3.1. Operating definitions

When defining epidemic recovery in their own words – what is it exactly and how does it come to be – interviewees often observed that the context matters and that definitions are subject to contestation.

Definitional tensions exist between recovery as a goal of returning to baseline or seizing the opportunity to improve: Some interviewees defined recovery as returning to normal, to steady state operations, or to an earlier baseline, while others spoke of “adaptation,” “building back better,” and preparing for subsequent waves or crises through better planning, healthcare, and community education. The transformative capacity of epidemics was captured in comments that no one should “waste a good crisis” (i.e., learning and improvement should follow), epidemics can produce an “entirely new normal,” and an epidemic is a transition to a new stage of history, rather than a bounded event. Because epidemics and their aftermath are subject to human intervention, what constitutes “recovery,” argued an interviewee, is a political question: e.g., a government could claim post-epidemic recovery has occurred once the immediate crisis resolves, and still not address societal dysfunctions amplifying a pathogen's human effects. Trends in human losses often reveal underlying structures in need of reform.

The importance of context to the emergence, spread, and resolution of an epidemic may defy a one-size-fits-all definition for recovery: Interviewees were quick to note that an epidemic is a complex, organic, and dynamic event in which politics, social sphere, culture, health systems, human biology, and pathogen converge. As a result, what recovery looks like and feels like may be different from one major outbreak to another. A bad influenza outbreak may produce mortality at the extremes of life, explained an interviewee, but “when it's over, it's over.” Such a situation contrasts with the 2014–2016 Zika outbreak, in which some women infected during their pregnancies are now raising children with neurological deficits; full recovery is not possible. Recovery, too, may be something easier to distinguish or call out if an epidemic has been expansive and affected a lot of people. When nonessential services that were put on hold resume, supply chains become predictable again, and healthcare providers turn to more routine demands, then recovery may seem more remarkable than in less disruptive epidemics.

Epidemic experiences in high-income countries differ significantly from those in low- and moderate-income countries, producing divergentrecovery"ideals": Multiple informants observed that pre-epidemic social, political, and economic conditions calibrate community expectations around post-epidemic recovery. Per one interviewee, higher-income countries “have zero tolerance for risk” compared to lower-income counterparts; as a result, the presence of a vaccine-preventable infection like polio would be unacceptable in most industrialized countries, while such diseases may be viewed as unremarkable in endemic countries. Additionally, in resource-poor countries experiencing protracted periods of crisis, low confidence in public institutions, and limited capacities for social service provision, community members might simply resign themselves to coping without government aid. In this vein, competing threats to public health – particularly in fragile states or those with significant burdens of endemic and epidemic disease – could complicate efforts to prioritize recovery activities following a major outbreak.

3.2. Response prioritized

Interviewees explained that, in contrast to the acute response phase, the post-epidemic period is vastly under-rated and under-resourced.

Urgent “life and limb” matters take precedence and evoke empathy, while recovery issues trail off into obscurity: To explain why epidemic response and recovery receive uneven attention, interviewees noted the high stakes of the crisis period: an insufficient epidemic response can result in more sickness, death, and disruption – highly visible, readily communicated impacts. Recovery is under-addressed, because funds are applied to an acute, emergent problem when life itself is threatened. Informants described that the constant enumeration of cases and death elevate the problem of epidemic response, commanding the focus of energy and eliciting an emotional response. By comparison, the post-crisis period is largely invisible, and people readily forget that survivors may have lingering needs. Recovery has no “spokesperson” comparable to a leader who inspires communities and mobilizes a response in a crisis. Often, a dearth of political will to direct funds and other material resources proactively further impedes long-term, holistic recovery. Too, by the time the crisis phase is ending, the individuals who served in response capacities are often exhausted and grappling with burnout making it especially difficult to conceive of continuing the level of work needed for a robust post-epidemic recovery.

Recovery is not problematized the same as response because the prolonged recoveries of marginalized people generate less social attention: How society assigns value to people on a differential basis, some interviewees noted, explains the lack of available energy for recovery. The people mostly heavily affected by epidemics, whose impacts are likely to be protracted, are those to whom society routinely turns a blind eye. Marginalized individuals and underserved communities are often without voice or political influence, and as a result, their struggles are not addressed to the extent genuinely needed. Further, an interviewee explained, there exists a disconnect between the focus of elites upon high-profile outbreaks and the “everyday public health emergencies” such as moldy housing, unclean water, and food deserts that people with limited means often face.

