Journal of a Plague is a new column, by Dr. Norman Doidge, that aims to help readers to stand back from, reflect on, and make sense of the pandemic, both in terms of how it is transforming life around us, and how it is affecting our individual psyches—the plague without, and the plague within.
Our column takes its name from A Journal of the Plague Year, the English writer Daniel Defoe’s classic account of the Great Plague of London of 1665. Defoe’s book is full of vivid observations that still resonate: early bouts of denial as the plague first enters London; the rich fleeing the city; the fearful exploited by quacks and con men; the poor dying in the streets; weakly enforced quarantines; moments of hope and human affection amid the creeping desolation.
Doidge is the pioneering author of two groundbreaking books about neuroscience—The Brain that Changes Itself and The Brain’s Way of Healing, which showed that the brain is remarkably more resilient and adaptable than had generally been appreciated. While Defoe’s book was composed years after the epidemic it chronicles, Doidge is writing now, in the midst of a pandemic that has just begun, with no clear end in sight. This new journal will make no attempt, in the midst of fast-moving events, to be a roundup of coronavirus news. Rather, it will be a diary of sorts, where readers can peek in to a scientific and clinical mind at work—as Doidge, also a psychiatrist and psychoanalyst, absorbs and metabolizes what he is seeing, connects what we learn about the virus to what we already know about human development and evolution, and ponders potential lessons for us individually, communally, and as a society.
Some installments will be several thousand words while others may be only a few paragraphs. All of them will be illuminated by Doidge’s deep knowledge of human history and science and how both have been indelibly shaped by disease. They will share one other aspect as well: Many will follow in some way a mysterious and awe-inspiring map that Doidge expands on here, in the third of his journal entries, and that each of us carries around inside of ourselves and which may reveal that we already know far more about the world of contagion than we think we do.
I was in Italy, in February and part of March, working most days in a library, at the Palazzo Corsini, at La Biblioteca dell’Accademia Nazionale dei Lincei—the world’s first Academy of Sciences, where Galileo was one of the members. I had booked this trip some time ago, to complete a project, and as there were hardly any cases of corona disease in Canada, and my practice was well covered, and my patients had my number, so I went, and did my work. I knew perfectly well there was a pandemic in Italy, in the north, as did everyone, and I came with a mask and sanitizer, and was greeted at the airport by a thermal scan, taking my temperature. It was a strange atmosphere indeed. Rome was beautiful, as always, and life was going on almost completely normally, on the streets. Every day I worked in the library, from opening until closing. True, every page of the newspapers was about the crisis in the north, and the pandemic. Counting cases, describing closures. But Romans were not behaving as though they were under threat in their city. That problem was in the north. There had only been two cases in Rome, two Chinese tourists, who had spent only a day in Rome before being hospitalized. People, myself included, went out, ate fresh food at restaurants, did not social distance in any way. No one was packing to leave, and there was nothing more rushed about the city than normal.
A few weeks into it, my own behavioral immune system—that is the complex of evolved instincts, attitudes, and behaviors that our species has developed over the millenia to protect us from getting sick in the first place, by helping us avoid potentially infectious people who might threaten our lives, and which I discussed at greater length in my previous journal entry—started to turn on, in a mild way, as the deaths accumulated. The government had begun imposing restrictions in the north, which, at the time, seemed utterly draconian to many, but which were always too little too late. I was reminded of one of my favorite passages in Machiavelli:
…as the physicians say of consumption, that in the beginning of the illness it is easy to cure and difficult to recognize, but in the progress of time, when it has not been recognized and treated in the beginning, it becomes easy to recognize and difficult to cure. So it happens in affairs of state, because when one recognizes from afar the evils that arise in a state (which is not given but to one who is prudent), they are soon healed; but when they are left to grow because they were not recognized, to the point that everyone recognizes them, there is no longer any remedy for them.
Thus, the Romans, seeing inconveniences from afar, always found remedies for them and never allowed them to continue so as to escape a war, because they knew that war may not be avoided but is deferred to the advantage of others. So they decided to make war with Philip and Antiochus in Greece in order not to have to do so in Italy; and they could have avoided both one and the other for a time, but they did not want to. Nor did that saying ever please them which is every day in the mouths of the wise men of our times—to enjoy the benefit of time—but rather, they enjoyed the benefit of their virtue and prudence. For time sweeps everything before it and can bring with it good as well as evil and evil and well as good.
The behavioral immune system (BIS), which seems so harsh, evolved, I would say, to address the precise conundrum Machiavelli was describing—“in the beginning of the illness it is easy to cure and difficult to recognize, but in the progress of time, when it has not been recognized and treated in the beginning, it becomes easy to recognize and difficult to cure.” As applied to an individual, late recognition means cure is less likely; as applied to a city, it means the illness will not be contained.
