Stoicism in the Times of SARS-CoV-2: Laboratory Leadership Lessons from the Antonine Plague

With the spread of the SARS-CoV-2 virus across the world, human society is facing an exceedingly high level of uncertainty in our daily lives. In a public health crisis, healthcare leaders (especially laboratory leaders) hold an elevated position in the public discourse. We must possess the right mental fortitude, an up-to-date knowledge base, as well as the ability to provide a reasonable assessment of a rapidly changing situation. Alas, for most of us, a raging pandemic was never a part of our medical training or our clinical practice. So, how can we lead our teams through this fog?

A reasonable way would be to study the pandemics in our history books. Historical accounts give us a glimpse into the minds and actions of successful leaders of ancient times. The Antonine Plague (or the Plague of Galen) is one such pandemic. As it ravaged the Roman empire and its economy, this scourge caused an estimated 5 million deaths over 15 years (165 AD–180 AD). During this tumultuous period, guided by his Stoic principles, Emperor Marcus Aurelius (121 AD–180 AD) kept the Roman Empire together. As medical laboratory professionals, we can be inspired by studying the adversity of the Antonine Plague, Marcus’s response to it, and the Stoic principles that guided him.

 

Antonine Plague–A Roman scourge

The story of the Antonine Plague is set in the second half of the second century AD, a period of paramountcy for the Roman Empire, which had claimed suzerainty over much of the western and near-eastern world. Around 165 AD, Roman armies conquered Seleucia (a city in present-day Iraq), a town founded by the successors of Alexander the Great. According to Roman accounts, Seleucia had a famous temple dedicated to Apollo, and within its chambers was a chest that had been cursed by the Chaldeans.¹ In search of treasure, Roman soldiers broke the chest—an action that seemingly cursed the unwelcome visitors with Apollo’s wrath, the Greek deity of, among other things, healing and plagues.¹

Soon a mysterious disease appeared among the victorious soldiers at Seleucia. As the legions marched back to Rome, the mysterious illness continued to spread among the soldiers and into the Roman hinterland. From Rome, the affliction spread among the soldiers being dispatched to the distant military outposts. As the disease spread within villages and households, people were afraid to approach the sick and the dying.¹ Within a year, with the help of marching legions and sailing merchant ships, the disease had spread across Europe. Slowly but steadily, trade and transportation were disrupted, large cities were depopulated, and the Roman economy came to a standstill.² Based on the records provided by the physician Galen, symptoms included fever, diarrhea, and dry pustular skin eruptions, indicating smallpox as the possible pathogen.^2,3

COVID-19–our own scourge

Two thousand years later, in late December 2019, an outbreak of pneumonia of unknown cause was detected in Wuhan, China.⁴ Epidemiological studies identified a cluster of cases that were traced back to the Huanan Seafood Market, and etiological studies identified a novel coronavirus (initially called 2019-nCoV) that was closely related to severe acute respiratory syndrome outbreak in 2003.⁵ Subsequently, the novel coronavirus was renamed as SARS-CoV-2.⁶ In the United States, the first known case of COVID-19 (the disease caused by SARS-CoV-2) was confirmed on January 20, 2020, in an individual who had recently traveled to Wuhan, China.⁷ By early April, SARS-CoV-2 had been detected in over 200 countries and all U.S. states and territories.⁸ By early July, over 100,000 Americans had succumbed to it and more than 200,000 are projected to die by fall of 2020.⁹ Beyond the cost in human lives, millions of Americans have lost their livelihood¹⁰, raising the prospect of a prolonged economic downturn.¹¹

The shared pathology of the two pandemics

Although separated by two millennia, there are eerie similarities between the Antonine Plague and COVID-19; both pandemics are believed to have started from a metropolis (Seleucia and Wuhan). On both occasions, the initial outbreak was limited to people who had frequented a crowded place (Apollo’s Temple and Wuhan Seafood Market). For both, conflicting origin stories abound—was the Antonine Plague divine wrath? Is SARS-CoV-2 a naturally occurring virus? Infected humans spread both pandemics—either riding on horseback or flying on commercial airlines. As sickness spread, people were afraid to travel and trade.

