After more than three very long years, it’s finally happening: The Covid-19 pandemic is ending, at least in the formal sense, both in this country and abroad. This moment is not being marked with parades or big parties but rather with the flourishes of two administrative pens. On Friday, the World Health Organization announced that Covid-19 no longer constitutes a Public Health Emergency of International Concern, and this Thursday, the United States is set to end its own public health emergency declaration.
So, what does that mean? Throughout the pandemic, I have written several essays about the United States as if it were my own patient. I think of the end of the public health emergency as my patient finally being discharged from the hospital after a lengthy illness. The hospitalization has been full of setbacks and improvements, stints in the ICU and then back to the general care floor, vital signs bordering on the catastrophic but also triumphs of modern medicine and human ingenuity.
And although it is a very good sign that the patient is getting discharged, it doesn’t mean America (or the world) is entirely out of the woods. There will still be testing, close monitoring and follow-up appointments – all, hopefully, to prevent readmission.
Last week, WHO’s International Health Regulations Emergency Committee met and decided that the Public Health Emergency of International Concern (PHEIC) should end because of declining Covid-19-related hospitalizations and deaths, and high levels of immunity in the population.
The committee “advised that it is time to transition to long-term management of the COVID-19 pandemic,” and WHO Director-General Tedros Adhanom Ghebreyesus concurred.
But like me, WHO plans to keep a close eye on the patient. The agency said that while the level of concern is lower, Covid-19 is still a global threat because the virus continues to evolve and spread.
“While we’re not in the crisis mode, we can’t let our guard down,” said Dr. Maria Van Kerkhove, WHO’s Covid-19 technical lead and head of its program on emerging diseases. She added that the disease and the coronavirus that causes it are “here to stay.”
Long before WHO’s announcement, the US had designated May 11 as the day to end its public health emergency. It may feel like an arbitrary day, but it’s not as random as it seems.
When Covid-19 was declared a US public health emergency on January 31, 2020, the nation was trying to head off the spread of the virus SARS-CoV-2.
The declaration – which has been renewed 13 times, typically in 90-day increments – essentially gave the government wide-ranging flexibility in the fight against the biggest public health crisis in a century. It enabled the government to temporarily implement certain policies and actions.
For example, at the societal level, it allowed for a wider social safety net, the expansion of Medicaid in some states and the ability to prescribe controlled substances via telemedicine. At the individual level, it gave Americans free access to Covid vaccines, tests and treatments. It also permitted the government to keep its finger on the pulse of the pandemic by requiring states and other entities to report data such as test positivity rates, death rates and vaccination numbers.
On February 9, the US Department of Health and Human Services announced that it was extending the PHE one last time and said it would subsequently allow it to expire on May 11. This means an immediate end to some programs and actions; others will wind down more slowly, and some will remain in place.
Another change: The US Centers for Disease Control and Prevention will lose access to some of the data it’s been using to measure the severity of the pandemic and guide its public health recommendations.
“It is the case at the end of the public health emergency, we will have less [of a] window as to the data,” CDC Director Dr. Rochelle Walensky said last week during a Senate committee hearing. “We will lose our percent positivity. We won’t get laboratory reporting. We won’t get case reporting. So we’ll lose some of that.”
But Walensky, who is stepping down at the end of June, reiterated that the CDC is “not changing the steam at which we are working through this resolving this public health emergency.”
The agency, she said, will keep a close eye on this virus around the country, utilizing more novel approaches like genomic sequencing and wastewater testing.
We must remain vigilant. Nobody wants to see the patient readmitted to the hospital.
If you look only at absolute numbers, the decision to end the PHE might make you scratch your head. After all, there were almost 9,900 new hospital admissions related to Covid in the US for the week ending May 1, and there were roughly 1,050 deaths per week at the end of April. Comparatively, when the first PHE declaration was signed at the end of January 2020, there were no deaths reported in the United States (the first US death wouldn’t be tallied until February 29). In fact, it wasn’t until February 10 that deaths worldwide topped 1,000.
