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June 7, 2023
Public Health COVID-19
Paula M. Lantz
Aug 24, 2023
May 24, 2023
Aug 23, 2022
Back to The Milbank Quarterly Opinion
On May 5, 2023 the World Health Organization deescalated the COVID-19 pandemic from “global public health emergency” status. On May 11, 2023, all remaining COVID-related federal public health emergency orders in the United States expired, bringing an end to numerous subsidies, regulations, and executive orders. This included the termination of mandatory reporting of COVID-19 laboratory results and immunizations to the Centers for Disease Control and Prevention (CDC), expanded access to the Supplemental Nutritional Assistance Program, and a variety of waivers related to health insurance coverage and health care access, including continuous enrollment provisions for Medicaid beneficiaries.
The sunsetting of emergency declarations and orders, while signaling a decrease in the turmoil caused by COVID-19, does not mean the pandemic is over in the United States or globally. Although numerous public health experts are communicating this distinction, the narrative that “the pandemic is over” is being widely perpetuated by the media, businesses, and some politicians and government officials. A March 2023 Gallup Poll revealed that nearly 50% of Americans believe the pandemic is behind us.
The Biden Administration’s Emergency Transition Roadmap prioritizes rapid sharing of scientific results, a new Vaccines for Adults program for the uninsured, FDA approval of new treatments, and strengthening CDC operations, workforce, and legal authorities. While this transition plan includes many critically important components, I worry that this roadmap is steering us toward a high level of endemic disease and away from the stronger local public health infrastructure and social policies needed to actually end the pandemic and improve population health.
A pandemic is generally considered to be over when an infectious pathogen is no longer causing significant disease across a wide geographic area or when it becomes endemic (or persistent) but with predictable patterns and rare uncontrolled outbreaks. COVID-19 hospitalization and mortality rates in the United States are clearly at relatively low levels right now, largely because a significant proportion of the population has some protection via vaccination or acquired infection. However, both of these types of immunity wane over time, and a new variant that escapes vaccine protection and/or causes more severe illness could emerge.
In addition, the absolute impact of COVID-19 on public health remains alarmingly high. According to data posted in the CDC COVID Data Tracker Weekly Review, almost 4 million new COVID-19 cases were reported during the first four months of 2023, continuing the US designation as a global “hot spot.” Moreover, this is a gross undercount because the vast majority of cases go unreported and official counts are declining rapidly as mandatory case reporting and subsidized testing sites have sunset. This high level of circulating SARS-CoV-2 virus is quite alarming because the effects of multiple infections and long-COVID (or post-COVID conditions) are not well understood.
Although hospitalization and death rates in the United States are currently relatively low, it is still alarming that approximately 39,000 people died from COVID-19 in the first 4 months of 2023, a number that rivals drug overdose deaths. While many countries have seen significant recovery in their pandemic-related life expectancy declines, the United States lags behind. This means that COVID-19 mortality remains high, including in age groups beyond the elderly.1
COVID-19 vaccination is core to ending the pandemic. While vaccine promotional campaigns and mandates are often fraught with political and legal challenges, COVID-19 vaccination in the United States has been especially stymied by misinformation and political partisanship which, in turn, have contributed to state and national vaccination rates that are below levels needed to reduce hospitalization and death rates to comparable levels attained by many other countries. Our low vaccination rate is likely to backslide further amid the collective delusion that the pandemic is in the rearview mirror. Furthermore, the end of emergency orders has led the Federal government along with many businesses, organizations, and colleges/universities to end their COVID-19 vaccination requirements.
A second important question is are we doing enough outside of vaccination and treatment to thwart the effects of the ongoing pandemic on population health? A medicalized approach that focuses on individual vaccination choice and effective treatments is insufficient for reducing incidence and ending the pandemic.2 For example, the “pandemic is over” narrative has contributed to reduced use of face coverings in crowded spaces. Anyone who has traveled recently likely observed a low rate of masking in transportation hubs and on planes, trains, buses, etc. In addition, the end of federal and state emergency orders is being used as a rationale for many health care systems (e.g., Mayo Clinic and Kaiser Permanente) to no longer require staff and patients to wear masks even though they could still have such policies in place, especially to protect immunocompromised and other vulnerable people.
Furthermore, our historically under-resourced public health system and its workforce at the local, state, and federal levels is in further shambles from the pandemic. As Sharfstein and Lurie argue, “…rethinking emergency preparedness programs demands a renewed commitment to public health broadly, recognizing that programs focused on emergency response depend on the foundation of core public health capacity to be successful.”3
We also need strong social welfare policies that are not dependent upon emergency declarations for their optimal design and impact. The provision of public goods such as education, food, water, housing, and health insurance should be secured before, during, and after a pandemic. For example, enhancements to the Child Tax Credit and Earned Income Tax Credit programs during 2021 led to an immediate and historic decrease in child poverty. However, because these effective poverty prevention programs were tied to the American Rescue Plan Act, they have since sunsetted and now face uphill political battles to reinstate. Another example is paid sick leave, an evidence-based public policy already in place in most high-income countries. Research shows that paid sick leave provides myriad socioeconomic and health benefits, including protections for front-line and other workers during the COVID-19 pandemic. However, most of the COVID-19 state and local paid leave mandates have already expired or will soon expire.
It is clear that COVID-19 took advantage of long-standing social, economic, and political inequities to ensure that the most marginalized populations and under-resourced communities suffered the worst outcomes.4 The extension of policy protections and safety nets during the emergency was important for population health and social welfare generally, not just in regard to COVID-19. Backsliding from these policies, many of which are promoted in Healthy People 2030, is a detour from the road to improved population health and health equity.
There is no question that the global public health threat from COVID-19 has been significantly mitigated and we are in a welcomed new phase of the pandemic. However, current levels of COVID-19 incidence, mortality, and vaccination in the United States remain alarming as public supports related to core social and economic drivers of health are ending for millions of Americans. The COVID-19 roadmap forward should be aimed toward low rates of endemic disease, strengthened public health infrastructure and authority, and progress in poverty prevention, health insurance coverage, sick leave, and other health-related policies. An off-ramp from public health emergency orders that makes a U-turn would be an even greater tragedy for population health.
Paula Lantz, PhD, MS, MA, is the James B. Hudak professor of health policy and a professor of public policy at the Ford School of Public Policy at the University of Michigan. She also holds an appointment as professor of health management and policy in the School of Public Health. Lantz teaches and conducts research regarding the role of social policy in improving population health and reducing health inequities. She currently is conducting research regarding housing policy and health, including opportunities within the Medicaid program for assisting with housing security. An elected member of the National Academy of Social Insurance and the National Academy of Medicine, Lantz received an MA in sociology from Washington University, St. Louis, and an MS in epidemiology and PhD in social demography from the University of Wisconsin.
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