Alberto Giubilini

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 our 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 no longer focussing 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, 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

 

 

 

Crosspost: Immunity Passports: A Debate Between Jay Bhattacharya and Alberto Giubilini

By Alberto Giubilini (University of Oxford) and

Jay Bhattacharya (Stanford University)

 

crosspost with Lockdown Sceptics

 

[Prof Jay Bhattacharya (Professor of Medicine, Stanford University) and I collaborate on Collateral Global, a new project that aims to evaluate the impact of lockdowns and other pandemic restrictions. We have the same view on lockdown and pandemic restrictions, but we do have our own internal, healthy disagreement. Most people who are skeptical and critical of lockdowns (as both Prof Bhattacharya and I are) are also against immunity passports (as he is), often for the same reasons. I disagree on this point and I think some form of immunity passport should be introduced. In this exchange published on Lockdown Sceptics, we try to explore exactly where our disagreement lies and try to identify possible areas of agreement on the matter. AG]

 

The Case For Immunity Passports

by Alberto Giubilini

Having read the excellent piece in the Wall St Journal by Prof. Bhattacharya and Prof. Kulldorff, I have the impression that they take many of the reasons against lockdowns to also be reasons against immunity passports. Among these, individual liberty is prominent.

I disagree.

Continue reading

What Is The Justification For Keeping Lockdown In Place? Two Questions For The UK Government

Written by Alberto Giubilini and Julian Savulescu

Oxford Uehiro Centre for Practical Ethics, University of Oxford

Given the success of the vaccine roll out in the UK and the higher than expected drop in COVID-19 deaths, it is legitimate to ask whether lockdown should continue to be the key strategy to contain the pandemic or whether the ‘roadmap’ announced by the UK Government should be adjusted. Because lockdown is a very exceptional measure, the burden of proof is on the Government to provide answers as to why the easing of lockdown is proceeding at the current pace and not faster. The impact of lockdown is devastating for the economy, mental health, and employment rates and the cost and benefits are in many cases very unevenly distributed. For instance, the young are at highest risk of redundancy, but benefit less from lockdown because COVID-19 pose a very low risk on them. There is a serious concern around the rise of referrals for mental health assistance for  children and teenager over the past year. If the lockdown is justified at this stage, the Government has the burden of proof of providing a strong justification for this.

Such justification might need to be updated with respect to the one offered when the roadmap was announced on 22 February. That justification was centred on the target of “keeping infections rates under control” as determined by 4 tests: successful vaccine deployment program; vaccines being successful at reducing hospitalizations and deaths in the vaccinated; infection rates not putting unsustainable pressure on the NHS; and the risk assessment not being significantly altered by new variants.

Even assuming those criteria are fair, the justification now needs to take into account the “very very impressive” and “spectacular” results of vaccine rollout, to quote a lead researcher from Public Health Scotland.  As we shall see below, there are reasons to think that the vaccines are producing better results than those expected by the Government and assumed by the modelling used to inform the roadmap. Plausibly also because of the vaccine roll out, the drop in COVID-19 deaths in the UK is now three weeks ahead of the estimates of the modelling that the Government has used to design its roadmap: while the modelling estimated that COVID-19 deaths would fall below 200 a day after mid-March, we reached that point on 25 February. The model suggested we would have as few as 150 deaths per day by 21 March, but we are at that point now.

In light of these data, the Government would need to justify using indiscriminate lockdowns to achieve something – protection of the vulnerable and the NHS – which data suggest is now achievable without overburdening the whole society (as lockdown is doing) and possibly even without burdening those who need protection the most (as selective shielding would do). Vaccines are offering a level of protection to the vulnerable (roughly 80-90% drops in hospitalizations and deaths) that, if it was achieved through measures like selective shielding, would plausibly justify considering selective shielding successful. But vaccines do this without the downsides of indiscriminate lockdown or of selective lockdown.

