Apollo's Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live

by Nicholas A. Christakis MD PhD

Given how deadly this pandemic was, it’s surprising that it’s not more salient in our collective memory outside of public health circles. Everyone learns facts about World War I, but few learn much about the pandemic, which was much deadlier. Perhaps that’s because dying of an illness at home seems less dramatic than dying in the trenches.

Public health decisions always involve difficult, utilitarian trade-offs between benefits and costs to different people.

Plots like this were first propounded by the British physician and historian Thomas McKeown in 1966 in order to illustrate this very point—that modern medicine was not the primary force that caused infectious diseases to go away.2 The actual cause, McKeown argued, was socioeconomic improvements and the implementation of public health measures. For instance, the great rise in wealth worldwide during the past two centuries has increasingly afforded humans access to the clean water and safe food that technological and scientific advances have yielded. These advances, along with improvements in family planning and education, have played a bigger role in reducing the spread of infection than vaccines or treatments. This became known as the McKeown hypothesis, and it has been thoroughly validated. To be clear, this is not to say we should not use medicines! They still prevent much loss of life—just not to the extent imagined.

With exponential growth, for a very long time, nothing seems to be happening. And then all of a sudden, a lot happens. It reminds me of Vladimir Lenin’s observation that “there are decades where nothing happens; and there are weeks where decades happen.” But it’s very hard to get people to take action while they are on the flat part of the curve.

And fear has an advantage over even the most contagious pathogens—people can contract a disease only through contact with other infected individuals, but they can contract fear through contact with either infected individuals or fearful ones.18 We respond to the fear brought on by epidemics in various ways, many of which are directed at asserting control over the threat. For example, people have a tendency to blame others for the disease, which makes them feel like they have some influence over the force that is affecting them. It is more soothing to feel that there is a human agent responsible for the problem, because this means human effort might be effective in response. It’s much more frightening to imagine that the plague originates from a vengeful, implacable god or from an uncaring and remorseless natural world.

This is one of the reasons it makes sense for public health authorities to encourage the use of masks, and it’s also why people can find mask-wearing beneficial: it gives them something concrete to do in the face of the threat, regardless of the exact benefits of masks (which are considerable). This helps restore their sense of control. Another example is the act of collective public cheering for health-care workers, seen in New York City and London, which also gives people a sense of control and social solidarity.20 This psychological benefit is important in itself, and such acts may in turn foster a willingness to engage in other more burdensome, difficult, and challenging practices. Getting fear and anxiety under control is critical.

People generally copy the visible behaviors of those around them, so there can be tipping points in both directions. As more and more people start to wear masks and obey rules of physical distancing, more people follow suit. Conversely, as more and more people ignore these practices, fewer people take them seriously. As psychologist Matthew Lieberman put it, “Our brains are built to ensure that we will come to hold the beliefs and values of those around us.”36

But the timeline of a pandemic is much more rapid than that of other public controversies about science (like climate change), meaning that the reality of the situation and the consequences of political acts that are divorced from scientific reality present themselves much more immediately for all to see.59 In location after location around the country and around the world, people seemed shocked that the virus could devastate their population and flood their hospitals with patients, even though the virus had done this exact thing in other places just a few weeks before.

A similar sort of wishful thinking emerged during the profound protests after the brutal murder of George Floyd in Minneapolis on May 25, 2020. The forty-six-year-old black man was already handcuffed and on the ground when a police officer knelt on his neck until he died. This, coming on the heels of many similar cases, led to massive protests erupting around the nation.62 In large part, these were due to pent-up anger about racial inequality, but the high levels of unemployment, the long periods people had been cooped up at home, the emotionally demanding experiences (including deaths of loved ones) that many people had suffered, and the disillusionment with the president all surely facilitated the protests.

