The bipartisan effort to tweak Colorado’s competency laws is backed by major players in the criminal justice system who hope the 197-page will plug gaps in the state’s competency system, but it’s opposed by mental health advocates and competency experts, who say the proposal is misguided and unlikely to actually solve the underlying problems in the state’s system.

“It creates a whole host of concerns around wholesale warehousing folks,” said Jennifer Turner, executive director of , a state office aimed at connecting criminal defendants with severe mental illness to support and care. “They all have incredibly diverse needs. And responding to people by just throwing them into the same facility with the same care… can create longer-term problems because they may not be appropriately placed in that setting.”

This latest effort to reform the state’s long-troubled competency system follows a high-profile case that drew attention from Elon Musk and Gov. Jared Polis last year, in which a 21-year-old man with an intellectual disability was found incompetent to stand trial in a pair of serious criminal cases in Weld County. He was released from custody with his charges dismissed, and then was arrested again within weeks after authorities said he brought a gun onto a college campus.

The new bill aims to create a clear pathway within criminal cases for such defendants to receive treatment and remain confined until they are no longer dangerous, even when the criminal charges must be dropped. The proposal would also shift some court standards and make it easier for people to qualify for involuntary mental health care.

“What we discovered is that not only do we not have adequate placements for people, we also don’t have the mechanism for civilly committing them,” said Sen. Judy Amabile, a Boulder Democrat and a sponsor of the bill.

There was often a “very long pathway” for some people to get placed in a facility, she added, which is what the bill is trying to address. But she also stressed that the state needs a more robust system “that helps people before they ever enter the criminal justice system to begin with.”

Creating a new pathway to commitment

Colorado’s competency process is designed to protect the constitutional rights of people who are mentally ill or developmentally disabled by ensuring they are not prosecuted for crimes when they are too sick or too disabled to understand the court process and to help defend themselves.

Defendants who are found to be mentally incompetent cannot be tried for crimes — rather, their criminal prosecutions are paused while defendants go through treatment aimed at restoring them to competency. If defendants can’t be restored to competency, the cases against them must be dismissed.

When such criminal cases are dismissed, judges can consider whether the defendant should be ordered into involuntary mental health treatment. Colorado has a narrow definition for who qualifies for civil commitment. The person must suffer from a mental health disorder, and, as a result of that disorder, be either a danger to themselves or others, or be gravely disabled.

Current state law says that an intellectual or developmental disability alone is not enough to qualify a person for civil commitment. The new bill would create an entirely new type of civil commitment, called an “enhanced protective placement,” for defendants who live with permanent disabilities or conditions like traumatic brain injuries or Alzheimer’s disease and who face serious criminal charges but are incompetent to proceed.

Under the bill’s proposal, prosecutors could seek either an enhanced protective placement or civil commitment for a permanently incompetent defendant if they can prove the defendant has a mental illness or developmental disability, committed either homicide, a crime of violence or a felony sex offense, and poses a substantial risk of serious harm to others.

That would then trigger a process in which the and its would look for a residential placement for the defendant. If the agencies can’t find a bed for the defendant, the person must be admitted to a state hospital.

The bill then sets up judicial oversight for the civil commitment — judges can terminate the commitment if they find the person is no longer a threat to others and is capable and willing to follow the law, or decide to extend a civil commitment if the person still presents a danger to the public.

“For these more dangerous people, it would be much more guaranteed the intervention happens… and the courts are more involved,”  said James Karbach, spokesman for the .

Bill focuses on involuntary care

The effort is aimed at people like the 21-year-old defendant in the Weld County case — but such people make up just a tiny portion of defendants in competency proceedings, and competency proceedings themselves make up just a small portion of overall criminal cases, so that portion of the bill would likely impact just a handful of people each year.

Between 2021 and 2023, roughly 25 to 40 people went through the court system with cases that might fit the criteria proposed by the bill, said Jessica Dotter, senior chief of legislative policy at the .

The bill is largely focused on involuntary mental health care. Turner said that framing is a mistake, because the vast majority of people who’d be targeted by the bill are willing to accept care voluntarily. In 2025, Bridges worked with 120 defendants who were found incompetent and unlikely to be restored and whose criminal cases were dismissed. A full 94% of those defendants were willing to enter a placement voluntarily, she said.

Bridges found placements for 60% of those people, but could not find placements for 34% of the group because of systemic barriers like regulations and finances, not because the group members were unwilling to receive care. Just 6% of defendants refused care, she said, and those cases included defendants with only misdemeanor charges.

“It’s rare that no beds exist,” Turner said. “We just can’t access the beds.”

The proposed new process, which orders that a placement be found for a defendant, doesn’t do anything to actually solve the regulatory and financial barriers that block people from care, Turner said. The process of finding a placement routinely takes longer than the timeframe proposed by the bill.

“It¶¶Ňőap assuming the individual is in an involuntary space, and all we need to do is order them into a placement and a placement will magically exist for them,” she said.

Bridges workers have spent 21 months trying to find a placement for one client — someone who would be a target of the proposed bill — and that person has been turned down by 64 facilities, Turner said, noting there is an “entanglement of state, federal and local regulations that inadvertently support risk-averse decision making by agencies which are meant to be society’s safety net.”

“That person is in their mid-30s, they are mortified at what happened, they have voluntarily agreed to live in locked memory care for the rest of their life,” she said. “…Even though this person has really proven they will be stable in the appropriate care, even though they are agreeing to something that is a heavy-duty version of a life sentence, they’ve still been refused care at 64 facilities. This bill does nothing to address the barriers that individual is facing.”

Rather than focusing on the “tail end of the legal process,” lawmakers could effect more change by reducing the state’s regulatory barriers, giving financial incentives to providers with existing beds and streamlining access to Medicaid and other benefits, she said.

But others said ensuring that dangerous individuals aren’t set free is a step in the right direction, even if it doesn’t solve the broader systemic issues.

“The timing of this is incredibly hard, but we have to find ways to make improvements,” Karbach said. “We are not going to solve the problem of an inadequate system of care for the mentally ill in this bill completely. But that doesn’t mean we can’t find a way to make some improvements.”

When a long-term care placement can’t be found, the bill would default to sending defendants to the — a facility that is perpetually full and understaffed. The bill would essentially prioritize people committed under the new process over those waiting for competency restoration services, potentially lengthening the competency waitlist, said Jack Johnson, public policy liaison at .

The judicial oversight also raises concern, Johnson said.

“A judge could theoretically overrule the medical professional’s decision and leave you in a world where you are indefinitely incarcerated and no longer receiving treatment,” he said. “That is a huge area of concern for us as it relates to people’s civil liberties.”

The impact on the waitlist might be mitigated by the small number of people going through the new process each year. Across the state in 2025, only five people faced Class 1 or Class 2 felonies, were found permanently incompetent to proceed, and saw their cases dismissed, Turner said. Four of the five were successfully placed into long-term care through Bridges or other legal mechanisms, she said. Only one of those people was released without a plan for care, and that person was not assigned a Bridges liaison, she said.

‘There’s infinite need’

Capacity at the state hospital remains a significant concern, Karbach said.

Amabile said lawmakers are proposing to convert a facility in Pueblo to serve people with intellectual and developmental disabilities. In all, that should create between 15 and 18 new beds. Lawmakers also want to contract with nursing homes and private mental hospitals to open more space as the state needs.

“There’s infinite need, almost, for these kinds of placements,” Amabile said. “It¶¶Ňőap about the level of security. So these most secure placements are what we’re lacking, especially in the nursing home and regional center space.”