At its height, the Antonine Plague claimed over 1,000 Roman lives each day.^2,3 A similar daily toll befell New York; she lost 560 of her residents on April 7, 2020.¹² While the Antonine Plague took its toll on the Roman aristocracy, including her senators and emperors; COVID-19 has afflicted the Crown Prince of the United Kingdom, the prime ministers of the United Kingdom and Canada, the Chancellor of Germany, and several officials.¹³

Marcus’s Response–an example for leaders

So, how did Rome’s emperor respond to the devastation of the Antonine Plague? During a reign marked by wars and a plague that bears his name, Emperor Marcus Aurelius Antonius Augustus continued to perform his imperial duties; organizing his diminishing army, providing solace to an out-of-work population, and controlling expenses. He made sure that Roman borders remained secure, and her society continued to function, albeit at a reduced scale. For his love of Rome and his sense of duty to her, Marcus came to be known as the last of the Five Good Emperors.¹⁴ Why was Marcus different from other members of Roman elite—most of whom decamped from the illnesses that plagued Roman cities? The answer lies in Marcus’s training in the Classics. Born in the Roman aristocracy, Marcus Aurelius was deeply influenced by Stoicism, a Greek philosophy of personal ethics informed by a system of logic and views on the natural world. The cardinal virtues of Stoicism are wisdom, temperance, justice, and courage.

According to Stoics, the path to happiness for humans is found in accepting those things that we cannot change and working to improve things we can influence. As a philosopher-king, Marcus kept a journal where he recorded his struggles and self-reflection. His writings give us an insight to the mind and thoughts of someone who held the highest of political power and yet was grounded by Stoic philosophy. Over two millennia, this journal has been published as ‘Meditations’ and translated into many languages. Let us explore some of his ideas here.

Help others counter the unknow and the unfamiliar

The Stoics observed that the tranquility of the human mind is disturbed whenever the mind encounters anything unforeseen or unfamiliar. Right now, clinicians (and the lay media) have raised questions about the ‘reliability’ of the COVID-19 laboratory results. As laboratory directors, we are aware that the majority of the clinically discordant results may be attributable to factors (such as collection procedure and the variation in viral shedding) that are outside the laboratory’s control. We should understand that it might be a natural reaction for our peers to dismiss an unexplainable result as a ‘lab error.’ To help clinicians understand SARS-CoV-2 testing, laboratory directors need to help everyone understand the basics of laboratory methods, the reasons behind false negatives and false positive test results, and the big impact that prevalence makes on the predictive values of a test. Thus, we need to evolve as a proactive and understanding partner.

Change is the norm not the exception–this too shall pass

Marcus observed that everything in our world is cyclical and recurring editions of an archetypal storyline, with the same set of characters (albeit different names each time) going through similar motions. He urges us to realize that everything visible to us will soon be altered or destroyed. Our society has experienced several downturns in living memory, including the 1918 flu pandemic, the Great Depression, two World Wars, and the 2008 Great Recession. After each downturn, our society has bounced back. While we long for the ‘things as they were,’ we should realize that humans are great at adapting to the ‘new normal.’ Even after the 2020 “Great Lockdown,” the 3% drop in global economic output may be followed by a 5.8% growth in 2021.¹⁵ Like any other sector in our economy, the healthcare sector will have irreversible changes in 2020. As laboratory directors, we should endorse the coming innovations since they will reshape the American healthcare enterprise.

Heroes are mortals too

Often hailed as corona-warriors working in the laboratory, we need to remind ourselves that thousands of healthcare workers are afflicted with COVID-19 and many have died from it.¹⁶ But, what can we do to ensure the well-being of the ones that we love? Seneca once remarked, “Let us postpone nothing. Let us balance life’s books each day. … The one who puts the finishing touches on their life each day is never short of time.”¹⁷ Across America, making sure that one’s loved ones will be taken care of is on the top of healthcare workers’ minds.¹⁸ As healthcare leaders, we should be sensitive to the risks posed by SARS-CoV-2 to our life and the life of our peers.

