The COVID-19 pandemic did not just introduce new social problems; it also exacerbated existing ones that were already nearing a breaking point when the virus began to spread throughout the United States in late 2019 and early 2020. Apart from the fact that social isolation among seniors has been identified as a major problem,¹ there has been a steady increase in the prevalence of anxiety, mood, and substance use disorders, which were already known problems.² In addition, deaths due to suicides, overdoses, and out of despair have been on the rise.^{3, 4, 5} Even metrics like average lifespan were on the decline in the United States.⁶ More than half of US adults (51.8%) had at least one of ten of the following chronic conditions: arthritis, asthma, cancer, chronic obstructive pulmonary disease, coronary heart disease, diabetes,
hepatitis, hypertension, stroke, or weak/failing kidneys; and 27.2% of US adults had more than one of these conditions, up from 21.8% in 2001.⁷

To blame political affiliations, let alone a few individual politicians, for these psychosocial ills is misguided since these problems have been developing for at least a generation and cannot be resolved overnight by even the most expedient political solution. While many of these problems do relate to a persistent refusal to pay for regular maintenance of existing infrastructure (medical or otherwise) at the federal, state, and local levels, the overarching problem is that leaders of organizations both public and private share a tendency to see redundancy as waste because it is injurious to the bottom line and because the bottom line is given primacy over all other objectives. When one is dealing with issues related to the field of medicine, this means, ipso facto, that saving dollars often takes priority over preparing for pandemics, which is why hospitals were unable to rely on their own stockpiles of supplies when circumstances radically changed as they did in March and April 2020.⁸ As discussed earlier (see Chapter 5: Psychosocial and Economic Impact of COVID-19—A Nation Under Siege), similar efforts to make supply chains more efficient rather than more adaptive and resilient to crisis left grocery stores’ shelves barren.⁹ Even in the second half of 2021, there are still shortages of a wide variety of consumer goods and manufacturing components.¹⁰

Similarly, many social problems are the results of sweeping structural changes that have roots in the reshaping of the American economy due to long-term trends like globalization and deindustrialization. Alterations to how supply chains are routed and how goods are manufactured go back over 60 years and, again, there is no one villain to blame for this process. Similarly, no one tech guru can be blamed for introducing new information technologies that have radically altered how we interface with one another and how we read and digest information.

Suffice to say, a thorough examination of all these factors is well beyond the scope of this book, but I believe that it is important to at least keep them in mind as we consider what steps we need to take moving forward to create more resilient social structures and to adopt or encourage healthier behaviors and lifestyles. Our goal should not be to return to a deeply flawed and untenable baseline but a new and improved world that is stronger and ultimately better for everyone.

I would have hoped that as of this writing (September 2021) the worst aspects of the COVID-19 pandemic would have faded away in time. True, more people have been vaccinated or developed natural immunity following
infection, case numbers have dropped (especially in areas with high vaccination rates), strict social distancing efforts have become unnecessary, and the pace of life prior to the pandemic is gradually resuming. However, considering the disparity in vaccination rates and masking policies in many areas of the United States, it now seems likely that COVID-19 will continue to be an endemic disease. It is something that we will have to live with for years to come, and there is no doubt that the world has been irrevocably changed by the pandemic and hopefully some lessons have been learned. Chief among them is that hopefully policymakers, officials, researchers, and most regular citizens will be far more vigilant about taking precautionary steps when another novel virus emerges. As we have learned time and time again, the longer we wait to mount a response to a threat, the worse it becomes.

We have enjoyed a long period of epidemiological tranquility that is outside of the norm of human history, and it seems as though the peace is about to be disturbed more regularly as wildlife habitats are increasingly encroached upon by humans throughout the world due to land-use changes such as deforestation. As a result, more contact between humans and wild animals—particularly in areas with a high biodiversity of mammals and birds—and increases in zoonotic spillovers will become inevitable, and, in fact, this is already happening.¹¹ Since 1980, new infectious diseases have emerged at a rate of about one every 8 months.¹² When this is combined with local health systems’ inability to detect or monitor novel disease outbreaks and the increasing connectedness of the globalized world, it becomes clear that another pandemic might be on the horizon before we even know it.

Given these three factors (increasing animal-human interface through encroachment, poor local health systems, and ease of international transit), a team led by Michael Walsh, an epidemiologist at the University of Sydney’s School of Public Health, has found that the zones with the highest potential for a spillover event are predominantly in sub-Saharan Africa, South Asia, and Southeast Asia.¹¹ To prevent high-impact spillovers, we need to improve conservation efforts, disincentivize the destruction of existing ecosystems, and invest in better health care and surveillance systems in these regions. These are, of course, long-term goals and will require coordination on an international level, but this is the only way to ensure that outbreaks are recognized early and contained before they can reach epidemic or pandemic levels.

