What will a Covid-19-Endemic World Look Like?

Everybody is hoping that towards the end of 2021 COVID-19 vaccines will have completed roll-out and we can hit the reset button turning back to life in November 2019. We’ve been through the initial panic then the realisation that the pandemic is a 1 to 2 year event. But wait, there’s more. Virologists anticipate that SARS-CoV-2 will become endemic. This means it will always be present in our communities. This is not unlike the many other coronaviruses that are endemic causing milder conditions such as the common cold.

The vaccines, to date, do not prevent transmission but do reduce the severity of disease if required. It is plausible that herd immunity will not be reached despite widespread natural infection and extensive vaccination programs. People will still become infected and the vulnerable populations such as the elderly, those with chronic disease and those with compromised immune systems will still be at greater risk of severe illness and death. So what should this mean for how we live in 2022 and beyond?

In considering this question we should consider viral influenza. Influenza as an illness poses a significant burden on the healthcare system due to the moderate symptom burden and some mortality in similar vulnerable populations as SARS-COV-2. SARS-COV-2 may have a higher case fatality rate although this may have reduced with improved understanding as to how to manage these patients. The greatest problem COVID-19 has created in regions with high rates of infection has been the burden placed on the local healthcare systems. Once intensive care beds are fully occupied by COVID-19 patients and less acute beds are also occupied the usual emergencies are competing for care and elective surgery and medicine is cancelled. Diversion of resources means other serious conditions aren’t treated.

So the endgame in a world for endemic SARS-COV-2 is to avoid shut down of the healthcare system. The caveat to this aim is that we must also find a way to avoid complete shutdown of the healthcare system without the trade off of completely locking down everything else – somehow daily life must go on. How is this to be achieved?

The first issue will be to change the mindset from crisis mode to a new business as usual mode. The current state of play in Australia is a very strong focus on public health strategies such as widespread testing, contact tracing, isolation of cases, quarantining of travelers and closed or restricted borders. The more extreme measures such as hotel quarantine won’t be sustainable if there is any intent to re-open for international tourism. There may need to be test-to-travel and proof of vaccination requirements if mass global movement is to resume.

Vaccinate as many people as possible and use every behavioral economic trick in the book to get people who don’t want to get the vaccine to do so. Altruism for the rest of society seems to be the answer. We also have to remember it is early days and there is uncertainty about the durability of the response to the vaccine but also whether there will be sufficient mutational variation to result in a COVID-20, not unlike the need to regularly update the influenza vaccine. Vaccination may need to be annual – we probably won’t know until next year

General measures to improve hygiene need to stay in place even if people are reassured that things are under control. This might mean that masking on public transport becomes routine: it was very common in Asian countries to use masks on a routine basis after previous coronavirus outbreaks. Perspex shields in customer service settings will continue. QR code check in, temperature checking and even facial recognition in less privacy concerned societies may become the routine as a way of facilitating contact tracing for positive cases. Risk minimization should prevail. Two hundred years after Semmelweis it might be time to take handwashing seriously. And other measures like proper use of PPE, not to mention the ability to make it locally.

There are going to be seismic societal changes. There are many displaced, unemployed workers around the globe. Sadly, the pandemic has taught us that many of these workers were not essential. Many work settings are getting by with fewer workers. Automation is coming into play: people still shop but they do it online and in turn the warehouses, despite some uptick in human employment, will increasingly rely on robot-based contributions to the supply chain. Drone or autonomous vehicles will start to appear on the roads. Initially these may simply serve as delivery services, replacing the e-bike powered food delivery services that currently navigate the roads with a death wish. Eventually autonomous vehicles will be driverless taxis providing a form of iso-public transport.

The lack of jobs for low-skilled and even some high-skilled people will mean a re-thinking of the welfare state. There may be a further decline in the middle class and an overall increase in inequality. Universal basic income may be not be imminent but more experiments with such societal support will occur. Regardless of the form it takes there is likely a need for increasing government supported social safety nets such as healthcare. This will mean governments will need to review and reform taxation. Note as well that society will be increasingly cash-less.

Work itself will change. Working from home will be increasingly accepted as an option for those whose jobs essentially involve screen time . Widespread broadband, 5G then 6G, team collaboration software and videoconferencing software and hardware are starting to come together to provide a more seamless experience. Working from home can provide a better work-life balance paradigm – providing of course the kids also don’t have to be at home to school (although more blended learning experiences may be offered). Productivity rather than hours may become a better metric for the output of labour especially as some companies move to modified working weeks like the 4 day week.

Live entertainment will also change. Film studios are moving to direct release to streaming and going to the cinema in person will mostly be for ‘event’ movies that benefit from the larger screen format. The trend to boutique cinema experiences will continue. For the theatre and live music, in particular for shows that are not long-runs or stadium events, there will be the public expectation that live-streaming will be available and that there will be the ability to replay at home for time-limited periods. Already such subscription services are rolling out. At at the classical concerts there will be less coughing between movements.

