Pandemic Ethics

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, 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

 

 

 

COVID: Media Must Rise Above Pitting Scientists Against Each other – Dealing With the Pandemic Requires Nuance

Krakenimages/Shutterstock

Trish Greenhalgh, University of Oxford and Dominic Wilkinson, University of Oxford

At the start of the pandemic, there was a striking sense of shared resolve and solidarity. Facing a public health crisis greater than any in living memory, people were largely united in their support of difficult measures to protect the vulnerable, safeguard the health system and sustain key workers.

There were, of course, differences of opinion. For example, some disagreed about the severity of the threat posed by COVID, about the wisdom of different national approaches to lockdown, about the timing of restrictions, and the effectiveness face masks.

More recently, there has also been disagreement on how vaccines should be distributed, whether vaccine passports are a good idea, and whether vaccination should be mandatory for certain occupations)

Throughout the pandemic, scientists attempting to explain their findings have had to deal with unprecedented levels of dissent, anger and abuse from the lay public and occasionally from other scientists.

Since the government lifted COVID restrictions on July 19, views on how best to handle the pandemic have become more polarised than ever, broadly splitting into two camps: the “open up” camp and the “not yet” camp. Continue reading

COVID: Why We Should Stop Testing in Schools

Dominic Wilkinson, University of Oxford; Jonathan Pugh, University of Oxford, and Julian Savulescu, University of Oxford

Education Secretary Gavin Williamson has announced the end of school “bubbles” in England from July 19, following the news that 375,000 children did not attend school for COVID-related reasons in June.

Under the current system, if a schoolchild becomes infected with the coronavirus, pupils who have been in close contact with them have to self-isolate for ten days. In some cases, whole year groups may have to self-isolate.

Such mass self-isolation is hugely disruptive. Yet despite the clamour to switch to other protective measures, such as rapid testing of pupils who have been in close contact with an infected pupil, the public service union Unison has supported self-isolation as “one of the proven ways to keep cases under control”. Continue reading

Mandatory Vaccination for Care Workers: Pro and Con

By Dominic Wilkinson and Julian Savulescu
An edited version of this was published in The  Conversation 

The UK government is set to announce that COVID-19 vaccination will become mandatory for staff in older adult care homes. Staff will be given 16 weeks to undergo vaccination; if they do not, they will face redeployment from frontline services or the loss of their job. The government may also extend the scheme to other healthcare workers.

It is crucial to achieve a high vaccine uptake amongst older adult care home staff due to the high mortality risk faced by residents. ONS Data suggest that there has been a 19.5% increase in excess deaths in care homes since the beginning of the pandemic, with COVID-19 accounting for 24.3% of all care home resident deaths.

According to SAGE, 80% of staff working in care homes with older adult residents (and 90% of the residents themselves) need to be vaccinated in order to confer a minimum level of protection to this vulnerable population. In mid-April, only 53% of older adult care homes in England were meeting these thresholds, whilst, as of the 10th June, 17% of adult care home workers in England have not had a single dose of the COVID-19 vaccine.

Mandating vaccination would increase vaccine uptake in care home workers, but would be a significant intrusion into individual freedom. Is it ethically justifiable?

Continue reading

No jab, no job? Vaccination requirements for care home staff

Written by Lisa Forsberg and Isra Black

Last night the Guardian was first to report that staff working in older adult care homes will be required to get vaccinated against Covid-19. According to BBC News, ‘Care staff are expected to be given 16 weeks to have the jab—or face being redeployed away from frontline care or losing their jobs’. This announcement follows news reports over the last few months that the government have been considering making Covid-19 vaccination mandatory for staff working in older adult care homes in England. As part of this process, an open consultation on vaccination for older adult care home staff was held in April and May of this year, to which we responded.

While we think a vaccination requirement for older adult care home staff may be a necessary and proportionate measure, we nevertheless have concerns about the government’s proposed policy.

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Care home staff vaccination – press release

Two (contrasting) perspectives on the news this morning about planned mandatory vaccination of care home workers.