There are many people, and not just those in positions of power, who have persuaded themselves that reality is “socially constructed”—that there is no objective reality, there is only that which we define using human faculties. This is a deeply interesting philosophical idea. But this has also led to the belief that we can change reality by manipulating words or images: if we call something by a different name, it actually is different. This is only partly true, in a narrow sense. The virus is real and it does not care how we see it or what we say about it.

Peer-review is not a guarantee of accuracy, but, like the jury system for criminal justice, it is—as some of my colleagues joke—the “worst system we have except for any other.”

The impulse to blame others for causing infections or for being infected is powerful, and the historical record brims with devastating examples.

Other hypotheses point to innate aspects of the immune system that differ with age. For example, children have more adaptive immunity (optimized for pathogens they have not previously seen), whereas adults have more memory-driven immunity (geared to pathogens they have encountered before).33 The immune cells dedicated to fighting foreign agents in children may be more efficient than those in adults, enabling them to make more effective antibodies against pathogens, including SARS-2.34 Younger immune systems may also be too immature to experience cytokine storms, the damaging immune-system overreaction that plays a major role in COVID-19 morbidity and mortality.35

This issue of controlling for other attributes that vary across groups in turn raises the issue of what statisticians call a causal model. If one adjusts for where people live, their wealth, their occupations, and their chronic health conditions, it’s true that the “effect” of race may disappear or be minimized. But what does this really mean? On the one hand, we could take this parsing of COVID-19 data to be good news because it means that there is no net effect of race—that racial difference is simply a red herring, and the real difference relates to the differential prevalence of health conditions or variation in the nature of occupations and so on. On the other hand, if in fact the way our society is structured ensures that ethnicity and race are associated with worse outcomes in these social factors, then adjusting for those factors and concluding that race has no effect is precisely the wrong thing to do. When I teach about these issues in my undergraduate classes, I observe that dismissing racial differences in health outcomes on the grounds of their being mediated by other factors is a bit like saying that, after adjusting for the quality of ingredients, the ambience, the sophistication of the menu, and the existence of a good wine list, there is no difference between a meal at McDonald’s and a meal at the fanciest restaurant in New York City.

If we really wanted to help our neighbors, we had to stay at home. Contact reduction was in fact not a selfish or even a timid thing to do. But it’s an odd thing to persuade people that sitting on their couch is an act of generosity. Yet people were more often willing to follow rules regarding physical distancing if they understood it was primarily to help others.36 After all, humans are moral actors capable of transcending their own self-interest. One study evaluated how public health messaging could be more successful. What was more effective, telling people, “Follow these steps to avoid getting coronavirus” or telling them, “Follow these steps to avoid spreading coronavirus”? It turns out that the emphasis on the public threat of coronavirus is at least as effective as, and sometimes more so than, the emphasis on the personal threat. This is in keeping with other work that shows that people are motivated to get vaccinated not only out of self-interest but also out of concern for the common good.

An increased sense of shared identity is very common among those experiencing catastrophes, and this is a powerful source of cooperative behavior and goodwill. One of the ways this happens is that a widely shared peril erodes prior divisions, bringing large numbers of people into the category of “us.” Everyone becomes part of the group confronting the problem. And the shared adversity creates what is possibly the most important division of all: those who are facing the same threat one is facing and those who are not. That activates an inborn tendency to look kindly upon members of one’s own group, and this in turn elicits a natural desire to be good to them.

Altruistic behavior is usually associated with improved subjective well-being and overall mental health for the do-gooder (as long as it does not feel unduly burdensome). Volunteering is often associated with reduced depression and anxiety.41 This connection between altruism and human psychology is especially critical in the time of COVID-19, when mental health is itself a concern, whether the harm originates from a fear of the virus or from social isolation.42 And so altruism and cooperation provide an antidote for many of the negative emotions we reviewed in chapter 4.