Beyond this kind of monitoring, we need to remember that masking, social distancing, hand hygiene, and other recommendations do work to prevent the transmission of airborne pathogens like SARS-CoV-2. In some cases, these methods may help prevent the spread of a specific pathogen, such as influenza. As mentioned earlier (see Chapter 7, specifically
Individual Ethical Duties), the preventative measures that were taken to flatten the curve for COVID-19 disrupted the 2020 to 2021 flu season. Fewer than 2000 laboratory-confirmed cases (down from around 200,000 in an average year) were reported during that time.¹³ Meanwhile, an estimated 600ⁱ Americans died of influenza during that flu season, down from an estimated average of 38,750.^{14, 15}

However, not every pathogen follows the same route of transmission, and different types of pathogens will require different preventative measures should the need arise. To mount an effective response against these pathogens, we will need to rely on public health directives which depend on improved and efficient communication to foster trust among the general population.

Primum non nocere: “first do no harm.” Every physician holds the Hippocratic oath deeply inside their core and intends to practice based on that principle. The foundation of medical treatment is inherently built on trust. It goes without saying that people tend to trust their medical providers and make treatment decisions based on the assumption that clinicians are there to offer them the best available information that is objective, unbiased, and free of any slant influenced by affiliation with a political party or other group. We have been operating under this premise for generations. The important question to ask is what changed during this pandemic that led to the loss and breach of this trust.

One hypothesis to entertain is that the preventive and treatment guidelines for COVID-19 were stated as mandates rather than as suggestions or recommendations, which is antithetical to the physician-patient relationship where recommendations do not feel like demands, information is freely shared, and courses of action are subject to discussion that ultimately allow the individual to make the final decision after hearing all the facts. The mandates about masks and social distancing measures seemed to violate this two-way conversation, and instead, the information was perceived as being delivered in an authoritarian manner. Why some of the public came to believe opportunist pundits and others who claimed that these mandates were based on some ulterior motives or political
affiliations will be debated for a long time to come and are beyond the scope of this book. However, what is clear is that the general public did not trust these guidelines despite ample evidence of COVID-19’s pathology, route of transmission, and the dangers associated with the illness. Public health officials must devise more effective ways of delivering information about safety measures during a public health crisis, especially when it is being rapidly updated, as was the case in the early days of the pandemic and even into fall 2021. Poor messaging can result in members of the public feeling frustrated and left in the dark, which can erode public trust in medical authorities and significantly hinder an effective response.

As much as one can sympathize with the public’s skepticism, it is exceptionally dangerous in the time when coordinated action is needed. When we cannot trust one another or officials, it is almost like refusing to believe what our senses tell us, and this leaves us in a treacherous situation. More importantly, mounting a public health response on a larger scale—especially in big organizations, hospitals, or other complex systems—becomes impossible, as this kind of strategy (or nonstrategy) cannot succeed without an all-hands-on-deck approach.

How we restore faith in institutions like the Centers for Disease Control and Prevention (CDC), which was once renowned for their impartiality, medical expertise, and ability to solve seemingly insurmountable logistical problems, is a question I cannot answer.¹⁶ How we restore trust in medicine and science is an even larger question that, once again, I oftentimes feel is too complex and laden with political land mines. However, for mental health professionals, clinicians of all types, and even people who have suddenly found it difficult to have a candid discussion with a friend or family member without it turning into a screaming match, what I can say is that a certain sense of stoicism is vital in these instances, and that one should make every effort to leave their politics at the door when discussing issues of medicine, risk analysis, and how one ought to behave during a pandemic. Our core objective should be to search out the truth and to present it as best and as thoroughly as we can when called upon to do so. Trying to put a thumb on the scale, even with the best of intentions, will ultimately erode trust and undermine whatever policies we believe should be implemented.

We do not know how the next pandemic will spread, but regularly cleaning surfaces is certainly not a bad idea since it can prevent the spread of a host of common pathogens that may be viral, bacterial, or fungal and
can discourage vectors (rodents and insects) from invading our spaces. However, rigorously scrubbing down surfaces has largely been an example of what one might call Hygiene Theater; meaning that it has been almost an entirely performative act that does little to flatten the curve and prevent COVID-19. As of April 2021, the CDC estimates that the risk of being infected with SARS-CoV-2 via fomite transmission is less than 1 in 10,000.¹⁷ However, if the objective is to prevent the spread of SARS-CoV-2 or another virus that follows similar transmission dynamics, there are far more productive means of doing so. One of those ways is to improve the air quality within indoor spaces.

While indoor air quality may not seem germane to a discussion of pandemics, the health of one’s indoor environment plays an enormous role in determining levels of respiratory and overall fitness simply because we spend so much time indoors. As Joseph G. Allen and John D. Macomber note in their book Healthy Buildings, the average person living in the United States spends upward of 90% of their life indoors. This means that the average 40-year-old American has spent 36 years of their life in an indoor environment.¹⁸ Rich Corsi, an engineering and computer science expert at Portland State University, provides a far more colorful way of digesting this datum: “Americans spend more time inside buildings than some whale species spend underwater.”¹⁸