Overlapping realities, response and recovery both need resources, planning and workforces; yet, only response capabilities are developed: Principally a medicalized process, epidemic response rests on the shoulders of skilled public health and healthcare workforces who strive to interrupt disease transmission and treat infected individuals. Stretching beyond urgent lifesaving, the post-epidemic recovery phase – many interviewees noted – does not have a comparably coordinated, well-resourced, and skilled workforce, that can deal with the protracted and diverse needs of affected communities (e.g., economic restart of businesses, social service provision to afflicted individuals and families). Moreover, as one informant noted, affected communities may expect responders to help them become whole again, but responders do not have the requisite skills and they eventually leave. Interviewees argued for a post-epidemic recovery “system” with a dedicated workforce, including social and behavioral experts, that could operate in tandem with the response, while thinking ahead and on a longer time-horizon.

3.3. Politics/economics

According to research subjects, recovery post-epidemic involves questions of effective governance – how are collective tradeoffs weighed, scarce resources applied, traumatized communities soothed, and institutional missteps remedied?

Public health measures to control epidemics often carry concomitant trade-offs: Several interviewees acknowledged the challenges associated with implementing certain public health interventions without disrupting livelihoods. One informant observed that the economic consequences of major epidemics could persist long after incidence and mortality subside, citing losses of income and benefits due to unemployment and business closures, erosion of supply chains for high-demand commodities, and lost revenue for key industries such as tourism and hospitality. On the other hand, long-term sequelae associated with infection could impede worker productivity or result in higher lifetime healthcare costs even after individuals recover, suggesting the primacy of public health interventions at the outset. The inherent tension between disease mitigation and economic well-being thus demands that post-epidemic recovery strategies include deliberative efforts to ensure that allocations of funds, resources, and investments align closely with community needs and priorities.

The process of allocating scarce public resources requires communities to consider complex trade-offs between response, recovery, and steady state activities: One informant remarked, “Often, in the planning cycle for an unknown occurrence, the issue of what to do in the recovery phase gets much less focus because … you want first and foremost to protect life and limb.” Dedicated pools of money such as the United States' BioShield Special Reserve Fund or the World Bank's Pandemic Emergency Financing Facility, for example, are primarily intended to support outbreak response activities. However, comparable funding mechanisms simply do not exist for post-epidemic recovery, despite considerable social, economic, and political costs. As a result, communities must make hard choices around how best to support long-term recovery while mitigating crises at hand with limited available resources. Noting that “it's easy to fall down the hole of spending money fixing things that are broken,” an informant pointed out that during the 2015–2015 Zika epidemic, increased public spending on mosquito remediation diverted funds from critical programs for routine immunization in some places.

From a humanistic standpoint, post-epidemic recovery entails making sense of mass trauma, fostering hope, and advancing community resilience: Effective crisis leadership is instrumental in restoring the social fabric of communities following an epidemic. Given that timelines for full recovery likely exceed the length of most elected officials' terms in office, adopting measures for long-term community revitalization could prove politically unpalatable. Nevertheless, one informant recommended that leaders of affected communities adhere to three principles: directly and visibly communicating with the public while also acknowledging unknowns; collaboratively developing strategies to sustain essential day-to-day operations; and coordinating recovery efforts across a broad array of stakeholders and sectors. Several informants further noted the importance of sustaining public trust in institutions, beginning with leaders’ efforts to elicit cooperation with prescribed mitigation measures. From a psychosocial perspective, effective leadership and empathetic crisis communication are essential to facilitating recovery from mass trauma and to advancing community resilience.

Taking both a moral and a managerial vantage point, post-epidemic recovery is a process of social learning: i.e., conducting after action analysis, improving operations, and evolving systems: Finally, systems for accountability dovetail with effective crisis leadership as catalysts of post-epidemic recovery. Efforts to institutionalize best practices and lessons learned during an epidemic – for example, through after-action analysis – not only enhance readiness for future crises but may also provide opportunities for affected communities to name harms experienced during the outbreak and assign responsibility for missteps in response.

3.4. Distinctive features

Disaster recovery models can inform epidemic recovery study and planning; yet, as key informants noted, certain aspects of infectious disease threats require greater weighting in frameworks regarding their resolution.

Recovery from epidemics is distinct from natural disasters due to an epidemic's potential to produce effects over wide areas for a long time. The scale and scope of epidemics present distinguishing features noted by informants. Natural disasters tend to be contained to a geographic area and present a more acute threat (e.g., a hurricane makes landfall, causes damage for a short time, and then recedes). On the other hand, epidemics can span the globe, with illness and death eventually occurring far from the place where the pathogen and its effects first emerged. Epidemics have fuzzy starts and stops. Depending upon the nature of the pathogen and the response, the health effects can linger, growing over time before resolving. One informant drew the analogy between epidemics and wildfires: both can persist for some time, threatening to spark effects in new places; however, unlike wildfires which are more contained geographically, epidemics can spread across oceans causing international crises.

