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How Will We Know When the Pandemic Is Over?

Who decides a pandemic is over, on what basis, and how will you know?

Key points

  • The end of a pandemic is not the mirror image of its beginning.
  • The start is determined by biology, the end by politics.
  • There’s no point in waiting for COVID-19 to vanish. It won’t.

In The Netherlands, where I live, most people seem to be living more or less as they did before the COVID-19 pandemic began. Restrictions ended weeks ago, unlike in China, where millions have been moving in and out of lockdowns for months—two extremes, with some oddities in between. If you travel from Latin America to Amsterdam via the United States, you’ll need to be tested and might need to quarantine. If you travel directly, you’ll no longer need any test at all.

Living as I am now, am I giving in to pandemic fatigue? Are I and others acting irresponsibly because we’re sick of living with restrictions? Or is the pandemic really over for some but not for others? Does that make any sense? Isn’t a pandemic, by definition, global?

What Are PHEICs?

Though "pandemic" is the term we all use, it lacks precision. The World Health Organization (WHO) uses the term Public Health Emergency of International Concern, or PHEIC. A PHEIC is a serious, sudden, unusual, or unexpected public health event, likely to spread internationally, and in urgent need of international action. When a PHEIC has been declared, all 196 WHO member countries are obliged to begin mass testing, report cases, and so on.

At the end of January 2020, the WHO declared that COVID-19 was a PHEIC. The declaration is reviewed regularly. It is still in force. As far as the WHO is concerned, the "pandemic" is not over. Will it end when the WHO revokes the PHEIC call? On what basis will it do that?

Not simply by counting cases. Too much is at stake. Declaring that the PHEIC has ended will have important social, political, and economic consequences. Global structures like COVAX, set up for helping poor countries access vaccines, may close down. In the United States, the end of the public health emergency could affect millions of people’s Medicare coverage. Some pharmaceutical companies committed to providing vital vaccines and drugs cheaply to poor countries—but only for the duration of the PHEIC.

Clearly, this isn’t the whole story. The PHEIC refers to the international obligations of governments. Domestically, governments make their own decisions. We citizens decide for ourselves how to make use of whatever freedoms we’re allowed. In Amsterdam, I can (more or less) resume my pre-pandemic life. In Mexico City, children wear facemasks in schools. In Beijing, lockdown is returning.

How Did Previous Epidemics End?

Virologists and epidemiologists have long been discussing how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began to spread in human populations. They’d previously studied the origins of many other viral epidemics. What about their ends? There are countless studies of how pandemics—or epidemics—begin, but very few studies of how they end.

They rarely end with a disease vanishing completely. The SARS epidemic of 2002–2004 was a rare example. Smallpox is the only human disease to have been eradicated by a public health campaign. Disease eradication will very rarely be possible.

Much of what’s been written about the ends of epidemics is the work of historians, not of epidemiologists or virologists. Numbers of cases are generally not their principal interest. Charles Rosenberg, for example, looked for patterns in how societies acted and how this changed over the course of an epidemic. He saw something comparable with a drama acted out on stage, with "actors" following a standard script:

Epidemics start at a moment in time, proceed on a stage limited in space and duration, following a plot line of increasing and revelatory tension, move to a crisis of individual and collective character, then drift toward closure.

Instead of a clear endpoint, there’s a "drift toward closure." The "drift" begins when the urgency of a disease outbreak has sufficiently diminished so that public attention shifts to the problems it left in its wake, or the underlying problems it brought to the surface. As historians Charters and Heitman note:

Epidemics end once the diseases become accepted into people's daily lives and routines, becoming endemic—domesticated—and accepted.

How and at what stage this happens varies from one society to another. What are people willing to accept? The answer doesn’t depend only, or even principally, on the virus. It depends on ways of life, on levels of tolerance or resignation, on people’s expectations.

How Will COVID-19 End?

If we put what virologists say together with what historians say, what follows? It’s most unlikely that the virus will disappear completely. It will continue to mutate. The Omicron variant, with its many subvariants, may soon lead to a new wave of infections. But the story won’t end even there. It’s not possible to predict the characteristics of future variants. Provided these are not too severe, the virus will eventually become endemic. We’ll have learned to live with it.

Epidemiological modeling cannot predict when this will be. Forecasting beyond a few weeks ahead is too inaccurate. It’s also because the transition from epidemic to endemic depends on how many deaths a particular society is willing to tolerate.

That a disease has become endemic does not mean it has become harmless. People will still be hospitalized, and some will still die. How many deaths is a society willing to accept? That can only be established collectively by an informed population. Since we don’t know what future mutations will be like, it can only be provisional. I’m going to enjoy my more-or-less normal life while I can.

References

Rosenberg, C.E.(1992) ‘What is an epidemic? AIDS in historical perspective’ pp278-292 in Rosenberg, C. E. Explaining Epidemics. Cambridge UK: Cambridge University Press,

Charters, E. & Heitman, K ‘How epidemics end’ Centaurus 63,1 (2021) https://doi.org/10.1111/1600-0498.12370

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