By Dr. Jim James

Since January of last year, the medical and public health worlds have been transfixed by the  SARS-CoV2 virus and the COVID-19 pandemic it generated. This all-consuming focus on the  medical, public health and socio-economic impacts of the pandemic has resulted in a plethora of  scientific articles submitted to medical and public health publications and by December 2020 the  number of new manuscripts approached 200, 000 by one estimate (1). This has had a profound  impact both on individual journals, many of which (to include DMPHP) have seen submission  increases of over 80 percent, and medical publishing as well, having to cope with an ever changing environment of open access, preprints and outdated business and subscription models.  One unwanted side-effect of this phenomenon has been the ability to find support for virtually  any theory, finding or recommendation somewhere in the published literature. This has, predictably, helped to propel the many contradictory, often divisive and acrid reactions to many  of the interventions intended to prevent and or mitigate the course of the Pandemic. The result  has been a mishmash of official mitigation and containment policies across and within countries  which, in retrospect, may have had a greater negative impact on global public health than the  virus itself. The purpose of this editorial is to look back over the past year and attempt to draw  lessons and make recommendations to help inform how we might move beyond the current  Pandemic and better prepare for, and respond to, the next such event. As a framework, we will  use the salient observations from the series of editorials we published over the course of the  Pandemic and will use reported numbers and logic to support conclusions and recommendations.  Citations provided in the original editorials are not repeated here. 

“A Tale of Two Epidemics” (2) was written during the first week of March 2020 when some 200,000 cases and approximately 4,500 deaths had been reported from over 100 countries with  an overall global population attack rate of .8% and a mortality rate of .02%, hardly comparable to the corresponding rates of 30% and 2.5%, respectively, for the 1918 Influenza pandemic to  which it was being frequently compared. Many of the hallmarks of COVID-19 were already  recognized and well established. Most importantly, the causative agent was a true Trojan horse  that spread primarily via respiratory droplets. The virus was widely distributed and well established in terms of sustained community transmission in many countries across the globe. In  terms of severity and lethality, COVID-19 was clearly a disease of the elderly and those with  chronic conditions – otherwise healthy individuals under 60, though not immune, were at  minimal risk of a fatal outcome. The most dangerous settings, in terms of risk, were observed to be in-door gatherings involving groups of people congregating for any length of time.  

Unfortunately, as the virus spread, a second epidemic could be identified. This was an epidemic  of fear and anxiety that was daily exacerbated by the media through sensationalized and tabloid  level reporting. From the beginning, the media controlled the narrative and molded public  opinion and could well have mediated this second epidemic but seemed more focused on the  pursuit of goals other than the public good. 

“From Epidemic to Pandemic” (3) was prepared in the weeks following the World Health Organization declaration on March 11,2020 that COVID-19 was now considered to be a  Pandemic with some 140,000 cases and almost 5,000 deaths having been reported worldwide, in  stark contrast to the almost 120 million cases and over 2.5 million deaths reported a year later. In  the US we went from 1,300 cases and 40 reported deaths to almost 30 million cases and over half a million deaths over the same timeframe. We addressed several issues, the most important of  which bear revisiting: 1) as the pandemic progressed, a plethora of predictive epidemiological  models (built on multiple guesstimates for critical parameters, such as infectivity and susceptibility that we had woefully little information on) were published with some worst-case  mortality estimates in the hundreds of millions and other outputs that were more speculative than  scientific. Unfortunately, the media seized on these worst-case numbers and used them as fodder  to effectively feed and nurture the panic and fear they had already sown, 2) a second problem  was the COVID-19 case definition, or lack of one. Defining a medical case based on a positive  lab value irrespective of the presence of symptoms or degree of severity does not provide enough  information to assess the medical impact of the disease, especially when 50% or more of positives are non-symptomatic and 80-90% of symptomatic cases do not require hospitalization,  3) many of the containment and mitigation strategies employed were quite draconian in nature  and across the US schools were closed, communities locked-down and non-essential businesses  shuttered, based on an assumption that we would lessen the medical impact by “flattening the  curve” and therefore save lives, and, 4) the overall public health impacts on the population  through lost wages, deferred and missed medical interventions, pervasive mental health issues  and lost educational years were not taken into account. Many would even argue that the cumulative health impacts secondary to the interventions might well exceed the direct medical  consequences of COVID-19. This is especially tragic when one considers that those most  negatively and disproportionately impacted secondary to these social determinants of health are  those socio-economically marginalized who already suffer poorer health outcomes, possibly  having reversed much of our progress towards achieving health equity.  

