Local, state, and federal officials are rushing to implement massively life-altering measures in the current pandemic even as we enter a situation that is still poorly understood.
Neither Deaths From Denial Nor Deaths From DespairPrevention of Covert COVID Iatrogenesis:
Weaving Beauty Into the Tapestry of the Pandemic
Local, state, and federal officials are rushing to implement massively life-altering measures in the current pandemic even as we enter a situation that is still poorly understood. Given the initial level of denial, resulting in lack of preparedness and testing of inconsistent quality and quantity in different countries and regions, there will be deaths from denial that could have been prevented. We still lack valid data on the prevalence of the virus, fatality rates, or so-called “excess mortality” beyond what might be expected in the 2- to 18-month period that has been proposed as critical for this pandemic. There are, however, indications that, unlike during the influenza pandemic a century ago, fatalities from the coronavirus are occurring disproportionately among the fragile elderly and others with already reduced life expectancy because of underlying conditions that weaken their immune systems.
Our most vulnerable people deserve (as do we all) specific attention to prevention and special care-prevention and care that may be diminished by the drain on limited resources that a blind-panic community-wide quarantine approach, which diminishes the dignity of a community, makes inevitable. We have to be careful that in search for perfect COVID-19 community-wide contagion prevention perfection, we do not inadvertently enter into a malignant competition as to who can be more perfect at the art of prevention. Competition among individuals and communities striving for perfection in COVID contagion prevention can inadvertently dehumanize both individuals and entire communities. This is vividly illustrated by the post-Holocaust artwork of the Latvian born American painter Hyman Bloom, (1913-2009) Flaying of Marsayas. (Exhibited at the Boston Museum of Fine Arts 2019-2020). Marsayas, a musically gifted Satyr, aspired to outdo the artistic perfection embodied by the Greek god Apollo. Alas, such perfectionism ended as it inevitably does, in dehumanization of the self, of figuratively being flayed alive of one’s humanity.
Sweeping measures of debatable efficacy in saving lives strive for perfect prevention. We need to ask questions such as are we really closer to perfect prevention of death or are we further from the good life when a state’s police are ordered to stop motorists with out-of-state license plates. When police are ordered to identify people as a threat to public health generically, as by their state license plate or whether they are wearing masks in even sparsely populated open air areas, there is the potential for abuse of power, and civil rights violations, humiliation, demoralization, and police and public health resource diversion. On the other hand, precise measures such as contact tracing, recently initiated in Massachusetts, empower the identified individual with an understanding of the need to be quarantined.
Such measures respect dignity and agency and are not demoralizing for individuals-who can receive support while quarantined-or stigmatizing for entire communities. Avoidance of demoralization and stigma is essential in the current pandemic, which leaves those affected susceptible to the ongoing isolation and humiliation characteristic of Enduring Personality Change After Catastrophic Experience (EPCACE), a useful diagnosis unwisely eliminated from ICD-11. The catastrophic trauma for which many around the world are now at risk creates a timely need to resurrect EPCACE, with its potential to support individual empowerment and the creation of healing communities.1
In my psychiatric practice, I am now spending much of my time responding to panicked patients and advising colleagues who are faced with such patients. People who already experienced heightened anxiety, a sense of loss of control over their lives, concerns about mortality, or feelings of hopelessness, understandably find these difficulties exacerbated not only by the emergence of the virus but even more by an atmosphere of societal panic amid a sea of unknowns. Given my career-long interest in iatrogenesis (medically caused illness or injury), I need to ask whether draconian proposals with yet uncalculated consequences, such as indefinite, community-wide long-term quarantines, may prove to be a cure worse than the disease.
Surely, we must work to prevent deaths from denial due to the current lack of widespread testing accessibility. We must take appropriate precautions such as handwashing, staying home when ill, reasonable physical distancing, and reasonable restrictions on movement and large gatherings. But we must also consider at what point deaths from denial may yet be exceeded by deaths from disruption leading to despair. Bioethical analysis must consider that people also die of loneliness, of helplessness, of the feeling that their lives have gone out of control and likely will never return to normal. Then, too, there are the foreseeably devastating economic consequences of an ongoing breakdown of established networks of interaction and exchange. While we can all see ourselves as vulnerable due to the denial that preceded the emergence of the pandemic, not all of us can see ourselves as being vulnerable to deaths of despair. Yet unraveling the fabric of society will give many of the most vulnerable people ample reasons to despair and panic.
My parents, who survived the Holocaust by being condemned to work as sanitation workers fighting a typhoid epidemic in the Lodz ghetto in Poland, often spoke of the need to be realistic, yet not give in to panic and despair. The costs of panic and despair are many. Today, they include the racist scapegoating being directed at groups such as Asian-Americans and Hasidic Jews. There are also some who will exploit a chaotic situation for economic gain. Likewise, those who seek to concentrate political power can manufacture or inflame a crisis as a pretext for postponing elections, or pander to prejudices by proposing community-wide quarantine.
contact tracing is among the prudent alternatives to economically and socially devastating collective quarantines. In South Korea and Singapore, specific yet successful health measures have included reasonable precautions, targeted testing for those in massive public contact, identification of those infected and tracing their contacts, and contact-specific and infection-specific quarantine. Massachusetts has now become the first state in the nation to initiate contact tracing. This should be a nationwide policy. It is vital that we now ramp up testing, tracking, identifying, and quarantining those infected and their high-risk contacts and focus resources on those in need.
The pandemic need not leave in its wake community-wide, overwhelming despair and demoralization. Even as we implement effective and ethical public health measures, we can prevent the long-term iatrogenic consequences of panic-driven public health. Even under conditions of uncertainty, we can still treat communities and individuals with dignity, do the right thing, and be open to learn from those who in other times either suffered from EPCACE or were able to be effective during such catastrophes and resilient in the aftermath of those catastrophes.
Harold J. Bursztajn, MD, is Co-founder of the Program in Psychiatry and the Law at Harvard Medical School and President of the American Unit of the UNESCO Bioethics Chair (Haifa). He is coauthor of Medical Choices, Medical Chances: How Patients, Families, and Physicians Can Cope with Uncertainty (1981/1990). He practices clinical and forensic psychiatry and risk management in Cambridge, MA.
1. Tanaka G, Tang H, Haque OS, Bursztajn HJ. How catastrophe can change personality: why EPCACE is a clinically useful diagnosis. Psychiatric Times. 2019;36(9):43,44,50.