COVID-19 has swept the world in a global pandemic of extraordinary proportions. The debate about its eventual health costs continues to rage, but one Centers for Disease Control estimate suggested anywhere between 200,000 and 1.7 million deaths could be expected in the United States alone, depending on the eventual fatality rate, and not adjusting for corrective measures currently in place (although in recent days a revised projected figure of 60,000 deaths has been reported by the Institute for Health Metrics and Evaluation). This makes the pandemic a terrifying proposition—one that has appropriately galvanized public attention globally.
In direct response, countries worldwide, starting with China, where the virus was first diagnosed, have been implementing physical distancing measures that are becoming increasingly comprehensive and prescriptive as COVID-19 infections continue to rise and threaten to overwhelm health systems. These measures vary by state and locality in the United States, and by early April included 30 statewide orders generally directing people to stay at home except for essential activities.
There is little question that some of these measures are necessary, and that absent such efforts we run the risk of overwhelming fragile health care systems and incurring substantial mortality. The challenge, unfortunately, is that the solution we are adopting is not cost-free and can have devastating health consequences in and of itself. We are causing an economic slowdown of the entire country, and by consequence the world, the effects of which will be felt for years to come. In terms of employment, the initial signs of damage are sobering. In the last three weeks, unemployment claims jumped to a shocking 16.8 million. Should unemployment continue towards 20 percent, as some forecasts indicate, tens of millions of Americans could be out of work
Should unemployment move into double digits, as forecasts generally indicate, tens of millions of Americans could be out of work. Unlike the Great Recession in which almost everyone was affected, it is highly likely that due to the nature of these measures, job losses will disproportionately fall on lower-paid jobs where teleworking is not possible. Data from the U.S. Bureau of Labor Statistics (2017–2018) showed only 9.2 percent of jobs with earnings equal or below the 25th percentile could be done through telework.
Reflecting historical and structural injustices reflected in the labor market, there are also stark differences by race and ethnicity in the ability to work remotely. Those who cannot do so include a disproportionate number of African Americans and Hispanic/Latino Americans; whites are twice as likely to be able to telework than are minority groups. Unemployment due to social distancing, in addition to being vast in scope, is thus likely to exacerbate existing inequities among racial/ethnic groups.
The attendant loss of income will most affect those least able to afford it. Data from 2018–2019 compiled by the U.S. Federal Reserve suggested that one in 10 U.S. adults already struggled with monthly bills. The research also reported that if faced with an unexpected bill of just $400, 27 percent of Americans would need to borrow or sell something to pay for the expense (not including use of credit cards) and 12 percent would not be able to cover the expense at all. These figures are likely to expand in response to job losses and reduction in available working hours in these populations.
Compounding job losses is the effect of school closures. School systems provide significant social support, particularly for single parent households. Over 10 percent of all African American households consist of a single female parent with one or more children, now facing the double burden of job insecurity and lack of childcare options. School closures also disproportionately affect the over 1,3 million U.S. school children who were already homeless, for whom the support of a school environment is particularly essential.
The coming economic recession is also likely to have a lasting effect on salaries in the longer term, with particular implications for those graduating in 2019–2020. Young workers often bear a significant burden in times of recession, both in terms of higher unemployment rates, and lower salaries, which tend to fall the most for new entrants to the job market. Just over half of graduates following the Great Recession found a job nine months after graduation, often with poorer conditions and pay than they would have otherwise. These consequences are long-lasting, with drops in earnings persisting decades later. Compared to entering work amidst unemployment rates of around 5 percent, those entering the job market when unemployment is high (around 20 percent), have in the past faced an average annual wage loss of 20 percent, even 15 years postgraduation.
Therefore, quantifying the economic changes brought about as a result of COVID-19 will require an account for the disproportionate effect on the 38.1 million Americans already in poverty (a number likely to substantially increase); the almost four million college graduates in 2019–2020; the 6.6 million Americans who filed for unemployment by early April; and the many more who may lose their jobs in the coming weeks. While the relief package enacted by Congress stands to mitigate some of these changes, much will depend on how the measures in this package are actually implemented and the extent to which this implementation succeeds in stanching job losses due to economic contraction.
The scale and unequal distribution of this disruption to human life must give us pause. Such measures do not just cause economic disruption but are also acutely harmful to population health. Focusing only on the health harms associated with unemployment, loss of income, and the broad impact on mental health outcomes associated with traumatic events and social isolation can give us a sense of the tip of the iceberg.
Unemployment has long been associated with a significantly increased risk of death in general, particularly for low-skilled workers in the U.S.. The risk of heart disease, the leading cause of death in the U.S. at almost 650,000 deaths per year, has been shown to increase by 15–30 percent in men unemployed for more than 90 days. Among older workers, involuntary job loss can more than double the risk of stroke, which already claims 150,000 lives in the U.S. per year, as well as increase the likelihood of depressive symptoms that then persist for years. Such harms are likely exacerbated by concomitant longer term social isolation, which in of itself is associated with a 30 percent increase in mortality risk. Loneliness and social isolation have been associated with a 29 percent increase in risk of incident coronary heart disease and a 32 percent increase in risk of stroke. The scale of these elevated health risks is significant—comparable to that caused by taking up light smoking or becoming obese.
Income itself, of course, is strongly associated with poorer health across the income distribution, whether measured by life expectancy, health status or infant mortality. The gap in life expectancy between the richest and poorest 1 percent of individuals in the U.S. is around 14 years, a gap that, unlike in other high income countries, has continued to grow in recent years.
The loss of earnings associated with being on a recessionary economic curve upon graduation also leads to adverse and lasting health outcomes. Graduating in a recession is associated with roughly a 6 percent increase in that cohort’s mortality rate, adjusting for age. A 1 percent increase in state unemployment level when first entering the job market has been associated with a 6.7 percent increase in depressive symptoms among men by age 40.
The toll on mental health at the population level is also likely to be substantial, bearing in mind the combination of social isolation; job and income loss; and justified fears regarding COVID-19. Previous research has shown severe economic recession to be associated with an increased prevalence of psychological distress, common mental disorders, substance abuse disorders and suicide.
The unemployed, those in debt or facing financial difficulties, people with preexisting mental health problems, and families with children being particularly affected. Economic recession is of itself a traumatic event, particularly when combined with a pandemic and social distancing measures. Following other natural or human-made disasters, the prevalence of post-traumatic stress disorder has been reported as 30–40 percent among those immediately affected, 10–20 percent among rescue workers and 5–10 percent in the general public. Almost 10 percent of New Yorkers increased smoking rates and almost 25 percent increased alcohol intake following the September 11 terrorist attacks.
COVID-19 is a global health threat that demands bold action, despite gaps in our data and understanding. However, all actions we take need to account for the full scope of their consequences, particularly as those consequences pertain to the most vulnerable in society. Serving the public good requires that we balance the urgent threat COVID-19 represents, while bearing witness to the inequity this crisis and measures to address it are exposing and exacerbating.
It also demands that we treat both with the same attention. The public discussion around COVID-19 has seen much conversation about the consequences of the urgent—those affected by the virus itself—but far less conversation about the important consequences of our mitigation efforts. Both are essential, both shape the health of the public, and both need to inform public policy, including our present-day actions and our future thinking about how we prevent the consequences of pandemics to come.