The end of the epidemic is not the same as the end of disease.
So you can see very much that disease, for the most part, continues on.
And so this is why it's very important to think about who decides how we make that declaration,
because it's actually not that the disease will disappear or the disease will be eradicated because,
of course, actually very few diseases have ever been eradicated.
Hello. I'm Katrien Devolder.
This is thinking out loud conversations with leading philosophers and sometimes other academics from around the world on topics that concern us all.
In this episode, I'll be talking to Erica Charters who is professor of Global History of Medicine at the University of Oxford.
Professor Charters leads a multidisciplinary project on how epidemics end.
So she's the ideal person to answer some questions for us about the end of the COVID 19 pandemic.
So before we talk about the end of the pandemic, I thought would be useful to refresh our memories a little bit about the beginning of the pandemic.
We all learnt quickly about this strange virus coming from Wuhan, and then we all remember the first reported cases in our countries.
And then suddenly the W.H.O. declared this, you know, there was a pandemic.
It was like I think it was the 11th of March 2020.
So presumably the. W.H.O. had some checklists with some criteria and checked whether, you know, all the criteria were met and they were met.
Then they said, we have a pandemic. So is that more or less correct?
What is interesting is and I and I don't know, full details on exactly the criteria the W.H.O. uses, but most often the W.H.O.,
rather than declaring, for example, when something is an epidemic, because that tends to be a very regional decision.
Their declarations are usually focussed on what's called a public health emergency of international concern.
And so there's a very specific criteria that has to do with when they feel there's a danger to it spreading beyond national borders,
but also that it requires international attention, including international aid.
So it's a it's an interesting point that it's not just a definition focussed on, say, biomedical information.
It's also thinking about whether the International Health Organisation,
whether international organisations need to be involved and whether other countries should be aware and involved in the outbreak.
How about the end of the pandemic? Is that sort of as straightforward or is it a bit more complicated?
We tend to think that it's the outbreak and the declaration of an outbreak is somewhat straightforward,
although we can also discuss how the origins when we say an epidemic actually started, as we will know with COVID 19, also is quite murky.
So it can go back further in time for HIV AIDS, for example.
There's been a long history of rethinking when that actually started.
But the same thing we see is the end also is is a process.
It's very complex. It's very messy.
And I think what we found most strikingly when we're doing research is that the end of of the epidemic is not the same as the end of disease.
So you can see very much that disease, for the most part, continues on.
And so this is why it's very important to think about who decides how we make that declaration,
because it's actually not that the disease will disappear or the disease will be eradicated because,
of course, actually very few diseases have ever been eradicated.
It seems that what you're saying is whether we decide an epidemic ends because it seems like a decision will depend on what our goal is.
A really important way to think about this is the definition of an epidemic is about disease rates above expected or normal rates.
So there's not actually, of course, a metric of what that means.
Right. So although you might say within different regions, okay, this is the expected disease rate.
And therefore, when it rises above that, then we call it an outbreak or an epidemic, or if it's across many countries, a pandemic.
And so the the kind of clinical definition of the end of an epidemic is, therefore,
when disease rates subside or reach what are called very often it's defined as acceptable levels according to what is locally acceptable.
And again, we can think about how different parts of the world live with different types of diseases and different rates of diseases.
So that's why, again, I'm very interested in this category of epidemic, because it's not actually something that we can take for granted.
And as much as it is true that we need the biomedical information and say numbers of cases or numbers of deaths to make that decision,
that alone isn't going to tell us. Right. So we can think about how there's many parts of the world in which they live with malaria.
If we had a malaria outbreak in England, it would probably be considered an epidemic because it would be a problem and it would be an unusual design.
So it's not even the rates, it's the type of disease. So you can see how it's a regional definition and the same thing.
The other way of thinking about this is the way that influenza works.
So we always have rates of influenza. It's an epidemic because it rises above expected levels.
And so therefore we have these kind of cyclical patterns to influenza.
And so to me, this is the really useful reminder when we're thinking about epidemics is the opposite of a of an epidemic is not a lack of disease.
We we always live with disease. The question is, in some ways, the proportion and the ratio.
And so therefore, it becomes a real question of what do we as a society,
what are we willing in some ways to live with, especially in terms of regulations and rates of disease.
But that will, of course, differ very much from societies to society.
And even within society. There are clearly groups who well, probably, first of all, never believed there was a pandemic.
Then there are groups who think the pandemic has been over for several months, and then there are groups who think the pandemic is still not over.
So does each individual then sort of decide for themselves whether a pandemic is over?
It is true that when you look at endings, it's very messy.
We definitely know that pandemics end in different places at different times.
So HIV AIDS, I think, has been a very classic example of how.
The pandemic ended as an epidemic for for many parts of the world, pretty much and western parts of the world.
But of course, it's continued on in various ways as an epidemic in other parts of the world, especially in Africa.
