Governments around the world are focused on mitigating the effects of the COVID-19 pandemic to save lives. Less attention is being paid to planning for recovery and building a “new normal” in a post–COVID-19 world—a process that comprises the recovery domain of the disaster lifecycle. Amidst this evolving public health crisis, it may seem premature or even counterintuitive to begin actively planning for postpandemic recovery in public health services and systems, but now is the time (Table).
Priorities for Public Health Recovery From COVID-19
|Increase traditional active and passive surveillance for entirely novel pandemic emergence or COVID-19 recurrence
|Develop behavioral health–specific surveillance systems to monitor impacts and needs
|Consider the role of novel technologies in sentinel surveillance (eg, Google FluView, Internet of Things (IoT) thermometers)
|Prepare for mental health recovery
|Engage faith-based and community mental health extenders using evidence-based techniques to build capacity
|Scale up resources for traditional public mental health treatments including through telehealth and expanded reimbursement procedures
|Plan for the specific recovery needs of traditionally vulnerable populations as well as health care providers who have been surged for months
|Increase critical supply capacity
|Replenish expended critical supplies such as PPE, ventilators, and respiratory testing supplies
|Improve systems to rapidly deploy critical supplies in future outbreaks
|Solidify lessons learned
|Document and validate the novel technologies (eg, new forms of PPE), engineering innovations, and system connections (eg, dashboards) developed during this pandemic
|Write comprehensive after-action reports and develop actionable strategies to implement solutions to problems
Abbreviation: PPE, personal protective equipment.
The traditional disaster lifecycle is a circular process beginning with mitigation, leading to preparedness, response, and recovery, and circling back to mitigation. In the United States, the Federal Emergency Management Agency's (FEMA's) National Disaster Recovery Framework (NDRF) aptly characterizes the timing for initiating recovery-phase planning efforts to be simultaneous with the onset of acute response-phase activities. Notably, “[t]he recovery process is best described as a sequence of interdependent and often concurrent activities that progressively advance a community toward a successful recovery.”1
Using the onset of the disaster as a starting reference, the NDRF divides recovery-phase activities into short-term (days), intermediate-term (weeks to months), and long-term (months to years). For these respective phases, traditional public health recovery includes a broad range of efforts relating to emergent care and surveillance, and risk and vulnerability assessments (short-term); continuity of care and messaging to communities about opportunities to “build back stronger”2 (intermediate-term); and reestablishment of disrupted health care facilities and implementation of related mitigation efforts (long-term).1
There are serious constraints to the NDRF for dealing with the impact of a pandemic. Historically, the United States has focused disaster preparedness efforts on nonbiological natural and man-made disasters. Hurricanes, earthquakes, floods, and acts of terrorism have shaped response- and recovery-based conceptual frameworks and infrastructure. The terrorist attacks of September 11, 2001, led to large-scale reorganization of homeland security posture through internal government agency realignments.3 After Hurricane Katrina in 2005, the postdisaster period included “restoration, reconstruction, and commemorat[ion]” of the lives lost.4 More recently, cyberattacks on hospital networks,5 banks,6 and even movie producers7 led to the creation of the Cybersecurity and Infrastructure Security Agency (CISA), among other private sector reforms. Yet, biological event recovery is an entirely different notion and one that most of the world has not significantly experienced. The most recent pandemic, 2009 H1N1, ended up being milder than anticipated.8
Second, a pandemic is a unique event in geographic scope and impact. We are most experienced at planning for and responding to a singular event that affects a circumscribed area. But a pandemic is a disaster that threatens entire populations. The impact is also drawn out over months instead of days. Most important of all, it is an event that causes no physical damage to infrastructure. The only damage is to our most important resource—people.
In the face of COVID-19, we find ourselves in uncharted waters for a modern, geographically dispersed, and more lethal9 rapidly evolving pandemic. It presents a novel test for the NDRF. Several of the NDRF's prescribed disaster recovery-phase activities for public health are not appropriate for a pandemic. The framework does state that “human pandemics ... may cause impacts that are dispersed throughout the Nation, thus creating different types of impacts for preparedness planners to consider.”1 However, the framework is largely written for the traditional, kinetic disasters that cause physical damage to a circumscribed geographic area. This distinction is of vital relevance to recovery-phase considerations for COVID-19 and other current and future infectious disease crises.
Despite the differences in geographic scope and infrastructural impacts between a localized kinetic disaster and a pandemic, addressing psychosocial impacts on populations is a crosscutting recovery-phase challenge for public health. The NDRF's concept of “build back stronger,” which is analogous to the United Nations' Office for Disaster Risk Reduction's “build back better,” invokes promoting community resiliency throughout the recovery process. From direct morbidity and mortality to disruptions in income, housing, and food security, and noted increases in domestic violence, public health systems' preparations for mental health–related sequelae are vital now to optimize postpandemic recovery.
