The end of the public health emergency...on paper.

Yesterday, May 11, 2023, was the final day of the Covid-19 public health emergency (PHE) in the United States. The WHO also recently declared the emergency phase of the pandemic to be over.

To understand what that means in terms of data tracking and other areas of interest, check out Dr. Katelyn Jetelina’s newsletter from yesterday. In addition, there are some other important changes that now go into effect too (including the end of the 3-day rule for nursing home placement after a person is hospitalized, and changes in telehealth, although those details are still being worked out and many things are not changing, thankfully).

This does not mean the Covid-19 threat is over, of course. However, the end of the PHE reflects that we don’t, for now, anticipate Covid-19 to pose an imminent threat that could suddenly overwhelm hospital infrastructure, nor are we seeing historic levels of mortality as we did so frequently from 2020 to 2022. It means that our challenges, while ample, are more static than we’ve perhaps grown accustomed to during the pandemic.

We know we have to get better vaccines and therapeutics.

We know we have to figure out Long Covid.

We know we have to improve air quality.

We know we have to stand up a better pandemic prevention and response plan for the future.

But we aren’t living from crisis to crisis, at least not just now. In the past, I attended off-the-record White House briefings for a group of outside medical experts where the questions being asked and answered (or deflected) would literally have never even occurred to anyone a week or month prior. Things were moving so fast, it’s almost hard to comprehend it now. By contrast, the White House Covid-19 Response Team held an on-the-record meeting this week for a few experts that I was able to attend. The questions asked by my colleagues and the information provided by coordinator Dr. Ashish Jha and his team were useful—but there was a different feeling than in the past. It was—and I am reticent to say this—almost boring. Not because the disease is somehow not a problem anymore. But because everyone present, I believe, has a realistic handle on the scope of the problem. We feel that things are no longer in constant flux. (Although I worry what will happen if a new variant pops up, because with the Covid-19 Response Team eventually winding down, the chain of command is not yet clear to me). In any case, for now, we need to zero in on protecting high-risk individuals, especially those who have severe immunocompromised states. We need to do the things mentioned above, and more, to protect those members of our communities.

The end of the PHE was also a time for me to look at where things stand. If you subscribe or have access to the Boston Globe, you can read my thoughts on where we are in terms of all-cause excess mortality (that is, the increase in deaths from any cause, not just Covid). The Globe published graphics created by Benjy Renton and I, based on our ongoing collaboration with colleagues at Yale’s Center for Outcomes Research and Evaluation. Below is the front page of yesterday’s Globe (see the bottom panel). Mainly I’m sharing the screenshot as an opportunity to thank my colleagues. While Benjy and I work constantly on this all, the insights and analyses would not be possible without my colleagues at Yale, including Dr. Chengan Du, Dr. Shu-Xia Li, Dr. Zhenqiu Lin, and Dr. Harlan Krumholz as well as a brilliant student here at Harvard named Alexander Chen. Without them, we could not have constructed the robust modules that we rely on to measure excess mortality.

The big messages from our work covered in the Globe are as follows:

1. By now, I had hoped we would see more “deficit mortality.” As I told the Globe, deficit mortality “occurs when surges of illness, like last winter’s COVID uptick, cause people to die sooner than expected, leading to a compensating period of fewer-than-usual deaths.” We’ve seen deficit mortality in the Northeast after major surges. But we’ve not seen as much as I might have anticipated. There are two possible reasons for this. First, Covid-19 is still causing adequate morbidity and mortality to overcome the deficit. Second, it might be that the life expectancy of the average person who died of Covid-19 is longer than we thought. If so, lower levels of deficit mortality for longer would be the expected finding. Maybe that’s what we have happening now, but it’s difficult to know for sure.

2. Not all states fared the same. Policies matter. Massachusetts and other states with higher vaccination rates and longer and more assiduous adherence to pandemic mitigation measures did comparatively well (especially after the first wave, which hit the Northeast before we realized what we were up against).

3. Older people have had the most excess mortality, but the largest increase relative to their normal mortality rates actually occurred in younger adults. (A lot of this was Covid, though some of it was increases in drug deaths and other non-natural causes). When vaccinations had just been given in early 2021, older populations actually had less excess mortality compared to younger groups.

4. And under-recognized disparity exists across gender lines: Men got crushed during the pandemic, compared to women. This is not surprising given that we men are less likely to have primary care doctors to begin with and our vaccination rates were lower.

5. Race and ethnicity disparities were magnified during the pandemic, but have somewhat normalized over time.

Again, here’s that Globe link.

I’ve always said that we could not declare the Covid-19 emergency over until excess mortality had ceased to occur. While in Massachusetts, we have not had much excess mortality lately, we have also had periods in the springs of 2021 and 2022 where we had a short-term break from excess mortality before it returned when a new wave of Covid-19 appeared. Other states’ data lags far behind ours here. So we won’t know for a few more months whether things are sustainably better, or whether we’re just having an apparently annual respite from historically high mortality rates. But public health emergency or not, we’ll be watching.