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January 6, 2022

A National Strategy for the “New Normal” of Life With COVID

Author Affiliations
  • 1Perelman School of Medicine and The Wharton School, University of Pennsylvania, Philadelphia
  • 2Center for Infectious Disease Research and Policy, University of Minnesota, Minneapolis
  • 3Grossman School of Medicine, New York University, New York, New York
JAMA. 2022;327(3):211-212. doi:10.1001/jama.2021.24282

As the Omicron variant of SARS-CoV-2 demonstrates, COVID-19 is here to stay. In January 2021, President Biden issued the “National Strategy for the COVID-19 Response and Pandemic Preparedness.” As the US moves from crisis to control, this national strategy needs to be updated. Policy makers need to specify the goals and strategies for the “new normal” of life with COVID-19 and communicate them clearly to the public.

SARS-CoV-2 continues to persist, evolve, and surprise. In July 2021, with vaccinations apace and infection rates plummeting, Biden proclaimed that “we’ve gained the upper hand against this virus,” and the Centers for Disease Control and Prevention (CDC) relaxed its guidance for mask wearing and socializing.1 By September 2021, the Delta variant proved these steps to be premature, and by late November, the Omicron variant created concern about a perpetual state of emergency.

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    13 Comments for this article
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    Primary Care at the Center of the New Normal
    Howard Haft, MD, MMM | Maryland Department of Health
    The authors provide a credible description of the future of our relationship with Covid-19 and a nearly complete list of the actions that are needed to cope with the new reality and be prepared for future threats. However the largest part of the healthcare delivery system was notably absent on this list, the primary care workforce. Primary care, when well resourced and integrated with public health, provides the ability to implement public health strategies broadly across states and jurisdictions. Widely deployed, capable of immunizing populations, testing for both surveillance and treatment, and highly trusted communicators of mitigation strategies, this workforce has the capability of filling in many of the gaps in the current public health system.

    For example, the broadly implemented Maryland Primary Care Program has demonstrated how bringing public health tools and resources to primary care can amplify and support public health response to a pandemic, amplifying the coordinated statewide response to testing, vaccination and therapeutics.

    As we contemplate the future of the overall healthcare delivery system in the USA , integrating primary care with public health should be a key initiative, with primary care serving as a public good.
    CONFLICT OF INTEREST: None Reported
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    Brilliant
    Judy Malmgren, PhD Epidemiology | University of Washington
    I have been thinking along these same lines for months. So glad someone else wrote the piece! We need to reestablish the public health traineeship program in Schools of Public Health that paid part of my tuition to become an epidemiologist. We need replacements for me and my cohort as we retire, but with an increase in numbers. Systems and infrastructure that function on a large scale need to be built that can handle millions of cases. Already the reporting scales used by health departments are inadequate. Build the infrastructure -  we need it desperately.
    CONFLICT OF INTEREST: None Reported
    A National Strategy for a Disunited Nation?
    Steven Livesey, History of Science | University of Oklahoma
    In their paper, the authors urge the creation of a new national strategy to look beyond the current Covid-19 crisis and to bring Covid responses into a larger, more robust public health system. They assert, “To cope with pandemic, and eventually endemic SARS-CoV-2, and to respond to future public health threats requires deploying real-time information systems, a public health implementation workforce, flexible health systems, trust in government and public health institutions, and belief in the value of collective action for public good.”

    These are laudable goals and certainly recognitions of necessary components. But nowhere in their essay do
    the authors tell us how we are to achieve trust in government and belief in the value of collective action for public good. On the anniversary of the January 6 insurrection, we seem to be very far from this collective purpose, and no one seems to have a feasible plan to rebuild the trust that has been eroding for at least the past 2 generations. We cannot convince sizable populations to adopt basic public health strategies like wearing masks in close interior spaces, and state governments across the country are actively opposing mitigation strategies that the authors suggest.

    Until the authors augment their paper by explaining how to heal the disunity so prevalent in modern America, I see little in the recommendations here that will be implemented successfully.
    CONFLICT OF INTEREST: None Reported
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    Endorsement and Integration with Mental Health Care
    John P. Glazer, MD | Child and Adolescent Psychiatry
    All Americans, and the medical provider community who serve our citizens, owe Dr. Emanuel and his colleagues a debt of gratitude. It is not comfortable to speak out so directly but absolutely necessary in the health crisis we all face.

