CHAPTER 1 - NEXT NORMAL

SUMMARY

The pandemic and its restrictive measures will likely end when Covid death rates decline to those of influenza. This is not to suggest that any deaths are acceptable. It is an interim period as approaches to addressing Covid change and the country transitions into the next normal. By enacting the new policies delineated in this report, society can mostly move on to the next normal, which will feel much like the old normal. However, in the next normal, the country can realize important improvements over pre-Covid.

The Next Normal

The SARS-CoV-2 virus is here to stay. The virus appears to be on a path towards becoming endemic. The world will likely be living with the SARS-CoV-2 virus for a long time. Omicron will not be the last variant. Indeed, it is possible there will be another variant of concern within the next 12 months.

But the world will not return to a pre-Covid normal. Normal will be different. For one thing, the SARS-CoV-2 virus will continue to evolve. Covid may recede in importance and no longer threaten the American economy, politics, schools, or daily life as it has for the last two years. Instead, the SARS-CoV-2 virus may join the ranks of other endemic respiratory viral illnesses like seasonal influenza, respiratory syncytial virus (RSV), adenovirus, parainfluenza, and others that routinely sicken and threaten lives but do not throw the country into crisis. “Endemic Covid” does not mean without potential to cause disease and health care burden. A shift toward endemicity does signal a need to establish ongoing approaches to monitor and react appropriately to changes in SARS-CoV-2 infections and spread.

Notably, the next normal is likely to be an improvement over what came before because some of the glaring problems revealed and exacerbated by Covid can be remedied or at least mitigated, reducing the impact of future variants or surges.

For instance, Covid made apparent the poor state of indoor ventilation and air filtration in many public and commercial structures, particularly schools and workplaces. Parents and employees are unlikely to forget that good airflow is essential for keeping everyone healthy and safe. Indoor air quality improvements can reduce transmission of SARS-CoV-2, as well as other respiratory viruses and airborne particulate matter that can exacerbate non-infectious conditions such as asthma. In the next normal, indoor air quality is likely to be much improved.

Similarly, employers are likely to implement improved sick leave policies and encourage employees with flu-like illnesses to use them, since sneezing and coughing throughout a workday will likely no longer be seen as laudatory or perhaps even acceptable.

What Will the Next Normal Be Like?

The next normal must look and feel a lot like the old normal, which means certain things must be the same. In the next normal, Americans should feel that they have adequate access to a full range of healthcare services at hospitals and physician offices with resilient healthcare providers and sufficient staff, and that precautions and environmental monitoring are in place to reduce exposure if a new variant or virus appears. With this and other reassurances, including societal acceptance of voluntary continued mask-wearing for immunocompromised individuals and others, they can feel confident enough to work, attend school, shop, worship, socialize, and take public transportation without the imposition of emergency measures or restrictions. For instance, grocery shopping or going to school should no longer require masking or distancing or be subject to periodic lockdowns.

Some of the key attributes of the next normal are:

Healthcare and Long-Term Care Providers
Hospitals, nursing homes, physician offices, and other healthcare and long-term care facilities will have sufficient staff, supplies, and the legal and regulatory flexibility to safely provide a full range of services, including virtual and home-care options and Covid vaccines and therapies, while keeping healthcare workers protected from infection and with care for their wellbeing. Surges will not overwhelm the health care system.

Schools and Childcare
Schools and childcare facilities will be safe and open to provide in-person instruction and care that ensures optimal education of America’s children.

Economy
The U.S. economy can operate normally, ending supply chain snarls and filling store shelves. Workers will have additional protections to keep them healthy and safe. There will be better worker sick leave policies to reduce transmission of viruses, as well as more flexibility in where people do their work to enhance work-life balance.

Religious Worship
Places of worship can operate with full congregation services, without the need for masking, distancing, or other public health restrictions.

Social Activities
Indoor activities and services, from sports games, concerts, and theatrical performances to bars and restaurants, can operate normally without the need for masking, distancing, or other public health restrictions.

Travel
Domestic plane, rail, bus, and other transportation can operate normally, without the need for masking, distancing, or other public health restrictions.

How will Americans know that the next normal has arrived?

Influenza has been a scourge for centuries. Its severity waxes and wanes depending upon minute genetic changes in each strain and how those changes interact with the immune system. Bad flu seasons can fill hospitals, cause temporary worker shortages, and kill more than 50,000 Americans in a year. Nevertheless, this is not viewed as a crisis, and the nation does not respond by imposing lockdowns, mask mandates, or other emergency public health measures.

The lethality of the SARS-CoV-2 virus and the absence of population immunity led to a two-year death toll of nearly 1 million Americans. A different response was necessary. Fortunately, the virus’s lethality among the vaccinated has dropped substantially.

The United States has long tolerated certain levels of community prevalence, hospitalization, and death from circulating respiratory viruses. From a risk perspective, the next normal should strive for a lower or equal amount of risk compared to pre-pandemic life, with a cumulative viral respiratory illness risk at about the level associated with a bad influenza and RSV season. Practically this means average mortality from major viral respiratory illnesses (as measured by the National Center for Health Statistics) should be less than 0.5 deaths per one million Americans per day, or 165 deaths per day. This could be measured directly from death certificates or based on excess population mortality, assuming this excess is likely from viral respiratory illnesses.

