The Day After

The COVID-19 pandemic will pass, but what will happen next?
The Day After, U Magazine Fall 2020
Illustration by Lucy Rose

When the coronavirus pandemic began, toilet paper became the unofficial icon of locked-down life. Shoppers stripped grocery shelves bare. Perpetual handwashing, along with the fruitless search for hand sanitizer, soon followed as symbols of an altered world. Today, the toilet paper aisles are mostly restocked. But, as the shape and scope of our lives continue to shift, the question becomes: Where does all of this lead?

“The pandemic has clearly upended all of our lives,” says Gary Small, MD (FEL ’83), professor of psychiatry and biobehavioral sciences and the Parlow-Solomon Professor on Aging at the David Geffen School of Medicine at UCLA. “It’s been an assault, and the world as we knew it is profoundly different. But people are resilient, and as this goes on, we’re adapting.”

For thousands of years, plagues and pandemics have savaged the civilized world. And each time, they’ve brought about lasting change. It was during the Black Death in the 14th century, which wiped out nearly one-third of the world population, that the city of Venice conceived the concept of quarantine. The word comes from the 40 days — quaranta giorni — that incoming ships were forced to sit at anchor before sailors were allowed to come ashore.

Recurring cholera pandemics throughout the 1800s, which at that time were blamed on noxious air, led to a building spree of wide city boulevards and vast urban green spaces. That’s the genesis of Central Park in New York, which landscape architect Frederick Law Olmsted believed would give city residents access to healing fresh air. After the 1918 influenza pandemic claimed 50 million lives, governments throughout the world began to develop centralized health care systems. Some historians argue that the scapegoating of black South Africans during that time sowed the seeds for the legislated racism of apartheid.

Months into this newest pandemic, we have come to view daily life through a lens of health and safety, if not in terms of life and death. Work, travel and worship potentially can be fatal. Even the most basic pleasures — an evening out at a restaurant, sitting together and chatting with friends, blowing out candles on a birthday cake — can pose a serious risk. Instead of connection, we now see contagion. And, as the COVID-19 pandemic grinds on, its effects are profound.

Take, for example, the social nicety of the handshake. A near-universal form of greeting in the U.S., shaking hands quickly became off-limits as the coronavirus spread. Its absence has left an awkward void of nodding, bowing and, for some people who just can’t help but touch, the particular weirdness of the elbow bump. For Mark Sklansky, MD, chief of pediatric cardiology at UCLA Mattel Children's Hospital, the end of the handshake is welcome news. He has long been a clarion voice advocating against handshakes, which he sees as natural spreaders of infection. “Our hands are warm and wet, and they are very efficient at transmitting disease,” Dr. Sklansky says. “The handshake is a relic from centuries ago, and the fact is that hands represent an excellent vector for disease.”

He has encouraged no-handshake zones, particularly in certain clinic and hospital settings, to protect vulnerable patients, and followed up with a no-handshake music video on YouTube. Our current reality has transformed the handshakesas-disease-vector paper he published in the Journal of the American Medical Association in 2014 from fringe thinking to prophecy. “That was certainly not the case a few years ago, when people laughed at this view, even in the medical setting,” Dr. Sklansky says. “The fact that it has become intuitive now to avoid a handshake shows that people’s thinking has come a long way.”

Previous pandemics have failed to wipe out the handshake. But Dr. Sklansky holds out hope that this one may bring lasting change. He points out that, thanks to public education and a clear link to heart/lung disease and cancer, the rate of cigarette smoking decreased significantly in the U.S during the latter part of the 20th century. In the meantime, he advocates for the “namaste” gesture of a slight bow over hands pressed together at the heart. “What’s important is eye contact, and even a smile,” he says. “A person’s humanity and kindness need to come through.”

AMONG THE MORE TROUBLING CHANGES BROUGHT ON BY THE PANDEMIC has been the explosion in isolation and loneliness. Close to one-third of all Americans — that’s more than 35 million people — now live alone. With in-person contact from work, shopping, socializing and recreation now off-limits and rife with risk, the result is a marked uptick in anxiety, depression and other mental health problems..

Over the long term, the physical toll of this type of social isolation is steep. Research has found that people who are isolated and chronically lonely develop heart disease at higher rates than do those with strong social connections. They’re more vulnerable to a range of other serious health issues, as well. These include metastatic cancer, an increased risk of stroke and higher rates of neurodegenerative diseases, such as Alzheimer’s and other types of dementia, than the general populace. Adults who are chronically lonely are more likely to die a premature death. And for older adults, who are at markedly higher risk of grave illness due to COVID-19, this pandemic has proven to be a double threat. Studies show that elderly people who are isolated and lonely die at significantly higher rates than those who are socially connected. Yet, now they’ve been forced to withdraw from most forms of human contact in order to preserve life.

