After each epidemic and disaster, our social norms and behaviors change. As researchers begin to study coronavirus’s impacts, history offers clues.
There was a time in the not-too-distant past when it wasn’t widely understood that germs could pass from person to person. Before the late 1800s, habits like sharing cups with strangers and spitting in public even amidst crowds weren’t considered unsanitary. Then a tuberculosis outbreak came, and our behavior changed — in some ways irrevocably and in some ways temporarily.
What will coronavirus do to our societal norms and relationships? We only have inklings thus far: Changed social expectations of face masks could be one, a new aversion to face-touching may be another. Images of crowds gathered during Memorial Day weekend may suggest that for some people, few social-distancing norms will stick. Still, past epidemics, disasters, and instances of social isolation have demonstrated how these societal disruptions can alter our behavior for years to come. They’ve also demonstrated time and again that humans are fundamentally resilient, making adjustments in the short-term but also falling back into old habits once an acute risk has passed.
Take the example of shaking hands. If it were up to Anthony Fauci, we might never shake hands again. But history suggests that handshakes, fraught with so much societal weight, come and go with waves of public health scares.
While there are no exact corollaries to our current cocktail of germs and social isolation — not even the 1918 influenza pandemic — understanding past shifts can help us prepare for change now.
The origins of germ fear
It was in the late 1800’s that much of Western society began recognizing that diseases spread through micro-organisms invisible to the naked eye — the culminating achievement of European biologists like Louis Pasteur in France and Robert Koch in Germany, who advanced the germ theory of disease. In fact, that period helped shape much of America’s modern-day hygienic behaviors. The public had already understood that common diseases like cholera and typhoid could spread like wildfire through food and water contamination. “People were worried about what's in their drinking water and how you take care of your toilet [system] so that if you had cholera, it's not getting into the water supply,” said Nancy Tomes, a medical historian at Stony Brook University and the author of “The Gospel of Germs.”
But as scientific evidence for germ theory mounted, and public health educators launched a massive anti-tuberculosis crusade, the most casual contact came under scrutiny: People avoided handshakes, and mothers shied away from kissing their babies as doctors warned of passing tuberculosis on to their infants. Aggressive public health campaigns urged the public to practice “proper” coughing and sneezing by covering their mouth, and to ban spitting as anxiety heightened over the spread of germs through droplets.
Precautions over coughing and sneezing prevailed, as did a general disgust toward spitting. “What reinforced the gospel of germs was that they really got put into our school systems so that children were taught these principles in the 1920s and '30s,” Tomes said. “And it becomes part of what your grandma and your aunt think, as it especially gets put onto women” — many of whom were teachers and caretakers.
Handshakes, though, never went away for good. The behavioral scientist Val Curtis at the London School of Hygiene and Tropical Medicine suggested in her book, “Don’t Look, Don’t Touch: The Science Behind Revulsion,” that the gesture may signal a degree of trust between two people to swap germs, so it may be more likely to fade in and out depending on the public health concerns.
As modern medicine lowered both the frequency and severity of disease outbreaks over the 20th century, Americans eventually eased up on those cleanliness tendencies. Even so, Tomes says there were enough reminders that when a public emergency arose, they “reactivated these germaphobic behaviors.”
That’s what happened in some Asian countries and cities when Covid-19 hit.
The Lasting Impact of SARS
Many credit at least some of Hong Kong, Taiwan, South Korea, and Singapore’s initial success in flattening the curve to their devastating experiences with the SARS outbreak in 2003. It was also caused by a disease in the family of coronaviruses, one that had much higher mortality rates —between 11% and 17% in that region — than the current Covid-19 strain.
When Covid-19 cases began emerging in Wuhan, China, citizens in those neighboring countries and cities became hyper-vigilant about not spreading or catching germs. Memories of the SARS outbreak, which lasted from March to June, have been seared into people’s minds years after the outbreak had been contained, and that’s shaped their hygienic behavior, as Nisha Gopalan, a Bloomberg Opinion columnist in Hong Kong, recounted:
I still compulsively wash my hands, 17 years after the outbreak. I have friends that have been using toothpicks to press elevator buttons for years. Some use tissues to open the doors of public washrooms, or carry spare masks in their handbags in case they catch the sniffles. This is all evidence of the indelible impact SARS has had on Hong Kong’s psyche.
