How many COVID deaths are ‘acceptable’? Answer is key to moving to a post-pandemic world

How many people are we willing to allow to die from COVID-19 each year in the post-pandemic world that is spawning the United States?

Yes, let’s go there.

Should your vaccinated grandmother’s death from COVID-19 be considered an acceptable loss? Should seasonal spikes in casualties among the unvaccinated cause more than a shrug? Should life go on undisturbed if a new strain of coronavirus starts killing as many youths as childhood cancers?

You will not see politicians calling press conferences to acknowledge that some deaths are inevitable and some lives are not worth what it would cost to save them.

The path from the pandemic

This is the second in an occasional series of stories about the transition out of the COVID-19 pandemic and how life in the US will be different after it.

But acceptable death counts are the common currency of public health professionals. And they’re a central factor in any discussion of when — and after what effort — it’s time to move on.

Declaring the end of the pandemic is about deciding how much disease, death and disorders “will be accepted and accepted as part of normal life,” said Erica Charters, a historian with the University of Oxford’s How Epidemics End project.

Setting a cap on the number of COVID-19 deaths the country will tolerate each year is the basis for making decisions about when it’s okay to lift pandemic safety rules and when it might be necessary to reintroduce them .

A growing number of Americans have concluded that now is the time to emerge from the pandemic. As of mid-March, 64% of adults who took part in an Axios Ipsos poll said they support lifting all federal, state and local COVID-19 restrictions — up from 44% in early February.

This feeling is not necessarily ruthless. This week’s average daily death rate is a little over a third of what it was a month ago and is down more than 75% since Omicron deaths peaked in early February. Essentially all of the coronavirus cases circulating here are versions of the Omicron variant, which causes a milder disease than the strains that preceded it. Also, the Centers for Disease Control and Prevention estimates at least 95% of Americans are immune to the virus because of vaccination, a previous infection, or both.

The decision to drop the last remaining safety rules requires a willingness to accept the current mortality rate. For the past week, COVID-19 has claimed an average of 626 lives each day in the United States. That’s fewer than the roughly 1,900 who die from heart disease each day on average and the 1,650 who die from cancer, but far more than the 147 lost to flu and pneumonia combined.

A worker rolls a stretcher with a deceased patient

Juan Lopez retrieves the body of a COVID-19 victim from a hospital in McAllen, Texas in 2020.

(Carolyn Cole/Los Angeles Times)

For public health experts, the calculus is clearer. Mortality and morbidity – the words her profession uses for death and disease – are on one side of the equation, and aids like seat belts, blood pressure medication, smoking cessation programs and vaccines are on the other side.

These tools vary in cost, urgency, and political acceptance. Despite public health campaigns and government regulations, Americans continue to drive drunk and do not wear seat belts. Tobacco kills more than 480,000 people in the United States each year, yet 34.2 million adults continue to smoke. Diabetes claims more than 100,000 lives each year, but efforts to eliminate the sale and consumption of sugary drinks – a key contributor – have met fierce opposition.

Eventually, any effort to limit preventable deaths will hit the hard wall of funding constraints, drug availability, and people’s willingness to take steps to protect themselves and others. Here the “acceptable” number of deaths comes into focus.

“We really need a national consensus on what the acceptable number of deaths is,” said Michael Osterholm, who directs the University of Minnesota’s Center for Infectious Disease Research and Policy.

No matter what steps the country takes, there is no way that number will be zero.

Unlike vaccines for diseases like measles, polio and diphtheria, the vaccines currently available for COVID-19 do not confer lifelong immunity. No past infection either, even a really bad one. And given that the coronavirus has become established in animals like ferrets and white-tailed deer, the threat of a resurgence will always be with us, Osterholm and two colleagues explained in a recent issue of the Journal of the American Medical Assn.

The CDC and other federal agencies are still deciding the criteria they will use to determine when the pandemic is over. There is still time – Dr. Rochelle Walensky, the agency’s director, said late last month that we’re not there yet.

