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Psychoanalysis must join campaign against mass non-adherence to medical advice

The denial evidenced by a mass failure to adhere to medical advice on COVID-19 is unique in modern history, notes an item in The Lancet. The time is ripe for psychoanalysis to discard “decades of insularity” and co-operate with experimental psychologists and epidemiologists.

Humanity’s toolkit of strategies to deal with SARS-CoV-2 is too narrow, they note, and propose that psychoanalysts, and insights into psychological denial, should be deployed against mass non-adherence to medical advice. Earlier, The Lancet’s editor-in-chief Richard Horton argued that COVID-19 is a syndemic of biological and social interactions – “the pursuit of a purely biomedical solution to COVID-19 will fail”.

Psychoanalysis in combatting mass non-adherence to medical advice

The failure of the United States to contain COVID-19 has been spectacular from every angle. Looked at as a case of mass non-adherence to medical advice, however, it’s unique in modern history, write Dr Austin Ratner and Dr Nisarg Gandhi in a letter published on 28 November 2020 in The Lancet.

This is the letter in Volume 396:

Never before have so many citizens had so much access to information and simultaneously protested public health recommendations with such full-throated denial of the medical facts.

The media has covered psychological denial as a cause of non-adherence to public health recommendations for COVID-19, climate change and other risks, but public health officials have not, to date, employed the concept in a systematic way, if at all.

We propose it is time that public health officials add the study and treatment of psychological denial to their toolkit for combatting medical non-adherence.

To do that, we suggest a new partnership between the fields of experimental psychology, public health and psychoanalysis – the field that first postulated defence mechanisms like denial, and still the only field that attempts to treat them.

While psychoanalysts have historically resisted collaborations with experimental psychologists and epidemiologists, the time is ripe for change.

After decades of insularity, the American Psychoanalytic Association has begun opening its doors and empowered constituents who have long sought more integration with experimental science and more involvement in public health.

This is critically valuable at a time when psychological denial has thrust itself into the spotlight on multiple fronts as a genuine public health crisis.

Many cognitive scientists have documented denial and related phenomena, like anxiety’s power to compromise rational thought, but they generally have not considered their findings vis-à-vis the psychoanalytic model of defence mechanisms, which might have helped explain the findings and suggested remedies.

Insular-minded psychoanalysts of the past helped bring about this disconnect, but it would be a mistake to assume because of it that psychoanalysts have no help to offer. Denial surrounds us at present; to ignore psychoanalytic wisdom under the circumstances could justly be construed as another instance of denial.

How might psychoanalysts help to treat mass denial and mass non- adherence?

Both epidemiologists and psychoanalysts solve problems by raising awareness; epidemiologists raise awareness of public health dangers, while psychoanalysts raise people’s awareness of their own psychological defences, which work to push danger and anxiety out of consciousness, precisely because they are hard to contemplate.

Although psychoanalysts cannot treat every case of denial individually, they can educate healthcare workers and government leaders about denial, and work with them on effective messaging that helps dispel and delimit this serpentine psychological force.

In the best of times, medical non-adherence costs untold numbers of lives and hundreds of billions of dollars annually.

Commentators on non-adherence call for better communication. Since communication around unconscious defences is what psychoanalysts do, it makes sense to add them to the care team. We believe they are ready to join.

Offline: COVID-19 is not a pandemic

As the world approaches one million deaths from COVID-19, we must confront the fact that we are taking a far too narrow approach to managing this outbreak of a new coronavirus, wrote The Lancet editor-in-chief Richard Horton in late September.

This is Horton’s comment:

We have viewed the cause of this crisis as an infectious disease. All of our interventions have focused on cutting lines of viral transmission, thereby controlling the spread of the pathogen.

The ‘science’ that has guided governments has been driven mostly by epidemic modellers and infectious disease specialists, who understandably frame the present health emergency in centuries-old terms of plague.

But what we have learned so far tells us that the story of COVID-19 is not so simple.

Two categories of disease are interacting within specific populations – infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and an array of non-communicable diseases (NCDs).

These conditions are clustering within social groups according to patterns of inequality deeply embedded in our societies. The aggregation of these diseases on a background of social and economic disparity exacerbates the adverse effects of each separate disease.

COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities.

The notion of a syndemic was first conceived by Merrill Singer, an American medical anthropologist, in the 1990s. Writing in The Lancet in 2017, together with Emily Mendenhall and colleagues, Singer argued that a syndemic approach reveals biological and social interactions that are important for prognosis, treatment and health policy.

Limiting the harm caused by SARS-CoV-2 will demand far greater attention to NCDs and socio-economic inequality than has hitherto been admitted.

A syndemic is not merely a comorbidity. Syndemics are characterised by biological and social interactions between conditions and states, interactions that increase a person's susceptibility to harm or worsen their health outcomes.

In the case of COVID-19, attacking NCDs will be a prerequisite for successful containment. As our recently published NCD Countdown 2030 showed, although premature mortality from NCDs is falling, the pace of change is too slow.

The total number of people living with chronic diseases is growing. Addressing COVID-19 means addressing hypertension, obesity, diabetes, cardiovascular and chronic respiratory diseases, and cancer. Paying greater attention to NCDs is not an agenda only for richer nations. NCDs are a neglected cause of ill-health in poorer countries too.

In their Lancet Commission, published last week, Gene Bukhman and Ana Mocumbi described an entity they called NCDI Poverty, adding injuries to a range of NCDs – conditions such as snake bites, epilepsy, renal disease and sickle cell disease.

For the poorest billion people in the world today, NCDIs make up over a third of their burden of disease. The Commission described how the availability of affordable, cost-effective interventions over the next decade could avert almost five million deaths among the world's poorest people. And that is without considering the reduced risks of dying from COVID-19.

The most important consequence of seeing COVID-19 as a syndemic is to underline its social origins. The vulnerability of older citizens; Black, Asian and minority ethnic communities; and key workers who are commonly poorly paid with fewer welfare protections points to a truth so far barely acknowledged – namely, that no matter how effective a treatment or protective a vaccine, the pursuit of a purely biomedical solution to COVID-19 will fail.

Unless governments devise policies and programmes to reverse profound disparities, our societies will never be truly COVID-19 secure.

As Singer and colleagues wrote in 2017: “A syndemic approach provides a very different orientation to clinical medicine and public health by showing how an integrated approach to understanding and treating diseases can be far more successful than simply controlling epidemic disease or treating individual patients.”

I would add one further advantage. Our societies need hope. The economic crisis that is advancing towards us will not be solved by a drug or a vaccine. Nothing less than national revival is needed.

Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food, and environment. Viewing COVID-19 only as a pandemic excludes such a broader but necessary prospectus.

Syndemic responses to COVID-19 should include an ecological dimension

In a letter also published in The Lancet on 28 November, Chris Kenyon writes:

Richard Horton argued persuasively that COVID-19 should be addressed as a syndemic of biological and social interactions.

When planning the ‘national revival’ he calls for, I consider it crucial that this syndemic approach includes an ecological dimension. Studies have found that widespread anthropogenic ecosystem degradation has played a crucial role in explaining why the rate of emergence of zoonoses has been increasing over the past 40 years.

For example, deforestation, intensified agriculture and livestock production, and climate change have been linked to the emergence of Ebola virus, HIV, Nipah virus, severe acute respiratory syndrome coronavirus 2, and Zika virus.

Unless reversed, the anthropogenic destruction of habitats will probably lead to the continued emergence of new zoonoses from the estimated 700 000 other unidentified viruses with zoonotic potential.

As argued in the recent Living Planet Report, COVID-19 is “nature sending us a message”: we need to cut human consumption to within the planet's “safe operating space”.

For the vital reasons Horton outlines, this needs to be done in a way which promotes, rather than exacerbates, national and international socio-economic equity. National revival plans could play an important role in this process but should be subordinate to international plans that are based on determinations of both global equity and ecological constraints.


[link url=""]Psychoanalysis in combatting mass non-adherence to medical advice[/link]


[link url=""]Offline: COVID-19 is not a pandemic[/link]


[link url=""]Syndemic responses to COVID-19 should include an ecological dimension[/link]


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