• William Miller, MD

Endemic versus Pandemic

We are hearing a lot of talk about how we are now in an endemic and no longer in a pandemic. What does that really mean? From a scientific perspective, it means that nature has established a new balance in which the infectious disease in question will continue to be present at a more or less steady state. I am not sure I agree that we are there yet, as I fully expect the infection rates to continue to decline both globally and in our own neck of the woods. The question is, how long will it take to reach this new level where we are no longer troubled with being at risk? We can look at two other major pandemics of the last century to get some ideas.


In 1918, a particularly aggressive stain of influenza gripped the world. It whipped around the globe in four big waves and mutated several times. The second and third waves were more deadly than the first and the fourth was less so. After about two years, it started to fade. H1N1 influenza, the strain that caused the 1918 pandemic, is still with us today. During those two years over 45 million people died, about 3% of the world’s entire population. COVID pales in comparison. Nonetheless, it is a good example to look at as there are many similarities. Both are upper respiratory viral infections and both are spread the same way through respiratory droplets. H1N1 has smoldered along since it faded as a pandemic after 1920. In 1976 there was an outbreak of “swine flu” at Fort Dix during which about 200 soldiers got sick and 13 died. A year later it popped up in Russia and was labeled “the Russian flu”. In 2009, it came back again as “swine flu” and qualified as a true pandemic as it spread around the globe causing about 284,000 deaths worldwide. For comparison, garden variety influenza causes between 12 million to 45 million infections each year, killing about 250,000 to 500,000 people annually according to the World Health Organization. The numbers for the US are 12,000 to 52,000 deaths due to influenza every year. When SARS-2, the virus that causes the disease COVID, eventually quiets down, it seems reasonable to expect similar numbers.


Another example of a global pandemic turned endemic within recent memory is HIV, the virus that causes AIDS. In the early 1980s it sprung up causing horrific deaths and much social fear and even hysteria in some segments of the population. The illness was essentially 100% fatal versus COVID with a death rate hovering between 2% and 4%. Of course, the way that HIV is transmitted is different and requires intimate contact. Another major difference is the 8-year incubation period from HIV infection to AIDS versus the 2 to 4 day incubation period of COVID and influenza. Nonetheless, from a societal perspective there are important corollaries.

Advanced nations developed effective treatments for HIV such that persons who are infected can now live normal lives without even being contagious. However, these treatments are extremely expensive. For example, a common combination of medications used to manage HIV is Truvada at $1,889 for a 30-day supply of pills which is taken along with Descovey at $1,979 for 30 days. Coming in at almost $4,000 per month, it is easy to see how developing countries cannot afford such treatments. As a result, HIV and the resultant illness AIDS has become a disease of third world countries where it still claims between 1 to 1.9 million lives each year. The same third world countries today are struggling to vaccinated even 5% of their populations against COVID. I predict that COVID infections and deaths will remain a major challenge for those countries long after the US, Europe and other developed nations have moved on from managing COVID to other issues.


From a social perspective, the term “endemic” may be understood by the general public quite differently from its definition in the scientific community. People long to return to normalcy and talk of this pandemic becoming endemic may be seen as a sign that it is over and that we can ignore it. Meanwhile, government bureaucracies have gained a lot of momentum in mobilizing against this disease. I predict that a political battle will play out between elected officials who urge continuation of public health measures on the one hand and those that argue for eliminating them in order to return to “normalcy”. I, for one, fear both extremes. I am concerned that public health measures that served us well at the beginning in quelling the rise of the pandemic, such as restricting visitation in hospitals and requiring healthcare workers to be masked and vaccinated, will be maintained long after such measures are no longer needed. I also fear a political agenda that undermines faith and trust in governmental institutions such as the CDC, the FDA and other public health entities. Of course, this political debate is already playing out as we saw from the failed recall election of Governor Gavin Newsom, fueled largely in response to his handling of the early pandemic by mandating lockdowns, to New Jersey’s gubernatorial campaign in November that largely centered around masking and vaccination.


It remains my hope that we can avoid further political division and agree on a course of action that moves us back to normalcy as quickly as reasonably possible without suffering the two opposing perils of continuation of public health impositions on the one hand and the doing away with public health all together on the other.

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