Infectious illnesses can be difficult to recognize for a number of reasons. Early on, they may be very mild and are barely manifest. Or they may have long incubation periods; or they display very different configurations of symptoms in different people, when they finally do express themselves fully. Physicians thought they had sorted out a core corona triad: fever, cough, and shortness of breath. But since they’ve learned there are many other symptoms, or combinations of symptoms. Some people lose smell and taste, some have gastrointestinal symptoms, others eye itching, and some are presenting with neurological problems, and of course some appear to have a mild cold. So, to detect it, an individual’s or a society’s BIS must have a low threshold for switching on (for milder presentations) and a lot of latitude in terms of what qualifies for a symptom, and who qualifies as a symptom bearer (recent travel to Italy, for instance).
In medical terms, one could say that the system is prone to “false positives.” Few medical tests are perfectly accurate. Most tend to overestimate or underestimate the presence of an illness. A test with high false positives tends to say an illness is present in patients more frequently than it really is. A false negative test is one that errs on the side of missing a few people with the illness. If that illness can wipe out much of your tribe if you miss a few carriers, that is not a good test. Better to err on the false positive side, or so it would seem. That is what the BIS does.
But, the BIS only does so once it is fully turned on, and it did not seem turned on in the Rome I was in in February. It seemed to me there were various reasons why this was so, above and beyond the obvious use by some of the psychological defense of denial.
Just as Freud showed that our various sexual and aggressive instincts can conflict, and block each other, so too, it seems to me, can the BIS conflict with other instincts, or the mental dispositions of competing instincts and wants. For the BIS to awaken, and function effectively, it must first overcome, and in effect turn off, opposing systems.
For instance, the BIS, by requiring avoidance and distancing, opposes and is opposed by our natural gregariousness, attachment needs, and erotic tendencies to unite with others, which are activated in good times.
One might imagine that the BIS would always work in tandem with our other self-preservative instincts. But even that is not always the case. At times, our aggressive and other self-preservative instincts work against the BIS. Those people at the grocery store, pushing each other, and you, out of the way to get the last can of food to stockpile or hoard, are, at the moment, concerned about starvation, not disease avoidance. Their BI systems are not turned on, and they are not especially worried that you might make them sick. You may wish to push back, but if your BIS is turned on, it will, as it were, say: “Leave it.”
And of course, acting on the imperatives of the BIS involves a lot of work, and requires us to override so many of our best laid plans, possibly for a significant amount of time, during the eruption of an epidemic.
The Italians often get a bad rap for their response to the pandemic. What went wrong in Italy was complicated.
It was not merely that they were so financially dependent on the Chinese that they were fearful of offending them by cutting off flights. (Italy ended all flights to and from China the same day as the United States, Jan. 31.) In fact, they were the first Western country to institute major restrictive measures, so had only a few democratic countries to learn from. Italy has one of the oldest populations in Europe, and Italians are gregarious and prone to enthusiastic, affectionate touching. When Italy started facing its catastrophe, less was understood about the transmission of the virus, and the best protective protocols. One of its main hospitals became contaminated, making it a death trap for staff and patients.
If the Italian leaders made a single major error in terms of prevention, it was that they hesitated to stop flights from China when they could have had the most benefit, and instead went along with the advice of the WHO leaders, who insisted, repeatedly throughout January—and even into February—that the organization was against countries imposing an international travel restriction on flights from China. WHO leader Tedros Adhanom, said, “We oppose it. … This is a time for solidarity not stigma.”
Travel restrictions during epidemics are, in fact, a fairly standard public health containment technique: You create a compartment, in which the infected people can only spread the disease to others in the compartment, to spare those outside the compartment, and then you concentrate resources to get control of the illness in that compartment. Apart from the difference in scale, creating a compartment in a nation is not much different, in principle, than, say, putting a sick patient in quarantine in a hospital room.
By using the WHO authority to say the standard public health practice of such containment (at least until we could better understand the virus, or had a treatment) would be “stigmatizing,” Tedros (as he is now called) was, in this case, actually working to get Italy and the rest of the world to undermine their own BISs. And he was making that “anti-stigma” statement, even though China itself had imposed severe restrictions internally, on Wuhan to anywhere else in China. Nor did the WHO vociferously object to that containment as stigmatizing Wuhan, but rather praised China’s handling of the outbreak. Flights containing people carrying the virus, from Wuhan to Italy, and the rest of the world, continued.
The Italians lost track of their Machiavelli just when they needed him most.
But then which countries did not make the error Machiavelli warned of, and properly prepare? Except for Taiwan, South Korea, and Iceland, there were very few—and that, I think, is related to how the BIS switches on.
Public health officials can warn of “the coming pandemic” and provide charts, with probabilities of spread, but that doesn’t turn on the system, it seems. It’s true that once these systems are turned on, they tend toward false positives, but, for most people, they are not turned on easily by spreadsheets. They are very archaic, and evolved in an animal context, and not in the virtual reality of our newsworld. They are not turned on until an infected person is felt to be very nearby, in one’s home territory, or within sight, or in the perimeter of one’s beating heart. Until we can practically smell them breathing down our necks. The animal must feel personally and imminently vulnerable. (Again, denial can be so strong in some people that they block it, even when the virus is near—but that’s for another day.)
