Facing the New Covid-19 Reality

Facing the New Covid-19 Reality
We’ve come a long way. From the early, ter- rifying days of a rapidly spreading deadly infection to the current circumstances in which — despite a recent steep rise in transmission
clinical terrain and to take to heart the lessons learned from the Covid-19 response thus far — both the successes and the mis- steps.
To date, monitoring of the ef- fects of Covid-19 has rested on several epidemiologic and clini- cal measures, which have shaped the recommended or mandated protective actions. Most common- ly, these measures have included estimated rates of Covid-19 cases, hospitalizations, and deaths; monitoring has also been con- ducted of circulating SARS-CoV-2 variants and their susceptibility to available vaccines and treat- ments.
Yet in the current situation, some of these traditional mea- sures have limited value. For ex- ample, the availability of rapid antigen tests that can be con- ductedathome—theresultsof which often aren’t captured by public health surveillance sys- tems — challenges the validity
The NEW ENGLAND JOURNAL of MEDICINE
Perspective
February 2, 2023
Facing the New Covid-19 Reality
Wafaa M. El‐Sadr, M.D., M.P.H., M.P.A., Ashwin Vasan, M.D., Ph.D., and Ayman El‐Mohandes, M.B., B.C.H., M.D., M.P.H.
rates — Covid-19 has, for many people, become no more than an occasional inconvenience, involv- ing a few days of symptoms and a short isolation period. It’s clear that for many, if not most, people, SARS-CoV-2 infection no longer carries the same risks of adverse outcomes as it did in the early months of the pandemic. These shifts have led to a widespread assumption, fueled by political and economic priorities, that the pandemic is behind us — that it’s time to let go of caution and resume prepandemic life.
The reality, however, would starkly contradict such a belief. Covid-19 currently results in about 300 to 500 deaths per day in the United States — equiva- lent to an annual mortality bur-
den higher than that associated with a bad inf luenza season. In addition, many people continue to face severe short- or long-term Covid-19 illness, including peo- ple who lack access to vaccines or treatment and those with un- derlying conditions that impair their immune response to vac- cines or render them especially vulnerable to Covid-associated complications. The ever-looming threat of the evolution of a new variant, one that can evade our vaccines and antivirals, remains very real. These facts support the assumption that SARS-CoV-2 will continue to play a major role in ourlivesfortheforeseeablefu- ture. This new reality compels us to navigate a more complex social, economic, political, and
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of reported case numbers and transmission rates in some juris- dictions. There is therefore a need for unbiased monitoring of trans- mission and infection rates by means of regular testing of sen- tinel populations or randomly se- lected representative samples of the general population.1,2 Hospi- talization and death rates are certainly more reliable measures than case rates, but these mea- sures are limited by the fact that some hospitalized patients with SARS-CoV-2 infection have been admitted for other reasons and only incidentally tested positive. Furthermore, hospitalization and death are distal outcomes, so their rates have limited value for triggering early action to control the spread of infection and avert- ing the consequences of a surge in cases. Other measures have gained prominence and now play a critical role in defining risk for infection or severe disease. Vac- cine and booster coverage and availability and utilization of treat- ment for Covid-19 are critical variables that affect both the risk of severe illness or death from SARS-CoV-2 and health system capacity and access.
We have gained a deeper ap- preciation of the breadth of the pandemic’s effects, beyond its ob- vious health effects. These effects have included loss of employ- ment or housing, disruption of ed- ucational systems, and increased rates of food insecurity. Many of these negative social and eco- nomic effects were unintended results of mitigation measures, including stay-at-home orders, the shutting down of public ven- ues, and transitions to remote learning. Although these mea- sures were appropriate at the time, their effects weren’t evenly
distributed, with some commu- nities facing disproportionate hardship, particularly historical- ly marginalized racial and ethnic groups and communities with limited social and economic re- serves. It is thus necessary to take into account the ways in which public health recommendations and policies may differentially affect various subgroups of the population. Government and non- governmental entities need to create clear pathways for vulner- able populations to obtain access to the resources they need, in- cluding masks, vaccines, no-cost treatment, direct economic assis- tance, supplemental food, rent abatement, and Internet access to support virtual learning and remote access to health services.3 Such an approach requires that the federal government continue to invest in the Covid-19 re- sponse, since private-sector in- vestment will be insufficient to meet all needs.4
One of the key challenges that the public health community fac- es as the pandemic evolves is the need to move away from univer- sal recommendations, or popula- tion-wide prevention policy, to- ward a more differentiated or tailored approach — one that takes into account the character- istics of various communities and the pathogen. Relevant charac- teristics may include those that inf luence virus transmission or clinical outcomes, such as vac- cine and booster coverage and risk factors for severe outcomes, including chronic medical condi- tions, racism and discrimination based on ethnicity, and lack of adequate health insurance. The implementation of tailored guid- ance for specific populations, however, is complicated by the
legacy of glaring health dispari- ties, the threat of stigmatization, and prevailing mistrust of au- thorities in some communities. Health-equityandantiracistprin- ciples and insights from the fields of health communication and behavioral science must therefore be taken into account from the start in the develop- ment and dissemination of rec- ommendations and the implemen- tation of programs and policies.3,5
There is much to lament in the politicization of the Covid-19 pandemic, the spread of disinfor- mation and misinformation, the deep divisions within the U.S. population and, globally, in peo- ple’s perceptions of the pandem- ic and willingness to trust guid- ance and embrace protective measures. These divisions should inspire a reexamination of the reasons that some public health recommendations fell f lat, in ad- dition to an acknowledgment that political expedience played a role in sowing mistrust. As the pandemic evolves, as the mea- sures of its effects become more complex, and as guidance re- quires greater tailoring to spe- cific populations, effective com- munication becomes even more important. Providing clear guid- ance, including explaining the rationale for various recommen- dations, acknowledging the so- cial and economic trade-offs in- volved in complying with them, and offering people the resourc- es they will need to effectively manage these trade-offs, would go a long way toward enabling the adoption of those recommen- dations.
Most important, attention to the engagement of trusted com- munity leaders and spokespeople is required, as is listening authen-