Professor Julian Savulescu

“The proposal to make vaccination mandatory for care home workers is muddle-headed. Vaccination should be mandatory for the residents, not the workers. It is the residents who stand to gain most from being vaccinated.  Young care workers have little to gain personally from vaccination and there are now lethal risks, as well as uncertain long term consequences of novel vaccines. They have already risked their own lives during the pandemic. Some will be immune from past infection. Those remaining should be offered incentives, including financial incentives, to be vaccinated, not coerced. Vaccines like hepatitis and influenza may be mandatory, but they have been around for years and have established safety profiles.

“It’s too soon to be talking about mandates. We’re still researching rare but potentially serious side-effects that have been thrown up by national monitoring, for example a possible link between Pfizer and myocarditis. We don’t have the full picture on how well they prevent transmission. Public Health England data about how transmission is only available for the first dose and it is currently at up to 50%. Meanwhile the level of protection afforded to vaccinated individuals themselves is holding up very well in terms of hospitalisation and death even against the new variants. With the level of confidence we have encouragement to vaccinate is warranted, and incentives are warranted. Mandates should only be made on the basis of bulletproof safety and efficacy data, including transmission data.”

Prof Dominic Wilkinson & Dr Jonathan Pugh

“In the earlier phase of the pandemic, some of the most medically vulnerable members of our community, patients in care homes and acutely ill patients in hospitals, ended up catching coronavirus from those caring for them. Some patients and care home residents died from infections that they caught from their caregivers.”

“That is a tragic and distressing situation that we must do everything possible to avoid repeating.

First, we should ensure that all those who are high risk have access to vaccination. There are still approximately 10% of older adult care home residents who have not had a 2nd dose of the vaccine.

Second, those who work in the frontline with vulnerable high risk patients have an ethical obligation to take all reasonable measures to prevent spread of the vaccine to those they are caring for. They must follow guidance about the use of measures like hand washing and PPE. They should take part in lateral flow testing schemes. And they should be vaccinated.

In England, as of 10th June, 17% of adult care home workers have not had the COVID-19 vaccine.

There is a strong ethical case that care home workers (and NHS staff) who have not had the COVID vaccine should be redeployed to areas other than frontline care.
It would be ethical to make COVID vaccination (in the absence of a medical exemption) a condition of employment in the same way that hepatitis B vaccination is currently for some health professionals.

If vaccines are made mandatory for health care and care home workers, they should be able to choose from available vaccines. Every effort possible should be made to address any concerns that they have about the vaccines.”

Guest Post: Frances Kamm- Harms, Wrongs, and Meaning in a Pandemic

Written by F M Kamm
This post originally appeared in The Philosophers’ Magazine

When the number of people who have died of COVID-19 in the U.S. reached 500,000 special notice was taken of this great tragedy. As a way of helping people appreciate how enormous an event this was, some commentators thought it would help to compare it to other events that involved a comparable number of people losing their lives. For example, it was compared to all the U.S lives lost on the battlefield in World Wars 1 and II and the Vietnam War (or World War II, the Korean War, and Vietnam). Such comparisons raise questions, concerning dimensions of comparison, some of which are about degrees of harm, wrong, and meaningfulness which are considered in this essay. (Since the focus in the comparison was on the number of soldiers who died rather the number of other people affected by their deaths, this discussion will also focus on the people who die in a pandemic rather than those affected by their deaths.)

Continue reading

Pfizer Jab Approved for Children, but First Other People need to be Vaccinated

Dominic Wilkinson, University of Oxford; Jonathan Pugh, University of Oxford, and Julian Savulescu, University of Oxford

Moderna and Pfizer have released data suggesting that their vaccines are well tolerated in adolescents and highly effective in preventing COVID-19. Canada, the US and the EU have already authorised the Pfizer vaccine in children as young as 12. And the UK has just approved the use of the Pfizer vaccine in children aged 12 to 15. But there may a case for holding out on an immediate rollout, for several reasons.

Whether a vaccine is beneficial for someone depends on three things: how likely they are to become seriously ill from the infection, how effective the vaccine is, and the risks of vaccination. Continue reading

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