The (Thai) New World

Remember a million years ago when we were comparing the pandemic to Columbus's voyage to the new world?  When we were complaining because it wasn't over after two months, even though Columbus took half that time to get across the Atlantic?

Remember looking for signs of land:  birds, branches in the water, a change in the sea?  And then realizing that we had so much longer to go?

Well, a hypothetical stick just floated by, and there goes a hypothetical bird:

Barely 2 months after it began, the Omicron wave is already ebbing in some countries. And although it has sickened huge numbers of people, caused massive disruption, and left many health care workers exhausted, it is also leaving something unusual in its wake: a sense of optimism about the pandemic’s trajectory. In countries where many people have been vaccinated or were infected, scientists say, the worst may finally be over.

“We anticipate that there will be a period of quiet before COVID-19 may come back towards the end of the year, but not necessarily the pandemic coming back,” Hans Kluge, director of the European Region of the World Health Organization (WHO), recently said in an interview...

The optimism is shared—although couched in caveats—even by some scientists and public health experts who have stressed the risks of the pandemic from the start and implored politicians to take stricter action. “We have reached a bit of a turning point,” says Devi Sridhar, a global health expert at the University of Edinburgh... Not only has the Omicron wave crested in several countries, but its toll has been smaller than feared. And the wave of infections has likely boosted immunity at the population level, which means future waves may wreak even less havoc.

Still, researchers urge caution. 

Yeah, I'll bet they do. 

The bird and the stick are hypothetical because they are signs of land only if the folks that are doing the predicting are accurate.  It's just a guess, but an informed guess.  Nevertheless, this kind of thing is new and refreshing.

Speaking of caution, Thailand has approved the protocols for declaring COVID-19 endemic, which would, at least for them, end the pandemic and usher in the new (Thai) world.  They set out three criteria*, and asserted that they already meet all three criteria - but they're going to wait six months to a year before declaring the pandemic endemic.  Caution, indeed.  This kind of range sounds kind of made up, suggesting that Thailand is not engaged in an ordered sequence that will end on a particular day, but is just testing the winds, like Spain did not too long ago.

So, keep a lookout.  Don't believe everything you see.  And if you live in the US, good luck.  Our vaccination rate isn't anywhere near what it takes to move into endemicity.  80% vaccination rate?  Ha!  Set the sails, get another hot meal, settle in, check the maps and charts.  Lots of patience.

 * - fewer than 10,000 new cases per day; the fatality rate is no higher than 0.1% of those who are admitted to the hospital with an infection; and more than 80% of at-risk people have had at least two vaccinations.

Sufficient Control

Anthony Fauci and White House Covid-19 response coordinator Jeff Zients, laying out their maps of the new world, says much the same as Aris Katzourakis did yesterday, but somehow making it sound like a hazy, bureaucratic place that could be benign if you only squinted your eyes just right.  Of course, when Fauci and Zients speak, it is US policy, and, therefore, inherently political.  But enough of that; decide for yourself:

• "We continue to move toward a time when Covid won't disrupt our daily lives. A time when Covid is no longer a crisis, but rather something we protect against and treat,"
• Fauci said there is still a "way to go" before cases and hospitalizations decline to what he described as an "acceptable situation."
• Fauci did not offer specific metrics on what that would look like.
• Fauci said the aim is to get to a place "sufficient control," which he explained was not "eradication" like with smallpox or "elimination" like with the polio epidemic and measles, but rather, "a level of control that does not disrupt us in society, does not dominate our lives, not prevent us to do the things that we generally do under normal existence."
• "That would be a level of infection, but more importantly, concentrating on the severity of disease, hospitalizations, and deaths that fall within the category of what we generally accept. We don't like it, but we accept it with other respiratory viruses: RSV, paraflu, and even influenza," Fauci said.
• Fauci said vaccines, boosters and infection will "hopefully, get us to the point where we have antivirals to be able to treat people who are at high risk that we no longer are in a situation of threat -- threat to our equanimity, threat to our economy, the threat to allow us to live a normal life."

To me, it sounds a lot like what we here at The New World have been talking about for some time.  This vision of the future, laid out by Administration spokesmen, in a political setting, at a time when people are dying and hospitals are full, must surely downplay the deaths and hospitalizations that we can see in the subtexts. But make no mistake:  there will be deaths and hospitalizations, and they will be in addition to, not somehow subsumed into, the deaths and hospitalizations caused by "RSV, paraflu, and even influenza," that we endure on an annual basis.  So thousands more will die, every year, than have ever died before.  That's the new world.

