As we reach the second anniversary of the World Health Organization acknowledging Covid-19 as a pandemic on March 11, 2020, we appear to be standing on the edge of the endemic phase of this global health crisis. For many, that’s the moment when we hope we can get back to our regular lives.
Several times during this pandemic, I have written essays about America as if the country was my patient. The current situation has me thinking along those lines again.
Doctors, like anyone else, love to give good news. We see the value of hope but also recognize that honesty must be our North Star. I would love to be the good guy here and tell my patient that it’s time to be discharged from this chapter of our lives. But a doctor’s job is to fully assess the situation and lean into the nuance, as opposed to simple axioms.
Time for a physical
So let’s examine America, the patient. On the one hand, the numbers are going down. Cases of Covid-19 are more than a third lower this week than they were last week and the lowest they’ve been since July, according to the latest data from Johns Hopkins University. And the number of people hospitalized is about a fifth of what it was during the country’s mid-January peak. Even deaths, the so-called lagging indicator, have been falling; they’re at their lowest point in two months.
All 50 states are in the process of lifting restrictions. On March 26, Hawaii will become the last state to end its indoor mask mandate.
At the federal level, the US Centers for Disease Control and Prevention made big changes in late February. Instead of primarily using levels of coronavirus transmission within a community as the key metric for determining mask guidance, the agency recommends that three data points be considered instead: new Covid-19 hospitalizations, hospital capacity and Covid-19 cases.
So now, instead of a transmission map that paints most of the country an “inflamed” red, the community levels map shows a lot of cooler green and yellow, with a bit of orange – the new low, medium and high categories. Since that change, there has been a big drop in the percentage of Americans living under masking recommendations, from 99% under the old metrics to just about 2% now.
And at the start of the month, the White House unveiled its National Covid-19 Preparedness Plan. The new plan focuses on “vaccines, treatments, tests, masks,” White House Covid-19 response coordinator Jeff Zients said. “These tools are how we continue to protect people and enable us to move forward safely and get back to our more normal routines.”
As part of that, government testing and treatment initiatives are being streamlined and made more widely available.
A closer look
But in medicine, we cannot rely on lab results and a medical history. We need to perform a thorough and detailed exam. And when we do that, a more complete picture of the patient emerges.
Truth is, America, my patient still has an active infection. Although the numbers are falling, they are still painfully high: The country is averaging just under 37,000 new cases of Covid-19 a day. It’s as if saying the patient used to have a very high fever but now only has a moderately high fever. The point is, it’s still too high. We wouldn’t stop treating the patient’s infection at this point but rather complete the course of treatment and care.
There’s also the issue of understanding the effects the illness may have on my patient in the future. In this case, it means acknowledging an entirely new disease: long Covid.
Many Americans are enduring the lingering effects of a past infection, battling health conditions like fatigue, brain fog, shortness of breath, cardiac issues. The list of long Covid symptoms is lengthy and varied; there are no answers as to who and why, nor are there easy, one-size-fits-all treatments.
We are in the early days of this disease, but I was particularly struck by the recent paper indicating a previous Covid infection being a significant risk factor for future heart problems.
And, even more important, there are still about 30,000 Americans hospitalized for Covid and, on average, more than 1,250 deaths a day. That’s the equivalent of about two jumbo jets dropping out of the sky every day.
My patient still needs lots of care.
Other factors at play
Despite the less red and inflamed transmission map, it still shows there’s a lot of virus out there. If the virus came in the form of a raindrop, parts of our country would still be getting drenched.
I have often imagined how different things would be if we could have actually seen the virus – little green particles circulating around people’s noses and mouths and becoming airborne. What if we had been able to witness its destruction and journey into blood vessels and lungs? This invisible enemy circumvented our basic human ability to detect a threat and, as a result, made us more likely to ignore and even deny it.
I would remind my patient we have been here before. We experienced moments of genuine hope earlier and then witnessed how quickly things can change. In the summer of 2021, the Delta variant surprised us, and in December, Omicron blindsided us. Both times, the spikes caused by these variants followed declarations of victory heralding the end of the pandemic.
