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COVID-19: Beyond Tomorrow
May 4, 2020

Choices for the “New Normal”

Author Affiliations
  • 1Institute for Healthcare Improvement (IHI), Boston, Massachusetts
JAMA. 2020;323(21):2125-2126. doi:10.1001/jama.2020.6949

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has only 15 genes, compared with 30 000 in the human genome. But it is a stern teacher, indeed. Answers to the questions it has raised may reshape both health care and society as a whole.

No one can say with certainty what the consequences of this pandemic will be in 6 months, let alone 6 years or 60. Some “new normal” may emerge, in which novel systems and assumptions will replace many others long taken for granted. But at this early stage, it is more honest to frame the new, post–COVID-19 normal not as predictions, but as a series of choices. Specifically, the pandemic nominates at least 6 properties of care for durable change: tempo, standards, working conditions, proximity, preparedness, and equity.

The Speed of Learning

Will the tempo for learning and improvement be faster in the new normal than before? A famous meme in health services research is that proven, favorable innovations take years to reach scale; one often-quoted study claims that the average cycle time is 17 years.1 Not in this pandemic. In London, the National Health Service converted the massive Excel Convention Center into a 2900-bed intensive care unit—renamed the Nightingale Hospital London—which admitted its first patient just 18 days after planning for this new center began. Within weeks of COVID-19’s arrival, US academic medical centers produced detailed clinical care guides with sound pedigrees available for all2; the more familiar, former pace of official guideline development would have taken months or years. Within weeks of the outbreak in China, a case series of nearly 73 000 patients defined the basic risk factors for mortality.3 Biomedical companies, start-up entrepreneurs, and universities are on a fast track toward new diagnostics, antivirals, and vaccines. Assumptions are dissolving about how much time progress takes.

The Value of Standards

Clinicians in the new normal may be less tolerant of unwarranted variation in health care practices. The COVID-19 norm is to welcome standardized clinical processes, as opposed to reflex defense of “clinical autonomy” as the primary basis for excellence. The strangeness of the COVID-19 clinical territory leaves even experts looking for guidance from trusted sources. Clinicians and hospitals want counsel on how to handle the unwelcome ethical dilemmas they may encounter if and when resources reach their limits, such as rationing ventilators.4 On March 11, 2020, the National Academies of Sciences, Engineering, and Medicine created a new Standing Committee on Preparedness for Emerging Infections and 21st Century Threats; by April 11 the committee had issued 11 formal “rapid expert consultation” documents, consumed immediately by both professional and lay media.5 Will the new normal embrace global learning, shared knowledge, and trusted authority as foundations for reducing harmful, wasteful, and unscientific variation in care?

Protecting the Workforce

SARS, MERS, and Ebola placed health care workers at very high risk, and the COVID-19 pandemic, because of its scale, amplifies that threat massively. Sadly, attention to health care worker safety has languished at far too low a level of priority for decades. Now it is evident how unwise that is, as millions of workers face personal risks that they would not encounter if protective equipment and preparatory procedures had been arranged in advance. Will the new normal address more adequately the physical safety and emotional support of the health care workforce in the future? Without a physically and psychologically safe and healthy workforce, excellent health care is not possible.

Virtual Care

Hippocrates saw patients face-to-face, and medical care still mostly relies on personal encounters. COVID-19 has unmasked many clinical visits as unnecessary and likely unwise. Telemedicine has surged; social proximity seems possible without physical proximity. Progress over the past 2 decades has been painfully slow toward regularizing virtual care, self-care at home, and other web-based assets in payment, regulation, and training. The virus has changed that in weeks. Will the lesson persist in the new normal that the office visit, for many traditional purposes, has become a dinosaur, and that routes to high-quality help, advice, and care, at lower cost and greater speed, are potentially many? Virtual care at scale would release face-to-face time in clinical practice to be used for the patients who truly benefit from it.

Preparedness for Threats

As virtual care has lagged leading up to COVID-19, so, even more, has preparedness for 21st-century threats. The foundations of preparedness, most crucially a robust public health system, have been allowed to erode or have never been laid in the first place. Several major reports in the past decade have tried to call attention to that lack of readiness, with only minimal response.5 The COVID-19 toll may be the largest paid so far for this failure, but without taking public health and preparedness seriously, it will be neither the last nor the greatest. Other pathogens, massive trauma, cyberthreats to the electric grid, and more no longer seem so abstract or distant. Will public health finally get its due?