The endemic diseases that kill millions of us each year have never really broken the surface, and come to our attention, in any meaningful or consistent manner.  Perhaps, after years of a pandemic that has reached every corner of the world, and every nook and cranny of our attention, we might decide it's time to do something about this war - The Endemic War - and maybe even start with adequate health care for all Americans, including proactive engagement and preventive medicine.

Is it being hyperbolic to call it a "War"?  You can look up the numbers.  Flu and pneumonia kill more Americans each year than died in the Vietnam War.  Diabetes, a largely preventable disease, kills even more of us.  And so forth.  Haven't we gotten to the point where we have the resources to address this kind of thing?  

Well.  This post sure got out of hand.  Sorry.  See you next time.

Lazy Optimism

Aris Katzourakis, writing in Nature, reminds us that the new world will not see COVID-19 fade away.  There will be no return to normal.  To an epidemiologist, "an endemic infection is one in which overall rates are static — not rising, not falling."  For instance, malaria and tuberculosis.  In 2020, when all eyes were fixed on the pandemic, these endemic diseases killed 600,000 and 1.1 million people, respectively.  The "normal" flu, of course, kills around 35,000 a year, just in the US.

So the new world will include a significant number of deaths from COVID-19, year after year.  How many?  Interestingly, it will depend a lot on how we manage it:

First, we must set aside lazy optimism. Second, we must be realistic about the likely levels of death, disability and sickness. Targets set for reduction should consider that circulating virus risks giving rise to new variants. Third, we must use — globally — the formidable weapons available: effective vaccines, antiviral medications, diagnostic tests and a better understanding of how to stop an airborne virus through mask wearing, distancing, and air ventilation and filtration. Fourth, we must invest in vaccines that protect against a broader range of variants.

So we must set aside "lazy optimism."  Will we?  How are you betting? 

One View

One view of the way forward.

Can you see the new world, way in the distance?   Neither can I.

Further Along the Path to Endemic

More talk about "pandemic" transitioning into "endemic."  The other day we looked at Spain's cautious call for more detailed planning in that direction, a position not yet shared with Spain's European colleagues.  But we have a little more detail regarding what endemic might look like:

Spanish officials would no longer need to record every COVID-19 infection and that people with symptoms would not necessarily be tested, but they would continue to be treated if they are sick. 

It's still a ways away.  But there will, eventually, be a situation of dynamic equilibrium:  no real surges, plateaus or declines in different parts of the world at different times, just seasonal waxing and waning, just like the normal flu.  

The article ends with some delightful news:

Even after the pandemic ends, “COVID will still be with us,” said Dr. Chris Woods, an infectious disease expert at Duke University. “The difference is people won’t be dying indiscriminately because of it, and it will be so routine that we will have much better and fairer access to vaccines, therapeutics and diagnostics for all.”

Do ya think?  Sounds good, but the first part of this prediction absolutely depends on the second part.

And what about long COVID?  Those of us who have been taking extraordinary measures to not get it for over two years - do we continue to live in caves and have everything delivered?  Or do we wash and store our masks and take our chances?  The answer may depend on learning more about long COVID, and the preliminary returns are encouraging.  We'll get into detail when there's a more comprehensive, useful body of research.  Stay tuned. 

Defining the New Endemic World

This is a few days late, but... plumbers, hot water...  Anyway:

It seems that there has been some high-level thinking regarding the end of the pandemic.  "High level" meaning government officials, not sterling quality thought.  AP reports that Spanish Prime Minister Pedro Sanchez is calling for European authorities to begin shifting to a COVID maintenance process that would treat the disease as endemic rather than continuing to approach it as a pandemic:

The change would mean treating COVID-19 as an “endemic illness” rather than a pandemic, Sánchez said Monday, adding that deaths as a proportion of recorded cases have fallen dramatically since the initial onset of the pandemic.

“I believe that we have the conditions for, with precaution, slowly, opening the debate at the technical level and at the level of health professionals, but also at the European level, to start evaluating the evolution of this disease with different parameters than we have until now,” Sánchez told Cadena SER radio.

This is the kind of bureaucra-speak we'll be hearing more and more of, especially when/if the incidence of Omicron plateaus and begins to recede.  Whereas the clean end of the pandemic, which we lost the opportunity to experience when so many of us decided to opt out of the process for political reasons, would be obvious - just a few manageable pockets of infection remaining, worldwide - the move to an endemic relationship with COVID will require only a little less monitoring and regulation than we have now - forever.

So, the new world:  just like the old world, but more complicated - and more "hard work, illness and death"?