With “Lockdown or Lockup” (4) from the end of April we further explored the relative costs of  different public health interventions versus the benefits achieved from their implementation. It  became obvious that because of the absence of standards for, and common definitions of,  specific interventions across and within countries, valid conclusions could not be drawn.  

However, comparing the epidemiologic curves for the 48 countries reporting 5,000 or more cases as of 28 April 2020 demonstrated no consistent pattern that would support very costly extreme measures (stay at home mandates and school and non-essential business closures) over far less  expensive measures such as social distancing and masking. The cumulative costs secondary to  the extreme measures taken will, unfortunately, not be fully recognized until the pandemic has  long subsided. In closing we concluded: “we are gaining the knowledge and tools to both better  protect our medical delivery systems and begin to repair our socio-economic damage. These do  not have to be competing priorities, we can address both and maximize lives saved. An important  first step is to accept the fact that this is not deciding between lives versus dollars, it is about  maximizing a state of physical, mental and social well-being for all.” 

“Reflections” (5) – prepared in mid-May, the US had by then recorded over 1.5 million COVID cases and approximately 100,000 associated deaths. We reflected on the declaration of a pandemic from three perspectives: 1) the criteria used by WHO in reaching such a declaration  are not as objective as might be expected. The main considerations are geographic spread and  number of individuals infected but are ill defined and lack specificity in terms of defining trigger  points. With Covid-19 the geographic spread criterion would certainly have been met but given  the global attack and mortality rates at the time of the COVID-19 declaration, one could legitimately question its necessity, 2) this is important because “pandemic” has become a hyper emotionally charged word that can have profound impacts on the global economy and the socio political systems within countries. Additionally, it is used dichotomously and does not allow for  any gradation nor judgement as to overall severity for a particular outbreak. With other disasters such as hurricanes and earthquakes we have developed scales and categories to better define  severity and risk as well as our response to a given event. We should give serious consideration  for doing the same with Pandemics, 3) as a preliminary example of such a scale we looked at  global mortality rates and total deaths for COVID-19 as well as several recognized historical  Pandemics. When total deaths were represented in proportionate circles, that representing the  plague of 1350 is over ten times the diameter of that for COVID-19 which is but a fifth of that  for the 1918 Flu. If these circles are rate adjusted for global population, the differences are  geometrically increased. In closing the editorial, we noted: “None of this is meant to diminish the  impacts of COVID-19 on thousands of Americans. It is a virulent and deadly disease that can be  horrific for those afflicted and their loved ones, and it has had devastating impacts on health care  systems and medical personnel. The purpose of presenting these numbers is to temper harmful  levels of fear and to put COVID-19 into a more balanced perspective regarding individual and  community risks, so that we can better mitigate its medical consequences while preserving our  socioeconomic infrastructure.” 

“Yin and Yang and Herd Immunity” (6) – by the end of June over 10,000,000 cases with some  500,000 deaths had been reported from over 200 countries across the globe. Our editorial at that  time discussed the Chinese construct of dualism (Yin and Yang), in which contrary forces may  be complementary, as an analogy for optimally reducing the medical impact of COVID-19 while  simultaneously limiting the negative socio-economic effects. The Great Chinese Famine of 1959- 1962, which resulted in the estimated deaths of tens of millions, was briefly examined to demonstrate the disastrous effects of counterproductive interventions coupled with an abuse of  power at all levels of government and fueled by misleading data and falsified and contrived  official reports. The COVID-19 response in the US was likewise marred with conspiracy  theories, counterproductive interventions, sensationalized and misleading headlines, uninformed  decision-making, and, most of all, political posturing at the expense of public health. As with the  Great Famine, measuring the full impacts of COVID-19 is obfuscated by the misuse of numbers  and reports. Principal among these is the reporting of PCR positives as cases which, of course,  falsely magnifies the true medical impact of COVID-19, as does reporting raw numbers without  adjustment for disease severity and pertinent demographics such as age and ethnicity. We  proposed several approaches to help alleviate the population anxiety levels by providing informed and consistent health communication, reporting COVID-19 hospitalizations, with  demographics, as the best measure for the medical impact of the pandemic risk assessment,  targeting interventions to risk profiles at the community level, and empowering public health and  medical officials, as opposed to politicians, to take the necessary actions to protect the total  health of our population. We also went on to address Herd Immunity which we will defer  consideration of to the closing discussion.  

