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Abstract

America's response to coronavirus disease 2019 (COVID-19) is evolving as quickly as the pandemic itself, with attitudes and actions diverging along the way. Exploring historical examples of population-wide responses to other large-scale, traumatic events may offer useful insights. In London during the 1940s, the populace was bracing for the devastation from German bombings. In addition to physical damage, physicians were also anticipating significant psychological damage to those living through the destruction. Several hospitals planned to increase their capacities to manage the psychological effects of war (1). However, most of London's citizens did not experience the expected paralyzing effects of combat stress. Are we seeing a similar phenomenon among Americans today during the COVID-19 pandemic?
The Remote Misses of COVID-19
Ahmad Mourad, MD
America's response to coronavirus disease 2019
(COVID-19) is evolving as quickly as the pandemic
itself, with attitudes and actions diverging along the
way. Exploring historical examples of population-wide
responses to other large-scale, traumatic events may
offer useful insights. In London during the 1940s, the
populace was bracing for the devastation from German
bombings. In addition to physical damage, physicians
were also anticipating significant psychological dam-
age to those living through the destruction. Several
hospitals planned to increase their capacities to man-
age the psychological effects of war (1). However, most
of London's citizens did not experience the expected
paralyzing effects of combat stress. Are we seeing a
similar phenomenon among Americans today during
the COVID-19 pandemic?
One proposed explanation for the dissonance be-
tween expected and observed psychological effects seen
in World War II London comes from J.T. MacCurdy, a
Canadian psychiatrist, who, in his book The Structure of
Morale, divides the population into 3 groups after a trau-
matic event (1, 2):
1. Direct hits: those who suffer direct injury, lead-
ing to their death or incapacitation. This group
cannot communicate their experiences or instill
fear in the population. In MacCurdy's words,
“The morale of the community depends on the
reaction of the survivors, and corpses do not run
about spreading panic.”
2. Near misses: those who feel but are not debili-
tated by a physical effect, or those who witness
the death of others. These persons “feel the
blast, see the destruction but they survive,
deeply impressed.”
3. Remote misses: those who see or hear the trau-
matic event and witness some of the aftermath
but evade physical or emotional harm.
MacCurdy postulates that these experiences result
in emotional and behavioral changes through a mech-
anism known as “passive adaptation to danger,” in
which near misses result in more cautionary behavior.
On the other hand, remote misses result in “a feeling of
excitement with a flavor of invulnerability” because
these persons have faced their fears and survived with-
out any physical or emotional effects. He also describes
“active adaptation,” such as preparedness drills, as a
mechanism that may produce an arguably more appro-
priate response to danger. However, most of the pop-
ulation learns through passive adaptation, and if the
proportion of remote misses in this population exceeds
direct hits or near misses, as MacCurdy suggests was
the case in London during World War II, we are left with
a general population that feels invulnerable and has a
false sense of security.
Is it possible that the COVID-19 pandemic has also
led to a division of the population through passive ad-
aptation? During the past several weeks, we have seen
pressure from many to increase business reopenings
despite dramatic signals of increasing cases. More peo-
ple, particularly young adults, are seen congregating
on beaches, crowding into bars, abandoning face
masks, ignoring social distancing, and reverting to their
daily routines. A possible explanation for these behav-
iors is that young adults have been experiencing more
psychological distress and loneliness during COVID-19
(3) and are seeking social companionship. Others are
enduring significant financial stress, and returning to
work may be necessary, despite increasing their risk for
exposure to the virus in the process. However, it could
also be that the pandemic has left us with many remote
misses—persons who are hearing about the cases on
the news and perhaps have acquaintances who have
had COVID-19 but have not had it themselves and have
not lost loved ones or seen them suffer through the
illness.
In addition, the pandemic has been a stark re-
minder of our society's health care and socioeconomic
inequalities. In states that have published mortality data
stratified by race and ethnicity, non-Hispanic Black and
Hispanic patients have had up to 4 times higher risk for
death from COVID-19 than White patients (4, 5). Also,
mortality has been higher in older persons (5). As such,
could we expect minority groups and older persons to
exhibit near miss behavior because a disproportion-
ately large number of those affected are among these
groups? Recent data suggest that non-Hispanic Blacks,
Hispanics, and elderly persons are in fact more likely to
wear face masks—an example of more cautionary be-
havior (6). Thus, the sense of invulnerability may be
more pronounced among nonminority and younger
age groups because a smaller proportion of cases or
deaths have occurred among them, making it more dif-
ficult for them to relate to those affected. It has been
estimated that the average American knows 600 peo-
ple, which would mean that approximately 500 000
deaths from COVID-19 would have to occur for every
American to know someone who has died, assuming
an equal distribution of cases in the population (7). As
the pandemic rages on, our population may evolve
from one of predominantly remote misses to one of
mostly near misses. However, our population seems to
have shifted from one of “fear” to one that has “faced its
fears” and, as a result, has developed feelings of invul-
nerability and a false sense of security. In times of war,
this may be a useful mechanism; in a pandemic, it may
prove devastating.