Protocols of the New World

I've spent the last few days trying to organize some hot water at the house here in Truro.  The hot water heater started leaking on New Year's Day.  We didn't know any plumbers.  So started the quest.  Nearly two weeks later, still no hot water, but we're closer.  I learned two things:  It's possible to be in contact with many professionals in the same area, regarding a relatively simple project, and not learn a single thing.  Because - the second thing - half of those professionals directly contradict the information the other half has provided.

Sound familiar?

Anyway, I've had some time to do a little reading, and here's something that struck me this morning while I was poking around the blogosphere:

So, in the new world, will both COVID-19 and climate change become endemic?  Remember the "Wired" article which suggested this definition of "endemic":

...at some point, we’ll achieve a balance that represents how much work we’re willing to do to control Covid, and how much illness and death we’ll tolerate to stay there. 

Substitute "climate change" for "Covid," and you have the protocols for the new world.  And guess who gets to do the "hard work... illness and death"? 

The Beginnings of a Map of the New World

After two years of the pandemic, Kevin Drum is thinking about the new world.  Good for him!  He's got a list of "things we'd pretty much make permanent":

• Get vaxxed and then get boosted every year or so. (Details would depend on our evolving understanding of vaccine effectiveness.)
• Mask up at indoor public places. But not routinely at work. (Or should we bow to reality and give up on masks entirely?)
• Require proof of vaccination for large indoor events.
• Close schools only briefly and only on rare occasions when prevalence is high locally and 2-3% of students have tested positive.*

All good-natured kidding of one of my favorite bloggers aside, this is one of the first examples of post-pandemic thinking that I've read, not counting the endless numbers of definitions of "endemic."  He also includes what he doesn't think will be part of the new world.  It's a list that, in summary, suggests that we will not shut down our society as we know it.

One quibble:  He suggests schools will be closed "when prevalence is high locally and 2-3% of students have tested positive."  Yet routine testing is not on the list, in fact, one of the things he doesn't think will survive the end of the pandemic is "Routine testing requirements in general (instead rely more on proof of vaccination)."  How do we know when to shut a school - test only when it feels like there may be a lot of COVID around?

Anyway, here's the beginnings of a map of the new world.  Something to chew on; it's a start.

Hard Work, Illness and Death

You probably don't want to read another post, here at The New World, about how COVID-19 will become endemic.  I don't want to write one.  I don't even want to look up all my other 'endemic' posts so I can link you to them.  Just type "endemic" in the search bar at the top left and enjoy.

So I won't comment or expand on what is really a pretty interesting article in "Wired," a periodical in which interesting articles about endemic flus are not always expected.  There are some pretty clear definitions of endemic, which are rarer than you might think:

Endemicity doesn’t mean that there will be no more infections, let alone illnesses and deaths. It also doesn’t mean that future infections will cause milder illness than they do now. Simply put, it indicates that immunity and infections will have reached a steady state. Not enough people will be immune to deny the virus a host. Not enough people will be vulnerable to spark widespread outbreaks.

Ah, that happy medium between immunity and vulnerability.  Forever.

Also:

Endemicity, in other words, isn’t a promise of safety. Instead, as epidemiologist Ellie Murray has argued, it’s a guarantee of having to be on guard all the time.

And finally - how we know when we get there:

...at some point, we’ll achieve a balance that represents how much work we’re willing to do to control Covid, and how much illness and death we’ll tolerate to stay there. 

So the new world will, it seems, include a constant conversation regarding hard work, illness and death.

Question:  If everyone - and I mean everyone - had gotten vaccinated by, say, the summer of 2021, would we be having this conversation right now?

No. 

No, It's Not

Over two years after the pandemic began, articles about its end are still featuring the world "endemic," and are full of phrases like "wait and see" and "No one can predict" and "We have no idea" and my personal favorite, "There's not even a measurement to say that something is an epidemic or pandemic. All of this is in the eye of the beholder."  All of these bold statements appeared in the same article, titled, a little dishonestly, "It won't be a pandemic forever. Here's what could be next."

What's next is "endemic."  We've already talked about what "endemic" means:  COVID-19 will be around forever, killing us in smaller numbers and mostly in the winter, just like regular flu.   Mostly because of variants and their origins:  large numbers of people who are not vaccinated, who serve as the breeding grounds for Delta, Omicron and whatever comes next.

Anyway, it turns out that, if you believe Dr. Arnold Monto - a professor of epidemiology at the University of Michigan and acting chair of the US FDA's Vaccines and Related Biological Products Advisory Committee, who gave us the "eye of the beholder" quote above - I get to decide when it's over.  I've been beholding this pandemic, right here at this blog, since April of 2020.  

Great!

Guess what.  It's not over.

Again

We've been down this road before:

Happy New Year!