What We’ve Forgotten About Getting Well

“What, then, is to be done with those who are not yet fit for work-a-day life? Every hospital should have its convalescent branch, and every county its convalescent home.” —Florence Nightingale

On a Monday night this winter, my wife and I awoke to the distinct sound of retching. We flung off the covers and ran down the hall with pails and towels, like a Victorian couple rushing to a bedroom fire. I grabbed our distressed 2-year-old daughter and dove into the bathroom seconds too late — it is a parental rite of passage to be covered in vomit, I realize. After getting her comfortable though, I thought only of myself: Oh, please, Do. Not. Be. Norovirus. 

Two days later we ran the same drill for our 4-year-old, one bedroom down. Now I was on edge. Every twinge of nausea was certainly the onset. Within a week, we all succumbed. Curiously, along with gastrointestinal upset, the manifestations also included high fevers, pinkeye, and upper respiratory infections. We deduced the house had been stricken with Proteus of the viral world: adenovirus. Symptoms waxed and waned for many weeks. As physicians, we were perplexed. “How can we still be sick?” “Why am I still so tired?” Victorians, in fact, would not have been puzzled by our symptoms. They understood something about medicine we have forgotten: the liminal space between disease and health called convalescence. 

The word “convalescent” conjures images of heroines of 19th-century novels resting, reading, and perambulating through rose gardens. A century ago, patients neither sought nor expected a “speedy recovery.” Rather, they embraced a delightfully slow meandering recuperation. This clashes with our current understanding. For diseases that have treatments, there is no halfway. If you are cured microbiologically, if your tests are normal, then you’re healthy. The model of medicine in that period was different. You were not cured until you had regained strength, a process that occurred between acute illness and health. To restore health required not just the work of doctors, but also the work of nurses and family. Convalescence happened outside of the stress and pollution of working life, preferably in the English countryside or highlands of India where fresh air, a green landscape, and books would be prescribed. The word comes from the Latin valescere, to grow strong and con-, together. They would have laughed at our bewilderment of long COVID. Of course, it takes weeks to months to recover from a serious viral illness! This is what the convalescent period is for. 

The idea is older than the Victorians. Galen writing in the second century described the three states of health as sick, well, and neutral — that condition when a patient was neither ill nor yet healthy. We might find much of Galen’s understanding of physiology as archaic, yet his understanding that health states are not binary might be more sophisticated than ours today. From that time though the physicians of the late 17th and 18th century described how the consumption of natural humors led to postacute symptoms of fatigue, anorexia, weakness, and melancholy. The remedy was rest, fresh air, good diet, and relief from the pressure and pollution of work. 

Whereas country convalescent homes proliferated in the mid-1800s, it was hospitals that eventually took over convalescent care. Toward the end of the 19th century, rehabilitation was medicalized, scientific. Convalescence was bound up with the need to preserve manpower in imperial India and South Africa and, later, with the British and American troops in World War I. The emphasis shifted from convalescence as a slow, organic process to an efficient, rigid one. With the development of physical and occupational therapy, it was pulled from the work of caregivers and family and given to physicians and case workers. With governments and payers now footing the bill, economy became the priority. Rather than the patient determining when they were well, we instead score activities of daily living, degrees of flexion and extension, ability to lift 10 pounds. We count patient day rates and hospital readmissions rather than the number of novels read or letters written. 

Modern medicine’s triumph over acute illness has been remarkable, but in focusing solely on disease elimination, we’ve forgotten the art of recovery. We measure vitals and labs but have no metric for the return of vitality. We rarely discuss the path back to stamina. Our electronic health records have no lexicon for “convalescent.” 

The pandemic forced us to rediscover this forgotten knowledge. Patients with long COVID describe precisely what our physician ancestors understood: that recovery is not linear, healing takes time. They seek what Florence Nightingale prescribed: spaces dedicated to recovery, time away from the demands of daily life, and recognition that they are neither sick nor well, but somewhere in between. 

Perhaps it’s time to reclaim this lost wisdom, to recognize that between illness and health lies a necessary space for recovery. Not every illness needs a Victorian-style retreat, but every healing body needs time to grow strong again. The Victorians may have not known much about medicine, but in their understanding of convalescence, they understood something profound that we would do well to remember. With our 4-year-old complaining of a sore throat today, I’m afraid our house will be reminded of this here again soon. 

Jeffrey Benabio is chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr Benabio is @Dermdoc on X.