Even in a cash-strapped budget year, lawmakers are trying to set aside millions of dollars to fund the bill. Amabile said the money set aside is about $9.6 million this year, $23.2 million next year and about $28 million after that.

But the bill’s current estimated cost far exceeds that. Amabile said the bill, as it’s written now, likely costs “hundreds of millions of dollars.” She said the bill will be amended to narrow its definition so it only captures people with specific needs, which will help trim the costs.

The bill has significant legislative heft behind it: Sen. Cleave Simpson, the Senate’s Republican minority leader, is sponsoring the bill with Amabile. The House’s top Democrat and Republican lawmakers — Speaker Julie McCluskie and Minority Leader Jarvis Caldwell — will take the reins if and when the bill reaches the lower chamber.

Through spokesman Eric Maruyama, Polis declined an interview request this week. Maruyama said the bill was part of the governor’s effort to lower Colorado’s crime rates.

“An important part of that is making sure that those who pose a danger to themselves and others are not released, which is what we want to see in this bill,” Maruyama said. “Governor Polis appreciates the work of the sponsors to protect public safety and improve our competency system, and looks forward to continued conversations to bring this bill to a place that the state can successfully implement.”

In the long run, everyone dies, but state health officials watch how death rates compare to what they’d expect based on the size of the population and the mix of ages within it. If younger people are dying in higher numbers than normal, it tells them that something has gone wrong.

Death rates shot up in 2020 and 2021 as COVID-19 and an increasingly dangerous illicit drug supply took out Coloradans at rates not seen in decades. They started to fall again over the following two years, but not back to their 2019 levels.

That pattern continued last year: six of the top 10 causes of death killed fewer people in 2024 than in 2023, according to newly finalized state data.

After adjusting for population growth and aging, death rates from cancer and Alzheimer’s disease also went down. The suicide death rate remained unchanged, after adjustment, while the diabetes death rate ticked up.

Most age groups are still above their pre-pandemic rates, after adjusting for population growth, though.

For people over 55, the difference is relatively small: death rates are within 3.5% of what they were in 2019. In their cases, reductions in deaths from cancer, heart disease, certain lung conditions and Alzheimer’s disease mostly offset increased mortality from overdoses, alcohol-related complications and, for the oldest Coloradans, malnutrition.

Physicians and coroners have gradually shifted away from ascribing deaths to “old age” or “failure to thrive,” and malnutrition is one of the causes they increasingly use to be more precise, according to the Colorado Department of Public Health and Environment.

Middle-aged people fared worse. The death rate in Colorado last year was still about 22% above 2019 levels for people between 35 and 44, and 11% higher for people in the 45 to 54 age group. Drug overdoses were the primary driver of increased deaths for both groups, though they did trend down last year.

The picture was more mixed for children and the youngest adults. Death rates went up for most groups under 25 from 2023 to 2024, with the exception of youth between 15 and 18. Those older teens had lower death rates than they did before the pandemic, as did infants, while the 1 to 14 group and adults under 25 had higher rates.

For children and younger teens, homicide and traffic accidents kept their death rates above pre-pandemic levels, while for adults under 25, the biggest contributors were transportation accidents and overdoses.

Death rates tend to fluctuate for people between 1 and 24, while infant deaths are more stable, according to the state health department. The causes of infant mortality, such as premature birth, don’t change as drastically from year to year as do accidents, homicide and suicide, which are the leading killers of children and teens, the agency said in a statement.

Nationwide, and began to gradually fall over the next two years, with preliminary data suggesting a more significant improvement in 2024.

Overdose deaths, nationally and in Colorado,  especially dropped among young people, perhaps reflecting that . Another possibility is that, since overdoses among teens already were uncommon, normal fluctuation produced seemingly dramatic changes, according to the state health department.

“Despite promising decreases in overdose deaths appearing in nationwide data, thousands of people across the country are still dying from preventable overdoses,” said Kirk Bol, manager of the state health department’s vital statistics program. “As the illicit drug supply continues to evolve, it remains essential to provide individuals with factual drug information and encourage engagement in proven public health strategies.”

But a reduction in deaths doesn’t necessarily point to fewer people using drugs or having nonfatal overdoses — it could simply reflect that friends or bystanders are more likely to have naloxone on hand to revive the victims than in previous years, said Dr. Anuj Mehta, a pulmonologist and critical care physician at Denver Health.

Younger people are more likely to survive an overdose, because their organs are generally healthier and better able to recover even if they went without oxygen for a time, he said.

Naloxone is likely an important contributor to the drop in deaths, and communities need to keep working to get it to the people who could help prevent an overdose from becoming a fatality, Mehta said. But ultimately, the way out of the overdose crisis is to help people get treatment for the addictions and mental health conditions that push them to take the risk of using illicit drugs, he said.

“We need to think broadly about mental health,” he said. “The data shows that deaths are decreasing, but it doesn’t show substance use is decreasing.”

The two grants total about $1.7 million. One is to study vaccine hesitancy in Alaskan Native communities, and the other is a partnership with Columbia University to study the link between diabetes and Alzheimer’s disease.

The National Institutes of Health are the world’s largest funder of medical research, distributing $35 billion in in grants in 2023.

, the Trump administration ordered the institutes to halt meetings to review about $1.5 billion in upcoming grants. It also announced that only 15% of grant funding could go for , such as , though a federal judge temporarily blocked that order. Supporters of the policy said limiting overhead spending would make more money available for research, while critics said it would make some types of labs impossible to fund.

The NIH has terminated grants to study ; for work at Columbia University, because of anti-Israel student protests; and for research in South Africa, because the administration believes the country is persecuting white citizens.

Some scientists also have reported receiving feedback that they shouldn’t pursue grants for research involving mRNA vaccines. The Pfizer and Moderna COVID-19 vaccines, which , use mRNA technology.

Greg Ebel, director of Colorado State University’s Center for Vector-Borne Infectious Diseases, said he doesn’t know of any other local projects that have definitively lost their funding, but uncertainty about government support for research will push young people out of the field. He spoke during a roundtable Tuesday on the Anschutz campus with Colorado Sen. John Hickenlooper, a Democrat.

“Nobody knows what to expect,” Ebel said.

Other researchers who spoke said the pharmaceutical industry and foreign powers would try to scoop up young people who couldn’t find funding for their research. Without their work, the United States could lose out on the kinds of advances that now allow most children with cancer to grow up, said Dr. Lia Gore, an oncologist who conducts clinical trials at Children’s Hospital Colorado.

“Fifty years ago, childhood cancer was uniformly fatal. There were no survivors,” she said.

Thomas Morrison, who is working on new vaccines and antiviral treatments on the Anschutz campus, said his department paused hiring while leaders sort out whether the NIH will continue funding their work. They’re trying to develop vaccines and treatments that work on multiple types of viruses, in the hope of having something that will work if a new type of flu caused a pandemic, for example.

“We may have funding, but it’s not clear that’s going to be there tomorrow,” he said.

Judy Regensteiner, who also works on the Anschutz campus, said she worries the grant that funds her work could disappear. The grant covers the salaries of young researchers working in women’s health, though Regensteiner’s work on sex differences in diseases such as diabetes affects both women and men, she said.

“It’s the uncertainty that’s so hard right now,” she said. “It’s painful to me, and especially to the early-career scientists” funded by the grant.

Hickenlooper said he believes Congress will push back against deep cuts to research, because significant numbers of Republicans support medical science, though no one has put together a bill or framework to get the NIH grants flowing again. The system of federal grants for research at universities allowed the United States to lead the world in science, he said.

“You’ve got to continue the investments that have got you there,” he said.

If the country doesn’t fund basic science, it will lose the ability to respond quickly to emergencies, Ebel said.