    I urge all Americans to take the authors’ specific recommendations with the utmost seriousness and the Biden administration to immediately open communication channels with these distinguished physician members of the former Biden transition team; and urge that the burden COVID, flu, and other respiratory viruses pose for Americans with limited resources, and those dealing with depression, anxiety, and suicidal
    feelings, particularly children and teens, be directly addressed, with desperately needed treatment resources directed to them.
    CONFLICT OF INTEREST: None Reported
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    COVID Data Analysis
    David Loiterman, MD | Past Board Chair and President, Chicago Medical Society ( Ret )
    Thank you for publishing Dr Emanuel and colleague’s perspective on proposed forward-looking strategies for dealing with COVID, RSV, and other endemic respiratory pathogens.

    The two newly released antiviral anti-replicative medications as well as other creative antiviral medications in the regulatory pipeline will play a large role in future management.

    Data context is also important when forming public health policy. Approximately 10,000 US residents die every day. Roughly 1600 of those are expected to be attributed to viral, bacterial, and respiratory diseases within a range of expected variance at the 95% confidence level.

    In formation
    of appropriate public health policy the distinction between mortality with COVID and mortality directly related to COVID is important to make.
    CONFLICT OF INTEREST: None Reported
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    What's Not to Agree With?
    John Zahradnik, MD | Private Infectious Diseases consultant
    This editorial supports what myself and a few others have been preaching for the past year. COVID-19 will never leave us for the foreseeable future. Too many people declining to wear masks, denying the disease, and insisting on the uselessness of any vaccine.

    I totally agree that the country needs a plan similar to what is presented here. The trouble is roughly half of US elected officials do not believe this is a problem and have long ago accepted influenza deaths as inevitable and not preventable.

    I will continue to receive the necessary vaccines and mask
    up today and in the future. My family does the same and hopefully will in the future.

    CONFLICT OF INTEREST: None Reported
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    Whence "Trust in Government and Belief in the Value of Collective Action"?
    Jim Recht, MD | Instructor, Harvard Medical School
    Its omission of economics/politics renders this statement practically useless. The authors affirm that "trust in government and public health institutions, and belief in the value of collective action for public good" are pre-requisites for an adequate response to respiratory virus pandemics. But this just begs the question of why our society appears so devoid of trust or shared belief. The authors offer a hint, by comparing our own dismal COVID response to Denmark's. What is it about Denmark that lends itself to trust, collective tolerance, and a sustainable response to widespread serious illness outbreaks?

    The answers are pretty elementary:


    1. Universal healthcare, and
    2. One of the world's lowest income equalities.

    These are not extraneous matters. They are crucial to the development and maintenance of a viable public health system.

    When are we health professionals going to acknowledge this and act accordingly?

    CONFLICT OF INTEREST: None Reported
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    Focus on Improving Personal Health
    Eileen Natuzzi, MD, MPH | Trauma surgeon (retired); San Diego Department of Public Health (volunteer)
    The authors stay focused on the same measures used throughout this pandemic and do not go beyond those measures or read what community tolerances for those measures have been. Their view is bureaucratic and not from the public's standpoint. It’s not a matter of doing more but rather what was tolerable to the public and what messaging worked. The authors hint at the possibility of lockdown or other severe measures for bad annual flu outbreaks but a weary and mistrusting public will ignore or push back against any additional constraining measures. Instead we need to encourage self-empowering behaviors such as improving one’s personal health risks through weight loss, better dietary habits, and regular exercise.

    Part of rebuilding the public health system must include the seamless integration of public health with the healthcare system. That has to include public service announcements and education that focuses on preventing diseases that put people at serious risk of respiratory infections. Two years into this pandemic we know what those risks are but have made no significant headway in helping the public address them.
    As the authors write, the vaccines will not take us to zero COVID. And while they have afforded protection from serious illness we are still placing way too much faith in them. The new public health paradigm must promote, not mandate, healthy habits and practices that can empower the public not restrict them. We can not do this with vaccines alone.

    CONFLICT OF INTEREST: None Reported
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    No Surrender - Where There's a Will There's a Way
    Yaneer Bar-Yam, Ph.D. and Coauthors | World Health Network
    The authors propose that, in contrast to a zero COVID policy, we surrender to the pandemic, setting an acceptable level of deaths as policy success. In an accompanying article Michales, Emanuel, and Bright propose this can be achieved by improved vaccination, testing, surveillance, masking, ventilation and distancing.

    Preventing exponential growth is the key to any control strategy, including the authors. There is no “level control”; rather the control variable is a growth rate R. Staying at a particular level requires keeping R=1, and if we could keep R=1 we could equally set R a bit lower and go down
    to any level we choose.

    A surge mentality might reduce the impact of variants or seasons. However, once that can be achieved, it is not only possible to reach elimination, it is easier, just as controlling a fire is easier when it's smaller. The easiest by far is elimination, even if there are new fires that arise from time to time.