So far, the CDC’s advice on easing COVID-19 restrictions has focused on local rather than national conditions. The key indicator is the capacity of a district’s hospitals to handle a new influx of patients.

Workers prepare to transport the body of a COVID victim

Hospital workers prepare to move the body of a COVID-19 victim to a morgue at Providence Holy Cross Medical Center in Mission Hills.

(Jae C Hong / Associated Press)

A panel of 23 prominent public health experts from across the country made further progress. In their “Roadmap for Living with COVID,” specialists in immunology, virology, health economics, and public health list a litany of conditions that must be met to safely lead the United States into a post-pandemic era.

In this “next normal,” the “roadmap” explains, the coronavirus is staying very much with us — an endemic virus that continues to circulate, sicken and kill, but at levels well below those of the last two years.

The experts suggest the country is treating COVID-19 as one among a group of respiratory viruses — including influenza, respiratory syncytial virus and other pathogens — that wreak a predictable level of devastation year after year. Hospitals are primed to deal with these annual bouts of illness, and Americans have accepted as normal the amount of illness and death they cause.

A clue to our complacency: Even in a bad flu season, nearly half of American adults don’t get a flu shot.

Hospitals can typically handle the influx of patients with respiratory illnesses without compromising care for people with cancer, heart disease, or other life-threatening conditions. Nor are they postponing or canceling the routine care that keeps patients with a range of diseases from getting sicker.

With this in mind, the authors of the “roadmap” directly summed up a proposed number of acceptable annual deaths from COVID-19 and other respiratory diseases: 60,225.

That number equates to 1 death for every 2 million Americans, or 165 per day nationwide. Add them all up and you have the approximate equivalent of an extremely severe flu season.

Family members load a coffin decorated with roses into a hearse

Family members load the coffin of Charles Jackson Jr., who died from COVID-19, into a hearse at the Angelus Funeral Home in Los Angeles in April 2020.

(Jason Armond/Los Angeles Times)

“There was no magic at all,” said Osterholm, who worked on the “roadmap.” “Our goal was to say that at those numbers and below, you’re putting a lot less of a strain on the healthcare system.”

This is important because “deaths increase when hospitals cannot provide optimal care,” the authors write. An overwhelming influx of respiratory disease patients can result in deaths from all kinds of diseases.

It also matters who dies, said Jeffrey Kahn, director of the Berman Institute of Bioethics at Johns Hopkins University. When deaths are concentrated in a stigmatized minority, as was the case with the HIV/AIDS epidemic, the world reacted more slowly. On the other hand, when children are the main victims, as with polio in the 1950s, the nation has been united in its determination to stop the spread.

“It is very important which segment of the population is most affected by this or other infectious diseases,” said Kahn.

When opioid overdose deaths took a heavy toll on whites in the 1990s, the public health response was just as quicker than for other types of drug deaths that hit black Americans hard.

But that could change, Kahn said. The pandemic’s disproportionate toll on communities of color has drawn attention to long-standing racial and ethnic health inequalities and prompted concerted campaigns to address them.

In addition to counting deaths, an ideal “dashboard” of the nation’s post-pandemic well-being would take into account how much of the population has immunity to circulating respiratory diseases and how many viruses are detected in wastewater. If those indicators get too high, they would trigger “circuit breakers,” like a renewed mask requirement and restrictions on social gatherings, the authors wrote.

Those circuit breakers reflect a core principle of ethical decision-making in democracies, said Kahn, who was not involved with the “roadmap.” Once people have the information and tools they need to protect themselves from harm, they should be free to go about their business unhindered by public health restrictions.

However, it is reasonable to limit these freedoms when exercising them hurts too many people, including vaccinated grandmothers and at least a few children.

“That’s the push-pull of public health,” Kahn said. How many COVID deaths are ‘acceptable’? Answer is key to moving to a post-pandemic world

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