Currently, there is a subvariant of Omicron called BA.2 that may spread even faster than Omicron itself. According to the latest figures from the CDC, it now makes up about 11.6% of Covid cases in the US; the week before, 6.6%. BA.2 is the dominant variant in Denmark, the United Kingdom, India, South Africa and more than a dozen other countries. According to the World Health Organization, studies estimate it is 30% more contagious than the original Omicron (BA.1).
And while studies suggest that BA.2 is not more likely to lead to hospitalization than BA.1, another patient that I’ve been keeping an eye on, the United Kingdom, is seeing cases and hospitalizations starting to trend up again after declining steadily since mid-January. Sometimes, doctors gain a lot of information from watching how other patients are faring.
Again, I get it. I would love to look at these past two years in the rearview mirror as well, but we need to learn the lessons of this pandemic and apply that knowledge in real time. Today. Now.
Delta and Omicron represent two cautionary tales in the span of a few months. It would be shortsighted to ignore that reality, believing it will never happen again.
A blend of science and judgment
The International Epidemiology Association’s Dictionary of Epidemiology defines a pandemic as “an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people.”
Two years ago, when we made the decision to use the word pandemic on CNN, before the CDC or WHO, it was fairly straightforward – fundamentally, it was an exercise in math and data analysis. My producers and I spent a lot of time looking at whiteboards where we kept tabs on the growing numbers and locations of Covid-19 cases. One day, I remember thinking, “If this isn’t the very definition of a pandemic, I don’t know what is. So why is no one else calling it that?”
And so we did.
Although the line was clear entering the pandemic, it will be much fuzzier as we approach endemicity. A disease is considered endemic when it is a “constant presence … within a given geographic area or population group.” It would also be predictable in its rate of spread without causing the level of disruption it does in a pandemic.
But what is considered disruptive may be very different in one country compared with another, even from one person to the next. Progressing into this next phase will be based on a blend of science and judgment.
What the exam reveals
So if America were my patient, the question I would be asking: Is it really time to downgrade the country’s present-day condition from pandemic to endemic?
It’s analogous in some ways to deciding when to discharge my surgical patients to the general care floor from the intensive care unit.
I make rounds in the intensive care unit, carefully reviewing each patient’s chart – full of lab results, metrics and data. And then I sit at the bedside, watching, examining and understanding how they really feel. Can they stand on their own, put a fork to their mouth and a comb through their hair? Are their basic bodily functions returning to normal, and can they get by independently? It is a judgment call. Two people can have the same vital signs but be in very different places.
If America were my patient, what would I see when I sit at its bedside? Beyond 1,300 people dying a day, I would make note that almost 60,000 people died of Covid-19 during the month of February alone. In other words, more people died of Covid-19 in one month than die of the flu during a bad year.
So the question ultimately is: What is too disruptive? What are we willing to tolerate? At what point do we as a society throw up our hands and say, “We can’t do any better than this,” so let’s call this level of sickness and death “endemic,” accept the numbers and move on with our lives?
And of course, my patient, America, lives on a planet with lots of other patients, all part of an intricate ecosystem. We must realize that America’s health is dependent on the health of all the other patients on the planet: When any one of us is at risk, we are all at risk.
Finding a measure of peace and quiescence
None of this is easy. It’s why epidemiologist and author Dr. Larry Brilliant said that “endemic” is a terrible word.
“Smallpox was ‘endemic’ when it killed somewhere between a third and half a billion people in the 20th century. Malaria is endemic, and it’s killing millions. Tuberculosis is endemic. And HIV/AIDS was sort of thrown out of people’s consciousness by just labeling it ‘endemic,’ ” he said.
Brilliant, who is CEO of Pandefense Advisory and a senior adviser at the Skoll Foundation, was a key player on the WHO team that eradicated smallpox.
He pointed out that the technical definition of “endemic” is a disease that is generating an expected number of cases, to the expected community and the expected time. “And because [Covid-19] is a baby of a disease … it’s way too early to try to figure out what is endemicity. We have to wait for it to become a teenager and see how it behaves,” he said.
Brilliant prefers the term “quiescent.” “We want this thing to be quiet,” he said.
He recalled that in the early days of 2020, he and other epidemiologists and public health experts speculated that the illness would come in waves.
“A wave is a really good metaphor to think about this. Sometimes, the waves come in a bunch at a time, and sometimes there’s not a wave for hours, even days. Some waves are too small to really be called waves. But every once in a while, there’s a rogue wave, this tsunami.”