And whereas some Americans are still grappling with orders to wear face masks — a result of mixed messaging from the government at the onset of the pandemic — the practice is almost instinctual in parts of Asia. In Hong Kong, it wasn’t just fear of catching Covid-19 that spurred the public to cover their faces. “This is a new social norm that has already been built up since the SARS outbreak in which the face mask was constructed as a sign of civic responsibility to prevent infecting others,” Judy Yuen-man Siu, a medical anthropologist at the Hong Kong Polytechnic University who studied the shifts in public opinion toward masks in the years following the outbreak, said in an email.
Meanwhile, public health measures that were adopted then — including the rigorous tracking of cases and strict quarantine enforcement — were quickly put into place as soon as China reported a surge in Covid-19 cases in January. “The higher mortality rate associated with the infection then can leave a longer lasting impression amongst those who have lived through it,” Sim Kang, a senior consultant at the Singapore Institute of Mental Health, said in an email. “And they may be more motivated to adhere with public health measures to contain the outbreak.”
What does that all say about our post-pandemic world?
Early results from an ongoing behavioral study by University of Southern California researchers of more than 2,000 Americans suggested that 86% of people are already washing their hands more frequently because of the coronavirus. Almost two-thirds of people engaged in social distancing, like working remotely and avoiding crowded places, and more than one in five people report stockpiling food and supplies.
“We're even seeing it in more subtle ways, that people are responding with disgust reactions or mild distress if they see other people touching their faces,” even when it’s someone on the TV screen, said Steven Taylor, a clinical psychologist at the University of British Columbia and author of the book “The Psychology of Pandemics.” (He wasn’t involved in the USC study.) He expects prolonged germaphobic tendencies to develop in only a small handful of people, namely in those who have preexisting obsessive compulsive tendencies.
In the same vein, Tomes predicts that while people will remain hyperconscious of what they touch, and will continue to worry about being exposed to the coronavirus outside their homes, they may become more casual about their hygiene practices as the anxiety over the current Covid-19 crisis eventually fades. Back in Hong Kong, Siu recalls that it took about a month after SARS was declared over for people to relax their hygienic behavior. “If my memory is correct, most people took off their face mask in July 2003, except those who had respiratory symptoms,” she said.
But things could also play out differently as new threats emerge. Three years after SARS ended, hospital employees in Beijing reported that they still think about the epidemic, and that the high level of contagiousness and initial mortality rate continued to provoke fear of another outbreak.
“Where I think this casualness really comes to a halt is with the rise of new viral diseases,” Tomes says. Some experts are already warning the Covid-19 is a trial run for the next pandemic as sprawl continues to bring humans and wildlife — and the novel viruses animals carry — closer together.
Will social isolation change us?
In a world that frequently experiences large-scale disasters like extreme storms, mass violence, and economic downturns, dealing with collective trauma is not an unfamiliar challenge. But in the case of coronavirus, that trauma can’t be separated from social isolation. Already, a third of Americans reported experiencing high levels of psychological distress during this pandemic, including more than half of people who described their financial situation as poor, according to the Pew Research Center.
In times like these, our instinct is to find comfort in our networks of friends and family, and in our community. Research by psychology professor Roxane Cohen Silver at the University of California, Irvine, has looked at how societies reacted to traumatic situations and found that communities became closer as people sought out the company of their loved ones and their neighbors. After the 9/11 attacks, people were more likely to seek greater meaning through engagement in religious and political activities that helped boost their well-being. And inside a small Israeli town that endured seven years of constant bombing, communities that got together in tight-knit groups and supported one another through sharing of resources did best in coping with attacks, Silver said.
The cruel irony is that the infectious nature of the coronavirus has forced billions of people across the globe to stay home and cope, or even grieve, alone. That may come with its own set of consequences, which could be especially pronounced among those who have had to be put in forced isolation.