Involving an invisible and lingering threat, an epidemic can generate much fear, uncertainty, anticipatory anxiety, and antisocial behavior. Without predictable cues as to its beginning and end, explained interviewees, an epidemic can prompt people to wonder just how long disruptions to daily life will last. Epidemics' protracted nature can exacerbate the stress of uncertainty, erode trust in institutions, and adversely affect mental health; deliberate epidemics can especially tear at a community's social fabric. Unlike a hurricane, tornado, or other natural disaster where communities of individuals come together, an epidemic represents a situation in which any individual could become infected and threaten others, thus producing fear and weakening social cohesion. Individuals may avoid places where contagion has spread and/or perceive certain groups of people as risky and to be avoided, especially already marginalized groups. Such stigma can create social isolation, disrupt treatment seeking, and contribute to unequal experiences of recovery.

The health sector is a priority infrastructure for renewal, given its unique response role and vulnerability. The primary damage in a natural disaster is obvious in the form of collapsed buildings or damaged roadways. Informants noted that – by contrast – the physical infrastructure in an epidemic remains intact; damages and adaptations are less visible to the naked eye. When HIV/AIDS emerged, it transformed the delivery of health services, including blood supply screening and isolation units. Now that the disease is manageable, HIV/AIDS health units have closed and most care is delivered in the outpatient setting. Human impacts of a major outbreak exist below the surface, even while hospital and health departments are still standing. Caring for infected individuals and working to prevent more infections, practitioners remain vulnerable themselves, especially when no effective vaccine exists. They also face the prospect of exhaustion and burnout given protracted, high-stakes work. Healthcare facilities, too, may experience blows to reputation and revenue, if associated with contagion. Preserving workforce wellbeing and bolstering resilience to future outbreaks by engaging in an effective course correction process were recovery priorities for informants.

4.1. Engagement with research on natural disaster recovery

Comparing key informant observations with learnings from the mature field of disaster recovery research suggests some potential parameters for epidemic recovery modeling as well as points of convergence. To begin, the study of natural disaster recovery has evolved from an initial focus on immediate and apparent damages that equated recovery with the rebuilding of physical surroundings, to a much more comprehensive treatment of disaster impacts and of integrated efforts to make communities whole again – politically (e.g., faith in institutions), economically (e.g., competing financial priorities), socially (e.g., social cohesion), environmentally (e.g., natural mitigation), and emotionally (e.g., sense of safety) (Arendt and Alesch, 2014; Johnson and Hayashi, 2012; Lindell, 2013; Monteil et al., 2020; Philips and Neal, 2007; Smith et al., 2018; Tierney and Oliver-Smith, 2012). Similarly, our key informants argue for a holistic model of post-epidemic healing, rather than a purely biomedical one; they cite, for instance, the greater psychological, social, and economic costs and, hence, the complex recovery challenges that arise with the fear of contagion.

Although warning against a medicalized definition of epidemic recovery, interviewees still want added scrutiny of the health sector due to its heightened vulnerability (especially human resources) in a major outbreak. Reflecting this, an epidemic recovery model can benefit from the natural disaster literature's holism and from the health systems-strengthening literature's emphasis on sector resilience in high-, middle-, and low-income settings. Health systems research suggests that success of disaster recovery efforts depends on sector capacities to absorb and adapt to the impacts of rapid onset crises, and to evolve to meet the demands of post-crisis environments (Blanchet et al., 2017; Kruk et al., 2015). Given that epidemic effects are most severe in low-income countries – which typically have weak capacity to deliver routine health services – the health systems-strengthening scholarship can help accommodate epidemic recovery thinking in applying to a spectrum of diverse geographies, resource levels, and governance structures.

Interviewee comments resonate with other major findings in the study of natural disaster, such as knowing multiple futures are possible post-disaster: on one end, transforming society, and the other, replicating the status quo (Fernandex and Ahmed, 2019; Kim and Olshansky, 2014). Where communities ultimately fall on this continuum depends in large part on how competing social aims, economic interests, and/or political powers play out: get back to how things were even though vulnerability to a future disaster remains (e.g., rebuild in a flood zone) or make systemic improvements (e.g., turn formerly occupied floodplains into green fields and build affordable housing elsewhere) (Arendt and Alesch, 2014; Smith et al., 2018; Tierney and Oliver-Smith, 2012). Key informants, too, highlighted that the post-epidemic process entails complex trade-offs, as in scarce public resources being carved up among response, recovery, and steady state needs, and that people waver in defining post-epidemic recovery as a return to baseline or a chance to evolve.