He explained, “what we want is the interval [between waves] to be long and the water in the waves to be quiescent. And that’s what we’re trying to say when people use the word ‘endemic.’ … To say that the pandemic has gone endemic is failure – it’s not success. We haven’t put it where we want it. So it’s the wrong way of thinking about it.”
Plus, said Brilliant, saying that the pandemic is over means “we give up our duty of care.”
He believes we still have a duty of care to the immunocompromised, the elderly, the vulnerable and, yes, even the unvaccinated, because they are the ones disproportionately dying.
Life with an endemic disease
Humans are increasingly living side by side with pathogens that were once in the wild but then took hold among us. We might not like it, and sometimes the pathogen comes too close for comfort, but we learn to live with it.
Take the parasite malaria. For millennia, it killed off wide swaths of the global population. In fact, the mosquito, which transmits the parasite that causes disease, is one of the most prolific killers of humans worldwide.
Inarguably, the course of humanity has been shaped by malaria: It’s believed to have contributed to the fall of Rome, and for hundreds of years, it helped protect Africa from European colonization even as it infected the local population. (And it’s why the gene for sickle cell anemia, which is protective against malaria, never died off evolutionarily.) In this country, Presidents George Washington and Abraham Lincoln grappled with it. The disease stunted the physical and economic growth of the rural South through the 1930s, and it is why the precursor to the CDC was founded.
It’s an understatement to say man has been living with malaria for a very long time. And although we may not have eradicated it from the face of the Earth or completely tamed it, we have learned to coexist with it and reduced it to an endemic disease in a shrinking number of countries. The United States eradicated it in 1951.
How did we do that? By arming ourselves with knowledge. Through scientific research, we learned about where malaria comes from and how it is spread. We developed mitigation strategies and medications to blunt its impact.
And our work is still not done: In 2020, malaria killed an estimated 627,000 people, the vast majority of them children in sub-Saharan Africa.
Early detection, rapid response
Many experts, including Brilliant, are pretty sure that Covid-19 is here to stay. Like the common cold (also often caused by a coronavirus) or the flu, it’s expected to be part of our lives for the next 10, 50 or 100 years, and life will never be quite the same again.
But we can improve the situation and learn to live with it.
“We want the disease to occur in places that we expect it, in the numbers that we expect, so we know how to deal with it,” Brilliant said. “You can go to Hawaii on vacation and not worry. Your kids can go to school. And you don’t need to worry about going to dinner with your parents or your grandparents. Maybe it’s quiet and you have to still wear masks. Maybe it’s quiet and you still have to be tested before you go someplace. But it’s not on the front page every day.”
The key, said Brilliant, is two-part: early detection and rapid response.
For that to happen, we have to have good monitoring tools and be nimble going into and out of protective mode. Maybe that means we carry a mask in our coat pocket during wintertime, just like we take an umbrella when the forecast predicts rain; maybe we keep a box of rapid tests and a packet of antivirals in the bathroom cabinet for when we are under the weather; maybe we close a school but like we do with the flu – with surgical precision, using a scalpel instead of a chainsaw.
The good news, Brilliant said, is that moving forward, our tools – vaccines, surveillance, tests, treatments, prophylactics – will only get better.
The inescapable fact is that we live in the era of pandemics. There are simply more and more opportunities for a pathogen, like the SARS-CoV-2 virus, to come in contact with the human population, make the jump and take hold. It’s a dance we are increasingly doing because we are infringing more and more on the microbes’ territory. Population growth, deforestation, climate change all contribute to this.
Get CNN Health's weekly newsletter
Sign up here to get The Results Are In with Dr. Sanjay Gupta every Tuesday from the CNN Health team.
These pathogens are going to keep emerging in humans, but pandemics are not inevitable. Humans have evolved to create remarkable public health tools to prevent that, just as long we are smart and humane enough to use them.
My patient – America – is still in precarious health and will have to be careful moving forward to maintain all of the gains and continue making progress. Both the patient and doctors will have to remain vigilant and act quickly if there’s any new infection.
It’s just not time for my patient to completely drop their guard, however much we would all like that to happen. We can and should be hopeful, but honesty must lead the way, full and transparent.
CNN’s Andrea Kane contributed to this report.