Perhaps the most notable wake-up call of all is inequality, as the worm in the heart of the world.6,7 Students of either health or justice are not at all surprised to read headlines about the unequal toll of COVID-19 on the poor, the underrepresented minorities, the marginalized, the incarcerated, the indigenous peoples. In Chicago, 30% of the population is African American, but they account for 68% of the COVID-19 deaths. In Wisconsin, African Americans account for 6% of the population, but 50% of the deaths. Anyone who studies the toll of vast inequality, in either the US or the world at large, could have predicted those disproportionate deaths with absolute certainty long before they occurred. The most consequential question in the new normal for the future of US and global health is this: Will leaders and the public now at last commit to a firm, generous, and durable social and economic safety net? That would accomplish more for human health and well-being than any vaccine or miracle drug ever can.

These tectonic changes in health care mirror similar ones in societies overall. Who could possibly have imagined billions of people willingly sheltering in place or social distancing barely 2 months after almost no one knew those terms? The public has become suddenly avid consumers of trustworthy scientific guidance on what they should do and what may lie ahead, and people are adopting skepticism about fake science and untested assertions. Tens of millions of people in a few weeks have replaced trips by air or car with virtual meetings on Zoom and Skype and are managing to work from home, get groceries online, visit grandchildren with FaceTime, and appreciate outdoor walks more (at a safe distance). People of New York, London, Milan, and elsewhere experience social solidarity as they cheer health care workers in synchrony from their balconies in the evening, and suddenly the grocery clerks and bus drivers are seen as heroes. Surgical masks in communities protect others, not those who wear them; and yet millions don masks.

Some favorable effects will quickly disappear unless policies are established and practices change after COVID-19. For now, motor vehicle crashes have plummeted. The temporary effects of the pandemic on carbon emissions and pollution are large and instructive. The planet is, by that measure, a healthier celestial body. For the first time in decades, people in Kathmandu can see the tallest Himalayas through clean air with their naked eyes. Will the smog simply return?

There will be political consequences, as well. Everywhere people ask, “How could this have happened? Why were nations caught sleeping? If they knew, why did they not act?” These questions will settle, as they should, soon at the doorsteps of policy makers and elected leaders. They will need good answers and better plans.

Fate will not create the new normal; choices will. Will humankind meet its needs—not just pandemic needs—at the tempo the COVID-19–related morbidity and mortality demand? Will science and fact gain the high ground in guiding resources and behaviors? Will solidarity endure? Will compassion and respect be restored for the people—all the people—who make life agreeable and civilization feasible, including a guarantee of decent livelihoods and security for everyone? Will the frenzied world of commerce take a breath and let technology help simplify work without so much harm to the planet and without so much stress on everyone? And will society take a break from its obsessive focus on near-term gratification to prepare for threats ahead?

Most important of all: Is this the time for equity, when the evidence of global interconnectedness and the vulnerabilities of marginalized people will catalyze at last the fair and compassionate redistribution of wealth, security, and opportunity from the few and fortunate to the rest? This virus awaits an answer. So will the next one.

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Article Information

Corresponding Author: Donald M. Berwick, MD, MPP, Institute for Healthcare Improvement (IHI), 53 State St, 19th Floor, Boston, MA 02109 (donberwick@gmail.com).

Published Online: May 4, 2020. doi:10.1001/jama.2020.6949

Conflict of Interest Disclosures: None reported.

