The end of the COVID-19 pandemic

 

Alberto Giubilini, Oxford Uehiro Centre for Practical Ethics and WEH, University of Oxford

Erica Charters, Faculty of History and WEH, University of Oxford

 

 

A discussion on the end of the COVID-19 pandemic is overdue. We keep hearing that ‘we are in the middle of a pandemic’. However, it is not clear what it means to be in the middle of a pandemic if we don’t know what it means for a pandemic to end.  How can we know what the middle is if we don’t know what the end is?

We were given a clear date by the WHO for the start of the pandemic (11 March 2020). A few days earlier the WHO Director-General had for the first time used the term ‘epidemic’ to refer to COVID-19 outbreaks in some countries (5 March 2020). A disease is categorized as an epidemic when it spreads rapidly, with higher rates than normal, in a certain geographical area. A pandemic is an epidemic spreading over more than one continent. Thus, declaring epidemic and pandemic status is a decision based on epidemiological criteria.

By contrast, the end of an epidemic is not determined by epidemiological factors alone. Historically, epidemics end not with the end of the disease, but with the disease becoming endemic – that is, accepted and acceptable as part of normal life.

However, when and how a disease becomes normal or acceptable is primarily a social, cultural, political, and ethical phenomenon, rather than scientific or epidemiological.  It is a more subtle phenomenon – and less precise – than the start of the epidemic.  The end depends on how a society decides to respond to a pathogen that keeps circulating.  We might well find ourselves out of this pandemic without realising when and how it happened.

So, when will this pandemic end?

The myth of eradication

Most likely, it will not end via eradication. There seems to be no alternative to accepting COVID-19 as part of normal life and the normal risks we take in life. The history of disease demonstrates that eradication – defined as the complete elimination of an infectious disease through purposeful human activity – is extremely uncommon.  Smallpox is the only human disease that has been declared eradicated.  SARS-CoV-1 (another coronavirus) was successfully contained in 2003 and some consider it eradicated, but there is less confidence on this claim than on the claim around eradication of smallpox. Some think that with SARS we simply got lucky and our control efforts made little to no difference to its disappearance (see here for an overview of hypotheses). Some describe it as a ‘mysterious disappearance’. In any case, SARS is markedly different from COVID-19: it spreads slower than COVID-19 and only through symptomatic transmission. In fact, SARS was successfully contained (or possibly eradicated) after there were just over 8,000 cases in the world. By contrast, there is now quite a strong scientific consensus that COVID-19 will not go away.

Most epidemic diseases remain with us, returning in cycles or waves – as with influenza. Or they become manageable for most populations through medical treatment – as with HIV/AIDS.  Even plague never fully disappeared after devastating outbreaks in the fourteenth century (which killed, according to some estimates, 50% of affected populations).  These high rates were simply the start of what is now called the Second Plague Pandemic, when plague returned and receded in intervals across hundreds of years.  As historian Nukhet Varlik explains, ‘living with the plague became a fact of life for societies of Afro-Eurasia’.  Plague remains endemic in animal reservoirs, with scattered human cases reported today.

 

Endemic diseases and acceptable levels

Epidemics of infectious diseases generally end by becoming endemic. As per clinical definition, a disease is endemic when disease rates are reduced to ‘a locally acceptable level’ and the disease becomes manageable (Charters and Heitman 2021).

However, what level is considered manageable and acceptable, particularly for a new disease, is not defined by epidemiology.  Such levels vary throughout time, among regions, and among different societies – even between groups within one society.   What is an acceptable level of disease requires societal, cultural, and political agreement.  Unlike the start of an epidemic, the end is a process of negotiation and its dynamics are often unclear and not explicit.

This understanding of an ‘end’ to the pandemic must inform public health policy.  After all, testing policies and border regulations are different if the end-goal is living with COVID-19, rather than eradicating it.  Early in the pandemic, countries that aimed for, and were able to implement, elimination goals through airtight border restrictions – such as Australia and New Zealand – were widely praised for effective disease management.  Other countries, such as Japan, instead devised explicit strategies to ‘live with’ the virus.  As we move through different stages of the pandemic, and as we adjust our understanding of ‘end’, countries may wish to re-think what their health policies are trying — and are able — to accomplish.

For example, England has lifted most of the restrictions while going through a “third wave” of the virus that saw a dramatic increase in positive cases but a relatively small impact on numbers of deaths and hospitalizations. This is a sign that we might be moving towards the end of the epidemic in this specific context: the virus keeps circulating, there are new waves, but many have accepted it as a simple ‘fact of life’.

Rather than being determined by a particular number of cases or deaths,  the end will require us to no longer focus on such numbers. The attitude we have towards such figures is as important to the end of the pandemic as the figures themselves.

There might well be a day in which the WHO declares the pandemic is over. There would probably be pragmatic reasons to do so — for example, AstraZeneca is distributing its vaccines at cost, with no profit, until the pandemic ends. But that type of announcement will likely not mark the actual end of the pandemic for most.  For some – those who have resumed normal life — the pandemic will have already ended.  For others, the pandemic will continue not only through the effects of COVID-19 related illness, but also through economic hardship, political instability, social dislocation, and non-Covid related health problems that restrictions imply.

 

Who has a say on when the pandemic end?

Considering the end of a pandemic can also help us consider who is involved in these decisions.  If the end requires societal, cultural, and political agreement on what is a ‘locally acceptable level’ of disease, discussions should include input from those who specialise in understanding society, culture, and politics.  Such discussions will necessarily involve articulating social priorities and cultural values, and calculating risks and benefits, alongside epidemiological data.  Such discussions must therefore involve experts beyond the fields of medicine – ethicists, philosophers, and historians, as well as anthropologists, sociologists, economists, and political scientists.

 

Conclusion

Ultimately, the process by which epidemics end reminds us that epidemics are as much social, cultural, economic and political phenomena as they are biological ones. Hence, social, cultural, and political factors will play a key role in driving and defining the end of this pandemic, even as the virus keeps circulating and recirculating.

 

 

Charters E, Heitman K. (2021). How epidemics end. Centaurus.63:210–224

 

See also:

How Epidemics End. A Multidisciplinary Project. based at Oxford’s Centre for the History of Science, Medicine, and Technology and Oxford’s Centre for Global History