PERSPECTIVE
Facing the New Covid-19 Reality
An audio interview with Dr. El-Sadr is available at NEJM.org
in the form of an emergency response, but must involve a consistent presence,
tically to communities from the start. Rather than focusing solely on what is being recommended, it’s equally important for public health leaders to focus on how recommendations are communi- cated and disseminated. Early en- gagement of community represen- tatives is critical so that various aspects of anticipated guidance can be discussed in detail, includ- ing rationales, trade-offs, and the most appropriate communica- tion channels and formats. En- gagement must not only come
being of millions of people throughout the world. At the same time, it’s important to ac- knowledge that objectively we are in a better place with regard to the virus than we’ve ever been and that in fact many people be- lieve the pandemic is behind us. This reality compels us to avoid using alarmist language and to offer valid and feasible solutions to bring people along to a new, nonemergency phase of the pan- demic. How we craft our poli- cies, programs, and associated messaging in this context and who delivers the messages is as important as ever.
Disclosure forms provided by the authors are available at NEJM.org.
From ICAP at Columbia University (W.M.E.‐S.), the New York City Department of Health and Mental Hygiene (A.V.), and the City University of New York Graduate School of Public Health and Health Policy (A.E.‐M.) — all in New York.
This article was published on January 28, 2023, at NEJM.org.

Christie A, Brooks JT, Hicks LA, et al. Guidance for implementing COVID-19 pre- vention strategies in the context of varying community transmission levels and vaccina- tion coverage. MMWR Morb Mortal Wkly Rep 2021;70:1044-7.
Imperial College London. The REACT-1 programme (https://www.imperial.ac.uk/ medicine/research-and-impact/groups/react -study/studies/the-react-1-programme/).
Bleser WK, Shen H, Crook HL, et al. Health policy brief: pandemic-driven health policies to address social needs and health equity. Health Aff, March 10, 2022 (https:// http://www.healthaffairs.org/do/10.1377/ hpb20220210.360906/).
Athey S, Conti RM, Fiedler M, Frank RG, Gruber J. The economic case for federal in- vestment in COVID-19 vaccines and thera- peutics remains strong. Washington, DC: Brookings Institution, April 1, 2022 (https:// http://www.brookings.edu/essay/the-economic-case -for-federal-investment-in-covid-19-vaccines -and-therapeutics-remains-strong/).
Overton D, Ramkeesoon SA, Kirkpat- rick K, Byron A, Pak ES. Lessons from the COVID-19 crisis on executing communica- tions and engagement at the community level during a health crisis. Washington, DC: National Academies of Sciences, Engi- neering, and Medicine, December 7, 2021 (https://www.nationalacademies.org/news/ 2021/12/lessons-from-covid-19-on-executing -communications-and-engagement-at-the -community-level-during-a-health-crisis).
DOI: 10.1056/NEJMp2213920
Copyright © 2023 Massachusetts Medical Society.
which can then be leveraged and activated further during times of urgent need.
The current moment in the Covid-19 pandemic is a pivotal one. There is an urgent need to confront a future in which SARS- CoV-2 will remain with us, threatening the health and well-
I F n a c v e i n s gt m t e h n e t N f e o w r C E oq v u i i d t – y 1 i 9 n R G e a l ol i b t a y l H e a l t h R e s e a r c h
Behind-the-Scenes Investment for Equity in Global Health Research
Jessica E. Haberer, M.D., and Yap Boum II, Ph.D.
“One hand cannot tie a bundle.”
Increasing attention is being paid to the inequity that pervades global health research, which re- sults from factors ranging from ignorance to colonialism and racism.1 Academic and economic resources heavily favor countries in the Global North (e.g., the United States and European
— Central African proverb
countries), which therefore drive research agendas.2 Researchers in the Global North largely deter- mine which questions get an- swered. Although this model has led to important improvements in health worldwide, inequity pre- vents research from achieving its full potential. Scientists through-
out the world need to conduct, together, rigorous research driv- en by local agendas. Efforts to rec- tify inequities require all stake- holders to examine the way in which research is conducted, including how partnerships are formed and implemented, who receives recognition for success- ful research initiatives, and who is empowered and enabled to lead as principal investigators.
Funders, such as the National
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