California’s New ‘Endemic’ COVID Plan: How Gov. Newsom Proposes Learning to Live With the Disease

Almost two years after Gov. Gavin Newsom imposed a “state of emergency” to deal with the growing threat of the COVID-19 pandemic, followed by a statewide “stay at home” order, the governor unveiled his new plan to cope with an ongoing pandemic that, when he made the announcement in mid-February of 2022, had killed more than 48,000 Californians.

The new strategy? Live with it.

Of course, Newsom’s plan went well beyond that oversimplification. But the key element of the new plan—christened SMARTER—was a change in direction from attempting to stop or at least minimize the spread of the virus to acceptance of the reality that COVID-19 is now a permanent fact of everyday life in California, as well as the United States and the world. With that acceptance, Newsom announced an ongoing program to manage the virus.

But was Newsom’s new plan a “politically motivated decision to make California the poster child of the ‘Pandemic is over if you want it’ movement,” as author and cultural critic Jeff Yang charged? Or is SMARTER what it claims to be? That is, a new approach designed to keep California “prepared to swiftly and effectively respond to emerging COVID-19 variants and changing conditions.”

The plan was widely reported as a shift in strategy from treating COVID-19 as a pandemic to dealing with the disease as “endemic.” The state’s official documents detailing the new plan never use the word “endemic,” however. Instead, the plan uses terms such as “preparation,” “flexibility,” and “adaptation.” But the plans make clear that the state is not expecting COVID to go away, and that it will effectively become endemic if it hasn’t already.

How is Newsom’s new approach different from how the state dealt with the COVID-19 for the first two years? And is COVID really “endemic?”

What is an ‘Endemic’ Disease?

On March 11 of 2020, the World Health Organization officially labeled the global COVID-19 outbreak a pandemic. The known amount of “novel coronavirus” outside of China, the country of its origin, had multiplied by a factor of 13 over the previous two weeks. The number of countries where the virus was known to be causing infections had tripled in that same time period.

That’s what made the disease a pandemic. It was increasing rapidly throughout the world, which is different from “epidemic” disease, which spreads rapidly throughout a limited locale or population.

What then is an “endemic” disease?

First of all, what an endemic disease is not is a disease that has been rendered harmless. “Endemic does not mean not harmful. It just means relatively stable and predictable,” Johns Hopkins University infectious disease professor Stuart Ray told the Washington Post. The “biggest misconception” about endemic diseases, Ray said, is that they are necessarily mild.

The only thing that distinguishes an endemic disease from a pandemic or epidemic, as far as epidemiologists are concerned, is stability of transmission. When the number of people newly contracting a disease is, generally speaking, neither on the rise nor on the decline, a disease can be called “endemic.”

There are similar, more colloquial uses of the word. The Centers for Disease Control says that “the amount of a particular disease that is usually present in a community” is the “endemic” level. It may be a high level, or a low level. As long as the disease has a “constant presence” in a community, that means it’s endemic. The word itself derives from the Greek word endēmos, which translates simply as “in the population.”

Do Diseases Get ‘Mild’ Once They’re Endemic?

As explained by the scientific journal Nature, “a disease can be endemic and both widespread and deadly.” Malaria, a disease which killed 600,000 people worldwide in 2020, is considered endemic in areas containing about half of the global human population.

Tuberculosis, despite a vaccine that has proven 70 to 80 percent effective, remains endemic in numerous countries—led by India, China, Indonesia and the Philippines. The bacterial disease killed 1.95 million in 2020 according to the WHO, about the same number as COVID.

“The word ‘endemic’ has become one of the most misused of the pandemic,” wrote Oxford University evolutionary virologist Aris Katzourakis in Nature. “And many of the errant assumptions made encourage a misplaced complacency. It doesn’t mean that COVID-19 will come to a natural end.”

Other diseases now considered endemic in certain parts of the world include HIV, hepatitis B, and syphilis. Of course, not all endemic diseases are quite that devastating. The common cold is an endemic disease.

So an endemic disease can still be extremely dangerous, even deadly.

A study in the journal Science published in January 2021 predicted that the COVID virus would eventually not only become endemic, but would also become merely a mild infection, just another common cold virus. (At least four different coronaviruses are currently known to cause the common cold.)

In his Nature article, Katzourakis also threw cold water on the “widespread, rosy misconception” that viral diseases such as COVID inevitably evolve to become less severe.

