Collective Responsibility

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

 

 

 

What If Stones Have Souls?

By Charles Foster

Over the 40,000 years or so of the history of behaviourally modern humans, the overwhelming majority of generations have been, so far as we can see, animist. They have, that is, believed that all or most things, human and otherwise, have some sort of soul.

We can argue about the meaning of ‘soul’, and about the relationship of ‘soul’ to consciousness, but most would agree that whatever ‘soul’ and ‘consciousness’ mean, and however they are related, there is some intimate and necessary connection between them – even if they are not identical.

Consciousness is plainly not a characteristic unique to humans. Indeed the better we get at looking for consciousness, the more we find it. The universe seems to be a garden in which consciousness springs up very readily. Continue reading

Is a Publication Boycott of Chinese Science a Justifiable Response to Human Rights Violations Perpetrated by Chinese Doctors and Scientists?

By Doug McConnell

Recently the editor-in-chief of the Annals of Human Genetics, Prof David Curtis, resigned from his position, in part, because the journal’s publisher, Wiley, refused to publish a letter he co-authored with Thomas Schulze, Yves Moreau, and Thomas Wenzel. In that letter, they argue in favour of a boycott on Chinese medical and scientific publications as a response to the serious human rights violations happening in China. Several other leading journals, the Lancet, the BMJ and JAMA have also refused to publish the letter claiming that a boycott against China would be unfair and counterproductive.

This raises two separate ethical issues: 1. Should journals refuse to publish a letter arguing in favour of a boycott on Chinese medical and scientific publications? 2. Should journals actually establish a boycott on Chinese medical and scientific publications? Continue reading

Lockdown Erodes Agency

By Charles Foster

A couple of lockdown conversations:

  1. The other day I met a friend in the street. We hadn’t seen one another for over a year. We mimed the hugs that we would have given in a saner age, and started to talk. ‘There’s nothing to tell you’, she said. ‘Nothing’s happened since we last saw you. And that’s just as well, because, as you’ll find, I’ve forgotten how to talk, how to relate, and how to read ordinary cues. We’ve not been out. We’ve not changed anything. I wonder if we’ve been changed?’
  1. Another friend. ‘Zoom’s great, isn’t it? You switch off your camera and your microphone, and the meeting just goes on perfectly happily without you. Everyone thinks you’re there. Your name’s up on their screen. But you are just getting on with your own business.’

And a lockdown fact: Lockdown has been great for book sales. 2020 saw an estimated rise of 5.2% in volume sales of print books in the UK compared with 2019 sales. This was the biggest annual rise since 2007: Continue reading

Mandating COVID-19 Vaccination for Children

Written by Lisa Forsberg and Anthony Skelton

In many countries vaccine rollouts are now well underway. Vaccine programmes in Israel, the United Kingdom, Chile, United Arab Emirates, Bahrain and the United States have been particularly successful. Mass vaccination is vital to ending the pandemic. However, at present, vaccines are typically not approved for children under the age of 16. Full protection from COVID-19 at a population level will not be achieved until most children and adolescents are inoculated against the deadly disease. A number of pharmaceutical companies have started or will soon start clinical trials to test the safety and efficacy of COVID-19 vaccinations in children and adolescents. Initial results of clinical trials seem promising (see also here and here).

There are strong reasons to inoculate children. COVID-19 may harm or kill them. It disproportionately affects already disadvantaged populations. For example, a CDC study published in August 2020 found the hospitalisation rate to be five times higher for Black children and eight times higher for Latino children than it is for white children. In addition, inoculating children is necessary for establishing herd immunity and (perhaps more importantly), as Jeremy Samuel Faust and Angela L. Rasmussen explained in the New York Times, preventing the virus from spreading and mutating ‘into more dangerous variants, including ones that could harm both children and adults’. Continue reading

This Machine Kills Viruses

Written by Stephen Rainey

If we had a machine that could eradicate coronavirus at the press of a button, there would likely be a queue to do the honours. Rather than having such a device, we have a science-policy interface, and a general context of democratic legitimacy. This isn’t a push-button, but a complex of socio-political liberties and privations. We can’t push the button, but we can learn how to use the technology we do have – by collectively following policies like staying inside, wearing masks outside, and keeping distance from others.

Because of the coronavirus pandemic a novel form of this scientific research, technological application, and influence or control of nature (including humans) is emerging. In this case, the application is public policy, as based on multitudes of scientific advice. That over which control is sought is twofold: the virus, and people. Control of the virus is not really possible without some control over the people. Likewise, control of the people becomes harder where the virus is not controlled. Public trust in tough policies wanes if there is no end in sight, or no clear rationale in place. Continue reading

The Duty To Ignore Covid-19

By Charles Foster

This is a plea for a self-denying ordinance on the part of philosophers. Ignore Covid-19. It was important that you said what you have said about it, but the job is done. There is nothing more to say. And there are great dangers in continuing to comment. It gives the impression that there is only one issue in the world. But there are many others, and they need your attention. Just as cancer patients were left untreated because Covid closed hospitals, so important philosophical problems are left unaddressed, or viewed only through the distorting lens of Covid. Continue reading

We’re All Vitalists Now

By Charles Foster

It has been a terrible few months for moral philosophers – and for utilitarians in particular. Their relevance to public discourse has never been greater, but never have their analyses been so humiliatingly sidelined by policy makers across the world. The world’s governments are all, it seems, ruled by a rather crude vitalism. Livelihoods and freedoms give way easily to a statistically small risk of individual death.