Americans want to know when the country and their community will be in this next phase so normal activities can resume without —or with minimal —precautions. There is no single metric that dictates being in the next normal or when emergency measures should be imposed or retained. Economists determine the health of the economy using multiple indicators, primarily unemployment, inflation, and GDP growth. Similarly, a dashboard for respiratory viral illnesses will be composed of several critical metrics. Each metric could be assessed both for their daily levels and how they have changed over the previous seven days. And like the economic indicators, the thresholds of concern vary, and different indicators necessitate different interventions. Slow economic growth for two quarters portends a recession and requires stimulative policies such as deficit spending, while inflation is usually addressed with higher interest rates. Finally, it bears noting that even when critical metrics provide positive indications, some precautions may still be warranted — America does not, for example, take zero precautions with respect to influenza.

The dashboard for viral respiratory illnesses includes several metrics: vaccination rates, seroprevalence, wastewater virus loads, health system stress, and death rates.

Vaccination rates are important for assessing population immunity, especially among the elderly. They are also critical because they impact the burden of disease in a community. Immunity from previous infections or seroprevalence is also important to assess how well the community can withstand viral infection. Wastewater virus levels are a way of determining the amount of circulating virus. Since people do not have to report personal tests and results, it serves as a passive but accurate early indicator of viral spread that often precedes confirmed cases and can demonstrate whether respiratory virus incidence is increasing or declining.

Stressors of the health care system, including staff shortages and excessive hospital occupancy, are also important since deaths increase when hospitals cannot provide optimal care. Deaths from respiratory viruses are obviously an important metric for policy decisions.

Figure 1 provides a mock-up of a respiratory virus dashboard for policymakers, while Figure 2 provides a mock-up of the dashboard components that might be useful for the public.

The U.S. Hospital Capacity Circuit Breaker dashboard (by Faust and colleagues) leverages public health data to determine when any jurisdiction is at high risk of exceeding hospital capacity in the following 1-14 days. On the included graph, dark blue bars indicate when hospital capacity is forecast to soon be exceeded (note: any capacity threshold can be chosen; 100% capacity is shown). With this warning, hospital systems can act to increase capacity by limiting or cancelling elective procedures, increasing staffing and physical care space, and carefully triaging admissions and discharge decisions; local governments can act by encouraging or requiring indoor mask use (and providing high-quality masks to the public), temporarily limiting capacity in crowded indoor environments, requiring proof of vaccination, and taking any other actions that slow the spread of Covid during surges, including delivering free rapid tests to all places of residence and businesses.

Each metric has a threshold to indicate when the country is sustainably at a tolerable respiratory viral illness level without the need for significant public health interventions like closing businesses or requiring masks in schools.

Importantly, each metric in this dashboard can be measured and utilized to inform policy at the national, state, and local levels.

Two important caveats: The United States does not presently have real time data for each of these metrics, and appropriate thresholds for some metrics have not been set at the national level, which hinders regional comparisons. For instance, wastewater surveillance is not yet standardized or timely enough to provide a comprehensive country-level snapshot across the whole United States. Given the lack of standardized data and differences in sampling technologies in local sewersheds, thresholds today must be set at the local level. Comparisons will only be possible if differences in data formats and reporting at local centers are standardized and accounted for using a consistent methodology for determining pathogen thresholds. Similarly, data on hospital bed occupancy is not reliably reported daily by all hospitals. To ensure accuracy and utility of such a dashboard, the data inputs for these critical metrics need rapid upgrading (see Chapter 9: Health Data Infrastructure).

Unfortunately, the United States has yet to arrive at the next normal. Going into March 2022, the country is currently experiencing about 5 deaths per million people per day from Covid. That is about 10-fold higher than was normal for major respiratory diseases prior to the Covid pandemic. And while wastewater surveillance testing indicates declining Covid infections, hospital bed occupancy still appears strained in several parts of the country.

Among the most important of these is the creation of a resilient infrastructure to manage new variants without imposing severe mitigation measures or inviting the divisiveness, disparities, and deaths that accompany them. Some of the groundwork must be laid by legislation to provide the authorities and funding necessary. Other important changes are regulatory or require enforcement of existing policies.

If the country takes the appropriate steps outlined in the subsequent chapters, many elements of the next normal can be quickly realized —and will likely look just like the pre-pandemic.

Among the most important of these is the creation of a resilient infrastructure to manage new variants without imposing severe mitigation measures or inviting the divisiveness, disparities, and deaths that accompany them. Some of the groundwork must be laid by legislation to provide the authorities and funding necessary. Other important changes are regulatory or require enforcement of existing policies.

If the country takes the appropriate steps outlined in the subsequent chapters, many elements of the next normal can be quickly realized —and will likely look just like the pre-pandemic.

Among the most important immediate steps are:

Assess the combined impact of major viral respiratory illnesses
Shift the approach from focusing solely on Covid-induced harms, including hospitalizations and deaths, to monitoring outcomes related to major endemic respiratory viral illnesses.