    The authors may have the misconception that there is a tradeoff with economic costs or individual freedom, debunked by economists widely, including those of the IMF [1-3]. Economic losses are higher and freedom restrictions more severe due to the need to eventually control a conflagration rather than relying primarily on contact tracing for a limited number of local outbreaks. Indeed, states in Australia that abandoned elimination aren’t returning to pre-pandemic mobility (Capital territory -27% in Q4, Victoria -20%, New South Wales -19%) measured by Google mobility data (Workplace % change from early 2020). Deaths are up and mobility is down. They are losing on all fronts. On the contrary, where elimination continued to be the goal, mobilities in Q4 had a slight increase (+2% Northern Territory or Queensland vs 5 weeks in early 2020) or a slight decrease (-3% South Australia) [4].

    Also missing from their considerations is accumulation of long covid over time, with widespread loss of normal life, organ damage, and disability.

    Or perhaps the authors are fatalistic about elimination. Despite the rapid transmission of Omicron, the recommendations they make—a surveillance system with widely available testing—are sufficient. Testing four times a week with self-isolation is enough. Even better would be twice daily saliva tests leading to a more rapid decline than Omicron’s growth. Combining this with other mentioned methods—N95/KN95 masks, distancing, ventilation—would make this even easier.

    We are proposing the same actions, but with a different goal: more ambitious, more compassionate, and more, rather than less, feasible—and a strategy for this pandemic and the next one.

    Not everyone may participate, but all-in participation is unnecessary for success, which is not guaranteed. Still, this is a robust strategy. Even if not all goals are reached, striving for elimination is the path paved with greater success along the way.

    Where there is a will, there is a way.

    We cannot surrender to COVID. A level of “acceptable deaths” is a euphemism for saying it is acceptable that immunocompromised people and those with risk factors that make them vulnerable to severe disease can die.

    Y Bar-Yam {1,6}

    S Bilodeau {2,6}

    C Philippe {3,6}

    MF Schneider {4,6}

    SK Raina {5,6}

    EL Ding {1,6}

    NN Taleb {1,6}

    Affiliations

    1} NECSI, USA

    2} Smart Phases, USA

    Institut économique Molinari, France 4} Physics Dept, Tech Univ of Dortmund, Germany 5} Dr. RP Govt. Medical College, India 6} World Health Network

    References

    1] SARS-CoV-2 elimination, not mitigation, creates best outcomes for health, the economy, and civil liberties Oliu-Barton, Miquel et al.The Lancet, Volume 397, Issue 10291, 2234 - 2236.

    2] https://www.institutmolinari.org/wp-content/uploads/2021/09/zero-covid-whn-sept2021.pdf 

    3] https://www.imf.org/en/Publications/WEO/Issues/2020/09/30/world-economic-outlook-october-2020 

    4] Google COVID-19 Mobility Reports - https://www.google.com/covid19/mobility/

    CONFLICT OF INTEREST: None Reported
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    In an Advanced Nation This would be Possible
    Christopher Cervantes, MD | Urgent Care
    I agree with Professor Livesey.

    To put it bluntly, these suggestions are painful fantasies for a nation as backward-looking as the United States. I am lucky to live and practice in a municipality that has made a valiant effort resisting the deliberate sabotage of public health measures by politicians and judges at the state and federal level, but we’re not the kind of nation that believes in the same set of facts, much less the same threats or the collective actions required to meet those threats.

    I recommend JAMA emphasize strategy pieces that can be implemented
    locally in a highly fragmented society. This is our reality.
    CONFLICT OF INTEREST: None Reported
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    Towards a Better US Public Health System – Alert Levels, Alliances, & Advocacy
    Maria Schletzbaum, MD / PhD Epidemiology (candidate, MSTP Program) | University of Wisconsin School of Medicine and Public Health
    Drs. Emanuel, Osterholm, and Gounder present key social and biological reasons underlying the likelihood that in the US and elsewhere we will need to adapt to living with SARS-CoV-2, crucially moving past biomedicine’s historical preoccupation with pathogen elimination. While laudable, it should be noted that eradication has succeeded only twice and, as the authors allude to, under vastly different biological parameters.

