1 00:00:00,060 --> 00:00:03,750 The end of the epidemic is not the same as the end of disease. 2 00:00:04,020 --> 00:00:07,560 So you can see very much that disease, for the most part, continues on. 3 00:00:08,400 --> 00:00:14,190 And so this is why it's very important to think about who decides how we make that declaration, 4 00:00:14,190 --> 00:00:18,989 because it's actually not that the disease will disappear or the disease will be eradicated because, 5 00:00:18,990 --> 00:00:22,620 of course, actually very few diseases have ever been eradicated. 6 00:00:26,630 --> 00:00:28,040 Hello. I'm Katrien Devolder. 7 00:00:28,070 --> 00:00:36,410 This is thinking out loud conversations with leading philosophers and sometimes other academics from around the world on topics that concern us all. 8 00:00:36,860 --> 00:00:43,700 In this episode, I'll be talking to Erica Charters who is professor of Global History of Medicine at the University of Oxford. 9 00:00:44,120 --> 00:00:48,950 Professor Charters leads a multidisciplinary project on how epidemics end. 10 00:00:49,340 --> 00:00:56,270 So she's the ideal person to answer some questions for us about the end of the COVID 19 pandemic. 11 00:01:00,800 --> 00:01:08,900 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. 12 00:01:09,050 --> 00:01:18,800 We all learnt quickly about this strange virus coming from Wuhan, and then we all remember the first reported cases in our countries. 13 00:01:18,800 --> 00:01:23,600 And then suddenly the W.H.O. declared this, you know, there was a pandemic. 14 00:01:23,780 --> 00:01:27,380 It was like I think it was the 11th of March 2020. 15 00:01:27,530 --> 00:01:37,390 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. 16 00:01:37,410 --> 00:01:41,730 Then they said, we have a pandemic. So is that more or less correct? 17 00:01:41,760 --> 00:01:48,780 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., 18 00:01:49,050 --> 00:01:55,290 rather than declaring, for example, when something is an epidemic, because that tends to be a very regional decision. 19 00:01:55,320 --> 00:02:00,960 Their declarations are usually focussed on what's called a public health emergency of international concern. 20 00:02:01,050 --> 00:02:07,440 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, 21 00:02:07,440 --> 00:02:11,820 but also that it requires international attention, including international aid. 22 00:02:12,090 --> 00:02:20,100 So it's a it's an interesting point that it's not just a definition focussed on, say, biomedical information. 23 00:02:20,100 --> 00:02:23,999 It's also thinking about whether the International Health Organisation, 24 00:02:24,000 --> 00:02:30,720 whether international organisations need to be involved and whether other countries should be aware and involved in the outbreak. 25 00:02:30,750 --> 00:02:39,090 How about the end of the pandemic? Is that sort of as straightforward or is it a bit more complicated? 26 00:02:39,390 --> 00:02:45,030 We tend to think that it's the outbreak and the declaration of an outbreak is somewhat straightforward, 27 00:02:45,030 --> 00:02:53,190 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. 28 00:02:53,760 --> 00:02:57,299 So it can go back further in time for HIV AIDS, for example. 29 00:02:57,300 --> 00:03:00,660 There's been a long history of rethinking when that actually started. 30 00:03:01,260 --> 00:03:06,080 But the same thing we see is the end also is is a process. 31 00:03:06,090 --> 00:03:07,950 It's very complex. It's very messy. 32 00:03:07,950 --> 00:03:16,200 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. 33 00:03:16,440 --> 00:03:19,980 So you can see very much that disease, for the most part, continues on. 34 00:03:20,820 --> 00:03:26,639 And so this is why it's very important to think about who decides how we make that declaration, 35 00:03:26,640 --> 00:03:31,410 because it's actually not that the disease will disappear or the disease will be eradicated because, 36 00:03:31,410 --> 00:03:35,040 of course, actually very few diseases have ever been eradicated. 37 00:03:35,130 --> 00:03:43,200 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. 38 00:03:43,200 --> 00:03:51,720 A really important way to think about this is the definition of an epidemic is about disease rates above expected or normal rates. 39 00:03:52,440 --> 00:03:55,469 So there's not actually, of course, a metric of what that means. 40 00:03:55,470 --> 00:04:00,000 Right. So although you might say within different regions, okay, this is the expected disease rate. 41 00:04:00,210 --> 00:04:07,680 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. 42 00:04:07,950 --> 00:04:12,179 And so the the kind of clinical definition of the end of an epidemic is, therefore, 43 00:04:12,180 --> 00:04:22,739 when disease rates subside or reach what are called very often it's defined as acceptable levels according to what is locally acceptable. 44 00:04:22,740 --> 00:04:29,280 And again, we can think about how different parts of the world live with different types of diseases and different rates of diseases. 45 00:04:29,280 --> 00:04:36,839 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. 46 00:04:36,840 --> 00:04:44,450 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, 47 00:04:44,460 --> 00:04:51,750 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. 