Powerful. In contrast with previous pandemics, COVID-19 has not remained confined to low- and middle-income countries, nor to low- and middle-income people, at least initially. By affecting centers of power and infecting powerful leaders, pandemics are no longer something that political elites can easily ignore. As Price-Smith and Porreca describe: “Aside from the persistent influence of the Fear/Apathy Cycle, it would seem that a threshold effect also moderates this system. The epidemic shock in question must be powerful and temporally bounded, and it must threaten the interests of economic and/or political elites in order to galvanize the necessary institutional changes at the international and/or domestic levels. Diseases that fail to meet this threshold of elite interest do not seem to generate substantive institutional change, in and of themselves.”

For now, the pandemic seems to meet the criteria of “elite interest” that they describe. However, it is not unusual for infectious diseases to start out infecting “democratically,” i.e., not discriminating based on socio-economic status, but later, as more information emerges about how to protect oneself, for the disease to descend the social gradient, affecting the poor more than the rich, as occurred with HIV.

We are seeing this acutely with COVID-19 in the US where initially high-profile celebrities and politicians were infected, but increasingly morbidity and mortality from COVID-19 are clustered in lower-income essential workers who are disproportionately race-ethnic minorities. The economic impacts are also are accruing to lower- and middle-income Americans and to small-businesses that are less resilient to economic shocks suggesting that COVID-19 could entrench already historically high levels of economic inequality, immiserating more of the “precariat”. As the immediate threat to economic and political elites recedes and the disease becomes less generalized, it could soon be seen as yet another excess burden shouldered by the poor and working class and recede into apathy.

As the world oscillates between Fear and Apathy, will the threat to the interests of economic and policymaking elites be enough to produce significant institutional change at the international level and what might that change look like? The SARS crisis motivated policymakers to substantively revise the International Health Regulations, and to create the Global Fund, and the West African Ebola outbreak prompted efforts to build a Pandemic Emergency Financing Facility (PEF). However, the PEF has been roundly criticized as being ineffectual on a number of levels. As COVID-19 continues to highlight the critical importance of ensuring economic security to the promotion of health security,  we will need to continue to think about response financing mechanisms in the context of a prolonged downward spiral.