“living with COVID” and and the realities of endemicity

We should remain hopeful, and be optimistic that we are finally in the last stages of the COVID-19 pandemic. However, we must remain vigilant and cautious about how quickly restrictions (masks, distancing, PCR testing) are being lifted. The “living with COVID” policies that have led to the lifting of restrictions are often based on a misunderstanding of “endemicity”, or what endemic means.

First it is important to understand that the status of pandemic, epidemic, and endemic is not about how severe a disease is but about where it is spreading and how fast.

Endemic means a disease is permanently present in our ecology (people and animals).

Epidemic refers to an outbreak of a disease and its spread in a population or community.

Pandemic is when an epidemic occurs in several countries and is global. 

So if the pandemic is declared over by the WHO, it does not mean that COVID-19 is gone or under control. It will remain with us and we still face outbreaks that could become epidemics.

Since SARS-CoV-2 is endemic, it will occasionally become an epidemic in certain cities, towns, villages, causing illness and death. 

Endemic means we failed to eradicate SARS-CoV-2 and it is part of our ecology (in people and animals) and will probably never go away. Just as “spillover” refers to how zoonotic [animals-to-human] diseases like SARS-CoV-2 are transmitted from animals (bats, civet cats) to humans, humans have now infected wildlife (mink, deer, wildcats, bats, rats), and this is called “spillback”. Humans have also infected domesticated animals (dogs, cats, horses, hamsters) with SARS-CoV-2. Now that the coronavirus SARS-CoV-2 is in wild animal populations it can mutate and infect people again.

Endemic does not mean that with each mutation (new variant) the coronavirus becomes less and less severe until it is like an ordinary influenza. New variants do not emerge from the existing dominant variant but from the original coronavirus or other mutations. So the next variant will not come from Omicron and automatically be less severe or “mild”. The next variant could easily be as infectious and as severe as Delta, or more so.

We should understand that “living with COVID” does not mean SARS-CoV-2 is no longer serious. It is a policy decision of governments based on politics and economics (not science) that have decided that the current level of illness, hospitalization and death is acceptable in relation to the economic and social benefits of lifting all restrictions. In countries where there is a good, well-funded, hospital system free to all, and a strong health care system, “living with COVID” might be manageable. We do not live in such countries. 

The Korean government declared a “living with COVID” policy and now 20% of the population (over 10 million people) have COVID-19, with over 13,000 deaths per day. Singapore also has a “living with COVID” policy. With a population of only 5.6 million, Singapore has over 8,000 cases per day and over 10 deaths per day.

The current acceptable death rate under “living with COVID” in Singapore (based on 13 deaths yesterday) is equivalent to 63,600 deaths per day in Indonesia, 51,000 deaths per day in Pakistan, and 38,300 deaths per day in Bangladesh. That is with the standard of healthcare and hospitals in Singapore. So the reality will be very different. 

It is for these reasons we must treat “living with COVID” with caution, understand what endemic means, and remain vigilant. We must continue wearing masks and distancing, as well as  self-isolating when we might have symptoms. 

More importantly, we need to support calls for a public healthcare system with well-funded, well-staffed public hospitals, and to ensure public investment in rebuilding rural public hospitals and rural healthcare infrastructure in our region.