His lab is studying how to control mosquitoes with less insecticide, and has equipment that nearby counties can use to monitor for West Nile virus in their mosquito populations. Early in the pandemic, they repurposed it to test nursing home workers for COVID-19, possibly saving lives by preventing them from bringing the virus to vulnerable people, he said.

Basic research “gives us the ability to be creative and flexible and nimble in the face of threats,” he said.

The combination of drugs targets two brain proteins critical in neuroinflammation, which is involved in brain aging and Alzheimer’s, according to a featuring CSU researchers.

Results from the study show this medicine could become “a game-changing tool” against Alzheimer’s,

“There are no effective treatments right now,” said Devin Wahl, a CSU postdoctoral fellow, who co-authored the study. “We have treatments that can manage symptoms, but we don’t have any that can stop the disease. We want to try to identify novel treatments that may be effective to slow, or even reduce, the effects of Alzheimer’s disease.”

This cocktail of medicines could also improve memory in aging adults, the study found, and, potentially, reverse cognitive decline.

The research came out of a partnership between CSU faculty member Tom LaRocca’s Healthspan Biology Lab and Colorado-based biotech company Sachi Bio.

“This is a novel and effective treatment to improve memory in mice,” said Prashant Nagpal, who co-founded Sachi Bio with his wife, Anushree Chatterjee. “A very important finding that we saw in this study is that you can reverse some cognitive decline. We are hoping to take this to human clinical trials next year.”

The mice behavioral tests measured memory and grip strength because grip strength and muscle function are closely linked to brain function, researchers said.

“If we can target what comes before Alzheimer’s disease, which is what this drug is meant to do, that will give people more treatment options, especially earlier in life,” Wahl said.

By next year or 2026, Nagpal hopes there will be a more conclusive data set including human trials.

“We’ve all been touched by seeing older parents and family members just being a shadow of themselves,” Nagpal said. “It¶¶Ňőap just heartbreaking. It may seem like just a glimmer of hope, but can you latch onto it and just, you know, go for it?”

Drug overdoses, COVID-19 and organ damage from alcohol were the biggest culprits behind the still-elevated number of deaths since the pandemic. In contrast, fewer people died last year of chronic diseases such as cancer and heart disease, after accounting for the state population’s growth and aging since 2019.

Last year, 44,862 people died in the state.

Colorado’s death rate peaked in 2021, when COVID-19 killed thousands of people, before dropping again in the next two years. But 5,544 more people still died in 2023 than had in 2019 — a 7% increase, after adjusting for population changes, according to newly finalized data released by the Colorado Department of Public Health and Environment.

Both men and women had higher death rates in 2023 than they did in 2019; the state’s data doesn’t break out nonbinary people. So did every age group except infants. Colorado changed how it reported racial data in 2020, so the numbers don’t allow for comparisons before the pandemic.

In 2020, Colorado’s mortality rate rose not only because thousands of people died from COVID-19, but also because deaths increased from heart disease, cancer, strokes and Alzheimer’s disease. Researchers haven’t landed on a single explanation for the increased death from multiple causes, but delayed medical care and complications from the virus could be factors.

Deaths from major natural causes dropped in 2021 and stabilized in 2022, though in most cases they remained above pre-pandemic levels. Last year was the first time since the pandemic began that most major causes of death had lower rates than in 2019, though the increase in overdoses overshadowed that improvement.

Colorado is doing relatively well in addressing the kinds of deaths that people can prevent through healthy habits and routine screenings, and medical advances are allowing people to live longer with diseases like cancer, said Cathy Bradley, dean of the Colorado School of Public Health.

Those same strategies don’t work as well in preventing deaths from drugs or alcohol, she said.

“It’s very different,” she said.

COVID no longer leading cause of death

Cancer overtook heart disease as the top killer in Colorado in 2023, though the death rate for both dropped after adjusting for population growth and aging.

Not enough time has passed to know whether people skipping cancer screenings at the height of the pandemic will lead to more deaths, Bradley said. (In 2023, the adjusted death rate for cancer dropped, though the number of deaths increased because the population is growing and aging.)

In the next few years, people who didn’t catch up on their screenings could start to seek care for advanced cancers that cause symptoms, but improvements in treatment for late-stage disease mean that additional deaths likely won’t happen for another decade, she said.

Accidents other than overdoses and chronic lower respiratory diseases, such as emphysema, retained their spots in third and fourth place among Colorado’s top causes of death in 2023. Strokes and similar conditions took over fifth place, followed by Alzheimer’s disease, accidental overdoses, suicide, chronic liver disease and diabetes.

In 2022, COVID-19 had been the fifth-largest cause of death in Colorado, but last year, it dropped out of the top 10. The state health department recorded 626 deaths from the virus in 2023, compared to 2,261 in 2022, when the state was coping with the tail end of the first wave of the omicron variant.

COVID-19 peaked as the state’s third-leading cause of death in 2021, when only cancer and heart disease killed more Coloradans.

Still, COVID-19 remained a bigger threat last year than other respiratory infections: 370 people died of flu and other diseases that cause pneumonia in 2023. It also explained about one-fifth of the excess deaths in 2023 compared to 2019, when the virus hadn’t yet arrived in Colorado.

COVID-19 likely will remain a threat for the foreseeable future, particularly to older people, Bradley said. The best way to address that is to continue to develop vaccines that are well-targeted to the latest versions of the virus, and to encourage people to get them, she said.

Deaths from cancer, heart disease, chronic lower respiratory disease, Alzheimer’s, suicide and diabetes were all down compared to both 2022 and 2019, after adjusting for population changes.

Stroke deaths were up slightly compared to the previous year and before the pandemic, while unintentional overdoses increased significantly. Chronic liver disease deaths were up compared to 2019, but down slightly from their high in 2022.

Overdoses were the largest source of Colorado’s excess death last year compared to 2019, explaining more than one-quarter of the rise. Strokes, in contrast, only accounted for about 3% of the difference.

Alcohol-related deaths, which included some cases of liver disease as well as other types of organ damage, explained 12% of the difference.

Heavy drinking jumped in 2020, though young people seem to be cutting back, perhaps in response to a growing scientific consensus that alcohol isn’t a health food, Bradley said. She isn’t sure if that information will change the behavior of older people, who aren’t curbing their drinking at this point.

“For a very long time, we believed alcohol had positive health effects,” she said.

Alcohol is available in more outlets in Colorado than it ever has been, and drinking levels that people perceive as normal can bring health risks over time, said Marc Condojani, interim director of statewide programs at the Colorado Behavioral Health Administration.

To bring down deaths, the state needs more treatment capacity for people with more severe alcohol use disorders, a shift in people’s perception of what constitutes low-risk drinking and to involve more health care providers in screening and counseling patients before heavy use turns into addiction, he said.

“We want to make sure we’re using all the tools in the toolbox,” he said.

Fentanyl fuels increase in OD deaths

The increase in death rates since 2019 wasn’t limited to a particular demographic.

Both men and women showed a similar pattern, with improvement compared to 2022, but worsening compared to 2019. The impact was slightly greater for men, though: their death rate remained about 9% higher than it was before the pandemic, compared to about 5% for women.

Death rates decreased from 2022 to 2023 for all age groups except infants and youth between 15 and 18. Compared to 2019, however, mortality rates were up for all groups except infants. (Deaths before a child’s first birthday are relatively rare, so the rate has more random fluctuation than in older age groups.)

Accidental overdoses were the top driver of increased deaths in people between 15 and 64. The top driver for children between 1 and 14 was homicide, and COVID-19 remained the largest cause of excess death for people 65 and older.