In “Are we “Waiting for Godot”- A Metaphor for COVID-19,” (7) we used Samuel Becket’s  play, a representative work of The Theatre of the Absurd to draw parallels to some of the  paradoxical, often dystopic approaches taken in our responses to the current pandemic. This is  most evident in that by the end of July, the US reported almost 5 million cumulative cases and  over 150 thousand deaths, alarming numbers indeed. However, these translated into overall  population rates of 1.3% and 0.045% respectively, not as alarming from an epidemiological,  population perspective. Further, at that time we were seeing case rates increasing four-fold while  mortality rates rose at a much more moderate rate of ten percent from early June. An analysis of  this phenomenon further demonstrates why measuring the health impact of COVID-19 by  “cases” as defined by a positive PCR lab test approaches the absurd because: 1) approximately 50% of test positives are asymptomatic, 2) of all clinical cases, 80% or so are mild, 3) with the  greatly increased number of tests being conducted a higher ratio of asymptomatic positives will  be identified, and 4) any test, even a highly sensitive and specific one, will identify a significant  number of false positives if the prevalence of the agent is less than 5%. Further compounding  this was the dramatic shift seen in the average age of test positives which had decreased from the  mid-fifties to the mid-thirties. Further complicating things was the looming presidential elections. COVID-19 was essentially weaponized by the mainstream media and responsible  reporting gave way to tabloid sensationalism and respected newspapers read more like editorial  digests presenting what they wanted us to hear instead of what we needed to know. However,  even more dystopic was the level of systemic child abuse we were subjecting our youth to. “The  full impact of the collective educational, economic, social, psychological, and physical damage  to these children is yet to be tabulated but the sum-total of healthy life-years in terms of morbidity and pre-mature mortality for this population will more than likely far exceed that  caused directly by the virus. The fact that this harm is inflicted on those virtually immune to  serious medical outcomes secondary to COVID-19 is a self-inflicted tragedy.” 

“Waiting for Godot – Epilogue” (8) – in a follow-up editorial to the Godot piece in early September we updated many of the areas previously addressed. Two discussions of note were: 1)  the further development of a rudimentary Pandemic Index comparing population mortalities for  several historical events and COVID-19 on a scale of one to ten. Compared to the Great Plague  which was scored a ten and the swine flu a one, COVID-19 was estimated to be a two or three,  and 2) it is worth revisiting the well-regarded work and policies of the Health Commissioner of  New York City, Royal Copeland, during the 1918 influenza pandemic, especially as to school  closures. To quote Copeland, “New York is a great cosmopolitan city and in some homes there is  careless disregard for modern sanitation… In schools the children are under the constant guardianship of the medical inspectors. This work is part of our system of disease control. If the  schools were closed at least 1,000,000 would be sent to their homes and become 1,000,000  possibilities for the disease. Furthermore, there would be nobody to take special notice of their  condition.” The hallmark of the 1918 NYC response was that health decisions rested in large  part with the public health authorities and not with elected officials pursuing political agendas at the expense of public health as is too often the case today. 

In “From COVID-19 to COVID-20: One Virus – Two Diseases,” written at the end of September  we considered reasons why a name change for COVID-19 might be in order. Not least among  these was moving away from a term which many have become hyper-sensitized to. However,  more importantly, is that the focus early on was with controlling a novel pathogen through containment and mitigation efforts, whereas, by early October, over 99% of US counties had  reported cases indicating that these efforts were largely ineffective. COVID-19 was not going to  be eradicated; it had, by then, joined the host of other diseases and that we must cope with on a  chronic basis. Additionally, given the full scope of the medical and public health impacts  associated with SARS-CoV-2, we must realize that we are dealing with much more than an  infectious disease. This is most evident in the evolution of our appreciation for those most at risk.  Early on the salient risk factors of age and co-morbidities were clearly defined. As the pandemic  matured it became all to obvious that in addition to these specific risk factors there were others  such as occupation, education, income, and a host of other social determinants of health that  significantly and negatively impacted our most vulnerable populations, and which are only partially susceptible to medical interventions. What began as an infectious disease has evolved  into a complex public health crisis that can only be addressed by integrated, all-sector interventions. This type of construct was advanced in the work of Merrill Singer who coined the  term “syndemic” to define it. We closed the editorial with these words: “This concept clearly  applies to COVID-19 today, which we can no longer consider a single biological disease entity  but one that significantly overlaps and interacts with other disease conditions, as well as concurrent public health crises defined more by the socioeconomic determinants of health rather  than by pathophysiological changes. The expansion of this model to include the unwanted side  effects of our interventions can also give us a framework to better assess and measure the direct  and indirect impacts of the COVID-19 pandemic. We are all familiar with individual iatrogenic  effects that may result from medical interventions, but we have tended to ignore or minimize the  population iatrogenic effects secondary to extreme public health interventions.” 

