Beneath a scruffy patch of grass where paths cross in Tower Hamlets Cemetery Park, east London, is a hidden reminder of plagues past. Somewhere underfoot lie the Wood family – Christopher, Ellen and their six-year-old daughter Katherine – who died in the same week in April 1920 during the fourth wave of the Spanish flu. There is no plaque, nor even a gravestone. They were buried, alongside perhaps five others, in a public grave, in one of Victorian London’s “Magnificent Seven” cemeteries, where I spent many lockdown walks.
There are soldiers here, too. A monument to local men who served in the First World War bears their names, but only the archives reveal how many died: not in action, but of flu. Private Henry Roney of the Royal Munster Fusiliers, born in Hackney, died aged 22 in October 1918 of influenza, less than a month before the war ended. Private William Henry Dear of the Sussex Yeomanry, born in Bethnal Green, died aged 18 in December 1918 of influenza and pneumonia, just after the war ended.
Between February 1918 and April 1920 the Spanish flu is thought to have killed 20 to 50 million people worldwide: more than all the soldiers and civilians killed in the First World War. Yet there is no public memorial to the 228,000 British citizens who died of it.
This is not merely a reflection of the time. Fast-forward to the Aids crisis of the Eighties and Nineties. There is no official memorial in the UK. More lives worldwide have been lost to HIV/Aids than were lost in the First World War.
“The problem is, people forget,” says Dr Howard Markel, a professor of the history of medicine at Clare College, Cambridge, who began studying past pandemics while working as an Aids doctor in 1989. He has since advised the US Centers for Disease Control and Prevention (CDC) on flu outbreaks as its historian on call. Amid Covid-19, he coined the phrase “flatten the curve”, now so familiar to a public accustomed to scanning graphs every day.
The “final act of an epidemic or a pandemic”, he tells me over the phone, is “global amnesia”. As the shocking first act of Covid-19 – two years of mass death, illness, lockdowns and global disruption – fades, its second act is preoccupying scientists, medics and politicians across the world. What happens next, and how does Covid-19 end, if it ends at all?
While some pandemics come to a close, others merely take on the sense of an ending. Smallpox, thanks to the first vaccine, was eradicated by 1980. Polio, again due to vaccines, has been eradicated in all continents except Asia.
Tuberculosis, however, is the 13th highest cause of death globally and the second leading infectious killer after Covid-19. Scientists call it the “forgotten pandemic”. Flu, for which vaccinations are more adept at preventing severe disease than infection, circulates freely outside the summer months. Chicken pox and malaria circulate at what the World Health Organisation deems a “normal” level. Everyone on the planet is infected with respiratory syncytial virus by the time they’re five, and reinfected periodically throughout their lives – with common colds.
We are still in the seventh cholera pandemic, which began in 1961, notes Dr Lee Hampton, a disease surveillance and vaccine safety expert at Gavi, which runs the Covax programme to vaccinate the world. “If you think about HIV, that started over 40 years ago – I think you would say we are in the HIV global epidemic still,” he adds.
“Sars 1 disappeared after six months, for some reason that I won’t understand,” says Jeremy Farrar, the head of the Wellcome Trust, who quit the UK government’s Scientific Advisory Group for Emergencies (Sage) last October. “We’re in uncharted territory. In my working life, 30-odd years, and looking back at the last 100 years, which pandemic can we talk about which has any similarity [to Covid]?”
Our ancestors were more familiar with disease and premature death. The severe influenza outbreaks of the late 1880s and early 1890s were still in living memory when the Spanish flu struck. In the 17th century victims of the Great Plague of London were buried in pits outside the city walls. On another lockdown walk through east London I noticed a plaque marking a spot where cattle were slaughtered during the Great Plague, but not one for the 100,000 Londoners killed by the disease.
Even today the pandemic is shaping how much horror we can tolerate. “In this country, people have come to accept, in a sense, 2,000 Covid admissions a day to hospital and 200-plus deaths a day – that has become the norm,” says Farrar. “We compare it to January and February of 2021, when there were 1,500 deaths a day, and we think that’s progress.”