Continue reading

The UK Should Share The Vaccine With The Other Countries – But Only After All The Vulnerable Have Been Vaccinated

Written by Alberto Giubilini, Oxford Uehiro Centre for Practical Ethics, University of Oxford

Cross posted with The Conversation

“We are all in this together”, except that we are not. One of the most widely used slogans of the pandemic might need to be adjusted. Maybe: “We are all in this together, until there is a way out.”

The way out is the COVID-19 vaccine. Or more precisely, the many COVID-19 vaccines. The UK has already approved three, with two more pending a decision by the drugs regulator.

Of these, one has been developed in the UK by the University of Oxford, with millions of pounds of funding from the UK government (aka, UK taxpayers), and made by the British/Swedish company AstraZeneca. Part of its manufacturing is in Europe, where Belgian plants have had production problems that have threatened the future supply to the EU.

Three vaccines are produced by US pharmaceutical companies (Pfizer, Moderna and Novavax), although the Pfizer vaccine has been developed in partnership with the German biotechnology company BioNTech, and the Novavax one is being made in the UK. One vaccine is made by Janssen, based in Belgium but owned by the American firm, Johnson & Johnson.

These geographical details might seem superfluous, but they are already making post-Brexit vaccine distribution more complicated than it should be. In the meantime, the World Health Organization has expressed concerns over the fading commitment to Covax, the programme set up to guarantee equitable access to COVID-19 vaccines around the world.

This is the moment countries part ways in their fight against COVID-19. We are no longer in this together. That is because we never chose to be in it together. We just happened to find ourselves in a pandemic that didn’t spare anyone. Now that we do have some choice, each country is taking care of their own first. Continue reading

Current Lockdown Is Ageist (Against The Young)

Written by Alberto Giubilini

Oxford Uehiro Centre for Practical Ethics and Wellcome Centre for Ethics and Humanities

University of Oxford

 

Former UK supreme court justice and historian Lord Jonathan Sumption recently made the following claim:

“I don’t accept that all lives are of equal value. My children’s and my grandchildren’s life is worth much more than mine because they’ve got a lot more of it ahead. The whole concept of quality life years ahead is absolutely fundamental if one’s going to look at the value of these things.”

This wasn’t very well received, to say the least. Experts were quickly recruited by the press to rebut his claims. Headlines were made to convey people’s outrage at the idea that we can put a value on human life, and what is worse, different values on different human lives (which, by the way, is precisely what the NHS regularly does whenever it decides whom to put on a ventilator when there are not enough ventilators for everyone, or when it decides not provide life-saving treatments that cost more than £ 30k per quality-adjusted-life-year). Continue reading

Cross post: Pandemic Ethics: Should COVID-19 Vaccines Be mandatory? Two Experts Discuss

Written by Alberto Giubilini (Oxford Uehiro Centre for Practical Ethics and WEH, University of Oxford )

Vageesh Jaini (University College London)

(Cross posted with the Conversation)

 

To be properly protective, COVID-19 vaccines need to be given to most people worldwide. Only through widespread vaccination will we reach herd immunity – where enough people are immune to stop the disease from spreading freely. To achieve this, some have suggested vaccines should be made compulsory, though the UK government has ruled this out. But with high rates of COVID-19 vaccine hesitancy in the UK and elsewhere, is this the right call? Here, two experts to make the case for and against mandatory COVID-19 vaccines.

 

Alberto Giubilini, Senior Research Fellow, Oxford Uehiro Centre for Practical Ethics, University of Oxford

COVID-19 vaccination should be mandatory – at least for certain groups. This means there would be penalties for failure to vaccinate, such as fines or limitations on freedom of movement.

The less burdensome it is for an individual to do something that prevents harm to others, and the greater the harm prevented, the stronger the ethical reason for mandating it.
Continue reading

Cross Post: Pandemic Ethics: Vaccine Distribution Ethics: Monotheism or Polytheism?

