Author and physician Anthony Kessel on uncertainty and coping in the time of Covid

As a teenager in the 1980s I read the full set of John Wyndham books. Although I can’t now remember all the details, I can still powerfully recall a recurrent theme. Wyndham liked to explore what happens to human beings – and to the human race – when presented with something out of the normal, something literally extra-ordinary. It was blindness and giant carnivorous plants in The Day of the Triffids; a dormant sea monster that stirs in The Kraken Wakes; and in the village of The Midwich Cuckoos alien-infected children’s minds exert telepathic control over the world. Wyndham was interested in how people reacted to new circumstances and a new threat: how they behaved, how they coped, and what their response tells us about the nature of the human experience.

In his novels How to Stop Time and The Humans a contemporary author, Matt Haig, also uses unusual happenings to examine, quite wonderfully, the meaning of our existence and what makes human beings tick. I read the latter during the opening weeks of the coronavirus pandemic. All around me the kind of scenario was unravelling – though in real life – that Wyndham or Haig might have picked for their fictional work. A nasty virus was spreading across the globe, leaving a trail of death and suffering; countries were combatting the invisible foe through large-scale steps around quarantine, restriction of movements, closure of parts of society, and other aspects of human health protection.

The happenings of spring 2020 were not, however, such a novelty for me, as tackling infectious diseases has been part of my professional life for over 20 years. I spent the decade before Covid-19 as global public health director at Public Health England and national director of public-health strategy at PHE’s predecessor, the Health Protection Agency. I visited countries across the world – rich and poor – advising on public health systems and threats to global health security, including supporting the response to Ebola in Sierra Leone. At home, I was part of the national leadership team tackling the swine flu pandemic, and have dealt with local outbreaks ranging from TB and meningitis to head lice.

The Covid-19 pandemic, however, did feel different from the outset and, as time has marched on, those differences have been amplified. As we now well know, the pandemic is truly global – unlike, say, the more restricted SARS and Ebola epidemics – and the impact has been devastating. At the time of writing, with the winter months in the northern hemisphere setting in, there have been around 1 million deaths worldwide. Alongside widespread mortality, the longer-term morbidities associated with Covid are similarly distressing, and all these adverse health impacts have been inequitably experienced by population groups both within countries (for instance, in the UK, the old, the poor, the overweight, and those from Black, Asian and other minority ethnic backgrounds have worse Covid-related health outcomes) and between countries. Richer countries in the north with better health systems fare better than poorer countries in the south.

"What we are witnessing is not so much an uncertainty pandemic, rather … a pandemic in our awareness of uncertainty"

Amidst all the chaos, though, one dimension of the pandemic – not considered core in most outbreak management textbooks – is gaining rising attention in the media and academically, and that is the impact on mental health. Direct consequences, for instance, of surviving a severe, hospitalised Covid episode include the post-traumatic stress of witnessing nearby ward deaths, survivor guilt, and the mental exhaustion as part of ‘long Covid’ – or renamed ‘long (haul) Covid’ in Paul Garner’s excellent personal blog in the British Medical Journal. The indirect mental health consequences of Covid are equally insidious, wide-ranging and impactful. Isolation, loneliness and loss of income all contribute significantly to rising levels of depression. Addictive behaviours – such as alcohol or substance misuse and gambling – have worsened, as has the incidence of domestic violence. Damaged education and work experiences contribute to loss of direction and purpose in children and younger adults.

One particular indirect mental health impact, however, has slipped somewhat under the epidemiological radar despite its prevalence – and that is the fear and anxiety associated with the uncertainty that the pandemic appears to have generated, across the demographic board. Uncertainty over one’s health and whether you will get the virus or not; uncertainty over the severity of any illness; uncertainty over the wellbeing of loved ones, and when you will next be able to hold them; uncertainty over the nature of social interactions; uncertainty about employment, income and educational experiences; scientific uncertainty – as I encounter in my current role as a clinical director at NHS HQ – over whether a vaccine or an effective treatment can be found; uncertainty around the impacts of the economic carnage; uncertainty for authors over the fate of pieces of work, published or unpublished; uncertainty over loss of creative spark; uncertainty around hopes and dreams held in the balance; uncertainty over what the future holds for each and every one of us. 

What John Wyndham would have witnessed – had he still been alive – is that human beings tend to cope poorly with uncertainty. Not all human beings and not always, but in the main. That said, people cope rather better with eventualities: when the bad stuff happens, which it inevitably does as such is the nature of life, people manage fairly well. Not all people and not always, but humans adapt to bereavement, job loss, relationship breakdown, a cancer diagnosis and the like because they have to. It doesn’t mean it’s easy but there is a remarkable innate capacity to cope in our psyche. But uncertainty is a different beast, creating stress and anxiety that people can find intolerable.

Yet there is more to uncertainty than meets the eye. The difficulty that many people experience in coping with uncertainty is premised on a widely held misappreciation of the relationship between thought and feeling. While it appears that we live in a direct experience of the outside world, instead we live in a thought-generated experience of the world. In other words, it’s not the unpleasant boss or the rainy weather that’s making us feel bad: it’s how we think about our boss or the rain that leads to our feelings about them. After all, a rain-shower isn’t always depressing, sometimes it can be beautiful. It is physically impossible for any external happening (including a pandemic) to put a feeling inside somebody, even though it often appears that our experiences of life are generated that way. As articulated eloquently in Michael Neill’s best-selling book, The Inside-Out Revolution, our feelings are generated from the inside, all of the time. We, quite literally, live in the experience of our own thinking.

"We, quite literally, live in the experience of our own thinking"

Many of us seek to counter the discomfort of uncertainty through efforts to control our external circumstances. After all, if our external circumstances are responsible for our feelings (which they are not), optimising and maintaining those circumstances should make us feel good: hence the laborious attention given to financial security, job security, relationship security and risk aversion. Life is, however, by its very nature, insecure, and nobody has the ability to command and govern what happens around them. Rather than making strenuous efforts to exert control, a true understanding of the insecurity of the human condition would be more helpful.

And this is precisely what the widespread uncertainty of the pandemic points to. During these most testing of times we have been more exposed to the presence of uncertainty – and made similarly more conscious of our limited ability to influence that uncertainty. Yet, without an appreciation of the underlying nature of uncertainty, rising levels of stress and anxiety easily ensue. What we are witnessing is not so much an uncertainty pandemic, rather – as the psychologist Oliver Burkeman wisely alluded to in his recent final personal column in The Guardian – a pandemic in our awareness of uncertainty.

There is some encouragement, though. A relatively new mental health initiative – sometimes referred to as the Three Principles – seeks to raise understanding of the thought-feeling connection. Informed by this approach, the charity iheart (www.iheartprinciples.com) is now spearheading provision of vital school-based programmes – in the UK and worldwide – aimed at improving psychological health and resilience in children and young adults, with very promising results to date.

It is over fifty years since John Wyndham died. While impossible to know what exactly he would have made of the current extra-ordinary circumstances that have beset humankind, I imagine he would have been struck by the immense spirit and remarkable fortitude exhibited by so many. I also sense that he would have been, at minimum, intrigued by what the (awareness of) uncertainty pandemic tells us about the nature of people’s psychological experience of life, and the possible ways in which that experience could be improved.

Originally published in the Winter 2020 issue of The Author

Anthony Kessel is a public health physician, academic and writer. He is a trustee on the board of BookTrust. The Five Clues, the first in his Don’t Doubt the Rainbow detective series for children, will be published by Crown House in July 2021. https://medium.com/@AKessel

Art © Antonio Rodriguez