“We know from past national disasters that mental health in general suffers,” says Emanuel Maidenberg, PhD, clinical professor of psychiatry and biobehavioral sciences and director of the Cognitive Behavioral Therapy Clinic at the Semel Institute for Neuroscience and Human Behavior at UCLA. “About 10 percent of people may go on to develop ongoing psychological problems such as depression, anxiety disorders and post-traumatic stress.”

The wild card here is the unprecedented length of this pandemic, and the ongoing uncertainty that surrounds it. “It is impossible to know the long-term consequences of an event of this kind, One of the challenges is that, when we’re isolated from others of different ages and races and ways of thinking, so much is lost,” Dr. Maidenberg says. “But I suspect that in the long run, the majority of the populace will do well. We humans have a level of resilience that carries us through these types of events, and even helps us find new meaning in life.”

That is an assessment with which Dr. Small would concur. “It is important for all of us to become aware of our friends and neighbors in need and to make that effort to reach out,” he says. Dr. Small holds out hope that helping the lonely and vulnerable among us will take hold as a lasting habit, even after the pandemic has passed.

One group hit particularly hard by the challenges of social isolation is new moms, says Melissa Brymer, PhD, PsyD, a psychologist and program director with the UCLA-Duke National Center for Child Traumatic Stress. Routine medical appointments and support services have become a logistical nightmare. Perhaps even more challenging is the loss of support from friends and neighbors and family members. The first weeks and months with an infant are already a stressful time, filled with physical rigor and emotional vulnerability. “Nurses spend a lot of time with new moms in the hospital, and what’s happened now is that they’re in more protective gear, and we’re hearing from new moms that it takes away from personal intimacy,” Dr. Brymer says. “Nurses are still supportive, but a new mother can no longer see their smiling faces. The nurses have had to adjust their body language and behavior for their warmth and reassurance to project.”

The challenges continue at home, too. Without a supportive community eager to admire and hold the new baby, to share stories and lend a helping hand, new mothers have been left to fend for themselves. The result has been a shift in newmom culture. “They’re posting baby pictures to social media, having lactation consultations online, having the food-train casserole left on the doorstep rather than in the kitchen, with a friendly chat,” Dr. Brymer says. “There’s a tipping point between risk mitigation and trauma, and everyone is having to adjust to find the right balance.

TO UNDERSTAND WHICH, IF ANY, OF THESE NEW BEHAVIORS MIGHT CONTINUE INTO THE FUTURE, it is helpful to look to the past. Take, for example, the reluctance among many people to wear a mask. Such resistance can be baffling to those who believe that wearing a mask can protect against spreading the virus, particularly to vulnerable populations, but it turns out this kind of response is not new. Strikingly similar scenes played out throughout the influenza pandemic in 1918 after elected officials in California ordered the closure of schools, theaters, restaurants and saloons.

As a deadly second wave of the influenza pandemic gathered steam in October of that year, San Francisco’s Board of Supervisors enacted a mandatory mask ordinance. Despite initial good results, the city’s residents soon rebelled. They not only ditched their masks, they organized and formed the Anti-Mask League. News reports of the day, chronicled in history books about the pandemic, show the group held a gathering of 2,000 unmasked sympathizers in an indoor arena. While there, they questioned the severity of the pandemic. A physician who preached the gospel of masks became the target of angry protestors, including one who attacked him with an explosive device — it failed to go off. The unsurprising result of this failure to unify against the disease was a lethal surge in new cases of influenza. By the time the pandemic finally wound down, San Francisco emerged as one of the hardesthit cities in the U.S.

It is true that, to a certain extent, such contrarian behavior, even in the face of a clear-and-present danger, can be chalked up to the vagaries of human nature. But Howard Markel, MD, PhD, George E. Wantz Distinguished Professor of the History of Medicine at the University of Michigan in Ann Arbor and director of the university’s Center for the History of Medicine, says that how a message is delivered to the general public also plays a role in how it ultimately is received. “Over the last century, there have been all sorts of creative ways, from posters to slogans to public-service announcements, that teach and encourage people to behave better,” he says.

He points to post-World War I campaigns in favor of toothbrushing, which moved the compliance needle from seven percent at the start of that century to more than 65 percent by the 1930s. In the coronavirus era, Dr. Markel is a fan of comedian and TV polymath Larry David’s often-profane public-service announcements. While promoting the need to wear a mask, and chiding those who refuse to do so, David sarcastically couches the benefits of self-quarantine in terms of a chance for limitless time in front of the TV.