Written by Alberto Giubilini, Julian Savulescu, Dominic Wilkinson

(Oxford Uehiro Centre for Practical Ethics)

(Cross-posted with the Journal of Medical Ethics blog)

Pfizer has reported preliminary results that their mRNA COVID vaccine is 90% effective during phase III trials. The hope is to have the first doses available for distribution by the end of the year. Discussion has quickly moved to how the vaccine should be distributed in the first months, given very limited initial availability. This is, in large part, an ethical question and one in which ethical issues and values are either hidden or presented as medical decisions. The language adopted in this discussion often assumes and takes for granted ethical values that would need to be made explicit and interrogated. For example, the UK Government’s JCVI report for priority groups for COVID-19 vaccination reads: “Mathematical modelling indicates that as long as an available vaccine is both safe and effective in older adults, they should be a high priority for vaccination”. This is ethical language disguised as scientific. Whether older adults ‘should’ be high priority depends on what we want to achieve through a vaccination policy. And that involves value choices. Distribution of COVID-19 vaccines will need to maximize the public health benefits of the limited availability, or reduce the burden on the NHS, or save as many lives as possible from COVID-19. These are not necessarily the same thing and a choice among them is an ethical choice. Continue reading

Conscience Rights or Conscience Wrongs?: Debating Conscientious Objection in Healthcare

Written by: David Albert JonesAnscombe Bioethics Centre

& Alberto GiubiliniOxford Uehiro Centre for Practical Ethics, Wellcome Centre for Ethics and Humanities, University of Oxford

 

For the purpose of this debate (held online on 12 October 2020), Alberto Giubilini and David Albert Jones each adopted a position on conscientious objection (CO) contrary to the one that he in fact holds. David A. Jones, who is a defender of a right to conscientious objection in healthcare, made the case against it. Alberto Giubilini, who is against a right to conscientious objection in healthcare, made the case in favour of it. What follows is an evaluation by each of the arguments of the other in relation to their strengths and how they were presented. Continue reading

Pandemic Ethics: Should Santa Claus Deliver Christmas Presents This Year? Preparing For Our First COVID-19 Christmas

Written by: Alberto Giubilini; Oxford Uehiro Centre for Practical Ethics, &

Wellcome Centre for Ethics and Humanities, University of Oxford

It’s that time of the year again, when Christmas decorations start to appear way too early in shopping malls. It’s beginning to look a bit too much like Christmas. Except that, being it 2020, of course this year “it will be different”.

Pubs are very optimistically accepting bookings for Christmas dinners, but many Christmas markets are (un)fortunately being cancelled. You might still see your distant relatives on Christmas day, but (un)fortunately no more than 6 of them at any one time.

Amidst the inevitable confusion, one obvious question is whether Santa Claus should deliver presents this year.

There are various factors to consider when deciding what Santa – but indeed everyone else – should be allowed to do over Christmas. The most relevant are probably the following:

  1. COVID-19 infection rate over Christmas.
  2. Risks and benefits for others of Santa’s job.
  3. Risks and benefits for Santa

Continue reading

COVID-19: Ethical Guidelines for the Exit Strategy

Alberto Giubilini

Julian Savulescu

Oxford Uehiro Centre for Practical Ethics

University of Oxford

Supported by the UKRI/AHRC funded project “The Ethical Exit Strategy”

(Grant number AH/V006819/1)

https://practicalethics.web.ox.ac.uk/ethical-exit-strategy-covid-19

These are the “Main Points” and the Executive Summary of a Statement on key ethical considerations and recommendations for the UK “Exit Strategy”, that is, the strategy informing the series of measures to move the country from the state of lockdown introduced in March 2020 to a ‘new normality’.

The full Statement can be found at https://practicalethics.web.ox.ac.uk/files/covidexitstatement1octaccpdf

The document has been produced also on the basis of the discussion among academics and stakeholders from different fields (ethics, economics, medicine, paediatrics, mental health, nursing), who participated in an online workshop on the “Ethical Exit Strategy”, held on the 8th of July 2020. Continue reading

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