The number of people infected with Covid identified by testing in India has been rising since April. The actual number of those infected or reinfected would be much higher as many asymptomatic or mildly symptomatic individuals would not have been tested. It was reassuring, however, that most of those infected by a member of Omicron’s extended family suffered mild illness. This Clan variant’s inability to penetrate deeper into the lungs and blood vessels may partially account for this trait. Previous immunity, acquired through previous infection or recent vaccination, may also protect against undesirable consequences.

Despite its mild reputation, Omicron infected large numbers of people worldwide and claimed many lives. Most seriously ill were either unvaccinated or not fully vaccinated. Even the definition of who is adequately vaccinated is shifting as one or more booster shots are added to the previous two doses and the interval between vaccine doses is shortened as new variants demonstrate their improved ability to infect and immune evade. Mask mandates, withdrawn when Covid appeared to be retreating, were reinstated as case numbers began a new surge.

In this ongoing competition with the virus, will we reach a steady state where the virus becomes endemic, with manageable seasonal outbreaks that don’t steal lives and seal society? Although some commentators have stated that the virus has already become endemic, its evolution, behavior and effects are not yet fully predictable as new variants are constantly emerging. There is currently no global steady state that can confidently be described as “endemic”. All we can say is that the virus is here to stay and seems to be moving towards endemic. However, the possibility of new recombinant viruses being born from the womb of global vaccine inequality and a worrying potential for transmission from recycled animals to humans create uncertainty about if and when steady state will be reached.

Even as we stand guard, restrictions must be gradually withdrawn. Lifting the mask requirement must not be hasty, while imposing travel bans and school closures should not be knee-jerk reactions. A calibrated response is required that strikes the right balance of trust and caution, both in policy action and personal protection at every stage of a wave-forming pandemic. Situationally adapted responses need to be dynamically implemented against the background of the health system’s constant capacity building for prevention, monitoring and patient care.

Perhaps flood protection measures can provide a model for endemic preparedness. We rain seasonally every year, but not floods every year. When recurring floods threaten, we raise the level of our embankments to prevent flood water from entering our cities. We build dams upstream to control water levels in rivers downstream. We create efficient drainage systems to prevent waterlogging on the streets.

We monitor weather patterns to anticipate the risk of flooding during extreme weather events. When such events are predicted, vulnerable groups of people are kept safe and people’s mobility is restricted to essential services. If not, life goes on undisturbed, even if it rains. We leave the rainwater removal and sewage disposal to the municipal routine services. Even then, we use umbrellas to protect ourselves from getting wet when exposed to rain.

Such adaptability is required as we move from an enhanced pandemic response to a stationary endemic response while being prepared to shift gears if necessary. We need early notification of new virus variants, much like warnings about changing weather patterns. When serious cases threaten to surge, we limit mobility, continue essential services, and pay particular attention to the safety of the elderly and those with comorbidities. A multisectoral response to a public health emergency that prioritizes public safety would be appropriate.

In an endemic state, routine health services are sufficient to test and treat cases while monitoring case numbers, clusters, and the clinical profile of cases. People’s mobility will not be restricted, but covering indoors in public and crowded places may be recommended during seasonal outbreaks. Vulnerable groups of people are given special protection with booster vaccinations. The general public will be informed of personal protection measures, but life will be close to normal during times of seasonal peaks that don’t turn into dangerous waves.

Cities will flood even without storms if stormwater drainage and sanitation are poor. Even a seasonal surge in endemic Covid can pose a serious threat if our health services are under-resourced and poorly managed. We need greater investment to strengthen our health services through better infrastructure, manpower, public health expertise, information systems and management. This requires constant attention, not just a crisis response.

While flood prevention and control requires planning and action at multiple levels of government and society, much of the responsibility lies at the local level and requires active community engagement. Even in the endemic Covid, urban local bodies, panchayats, community-based organizations and voluntary citizens must form a coalition that conducts situational analysis and responds with contextual prevention, control and relief measures. Health communication must be effective through community networks to avoid panic and guard against misinformation. Community-based mental health services will help reduce anxiety and prevent disease.

Timely immunization must be made available to all who need it, without coercion but through trust-building. Still, there will be some who are highly susceptible to serious illnesses during a seasonal outbreak. Civic sensibility must be encouraged so that anyone exhibiting symptoms suggestive of a respiratory illness will voluntarily dress up during a seasonal outbreak to protect others. Those infected must be isolated, with assurances of medical and social care during the period of illness.

If there is an accumulation of cases, a mask requirement must be ordered outside the house so that there is no danger from asymptomatically infected people. When we walk in the rain, we take care not to splash water on others. Likewise, in the endemic Covid, it will be our civic duty not to infect others.

This column first appeared in the print edition on May 16, 2022 under the title “Endemic Covid”. The author, a cardiologist and epidemiologist, is President of the Public Health Foundation of India (PHFI). Views are personal

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