Meanwhile tolerance for restrictions on our day-to-day lives has declined, says Linda Bauld, the Scottish government’s chief social policy adviser and a professor of public health at the University of Edinburgh. There was unrest in European countries – Austria, the Netherlands – that tried to impose lockdowns late last year. “Governments have far fewer choices: they can’t repeat some of the measures they used earlier on.”
The public mindset, therefore, will play an inevitable part in deciding when the pandemic is over. As one NHS doctor in England, who still treats Covid-19 patients, tells me, the sign that the pandemic has ended for him and his colleagues will be “people being less scared of it, and part of that is when people just get bored of it, and therefore it affects daily life less”.
This is now the reality in England, where all restrictions were dropped in January other than the legal requirements to self-isolate if you test positive and give details to Test and Trace, which Boris Johnson, the Prime Minister, has announced will end a month early, by the end of February. The rest of the UK has also eased restrictions, though mask-wearing continues in Scotland, working from home is still advised and Covid passes are still required at large events in Wales and Northern Ireland.
If people feel the pandemic is over, future infection control measures will be tougher for governments to justify. Covid cases in England rose steeply after most restrictions were dropped at the end of January, while 2 February marked the highest daily rise of Covid deaths in over a year.
“Expectations management” from our leaders is crucial, says Farrar: “The sense that we will no longer have Covid as part of a national, global discourse again – that’s not going to happen.” He recalls George W Bush’s ill-fated “mission accomplished” speech as US president, delivered from an aircraft carrier following the Iraq invasion in 2003. “It was proved wrong then, and it would prove unwise to say that now.”
The coronavirus pandemic will only have officially ended when Dr Tedros Adhanom Ghebreyesus, the director-general of the World Health Organisation, determines that it is no longer a “public health emergency of international concern”.
To reach this decision, he will be advised by the WHO’s emergency committee of international experts, taking into account the latest scientific evidence, the risk to human health, and to international traffic and trade. On 19 January Tedros warned that the pandemic is “nowhere near over”.
Nevertheless, the WHO’s tone has shifted with the arrival of the Omicron variant. Last May its leading coronavirus expert, Maria Van Kerkhove, was still advocating a New Zealand-style approach, or “zero Covid”. On 29 December 2021, the WHO’s emergency expert Mike Ryan announced that the acute phase of the pandemic could end in 2022 but that the disease would not disappear.
“There are a lot of uncertainties around the future evolution of this pandemic, and WHO is considering a number of scenarios,” a spokesperson for the organisation tells the New Statesman. “Even if the virus is to become endemic, it doesn’t mean that it stops being dangerous or disruptive.”
In January Sajid Javid, the Health Secretary, announced: “We are leading Europe in the transition from pandemic to endemic and we are showing the world how you can live with Covid.”
That word “endemic” is the latest in the layman’s suddenly vast epidemiological vocabulary. Never before have so many people casually discussed concepts like the “R number” and “viral load” in the pub or over the dinner table, and now they have a new one to play with. Yet some disease experts balk at using this word in the context of Covid. “One of the important parts of the definition of ‘endemic’ is that there are predictable patterns of a virus or a disease,” warns Dr Linda Bauld. “We are just not there yet.”
To be endemic, a disease has to be doing what scientists “expect” and there are no established expectations when it comes to Covid-19.
Scientists outlined a number of scenarios to the New Statesman. The “central scenario”, as described by Farrar, is the most likely: Covid-19 becomes endemic, vaccines carry on working, some people still become seriously ill, but those numbers are low and therefore manageable. Farrar only puts this outcome at a “40, 50 per cent” likelihood, and warns policymakers to plan for other scenarios: from the “rosy spectacled” view that it disappears entirely, like Sars (which he gives a “less than 1 per cent chance”), to the nightmare prospect of another major pandemic from an entirely different infection.
There is also a “10, maybe 20 per cent” chance of a new variant that escapes our immunity and is more severe, he warns. “I would be cautious about anybody who can give you a crystal ball and tell you, at 10.30 next Tuesday, it’s going to end,” he says. “The pandemic is not coming to an end – we’re going to go to a different phase.”