On a more serious note, Dr. Markel points to a successful behavioral change — sneezing or coughing into one’s elbow — that emerged in response to mitigation efforts during the 2009 H1N1 (swine flu) pandemic. “Prior to that time, all the way back to the 1920s, people had been instructed to put their hand on their mouth whenever they were going to cough or sneeze,” Dr. Markel says. “But now, due to changed behaviors adopted during the 2009 pandemic, you cough not into your hand but into your elbow.”

A serious challenge to that type of messaging today is the fraught and fragmented landscape of public discourse. Information bubbles, chosen to match each person’s pre-existing beliefs, preach to the converted. Add in the fact that the novel coronavirus is, well, novel, and so we are learning on the fly, and recommendations evolve according to new information, and, thus, a certain level of chaos is inevitable. “Information gets buried in a fog of war,” Dr. Markel says. “Without a coherent narrative, you don’t get all of the details. You won’t ever learn the science of it.”

SO WHAT HAPPENS IN A POST-COVID WORLD? Is such a thing even possible? In a bestcase scenario, the development and deployment of a successful vaccine remains months away. And even as researchers around the world work at an accelerated pace to develop one, questions about a potential vaccine’s efficacy remain. Due to the nature of the novel coronavirus, it won’t match the success of the smallpox vaccine, which stamped out that disease. Nor will it offer the near-total protection of the two-dose measles vaccine. Even if things go well with manufacture and delivery, there’s the wild card of the anti-vax movement. Bottom line: COVID-19 likely will continue to define our lives for years to come.

“The reality, of course, is that social distancing cannot cure or defeat COVID-19. It only allows us to hide from the virus while scientists do their work,” Dr. Markel — whose 83-year-old mother died in February after contracting COVID-19 — wrote in The New Yorker in August. “The overwhelming majority of Americans — perhaps as many as 300 million people — are still susceptible to infection. As they venture back into a reopened world in which the virus is still circulating, they are at risk.”

Andrea Bertozzi, PhD, Distinguished Professor of Mathematics and holder of the Betsy Wood Knapp Chair for Innovation and Creativity in the UCLA College, has the numbers to back up Dr. Markel’s assessment. Along with fellow scientists and mathematicians, she has examined a trio of mathematical models and seen a potentially distressing future. In a study published in April in the Proceedings of the National Academy of Sciences, Dr. Bertozzi and her team reported that, unless physical-distancing measures remain in place until a viable vaccine is ready for release, the nationwide sacrifices to flatten the curve will have been squandered. Without continued vigilance by everyone living in the U.S., the number of resulting coronavirus infections may turn out to be of similar magnitude as if the lockdown and subsequent distancing had never happened.

“Distancing efforts that appear to have succeeded in the short-term may have little impact on the total number of infections expected over the course of the pandemic,” says Dr. Bertozzi , who also is Distinguished Professor of Mechanical and Aerospace Engineering. “Our mathematical models demonstrate that relaxing these measures in the absence of pharmaceutical interventions may allow the pandemic to reemerge. It’s about reducing contact with other people, and this can be done with PPE as well as distancing. As a nation, we still are in the early stages of understanding the best methods to protect the general population. But it is clear that infection spread can be controlled in a hospital setting, so this means there are ways to mitigate the spread in the workplace, as well.”

Health experts surmise that habits like handwashing and the use of hand sanitizers will become permanent. Hugs and handshakes will likely return, but for a while, at least, we’ll be keenly aware of the risk. Remote learning and remote working are likely to continue even when the pandemic has passed.

In fact, many experts suggest the workplaces of the future will be gradually but profoundly transformed. Outdoor spaces, so much safer than indoor venues, will continue to be a top choice for gatherings both large and small. In the meantime, as we wait for that elusive post-COVID world, we each do our best and cope.

Dr. Small’s family found a way to move a cherished weekly card game with friends online. Others have rediscovered retro pleasures like nightly family dinners and frequent movie nights. More recently, drive-in theaters, once bound for extinction, have made a social-distancing comeback. Older adults have learned, and even embraced, app-based visits through Skype and Zoom and Facetime. “You have these little moments where you get beyond the challenges, and that’s good,” he says. “You feel a sense of empowerment that you can still live a full life.”

And Dr. Small is working to remain hopeful. “It’s gradual, but we’re adapting,” he says. “We’re resilient, and although it takes work and time, we are adjusting to this new normal.”