For yesterday, March 21, 39,505 new cases (positive lab tests) of COVID-19 were reported along with 455 deaths and some 40,976 hospitalized as compared to the corresponding peak numbers of 300,519 cases, 4,518 deaths and 141,480 hospitalized in early January 2021 (10). There has been some concern that the new case rate of decline has plateaued somewhat over the past  several weeks but this is to be expected as restrictions are relaxed and there is an increase in  person-to-person contacts; the more important metric, mortality has continued its downward  trend band should continue to do so as more and more of the higher risk are taken out of the  susceptible pool (see below). This is certainly heartening and if the trend continues, which it  should, we need to seriously think about when we officially go from a pandemic to an endemic  state, especially in those countries where transmission has been effectively suppressed. However,  before discussing this further we should review the role of Herd Immunity (HI) in the context of  where we are today and, hopefully, we can dispel some of the many mis-conceptions attendant to  it. Some basics: 1) HI is not dichotomous, it is a continuous variable that rises and falls over time  with population immunity, 2) population HI too often assumes homogeneity across different  demographic groups assuming all are at equal risk. Our experience with COVID-19 clearly  shows this to be invalid and as estimated HI levels need to be considered in vaccine allocation, we need to set different goals to target those at greatest risk, and 3) HI is better thought of as the  percent of non-susceptible individuals {vaccinated + previously infected + relatively immune  (such as children vs. the elderly in COVID-19)} in the population, and as the percentage goes up  the rate of transmission goes down eventually reaching seasonal levels of CORONA virus  transmission. 

As of today, almost 25% of the US population has received at least one dose of a COVID-19 vaccine including 69% of those over 65 years of age (10). Additionally, another 10% of the total population has tested positive up to now, and upwards of 20% may have been infected but non detected (12,13). From these numbers alone you cannot determine the degree of overall population immunity, but a reasonable estimate would put it between 40% and 50%. More  importantly, the higher levels of previous infection and vaccination in the highest risk group for  severe disease and lethality, the elderly, should significantly decrease the overall clinical impact  of the pandemic and get us back to the “old normal” earlier than expected. This brings us back to  a critical question – when does a pandemic end? This issue came up as the 2009 H1N1 pandemic  wound down and on Aug. 10, 2010 the WHO announced that it was effectively ended. The  decision was based on the facts that in most countries, outbreaks were no longer occurring, and  that influenza was transitioning towards seasonal patterns of transmission. WHO went on to note  that H1N1 viruses would continue to circulate for years to come – the virus had not disappeared  (14). As the SARS-CoV-2 virus wanes in the US we need to establish some metrics to acknowledge when we transition from the pandemic to the endemic phase. Impeding this  consideration at the present time is our seeming unrelenting negativity, in spite of our progress,  and the current focus on “variants” and the fear of another surge. This is somewhat perplexing as  genetic variants are constantly evolving as the virus competes to propagate. A small number of  the variants have raised concern because of possible increased infectiousness and/or lethality,  but, to date, existing vaccines continue to be effective against them (15). A vaccine resistant  variant may well evolve and need to be addressed at some point in time, but if we are going to  extend the pandemic phase with every new variant, we will be in permanent PPE. 

The single greatest factor in replacing pessimism with optimism is, of course the increasing availability of effective vaccines. By the end of December shipments had begun across the US  and officials had a chance to target limited supplies to those at highest risk of a negative clinical outcome, but, in too many instances, let that opportunity slip by. We could do a discourse on the  many reasons for this but two stand out: 1) we shifted goals from the initial focus on saving lives  to addressing societal ills that a vaccine would do little to ameliorate, and 2) continuing to  measure the medical impact of the pandemic in terms of “cases” primarily defined by a positive  lab test. From the onset of the pandemic the sentinel risk factor has been recognized as age,  especially for those 65 and older who have accounted for 80 percent of deaths, the logical target  group for an effective vaccine. Unfortunately, when dealing with a potentially lethal infectious  disease and a limited supply of an effective medical intervention it is not difficult to justify its  allocation to just about any sub-group through an exercise in ethical gymnastics. However, given  the clearly defined risk factor, age, that cuts equitably across all socio-economic groups it is difficult to understand the justification of allocating by other factors if indeed the primary objective is, as it should be, to save lives. To date, we have administered over 80 million doses in  the US, more than enough to have protected the approximately 50 million seniors over 65 of all  ethnic and racial backgrounds. We should note that after a rough start to the vaccination program  regarding prioritization of seniors, we are now making excellent progress and have now vaccinated almost 70% (11). A logical corollary to this is that the continuing use of “cases” to  define the impact of the Pandemic becomes increasingly fallacious as the ratio of clinically  significant events to total test positives becomes smaller and smaller. 