Others describe an imperfect future in which we “live with” the virus. “I don’t want to live with Covid-19, but we don’t actually have a choice,” says Dr Tim Colbourn, professor of global health systems, epidemiology and evaluation at University College London and the most prominent UK scientist to publicly map out a potential Covid-19 endgame. His theory is that vaccines, new treatments such as antivirals and immunity from prior infection will lead to Covid-19 dropping out of the top ten causes of death – a “reasonable goal” to measure the end of the pandemic’s acute phase.
The UK will reach this stage “in the next few months, and certainly by the end of the year”, he predicts, and other countries will follow. Those without wide access to vaccination or new drugs will get there via natural immunity because Omicron spreads so fast, goes his theory; meanwhile those following a zero Covid strategy will find it politically untenable.
“There are still a lot of senior academics with big platforms on social media saying we simply can’t live with the virus, we’ve got to eliminate it, but none are actually thinking through how to do that,” Colbourn says. “Global elimination literally means asking eight billion individuals to do exactly the same thing at the same time, so that’s never, ever going to happen.”
Allowing the virus to spread, however, brings risks. Long Covid can linger for months and is little understood. Colbourn says data is required to work out its impact when compared with the “burden of dementia, cancer and heart disease, so that we can place it in a wider context and not hold it up as this exceptional thing, more important than any other health condition, devoid of context”.
Meanwhile, developing countries with low vaccination rates may harbour new variants. Hampton, of Covax, emphasises the need to “vaccinate the world to achieve immunity through the safest way possible, as quickly as possible”. He warns, however, that vaccinations alone won’t prevent the emergence of new variants: “Omicron is quite capable of infecting people with some degree of immunity, so that suggests it is going to keep circulating, and continue to evolve.”
In any case, the prospect of vaccinating the planet “every four to six months” has been deemed “not sustainable or affordable” by Andrew Pollard, head of the UK’s Joint Committee on Vaccination and Immunisation. On 5 January Pollard stressed the “need to target the vulnerable”, instead of everyone 12 and over.
Depending on cost, demographic and other priorities, vaccine programmes across the world will vary. In the US, everyone is encouraged to have a flu vaccine each year, for example, whereas only the elderly and vulnerable are targeted in the UK. In the US they vaccinate against chicken pox, whereas the UK favours developing natural immunity in childhood.
Yet even without mass vaccinations we will all do things a little differently. After the spread of swine flu in 2009, American children were taught to sneeze into the crooks of their elbows, rather than their hands, so that they wouldn’t go on to wipe germs elsewhere. This practice, which Markel calls a “vampire sneeze”, is now commonplace. The aftermath of Sars, which spread chiefly in south-east Asia in 2003, explains the prevalence of mask-wearing there – particularly in Hong Kong, which suffered more than a third of fatalities.
Disease changes our behaviour. In the 19th century spitting on the streets when chewing tobacco was commonplace throughout the western world. Yet with the fear that it would spread tuberculosis, this habit was curtailed first by New York City’s 1896 Anti-Expectoration Law, which made spitting punishable by a fine and up to a year in prison.
Coronavirus may even affect the British culture of the stiff (and sniffly) upper lip, as the former health secretary Matt Hancock mused at a select committee hearing in November 2020. “Why in Britain do we think it’s acceptable to soldier on and go into work if you have flu symptoms or a runny nose, thus making your colleagues ill?” he asked. “That should change.”
Leaving the Spanish flu victims of Tower Hamlets Cemetery Park behind in the wooded thicket of their resting place, it’s a two-minute walk to a main road. Here there is a community pharmacy, with posters plastered on its door. One urges passers by to “boost your immunity this winter with the flu vaccine and Covid-19 booster”. An advertisement to protect ourselves against the illness that struck down millions over a century ago is now a footnote in a quotidian public health campaign.
“This is the way the world ends, not with a bang but a whimper.” Markel recites the final lines of TS Eliot’s 1925 poem, The Hollow Men, to me down the phone. “That is exactly how epidemics go. They go away before you notice.”