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COVID-19 Clinical guidelines. Brigham and Women’s Hospital. Accessed April 29, 2020. https://covidprotocols.org/quick-guides
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7 Comments for this article
Thank You
Balasubramania Athreya, M.D | University of Pennsylvania Perelman School of Medicine, Retired Faculty
Many of us think about what we have learnt from this pandemic and what we can do to help the future generation. Thank you for giving voice to the feelings and thoughts of many of us in a few succinct words. They are words of hope with guidance for action.
Thank you very much!!
Gonca Ercegil |
Thank you very much for these innovating observations and thoughts. I felt emotional reading it.
Golden Opportunity?
William Andrews, MD MS |
We have demonstrated what is possible when emergency strikes. Can we learn that we need not wait for crisis time before we act? Let us take these lessons and address the climate as well as the next pandemic.
Thank You
Prabhakar G V J, M.B.B.S., M.Phil | Healthcare Group
Very thoughtfully put. The new norm will certainly not be able to ignore the power of science & value of preparedness. Apart from speeding the tempo of learning & improvement, It will remind us to slow the tempo of life & enjoy it in its simple terms, valuing relationships.
The Emperor is Naked; It's Obvious Now
David Egilman, MD, MPH | Alpert Schol of medicine
1. Income inequality per se, not just lack of resources, drives unhappiness and unhappiness drives disease.

A "safety net" will not solve this. The solution is redistribution of wealth. The bottom fifty percent must vote to take money from the rich.

2. Employer-based health insurance is dependent on employment with capital-rich employers. No employment = no health care. A national health service is the solution.

3. The U.S. does not have the best health care.
The Forgotten Population: Older Adults in the Nursing Home and the Community
Robert Schreiber, MD | VP/Medical Director of Summit ElderCare Worcester, MA
Dr. Berwick’s viewpoint addresses many salient issues, including what we can learn from the ongoing SARS–Cov-2 pandemic. He forgets to mention our community-dwelling and nursing home older adults. This forgotten population has had a stunningly high mortality rate. In fact one-third of all US SARS–Cov-2 deaths are nursing home residents or workers. This age bias ripples through the lower pay, social, and economic disadvantage of these workers. In addition, it took weeks to get most nursing home front line workers personal protective equipment since they were not considered essential personnel in the care of patients. Testing has been unavailable and lacking, with public outcries finally forcing this issue to be addressed.
Are ageist attitudes impacting not only our health system, but also our governmental and policy leaders such that older adults and their caregivers are given lower priority? Will our country learn from the devastating outcomes we continue to see in this population and make the necessary changes to protect this vulnerable group? Nursing home and homebound older adults have faced social isolation from their families and friends. This lack of social contact is one of the vital necessities to spark joy in their lives. Without this, it has resulted in the inability for those at the end of their lives to be near those who matter most to them. How do we deal with this issue in the choices of the “New Normal”?

There are validated care models that can address many of the issues highlighted by Dr. Berwick while also involving nursing home eligible populations and frail older adults. To understand these models we must look to and embrace Age Friendly Health Systems. These “population value-based programs” include the Program for All-Inclusive Care for Older Adults (PACE), Independence at Home programs, dual eligible programs and primary care home-based programs. Unfortunately, their value proposition has not been understood by state governments and healthcare systems. Their value must be recognized, as these programs are showing remarkably better outcomes for nursing home eligible populations.

One such model is PACE. Currently, 132 PACE programs operate 264 PACE centers in 31 states, serving more than 51,000 participants These programs support older adults over age 55 who are nursing home eligible, as well as dual eligible. These programs allow for vulnerable older adults to live in the community with dignity and independence, with health care needs reliably met, and with a sense of well-being and inclusion in personal relationships and in the community, all while maintaining cost-effectiveness for both families and society as a whole.

Each older adult in a PACE program has an interdisciplinary team of at least 11 individuals focused on meeting their needs of what matters most to them. It appears that PACE populations will have a statistically significantly lower SARS–Cov-2 infection and death rate compared to nursing home populations. In addition, the PACE model has found ways to have families stay protected while visiting with their loved ones during the end of life process. The ability for safe, family proximity is remarkable given the status quo.

As we look at choices for the New Normal Post SARS–Cov-2 , we cannot forget our older adults, those living in nursing homes and their caregivers. We must support and promote access to programs combining social supports and medical care , with a focus on what matters most as the best option moving forward as we continue to learn from this pandemic.
Great Reflection
Ngozi Ogu, MBBS | General practice
As a frontline worker it was encouraging to see increased hazard awareness among policymakers with the aim to protect workers. I hope this will not be unlearned post-COVID-19.