48 00:04:51,990 --> 00:05:00,300 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. 49 00:05:00,490 --> 00:05:06,810 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. 50 00:05:07,260 --> 00:05:10,560 The other way of thinking about this is the way that influenza works. 51 00:05:10,800 --> 00:05:17,760 So we always have rates of influenza. It's an epidemic because it rises above expected levels. 52 00:05:17,940 --> 00:05:21,900 And so therefore we have these kind of cyclical patterns to influenza. 53 00:05:22,320 --> 00:05:32,130 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. 54 00:05:32,280 --> 00:05:37,860 We we always live with disease. The question is, in some ways, the proportion and the ratio. 55 00:05:38,100 --> 00:05:42,540 And so therefore, it becomes a real question of what do we as a society, 56 00:05:42,540 --> 00:05:49,080 what are we willing in some ways to live with, especially in terms of regulations and rates of disease. 57 00:05:49,260 --> 00:05:52,799 But that will, of course, differ very much from societies to society. 58 00:05:52,800 --> 00:06:00,360 And even within society. There are clearly groups who well, probably, first of all, never believed there was a pandemic. 59 00:06:00,380 --> 00:06:08,100 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. 60 00:06:08,110 --> 00:06:15,030 So does each individual then sort of decide for themselves whether a pandemic is over? 61 00:06:15,720 --> 00:06:20,460 It is true that when you look at endings, it's very messy. 62 00:06:21,180 --> 00:06:25,709 We definitely know that pandemics end in different places at different times. 63 00:06:25,710 --> 00:06:29,330 So HIV AIDS, I think, has been a very classic example of how. 64 00:06:29,530 --> 00:06:36,129 The pandemic ended as an epidemic for for many parts of the world, pretty much and western parts of the world. 65 00:06:36,130 --> 00:06:41,770 But of course, it's continued on in various ways as an epidemic in other parts of the world, especially in Africa. 66 00:06:41,800 --> 00:06:48,190 So that's a very good example of the way that a pandemic then kind of ended in these different ways and different regions. 67 00:06:48,550 --> 00:06:53,290 But I think you're right that even within one society, the ending is very messy. 68 00:06:53,320 --> 00:07:00,969 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. 69 00:07:00,970 --> 00:07:04,600 In fact, there's going to be a lot of competing definitions. 70 00:07:05,410 --> 00:07:11,390 And partly because I think people measure different things when they're talking about what is the end of an epidemic. 71 00:07:11,590 --> 00:07:19,809 And people have different values. So you can think of maybe the U.K., where people's liberty is valued quite highly. 72 00:07:19,810 --> 00:07:29,110 And then maybe if I think of some Asian countries, maybe where public health is valued much more compared to liberty. 73 00:07:29,660 --> 00:07:35,410 And so these societies have different values, but different weight on these values. 74 00:07:35,410 --> 00:07:38,559 So they will reach different conclusions. Exactly. 75 00:07:38,560 --> 00:07:42,430 And I think, again, this is why it's so fascinating, because on the one hand, 76 00:07:42,430 --> 00:07:46,690 we think of disease, obviously, about the way that it affects us as individuals. 77 00:07:46,690 --> 00:07:50,110 Public health is about the community and how it affects other people. 78 00:07:50,110 --> 00:07:53,690 And so constantly I think there's this tension between those two. 79 00:07:53,830 --> 00:07:59,590 And and I as a historian, I can't say that there's one answer or one trend. 80 00:07:59,830 --> 00:08:09,040 If anything, we can simply see how important social context, even cultural understandings of, say, health and disease can't be taken for granted. 81 00:08:09,370 --> 00:08:15,220 And so there's there's certainly no historical model that you could say this is the solution. 82 00:08:15,250 --> 00:08:18,190 I think what you're going to see instead is a number of different ways. 83 00:08:18,190 --> 00:08:23,160 In the same way, I think there's been a number, a number of different models of dealing with COVID. 84 00:08:23,170 --> 00:08:28,390 So I think in the same way, that's going to be a number of different ways of thinking about how the epidemic ends. 85 00:08:28,510 --> 00:08:30,760 I just wonder whether there is a risk there, though. 86 00:08:30,760 --> 00:08:40,180 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. 87 00:08:40,180 --> 00:08:44,319 It's an acceptable level. So the pandemic is over. 88 00:08:44,320 --> 00:08:52,630 And in the meantime, in Africa, there might be new variants developing because vaccination rate is low because of our, 89 00:08:53,170 --> 00:08:58,330 you know, immoral decision not to distribute vaccines fairly and not blaming them. 90 00:08:59,680 --> 00:09:05,470 So if we say that the pandemic is over, that might actually be quite a risky. 91 00:09:06,160 --> 00:09:11,709 Yeah. Yes. Oration, so to speak. Yeah. And I think one way of thinking about this, 92 00:09:11,710 --> 00:09:16,480 so it's a bit like as you were saying at the beginning about the declaration when 93 00:09:16,480 --> 00:09:21,129 someone decides and who decides to say it is an epidemic or for the W.H.O., 94 00:09:21,130 --> 00:09:26,160 it's a public health emergency of international concern. That, of course, is actually a declaration. 