Excess Deaths During the COVID-19 Economic Downturn

More than 700 000 people have died from COVID-19 in the United States over the last year and a half since the pandemic began.¹ Measures to stop the spread of COVID-19, such as stay-at-home orders and business closures, together with severe disruptions in overall economic activity brought about a short but deep economic recession. The Bureau of Economic Analysis of the US Department of Commerce estimates that real gross domestic product in the United States decreased at an annual rate of 19.2% from the fourth quarter of 2019 through the second quarter of 2020.²

In this issue of AJPH, Brenner (p. 1950) investigates excess deaths associated with unemployment and bankruptcies during the COVID-19 recession. The sharp economic downturn experienced by the United States last year is likely to lead to higher mortality over the next five to 10 years.³ The key question Brenner answers is whether higher unemployment and business closures due to the pandemic have a more immediate, same-year effect on excess deaths.

EXCESS DEATHS BEYOND COVID-19

Brenner uses data for the 50 US states from prepandemic years (2000–2018) and pandemic months (February 2020–November 2020), together with regression analysis, to study how the unemployment rate, GDP per capita with a 5-year lag, health care workforce size per 1000 total employment, and bankruptcies are related to excess deaths. His statistical approach controls for the number of COVID-19 cases and other key demographic and behavioral risk variables. The results of his study show that unemployment and bankruptcies during COVID-19 are significantly related to excess deaths. For example, 10% additional unemployment (i.e., unemployment rate as a proportion of the total labor force) is associated with 35 700 excess deaths, and a rate of 120 total bankruptcies per 100 000 people is associated with 144 483 excess deaths (Brenner, Table 2). Interestingly, his study finds that the size of the health care workforce also has a strong inverse relationship to excess deaths. This may have implications on the role of public health and health care delivery system investments in mitigating the negative population health consequences of economic downturns.

There is no question that the COVID-19 pandemic has had a disproportionate impact on communities of color, particularly Blacks and Hispanics/Latinos. Survey data from April 2020 to March 2021 from the Understanding Coronavirus in America Tracking Study show that 89% of Latinos and 86% of Blacks experienced at least one serious economic, psychological, or health-related hardship compared with 76% of Whites.⁴ Brenner’s study suggests that the impact of the pandemic will be even larger than expected for these two racial/ethnic groups given their high unemployment rates and their high presence in business sectors highly affected by the pandemic, such as the hospitality industry and retail and food services. In other words, not only are Blacks and Hispanics/Latinos at relatively high risk for COVID-19 because of where they live and work, but the population health and equity consequences of the pandemic are likely to be dramatic for them given the independent impact of unemployment and bankruptcies on excess deaths. What we are seeing now is just the tip of the iceberg in the sense that these economic effects take a few years to fully manifest themselves (i.e., they occur with a lag).

THE TIME TO ACT IS NOW

Brenner’s study highlights the need to implement measures to address issues directly related to a specific event, such as a pandemic or a natural disaster. In addition, it points out that it is essential to immediately and swiftly confront related challenges such as job loss and disruptions in economic activity in economic sectors and communities affected by a catastrophic event. Policy conversations often tend to focus on dealing with what may seem like the most critical, immediate needs (e.g., vaccine distribution in a pandemic, food distribution after a hurricane), but it is never too early to start the conversation and, more importantly, to act to meet other needs that become evident much later, when it could be too late (e.g., avoiding business closures or providing adequate unemployment assistance). The main consequence of not doing something in the face of a sharp economic downturn is a more pronounced impact on the most vulnerable. The experience from the COVID-19 recession and other economic downturns and natural disasters suggests that this will certainly be the case.

INVESTMENTS IN PUBLIC HEALTH INFRASTRUCTURE

An interesting finding of Brenner’s study is that the size of the health care workforce seems to have partially suppressed the harmful effects of economic downturns during the 2000–2018 period. Although this finding may be difficult to interpret, it is consistent with the idea that a strong public health and health care infrastructure can help everyone to weather the negative effects of economic downturns on population health. The Affordable Care Act led to substantial investments in the health care infrastructure of the United States and expanded health insurance coverage.⁵ Perhaps these types of investments have had the unintended benefit of making it easier to address COVID-19 challenges for public health and health care delivery systems. For example, the largest municipal health care system in the United States (New York City Health + Hospitals) reports that its ability to effectively serve COVID-19 patients, and all other patients, resulted from investments in an integrated electronic health system for its multiple safety net clinics and hospitals shortly before the pandemic began.⁶

THE FUTURE IS SOMEWHAT PREDICTABLE

Highly transmissible variants of the SARS-CoV-2 virus (the virus that causes COVID-19) have surfaced already and are likely to continue emerging without the adoption of strong mitigation measures.⁷ A more transmissible virus threatens to partially reverse the progress made to contain COVID-19 through vaccination and other preventive efforts. A virus resurgence and a subsequent economic slowdown will certainly have a disproportionate impact on the same populations that have experienced the worse effects of what feels like a never-ending pandemic.

Brenner’s study provides important insights on what to expect in the immediate and near future in terms of mortality. The most recent life expectancy estimates from the National Vital Statistics System show that between 2019 and 2020, life expectancy at birth in the United States declined by 3.0 years for the Hispanic population, 2.9 years for the non-Hispanic Black population, and 1.2 years for the non-Hispanic White population.⁸ These sharp declines in life expectancy and the differences across racial/ethnic groups highlight the need to continue to delve deeper into how recessions, pandemics, and natural disasters are related to population health and health disparities.