Usually, when one cause is increasing death rates for a large swath of the population, that cause is something like a new virus, Bradley said. Overdoses are different, because society’s existing problems, like untreated mental health conditions and addictions, are driving the deaths, she said.

“It’s not an infectious disease that’s spreading like wildfire through our society,” she said. “It’s something that’s arising in our society.”

The rate of Colorado’s overdose deaths had decreased slightly in 2022, raising hopes that the worst of the opioid epidemic might be over. The 2023 numbers, which showed overdoses increasing about 3%, dashed those hopes.

The biggest culprit was fentanyl, which killed nearly 1,100 people in Colorado, though deaths involving methamphetamine and cocaine also increased. While some people do die solely from a stimulant overdose, many of those deaths were in people who bought meth or cocaine that also contained fentanyl, Condojani said.

“This is probably our new normal because that just seems to be the way the data have been running the past few years,” said Dr. Tyler Coyle, an addiction medicine physician at the University of Colorado’s Anschutz Medical Campus and the president of the Colorado Society of Addiction Medicine. “I don’t like saying it, but that seems to be the message that I’m taking away from (the data), that this is just where things are now. It highlights the need for us to start looking at newer and alternative solutions that have not been acted on so far.”

Colorado is taking steps to reduce overdoses, such as distributing reversal medications more widely and increasing youth education about the risk that pills that don’t come from a pharmacy could contain fentanyl, Condojani said. The Behavioral Health Administration also is trying to change views about addiction, so people who need help don’t feel ashamed asking for it and have more hope for recovery, he said.

“Recovery is more than possible. It’s the expectation,” he said.

“It’s hard to change society”

Most racial and ethnic groups’ death rates dropped from 2022 to 2023, with the exception of Native Americans and Native Hawaiians/Pacific Islanders. Those groups are the smallest, by population, in Colorado, so their mortality numbers are more prone to fluctuations.

Colorado changed how it groups data by race and ethnicity in 2020, so it doesn’t allow for pre-pandemic comparisons.

Still, significant disparities remained unchanged, with Black, Native American and Pacific Islander Coloradans having the highest death rates, while white, Asian and multiracial residents of the state had the lowest adjusted rates.

To fully close disparities in mortality, Colorado would have to first address them in other areas of life that contribute to poor health, such as education and housing, Bradley said. That kind of broad change isn’t likely to happen quickly, but the state could make significant progress if it ensured everyone had access to health insurance, she said.

“It’s hard to change society all at once,” she said.

Colorado legalized medical aid in dying in 2016, when voters passed Proposition 106. Under the law, two physicians must agree that an adult patient is mentally competent to make the decision to die and would have less than six months until natural death. If approved, the person would then give themselves a drug cocktail meant to cause death painlessly.

Under current Colorado law, a patient has to request medical aid in dying twice, at least 15 days apart, before they can get a prescription. would shorten the timeline to 48 hours, and allow physicians to waive the waiting period if they believe the patient will die in less than two days.

It would also allow people who aren’t Colorado residents to end their lives under the state’s law, and let advanced practice registered nurses prescribe the drug cocktail. , but limits medical aid in dying prescriptions to physicians.

Shelby Marcuse, of Colorado Springs, said that having more providers able to prescribe medical aid in dying would have made the process easier for her mother, Vyki Bishop.

Bishop was diagnosed with terminal in April and made it clear from the beginning that she wanted the option to end her life on her terms, but Marcuse said the family couldn’t find a local doctor who would evaluate her and write the prescription. The closest doctor who could see her within a month was in Littleton, and fortunately offered telemedicine, since Bishop’s gastrointestinal symptoms would have made driving there a challenge, Marcuse said.

The waiting period was a smaller obstacle, though her mother worried during that period that something would go wrong and she’d no longer qualify, Marcuse said. Ultimately, Bishop chose to take the medication after her symptoms escalated in October, and she spent her last day calling family members and listening to her favorite music, her daughter said.

“Her anxiety decreased immensely because she had that choice” to die when she was ready, Marcuse said.

Julie Reiskin, co-executive director of the Colorado Cross-Disability Coalition, said she’s concerned that speeding up the timeline would result in people deciding to die while in despair over a diagnosis, before they’ve had time to process their options and adjust to a new life.

When she first became disabled, she thought she’d rather die than rely on a wheelchair, but with time found life was as fulfilling as ever, she said.

“That just feels way too fast,” she said.

Reiskin said she’s also concerned about allowing people who aren’t Colorado residents to come here to end their lives, because they won’t be working with a medical provider who knows their history and needs.

While some physicians in Colorado caused a stir by raising the possibility that , state law doesn’t specifically address aid in dying for those patients. People with Alzheimer’s disease or other forms of dementia aren’t eligible.

The new bill clarifies that if providers aren’t sure if a patient is mentally capable of deciding to die, they should refer that person to a mental health provider for evaluation, and specifies that insurance companies may not attempt to persuade a terminally ill customer to die so they can avoid paying for care. It also removes a sentence from the request format that the person understands “the seriousness of this request” and expects to die if they take the medication.

Medical aid in dying is legal in , with some limiting their programs to residents and others allowing patients from elsewhere to receive life-ending prescriptions. Minnesota’s legislature is to authorize the practice this year.

In 2022, 316 people were prescribed drugs under Colorado’s medical aid in dying law, . During the same year, 246 people opted to fill the prescriptions, and 243 died, though the state data doesn’t show how many took the medication and how many died naturally. (It’s possible some people who received a prescription in 2021 filled it or died in 2022, and that some people who got their prescription in 2022 died later.)

Those who died after receiving a prescription — whether they took it or not — were more likely than the general population to be white and to have a college degree. About four out of five were receiving hospice care at the time of their deaths.

Of the group that received a prescription, 184 had a form of cancer; 45 had progressive neurological conditions, such as amyotrophic lateral sclerosis (Lou Gehrig’s disease) or Parkinson’s disease; 25 had chronic lung conditions; and 24 had cardiovascular diseases.

Reiskin said the state needs to do a better job documenting whether patients who seek medical aid in dying received adequate pain medication and home medical care. As is, no one knows if people were truly finished fighting their illnesses or were worried about burdening their families, she said.

“We need more information before we make it easier,” she said.

Mike Reagan, a death doula, said pain management isn’t perfect, however, and people nearing the end of their lives often want to exercise some control.

About six months ago, Reagan worked with a man who had been diagnosed with stage four pancreatic cancer and given one or two months to live. The man wanted to die before the pain required heavy medication, because he wanted to gather his loved ones and say goodbye at the end. As it happened, the man died during the 15-day waiting period, under the influence of painkillers and unable to communicate, he said.

“He got to a state he never wanted to get to,” Reagan said. “An elongated waiting period will rarely move someone to change their perspective” on dying.

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Nearly all of the improvement in Colorado’s death rates from 2021 to 2022 was because less than half as many people died of COVID-19. That was partially offset by an increase in deaths from other diseases, however, as overdose deaths stabilized well above their pre-pandemic levels.

The state’s mortality data is delayed three to four months, so it’s not yet known whether those same trends have continued into 2023, said Kirk Bol, manager of the vital statistics program at the Colorado Department of Public Health and Environment.

COVID-19 deaths will most likely be lower this year, because 2022 included the second half of the massive omicron-driven wave and nothing comparable has happened since, he said. But the trends aren’t as obvious for other causes of death.

“That’s tough to tell,” he said.

Colorado recorded 46,751 deaths in 2022, a decrease of about 1,500 from the previous year. Even after adjusting for population growth and aging, however, mortality in the state remained 12% higher than it was before the pandemic hit. COVID-19 caused more than two-fifths of the increase, and accidental drug overdoses were responsible for about 15%, even though both caused fewer deaths than in 2021.

