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For the first two years of the Covid-19 pandemic, people working in the infectious diseases and global health spheres were largely focused on the new disease. In 2022, however, gears shifted.

Covid didn’t go away, but diseases like flu that had been held in abeyance by the new virus and the measures we used to slow its spread — well, they’re baaack. From late summer onward in the United States, hospitals have been packed with people sick with one respiratory illness or another.

As the third year of the Covid pandemic ends and 2023 begins, what can be spotted on the horizon? We already know about a bunch of things that are going to jostle for our attention; rest assured others we’re not anticipating will materialize as well.

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We’ll report on them when they do. But let’s talk about three issues we can see right now.

Covid in China

The country from whence the pandemic virus emerged is finally dealing with Covid the disease.

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The country’s zero-Covid policy has kept cases and deaths to extraordinarily low levels as the SARS-CoV-2 virus has sickened and killed people in other parts of the world over the past three years. But the people of China are tired of being literally locked into their homes and in late 2022 took to the streets in unprecedented demonstrations across the country. The shaken government of Xi Jinping has been loosening Covid restrictions. The move is overdue, but exiting a zero-Covid strategy requires careful planning and execution and it’s clear China hasn’t done the necessary preparatory work.

And in less than three weeks, right around the third anniversary of the original lockdown in Wuhan, China will celebrate the lunar new year, its most important holiday and one in which there are family gatherings and mass movement within the country.

This could get very ugly.

Too few of China’s oldest citizens have had Covid vaccine boosters, and some of those who have been boosted got their latest jab months and months ago. Easing measures aimed at blocking Covid transmission in an undervaccinated, vulnerable population is leading to transmission at a rate the country has not yet experienced. Its health care system — like all the others that faced unfettered Covid transmission — will struggle to meet the demand.

 

Modeling recently done by The Economist estimated that as many as 1.5 million people in China could die from Covid in the coming months. This in a country that had been led to believe it didn’t need to experience Covid. The United States has lost about 1.09 million people in the pandemic, but over a period of more than two and a half years. Granted, China’s population is more than four times that of the U.S. Still, that level of loss, if it occurs, will send shock waves throughout Chinese society.

What happens to the Chinese people is obviously the primary concern here. But what happens there will reverberate elsewhere. There are worries that the cycling of the SARS-2 virus through hundreds of millions more people may drive the virus to evolve further — in other words, generate new variants that could spread around the world. And if China is sick, the industries that rely on Chinese exports — and the consumers who buy products from those industries — should expect disruptions.

What do winters look like with Covid in the equation?

For the past two years, respiratory syncytial virus — RSV — has surged in late summer and into the autumn. RSV causes colds for most people but can be dangerous for very young children and older adults. In pre-Covid times, RSV was a winter bug.

So was the flu, which after a year of little transmission in 2020-2021, transmitted well into June this past spring. It returned earlier than usual for the 2022-2023 season — before Halloween — and has triggered high levels of illness since. It’s still early, but there are some signs that the flu season may have peaked. Covid activity is now picking up speed.

Is this the new normal? Will the addition of a new and highly transmissible respiratory virus to the mix of respiratory bugs change the pattern of when different viruses spread? Or is this just a case of viruses that didn’t circulate much for a couple of years finding enough susceptible people that they can transmit in times of the year when previously they could not have?

We’re going to have to wait to see what kind of a rhythm the respiratory pathogens settle into. “I don’t know if things are going to behave the way they used to behave or not,” Lynnette Brammer, who is the team lead for domestic influenza surveillance at the Centers for Disease Control and Prevention, told STAT recently.

The people who care for us are exhausted

Primary care providers, hospital staff, and the people who work in public health and emergency response efforts around the world are beyond drained. Running on fumes doesn’t begin to describe it. The last few years have been brutal for them.

As we noted above, Covid hasn’t gone away but all the other things that weren’t bothering us much early in the pandemic are back. Hospitals that in the Before Times knew to beef up staffing for flu season have been overwhelmed since the late summer — normally not peak respiratory illness season — by a tsunami of sick people.

In addition, this year mpox made a very successful foray out of its normal territory, West and Central Africa, and in the process ignited a global outbreak. Vaccine-derived polio was found in New York State, London, and Israel, and wild-type polio from Pakistan was found in Malawi. Measles broke out in Africa, the Middle East, Afghanistan — and Ohio. Ebola started spreading in Uganda. A global bloom of cholera outbreaks occurred, and a global shortage of cholera vaccine followed. There’s more, but you get the point.

It’s not that STAT expects a pivotal event in 2023 — a mass health worker walkout or a public health worker exodus, say. (That said, just before Christmas British nurses and paramedics announced they will continue rotating strikes in January over pay and working conditions.) It’s just that we think everyone — policymakers and people who rely on health care — should give some thought to the fact that nurses and doctors and EMTs and hospital staff and laboratory technicians and public health officials at every level are simply tapped out. Some of them have quit or are quitting. And there’s evidence doctors-in-training are choosing not to go into these specialties, deterred by the experience of the pandemic.

“The incidence of PTSD and social anxiety syndromes is very high in health workers and many health workers are leaving the field. Health workers have seen their incomes fall behind; as they’ve worked hard at the front line and the economic crisis hit, they were left behind,’’ Mike Ryan, the World Health Organization’s health emergencies director, said last week at the agency’s final news conference for 2022. “Are we ready to take the hit of another wave of a new variant that might emerge? I don’t think so.’’

That’s the thing. We’re not safe if they’re not valued. We’re not safe if they aren’t there when we need them. This is a situation that we should be paying more attention to, working to resolve. For them. For all of us.

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