Intended for healthcare professionals


The covid public health emergency is ending: it now joins the ordinary emergency that is American health

BMJ 2023; 381 doi: (Published 26 April 2023) Cite this as: BMJ 2023;381:p949
  1. Anne N. Sosin, policy fellow1,
  2. Esther Choo, professor2,
  3. Martha Lincoln, assistant professor of Anthropology3
  1. 1Nelson A. Rockefeller Center for Public Policy and the Social Sciences,Dartmouth College
  2. 2Center for Policy & Research in Emergency Care, Department of Emergency Medicine, Oregon Health & Science University, Oregon Health & Science University
  3. 3San Francisco State University
  1. Twitter: @asosin @choo_ek @heavyredaction

On 10 April 2023, the US President Joe Biden signed into law a resolution terminating the covid-19 national emergency. Though the virus remains a leading cause of death in the US, the administration will disband its covid response team next month.12 These decisions came with very little fanfare, especially given Biden’s repeated promises to end the pandemic. Indeed, many Americans who witnessed the declaration of the public health emergency in March 2020 are not here to see its end. The US has buried more than 1.1 million Americans—more casualties than in almost any other country.34 For three years running, covid has been our nation’s third leading cause of death.5

In recent months, the Biden Administration has pointed to falling covid death rates as a sign that the emergency is over.6 It’s true that covid deaths have declined from the peaks of more than 3,000 daily deaths in winter 2021.7 Yet, even as covid fatalities finally subside to weekly lows under 1,500 per week, covid is on track to become the 9th leading cause of death in the US.8 Now, with the end of the public health emergency on 10 April, covid has simply joined the ordinary emergency that is American health.

Following the end of the public health emergency, Americans will continue living sicker, shorter lives than our counterparts in other high income countries. Even before the pandemic, the US spent more on healthcare as a share of its economy while lagging behind most other peer countries in life expectancy, chronic disease burden, and preventable deaths.9 Study after study has revealed unequal access to healthcare—and to the conditions necessary for healthy lives—as the defining features of the American health landscape.1011

The pandemic made these chasms deeper. Life expectancy in the US has fallen by 2.7 years since the start of the pandemic, reaching the lowest level since 1996, with large disparities by race.12 Maternal mortality soared in 2021, and racial gaps in maternal health outcomes widened.1314 For the first time in decades, mortality rates among children and adolescents also increased in 2021, with firearms becoming the leading cause of death among youths aged 1 to 19.15 Though the American pandemic story is tragic, it is also, in a sense, an unremarkable chapter in American public health.

Societies have choices,16 but political leaders and the public health community in the US have repeatedly behaved as if there were no options—beyond resignation—for addressing our accumulating failures. Writing on the end of the public health emergency, epidemiologist Katelyn Jetelina cited a colleague who stated “If it’s always an emergency, nothing’s an emergency.”17 It may indeed be challenging for our leaders to view covid as an emergency given that nothing currently qualifies as an emergency in the US: not the nation’s mental health crisis, not daily mass shootings, not plummeting life expectancy, not devastating health inequities, not the collapse of rural hospitals, not expanding maternal care deserts, and not the fact that emergency departments—the safety net of last resort—are at a breaking point.18, 19, 20, 21, 22, 23, 24

It’s worth noting that during covid, the US also accessed our better selves. The country made sweeping changes to daily life to prevent the collapse of the healthcare system. Free covid testing, vaccines, and treatment made healthcare affordable and accessible, even if only narrowly and temporarily. The uninsurance rate in the US fell to a historic low of 8%, thanks to the expansion of Medicaid enrollment.25 Policymakers transformed the country’s tattered, piecemeal social safety net into a system of robust social protections.26

These experiences might have inspired Americans to think differently for the future. We could embrace a “new normal” that includes Medicaid expansion and paid leave—recognising that these policies are essential not only for managing covid-19 but also for improving health more broadly. We could shore up our safety net hospitals and make bold investments in growing the health workforce in rural and underserved communities. We could make permanent pandemic innovations such as expanded Supplemental Nutrition Assistance Program (SNAP) benefits, the Child Tax Credit, and eviction prevention programs that protected Americans’ health and our economy.27 We could invest in the kinds of infrastructure that would make our schools, workplaces, and public spaces safer now, as well as better prepared for future pandemics.

If the end of the public health emergency does not feel as full of celebratory closure as it should, it may be because many of our “emergency” responses felt like simple decency: covid called for a society that safeguards health. But the starting point should be to cure the country’s larger affliction—its ethos of giving up.


  • Competing interests: Esther Choo is a Senior Advisor for the Wellness Equity Alliance, a company that provides public health extension services. Martha Lincoln and Anne Sosin have no competing interests to declare.

  • Provenance and peer review: not commissioned, not peer reviewed.