How Will We Know It’s Over?

When looking back on the 2003 mission to eliminate perceived weapons of mass destruction from Iraq, then-Pentagon Chief Paul Wolfowitz has said that it misjudged the “the tenacity of Saddam’s regime”, but denied it was grounded in any attempt to deceive the American people, saying “A mistake is one thing, a lie is something else.”

The biggest risk to our well-being would be to underestimate the tenacity of the virus and declare ‘mission accomplished’ without rational, evidence-based scientific benchmarks. Historically, the public health imperative has prioritized preventing physical over economic harm.

This means we must increase public health literacy about the course of this pandemic, and, for our own safety, adopt some benchmarks against we can compare the behavior, language, strategy and policy of the White House.

First, there will be no ‘victory”. Battles with viruses are not wars, they are insurgencies. The virus will ambush a community, its damage level enhanced by population density. And it does not affect a whole country equally, but spreads in geographic waves from a nidus (or two). In our current situation, the infection would be predicted to move inward from the coasts in a long march of regional waves over a 3–5-month period. In the rest of the world, the spread in southern Europe and the Middle East does not bode well for currently under-infected Africa.

However, like many insurgents, the virus cannot be defeated, only suppressed, and it can return. It can also change strategy, mutating to overcome barriers that it has sensed in those it wished to overcome (when they do disappear it is usually due to inherent inability to adapt to changing conditions). We should be prepared for a second outbreak next winter. This is when we will know the true extent of population immunity from the initial exposure. Based on the same concept of ‘herd immunity’ we create with vaccines, if the virus cannot infect enough people to establish its base of operations, its impact on community is attenuated. This is why physical distancing and extensive testing is so important in the pandemic phase, physical measures to prevent spread will effectively leave the insurgents with no food and water, and no choice but to retreat and regroup.

But when can we go back outside?

With the wrong signals from leadership, especially as we hear about new case numbers and death rates dropping in our community, there may be an inclination throw off the cloak of ‘shelter in place’ and rush back into the dynamics of civil society; we will need to move carefully: there will be viral hotspots where people who were protected in the first wave will subsequently be exposed to a long tail of persistent asymptomatic carriers.

The virus has caused a rent in the fabric of our society and we cannot simply flip a switch and go back to the way things were. Some people will have a version of post-pandemic stress disorder, with the demands of isolation triggering underlying anxieties and disrupting the capacity for relationships and social interaction. As a nation we need to be forgiving and patient with ourselves as we move tentatively to build trust, not in each other as much as in the security of being exposed in our communities.

This is about managing a careful transition. There will be great value in sustaining some of the social structures that have been reinvigorated during this time: renewed interest in the arts; walks with family; cooking at home; reading. We need to evolve based on what we have learned from the challenges to, and responses of, our structural systems such a healthcare, supply chain, and others.

The COVID crisis is touching every aspect of our lives — health, work, community, parenting, physical fitness, mental wellness, education, entertainment, economics, infrastructure and expectations of government — effects of which may not be felt or understood until we are further along the curve, or even after the crisis has started to wane.

Achieving integrated recovery will require reconsideration of the economic models for public investments. The traditional funding siloes of health, education, and finance and social services cannot be allocated in isolation; investments in the economy must accrue benefits to repairing the integrity of our social fabric. These must not be point solutions but offer sustained support over the long tail of recovery. Just going back to (work, school, life) will not be enough.

In their 2014 book Scarcity, Harvard economist Sendhil Mullainathan and Princeton cognitive psychologist Eldar Shafir make a compelling case for how the perception of threat to personal resources has a significantly adverse effect on cognitive function. While their work focused on the correlation between poverty and counterproductive behaviors, subsequent work demonstrated that the concept of threat was relative and independent of income or even wealth; adverse neuropsychological consequences can be triggered simply by the perception of looming or impending peril.

The COVID-19 crisis will the impose a burden on individuals that may impede their capacity to contribute — emotionally and economically — as active, productive members of family and community. Recovery will require rebuilding community fixtures and government to support a sense of security in our social capacity to respond to the next threat. This speaks to the need for a “whole person” economic model that integrates the societal costs of recovery (jobs, housing, health, fitness, education, infrastructure and community) and acknowledges the value of investments in the total cost of recovery.

Physician-leader; health strategist; Founded Former Chief Medical Officer; public-health official; communications executive

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