What will be the psychological legacy of quarantine? History may have answers

Through the centuries around the world, enforced isolation has taken many forms. Here's what we can learn – and what a leading psychiatrist believes will be this one's lasting effects.

Published 16 Apr 2020, 15:41 BST, Updated 5 Nov 2020, 05:13 GMT
The village of Eyam in Derbyshire, often referred to as the 'plague village' – where, in ...

The village of Eyam in Derbyshire, often referred to as the 'plague village' – where, in 1665, the entire population voluntarily quarantined itself to contain a spread of bubonic plague. An estimated 250 of its citizens perished. 

Photograph by Neil McAllister / Alamy

In February 1972, Ibrahim Hoti returned to his home town in Kosovo, feeling tired, with aches and pains after a long journey from Iraq. He developed a rash and a fever, but recovered quickly. What he didn't know, however, was that he had contracted a highly contagious form of smallpox while abroad.

Starting with those he’d been in contact with, cases of the disease quickly spread. Eventually a total of 35 people would die. Within a month the government had declared martial law across all of Yugoslavia, closing the borders, confining people to their homes, erecting roadblocks, quarantining 10,000 potentially infected people under strict army guard, and vaccinating almost the entire population. 

Ibrahim Hoti (centre) stands with two doctors during the smallpox epidemic in Kosovo, 1972.

Photograph by CDC / Dr. William Foege / Alamy

If suddenly our coronavirus social distancing seems lenient, go back a little further in history and cases of quarantine can be frighteningly punitive. Take the people of the Derbyshire village of Eyam, for example. Back in September 1665 villagers became infected with the bubonic plague after a local tailor received a delivery of a flea-infested cloth from London, where the disease had already taken hold.

Despite the high risk of death, villagers agreed to quarantine themselves from the outside world, erecting a cordon of stones around the village which no one breached. They knew that thousands in nearby towns and cities would die if they failed to isolate themselves. Neighbouring villagers, meanwhile, regularly deposited food for them on the stone boundary.

The tragedy of Eyam is today memorialised in the so-called "Riley Graves", where Elizabeth Hancock – despite not becoming ill herself – buried her husband and six children in the space of 8 days.

Photograph by William Robinson / Alamy

For 14 months the selfless people of Eyam lived – and died – inside their ring of stones. The bodies piled up as they stoically accepted their lot. No one knows exactly how many perished (250 is a figure often quoted), but by the end of their lockdown, the village population had been decimated.

Coronavirus is not the plague. But isolation – even the relatively lenient form we now find ourselves in – is sure to have psychological effects. Professor Neil Greenberg is an occupational and forensic psychiatrist based at King’s College London. Right now he is providing mental health support for healthcare staff working at NHS Nightingale Hospital London. In February this year he co-authored a report – published in The Lancet– that addressed the psychological impact of quarantine.

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The Mompasson memorial window in Eyam's parish church, depicting a citizen of Eyam succumbing to the plague.

Photograph by Charles Walker Collection / Alamy

He and his colleagues researched 24 cases of medical quarantine in ten countries over the last two decades. Diseases included SARS, Ebola, H1N1 influenza, MERS and equine influenza. In the paper (entitled The psychological impact of quarantine and how to reduce it), the authors highlight negative effects such as “emotional disturbance, depression, stress, low mood, irritability, insomnia, post-traumatic stress symptoms, anger and emotional exhaustion”.

Effects were particularly severe for healthcare workers who had been quarantined. Long-term effects included “alcohol abuse or dependency” and “not reporting to work”. For those quarantined due to SARS, a long-term fear of crowds and public spaces was common.

But Greenberg stresses that the cases he studied were small quarantine groups – ranging from a dozen college students in Taiwan suspected of SARS, for example, to some 6000 South Koreans suffering from MERS – rather than entire national populations. Right now, of course, the whole of the UK is in national lockdown, with everyone subject to the same restrictions. 

“Everyone is in it together,” says Greenberg, an academic psychiatrist who has worked with the British armed forces and has helped repatriate kidnapped UK nationals. “Even if there’s an extension to our quarantine, as long as everyone gets extended, I don't think that will be particularly difficult for us. It would be unpleasant and frustrating, but it's important to distinguish between that and being mentally ill. They are two very different things.”

In his paper, Greenberg pinpoints stress factors that make quarantines more psychologically damaging. Reduced social contact, for example, resulted in boredom and frustration; inadequate food or medical supplies caused anxiety and anger, as did a lack of information from the authorities; fears of infection were obviously high, particularly among pregnant women and parents with young children; and those who were quarantined for more than ten days “showed significantly higher post-traumatic stress symptoms”. Once quarantines had been lifted, the inevitable financial loss “created serious socio-economic distress”.