That might or might not be the morally right result. I’m not considering here the appropriateness of any government measures, and simply note that whatever one says about the UK Government’s response, it has been supremely successful in generating fear. Presumably that was its intention. The fear in the eyes above the masks is mainly an atavistic terror of personal extinction – a fear unmitigated by rational risk assessment. There is also a genuine fear for others (and the crisis has shown humans at their most splendidly altruistic and communitarian as well). But we really don’t have much ballast.

The fear is likely to endure long after the virus itself has receded. Even if we eventually pluck up the courage to hug our friends or go to the theatre, the fear has shown us what we’re really like, and the unflattering picture will be hard to forget.

I wonder what this new view of ourselves will mean for some of the big debates in ethics and law? The obvious examples are euthanasia and assisted suicide. Continue reading

Pandemic ethics: Never again – will we make Covid-19 a warning shot or a dud?

by Anders Sandberg

The Covid-19 pandemic is not the end of the world. But it certainly is a wake-up call. When we look back on the current situation in a year’s time, will we collectively learn the right lessons or instead quickly forget like we did with the 1918 flu? Or even think it was just hype, like Y2K?

There are certainly plenty of people saying this is the new normal, and that things will never be the same. But historically we have adapted to trauma rather well. Maybe too well – we have a moral reason to ensure that we do not forget the harsh lessons we are learning now.

Continue reading

Coronavirus: Dark Clouds, But Some Silver Linings?

By Charles Foster

Cross posted from The Conversation

To be clear, and in the hope of heading off some trolls, two observations. First: of course I don’t welcome the epidemic. It will cause death, worry, inconvenience and great physical and economic suffering. Lives and livelihoods will be destroyed. The burden will fall disproportionately on the old, the weak and the poor.

And second: these suggestions are rather trite. They should be obvious to reasonably reflective people of average moral sensibility.

That said, here goes:

1. It will make us realise that national boundaries are artificial

The virus doesn’t carry a passport or recognise frontiers. The only way of stopping its spread would be to shut borders wholly, and not even the most rabid nationalists advocate that. It would mean declaring that nations were prisons, with no one coming in or out – or at least not coming back once they’d left. In a world where we too casually assume that frontiers are significant, it doesn’t do any harm to be reminded of the basic fact that humans occupy an indivisible world.

Cooperation between nations is essential to combating the epidemic. That cooperation is likely to undermine nationalist rhetoric.

2. It will make us realise that people are not islands

The atomistic billiard-ball model of the person – a model that dominates political and ethical thinking in the west – is biologically ludicrous and sociologically unsustainable. Our individual boundaries are porous. We bleed into one another and infect one another with both ills and joys. Infectious disease is a salutary reminder of our interconnectedness. It might help us to recover a sense of society.

3. It may encourage a proper sort of localism

Internationalism may be boosted. I hope so. But if we’re all locked up with one another in local quarantine, we might get to know the neighbours and the family members we’ve always ignored. We might distribute ourselves less widely, and so be more present to the people around us.

We might even find out that our local woods are more beautiful than foreign beaches, and that local farmers grow better and cheaper food than that which is shipped (with the associated harm to the climate) across the globe.

4. It may encourage altruism

Exigencies tend to bring out the best and the worst in us. An epidemic may engender and foster altruistic heroes.

5. It may remind us of some neglected constituencies

Mortality and serious illness are far higher among the old, the very young, and those suffering from other diseases. We tend to think about – and legislate for – the healthy and robust. The epidemic should remind us that they are not the only stakeholders.

6. It may make future epidemics less likely

The lessons learned from the coronavirus epidemic will pay dividends in the future. We will be more realistic about the dangers of viruses crossing the barriers between species. The whole notion of public health (a Cinderella speciality in medicine in most jurisdictions) has been rehabilitated. It is plain that private healthcare can’t be the whole answer. Much has been learned about the containment and mitigation of infectious disease. There are strenuous competitive and cooperative efforts afoot to develop a vaccine, and vaccines against future viral challenges are likely to be developed faster as a result.

7. It might make us more realistic about medicine

Medicine is not omnipotent. Recognising this might make us more aware of our vulnerabilities. The consequences of that are difficult to predict, but living in the world as it really is, rather than in an illusory world, is probably a good thing. And recognising our own vulnerability might make us more humble and less presumptuous.

8. Wildlife may benefit

China has announced a permanent ban on trade in and consumption of wildlife. That in itself is hugely significant from a conservation, an animal welfare, and a human health perspective. Hopefully other nations will follow suit.

Continue reading

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