95 00:09:26,170 --> 00:09:29,520 I was thinking about what we should do with our attention. Right. 96 00:09:29,530 --> 00:09:34,239 And saying this is a problem and also that it becomes the most urgent problem. 97 00:09:34,240 --> 00:09:40,090 And so, you know, we have limited resources as individuals and as states. 98 00:09:40,090 --> 00:09:44,829 And so I think it's a real question of when you say this is an epidemic or a pandemic, 99 00:09:44,830 --> 00:09:49,209 what you are saying is this is a problem and very often the most urgent problem. 100 00:09:49,210 --> 00:09:55,570 And then the question becomes, all right, when do either other problems become more pressing or when, 101 00:09:55,570 --> 00:10:01,959 as you're saying, when does it become someone else's problem and therefore not one not one that we're looking at? 102 00:10:01,960 --> 00:10:07,330 So I think this is I think there's a real power to the declaration and therefore 103 00:10:07,330 --> 00:10:11,680 also real power to kind of when you are saying the crisis is now over, 104 00:10:12,010 --> 00:10:19,060 the there's a historian, Doris Varga, who said how an epidemic is over when it becomes someone else's problem. 105 00:10:19,810 --> 00:10:25,540 And I think, again, you're right that that you how it's a it becomes a regional concern. 106 00:10:26,110 --> 00:10:32,050 That's exactly this point about what type of problem it is and and where it ends up being located. 107 00:10:32,410 --> 00:10:42,819 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, 108 00:10:42,820 --> 00:10:51,580 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? 109 00:10:51,670 --> 00:10:57,010 I think one one thing which might not be comforting for people to hear might be in other ways, 110 00:10:57,010 --> 00:11:01,060 is that very often people don't know when they're in the end of an epidemic. 111 00:11:01,750 --> 00:11:05,740 It's very hard, of course, to predict when you're when you're in the midst of a disease outbreak, 112 00:11:05,770 --> 00:11:10,360 especially because as we've seen disease, it tends to come in cycles. 113 00:11:10,360 --> 00:11:16,780 And so you you're in a decline. And is that the final decline or is that just the climate for the next wave? 114 00:11:16,780 --> 00:11:23,799 And so what is interesting is there's many cases so that the end of the second pandemic in places such as England, 115 00:11:23,800 --> 00:11:29,250 it took them at least 100 years to be convinced that actually plague really wasn't returning back to. 116 00:11:29,330 --> 00:11:34,100 England. And and so you can see it's an interesting point of when you're a historian, 117 00:11:34,100 --> 00:11:39,290 you can look back and we might know so much more than people who were living through it at the time, 118 00:11:39,290 --> 00:11:43,730 which I think is somewhat unnerving for those of us living through an epidemic. 119 00:11:44,000 --> 00:11:49,550 But I think that the comforting part is, of course, societies really do come back together. 120 00:11:49,580 --> 00:11:58,300 One of the I think one thing which historians would want to stress is that an epidemic is not just about medicine. 121 00:11:58,310 --> 00:12:04,010 It's not just a biological crisis, because it's also a period when everything seems to become uncertain. 122 00:12:04,010 --> 00:12:08,660 So politics becomes uncertain. The way that we respond to other humans becomes uncertain. 123 00:12:08,960 --> 00:12:15,470 All of our frameworks for ending understanding the world in many ways seem to collapse during an epidemic. 124 00:12:15,680 --> 00:12:24,740 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. 125 00:12:25,070 --> 00:12:32,300 And so the end process isn't just about the decline in disease, it's also about how does society reconvene. 126 00:12:32,330 --> 00:12:37,190 Because of course, what an epidemic does is it tends to tear people apart. 127 00:12:37,490 --> 00:12:37,840 Right. 128 00:12:37,860 --> 00:12:46,879 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. 129 00:12:46,880 --> 00:12:50,870 Right. They tend to divide communities. They polarise opinions. 130 00:12:51,170 --> 00:12:55,819 And so this end process also needs to be one which there is a kind of social and 131 00:12:55,820 --> 00:13:02,690 moral restitution and and a way of how do you rebuild communities and rebuild trust, 132 00:13:02,900 --> 00:13:11,959 which very often has been eroded. And I will say, look, the cholera epidemics in the 19th century, there were very violent uprisings. 133 00:13:11,960 --> 00:13:18,200 And so in that sense, we can take some comfort from history and knowing that even though things have been very difficult, 134 00:13:19,280 --> 00:13:23,780 there's there's been much more there's been epidemics that have been fundamentally 135 00:13:23,780 --> 00:13:27,710 troubling to societies and and humans have come back together after them. 136 00:13:30,350 --> 00:13:37,130 If you like this episode, don't forget to subscribe to the Thinking Out Loud podcast or to the Practical Ethics Channel on YouTube.