How “New” Will “Normal” Actually Be?

Be careful what you wish for. Just a few months ago, before the words “COVID-19” and “social-distancing” became a regular part of our conversations, I was speaking with the Operations Chief of an EMS service about the difficulty in hiring and retaining paramedics. He said it would take “a downturn in the economy before we could hire enough medics” since candidates typically gravitate toward stable jobs in public service when the market is in a recession. Well, its technically not a recession, but the current pandemic is clearly stressing the world economy and even altering patterns of use for many EMS agencies. In some areas of the country, call volume is now out-stripping capacity while others find themselves in a very different place with far fewer calls than normal. So, as we even consider whether we still need the paramedics we had planned, the immediate questions become “what is ‘normal’,” and “what could be so ‘new’ about it?”

The past can often be a good guide. My primary job in consulting is helping agencies with the optimization of their resources. Doing this successfully requires that I can discover patterns from history to guide forecasts of the immediate future. This is a difficult position when the world is no longer behaving according to the regular fluctuations of the past. Yet, as an undeterred student of history, I continue to search for models that can illuminate the path before us as I did regarding demand in my previous post. There is no shortage of significant anecdotes from history to review, but each has its limitations when applied to today.

My first study was the so-called “Spanish Flu” of 1918-19. It was the deadliest pandemic in history that infected nearly a third of the human population and killed well over 20 million (or by some estimates more than 50 million) victims, including some 675,000 Americans. This historic pandemic had a similar effect to today by shutting down world economies and hiding its population behind face masks. The scariest consideration of a modern parallel to this period would be the idea of an even more devastating second (or even third) wave of infections yet to come. This historic flu, however, was still not able to destroy the world order as some feared. In fact, it preceded one of the greatest economic expansions of industry leading to a period that would be known as the “Roaring Twenties.” The score of our current pandemic is merely a shadow of its predecessor with less than 5 million worldwide infections known and slightly more than 300 thousand total deaths around the globe. So, could we also expect a similar economic boom following our current crisis? That is highly doubtful as the economic conditions preceding this shutdown were entirely different than a century ago. And I’m also not sure we would necessarily want that same exuberance that stemmed from a generation that developed an attitude of “nihilistic hedonism” born from a season of austerity and fear caused by the disease. The age group primarily affected at that time developed a laissez-faire attitude toward life fueled by a rapid rise in prosperity induced by sweeping changes in technology, society, and economy. It was literally the beginning of the modern age – and then came the worst economic depression ever.

Fortunately, the current death toll is still far too low to engender a similar sociological backlash even in a time of modern polarized politics echoing the protests of the last century. With a presidential election less than six months away, many states have entered some form of “Phase 1” of a controlled economic reopening of society. There are probably as many anecdotes as opinions with states like Texas going big on economics over epidemiology compared to the more cautious moves of hard-hit states like New York and New Jersey only ‘cracking open’ slowly. While scientific advances are promising, we still do not have a vaccine, effective treatment, or even reliable tests. Yet we seem reliant on the promise of “contact-tracing” in an environment of community-spread rather than recognized efforts elsewhere at “contact-isolation.” So we can likely plan on seeing more cases of COVID-19 in the coming months and political reactions will likely vary with an increased influence of politics.

What is likely to be lasting from our current experience are new “telemedicine practices” being implemented by physicians and widely accepted by a public that fears even going to the hospital at the moment. If EMS will ever be able to justify the continuation of Community Paramedicine practices or possibly even extending them through their own Mobile-Integrated Healthcare outreach (or as a home-provider within the telemedicine practice of doctors) it will be right now. If the opportunity of the current crisis passes without making political gains to extend the reach of EMS, it will only be more difficult to accomplish in the future. We have also seen traditional conferences gone virtual to eliminate travel and large physical gatherings. Although the experience lacks some of the traditional perks, it has huge cost and time savings. Similarly, professional-referred journals are quickly giving way to a faster social exchange of information and ideas online that bypasses traditional peer-review being replaced by a new social review creating “healthcare influencers” online. To continue this trend, we must figure out how to “qualify” these social icons in the long-term and socially circumscribe their power.

There are also examples we could study of pre-hospital responses to HIV/AIDS, MERS, and SARS. Even though each occurrence caused a significant public panic and subsequent EMS response, their lasting influence quickly waned and the lessons they taught for preparedness were not applied nationally to help us respond to a pandemic. Consequently, the real strategic question we must consider in planning for the future is fortunately not how society will react or estimate how many cases of COVID-19 we will experience, but what effective change will be wrought related to how EMS functions or is financed going forward. As we contemplate moving out from the Department of Transportation  where we are paid only for moving patients, we could consider the terrorist attacks of September 11, 2001, as another example of a precedent model. However, that initiating event concluded within hours and its perpetrators targeted an ideology rather than a lack of immunology. Both passions and fears were inflamed worldwide by these coordinated attacks, but the only lasting results have been legislation expanding government surveillance in the Patriot Act (reauthorized yet again nearly two decades after the event), the creation of a new government bureaucracy over the traveling public in the Transportation Security Administration (which remains focused largely on airline travel which was the target of the terrorists at that time), and the longest on-going war of American history.

Today, the enemy has no flag and the world (or even our industry) also has no unified leader to coalesce a response tactic. Even in the field, the providers of EMS services cannot agree on whether we represent public safety (which justifies an essential funding stream for the public good) or that we provide bona fide healthcare services as a part of an integrated service stream offering appropriate care anywhere from the home to a hospital (that is worth reimbursement independent of driving someone to the hospital.) What history teaches us are several lessons. First, government responds to situations that expand its own interests and that are simultaneously supported by the affections and desires of the public. Even during this EMS Week, it is doctors and nurses who are seen on the front lines of the pandemic war even though the tip of the spear is made up of Emergency Medical Services professionals who go into the homes of the sick and reach through the wrecked vehicles of the injured to risk themselves in the preservation of others. We will continue to be the ‘invisible third service’ as long as we struggle with our identity and lack the statement of a value proposition for a suitable underlying financial mechanism. Second, government consistently responds along an evolutionary path to the last threat rather than a forward-thinking approach. Until we can justify the payment for necessary treatment on scene in addition to any transport to definitive alternative destinations, we will not see revolutionary change. Even wars can be waged indefinitely as long as no one notices they continue. 

We may see some fluctuation in demand for a while, but in the long-run we will return to a familiar normal fare of heart attacks, strokes, and falls once again. It may not be the exact same place we left months ago, but it will not be an entirely new place either. The struggles we fought before will continue to be our struggles again. Hiring and retaining paramedics will again become a topic of discussion as we continue to fight for budgets to maintain our response metrics. That is unless we can learn from one other historical example that comes from back in 1843.  That is the year that Charles Dickens published his famous work known as, A Christmas Carol, where the the Ghost of Christmas Yet to Come prophesies, “If these shadows remain unaltered by the Future, the child will die.”

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