Most other major causes of death also caused slightly lower mortality rates in 2022 than in 2021. The exceptions were chronic lower respiratory diseases, such as emphysema; transportation accidents; Alzheimer’s disease; and heart disease. , though it’s not clear if that was a factor in the mortality rise.

Deaths from influenza and non-COVID pneumonia also were up, though still slightly below 2019 levels, as the country had its first relatively normal flu season in years.

It’s likely that people’s decisions to stop wearing masks and taking other precautions played some role in the increased deaths from other respiratory diseases, though it’s difficult to know how much, since the virulence of the circulating flu strains and how well vaccines match them also influence mortality, said Dr. Ned Calonge, chief medical officer at the state health department.

After adjusting for population growth and aging, the death rate also remained higher than it had been in 2019 for traffic accidents, heart disease and diabetes. Death rates in 2022 were lower, after adjusting, for cancer, chronic lower respiratory diseases, strokes, Alzheimer’s and suicide.

Some people may have delayed care during earlier phases of the pandemic, making them more likely to die of chronic diseases now, and the decrease in COVID-19 deaths may mean that people lived a bit longer before they were killed by other conditions, Calonge said. And of course, there’s some random variation from year to year, he said.

“While we can always observe things, we can’t always explain them,” he said.

Colorado’s mortality followed a similar trajectory to the rest of the country in 2022 and likely will this year, said Andrew Noymer, an epidemiologist and associate professor at the University of California Irvine.

In the first three months of 2023, all-cause mortality nationwide was still above what would have been expected before the pandemic, even adjusting for population aging. It appeared to drop to near-normal levels in the second quarter of the year, but the country will have to wait for the summer data before it’s clear if the excess deaths are really over, he said.

“That is really, really the question,” he said.

Overdoses hit young, COVID continues to kill older people

Fewer children under 10 died in Colorado last year than did, on average, in the three years before the pandemic, mostly because of a reduction in infant deaths and fatal injuries of older children.

Deaths increased among people between 10 and 17, however, as a rise in homicides and accidents, including drug overdoses, more than wiped out a small decrease in suicide deaths. Since most homicides involve guns, as do a non-trivial number of accidents, parents could reduce deaths by making it more difficult for youth to access firearms, said Dr. Maya Haasz, a pediatric emergency physician at Children’s Hospital Colorado.

Dr. Laurie Halmo, a pediatric hospitalist and medical toxicologist at Children’s Hospital Colorado, said most of the increase in overdose deaths was due to fentanyl poisoning in older teens. While it’s encouraging to see a small drop in suicide deaths, young people are clearly struggling with substance use, and more adults need to keep naloxone on hand so they’re prepared to respond to an overdose, she said.

A similar pattern held in adults under 25, who were less likely to die by suicide than before the pandemic but more likely to be killed by homicide, overdoses or other accidents.

For people between 25 and 44, the biggest increases were in overdoses and chronic liver disease deaths. While the state’s data on liver disease didn’t specify what caused patients’ illnesses, .

Unfortunately, those trends aren’t likely to reverse any time soon, said Beth Carlton, an associate professor of environmental and occupational health at the Colorado School of Public Health. “Deaths of despair,” including overdoses, liver disease and suicide, have been rising in working-age populations since the early 2010s, she said.

“That’s not just pandemic-related,” she said.

For people over 45, COVID-19 was still the largest contributor to increased deaths above the 2017-to-2019 average. Nationwide, the virus was still the fourth-leading cause of death in 2022, which is “pretty mind-blowing,” though it dropped to fifth place in Colorado, Carlton said.

COVID-19 killed 2,261 people in Colorado in 2022, down from 5,298 the prior year. While the virus will likely cause even fewer deaths this year, it’s still a significant factor that’s keeping mortality up, Carlson said.

“It’s hard for so many of us who lived through the pandemic… to see COVID is still a major cause of death and hold that in tension with that COVID is much less of a threat” than it was two years ago, she said.

Men, people of color see more improvement

Nationwide, groups that saw larger increases in deaths in 2020 and 2021 had larger decreases in 2022, . Those included men and people who identified as Hispanic, Black, American Indian or Pacific Islanders.

A similar pattern appeared in Colorado. Men saw a bigger drop in their death rate from 2021 to 2022 than women did, after two years of a widening gap in mortality driven by COVID-19 and overdoses.

All ethnic groups in Colorado saw a decrease in death rates, except those identified as multiracial. The number of people whose death certificates list more than one race is so small, however, that it’s difficult to tell if that¶¶Ňőap a trend or a blip.

White Coloradans had the smallest decrease in mortality, with increases in more cause-of-death categories than other groups, which partially offset their drop in COVID-19 deaths. Still, they had the third-lowest mortality rate, behind Asian and multiracial Coloradans.

Compared to 2021, American Indian and Pacific Islander Coloradans had the largest increases in life expectancy, though they still could expect shorter lives, on average, than Asian, multiracial and white residents. Men also posted a larger increase in life expectancy than women, or in the case of the multiracial population, a smaller decrease, but still died younger.

That may reflect that men and people of color were hit particularly hard by COVID-19, so they experienced more improvement as mortality trends came closer to normal, said Bol, of the state health department.

Calonge, the state’s chief medical officer, said it’s too early to be sure, but he hopes that Colorado’s increased investment in promoting health equity is helping to reduce mortality disparities. The health department started an office focused on equity during the pandemic, and both public- and privately-funded programs have listed closing health gaps as a new goal since 2020.

“Hopefully our culture and our society… will recover at least to where we were, if not better,” he said.

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Colorado nature photographer and environmentalist John Fielder sat on a couch inside his Summit County home recently gazing at jagged Gore Range mountains, not through the frame of a camera but a window — a spectacular scene among thousands that he has immortalized.

A herd of elk had passed outside. A mountain grouse had been singing at the door.

“Here I am at 72,” Fielder said, “and cancer is trying to take my life.”

He’s been enduring pancreatic cancer by relying on the same rational approach he honed in handling countless “curveballs” nature hurled while he covered all of Colorado’s 104,094 square miles photographing landscapes. Vehicle breakdowns above timberline, rafts flipping in whitewater rapids dumping him and all his gear, bears bulling into his camp, sudden storms plunging temperatures below freezing — all became challenges for the father of three to overcome by using brainpower, avoiding panic, and summoning strength the way a mountain climber does in ascent.

Fielder also got through personal tragedies — losing his wife, Gigi, after she was diagnosed at 52 with Alzheimer’s disease. He suffered especially after his son died by suicide.

“You know, I have had to self-rescue myself, get out of difficult situations, over 100 times before,” Fielder said. “To me, this is simply self-rescue number 101. It is a problem to be solved.”

Chemotherapy interrupts a slower existence he’d envisioned, skiing with titanium-reinforced knees, hiking and taking photos in Colorado’s Blue River Valley. But the cancer, diagnosed a year ago, also has spurred Fielder to review his life’s work and focus on his mission: helping Coloradans respect nature, most urgently by slowing global warming and stopping environmental destruction.

Taken together, his photos over nearly 50 years give residents an unprecedented perspective on their natural heritage and how large-scale settlement has affected landscapes where the previous human inhabitants, native tribes, lived sustainably on the land. The photos — including 7,300 entrusted to the public at the state’s History Colorado repository — have become the main visual baseline for assessing changes as the climate warms.

“No matter what happens to me in the next six months, my photos are there at History Colorado,” he said as he sat. “Whatever we can do to stave off the impacts of climate warming, maybe my photos can be part of that.”