This requirement of proximity to trigger the BIS is one of the reasons, I reckon, that Sandra Zampa, the Italian Health Ministry under secretary, concluded that when her fellow citizens and administrators looked at China, they did not see its problem as a practical warning, but as a “science fiction movie that had nothing to do with us.” When the outbreak reached Northern Italy, it seemed that many Romans still felt the problem was elsewhere, in the north. And when it reached Rome, the French and the Germans and Spanish still did not immediately take dire measures, but introduced them piecemeal, thinking, “but that problem is in Italy.” And perhaps that is why Floridians, persisting in their spring break bacchanalias, and Louisianians with the Mardi Gras, and did not protect themselves when New York was succumbing. In fact all but a handful of countries waited about the same three to four weeks too long to close borders—if they had hoped to control the pandemic by education, case-tracking, and testing, and not have to resort to massive shutdowns to buy time to figure out the virus’s biological features and vulnerabilities.
This requirement for proximity is probably why my wife and I stayed in Italy, working away in Rome, I concentrating very well on my work, as long as there were no reported cases of local community transmission nearby. Then, within one hour of learning of three such cases (and the likelihood increased that we could get stranded there as plane flights were suddenly being canceled) we got tickets home on March 3. Staying as long as we did was not simply a matter of denial; we had come to Rome, after all, with masks and sanitizer, and kept an eye on the Italian corona case stats daily, and never minimized the disaster. We had all the information.
What changed—once the BIS was fully switched on—was the emotional weight of that information. The system, once on, was helpful. It energized us to mobilize ourselves, and to protect ourselves. We wore those masks on the airplane home, and were worried, but it was a constructive worry that heightened our alertness, and focused us on our immediate task, as opposed to being a free-floating cloud of anxiety that simply wore us down.
Even though the BIS, at a conscious level,helps us to recognize potential threats, it is not a purely conscious system, divorced from our deeper biology. Indeed, it can have a profound effect on our cellular, and bodily state. A recent study by Schaller and colleagues showed subjects pictures of diseased people, then measured their immune response, and found just seeing disease imaged actually triggers an aggressive white blood cell response.
In other words, the behavioral immune system is, as it were, braided into our being, from cell to psyche, from the literal braids of our DNA, up through to the tangled extensions of neuron cell bodies and axons that make our brain circuits, and it is braided into our mental lives.
The proneness to stigmatizing others, false positives, and suspiciousness, makes the BIS appear, were it a person, someone you would definitely not want to meet at a party, except, perhaps, just before a plague. For who in Italy, and elsewhere now wishes, that it, and its harsh triage—you are allowed in, you not—had not been engaged sooner? We simply would not likely have survived as a species had not these protective modes achieved some degree of expediency in their task.
The BIS doesn’t stigmatize for the sake of it. Six studies by Jason Faulkner, Schaller, and colleagues show, for instance, that stigmatizing attitudes toward unfamiliar foreign immigrants are correlated with how personally vulnerable to disease (PVD) people perceive themselves to be. Interestingly, these stigmatizing attitudes are not triggered toward familiar foreign immigrants. This suggests to me that perhaps the BIS may be triggered in significant part by unfamiliarity, and the threat of disease that that may bring, rather than by the person’s ethnic group per se.
Thus the BIS has both “hard-wired” instinctual tendencies (disgust is fairly universal), but because it is processed by a plastic brain circuit, it can also learn, and adjust.
The capacity to learn is essential to its success. Every pandemic is different. Aboriginals in Australia and the Americas were devastated by the European foreigners, because the former were hunter-gatherers, and had a different disease experience than the Europeans, who had more resistance to agriculture-based disease. What is interesting about this moment, is that it seems that the novel coronavirus clearly can sicken subsets of people within most ethnic groups, because it is so new. Once we get reliable testing, we shall see if “test status” is taken into account by the archaic BIS, and whether those with a high PVD can “learn” that a “foreigner” who is COVID-19 negative, is less threatening than a “nonforeigner” who is positive.
As we wait for science, using its tools, to teach us more about the virus, it is important not to underestimate nature’s vitality: that of the virus, and our own. The virus may mutate in significant ways. But so can we change our response to the threat as we go along. It’s a tribute to the higher animal brain that it has a BIS, sufficiently soft-wired, that it can, over time, actually learn, and go from seeing “foreigners” as a contagion threat, to not, when warranted. But probably this kind of assessment can only occur in a context where the person making that decision is not, at that moment, feeling overly vulnerable to infection.
My wife and I landed in Toronto, on March 3. The customs and immigration officials seemed less mobilized than the Italians had been at our arrival in Rome three weeks earlier, even though we had just come from the European epicenter of the pandemic. We weren’t screened for fever on arrival, or asked to quarantine ourselves. Canada was still two to three weeks away from the provinces’ and the country’s BIS switching on. The virus wasn’t in our faces quite enough yet. The next three weeks were odd ones for us—it was like we were living in a time warp as we watched our fellow citizens go through the same stages the Italians had just gone through, always acting too little too late to avoid the need for more drastic measures, having failed to perfect the art that the ancient Romans had, of seeing, then promptly dealing with “inconveniences from afar.”