When Will Things Get Back To Normal?

Great calamities often lead to lasting changes in how we function as a society. History is replete with paradigm shifts brought about by wars and pestilence. The current pandemic will likely leave indelible marks on the social order. While the rapid development of effective vaccines for SARS-CoV-2 is grounds for optimism, experts are still reluctant to answer the question on everyone’s lips: When will things get back to normal? 

Waves of infectious diseases have shaped our civilization. For most of human history, these epidemics disproportionately afflicted the poor and underprivileged. There is no more horrifying example than the Columbian Exchange in which European diseases like smallpox and measles essentially depopulated the existing Native American civilizations. 

Before the development of germ theory, efforts to mitigate epidemics were haphazard and based on superstition. Our language preserves the traces of these prescientific concepts, including mistaken etiologies like “bad air” (malaria) and the “influence of the stars” (influenza). Surviving an epidemic before the Age of Reason was a matter of luck and privilege, and the experience was unlikely to leave the survivors with knowledge or tools for dealing with the next wave of contagion. 

That all changed during the 19th Century. Epidemics of tuberculosis and cholera led to permanent advancements in hygiene and public sanitation. They also spurred the creation of public health departments and investments in massive works of civil engineering. These lasting changes produced significant gains in health and life expectancy long before there were effective therapeutics for infectious diseases. 

The epidemics of the 19th and 20th Centuries permanently changed how we live and interact with each other. There was no going back. We learned from our experience. We changed what needed changing, and we moved forward. This is how it works. This is how you get back to normal. 

I started my medical education in the autumn of 1979, just before the start of the AIDS epidemic. I have vague memories of seeing hospital residents toss used IV needles into wastebaskets. I remember an older attending scoffing at the notion of wearing gloves while performing a sigmoidoscopy. This was the status quo before the AIDS epidemic, but all of that would change—albeit slowly (OSHA would not publish its Bloodborne Pathogen Standards until 1991). 

Things have changed much faster during the coronavirus pandemic, and for that, we should be both proud and grateful. Our Academy was proactive in recommending changes in office practices—early on publishing guidelines to protect our staff, patients, and families from the virus. The AAFP has worked diligently to relax the rules governing telemedicine, and I very much hope that these changes become permanent. Telemedicine may not be a substitute for face-to-face visits but it has great value in increasing patient access and for triaging acute illnesses. The AAFP is working now to ensure that family physicians will be an integral part of the coronavirus vaccine infrastructure. 

I miss the social interactions and freedom of travel that we have sacrificed to defeat this pandemic. However, I could care less if we ever go back to shaking hands. After not shaking a single hand in the past 12 months, the practice now seems like a silly relic of a bygone era. The same goes for elbow-knocking, fist-bumping, and virtual high-fives. Good riddance to them all. Just smile (behind your mask) and say hello. In addition, I hereby proclaim that I will keep wearing scrubs at work, and I am completely done with neckties. We should have abandoned these years ago. 

It would not bother me if mask-wearing became the norm during “cold and flu season.” Even with a substantial percentage of Americans refusing to wear masks, we have managed to suppress the incidence of influenza and RSV during the current season. Regardless, I will continue to wear a mask and practice social distancing for as long as it takes. 

It has now been a full year since the first American died from COVID-19. As I write, the death toll is passing 450,000. The United States of America—with less than 5% of the world’s population—accounts for nearly 20% of all COVID-19 deaths. How can this be happening to the most powerful nation on Earth? How could this happen to the nation that planted its flag on the Moon? 

We must do more than simply arrive at the new normal. We must learn from this experience and use this knowledge to prepare for the next catastrophe. To do this our nation needs a thorough accounting of why it has performed so poorly. 

An editorial this month in the British Journal of Medicine lays the blame for the tragic pandemic response in the US, UK, India, and Brazil squarely at the feet of their respective national leaders. They go as far as suggesting the excessive death toll in these countries is a form of “social murder” attributable to the deliberate undermining of public health institutions. An editorial in JAMA, also published this month, addressed the pernicious influence of a White House physician advisor who promoted a strategy of allowing the virus to “spread naturally” to achieve “herd immunity”—which nearly all public health experts warned would lead to tens of thousands of unnecessary deaths. 

The JAMA editorial concludes that “physicians and scientists have a professional obligation to respond when science is being misrepresented” and ”when the voices of physicians are coupled with the power of national leaders and provide support for misguided policies, serious public harm can result. When this happens, physicians must speak out or risk being complicit.” 

History will condemn harshly those who downplayed the pandemic, politicized mitigation, and undermined public health institutions—but the judgment of history alone is insufficient. We owe much more to those who died unnecessarily, and to those minority communities who suffered disproportionately during this pandemic. We need to restore public trust in science, and after we conquer the viral pandemic, we must turn our attention to conquering the plagues of disinformation and denialism. 

The coronavirus pandemic is a historic tragedy. We will never return to the status quo ante, but we will—someday soon—arrive at the new normal. Before that day arrives, we must become both wiser and better prepared for the inevitable next pandemic.

This article was published in South Carolina Family Physician.