Fielder grew up in North Carolina, nudged toward a life in commerce. His father excelled in that arena, building up the Ivey’s department store chain and embracing public service. Upon graduation from Duke University, Fielder fell into work as a real estate broker and, married in 1982 with two children and a third on the way, was managing a May D & F store in south metro Denver.

He and Gigi made an escape plan for a life lived largely outdoors. He would turn his nature photography hobby into a business by selling photo calendars and coffee table books. Forty years later, he tallies some 50 collections of photos he has published with roughly 1 million copies sold.

One book — “Colorado: 1870 to 2000” — leverages 19th century photos by William Henry Jackson, who was sent by the U.S. Geological Survey to document western territories at a time when census records show Colorado had 39,864 residents. Fielder re-photographed what Jackson saw and created a side-by-side comparison at the start of the 21st century — when Colorado had 4.3 million residents and industries including cattle ranching; mining of gravel, gold, coal, gas, and oil; house-building; and tourism. He dedicated the book to the people of Colorado, urging them to “examine our relationship with the land,” declaring “there is no more beautiful place on Earth than Colorado” and “very few places more fragile.”

His photos of high mountains and valleys exposed Colorado to the world, drawing tens of thousands of visitors and new residents and inspiring some to value the wildness that remained in the West. Perhaps only John Denver, with his song “Rocky Mountain High,” drew more attention to Colorado, said Jerry Mallet, a former Chaffee County commissioner who runs the river protection organization Colorado Headwaters.

Looking back, Fielder wrestles with his role. “Obviously, too many people in one place, too many footprints, can destroy the very place you want to protect,” he said. “But the more people that go out and smell, taste, touch, hear, as well as see, Colorado, the more people are likely to vote for the right candidates and issues on their ballots — to not only repair environmental damage but to protect these areas.”

In the early 1990s, he decided he had to do more to save the natural landscapes he photographed. An environmental movement in the state gained momentum under Fielder’s leadership, Mallet said.

Fielder observed a widening degradation from multiple threats: development devouring open space, tourists overrunning national parks, and now the ruinous fires, droughts, and extreme storms driven by climate warming.

His advocacy began as Sen. Tim Wirth was leading work under the nation’s 1964 Wilderness Act to save land in Colorado that was “untrammeled by man” and “retaining its primeval character.” Fielder went out and photographed pristine terrain for a book circulated to county commissioners, mayors, chambers of commerce, and others whose support was required for the federal government to designate wilderness.

Now retired, Wirth credits Fielder as “an integral part of the effort” that set aside more than 600,000 acres of Colorado as wilderness. Fielder “is a wonderful enthusiast and advocate, and his photos surely helped to persuade many Coloradans to support our work,” Wirth said.

Former Congressman David Skaggs, who carried the Colorado Wilderness Act of 1993 to final passage, said Fielder’s photos “served to convey something spiritual about the wilderness” that may have “seeped into the pores of some of our skeptical colleagues.”

Fielder also lobbied for land preservation through Great Outdoors Colorado, the program voters launched in 1992 directing the use of Colorado Lottery revenues to protect wildlife habitat and river corridors and to improve parks and trails. And as Colorado’s population exploded, reaching 5.87 million this year, he supported environmental projects, such as efforts to ensure sufficient water in the upper Colorado, Yampa, and Dolores rivers and protect the canyons they carve as new wilderness.

“He’s one of the most consequential conservationists in Colorado history,” said Save the Colorado River Director Gary Wocker, a longtime friend. Fielder has focused on “art and beauty. … a side of things that humans value,” Wockner said. “He knew that, by taking these beautiful photos and selling them, he was probably leading more people to visit the places. But he wasn’t just commodifying them. He has dedicated his life to protecting those places — and restoring them.”

Damage over four decades of population growth and urbanization in Colorado could have been worse, Fielder said, lauding voters who sometimes made saving nature a priority. “We have accomplished much in the past 23 years to deflect inappropriate development.”

But he has seen a transformation.

“Back in the 1980s, there just weren’t as many folks hiking and camping for the sake of just getting away from the city to enjoy the sounds, smells, taste, and touch — the sensuousness of nature.” Crowded conditions inside costly Front Range cities increasingly drive more people out. “People follow other people to the same places they read about online.”

Climate warming with temperatures rising nearly twice as fast as the global average in western Colorado is shrinking snow and favoring droughts, ruinous fires, and insect infestations — ravaging forests where he used to shoot photos. “Just about all of our Colorado forests between 10,000 feet and 12,000 feet in elevation now are dead, not to mention 5 million acres of dead lodgepole pine forest at lower elevations. I can no longer make a beautiful photograph of green trees in the foreground of a Rocky Mountain composition. And most of the snow and ice that were remnants of ancient glaciers has melted. I can no longer include in my designs the dramatic contrast of a white glacier nestled in a rocky cirque,” he said.

“As an artist, I am not sure I can deal with that.”

In the future, more people likely will move to western Colorado, requiring the preservation of more natural landscapes, he said, calling for greater funding by Congress and state lawmakers to make sure federal, state and local public land managers can keep ecosystems healthy.

Much will depend on how fast humans address climate change. Another decade of burning fossil fuels, emitting more heat-trapping carbon dioxide and other gases into the atmosphere, “doesn’t bode well for humanity and for biodiversity,” Fielder said. “We can’t stop climate warming, but we can slow it. There’s a difference between a place that is 120 degrees versus a place that is 100 degrees. That increment could make all the difference….The sooner we get out of the oil and gas business, the sooner we are not part of the problem.”

Meanwhile, on his 20 acres of forest and wildflower meadows, Fielder has been basking in the beauty of a place he has protected, stars still visible in the darkness of night, away from traffic and industrial noise, wonders of evolution over 4 billion years on display.

He counted the elk that surrounded his house — more than 30. The mountain grouse at the door, the first of spring, sang as if wild birds no longer were imperiled.

“With this cancer now, I realize how fortunate I am to be in a place like this,” he said. “It makes all the difference in the world, being in the middle of nature.”

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In comparison to that 91.7% CTE rate of studied former NFL players, a past BU study of 164 brains of men and women found that only 1 of 164 (0.6%) had CTE. The lone CTE case was a former college football player.

The BU researchers noted that they’re not saying 91.7% of all current and former NFL players have CTE because brain bank samples are subject to selection biases. The prevalence of CTE among NFL players is unknown, as CTE can only be diagnosed after death.

Repetitive head impacts appear to be the chief risk factor for CTE — which is characterized by misfolded tau protein that is unlike changes observed from aging, Alzheimer’s disease, or any other brain disease.

“While the most tragic outcomes in individuals with CTE grab headlines, we want to remind people at risk for CTE that those experiences are in the minority,” said Ann McKee, director of the BU CTE Center and chief of neuropathology at VA Boston Healthcare System.

“Your symptoms, whether or not they are related to CTE, likely can be treated, and you should seek medical care,” McKee added. “Our clinical team has had success treating former football players with mid-life mental health and other symptoms.”

Research on CTE has advanced considerably over the past five years, and the BU CTE Center will soon publish its 182nd study on CTE.

In part because of advances in CTE research, the National Institutes of Neurological Disorders and Stroke recently updated their position on what causes CTE: “CTE is a delayed neurodegenerative disorder that was initially identified in postmortem brains and, research-to-date suggests, is caused in part by repeated traumatic brain injuries.”

“We’d like to thank our 1,330 donor families for teaching us what we now know about CTE, and our team and collaborators around the world working to advance diagnostics and treatments for CTE,” McKee said.

