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Endemic is not the end—it never has been

March 10, 2022 by PATH

PATH calls for leaders in high-income countries to consider those most vulnerable to COVID-19—within their own borders and beyond.

A taxi driver in Kampala, Uganda, displays masks provided to him by local health workers. Photo: PATH/Will Boase.

Many governments have begun dropping mask mandates and reducing funding for sustained COVID-19 response measures. Photo: PATH/ Will Boase.

As Omicron ebbs, dangerous complacency has started to swell. Masking guidelines have relaxed. Political commitment among world leaders to a sustained global response has begun its predictable decay.

Some models suggest this pandemic has started its descent to endemicity. Many high-income countries interpret this as the end. But endemic does not mean the end, nor even the beginning of the end—it’s simply an epidemiologic term for a disease that occurs at some steady rate with some predictable occurrence in a population. It doesn’t mean the attack rate is low. It has nothing to do with the severity of the disease if infected. And it certainly doesn’t mean we can move on nor abandon public health and social measures.

Take an endemic disease like malaria, once prevalent from Washington, D.C., to Rome to Shanghai. Effective public health measures shrunk the endemic malaria map to mainly tropic and subtropic areas. Yet in 2020, malaria caused 600,000 deaths—mostly in children in Africa—and requires consistent use of public health tools, such as bed nets, insecticides, and robust test and treat programs, just to keep this mosquito-borne parasite in check.

And tuberculosis (TB), which reached its peak in the 18th and 19th centuries, still infects a quarter of the world’s population, and causes 1.5 million deaths year-in and year-out, despite routine use of TB public health measures in nearly all health systems worldwide.

Though endemic, the annual death rates and burden of severe disease from these and many other endemic pathogens are not low. They rage at unacceptably high levels—concentrated in those left behind: the poorest and most socially and economically marginalized communities.

What would happen if the world abandoned the public health and social measures that help control endemic malaria and TB? The same thing that will happen if we abandon the measures that control the spread of SARS-CoV-2 and prevent COVID-19: a predictable increase in preventable disease and human suffering, borne primarily by those already most burdened. Minimizing preventable disease and death requires consistent, costly, and increasingly complex control measures, because SARS-CoV-2, like other pathogens, will persistently probe for ways to evade our preventive measures.

The next variant is on its way—how we act now will in large part determine the fate of those at greatest risk. For those in good health and protected by dependable access to food, shelter, healthcare, and lifesaving health interventions, like vaccines and anti-infective, many of the endemic diseases are out of sight and thus out of mind. Left unprotected are the most vulnerable—those with underlying medical conditions, the youngest and the oldest, and those one infection away from poverty—none of whom have the option of moving on.

The evidence is clear for acute COVID-19. Hospitalizations, case counts, and PCR positivity rates are good metrics to monitor—and indeed they’re dropping in many places—but decision-makers must track other data points. Locally, regionally, and globally, policy makers must consider persons most vulnerable to illness, those most likely to suffer because of age, underlying medical conditions, pregnancy, or occupational exposure to high forces of infection—as well social and economic determinants of health, such as mental health services, food, housing, and living wages.

For the vulnerable, acute COVID-19 remains a clear and present threat. Let’s not allow complacency to creep in and make acceptable the significant ongoing burden of preventable disease or death because we are fatigued, frustrated, or simply want to forget the pandemic.

We must also acknowledge the gaps in the current evidence and the uncertainties that remain; for example, post-COVID-19 conditions (or, long COVID). While much has been learned about the long-term brain, heart, lung, kidney, and mental health conditions suffered by some after recovering from acute COVID-19, much remains uncertain. Complacency now could be catastrophic later.

Our best chance to move on from this pandemic, leaving no one behind, is for each of us to maintain effective public health measures and for decision-makers to accelerate equitable, global access to vaccines, treatments, and other essential medicines and health services. It is not to allow wishful thinking to put out of sight and out of mind the heavy toll exacted by endemic diseases.

The United States and other wealthy countries have benefited from early access to lifesaving interventions. Those with that privilege should continue to wear a mask to protect the vulnerable in their local communities and call upon decision-makers to accelerate access to fellow global citizens who wait their turn for the tools now taken for granted in high-resource settings.

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