The U.S. is taking a crash course in learning to “live with the virus.” Policymakers and health experts agree that we have migrated to a less-disruptive COVID-19 endemic phase. This has produced extensive commentary on what living with the virus, and achieving the “new normal” might look like—liberating some while confusing others. Many people have spent two years avoiding and fearing the virus and are now being advised that it’s safe to unmask and to resume a normal social life. This hasn’t brought about a natural, comfortable transition for them but has instead caused national emotional whiplash. This is called avoidance conflict by psychologists.
CDC’s new look-up map tool for COVID-19 community risk-level attempts to balance key goals of preventing hospital overload and flattening the curve of serious disease. The agency’s previous map based on level of transmission reflected most counties as high-intensity bright red. This new map is mostly composed of a low-risk, reassuring green. Critics of this new approach say that the agency “seems to have moved the goalposts to justify the political imperative to let people get back to their normal lives.” What both the critics and supporters of the CDC’s new tool have missed is that—whether red or green—the tool doesn’tOur previous fundamental relationship to this virus has not changed since the start of the pandemic. We are all still advised to warily avoid it until it becomes “safe enough.” This old paradigm will not lead us to a “new normal”.
The old paradigm problems are no longer relevant with the new CDC guidance. What should I do if my child has the sniffles? Can I send my child back to school with sniffles? After receiving cancer chemotherapy, can I go back to work? What is the fourth shot I will need? How do I perform home rapid tests? Our family should fly to the usual spot for summer vacation?
Even though there is a lot of optimism and cautiousness, many people have not realized that the nation must move from accepting infection to acceptance in order to survive an endemic period. Let’s sit with that for a second. This is the central point of all endemic phase policies and practices. This is the shift we need to create a sustainable, new normal.
These are the five steps that will get us there.
1) Accept that we can’t outrun Omicron
Omicron can be transmitted to a great extent. Omicron is a ubiquitous variant that will infect almost all people who are susceptible, regardless of whether or not they attempt to prevent infection. The Institute of Health Metrics and Evaluation estimates that about three-fourths of the country already has “functional immunity” to Omicron, and expects this to continue to “grow through the tail-end of the Omicron wave.”
We should anticipate a pattern of seasonal spikes in the number of cases (positive tests) as with other respiratory viruses such as colds, flu and pneumonia. Further outbreaks of high caseloads should not set off alarms to deviate from a steadfast endemic-phase new paradigm, as long as the vulnerable population—which suffers the brunt of the disease burden—is protected from infection. In the past we have learned to live with other communicable diseases with similar features without any mental trauma and physical disruption. Now it’s COVID-19’s turn.
2) Identify “vulnerable” and “non-vulnerable” risk sub-groups
Public has been constrained by the dire numbers of whole populations (all cases and hospitalizations that have resulted in a positive test, as well as all deaths). This influences risk perceptions as well as many COVID-19 policy actions. This led to a poor and inaccurate view of risk for individuals and bad policies. It is time to replace this flawed lens.
To enable the “new normal,” Americans can be separated into two discrete risk-based sub-populations: those that if infected have a similar or lower risk of hospitalization and death than that from influenza (called the “non-vulnerables”) and those that have a far higher comparative risk of these outcomes (called the “vulnerables.”) Risk is actually a continuum from very low to very high, but this simplifying binary categorization is intended to offer clear public understanding.
Three factors are the most important in determining vulnerability to Omicron infection. They are age, immune susceptibility and other underlying conditions. Risk is also associated with poverty and ethnic/racial characteristics, as well as indirect health and equity disparities.
One of the most significant predictors of infection outcomes is age. Recent CDC research revealed that people 65 and older who become infected have a 5-10% higher chance of being hospitalized, 65-34% more likely to die, and 3-50% more likely to get sick. These numbers are shocking in absolute terms. The population over 65 is 13 percent and in January, Omicron was responsible for 80 percent of all deaths. Over 75s make up 6 percent of Omicron’s population. They accounted for approximately half of January’s 2600 death rate.
Infection or complete vaccination can reduce the susceptibility of individuals and populations. Both are approximately 80 to 90 percent effective in protecting against death and serious diseases, but their effectiveness decreases with time and age. It is a dynamic, ever-changing equilibrium of waxing and waving forces that determines the level of susceptibility. As Omicron decreases, it should slowly increase in the coming months. We should expect higher levels of immunity, given the likely increase in transmission later in the year and the further booster uptake.
The CDC lists over 20 underlying medical conditions that are associated with higher risks for COVID-19. These include advanced diabetes, obesity and mental disorders. There are also an estimated 10 million Americans who are immunocompromised. They have either autoimmune diseases, cancers, chemotherapy or any other reason for immune suppression.
This new model shows that approximately 20-25% of Americans are at risk for serious Omicron-related illness. It is significantly higher than the annual flu season. This group includes anyone older than 65 years old, with the risk of serious illness from Omicron increasing rapidly as a result of increased immunological susceptibility and other significant health conditions. All ages of the immunocompromised are included. They must also avoid infections, as this is the key to their prevention.
The remaining 75-80 percent of Americans are “non-vulnerable” as defined by having a similar or lower chance of serious outcomes from Omicron than from the seasonal flu. They do not need to get infected. They are interested in serious diseases and death, not just cases.
Protect high-risk, vulnerable populations first
This binary scheme produces a simpler, more focused and efficient disease-mitigating system: The non-vulnerable “new normal” can look similar to the previous normal for interactions with non-vulnerables. However, when non-vulnerables directly intersect with the welfare of the “vulnerable” population, specific accommodations should be required. This means that universal masking is required on all public transport and vaccinations, as well as boosting and masking health care workers in hospitals and congregate facilities such nursing homes. As a country we have precedents for balancing “freedom to” with “freedom from”—for example in establishing smoke-free public spaces.
There is no new normal for the most vulnerable. This is not a social but viral imposition. COVID-19, and variants thereof have caused an inequitable and unimaginable loss of life in vulnerable populations. This tide has not been stopped by vaccines or boosters. The society will have to work hard through protection public accommodations. Every vulnerable person and family will require a plan.
4) Prepare for the best scenario
Many are rightfully apprehensive about important “known unknowns” relating to COVID-19 infection. There are many unknowns. These include new forms, Long Covid dangers and the inability to provide a vaccine that is safe for children and babies. While these are legitimate concerns, the risk-benefit calculation for society and most people favors normal life. Strategic decisions in war are usually focused on “most likely case” assumptions while also preparing for a “worst case.” As new information develops we must maintain the capacity to pivot quickly if things change for the worse.
5) Reduce restrictions and unite the nation
This “new normal” can perhaps take us from the rancor of partisan politics and ideology to focusing on what works for the country in saving and restoring lives. It is about protecting vulnerable people, and not masking and other intervention. Obligatory protections should only focus on areas that intersect with vulnerable people. This priority should be agreed upon by many Americans or all Americans regardless of political orientation.
The collective expression of each individual’s thoughts and feelings is what makes a group more effective than if they are working together. This would not only produce public health dividends, but also boost the economy and help restore America’s full productivity and dynamism at a particularly challenging time in our history.
These guidelines will help us move towards the new norm faster. To reach this goal, it will require persistence, perseverance, and social consensus. However, the pandemic on-ramp is already in sight.
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