Recognize preexisting risk tolerance
Pre-Covid, Americans tolerated risks from respiratory viral illnesses like influenza and RSV, and they need to be ready to continue to tolerate similar levels of risk in the next normal. Efforts to find, improve, and increase uptake of vaccines and treatments for these earlier illnesses should be accelerated.

Improve on prior measures to combat major viral respiratory illnesses
Many of the measures implemented to combat Covid, such as improvements in indoor air, will help mitigate major respiratory viral illnesses.

Establish thresholds to monitor the status of viral respiratory illnesses
A straightforward characterization of normal —with a clear dashboard of metrics, as outlined in Figure 1 —clarifies tolerable and emergency risk levels, which inform public health activities and the imposition of mitigation measures.

Disseminate a respiratory illness prevention approach
The nation should revise the CDC’s well-accepted approach to combating influenza and disseminate a comprehensive Respiratory Disease Prevention approach. This would include improving indoor air quality, using high quality N95 filtering facepiece respirators (especially among vulnerable populations and when there is high local respiratory viral transmission), using rapid at-home testing, and staying at home when ill with flu-like symptoms. This will require investments in HVAC systems and HEPA filters, along with paid sick leave for all workers and ubiquitous and free or low-cost at-home tests for respiratory viruses.

Invest in future capabilities
Significant public and private investments and partnerships are required to get to and sustain the next normal, returning substantial economic, health, social, educational, and security benefits. Specifically, this report’s authors estimate that $100 billion is necessary in year 1, $30 billion in each of years 2 and 3, and $10 - $15 billion annually on a permanent basis.

Design health interventions with equity in mind
The Covid pandemic has hit communities of color and rural populations particularly hard, exacerbating existing health and economic disparities. Public health and healthcare supports must be tailored to reduce and ultimately eliminate these disparities experienced by underserved communities, and community leaders must be included in this design process to ensure interventions are effective. Investments targeted to low-income, rural, and minority communities are necessary to support those most in need.

To get to and sustain a next normal for the long term that improves upon the pre-Covid world, the country must:
Invest in biosecurity
Improved surveillance of viral threats in the United States and around the world can provide an early-warning system accelerating the deployment of treatments and vaccines.

Buttress equitable health delivery
Pre-Covid, the health care system has had persistent and widely acknowledged problems, including low provision of mental health services, poor use of telemedicine, and racial, socio-economic, and geographic disparities in healthcare access, affordability, and outcomes. These deficiencies have contributed substantially to the adverse impacts of Covid. Investments in the next normal must proactively institute policies to enhance virtual medicine and mental health care, as well as eliminate unfairness in access to and provision of services. There must also be investment in the health care workforce to ensure adequate staffing at all facilities and reduce burnout.

Instill trust
Countries with high levels of societal trust fared comparatively well over the past two years. Political divisiveness cost hundreds of thousands of American lives. A national effort must be launched to implement fixes that go well beyond health to target misinformation and enhance social and political inclusiveness. Indeed, misinformation about Covid vaccines is a major factor in the low rate of vaccine uptake in the United States compared to peer nations. In the next few years, misinformation is likely to suppress the uptake of standard childhood vaccines, leading to more avoidable deaths. Covid misinformation is part of a larger problem of media-driven falsehoods and factual inaccuracies that must be addressed to achieve as high a vaccination rate as possible. Additionally, the U.S. government should acknowledge prior mistakes, as well as existing disparities in care and outcomes, to lend credence to its trust-building efforts.

Rebuild public health and preparedness for future pandemics
Before the pandemic, the nation’s public health infrastructure and workforce were starved for resources. A new system must be built on sustained and adequate funding to overcome the mistakes of the past. As reflected in the draft PREVENT Pandemics Act, the federal government should invest in more rigorous and regular assessments of the country's readiness for future viral disease outbreaks and broader public health crises. Key public health agencies should stand up regional hubs, in addition to central headquarters, to better coordinate with state and local governments.

Improve public health communication and messaging
The nation’s public health professionals are being demonized because their tools are blunt, invasive, and not always fully effective. Their messages are valuable and important but have been shifting, unclear, and anxiety-producing. New tools such as secure, real-time data platforms and better surveillance would improve messaging and offer reassurance rather than alarm. Additionally, consideration should be given to the messengers selected to deliver these messages. For example, in minority communities, trusted community leaders and local clinicians can be better leveraged as public health advocates.

Achieving these measures will require spending money. But these allocations must be viewed as investments with lasting societal benefits. Two years of Covid cost the country trillions of dollars. Investing billions to ensure better surveillance, vaccine and therapeutic development, air quality, and other measures will provide a handsome return.

To get to and sustain the next normal necessitates a wide array of interventions. The subsequent chapters provide the outline of some of the strategic goals and a few of the initial operational steps to get there. But more research and experience will invariably reveal other actions that will be needed or show that some of the recommendations listed here are wrong. The authors of this report disagreed on some of the nuances of its many recommendations but agreed that actions taken now can substantially shape the path to, and the actual state of, the next normal.