The end of the pandemic will not be televised

December 14, 2021

Translation of the article: http: //dx.doi.org/10.1136/bmj-2021–068094

Tables of numbers about the pandemic dominated the screens and helped track the progress of COVID-19, but  David Robertson and  Peter Doshi explain why they may not be enough to determine when it will end.

As the year 2021 began, the COVID-19 pandemic appeared to be in retreat. Discussions and predictions about a « reopening », a return to « normal », and the acquisition of herd immunity were in the air^{(1) (2) (3) (4)}. But for many, the optimism faded as cases and deaths emerged in India, Brazil and elsewhere. Attention turned to variants of the SARS-CoV‑2 virus — and more recently, with the emergence of the Omicron variant. Just when it looked like the end was on the horizon, this feeling was replaced by the idea that the pandemic was far from over ^{(5) (6)}.

Unlike any previous pandemic, COVID-19 has been closely monitored using charts to report the progress and effects of the coronavirus in real time; these charts include indicators of laboratory tests, hospital and intensive care unit admissions, transmission rates, and, most recently, vaccine doses that have been administered. These charts — with their grids of numbers, statistics, epidemic curves and attendance maps — have invaded our TV, computer and smartphone screens. At their core is the appeal of objectification and data to hold on to, while we are plagued by uncertainty and fear. These elements helped people to visualize the need for rapid containment and control, to guide general sentiment, to fuel pressure for action, and to maintain a climate of urgency ⁽⁷⁾. They provide a sense of control when cases decrease as a result of certain measures, but can also lead to a sense of helplessness and impending disaster when cases increase.

The problem of defining the end of a pandemic

There is no universal definition of epidemiological parameters that mark the end of a pandemic. So what indicators will tell us that it is really over? The World Health Organization has declared the existence of the COVID-19 pandemic. But who will tell us when it will end?

The ubiquity of these graphs has contributed to a sense that the pandemic would be over when all indicators reach zero (zero infections, zero cases, zero deaths) or 100 (in percentage of vaccination). However, the respiratory pandemics of the 20th century show that the end of an epidemic is never clearly established, and that it is better understood with the resumption of social life, and not in the achievement of epidemiological targets^{(8) (9)}.

The respiratory pandemics of the past 130 years have been followed by annual seasonal waves fueled by viral endemicity that generally continues until the next pandemic ⁽¹⁰⁾. What grows decreases again, and the difficulty of dating the end of a pandemic is reflected in the historical and epidemiological literature.

Although many researchers describe said « Spanish Flu » as occurring in three waves, from « 1918 to 1919, » references to a pandemic from « 1918 to 1920 » are also abundant, usually encompassing what some call a « fourth wave. »⁽¹¹⁾. Similarly, the mid-century « Asian flu » pandemic is generally described as a two-wave event, from 1957 to 1958, while others include a third wave, placing the end of the pandemic in late 1959 ⁽¹²⁾.

This variability in the dating of historical pandemics underscores the imprecise nature of using mortality rates to determine, even retrospectively, the « end » of a pandemic and the beginning of the inter-pandemic period. For example, the CDC(Center for Desease Control) now states that approximately 100,000 Americans died during each of the influenza pandemics of 1957 and 1968^{(13) (14)}. But these estimates include deaths occurring at times that many would consider to be intermediate periods between two pandemics (in 1957–1960 and 1968–1972, respectively) ^{(15) (16)}.

The notion, reinforced by epidemic dashboards, that a pandemic ends when the number of cases or deaths falls to zero, contradicts the historical evidence that substantial influenza-related morbidity and mortality continue, season after season, between pandemics. During the 1928–1929 inter-pandemic season, for example, an additional 100,000 deaths related to influenza A/H1N1 (1918 pandemic virus) are estimated to have occurred in the United States in a population one-third smaller than today ⁽¹⁷⁾. In addition, it may be difficult to determine which deaths can be attributed to the pandemic and which are in the inter-pandemic phase. These distinctions are not unimportant, as excess mortality is the classic measure of severity⁽¹⁸⁾. Inter-pandemic years have sometimes seen a higher number of deaths than in subsequent pandemic seasons: this was the case in the 1946–1947 season that preceded the 1957–1958 pandemic (Fig. 1)⁽¹⁹⁾. Therefore, the end of a pandemic cannot be defined by the absence of excess mortality associated with the pandemic pathogen.

(fig. 1) Monthly rate of all-cause deaths in the United States, with bold arrows and dates indicating the onset of pandemics, from January 1900 to September 2021. The red line indicates the average every 12 months. Note that from 1905 to 1909, the U.S.Bureau of the Census provided only annual (not monthly) data. 