McKee and her team are inviting former athletes, including women, to participate in research studies designed to learn how to diagnose and treat CTE.

The BU CTE Center is collaborating with its education and advocacy partner the to recruit former football players and other contact sport athletes to five active clinical studies.

One of the studies, Project S.A.V.E., is recruiting men and women ages 50 or older who played 5-plus years of a contact sport, including football, ice hockey, soccer, lacrosse, boxing, full contact martial arts, rugby and wrestling.

To learn more about Project S.A.V.E. and four other studies enrolling participants, visit .

While the raw number of deaths rose by 1,428 from 2020 to 2021, the state’s overall death rate ticked down slightly — from 785.4 deaths per 100,000 people to 784.8, after adjusting for population growth and aging. That¶¶Ňőap a small enough change that it could be just statistical noise, according to state health officials

The state’s 2021 mortality data, finalized this month by the Colorado Department of Public Health and Environment, shows middle-aged people were especially hard-hit, the gap in death rates between white Coloradans and people of color narrowed slightly, and men’s life expectancy dropped more than women’s.

2020 was an inarguably bad year, with the pandemic contributing to above-average death rates for all major causes in Colorado except chronic lung disease and the general “influenza and pneumonia” category, which doesn’t include pneumonia caused by COVID-19.

But the year ended with hopes that vaccines would end the days of mass casualties from the virus and deaths from other causes would gradually return to normal as people were able to seek medical care and social support more easily.

That didn’t happen. While the COVID-19 vaccines did dramatically reduce the odds of dying, not enough people got them. A drug supply tainted with fentanyl drove overdose deaths to new heights. And though death rates from most chronic conditions fell in 2021, they didn’t get back to their pre-pandemic levels.

COVID-19 was the biggest factor by far, though.

In 2021, Colorado recorded 48,284 deaths, a figure that was 10,363 more than the pre-pandemic average — and 5,298 of those were caused by the virus. The rise in drug overdoses contributed 911 additional deaths, and increased heart disease deaths added 796.

“It is disconcerting to see (death) rates are still this high at the end of 2021,” said Emily Johnson, director of policy and analysis at the Colorado Health Institute.

Middle-aged adults hit hard

Death rates rose in 2021 for all age groups in Colorado except children between 10 and 17 and adults older than 75.

For younger children, the death rate was unusually low in 2020, mostly because fewer kids were killed in accidents or died by homicide. In 2021, both rebounded to pre-pandemic levels.

Fewer teens died in 2021 than in 2020, after adjusting for population growth, because of decreases in deaths from suicide, homicide, drug overdoses and other accidents. Most causes of death remained above pre-pandemic averages, with the exception of suicide, which last year took Colorado teens at the lowest rate since 2015.

The picture was bleaker for adults.

Most age groups in Colorado had higher death rates than in 2020, which was itself an unusually deadly year. For people between 45 and 74, COVID-19 caused the majority of the deaths beyond what was seen in 2020.

Deaths from the virus more than doubled in the 45-to-64 age group, from 594 in 2020 to 1,432 in 2021, and rose about 52% in people 65 to 74. Middle-aged people were somewhat slower to get vaccinated than the oldest groups, and the more-deadly delta variant walloped them in the summer and fall of 2021.

For adults younger than 45, overdoses were the biggest driver of increased death.

In the first decade of the millennium, overdose deaths were increasing most among women in their 50s, since that was the group most likely to be prescribed opioids, said Dr. Nora Volkow, director of the National Institute on Drug Abuse. Since about 2011, younger people have been more likely to die as heroin eclipsed prescription pills as the top threat, and then was surpassed by fentanyl, she said.

“We’re seeing, increasingly, groups that were not at risk for overdose are overdosing,” she said.

Death rates actually dropped for people over 75 in Colorado last year compared to 2020, though they remained above pre-pandemic levels. For the 75 to 84 group, the biggest factor was a drop in cancer deaths, which last year fell below the average in the five years before the pandemic. For people over 85, reduced deaths from COVID-19 and Alzheimer’s disease drove the decrease.

It’s possible that the decimation of older populations by COVID-19 in 2020 set the stage for at least a temporary decrease in death rates the following year, said Dr. Rong Xu, a professor of biomedical informatics at Case Western Reserve University’s School of Medicine.

“The population that survived 2020 may be healthier,” she said.

Men’s COVID, overdose deaths rose faster

The death rate among Colorado men increased slightly from 2020, while women’s death rate fell by a small amount, but neither was statistically significant. (The state’s data doesn’t account for people who are intersex or transgender.)

When comparing life expectancy, however, a bigger gap emerges. Colorado women lost roughly one month of life expectancy in 2021, bringing the average to 80.9 years. Men lost closer to 10 months, falling to 75.2 years.

Drug overdoses were a significant factor in the expanding gap. Fatal overdose rates rose about 59% above pre-pandemic levels among women and 95% among men. Since men were before the pandemic — as they have nationwide since at least the late 1990s — that translated to roughly double the death rate from drug poisoning that women faced in 2021.

Men have been more likely to use illicit drugs than women for a long time, and with more people exposed, there are more deaths, Volkow said. The gender gap was narrower when prescription drugs were the top threat, but has expanded over the past decade, she said.

The gender gap was smaller, but still significant, when it came to COVID-19. There were about 107 deaths from the virus for every 100,000 men in Colorado last year and 62 deaths for every 100,000 women.

The biggest risk factor for dying of COVID-19 is age, and women live longer than men, meaning they’ve hardly been spared from the virus.

The gender gap is most evident when looking at people ages 45 to 64, said Richard Reeves, a senior fellow at the Brookings Institute who has written a book about men’s health. While both sexes were about equally likely to get the virus, studies in multiple countries have found men are more likely to be hospitalized, need intensive care or die from COVID-19, he said.

“It suggests that it’s not just cultural factors and the way American men are behaving,” he said.

Initially, women made up a disproportionate share of people receiving COVID-19 vaccines. Colorado’s population is split almost 50-50, but 62% of people who’d received a vaccine at the end of January 2021 were women, perhaps because they account for a larger percentage of health care workers and nursing home residents, who were among the first groups allowed to get the shots.

By the end of July 2021, as eligibility opened up, the state was much closer to parity, with women making up 52% of vaccine recipients. The percentage hasn’t changed much since.

There’s no one answer to why men seem to do worse when infected with COVID-19, but a few factors may contribute, said Dr. Michelle Barron, senior medical director of infection prevention and control at UCHealth.

Women generally produce more antibodies after vaccination or infection, which may help their immune systems stop the virus early — but also put them at higher risk for conditions where the immune system attacks the body itself. There’s also some evidence that estrogen may help tamp down runaway inflammation that causes severe lung scarring, she said.

It’s also possible that the average man who got the virus had more underlying conditions than the average woman, or that smoking rates may be a factor, Barron said. Most respiratory viruses don’t have this kind of gender gap, though, so it’s going to take time to sort out where it might come from, she said.

“I don’t think we’ve come to any definitive conclusion yet as to the ‘why,'” she said.

Continued disparities in life expectancy

Most ethnic groups in Colorado saw lower overall death rates in 2021 than in 2020, but the drops varied significantly, and long-standing disparities remained in place.

In 2020, life expectancy dropped most for Black and Hispanic Americans. In 2021, however, those groups held steady while life expectancy dropped among white Americans — though the 2020 drop was severe enough that the impact on Black and Hispanic communities .

In Colorado, life expectancy increased slightly for the Black and Asian populations from 2020 to 2021, and held steady for white women. All other groups saw life expectancy drop, though the existing disparities didn’t change much: multiracial, Asian and white populations continued to have the highest life expectancies, while Black and American Indian residents were projected to live the shortest lives.