Focus is important

In a world that has ‘gone viral’ with social media and is connected via instant texts and emails, unfiltered information and external priorities can easily derail the focus of a laboratory director. We find ourselves trying to keep pace with the ever-expanding list of COVID-19 tests and are expected to react to requests that may not be rooted in the scientific method. A pandemic can be a very stressful time, especially for those in leadership positions. In his journals, Marcus rues the fact that the human mind is easily distracted, and that it is easy to waste our valuable time and mental peace. When facing adversity, Marcus urges us to keep a check on our emotions and reactions as they can easily lead to undirected actions and unintended consequences.

In conclusion

What did Marcus do differently that most of his contemporaries did not? The answer may be surprising: He merely continued to do his job and remained visible. In 2020, all we need to do is to be visible to our clinicians and align our actions to the Hippocratic oath, the most ancient of all job descriptions. Eventually, SARS-CoV-2 will subside. Till then, we are all to be Marcus—Stoics carrying on their duties, accepting those things that we cannot change and working to improve things that we can.

References

1. Robertson DJ. Stoicism in the Time of Plague. Medium. Available at: https://medium.com/stoicism-philosophy-as-a-way-of-life/stoicism-in-the-time-of-plague-652759c274b2. Accessed March 12, 2020.
2. Greenberg J. Plagued by doubt: Reconsidering the impact of a mortality crisis in the 2nd century A.D. J Rom Archaeol. 2003;16:413-425. doi:10.1017/S1047759400013222
3. Murphy V. Past pandemics that ravaged Europe. BBC News. Available at: http://news.bbc.co.uk/2/hi/health/4381924.stm. Accessed November 7, 2005.
4. WHO. Events as they happen. World Health Organization. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen. Accessed April 28, 2020.
5. Zhu N, Zhang D, Wang W, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020;382(8):727-733. doi:10.1056/NEJMoa2001017
6. Gorbalenya AE, Baker SC, Baric RS, et al. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol. 2020;5(4):536-544. doi:10.1038/s41564-020-0695-z
7. Holshue ML, DeBolt C, Lindquist S, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020;382(10):929-936. doi:10.1056/NEJMoa2001191
8. CDC. Cases in the U.S. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html#2019coronavirus-summary. Accessed April 4, 2020.
9. IHME. COVID-19 Projections. Institute for Health Metrics and Evaluation. Available at: https://covid19.healthdata.org/united-states-of-america. Accessed April 30, 2020.
10. Cox J. Weekly jobless claims hit 5.245 million, raising monthly loss to 22 million due to coronavirus. CNBC. Available at: https://www.cnbc.com/2020/04/16/us-weekly-jobless-claims.html. Published 2020. Accessed April 16, 2020.
11. Jackson JK, Schwarzenberg AB, Weiss MA, Nelson RM. Global Economic Effects of COVID-19. Washington; 2020. Available at: https://fas.org/sgp/crs/row/R46270.pdf.
12. Health N. COVID-19: Data. New York City Health. Available at: https://www1.nyc.gov/site/doh/covid/covid-19-data.page.
13. Palder D, Mackinnon A. Coronavirus in the Corridors of Power. Foreign Policy. Available at: https://foreignpolicy.com/2020/03/18/coronavirus-corridors-power-which-world-leaders-have-covid-19/. Published 2020. Accessed May 6, 2020.
14. Machiavelli N, Thomson NH. Discourses on Livy. Courier Corporation; 2012. https://books.google.com.pk/books?id=a3hylAentHAC.
15. IMF. World Economic Outlook, April 2020 : The Great Lockdown.; 2020. Available at: https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/World-Economic-Outlook-April-2020-The-Great-Lockdown-49306.
16. CDC COVID-19 Response Team. Characteristics of Health Care Personnel with COVID-19 — United States, February 12–April 9, 2020. Morb Mortal Wkly Rep. 2020;69(15):477-481. https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6915e6-H.pdf.
17. “Memento Mori”: The Reminder We All Desperately Need. Daily Stoic. https://dailystoic.com/memento-mori/
18. Knight H. Bay Area doctors treating coronavirus patients rush to draw up wills, just in case: ‘We have to be brave.’ San Francisco Chronicle. Available at: https://www.sfchronicle.com/bayarea/heatherknight/article/Bay-Area-doctors-treating-coronavirus-patients-15176067.php. Accessed April 3, 2020.