The NDRF lists “Psychosocial and Emotional Recovery” as one of its 8 guiding principles and acknowledges that recovery starts with the individual and family. As we consider the complex recovery-phase challenges in the eventual aftermath of COVID-19, it must be recognized that “human perception is an active, multidimensional process such that for unpredictable societal threats” the recovery process will be dynamic and unique.10
The focus of the recovery must move beyond the recovery of systems and infrastructure to restore the physical and mental health of the American people. There are 2 specific populations that warrant particular discussion in this regard: health care workers and children. Health care workers have faced the brunt of this pandemic, often working long hours with limited personal protective equipment in an environment of sickness and death. After the SARS outbreak of 2003, multiple studies found health care workers who were quarantined following a possible exposure suffered mental health consequences up to 3 years later.11
In addition, children are at special psychological risk from a pandemic. With widespread school closures, compounded with family tragedies, morbidity, and the impact of social distancing on grieving, there may be long-term consequences in children that will need to be comprehensively addressed. Often quantified through adverse childhood experiences (ACEs), these incidents have been linked to long-term negative physical, economic, and social health outcomes.12 Specific to a quarantine situation, children quarantined or isolated experienced 4 times higher mean posttraumatic stress disorder scores.13 Given the disruptions to school and home life from the ongoing pandemic, recovery efforts must consider blunting the effects of the anticipated surge in ACEs to promote long-term health. In addition to traditional methods, mobilizing faith-based entities and other community sectors such as public mental health extenders can provide added scale,14 which may prove critical in such a widespread disaster. This will also entail scaling up of surveillance systems (eg, Behavioral Risk Factor Surveillance System15) for monitoring and addressing postpandemic community mental health impacts, in addition to ongoing public health surveillance of entirely novel pandemic emergence or COVID-19 recurrence.
Thus, we must begin readying for post–COVID-19 recovery without delay. Health systems that were depleted of critical supplies will need to be replenished. The economy must be gradually reopened and supported through effective testing and protective measures that balance health, individual safety, and economic reinvigoration. The public in general, and health care and other frontline response workers specifically, will need to have physical and psychological needs met. Victories in clinical care, engineering innovations, and system connections will need to be codified. Real-time documentation of public health observations for future inclusion in detailed, comprehensive post–COVID-19 after-action reports should begin now, as problems and solutions accrue.16 Engaging local communities, including faith-based organizations, as purveyors of psychological first aid can and should begin.
Now is the time to consider those recovery next steps. As parts of China begin to cross the threshold from response to recovery,17 the United States and other countries should preemptively begin their recovery processes as well. This means restarting economic activity using the best public health and infectious disease guidance available, driven by widespread and directed testing to identify and track cases, as well as those already immune. It is during this gradual return to a new normal where these recovery efforts will have their greatest benefit.
As the world conducts COVID-19 response, simultaneous recovery considerations also include promptly scrutinizing the suitability of public health doctrine. The World Health Organization (WHO) declared COVID-19 a public health emergency of international concern (PHEIC), the sixth such declaration in the 15 years of the modern International Health Regulations (IHRs).18 Given these rapid and increasingly frequent declarations, the role of the WHO and IHRs as stewards in a global disaster should be considered around the world. In the United States, in unprecedented fashion, 50 governors plus the federal government declared states of emergency; however, the system of federalism has yielded a patchwork framework of regulations, rules, stay-at-home orders, and other executive declarations.19 At the operational level, public health workers' needs for supplies, training, and emergency response tools should be assessed for follow-on action.20 Interventions of this nature have been shown to increase self-efficacy and willingness to respond in future disasters,21 key components of ensuring a resilient society properly recovering for the future.
The 1960s revolutionized injury prevention through the use of the Haddon matrix, which explicitly includes the time-phase “postevent.”22 The importance of what comes after the “event” was recognized then, as it must be now. Even in these uncertain times as COVID-19 unfolds, the timely importance of efficiently recovering to cycle back into mitigation and preparedness cannot be neglected. As the NDRF points out, “decisions made and priorities set by a community ... early in the recovery process have a cascading effort on the nature, speed, and inclusiveness of recovery.”1 Now is the time to set up for success in public health dimensions of pandemic recovery.
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2. Federal Emergency Management Agency. Build Back Safer and Stronger Fact Sheet. Washington, DC: Federal Emergency Management Agency; 2018. https://www.fema.gov/media-library-data/1531251928965-e646d1b0e92038ab44410f2562061da0/Build_Back_Safer_and_Strong_Fact_Sheet_508.pdf
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18. Jee Y. WHO International Health Regulations Emergency Committee for the COVID-19 outbreak. Epidemiol Health. 2020;42:e2020013.
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20. Association of State and Territorial Health Officials. ASTHO Profile of State and Territorial Public Health. Vol 4. Arlington, VA: Association of State and Territorial Health Officials; 2017. https://www.astho.org/Profile/Volume-Four/2016-ASTHO-Profile-of-State-and-Territorial-Public-Health
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