As physicians and health care workers, we experi-
ence direct hits and near misses on a daily basis
This article was published at Annals.org on 19 August 2020.
Annals of Internal Medicine IDEAS AND OPINIONS
Annals.org Annals of Internal Medicine © 2020 American College of Physicians 1
throughout our careers. Many of us have fallen ill, cared
for loved ones, and treated patients afflicted with
COVID-19. We have personally seen and experienced
the true devastation this pandemic has caused. We
carry with us the stories of suffering and death, as well
as those of compassion and caring. These narratives
have the capacity to appeal to emotions and to edu-
cate. We must use them to illustrate to the broader
public that we still have a lot to fear from this disease.
Remote misses should never feel remote. We need to
“feel the blast” caused by anyone who becomes ill with
COVID-19, and we need to be “deeply impressed.” For,
if we do not value the losses, we are not valuing the
lives that are bound to be affected.
From Duke University School of Medicine, Durham, North
Carolina (A.M.).
Disclosures: The author has disclosed no conflicts of interest.
The form can be viewed at www.acponline.org/authors/icmje
/ConflictOfInterestForms.do?msNum=M20-4984.
Corresponding Author: Ahmad Mourad, MD, Duke University
School of Medicine, Duke Box 102359, Durham, NC 27710;
e-mail, ahmad.mourad@duke.edu.
Author contributions are available at Annals.org.
Ann Intern Med. doi:10.7326/M20-4984
References
1. MacCurdy JT. Passive adaptation to dangers. In: MacCurdy JT, ed.
The Structure of Morale. Macmillan; 1943:1-27.
2. Gladwell M. “How Jay did it, I don't know.” In: Gladwell M, ed.
David and Goliath: Underdogs, Misfits, and the Art of Battling Giants.
Little, Brown; 2013:125-164.
3. McGinty EE, Presskreischer R, Han H, et al. Psychological distress
and loneliness reported by US adults in 2018 and April 2020. JAMA.
2020;324:93-94. [PMID: 32492088] doi:10.1001/jama.2020.9740
4. Gross CP, Essien UR, Pasha S, et al. Racial and ethnic disparities in
population-level Covid-19 mortality [Letter]. J Gen Intern Med. 2020.
[PMID: 32754782] doi:10.1007/s11606-020-06081-w
5. Wortham JM, Lee JT, Althomsons S, et al. Characteristics of per-
sons who died with COVID-19—United States, February 12-May 18,
2020. MMWR Morb Mortal Wkly Rep. 2020;69:923-929. [PMID:
32673298] doi:10.15585/mmwr.mm6928e1
6. Fisher KA, Barile JP, Guerin RJ, et al. Factors associated with cloth
face covering use among adults during the COVID-19 pandemic—
United States, April and May 2020. MMWR Morb Mortal Wkly Rep.
2020;69:933-937. [PMID: 32673303] doi:10.15585/mmwr.mm6928e3
7. Gelman A. The average American knows how many people? The
New York Times. 18 February 2013. Accessed at www.nytimes.com
/2013/02/19/science/the-average-american-knows-how-many-people
.html on 8 July 2020.
IDEAS AND OPINIONS The Remote Misses of COVID-19
2Annals of Internal Medicine Annals.org
Author Contributions: Conception and design: A. Mourad.
Drafting of the article: A. Mourad.
Critical revision of the article for important intellectual con-
tent: A. Mourad.
Final approval of the article: A. Mourad.
Collection and assembly of data: A. Mourad.
Annals.org Annals of Internal Medicine
... In contrast, others who likely knew of cases in their communities or neighboring communities reflect more "remote miss" experiences. Near-miss behavioral dissonance has been discussed in the context of COVID-19 [41,42], but limited empirical evidence exists. ...
