As the COVID-19 pandemic spreads throughout the world, the World Health Organization (WHO) has released a mental health bulletin on psychosocial considerations, expecting that “this time of crisis is generating stress throughout the population” (WHO, 2020). Although there is some familiarity with “[natural] disasters, terrorism, conflict, torture” (p 247) in disaster psychiatry (Raphael and Ma, 2011), there is little experience with the effect of a globally spreading pathogen on mental health. However, plagues and their effects have been described for millennia. In this article, we analyze three central landmark accounts of plagues to better understand psychosocial reactions. In this context, we use the word plague to refer to highly infectious diseases with varying mortality rates regardless of their pathogen. We propose that despite differences between historical plagues and today's crisis, this knowledge can help psychiatrists and other healthcare professionals understand people's reactions today and find coping strategies.
As an account from antiquity, we chose Thucydides' (455 to circa 400 BC) History of the Peloponnesian War with its famous description of the plague of Athens starting in 430 BC (Thucydides, 1972). There is ongoing research concerning its pathogen (Papagrigorakis et al., 2006). Thucydides is sure that the events he describes, “human nature being what it is,” will be repeated and that his work “was done to last for ever” (Thucydides, 1972, II, 22, p 48).
From the late Middle Ages, we chose Giovanni Boccaccio's (1313–1375) description of the plague in Florence (1348) in his major work The Decameron (Boccaccio, 1903), a work that inspired subsequent authors such as William Shakespeare and filmmakers such as Federico Fellini.
From modernity, we chose Nobel laureate Albert Camus' (1913–1960) novel The Plague (1947), which is widely recommended throughout the globe during the COVID-19 pandemic with steeply rising sales reported (Willsher, 2020). Although The Plague can be understood on several levels, including as an allegory to the occupation of France by Nazi Germany (Willsher, 2020), it contains, foremost, a thorough description of psychosocial reactions to a fictional outbreak of bubonic plague in an Algerian city in the 1940s, for which Camus did extensive research on epidemics.
We performed a narrative inquiry, which is a systematic and focused approach toward a series of narratives, taking into account the position of the story, the storyteller, and the listener or reader, in our case, ourselves as researchers (Taylor and Francis, 2013). We are critically aware of our retrospective postmodern look at these works.
The foci of our analysis are descriptions of psychosocial reactions to plagues on an individual and a societal level, which is important because in disaster psychiatry, “there is the need to encompass population aspects of mental health as well as individual experience” (Raphael and Ma, 2011, p 247). We looked for stable patterns of reactions over the millennia and tried to discern helpful behavior giving rise to resilience.
One striking similarity among all descriptions is that reactions to plagues tend to be ambivalent and contradictory, e.g., fear and seclusion vs. pleasure and living for the moment, compassion and altruism vs. maximizing profit, feelings of equality and solidarity as people from all social classes are affected vs. augmented social inequalities once resources become sparse, and hope to survive vs. uncertainty and despair. Responses to pandemics are complex, and they oscillate between contrasting positions in both society and the individual.
Phases of Response
Responses to epidemics often follow a certain pattern (Žižek, 2020), and we could discern several phases in the novel of Camus (1991): denial and disbelief, “they disbelieved in pestilences” (p 37); fear and panic, “the perplexity of the early days gradually gave place to panic” (p 23); acceptance paired with resignation, “they had adapted themselves to the very condition of the plague” (p 181); hope mixed with uncertainty, “Though this sudden setback of the plague was as welcome as it was unlooked-for, our townsfolk were in no hurry to jubilate.” (p 269); elation mixed with grief, “as he listened to the cries of joy rising from the town, Rieux remembered that such joy is always imperilled” (p 308).
During the height of disease activity, all three accounts report a certain breakdown of social norms, especially burial rituals. Thucydides (1972) writes of “shameless methods” (p 155, II, 52) such as throwing corpses on someone else's pyre.
Boccaccio describes how 10 young people flee the plague-ridden city of Florence to the countryside. This self-imposed quarantine is no escape from infection because they know that the plague is equally present in the countryside, but it can rather be interpreted as “psychological quarantine” (including elements of hedonism) (Usher, 1986, p 624) of being in a pleasant environment, excluding plague-related bad news, telling stories, making music, and following self-imposed rituals. This “admixture of reason and pleasure” (p 623) is in line with the medical opinion in Boccaccio's time (Usher, 1986).