Black Coloradans continued to have the highest age-adjusted death rates, despite a nearly 7% improvement from 2020. Death rates among Asian residents dropped by about 9%, while for white and Hispanic Coloradans, the drop was less than 1%. (Rates rose among people who identified as American Indian, Pacific Islanders or multiracial, but the populations are so small that the increases can’t tell us much.)

The narrowing gap between white residents and people of color in Colorado largely reflects a change in the pattern of COVID-19 deaths, Johnson said. Larger drops in deaths from the virus among Black and Asian people suggest vaccination outreach efforts to those communities were generally effective, while there’s still work to be done reaching Latinos and certain subgroups of the white population, she said.

Colorado changed how it collected data about race and ethnicity in 2020, so it’s difficult to make direct comparisons between current and pre-pandemic death rates, Johnson said. Still, even though the numbers aren’t exact, it’s clear death rates increased more for people of color in the first year of the pandemic, she said.

“The gaps widened worse than ever, and then narrowed somewhat” in 2021, she said. “COVID put in stark contrast where those inequities are.”

More accidents, fewer lung disease deaths

Cancer dropped to the second-leading cause of death in 2021, behind heart disease. Despite the widespread availability of vaccines for half of 2021, COVID-19 was the third-leading cause of death again, and the death rate from the virus actually increased more than 10% over its 2020 level.

Colorado’s first COVID-19 deaths weren’t recorded until early March 2020, meaning the virus had about 10 months to wreak havoc, rather than the full year in 2021. Still, most experts thought the worst was over at the start of 2021 because vaccines were starting to reach older people, who were at the highest risk of dying; hospitals had learned how to better treat COVID-19 patients; and some of the population had partial protection from previous infections.

Vaccine uptake was slow in some groups, though, and Colorado and other states started lifting restrictions to control the virus just as the delta variant arrived last year. Delta was more likely to cause severe illness, though vaccines remained highly effective at preventing hospitalizations and deaths.

Accidents other than drug overdoses moved up to become the fourth-leading cause of death, as more people died that way and fewer were lost to chronic lower respiratory diseases, such as emphysema.

Cerebrovascular disease (strokes and related conditions) and Alzheimer’s disease remained in sixth and seventh positions, as they were in 2020. Accidental overdoses overtook suicide as the eighth-highest cause, and chronic liver disease rounded out the top 10 causes of death.

Overdose deaths have been generally trending up since 2000, though they jumped faster in 2020 and 2021. The state reported 1,680 overdoses believed to be accidental, and 201 where the death was ruled a suicide in 2021.

Almost half of the fatal overdoses in 2021 included fentanyl, and about 40% involved methamphetamine. About 17% involved both.

Fentanyl is cheap and easy to ship by mail, so drug dealers are mixing it with other illicit drugs or pressing it into pills that look like medications for pain, anxiety or attention deficit disorder, Volkow said. It only costs about $1.25 to make a fake pill out of fentanyl, so dealers can offer it at a significant mark-up and still have a cheaper product than people selling real pills that have been stolen, she said.

Some people choose to mix substances like fentanyl and methamphetamine, while others tried to buy one drug and unknowingly took more, increasing their risk of death, Volkow said. People are also at increased risk if they take certain medications, such as benzodiazepines for anxiety or gabapentin for pain or seizures, and then take legal or illicit opioids, she said. Drinking alcohol while using opioids also increases the odds an overdose will be fatal.

If 2021 was a particularly bad year for overdoses, it was a relatively good one for lung disease in Colorado. The death rate from influenza and pneumonia, one of the only causes to decline in 2020, fell for a fourth straight year. Chronic lower respiratory diseases also resumed the downward trajectory that had been interrupted in 2020, and killed fewer people than before the pandemic, after adjusting for population growth and aging.

Treatment of lung disease has improved in recent years, as newer and easier-to-use medications came on the market, said Dr. Carrie Horn, chief medical officer at National Jewish Health. It’s difficult to know how much of the reduction in lung disease deaths in 2021 was due to a continuation of that trend, versus a mild flu season caused by COVID-19 precautions, or even differences in how death certificates were filled out, she said.

Alzheimer’s disease deaths fell in 2021 and approached pre-pandemic levels, but it’s not clear if that’s a one-time phenomenon. In Colorado and nationwide, they had spiked in 2020.

COVID-19 appears to speed up the process of decline in people with Alzheimer’s, so it may have pushed some people who otherwise might have lived longer to the end stage of the disease in 2020, Xu said. By 2021, vaccines and treatments made the virus less of a threat, which may have helped lower the toll from causes like Alzheimer’s, she said.

“Probably COVID played a big role,” she said.

When will “normal” return?

It’s not clear whether death rates will return to pre-pandemic levels in 2022. Economic downturns typically lead to increases in violent crime, overdoses and delayed medical care, so if there is a recession this year, it would work against any positive trends, Johnson said.

So far, Colorado has recorded 434 drug overdose deaths halfway through the year. Unfortunately, that doesn’t necessarily mean this year is on track to be less deadly, because it can take months for full toxicology information to come in.

Volkow said she doesn’t expect overdose deaths to decline just because life is more normal. To make a change, the country needs more treatment for people with opioid use disorders; education for people casually buying pills about the danger they may contain undeclared fentanyl; access to fentanyl test strips for illicit drug users; and information about reducing the risk of a fatal overdose for people who choose to use fentanyl, she said.

“I am afraid the patterns (of overdoses) will continue to increase unless there is a very strong investment,” she said. “It’s not going away by itself.”

It’s less clear if the worst of the death toll from COVID-19 is over.

Since Jan. 1, the state health department has reported 2,228 deaths among people who had COVID-19, with more than half recorded in the first two months of the year during the omicron wave. The death toll had fallen steadily since mid-February, though it has started to tick up in recent weeks.

While the tallies include some people who had COVID-19 and died of something unrelated, those are expected to account for a small percentage of deaths with the virus. Barron estimated that fewer than 5% of those who die among people hospitalized with the virus ultimately are found to have died of something else.

The odds of dying from the virus went down as treatment improved and omicron replaced the delta variant, Barron said, but the raw number of deaths at the worst point of the omicron wave over the winter was comparable to delta’s peak in fall 2021, because so many people were infected that even a relatively low mortality rate translated into a high toll.

What happens with COVID-19 deaths this year will depend on several factors, like how well the vaccines available this fall match circulating variants and whether people choose to get them, Horn said. About 75% of Colorado residents over 65 have received a third dose of the shot, though booster uptake is considerably lower in younger age groups. The state doesn’t publish data on fourth doses.

No one knows yet if some of the drops in death from chronic illnesses are a step toward returning to pre-pandemic conditions or a blip. Deaths from Alzheimer’s may actually increase beyond the growth expected from an aging population, as people who experienced cognitive damage from COVID-19 develop dementia earlier than they otherwise might have, Xu said.

It also remains to be seen how much of an impact delayed care will have, Horn said. Waiting longer to start medications and pulmonary therapy for chronic lung disease tends to lead to worse outcomes, but a delay of the same length could be far more damaging for one person than another, she said.

“The earlier we can catch a disease process, the more we can stop that downward slope,” she said.

Horn said she hopes that the dramatic reductions in flu deaths in 2020 and 2021 motivate changes to protect vulnerable people going forward, by showing what’s possible. The age-adjusted death rate from flu was about 17% below the pre-pandemic average in 2020 and 48% below average in 2021.

“It was really impressive to see what masking and social distancing and hand hygiene could do,” she said.