Natural disaster theorists have moved away from early recovery models marked by fixed phases, predictable milestones, and uniform progression (Rubin, 2009). Instead, they have envisioned post-disaster recovery as a non-linear, multi-level process that can unfold unevenly, depending on an affected group's socio-demographics and the unit of analysis under study: e.g., household, neighborhood, community, sector, region (Arendt and Alesch, 2014; Finucane et al., 2020; Johnson and Hayashi, 2012; Monteil et al., 2020; Tierney and Oliver-Smith, 2012). After a major flood or hurricane, an affected city may seemingly be back to normal. Yet, specific neighborhoods may still be lacking critical services and individual families still reeling from financial and psychological effects. Disaster researchers note, too, that event severity can influence the cadence and quality of recovery (Philips and Neal, 2007). Similarly, study informants cautioned that a one-size-fits-all model for post-epidemic recovery may be impossible because “it depends.” An epidemic is a very organic event in which elements of culture, the social sphere, politics, health systems, human biology, and pathogen are integrally related.

The study, policy, and practice of natural disaster recovery reinforce the need for certain elements in a model of epidemic recovery and potentially speed a model's development. At the same time, the key informants called out the need for any epidemic recovery modeling exercise to be mindful of the idiosyncrasies and complexities of a biological incident.

4.2. Implications for community recovery from COVID-19

The course of the COVID-19 pandemic is still unfolding. Recovery is highly desired, but consensus about what that means and how to get there seems lacking. In their commentary on post-epidemic recovery, the study informants called out dilemmas and unsettled questions that seem prescient, when applied in the current context: Are medical and/or economic indicators alone sufficient to gauge if a community has really recovered from the pandemic, or should indicators for things like social connectedness and solidarity and/or psychological stability and growth after trauma also be included (South et al., 2020; Jewett et al., 2021; Yong, 2021)? Can a city or country claim that the pandemic is “over” for its residents, when specific communities and social groups are still struggling (Corbie-Smith et al., 2021; Baral, 2021)? Does or should recovery from the pandemic equate with a return to the familiar rhythms of life before the SARS-CoV-2 virus emerged or a fundamental reconfiguration of society so as not to have the same thing happen again (Carlson and Phelan, 2020; Loewenson et al., 2021; UN, 2020)?

In the U.S., pandemic recovery – judging from news reports and official statements – has been to date conceptualized largely in terms of falling case numbers, hospitalizations, and deaths; the number of vaccinations administered at state and national levels; and the resumption of educational, social, and commercial routines (National Governors Association & Association of State and Territorial Health Officers, 2020). Rare is the vision of pandemic recovery in a more holistic and transformative sense, as in the case of the Hawaiʻi State Commission on the Status of Women (2020). This state body sees the process as a chance to advance sustainable livelihoods, strengthen the state's social infrastructure (i.e., childcare, education, and health care), protect the state's natural ecology, and repair historical harms and intergenerational trauma due to sexism and racism.

The trajectory of the COVID-19 pandemic in the U.S. illustrates the scale at which holistic recovery efforts must proceed, as well as the levels of coordination, stakeholder involvement, and investment of human, social, and financial capital that this undertaking will undoubtedly demand. These efforts must also consider how the health and economic burdens of COVID-19 have disproportionately harmed marginalized communities, particularly lower-income communities of color (Alcendor, 2020; Corbie -Smith et al., 2021). Concomitantly, the benefits of vaccination, remote working arrangements, pandemic relief loans to businesses, and other measures intended to alleviate these burdens have not been equitably distributed among the communities hit hardest by the pandemic (Gould and Shierholz, 2020; Hamel et al., 2021; Heeb, 2021). Thus, recovery plans must necessarily center transformation, taking care to ensure that restorative efforts do not simply refabricate the starting conditions that gave rise to the inequitable impacts of COVID-19 (Schoch-Spana et al., 2021).

Post-pandemic recovery will likely proceed at varying timelines across different settings and communities, depending on the unique social and structural factors modulating the trajectories of local COVID-19 epidemics. A robust model of epidemic recovery that accounts for these factors, articulates the relationships between them, and centers input and evidence from the hardest-hit populations, could help decision-makers at all levels navigate the process of restoring and transforming their communities.