So that's a very good example of the way that a pandemic then kind of ended in these different ways and different regions.
But I think you're right that even within one society, the ending is very messy.
It's something that I found really fascinating in the project is this is not really about consensus and there's not one single answer.
In fact, there's going to be a lot of competing definitions.
And partly because I think people measure different things when they're talking about what is the end of an epidemic.
And people have different values. So you can think of maybe the U.K., where people's liberty is valued quite highly.
And then maybe if I think of some Asian countries, maybe where public health is valued much more compared to liberty.
And so these societies have different values, but different weight on these values.
So they will reach different conclusions. Exactly.
And I think, again, this is why it's so fascinating, because on the one hand,
we think of disease, obviously, about the way that it affects us as individuals.
Public health is about the community and how it affects other people.
And so constantly I think there's this tension between those two.
And and I as a historian, I can't say that there's one answer or one trend.
If anything, we can simply see how important social context, even cultural understandings of, say, health and disease can't be taken for granted.
And so there's there's certainly no historical model that you could say this is the solution.
I think what you're going to see instead is a number of different ways.
In the same way, I think there's been a number, a number of different models of dealing with COVID.
So I think in the same way, that's going to be a number of different ways of thinking about how the epidemic ends.
I just wonder whether there is a risk there, though.
So I sort of have the I don't know, this maybe the worry that here will stay like, oh, the disease is more or less under control.
It's an acceptable level. So the pandemic is over.
And in the meantime, in Africa, there might be new variants developing because vaccination rate is low because of our,
you know, immoral decision not to distribute vaccines fairly and not blaming them.
So if we say that the pandemic is over, that might actually be quite a risky.
Yeah. Yes. Oration, so to speak. Yeah. And I think one way of thinking about this,
so it's a bit like as you were saying at the beginning about the declaration when
someone decides and who decides to say it is an epidemic or for the W.H.O.,
it's a public health emergency of international concern. That, of course, is actually a declaration.
I was thinking about what we should do with our attention. Right.
And saying this is a problem and also that it becomes the most urgent problem.
And so, you know, we have limited resources as individuals and as states.
And so I think it's a real question of when you say this is an epidemic or a pandemic,
what you are saying is this is a problem and very often the most urgent problem.
And then the question becomes, all right, when do either other problems become more pressing or when,
as you're saying, when does it become someone else's problem and therefore not one not one that we're looking at?
So I think this is I think there's a real power to the declaration and therefore
also real power to kind of when you are saying the crisis is now over,
the there's a historian, Doris Varga, who said how an epidemic is over when it becomes someone else's problem.
And I think, again, you're right that that you how it's a it becomes a regional concern.
That's exactly this point about what type of problem it is and and where it ends up being located.
So, yeah, because you're a historian, so what can we learn from these from the pandemics in the pasts to deal with current pandemics,
especially when it comes to the end of pandemics? How how did we determine that there was the end of the Spanish flu pandemic, for example?
I think one one thing which might not be comforting for people to hear might be in other ways,
is that very often people don't know when they're in the end of an epidemic.
It's very hard, of course, to predict when you're when you're in the midst of a disease outbreak,
especially because as we've seen disease, it tends to come in cycles.
And so you you're in a decline. And is that the final decline or is that just the climate for the next wave?
And so what is interesting is there's many cases so that the end of the second pandemic in places such as England,
it took them at least 100 years to be convinced that actually plague really wasn't returning back to.
England. And and so you can see it's an interesting point of when you're a historian,
you can look back and we might know so much more than people who were living through it at the time,
which I think is somewhat unnerving for those of us living through an epidemic.
But I think that the comforting part is, of course, societies really do come back together.
One of the I think one thing which historians would want to stress is that an epidemic is not just about medicine.
It's not just a biological crisis, because it's also a period when everything seems to become uncertain.
So politics becomes uncertain. The way that we respond to other humans becomes uncertain.
All of our frameworks for ending understanding the world in many ways seem to collapse during an epidemic.
And so historians have traced how humans then tend to respond by practising kind of communal behaviour and rituals as a way to come back together.
And so the end process isn't just about the decline in disease, it's also about how does society reconvene.
Because of course, what an epidemic does is it tends to tear people apart.
Right.
We not only have the disease that's given us a different experience of illness, but we also have public health measures that tend to be very divisive.
Right. They tend to divide communities. They polarise opinions.
And so this end process also needs to be one which there is a kind of social and
moral restitution and and a way of how do you rebuild communities and rebuild trust,
which very often has been eroded. And I will say, look, the cholera epidemics in the 19th century, there were very violent uprisings.
And so in that sense, we can take some comfort from history and knowing that even though things have been very difficult,
there's there's been much more there's been epidemics that have been fundamentally
troubling to societies and and humans have come back together after them.
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