Continuing this line of reasoning, we should consider the global situation as well. Of a global  population of almost 8 billion, there are an estimated 703 million (roughly 10%) aged 65 and  over. To date almost 500 million doses of vaccine have been administered across 128 countries;  if targeted to those 65 and older, over 50% could potentially have already been vaccinated and  the global medical impact of the pandemic would be significantly reduced (16). This approach is  further enhanced by looking at the promising results coming out of Great Britain, specifically  targeting the elderly, and using a single jab while delaying the second dose for up to 12 weeks  (17). Given the concerns with variants we might even consider using the second dose as a  “booster” modified to target those that are most worrisome. More pressing, from a Global Health  Security and humanitarian perspective, is the issue of ethically justifying the vaccination of  extremely low risk groups in some countries at the expense of millions at much greater risk in  others. The US has a rare opportunity to reburnish its image on the world stage by taking the lead  in a vaccine diplomacy initiative that would truly represent our professed ideals, especially  regarding the value of individual life. Such an initiative, to be successfully carried out, however,  requires defining the goals of national and global vaccination programs. In the US we are  officially being told that life will not return to normal until 75%-85% of our population is fully  vaccinated (16). This hyper-inflated figure discounts the population immunity level we have  already reached through the previously infected, and relatively immune, but most importantly,  perpetuates the unwarranted state of anxiety and fear that we have experienced over the past  year. At the Global level, attaining such a goal will take years by which time the virus may well  have mutated to a vaccine-resistant strain and we will, indeed, be inviting new Pandemic waves.  Rather, with the setting of more realistic, science based goals, we have reasons to be optimistic.  We are not there yet, we must continue to be vigilant and cautious, but we are well on our way;  Godot is in sight.  

  1. https://www.nature.com/articles/d41586-020-03564-y
  2. James JJ. COVID-19: A Tale of Two Epidemics. Disaster Medicine and Public Health Preparedness.2020. DOI: 10.1017/dmp.2020.58 
  1. James JJ. From Epidemic to Pandemic. Disaster Medicine and Public Health Preparedness.2020. DOI: 10.1017/dmp.2020.84
  2. James JJ. Lockdown or Lockup. Disaster Medicine and Public Health Preparedness.2020. DOI: 10.1017/dmp.2020.127
  3. James JJ. COVID-19: Reflections. Disaster Medicine and Public Health Preparedness.2020
  4. James JJ. COVID-19: Yin and Yang and Herd Immunity
  5. James J. Are we “Waiting for Godot” – a metaphor for COVID-19. Disaster Med Public Health Prep.2020;epub, 1-3. DOI: 10.1017/dmp.2020.28
  6. James JJ. Waiting for Godot – Epilogue. Disaster Medicine and Public Health Preparedness.2020 DOI: 10.1017/dmp.2020.307 
  1. James JJ. From Covid-19 to COVID-20: One Virus – Two Diseases. Disaster Medicine and Public Health Preparedness.2020 DOI: 10.1017/dmp.2020.363
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  2. https://covid.cdc.gov/covid-data-tracker/#vaccinations (accessed 3/16/2021)
  3. https://www.npr.org/sections/health-shots/2021/02/06/964527835/why-the-pandemic-is-10-times-worse-than-you-think (accessed 3/16/2021
  4. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/burden.html (accessed 3/22/2021) 
  1. https://www.sciencemag.org/news/2010/08/who-declares-official-end-h1n1-swine-flupandemic#:~:text=The%20H1N1%20pandemic%20that%20started,World%20Health% (accessed 3/22/2021) 
  2. https://jamanetwork.com/journals/jama/fullarticle/2776739
  3. https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/ (accessed 3/17/2021)
  4. https://pharmaceutical-journal.com/article/feature/everything-you-need-to-know-about-the uks-covid-19-vaccination-programme