In one study, researchers found at the end of a nine-day quarantine during SARS in Taiwan, health care workers (who tested negative for the disease) were more likely than their non-quarantined colleagues to develop symptoms of stress disorders, like exhaustion, irritability, insomnia, and poor concentration. “That traumatic stress can linger even after the episode is over,” says Kang at the Singapore Institute of Mental Health.
And in a small qualitative study in Toronto, which surveyed 21 people who were quarantined during the SARS outbreak, some participants described long-term behavioral changes years after it ended: continued vigilant hand washing, for example, and crowd avoidance. Others said that they struggled to reestablish relationships because of the stigma they encountered, and that a “return to normalcy” was delayed by several months.
But it’s worth noting that these studies focus on specific groups of people who endure more extreme forms of isolation than most of the population is currently experiencing under social distancing measures. “The current situation is new, and many people are dealing with some degree of distress and anxiety, but most people are able to bounce back,” said Taylor. “Life might not be a return to what it was before, but most people are able to deal with stresses like this.”
There’s one thing that’s particularly different about our current condition of social isolation, adds Taylor: the internet. Research is limited on that front in the study of epidemics given the relatively recent rise of those technologies — but we can look to their effects on space travelers.
“These are people who are isolated for four to six months in space, and they are under the potential dangers of space and can’t go outside and take a walk easily,” says Nick Kanas, a psychiatrist at the University of California, San Francisco, and author of the book “Humans in Space.” He spent 15 years as the principal investigator of various of NASA-funded research on the psychological hurdles of space travelers.
In one study, he looked for signs in space of what isolated Antarctic researchers call the “third quarter phenomenon” — a period of increased stress and interpersonal tension midway through a mission as explorers acknowledge that they must endure the other half before returning home.
“We did not find evidence of third quarter phenomenon in our study of the 30 astronauts and cosmonauts,” Kanas said. “Some got depressed in the third quarter and some got depressed during the first quarter as they were getting acclimated, so there was no consistent effect.” He suggests that may be because unlike the Antarctic researchers who are isolated in an area with almost no telecommunication access, space explorers are able to connect 24/7 with their families through video calls on the International Space Station. (It probably also helps that the crew goes through extensive training beforehand and has support staff who provide brain-stimulation activities as needed.)
That’s not unlike many who are currently isolating at home and experiencing quarantine fatigue. Zoom calls and social apps have virtually connected many to the outside world. Yet the reality is that that connection can’t fully replace physical touch. When the pandemic eases, it’s possible our longing for social interaction in the physical space will have us running to friends and family, but stopping short of jumping back into crowded areas as we remain hyper-vigilant about the threat of the coronavirus.
Adjusting to a new normal
Taylor is currently studying how people are coping with the various psychological impacts of Covid-19. “Pandemics are not static,” he said. ”They’re dynamic, unfolding, and changing events where people's behavior changes over time.”
And while findings from past epidemics can give researchers like him a good place to start, they’re not exact parallels. In general, studies specifically on the long-term, society-wide impacts of pandemics are limited, according to Taylor. It was only in the last 20 years that academics began looking at the psychological aftermath of the 1918 Spanish Flu — one of the deadliest pandemics in modern history and one that often gets compared to the current crisis — and even then, he says, its similar timing to World War I complicates the findings.
Silver and her team are also in the midst of studying Covid-19, looking at the role of media and constant news consumption in amplifying the symptoms of stress. “We're still in the eye of the storm and we're still anticipating what might happen,” she said. “We don't know how long this is going to last, and we don't know how bad it's going to get.”
But she predicts that over time, as new public health measures get phased in, people will gradually adjust to a new normal so that they can leave their homes feeling safe again. (Although the current partisan divides in the U.S. and the politicization of science is expected to muddle the transition.) That’s what happened after 9/11 completely transformed the way people fly. First people accepted that knives were no longer allowed on flights, then as new threats emerged, travelers agreed to take off their shoes during security screenings and tolerated the ban on water bottles.
“I do not believe we will ever go back to where we were on January 1, 2020,” Silver said. “But as we get further and further from that time, fewer people may remember how it was before.”
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