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Background The burden of the COVID-19 pandemic in terms of morbidity and mortality differentially affected populations. Between and within populations, behavior change was likewise heterogeneous. Factors influencing precautionary behavior adoption during COVID-19 have been associated with multidimensional aspects of risk perception; however, the influence of lived experiences during other recent outbreaks on behavior change during COVID-19 has been less studied. Methods To consider how the direct disease experience (“near misses”) and behavior change during the 2014–2016 Ebola virus disease (EVD) outbreak may have impacted behavior change during the early waves of the COVID-19 outbreak in West Africa, we analyzed data from a mixed-methods study that included a phone-based survey and in-depth interviews among vaccinated Liberian adults. Logistic regression via generalized estimating equations with quasi-likelihood information criterion (QIC)-based model selection was conducted to evaluate the influence of the interaction between and individual effects of the outbreak (EVD and COVID-19) and the “near-miss” experience on adoption of individual precautionary behaviors. Thematic analysis of interview transcripts explored reasons for differential behavior adoption between the two outbreaks. Results At the population level, being a “near miss” was not associated with significantly different behavior during COVID-19 versus Ebola; however, overall, people had lower odds of adopting precautionary behaviors during COVID-19 relative to during Ebola. Participants who report near miss experiences during Ebola were significantly more likely to report having a household member test positive for COVID-19 (p<0.001). Qualitatively, participants often reflected on themes around more proximal and personal experiences with Ebola than with COVID-19; they also commented on how EVD led to better preparedness at the systems level and within communities for how to behave during an outbreak, despite such awareness not necessarily translating into action during COVID-19. Conclusions The results suggest that perceived proximity and intensity to disease threats in space and time affect behavioral decisions. For successive disease threats, comparisons of the present outbreak to past outbreaks compound those effects, regardless of whether individuals were directly impacted via a “near-miss” experience. Measures, such as risk communication and community engagement efforts, that gauge and reflect comparisons with previous outbreaks should be considered in response strategies to enhance the adoption of precautionary behavior.
... More direct experience with Ebola virus disease (EVD) such as due to having a household member experience Ebola infection 33 could be considered 'near miss' or proximal experiences, while others who likely knew of cases in their communities or neighboring communities re ect more 'remote miss' experiences. Near miss behavioral dissonance has been discussed in the context of COVID-19 34,35 , but limited empirical evidence exists. ...
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Full-text available
Background The burden of the COVID-19 pandemic in terms of morbidity and mortality differentially affected populations. Between and within populations, behaviour change was likewise heterogeneous. Factors influencing precautionary behaviour adoption during COVID-19 have been associated with multi-dimensional aspects of risk perception; however, the influence of lived experiences during other recent outbreaks on behaviour change during COVID-19 has been less studied. Methods To consider how the direct disease experience (‘near misses’) and behaviour change during the 2014–2016 Ebola virus disease (EVD) outbreak may have impacted behaviour change during the early waves of the COVID-19 outbreak in West Africa, we analyzed data from a mixed-methods study that included a phone-based survey and in-depth interviews among vaccinated Liberian adults. Logistic regression via generalized estimating equations with QIC-based model selection was conducted to evaluate influence of the interaction between and individual effects of outbreak (EVD and COVID-19) and ‘near miss’ experience on adoption of individual precautionary behaviours. Thematic analysis of interview transcripts explored reasons for differential behaviour adoption between the two outbreaks. Results At the population level, being a ‘near miss’ was not associated with significantly different behavior during COVID-19 versus Ebola; however, overall, people had lower odds of adopting precautionary behaviors during COVID-19 relative to during Ebola. Qualitatively, participants often reflected on themes around more proximal and personal experiences with Ebola than with COVID-19; they also commented on how EVD led to better preparedness at the systems level and within communities for how to behave during an outbreak, despite such awareness not necessarily translating into action during COVID-19. Conclusion The results suggest that perceived proximity and intensity to disease threats in space and time affects behavioural decisions. For successive disease threats, comparisons of the present outbreak to past outbreaks compound those effects, regardless of whether individuals had directly been impacted via a ‘near miss’ experience. Measures, such as risk communication and community engagement efforts, that gauge and reflect comparisons with previous outbreaks should be considered within response strategies to enhance precautionary behaviour adoption.
... The final group, remote misses, was composed by those who witnessed the traumatic event but evaded physical or emotional harm. According to the author, the traumatic experience leads to what he calls passive adaptation to danger, characterized by being cautious in the near misses' group, whereas the remote misses exhibit feelings of invulnerability [14]. Our population represents a relatively young cohort, inherently less susceptible to infection by COVID-19. ...
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... The concept of "remote misses" and "near misses" as explained by Malcolm Gladwell, stated that there were two kinds of reactions from the Londoners to the air bombings. [1] The ones who directly witnessed the carnage brought on by the bombings, but were not killed, had "near misses;" these people were traumatized by the visible destruction. However, there were millions of people who had only heard the stories of airstrikes but never actually witnessed the bomb destruction directly; or in other words, had "remote misses." ...
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Passive adaptation to dangers
  • J T Maccurdy
MacCurdy JT. Passive adaptation to dangers. In: MacCurdy JT, ed. The Structure of Morale. Macmillan; 1943:1-27.
David and Goliath: Underdogs, Misfits, and the Art of Battling Giants
  • M Gladwell
Gladwell M. "How Jay did it, I don't know." In: Gladwell M, ed. David and Goliath: Underdogs, Misfits, and the Art of Battling Giants. Little, Brown; 2013:125-164.
The average American knows how many people? The New York Times
  • A Gelman
Gelman A. The average American knows how many people? The New York Times. 18 February 2013. Accessed at www.nytimes.com /2013/02/19/science/the-average-american-knows-how-many-people .html on 8 July 2020.