Looking for the exit

The beginning of the pandemic was clear. But how will we know when it’s over?

The biggest public health crisis in a century had an unmistakably official start.

On March 11, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic.

Now, almost 1,000 days later, and after millions of deaths worldwide, many millions more infections and an unprecedented international vaccination effort, it’s becoming clear the end of the pandemic won’t be as explicit.

Though the WHO declared the pandemic’s beginning, it won’t declare its conclusion. Meanwhile, the uncertainty of a new viral pathogen and the relentlessness of its evolution, combined with everchanging human behaviour, means there can’t be a straight path to the finish line, however much we might want one.

In this third pandemic year, there’s clearly been a shift in how we perceive the danger of the virus, along with a burning desire for an end — a firm conclusion to two and a half years of fear, sacrifice, loss and inconvenience. As with kids in the back of the car on a road trip, there is a collective desire to hear an answer to the question, “Are we there yet?”

A potential reply came this month, when WHO director Tedros Adhanom Ghebreyesus suggested the end of COVID-19 as a pandemic illness is in sight. And, days later, when U.S. President Joe Biden stated with even more conviction that “the pandemic is over.”

Immediately, scientists who have led the years-long fight rose up to scoff at the notion. Health authorities pointed to death tolls climbing ever higher, to heavy caseloads and to those for whom the virus is raging still.

Yet the leaders’ comments have created a moment, intentionally or not, to talk about what we mean by the “end.” The disease itself is not going away. It will be part of the infectious disease landscape for the foreseeable future. And there are, as of yet, few defined metrics for when a pandemic coronavirus slides into its endemic state.

“The tricky thing is we really don’t know when the end of a pandemic occurs until well after the end has occurred,” said J. Alexander Navarro, assistant director of the University of Michigan’s Center for the History of Medicine.

“It’s only really with some degree of hindsight that we can look back and say, ‘Oh yes, this ended around this time; cases, hospitalizations and deaths were down.’ ”

It may be that our desire for it to be over will play a bigger role in the closing chapter. And that means the pandemic’s end will mean different things for different people, across countries, between neighbourhoods, among families. Never mind the economic pressures, the political push to return to normal and the social media-fuelled misinformation campaigns.

And so, the “end” of the pandemic becomes uncharted territory, forcing us to discover what accommodations we are or aren’t willing to make for our most vulnerable, and to come to terms with the likelihood that even if we believe or act like the pandemic is over, COVID-19 itself will still be here and still threaten many.

Despite its clear statement on the start of a pandemic, the WHO will not declare its end, said Maxwell Smith, a bioethicist who specializes in infectious diseases and an assistant professor at Western University.

“There’s no mechanism by which to declare it over … that simply won’t be forthcoming,” said Smith, a member of the WHO International Working Group on Ethics and COVID-19.

Instead, the WHO will call an end to the Public Health Emergency of International Concern that it declared on Jan. 30, 2020, after the emergence of SARS-CoV-2, he said. This is the highest alert level it can give for what the WHO calls “an extraordinary event that may constitute a public health risk.”

According to Smith, moving out of the pandemic state will mean monitoring the epidemiology of the pathogen. Scientists will be looking for the disease to be relatively stable and predictable; no more massive unforeseen waves or unexpected variants. Health leaders will also want to see COVID become a “manageable disease,” one that doesn’t overwhelm hospital emergency departments or trigger huge swaths of doctors and nurses to be off sick.

Perhaps the biggest — and hardest — benchmark to meet for the end of the pandemic is what society will consider as acceptable levels of disease, suffering and death, Smith said.

Are we OK with 70 people a week dying in Ontario, which is how many died in the last week of August? Will we tolerate more?

People are still dying of COVID in Canada, more so than even last year. So far in 2022, the country has seen 14,727 COVID deaths, more than 350 more than in all of 2021. And outbreaks are still making life risky in nursing homes and hospitals; for a couple of days this past summer, just over 30 per cent of long-term-care facilities had outbreaks at the same time.

But go into any grocery store, a crowded restaurant or a movie theatre on a Friday night and there are few reminders of a devastating pandemic. For many people, things feel better; the initial fear has dissipated with the arrival of vaccines, or they have got sick themselves with minor symptoms and no discernible disruption. Or they are just tired of it all.

Smith argues that feeling safe is a reflection of one’s advantage.

“Time and time again, we see with infectious diseases that we tend to move on with the universal societal interventions when the majority of the most privileged, most advantaged people no longer consider themselves to be at risk. And what that does is shift the burden entirely to the most at-risk, the most vulnerable segments of our population.”

With each devastating turn of the pandemic, it’s clear COVID costs are not borne equally.

In Ontario, in wave after wave, lower-income residents died of COVID at much higher rates than those with more means.