Overall, possibly as many as 1 percent of patients admitted to American hospitals die from a medical mistake!47 Doctors know this. When I was doing my medical internship at the University of Pennsylvania Medical Center in Philadelphia in 1989, a senior doctor advised the new interns to think carefully before admitting patients: “Hospital admission is not a benign procedure,” he cautioned. Americans often equate more with better when it comes to medicine, but much data suggest otherwise. One way to assess the potentially deadly impact of health care is to look at what happens when doctors go on strike. This is a rare event, but an analysis of five strikes by physicians around the world, occurring between 1976 and 2003 and lasting between nine days and seventeen weeks, showed that, overall, mortality either stayed the same or declined during the strike.48 Possible explanations for a decrease in mortality include a delay in elective surgeries (with their attendant risks) and a decline in medical errors and injuries. What about other times when doctors are relatively unavailable? One study examined mortality among elderly Americans who had heart attacks or heart failure and were hospitalized during the two annual national cardiology conferences (when fewer cardiologists were available to treat them) over the course of ten years. The study found that, of the tens of thousands of patients with heart failure who were admitted during meeting days (when they were cared for by docto...

Science has come to be seen by too many as serving political ends. Many people have even abandoned the fundamental idea that it is possible to have an objective appreciation of the truth. For instance, right-wing politicians have not wanted to acknowledge findings from climate-science or gun-violence research, and left-wing politicians have wished to deny the role of genetics in human behavior. Rather than engage difficult topics head-on using our best efforts at objective research, many people have found it easier to ignore inconvenient truths and suppress the scientific inquiry that might reveal them. Scientific literacy is low among the general public as well. A total of 38 percent of Americans believe that God created humans in their present form sometime in the last ten thousand years.104 Over 25 percent of Americans believe that the sun revolves around the Earth. And 61 percent cannot correctly identify that the universe began with the big bang.

If a host population is too small, the pathogen runs out of runway and auto-eradicates. Human populations need to be large enough to sustain the ongoing transmission of any particular pathogen. These observations help explain the perplexing fact that when Europeans came into contact with American Indians, the transfer of deadly germs was all one way (with the possible exception of syphilis).

Typically, with time, viruses become less lethal as a result of this preferential spread and survival of milder strains.

Still, one way a pandemic of a pathogen such as SARS-2 can come to an end is that the virus mutates over a period of years to get much milder. In fact, it’s possible that the four coronavirus species that cause the common cold are distant echoes of long-ago pandemics, now domesticated through a combination of herd immunity and genetic change.

So we will reach herd immunity, or the pathogen will evolve to be less lethal, or (after a very long time) humans will evolve to be resistant. That is the biological end of the story. But pandemics are also sociological phenomena, driven by human beliefs and actions, and there is a social end to pandemics, too, when the fear, anxiety, and socioeconomic disruptions have either declined or simply come to be accepted as an ordinary fact of life.

As Allan Brandt observed, “Many questions about the so-called end are determined not by medical or public health data but by sociopolitical processes.”57 I’ve seen this for years in the American response (or lack thereof) to mass shootings, automobile fatalities, rising suicide rates, and drug overdoses. After much anxiety and commentary, people eventually seem willing to accept an affliction that would have been intolerable at a prior point in time.

The COVID-19 pandemic awakened Americans to the importance of public health in the same way that 9/11 opened our eyes to the sophisticated threats to our national security, the great recession to the fragility of our financial system, and the election of various populist leaders around the world in the twenty-first century to the dangers of political extremism.

In Prometheus Bound, a play by Aeschylus, Prometheus is chained to a rock as punishment for giving humans the gift of fire (and thus technology). In addition, he gave us another gift: he made it impossible for us to foresee our own deaths. But since we still know that we can suffer and die (because we observe others doing so), this ignorance and uncertainty tends to make us miserable. We can use technology to predict the future, but this can also make things worse if the predictions are both accurate and dire. The chorus in the play asks Prometheus, “What cure did you discover for their misery?” And Prometheus responds, “I planted firmly in their hearts blind hopefulness.” But blind hope is a fickle companion for our woe. It is not enough. Still, by forcing our gaze to the future, hope can serve another purpose: it can motivate us to prepare.