Other experiences like dining out may also change. Design of dining spaces to facilitate physical distancing will become more common and in places with favorable climates al fresco dining will become more common. This in turn will impact street design with broader sidewalks or other more pedestrian friendly designs.

Healthcare will be catching-up to other digitized service industries like banking. Virtual consultations and care via telehealth, remote home monitoring and many other innovations that have been brewing for decades have been given the challenge needed to implement them more quickly and in a more integrated way. The other change in healthcare will be more widespread use of rapid testing kits to diagnose many different types of infection. These will be important for rapid triaging to the right treatment and infection control measures. Rapid testing also has the potential to reduce anti-microbial resistance.

The pandemic and other natural disasters have been attributed in part to activities that result in climate change and it has also shown many people how the air can be cleaner when the world stops burning as much fossil fuel. As such the pandemic has become a catalyst for more rapid adoption of cleaner technologies. Housing has become more than ever a refuge for the world. New housing should be designed both mindful of the environment but also of the different needs of a society that goes into periods of lockdown. Having been forced to stay indoors many will have greater appreciation of the outdoors. This should prompt increased efforts to preserve and protect natural environments and also to improve urban design. Urban design will also increasingly accommodate pedestrians, cyclists, scooterists and other non-car based commuters.

Perhaps most importantly the COVID-19 endemic world needs to be ready to recognize and react quickly to the next pandemic. This is not a once in 100 year event. Pandemics or potential pandemics are occurring more frequently: think Ebola, SARS, MERS, Zika, etc. The ability for global co-operation, public/private partnerships and governments to move at pace and scale needs to be implanted in our memories and embedded into our systems. Vaccines were produced in record times. The next pandemic is most likely going to be a coronavirus sufficiently mutated and different to COVID-19 to garner it’s own name. If this is the case then vaccine development, building off existing platforms, should be even quicker, like the current status with the annual influenza vaccine.

We cannot keep living waiting for the 11 am press conference telling us how many cases there have been and what the next adjustment to restrictions will be. Now the vaccines are arriving governments need to turn to how they will manage endemic COVID-19 otherwise the light at the end of the tunnel will be the next oncoming disaster.


  1. Shelley Holderness

    Brilliantly executed, and a thought-provoking article, Winston.
    Your comment “less coughing between movements” tickled my sense of humour. I pictured the seriously surly audiences swiftly swivelling their heads to frown disapprovingly, should One let loose an involuntary splutter!
    I, too, had used New Years Eve to reflect upon the effects this pandemic had made to our society. In particular the way that most folk have re-evaluated the relationships of those they love. Time together (for those who don’t live under the same roof) is more precious, and we now go out of our way to remain connected, seizing every opportunity to be together, rather than taking things for granted.
    I’ve observed many kindnesses that I hadn’t seen pre-COVID; shop assistants shuffling my elderly father to the warehouse out the back to secretively present him with a prized pack of dunny paper; customers sacrificing their own groceries when they observed my elderly mother staring blankly at an empty shelf; and, in general, more consideration and greater patience when queuing up for things. It’s refreshing to observe these long-lost kindnesses returning to our everyday lives.
    I also pondered about how this new world might’ve impacted my dear brother, if he were still alive. The job he loved so much in Tourism might look completely different. I envisage, just like the streaming of music events and movies, there’d be an explosion into the virtual travel experience. David and I would often have (liquid-fuelled) discussions about how to get people to travel more. And, oh how I would love to talk to him about the opportunity to ‘meet’ someone (a real person, in real time) in a German bar, or to sit down (via Zoom or similar) with an Italian local to share a meal and converse in broken English! We would debate the merits of whether this would satisfy our hunger for adventure.
    Another thought I had about my brother, was how terrified he might’ve been, living with a compromised immune system. It was almost too much to bare, thinking about the risks he would’ve been exposed to, just going about his everyday life.
    Working in the Disability sector, I’ve seen firsthand the impact that lockdowns and restrictions on community socialisation has had on those who often struggle to understand the reasons behind them, and it’s heartbreaking to see their faces when they’re denied the activities they yearn for, like musical get togethers, and day trips. In fact, there’s been a remarkable increase in demand for Positive Behaviour Support, to address these struggles.
    My hope is that we will become more resourceful and consciously make an effort to comfort those who are more vulnerable.
    Thanks for sharing your thoughts, and here’s wishing you and your beautiful family all the very best for the year ahead!
    Shelley Holderness

    • wliauw

      For your interest Shelley I subscribed to the Australian String Quartet livestreams from Ukaria in South Australia last year – an example of making those connections

  2. Craig underhill

    Thanks Winston
    Very thought provoking
    What do you think will be some of the specific impacts in cancer space?

  3. Pingback: Oncology After the Pandemic | winstonliauw

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