Even before President Biden’s highly publicized recent assertion that the COVID-19 pandemic is over, there was plenty of discussion on this topic in public health circles and beyond. Dropping the “p” word from our COVID-19 discourse would suggest to many that our current state of play is something we should accept for the foreseeable future.
If that’s the case, we should brace ourselves for a new normal in the U.S. with persistent labor shortages, buckling health care and a daily death toll that would have seemed unthinkable in February 2020.
The definition of “pandemic” is not precise or widely agreed upon, so this debate was never going to be straightforward. From a public health perspective, this still looks like a pandemic — transmission is global, high and somewhat unpredictable. But in the U.S. (and most of the world besides China), disruptive COVID-19 policies are a thing of the past and individual risk has gone down considerably — thanks to some combination of vaccination, previous infection, treatments and weaker variants. That’s enough for many people to declare the pandemic over, choosing a broader definition that is as much psychological as it is epidemiological.
Biden’s comment last weekend was very much a reflection of this — he is well aware that there is now nothing but political downside for expressing COVID-19 caution. And with federal funding in limbo and politicians competing to see who can do less on COVID-19, Biden is now part of the broader movement to either implicitly or explicitly treat COVID-19 like it’s an “endemic” disease.
Like pandemic, agreement on the precise definition of “endemic” is hard to come by. But endemic usually refers to an epidemiological state whereby transmission follows some type of vaguely predictable pattern.
One thing endemic doesn’t mean is harmless. Seasonal flu, which is typically characterized as endemic, causes substantial amounts of illness, death and health care strain during a predictable time period (winter) and within predictable populations (elderly, immunocompromised and the very young). Endemic malaria in tropical parts of the world kills over half a million people a year, many of them children, usually during rainy seasons.
So, if COVID-19 is now settling into a predictable endemic pattern, what can we expect?
First off, whatever funding there is will mostly dry up as attention shifts elsewhere.
Based on 2022 outbreak dynamics, we are looking at about four to five waves of illness every year. Winter outbreaks will be worse than summer and coincide with a resurgent seasonal flu. But unlike flu, there will be no respite during the warmer months.
Economically, the service sector will struggle to regain its footing amidst large waves of illness, absenteeism and burnout from over-stretched employees.
Similar dynamics will affect our health care system, which is already running on fumes. Nurse and doctor shortages will continue due to illness and burnout, increasing the risks of bad outcomes for all illnesses, not just COVID-19. Health care costs will likely rise even faster as care for both COVID-19 and Long COVID creates additional upward price pressure on providers.
We should expect testing levels to continue to go down as people get on with their lives, leaving us increasingly in the dark on true case counts.
But deaths from COVID-19 are somewhat easier to track. And while death certificates are not always 100 percent accurate, they are less susceptible to the “with COVID not from” challenge that has characterized the COVID-19 hospitalization numbers in 2022 (claims that this was widespread in 2020 and most of 2021, however, are inaccurate). If 2022 is any indicator, we could see around 125,000 deaths per year, or about four times worse than a typical flu season. Not exactly the herd immunity sweet spot that armchair epidemiologists were latching on to in 2020 and far from a post-pandemic new normal that anyone would have characterized as desirable in 2020.
But if all of this sounds overly certain, it is. The reality is that identifying an endemic state for COVID-19 can only be done in the rear-view mirror after a few years of roughly similar outbreak dynamics.
And if COVID-19 has taught us anything, it’s that long-term predictions that are delivered with extreme certainty are usually wrong.
So, it remains very difficult to characterize this moment in time. Perhaps the best-case scenario is that COVID-19 is, in fact, not endemic right now. Perhaps new virological twists and turns introduce a less virulent variant into the mix and COVID-19 finally settles into similar territory as other common cold coronaviruses. Perhaps intra-nasal vaccines will be better than our current vaccines at preventing infection, limiting the size of future waves.
Or perhaps the virus has other plans and severe illness and deaths far exceed the projections mentioned above.
While no one really knows where this will go, one way to increase the likelihood of these worst-case scenarios is to ignore them. Nobody is seriously advocating for lockdowns or suggesting we can eliminate all cases and deaths — but citizens and policymakers settling into a false sense of certainty and defeatism aboutCOVID-19 also isn’t the answer. Less disruptive investments like ventilation, wastewater surveillance and next generation vaccines and therapeutics could still go a long way to mitigate risk as we traverse this highly uncertain road to endemicity.
Scott Rosenstein is a public health adviser and a professor at Bard College’s Globalization and International Affairs program.