Interruption and resumption of social life

Another way to declare the end of a pandemic is to consider the imposition and lifting of public health measures or restrictions. The measures used in previous pandemics were more transient and less intrusive than those implemented in COVID-19. Even for the terrible Spanish flu, which killed three times as many people in the United States as COVID-19, with an average age of death of 28 years ⁽²⁰⁾ — life returned to normal in a short time, perhaps only because there was no other option. Before the Internet and its food delivery apps and video conferencing, widespread and prolonged social distancing was simply not possible, and indeed it is a situation that remains for many workers in what is considered the « essential » sector. Indeed, a brief look at past pandemics in the United States shows that there is no fixed or determining relationship between the pathogenicity of a virus and the intensity and longevity of public health interventions.

Compared to previous pandemics, the COVID-19 pandemic has caused unprecedented disruptions in social life. Populations have always been plagued by tragic illnesses or unexpected deaths throughout pandemic and non-pandemic periods. But the COVID-19 pandemic is historically unprecedented in that the interruption and resumption of social life was so closely linked to epidemiological indicators.

Epidemic boards: to fight or to feed the pandemic?

Although visual representations of epidemics have existed for centuries ⁽³¹⁾, with COVID-19 it is the first time that tables of numbers broadcast in real time have saturated and structured the public’s experience in this way.

Some historians have observed that pandemics do not cease when the transmission of the disease ends « but rather when, in the attention of the general public and in the opinion of some of the media and political elites who direct that attention, the disease ceases to be seen as a media issue [see note 8]. » These tables of epidemic numbers provide endless fuel, ensuring the constant currency of the COVID-19 pandemic, even when the threat is low. And in doing so, they can prolong the pandemic state by inhibiting the sense of a way out or a return to the way things were.

Turning off or disconnecting ourselves from these dashboards may be the most effective action to end the pandemic. It’s not about burying your head in the sand. Rather, we must recognize that no single or combined indicator in these dashboards can tell us whether the epidemic has stopped.

The end of the pandemic will not come by itself

History tells us that the end of the pandemic will not simply result from the achievement of herd immunity or an official declaration, but will occur gradually and unevenly as societies cease to be mobilized by the shock indicators of the pandemic. The end of a pandemic is mainly a matter of lived experience, and is therefore more of a sociological than a biological phenomenon. And so the epidemiological tables — which do not measure mental health or the impact on education, and deny the importance of social connections — do not provide the tool that will tell us when the pandemic is over. Indeed, if we consider how societies have come to use epidemiological tables, they may prove to be a tool that prevents a return to normalcy. Pandemics — at least those of respiratory viruses — simply do not end in a way that can be translated into a table. Far from a theatrical « end », pandemics gradually fade away as society adapts to a new infectious agent and social life returns to normal.

The COVID-19 pandemic is part of an extraordinary period in which social life has been turned upside down. It will end when we turn off our screens and decide that other issues deserve our attention. Unlike its beginning, the end of the pandemic will not be televised.

Authors and sources: DR is a doctoral student in the history of science at Princeton University. He has published in the field of medical history and infectious disease epidemiology. PD has been studying the science and politics of infectious disease outbreaks for nearly two decades, focusing primarily on influenza. Both authors contributed to both the research and analytical aspects of the article, and both were responsible for gathering secondary sources related to COVID-19 and the history of influenza pandemics. Primary sources as well as mainstream media sources from the press and elsewhere were largely processed by DR, while PD processed all-cause mortality data. The data and calculation method are available at https://doi.org/10.5281/zenodo.5764277. Both DR and PD are responsible for this.

Conflicts of interest: we have read and understand the BMJ (British Medical Journal) charter on declaration of interest and declare that: PD has received travel funding from the European Respiratory Society (2012) and Uppsala Monitoring Center (2018); grants from the FDA (through the University of Maryland M‑CERSI; 2020), Laura and John Arnold Foundation (2017–2022), American Association of Colleges of Pharmacy (2015), Patient-Centered Outcomes Research Institute (2014–2016), Cochrane Methods Innovations Fund (2016–18), and UK National Institute for Health Research (2011–14); and is an editor at BMJ. The opinions expressed here are those of the authors and do not necessarily reflect those of their employers.

by David Robertson (Princeton University, Princeton, NJ, USA) and Peter Doshi (University of Maryland School of Pharmacy, Baltimore, MD, USA) 

Translation by Vera