In medicine, however, numbers and data are important, but trends tell an even richer, more complete story.
Imagine my patient, America, coming into the hospital when they first started feeling ill. Maybe their fever was 101 degrees, their pulse was fast, and they felt some malaise. I noted their vital signs – cases, hospitalizations and deaths – but what I really monitored was the trend. Were those numbers getting better or worse? Had the illness peaked, or was it only just getting started? In early 2020, all those numbers were trending in the wrong direction.
But right now, the trends – in cases, hospitalizations and deaths – are all still high but thankfully moving in the right direction for my patient, our country.
This is also true globally. “For more than a year, the pandemic has been on a downward trend,” WHO’s Tedros said Friday, explaining why the PHEIC declaration was coming to an end. But he said that he would not hesitate to declare a global health emergency again if there is a significant rise in Covid-19 cases or deaths in the future.
To be clear, we have the ability to do much better and bring the numbers down much further before discharging our patient, but that raises a philosophical question, even more than a medical one: What are we willing to tolerate as a society in order to prevent illness and death?
During the past three years, I would often speak with public health and other experts to try to work out exactly when we would move out of the pandemic phase and into the endemic stage of this health emergency. There were few hard answers. Instead, many told me that it came down to the number of Covid deaths we could stomach as a society, in exchange for an end to having our lives disrupted.
At the time, I wrote: “At what point do we as a society throw up our hands and say, ‘We can’t do any better than this,’ so let’s call this level of sickness and death ‘endemic,’ accept the numbers and move on with our lives?”
We seem to have collectively, emotionally reached that point. If the US weekly death rate at the end of April held steady for 52 weeks (or represented the average weekly death rate), we would have about 54,700 deaths per year. This puts Covid on par with a bad influenza season. And remember, when it comes to flu, less than half the adult population in the United States gets a vaccine every year.
Solid medical science in the form of vaccines and effective public health strategies, such as high-quality masks and indoor ventilation, can get us only so far if there isn’t a collective will to use them.
Many of us are ready for this chapter in history to be over, and truth be told, I am well aware that many people already moved on weeks – if not months – ago. But we must also remember that there is a substantial group of Americans who are still very worried about contracting Covid, in particular the older and the sicker.
As you probably know by now, the CDC estimates that the risk of hospitalization for those 75 or older is between 9 and 15 times higher than for those who are 18 to 29, and here in the United States, nearly 25 million people are older than 75. When it comes to our general health, a study published in the journal Clinical Infectious Diseases found that people with asthma had a 1.4 times higher risk of hospitalization than a healthy person, hypertension bumped up the risk to 2.8 times higher, chronic kidney disease to four times higher and severe obesity to 4.4 times higher. Someone with three or more health conditions had a five times higher risk. Forty percent of Americans are obese, and nearly 70% of the country has at least one of the conditions that greatly increases their risk.
Therein lies one of the greatest lessons of the pandemic for my patient, the United States. While we had tremendous resources to combat this pandemic, our collective poor health put us at a tremendous disadvantage. We must do all we can to focus on the basics, because no amount of wealth can buy good health.
For now, however, my patient is taking crucial steps out of the hospital and back into the world. I am elated.
On the discharge papers, I write these parting instructions: Be prudent. Stay at home if you are sick. Talk to your doctor about keeping a course of oral antivirals (like Paxlovid) in your medicine cabinet if you are at higher risk of hospitalization or death. Remember what Dr. Anthony Fauci recently said: “If you are vaccinated and boosted and have available therapy, you are not going to die [of Covid], no matter how old you are.” That should be reassuring to people like my parents, who are now in their early 80s.
And, yes, please use the formal end of the pandemic as a new beginning for yourself personally. Invest in yourself to get into the best possible health to feel better, happier and stronger now, as well as to weather any medical storm in the future.
But most of all, go enjoy all the things that a major emergency or the threat of severe illness wouldn’t let you do. Call if you have any problems.
I wish my patient well. I wish us all well.