Comment: We may not wait for covid numbers to call ‘all clear’

In past pandemics, illness and deaths continued for years while society went on with little notice.

By Peter Doshi and David Robertson / Special To The Washington Post

It feels as though we’ve been fighting about the end of the coronavirus pandemic almost since the day it began. In March 2020, President Trump wanted to lift the lockdowns. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, countered, “You don’t make the timeline. The virus makes the timeline.”

Nearly two years later, as the omicron variant surged during the winter holidays, it dashed optimism among many that the end of the pandemic was near. This newest of new variants has produced widely varying responses, with some suggesting it heralds the end phase of the pandemic and others doubling down on containment measures.

So when will the pandemic actually end?

According to Fauci’s logic, the answer is only when the numbers of cases, hospitalizations and deaths come down and stay down. But as appealing as this notion is in its simple clarity, it clashes with history: Over the past century, the end of respiratory pandemics has never been clear-cut.

Instead, in four cases — the 1918, 1957, 1968 and 2009 flu pandemics — hospitalizations and deaths ascribed to the pandemic pathogen continued for years after the sense of emergency had passed. This reality reveals that the “end” to a pandemic can’t be determined by some sort of epidemiological milestone or acquiring a magic-bullet treatment that removes all risk from the virus. Rather, historically, the resumption of regular life — if it was even interrupted in the first place — guides the end of a pandemic.

Most experts agree that the 1918 flu pandemic, caused by an H1N1 virus, had three waves, concluding in the winter of 1919. Some, however, include a fourth wave and date the end to 1920. This cloudiness arises because deaths continued in the years after the declared end of the pandemic; as late as the winter of 1928-29, for example, H1N1-related deaths in the United States topped 100,000.

Yet, while the 1918 pandemic may have been years-long on paper — killing three times as many people as covid-19 when adjusted for population — in real life, countermeasures were rarely sustained for longer than six weeks. Cities varied widely in how they confronted the virus. For instance, while many major cities closed schools for an average of four weeks during 1918, New York and Chicago — then the nation’s two largest cities — kept schools open throughout the pandemic. And as historian John Barry notes, many places experienced “several months of relative normalcy between waves.”

While the history of the 1918 pandemic has become more familiar since the latest pandemic began, the 1957 and 1968 ones have received less attention.

Over the course of nine months in 1957-58, an estimated 66,000 excess deaths associated with influenza occurred in the United States and about “80 million Americans were bedridden with respiratory disease,” according to one report.

Even so, there were no nationwide shutdowns or stay-at-home measures, and school closures lasted only weeks, if they happened at all. People got sick but society continued churning. That occurred even though 60 percent of schoolchildren experienced illness, with schools averaging absence rates between 20 percent and 30 percent, and teachers and health-care workers logged unusually high rates of absenteeism. But even in New York, where 40 percent of students were absent in some schools, administrators advised that there was “no cause for alarm.” On the advice of the health department, they also curtailed no activities.

Public health officials made the deliberate decision, in fact, not to cancel large meetings and gatherings for the purpose of stopping or slowing viral transmission. They saw the epidemic as spreading too quickly for such measures to be effective. Instead, officials emphasized providing medical care to those who were afflicted, not “getting ahead” of the virus.

The 1957 pandemic came and went, but as with the 1918 flu, the epidemiological impact of the virus continued long after life returned to normal. As Newsweek reported in 1960, two years after the “end” of the 1957 pandemic, the same virus was “quietly picking off almost everyone it missed the first time around.” One estimate put the excess death toll that season at 12,000.

By the end of the 1960s, a new pandemic virus had arrived: the H3N2 influenza, which officials estimated claimed 1 million lives globally over several seasons. Again, however, officials put few countermeasures in place, and disruptions to social life hovered somewhere between minimal and nonexistent; reflecting a society largely unaware of the deadly pandemic. While in December 1968 the New York Times called the outbreak “one of the worst in the nation’s history,” according to historian Mark Honigsbaum, “there were few school closures and businesses, for the most part, continued to operate as normal.”

Just why the 1968 pandemic was largely imperceptible to most people is unclear, but it may be related to its mildness. The season did not rank as particularly deadly compared with preceding years, and much of society was preoccupied with the Vietnam War and other social issues. The pandemic was a major event for virologists and some epidemiologists, but for most of society, it was a nonevent.

Yet, while the epidemic wave of the 1968 pandemic receded, the H3N2 virus never disappeared. A Centers for Disease Control and Prevention analysis reported that strains of the virus were associated with, on average, tens of thousands of deaths annually for three decades after the pandemic.

Something similar happened with the “swine flu” in 2009. While the media devoted enormous airtime to the outbreak, disruptions to life were transient, and the epidemic largely receded from the public conversation within months. When the World Health Organization officially announced the transition to a “post-pandemic period” in August 2010, few people noticed, for social life had long returned to normal. Yet, as in previous pandemics, the virus continued to circulate. According to estimates of the CDC, most post-pandemic seasons saw influenza-related death tolls exceeding those of the pandemic itself.

Yet, while life either wasn’t interrupted or returned to normal quickly in these four pandemics, we’ve treated covid-19 very differently. While medicine has progressed over time, hope for a silver-bullet vaccine or therapeutic does not fully explain our different response. Indeed, a vaccine was produced in record time in 1968, with a total of 22 million doses distributed in the United States by the end of January 1969. But social life never paused while waiting for that vaccine.

Instead, our unprecedented focus on data may help explain why people have treated covid-19 so differently. Dating to the early phase of the pandemic, news sites and television networks have consistently featured dashboards with data feeding perceptions of a continuous state of emergency, prompting interventions and preventing the resumption of our social lives. The constant saturation of data has fed the perception that only specific epidemiological metrics will allow for the resumption of normal life.

But despite our unprecedented capacity to surveil the spread of SARS-CoV-2, history tells us there won’t come a moment when the data signal the end of the pandemic. If history is any indication, cases, hospitalizations and deaths from covid will be here for decades to come.

The key to ending the pandemic, therefore, isn’t biological. It is social. Today the public is profoundly divided on how to move forward, with some long ago entering a post-pandemic state, while others recently restarted virtual education and enhanced mask mandates in response to the omicron variant. But a state of emergency cannot last forever, especially since interventions have divided families and caused harm to children and young people, who are at the lowest risk from the coronavirus.

And for those embracing stricter mitigation methods, it is crucial to understand that there won’t be a clearly definable biological endpoint to the pandemic. Only when they integrate the risk from covid into their lives and resume normal social interactions will the pandemic end. Much as they hope for a clean, neat endpoint, history indicates such a thing doesn’t exist.

At the end of the day, it is not the virus that makes the timeline; it is us. The pandemic will be over when we say it’s over.

Peter Doshi is an associate professor of pharmaceutical health services research at the University of Maryland. David Robertson is a doctoral candidate in the history of science at Princeton.

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