“This is not the case: there is no predestined evolutionary outcome for a virus to become more benign, especially ones, such as SARS-CoV-2, in which most transmission happens before the virus causes severe disease,” he wrote.

Has COVID Reached the ‘Endemic’ Stage? No.

Writing in Atlantic Monthly in December, science journalist Sarah Zhang explained that COVID-19 was not yet an endemic disease for one simple reason—not enough people have immunity to the coronavirus. A stable level of transmission occurs only when a population’s immunity level is high enough, and as of April 2022, the U.S. isn’t there yet.

Where does immunity come from? There are two sources. Vaccination, and catching the virus itself.

Catching COVID produces “natural immunity.” But a 2021 study by the CDC found that people who had contracted COVID were still 5.49 times more likely to test positive for the virus again than those who were fully vaccinated but were never infected, though previous infection did provide some protection.

Relying on natural immunity as protection against COVID is also risky compared to vaccination because, according to a separate CDC study, one-third of people who get COVID produce no natural immunity to the disease at all. 

Of course, catching COVID without getting vaccinated is also a significant risk because you might die. The CDC in a 2022 study found that unvaccinated persons who caught COVID were 53.2 times more likely to die from the illness than fully vaccinated people who caught the virus.

“Full” vaccination is highly effective at preventing severe illness or death from a COVID infection, and also significantly reduces the chances of getting infected at all, even against the more contagious Omicron variant COVID viruses, as a February 2022 study published in Nature Medicine found.

Here’s the problem. In the United States, only about two-thirds of the population (66 percent) has been fully vaccinated. That may seem like a lot, but in a country of almost 330 million people, that leaves in the neighborhood of 100 million people unvaccinated, or only partially vaccinated. About 43 percent of the U.S. population has experienced a COVID infection, according to a CDC estimate in March 2022.

“We might approximate the start of endemic COVID as the point where nearly everyone has been vaccinated or infected,” Zhang wrote in her Atlantic story. To get to that point, according to one infectious disease expert quoted in her article, “there’s still a long way to go.”

What Is Newsom’s New COVID Plan?

In California, COVID appears somewhat closer to becoming an endemic disease. As of mid-April 2022, 71.1 percent of the state’s approximately 39 million residents were fully vaccinated, with 9.13 million reported infections, or slightly less than one of every four Californians getting the disease at some point. But the state would appear to still have some distance to travel before reaching endemicity.

According to the state’s SMARTER plan, “it is clear the virus will remain with us for some time, if not forever. It is less clear how often and how much it will continue to impact our health and well-being.” 

The plan says that the “next phase with COVID-19” may “include future surges and new variants.” In other words, Newsom and the state’s public health officials fully understand that this isn’t over. In fact, the SMARTER plan makes clear that the State of Emergency declared by Newsom on March 4, 2020, remains in effect.

SMARTER is an acronym for “Shots, Masks, Awareness, Readiness, Testing, Education, Rx,” with the “Rx” referring to therapeutic treatments that were not available during most stages of the pandemic, but have since been shown to significantly reduce the severity of COVID illness. Among those are two antiviral pills—Paxlovid, made by the pharmaceutical giant Pfizer, and Merck’s molnupiravir—which have been approved by the Food and Drug Administration for emergency use, as well as several other forms of treatment.

“Shots,” of course, refers to vaccines. The plan says that the state will “continue to educate” residents about the benefits of vaccination against COVID, including the need for booster shots for those who have already received the initial vaccine. Health officials, the plan says, will also prepare for FDA approval of vaccination for children five years old and younger, to guarantee that pediatric physicians are ready to administer the shots.

As for masks, the state lifted its indoor mask mandate for vaccinated people on March 1, and for schools 10 days after that. But that doesn’t mean the era of masking is over. While the SMARTER plan makes no mention of reimposing mandated mask use, it does say that the state will “emphasize and encourage mask use messaging” for such settings as hospitals, public transportation, and crowded indoor areas—as well as for unvaccinated individuals.

The state plans to keep a “stockpile” of 75 million masks as well as 30 million over-the-counter COVID test kits. The plan also calls for a stockpile, of sorts, of healthcare workers. Using a new system of registration and employment contracts, the state says it will be able to hire 3,000 new healthcare workers over a two- or three-week period, if the need arises.

“We aren’t out of the woods,” Health and Human Services Secretary Dr. Mark Ghaly said at the February announcement of the SMARTER plan. “We’re just more familiar with the woods and don’t need to live fully afraid of what’s behind the next tree.”