Helping others in times of plagues can be dangerous because one risks contagion: “When […] they did visit the sick, they lost their own lives, and this was particularly true of those who made it a point of honour to act properly.” (Thucydides, 1972, II, 51, p 154). On the other hand, helping others can counteract despair and thus help both society and those who provide support.
Camus describes the formation of volunteer groups fighting the plague with different means and different motivations. Although this act of living and dying together is not described as an act of heroism but as “merely logical” (p 133), it still results in helping “men to rise above themselves” (Camus, 1991, p 125). While working tirelessly, some element of emotional distancing and effort of abstraction is described as helpful.
DISCUSSION AND CONCLUSIONS
Psychiatrists are called for in times of crisis on two levels, namely, in treating the mentally ill and also by taking into account population distress (Raphael and Ma, 2011). In doing so, it helps to be aware of common patterns of psychosocial reaction.
- Responses to plagues are known to be contradictory: “Calm down and panic!” (Žižek, 2020, p 61). Psychiatrists and other healthcare professionals should take such emotional ambivalence into account.
- Although generating hope, for example, has been described to be a strong positive predictor of mental health (Raphael and Ma, 2011), hope in times of plagues is often imbued with uncertainty and may oscillate with fear even while the disease is retreating.
- Promoting resilience and coping mechanisms is an important psychiatric task in times of crisis (Raphael and Ma, 2011; WHO, 2020). In our sources, we found descriptions of a psychological quarantine (Boccaccio) as well as coming together to help others (Camus) to be helpful. Both strategies hold promise and are promoted by WHO (2020).
- Identifying the vulnerable is a general rule in times of crisis (Raphael and Ma, 2011). Although at first glance infectious diseases equally affect persons from all social spheres, we found descriptions that the poor are often hit the hardest, which holds true also during the ongoing COVID-19 pandemic.
- Healthcare professionals dealing with the aftermath of a pandemic situation should be aware of the fact that in regions with very high death tolls, burial procedures and rituals may collapse, a phenomenon described in all texts analyzed here.
Finally, the mentioned psychosocial responses to plagues are likely to affect the mourning process of the survivors. A “search for meaning” (Raphael and Ma, 2011, p 251) is not uncommon and may influence the cultural appraisal of a pandemic. However, all three authors of the given historic accounts of pandemic crises have refrained from ascribing plagues any higher meaning. This intellectual position might promote the acceptance of the fact that life is more vulnerable and threatened than many thought possible before this global crisis (Žižek, 2020).
M. E. W. was supported by the Clinician Scientist Programme of the Medical Faculty of Ulm University. The funding source had no role in any aspect pertinent to this article.
The authors declare no conflict of interest.
Boccaccio G (1903) Stories of Boccaccio (The Decameron): Translated by John Payne
. London: Bibliophilist Library.
Camus A (1991) The Plague
. New York: Vintage Books.
Papagrigorakis MJ, Yapijakis C, Synodinos PN, Baziotopoulou-Valavani E (2006) DNA examination of ancient dental pulp incriminates typhoid fever as a probable cause of the plague of Athens. Int J Infect Dis
Raphael B, Ma H (2011) Mass catastrophe and disaster psychiatry
. Mol Psychiatry
Taylor BJ, Francis K (2013) Qualitative Research in the Health Sciences: Methodologies, Methods, and Processes
. Milton Park, Abingdon, Oxon, New York, NY: Routledge.
Thucydides (1972) History of the Peloponnesian War: Translated by Rex Warner
. London: Penguin Books.
Usher J (1986) Boccaccio's ars moriendi in the Decameron. Mod Lang Rev
Willsher K (2020) Albert Camus novel The Plague
leads surge of pestilence fiction. The Guardian
. March 28, 2020. Available at: https://www.theguardian.com/books/2020/mar/28/albert-camus-novel-the-plague-la-peste-pestilence-fiction-coronavirus-lockdown
. Accessed April 4, 2020.
World Health Organization (2020) Mental health and psychosocial considerations during the COVID-19
outbreak. Available at: https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_10
. Accessed April 4, 2020.
Žižek S (2020) PANDEMIC!: Covid-19 Shakes the World
. New York, London: OR Books.