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Wednesday, February 21, 2024

When Will the Pandemic Truly Be ‘Over’?

It was a political stumble that turned into a policy two-step. In a 60 Minutes interview, US President Joe Biden declared the Covid pandemic over. Within 12 hours, public health officials, including in his own administration, weighed in to say “No, it’s not.” And within 12 hours after that, the White House—somewhat—walked his comments back.

Chalk it up to exuberance—the updated boosters were just rolling out—or to pandemic fatigue. But look past the immediate messaging failure, and the episode poses an important question: If the pandemic isn’t over yet, how will we know when it is?

It’s a question that can be countered with layers of answers. Official pronouncements for instance: The World Health Organization says “We are not there yet, but the end is in sight,” while the Department of Health and Human Services notes that the US remains in a public health emergency that could be redeclared next month. Or metrics, for example: According to data from the Centers for Disease Control and Prevention, cases, hospitalizations, and deaths are all declining—but at the same time, Covid has been ranked the third-leading cause of death in the US. Meanwhile, only a third of US residents who are over 50, and thus considered at higher risk of illness, have taken the full four-shot vaccine protocol. As of last week, only 4.4 million people—1.5 percent of those eligible—had received the newest bivalent booster.

Look past that mess of contradictions, and beyond them lies a difficult reality: We might never achieve a benchmark that lets us declare the pandemic is behind us. The best “over” we may be able to hope for is that it settles into an endemic state, present but no longer overwhelming. Worst case: It persists, but we cease to care.

“There’s no exact point at which we can say, ‘OK, we’re done,’” says Jennifer Kates, a health policy analyst and senior vice president at the Kaiser Family Foundation. “And that’s hard, because people want certainty. Where we are today is very different than where we were a year and a half ago, when the vaccines were new. But we are still at a place where there is an unacceptably high number of deaths—almost 400 a day, three or four times higher than a really bad flu year.”

Humans live by stories, and we especially like stories that end happily; it’s alluring to think of the pandemic as a storm that shakes your house but then blows through and reveals blue sky. But the more accurate narrative may be a storm that cracks a seawall holding back the ocean—and ever after, your tap water tastes the tiniest bit like salt.

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“There’s no going back to 2019,” says Abraar Karan, a physician and infectious-disease researcher at Stanford University who studies the role of air filtration in reducing infection. “The dead aren’t coming back. The long-term consequences won’t be fully appreciated until we have more time to analyze them. And the variants aren’t going away.”

When the pandemic began, we could imagine that the restoration of specific things we’d put on hold would signal life was returning to normal. Schools would reopen; masks would come off; offices would fill back up, and restaurants would buzz with diners. Thirty months on, we got all those things back—social mixing, return to office, bare faces—without vanquishing the virus. If their return was not the signal, it’s difficult to imagine what could be.

“There won’t be a single moment,” says Caitlin Rivers, an assistant professor at the Johns Hopkins Bloomberg School of Public Health and part of the founding leadership at the CDC’s new epidemic forecasting center. “We will recognize the transition only in retrospect.” But among possible milestones—interrupting transmission, suppressing hospitalizations and deaths, relaxing self-sequestering—she points out that we’ve only achieved the third one. “The last dimension that I think about in moving from emergency to routine is when people live their lives in the way that they wish to,” she says. “And I think on that point, we may be close to there.”

That makes moving on from the pandemic a sociopolitical decision rather than an epidemiological one. While it’s not clear whether SARS-CoV-2 can settle into a steady state alongside humanity, we can be pretty confident it hasn’t done that yet. On the same weekend that Biden was declaring the pandemic over, Swedish researchers announced in a preprint (not yet peer-reviewed) that they had identified yet another viral variant, dubbed BA.2.75.2. Ben Murrell, the preprint’s senior author, said on Twitter that it “exhibits more extreme antibody escape than any variant we’ve seen so far,” meaning that existing vaccines—possibly including the brand-new Omicron bivalents—might not successfully suppress it.

It’s unnerving to recognize that we might be done with Covid, but Covid might not be done with us. It evokes the Groundhog Day feeling of making yet another exhausting circuit through a series of identical events. Except, of course, the moral of Groundhog Day is that sincere intention can change the future. There are lessons within the pandemic that we could leverage. We just haven’t taken advantage of most of them.

“In 2020, as awful as it was, I thought: This is finally the time that we’re going to end the cycle of boom and bust—because this event is so profound that we are not going to want to come out of it and just head right back into another one,” says Jennifer Nuzzo, an epidemiologist and director of the Pandemic Center at Brown University School of Public Health.

But in fact, though the US spent trillions on Covid—in stimulus funds, business rescues, health care subsidies, and vaccine research—things that could make a difference to the next pandemic have yet to be created. Those include funding state and local health departments so they can build back permanent workforces, and reconsidering the health care cost-cutting that left understaffed hospitals so vulnerable to Covid overcrowding. It also includes fixing the collection of disease data in the US. The pipeline is so leaky thanks to incompatible forms and platforms that a coalition of public health organizations estimate it would take almost $8 billion to repair. One recent example of the system’s ineffectiveness: In many states, men who believed themselves at risk for monkeypox, but who also thought they might have been protected by childhood smallpox vaccinations, discovered their paper vaccination records had never been added to digital systems.

Another way to ascertain when the pandemic is over is to ask whether we’re ready for the next one. About that: We’re not. “That is not one of my indicators, because I don’t think we’re ready for the next pandemic,” Kates says. “And I don’t think we’ll be ready for a long time.”

Which might sound defeatist. But another way to think about getting to “over” is to imagine what actions it would take to suppress Covid as much as possible, and then make them milestones that lead us to the pandemic’s end. “To me, it will be ‘over’ when there’s little left that we can do,” Karan says. “But there are very doable things we can do right now, between closing the booster gap for severe disease and death, to air filtration to reduce super-spreading. And they’re not going to get done if the political will is not behind it.”

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