Even after the rollout of vaccines and treatments, death rates from the virus in the lowest-income neighbourhoods have been roughly double those in the province’s richest neighbourhoods.

“It begs the question: Among whom are we flattening the curve?” Dr. Sharmistha Mishra, an infectious disease physician and mathematical modeller at Toronto’s St. Michael’s Hospital, told the Star in July.

The elderly, too, have suffered unequally. Death figures show that since the arrival of Omicron in mid-December, COVID has been more deadly for Ontarians 60 and up than the previous two waves combined.

Virginia Parraga, a resident of Kensington Gardens, a non-profit long-term-care home in Toronto, knows she is vulnerable.

At 82, she worries that her health could worsen if she caught COVID, especially given underlying health issues, including a heart condition.

“I am worried about it because people seem to be gung ho as far as ‘The pandemic is over, it’s over, it’s over!’ It’s not over yet,” she said. “I think we have to continue with our precautions, such as getting your vaccine, using a mask and being careful where you go. Not this complete failure to do anything.”

Recently a social worker who assists Parraga in her role as president of the home’s residents council got sick, meaning she was without help for a week.

“This just happened. How can you say there’s no COVID?”

As a palliative care physician specializing in long-term care, Dr. Amit Arya has seen first-hand the damage COVID can inflict on vulnerable seniors like Parraga and those with more serious health conditions. Arya, who works in hospital and long-term-care settings, says he is “alarmed” by messaging that signals the end of the pandemic since there are millions of people for whom it is far from over.

He notes that while Ontario has seen a dramatic reduction in deaths compared to the pre-vaccine pandemic, the virus presents a serious risk for those who suffer from a life-limiting condition, such as cancer, COPD, heart disease and dementia, or a combination.

“Many of these people are not necessarily dying of COVID-19, but their level of function and health definitely takes a downturn with the infection and they don’t always recover,” said Arya, who is also palliative care lead at Kensington Health.

He has also seen situations in which COVID “tips the balance” — sometimes fatally — in people who show up at hospital already suffering from acute illnesses.

Beyond the ethical debates and the ongoing human toll, there remain the hard facts of COVID: The virus is not done with us; we don’t yet have a cure, and it’s not clear what new variants will emerge.

Maria Van Kerkhove, the WHO’s technical lead for COVID, noted during a media briefing last week that the virus continues to “circulate at an incredibly intense level around the world,” providing opportunities to further evolve. Scientists continue to monitor the crowded field of Omicron subvariants, including BF.7, which has demonstrated in countries including Denmark and Germany an ability to spread fast and jump ahead of other variants.

“Part of ending this pandemic is really trying to reduce the spread of transmission … the more this virus circulates, the more opportunities it has to change,” Kerkhove said. “This is something we are deeply concerned about.”

It’s a sentiment echoed by Marc-André Langlois, professor at the University of Ottawa’s faculty of medicine and executive director of the Coronavirus Variant Rapid Response Network, created to respond to variants of concern. He said while the most acute stage of the pandemic seems to have passed, it is not over.

“The variants continue to evolve, they continue to emerge and they continue to cause waves of infection,” he said.

“We are just in a stage where the variants that are emerging are being well taken care of by the current booster shots. But ultimately, the virus continues to evolve and may at some point become much more resistant to vaccine-induced immunity.”

Perhaps the most we can expect is to continue living with uncertainty, at least into the near future.

The WHO’s Ghebreyesus hinted at this during a media briefing last week.

“We have spent two and a half years in a long, dark tunnel, and we are just beginning to glimpse the light at the end of that tunnel. But it is still a long way off, and the tunnel is still dark, with many obstacles that could trip us up if we don’t take care.”

On this point, history can teach us some lessons. Navarro points out that several U.S. jurisdictions, such as San Francisco, lifted their restrictions too soon during the deadly Spanish flu epidemic of 1918. While largely spared by the first wave early that year, and despite plenty of warning, San Francisco got slammed with more than 4,000 cases by mid-October, less than a month after the virus is suspected to have arrived in the city.

And while there is room for cautious optimism that the worst is over, Navarro also questions whether we are prepared for a new normal that includes so many people ill and dying due to COVID.

Smith worries that when we no longer label COVID-19 a pandemic, there will be little remaining urgency to care about those left behind.

Ultimately, what we choose to accept and how we treat our most vulnerable will be a reflection of our collective humanity.

Our desire to declare an end to this disaster and press on with our lives is strong.

How we balance that almost innate drive to move forward with our compassion is undoubtedly how we will be judged by future generations.

‘‘ There’s no mechanism by which to declare it over … that simply won’t be forthcoming.

MAXWELL S MITH BIOETHICIST