Spain, 2026: SARS-CoV-2 has become endemic and is just another seasonal respiratory virus. Still, 15,000 people died in 2025 from it, according to data released at the end of the coronavirus season. More than 50,000 were hospitalized and thousands of them ended up in the ICU. After so much suffering and the most ambitious vaccination campaign of the century, would we settle for a similar ending for COVID-19?
The above data are real, but behind them is not the coronavirus, but another preventable respiratory infection and for which we also have a vaccine. It’s all about the numbers calculated by the Carlos III Health Institute for the 2017-2018 flu season, one of the most complicated in recent times. Deaths are estimated and higher than official records, since real numbers are difficult to obtain for this disease. Similarly, Every year around 10,000 people die from pneumonia in Spain.
If SARS-CoV-2 does not disappear or become a mild cold like the rest of endemic human coronaviruses, it will join the list of communicable diseases that cause deaths every year. But, what figures will the post-pandemic leave us and which ones would allow us to return to the long-awaited normality? The experts in preventive medicine and epidemiology consulted agree that the question at the top of the text does not have a clear answer. Ideally, preventable pathologies are, as the name suggests, prevented. The reality, however, is more complex.
The epidemiologist Pedro Gullón thinks that what we consider “bearable” will depend on the evolution of the epidemic and ourselves. “We like to think that we make these complex decisions academically, weighing benefits and risks, but the reality is not like that: in the end we get used to what happens, and that is a problem if we become tolerant at high levels [de hospitalizaciones y muertes]”.
The doctor specializing in preventive medicine and public health Mario Fontán does believe that figures as high as those cited for influenza and pneumonia would be “unaffordable” after so much “suffering” now that we have such effective and demanded vaccines. “The mortality [del coronavirus] it should be much less, “he says.
The same is the opinion of the deputy director of epidemiology of the Ministry of Health of the Generalitat Valenciana, Herme Vanaclocha. “If the vaccine lasts a long time, it will be very different from the flu, because in Spain everyone is going to be vaccinated and we should have very few deaths,” he says.
Fundació Fisabio Salvador Peiró researcher explains that it is difficult to achieve balance in a context of always limited resources in which it is sometimes impossible to maximize collective and individual well-being at the same time. “In practice, we will have to choose and those elections will not be visible or formal, but with COVID-19 I think it will be easier,” he explains.
Peiró hopes that in a few months COVID-19 patients can be treated with the usual resources of the system, as is already done for influenza and respiratory syncytial virus. “When the death from COVID-19 is something extraordinary and the weekly or monthly figures can be counted on one hand, it will begin to be, from there, acceptable,” adds Gullón.
Fontán considers that the pandemic has changed the analysis framework “for many things, including what death figures are acceptable.” That is why he believes that it is difficult to compare with other historical moments and diseases, since there is a cultural and social component that is not constant. “The hospital saturation of the flu we have seen every year as something normal and the pandemic has changed our vision of many problems that already existed, such as the impact of inequalities on health, but that did not generate that social debate.”
In any case, the experts consulted agree that the pandemic in Spain is in a “downward spiral” in which there will continue to be smaller and smaller waves until reaching a point similar to that predicted by Gullón. But what if deaths aren’t the only thing that matters?
The danger of hospitalizations
“If we have managed to ensure that communicable diseases do not pose a threat to the normal functioning of society, we cannot remain in the deceased”, considers Adrián Aginagalde, director of the Public Health Observatory of Cantabria. In his opinion, we must look at other indicators before deaths: “How many hospitalizations, ICU admissions and demand for Primary Care are we willing to endure? For me that is the question.”
Until now, COVID-19 has also been “unaffordable” in that regard. Compared to 50,000 annual flu hospitalizations, the coronavirus has left 400,000, eight times more. While the first translates into some 3,000 admissions to the ICU, the second has caused more than 30,000. “Unlike other acute respiratory infections, the proportion of patients who end up in the ICU is higher,” warns Aginagalde.
The number of hospitalizations was already a concern in other previous pandemic flu. Also what set off some of the initial alarms with the SARS-CoV-2, when it was discovered that the income percentages were incompatible with any health system. The importance of this factor goes beyond the control of the epidemic: “Years of life adjusted by years of quality of life matter. An ICU has consequences just for stepping on it,” explains Aginagalde. “We cannot afford these sequelae in young people every year in amounts much higher than the flu.”
“Would we be able to endure a Christmas with something that was twice the flu in terms of ICU admissions? How many beds are we willing to add?” Asks Aginagalde. Above all, he highlights the importance of ICUs, necessary for the rest of the system to function: “People have heart attacks and surgical interventions and we cannot make them disappear. With the flu, hospitalization reaches its limits, but ICUs do not usually be the big problem. ”
Vanaclocha has no doubts that the health system will be saturated “at specific times” due to the coronavirus. “It’s like the queues on the highways after the holidays: we cannot have ten-lane roads for the bridge. We should have more beds, but we cannot oversize for the season and it is logical that there will be an increase in autumn and winter as already happens with the flu”. Financial and human resources are limited.
Let’s rephrase the initial question: how many hospitalizations would be acceptable after the pandemic? “Similar to those of other acute respiratory diseases in each age group,” says Aginagalde. In other words, numbers similar to those caused by bronchiolitis in children and the flu in adults. “It is what we should aspire to if a brutal reduction in transmission with vaccines is not possible, which I hope it is.” This is a point that, according to him, is still “a long way off”.
“We do not want two flu, because it is something that we have to improve for a long time. It is a drama and saturates the hospitals every year,” says Gullón. Although it is not clear that both viruses coexist, the union of two seasonal respiratory diseases could be complicated from a hospital point of view.
Insensitized or scared?
People may continue to die from COVID-19 in the future. Against this background there are two possibilities: that the population is desensitized to these deaths, incomparable to the hardest moments of 2020, or that it overreacts due to those traumatic memories.
“I think both phenomena will occur at the same time,” says Gullón, who assures that we already “trivialize” daily deaths as acceptable. “Now we are a bit anesthetized by the figures,” Fontan admits. However, Gullón thinks that, if after several weeks without deaths there is an outbreak with deaths, “some will again call for drastic measures.”
“We will normalize COVID-19 and it is possible that there are sectors in which the acceptability is greater than in others,” says Aginagalde. It regrets that the social perception of the coronavirus is caught between two camps: “Pandemics are mediated and polarized, decision-makers have to move between these extremes and the health system follow the rules of the game.” He adds that, even if one part of society calls for interventions and another opposes it, in the end, consensus will have to be reached.
Vanaclocha foresees that, after the pandemic, COVID-19 will be “one more respiratory disease”, but with low mortality outside of risk groups. It does fear that, in the hypothetical case that new doses are necessary in the future, the population will forget what they have experienced and will not be vaccinated again. He gives as an example the low coverage that the flu tends to have each year.
“Not everything is preventable and totally preventing some diseases would cause others to arise, so we have to find a balance and see where we want to put the focus,” concludes Gullón. The epidemiologist does hope that the pandemic will make us reflect and put more effort into the thousands of preventable deaths that go unnoticed each year, from pneumonia to contamination.
Peiró is confident that we will draw some lesson from the pandemic: “I hope that flu patients are not in the waiting rooms infecting the rest, that people with respiratory symptoms wear masks, as well as the health workers who treat them.” Also that “respiratory circuits” are installed to prevent these diseases from reaching the most vulnerable populations in health centers and hospitals, “as happened in the first wave.” Not all deaths can be avoided, but we can learn from them.