A teacher checks the body temperature of students in a primary school in Seoul, South Korea, June 2015. Over 2,000 schools in South Korea were closed due to the outbreak of Middle East Respiratory Syndrome (MERS). 

Photograph by Yao Qilin/Xinhua/Alamy Live News

It's financial hardship that Greenberg sees as most damaging in our current coronavirus lockdown. However generous the economic support from the government, there will always be some who fall through the cracks, he says. And even the better off will be subject to lifestyle changes. “That impact is likely to be the most difficult in the long term,” he adds. “We know that after the financial downturn [2007 to 2008], this had an impact on people’s mental health.”

Greenberg says there will be varying psychological effects, depending on whether peopled are boxed up in inner-city apartment blocks, or living in the countryside with the extra space that has to offer. “We know, generally, that being out in the countryside is good for your mental health. It will be more challenging if you’re in a small flat, trapped with lots of members of your family.”

Relationships will inevitably become strained. Already, since the UK has been locked down, phone calls to the country’s largest domestic abuse charity, Refuge, have increased by 25 per cent.    

When it comes to COVID-19, “everyone is in it together.” Lockdown amongst tower block residents in Erfurt, Germany, March 2020.

Photograph by Craig Stennett / Alamy

Greenberg says his research proves quarantine increases divorces and relationship breakdowns. He regrets that during our lockdown, some relationships are bound to fall apart. “But other relationships will of course come together because you get to spend more time with your family,” he adds optimistically. “There are going to be winners and losers.”

In every time of hardship, there are those who have a good war and those who have a bad war. This idea of mixed fortunes is borne out by many documented cases of quarantine – both voluntary and involuntary.

Terry Waite famously spent four years incarcerated in solitary confinement by Islamist terrorists in Lebanon. “It can be bad, but it need not be a disaster,” he told the Sunday Times. “You may become rather introverted, but remember we are all a mixture of light and dark: we’re human. It may feel empty but take solitude in the right spirits and it can be a formative experience.”

Helen Sharman was the first British person to go into space, spending seven days with a handful of other astronauts on the Mir space station in 1991. Now in lockdown on Planet Earth like the rest of us, she says her experience gives her an insight into the psychology of quarantine.

“Long-term effects included ‘alcohol abuse or dependency’ and ‘not reporting to work’. For those quarantined due to SARS, a long-term fear of crowds and public spaces was common.”

“I still take pleasure in the small things – deciding my morning run and what path I take. I remember that lesson from space: letting go of what you can’t control and focusing on what you can. We have all been told to stay at home – but we can still decide how we use our time.” Speaking in 1843 magazine, she warns how living in quarantine with other people demands extra tolerance. “Now is a time to work on the relationships with the people you’re in close proximity to.”

There are even benefits to the crashing boredom imposed by the coronavirus lockdown. Dr Sandi Mann is a psychology lecturer at the University of Central Lancashire and author of The Science of Boredom: Why Boredom is Good

“This period in time could represent the biggest surge in creativity in the history of humankind,” she told National Geographic. “We’re already seeing the benefits of this creativity in so many ways: with parents home-schooling; with people in the workplace coming up with creative solutions to online working.”

Mann explains how boredom arises when our mental search for neural stimulation is not satisfied. “So when we’re in lockdown, if we let our minds wander, they will create things. Daydreaming is the real key to creativity because it allows us to think outside the box and come up with creative solutions.”

Different character types endure quarantine in different ways. And each nation imposes isolation on its citizens with varying levels of stringency. But is there perhaps something in the British psyche that prepares us better for a lengthy lockdown? 

Although Greenberg’s research didn't distinguish between nationalities, he agrees that the British sense of fair play may help us all psychologically. 

“We could speculatively say that the Blitz spirit is something that happens in the UK. We have a great sense of fairness, so as long as we are all in it together, we’ll be okay. But if certain groups were singled out for particular measures, we could have great trouble.” 

Children's drawings in a window in Southborough, Kent, April 2020. Around the country during the government-imposed COVID-19 quarantine, many windows are filled with such images, often with hopeful sentiments or thankful messages for front-line health workers. 

Photograph by James Brunker News / Alamy

That’s a salient point. The oft-cited idea of the Blitz spirit could quickly melt away if certain regions of the UK were released from lockdown earlier than others, or if older or medically vulnerable people are forced to self-isolate for longer.

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Overall, though, Greenberg is optimistic about the long-term mental health of the average Briton. “The most likely outcome is that the majority of the population will be resilient,” he says.

He concedes some of us will be “psychologically injured” by the virus and the lockdown, especially front line health workers. “But the majority will not,” he concludes. “And some people will even go grow positively as a result of this. They will say: ‘If I can deal with that situation, then I can deal with whatever’s coming next.’”

Follow Dominic Bliss on Twitter.

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