    Perhaps most importantly, the authors present four key elements for building the US public health infrastructure. While the authors highlight some of the most pressing holes identified by the pandemic – data infrastructure, personnel, and trust –
    three vital points should be expanded upon as necessary to implementing the outlined vision for US public health:

    1. Regarding the “national risk level” and “risk threshold[ing],” we can do, and other countries have done, much better than having a single level based on weekly national counts of cases, hospitalizations, and mortality. The development of a public health alert level system, such as the one used by New Zealand (1), could be implemented at not just national but also state and local levels. Critically, the alert levels should be tied to public health actions, such as mask mandates or gathering restrictions. This will bring transparency, consistency, and a greater ability to anticipate future public health guidance, addressing criticisms currently brought against public health messaging in the US. These alert levels can be based on multiple objective metrics derived from local data, providing real-time risk information to the public, and should be shielded from real or perceived political influence.

    2. We need to acknowledge that past US pandemic strategies have been too narrowly focused on the public health system and short-term threats, with little attention paid to other systems that keep society moving, especially over prolonged periods of time. Part of the building of American’s public health infrastructure must include greater integration with other systems, including healthcare organizations, schools, non-profits, businesses, and industry. It is not just public health that needs a pandemic plan, but every organization, institution, company, and level of government that needs guidance and altering of operations under public health emergencies.

    3. The authors rightly highlight the ‘collective action problem’ that faces public health. Done well, public health benefits nearly everyone (though not necessarily equally) in ways that are imperceptible. Thus, public health does not have concentrated interest groups lobbying for it, but there are often powerful concentrated interest groups lobbying against specific public health-oriented actions or policies. At times, some of the fiercest opposition to expanded public health infrastructure has come from physician professional organizations and the healthcare industry. Implementing some of the programs the authors mention (school health expansion, real-time data sharing) will require concessions and support from these powerful groups. In medicine, it will be crucial for us to move beyond the protection of our professional sphere in order to lend our powerful voices to improving the health of the American public by endorsing the building of America’s public health infrastructure.

    Reference

    1) New Zealand Government. History of the COVID-19 Alert System. https://covid19.govt.nz/about-our-covid-19-response/history-of-the-covid-19-alert-system/#alert-levels. Updated December 3rd 2021. Accessed January 18, 2022.

    CONFLICT OF INTEREST: None Reported
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    Public Health and Public Trust
    Michael Akers, Pharm.D. | Retired
    While the essay by Ezekiel et al provides a framework for moving forward with COVID in America, it does not address conceptions of individual freedom. The authors' fourth point suggests that elevating the level of trust in public health institutions will allow for more robust collective action for public health in America. Denmark is then highlighted as exemplary for their level of trust for public health. The accompanying citation does not include any discussion of Denmark’s level of trust for public health. In fact, the only country specifically mentioned in the citation is China. This adds an interesting twist when speaking of social trust, because can social trust be accurately measured in China when compliance is required as opposed to optional?

    People often do not understand the pushback regarding public health policy in America. It is because while any policy may provide benefit for some individuals, there is no way it can provide benefit for all individuals. No public health policy will affect everyone equally. Individuals are the only ones who can and should be making decisions regarding their health. Does that mean that guidance should not be offered when individuals need health care? Of course not, but the ultimate decisions should be up to the individual.
    CONFLICT OF INTEREST: None Reported
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    Predictions
    Daniel Krell, MD | Retired PCP
    I’m pleased with this article and with many of the comments, and have thoughts about one aspect mentioned, building public trust. It would be very helpful if news media and influencers are better schooled in the realities of epidemics and pandemics, and infectious diseases in general. I feel disappointment and anger every time a media personality or influencer asks a speaker (epidemiologist, infectious disease expert, CDC or NIH representative, the president, others) to opine when this will be over, and/or when we will be able to return to normal. I have even heard more than one interviewer use the term, "date certain" for when masks, immunizations and other mitigating strategies will no longer be necessary.

    There is no "date certain"; we have no idea when the urgency will be over. Given the lack of adequate global vaccination; global travel; organized resistance to mitigation measures; hand-puppet politicians; and mistrust of government and "science, it's not hard to envision national and regional new viral variants that quickly become global. We lucked out with omicron but there is no guarantee that the next global variant will not be distinctly worse. If an informed speaker opines about an estimated timeframe, they will likely be wrong. If the speaker commits the sin of saying, "I don't know," they will be responding honestly but may not be asked again, or asked back, based on their honesty. The interviewer puts the speaker in a lose-lose situation if they demand specifics.

    Thus, media personalities and influencers have a responsibility to avoid direct questions about timetables for return to normal, but to work to educate their audiences about the uncertainties at play. I know that such interviewers are motivated to have interesting and provocative interviews to keep their audiences and sponsors attentive and happy, but they do a disservice to the speaker and ultimately the public and the national effort to constructively engage with the pandemic.
    CONFLICT OF INTEREST: None Reported
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