Will “Deaths of Despair” Outpace Deaths From Coronavirus?
By most accounts, modeling of the coronavirus epidemic by researchers at Imperial College London convinced the Trump administration to call for extreme social distancing (no more than 10 people gathered) in order to “flatten the [growth] curve” of the coronavirus epidemic. The Imperial College London modeling also became the basis for the 100 page “U.S. Government COVID-19 Response Plan.”
The Imperial College London model is woefully inadequate. It does not model increased use of personal protective equipment in the general public such as face masks. It does not model medical interventions that have shown promise in reducing fatalities including chloroquine, hydroxychloroquine, hydroxychloroquine + azithromycin, and intravenous L-ascorbic acid. And the Imperial College London model does not take into account “deaths of despair” from a sharp rise in unemployment that will be triggered by sheltering in place for weeks, months, or years (the “U.S. Government COVID-19 Response Plan” estimates that the “pandemic will last 18 months or longer”).
The social determinants of health
There is a large volume of academic literature on “the social determinants of health” and “deaths of despair” caused by increases in the unemployment rate. The pioneering work in this field was conducted by Harvey Brenner (then at Johns Hopkins University) on behalf of the Joint Economic Committee of the United States Congress in the mid 1970s. Reviewing U.S. historical data over the period 1940 to 1973, Brenner found that:
…a 1% increase in the unemployment rate sustained over a period of six years has been associated (during the past three decades) with increases of 36,887 total deaths, including 20,240 cardiovascular deaths, 920 suicides, 648 homicides, 495 deaths from cirrhosis of the liver, 4,227 state mental hospital admissions, and 3,340 state prison admission.
Brenner’s estimates held up in subsequent studies of England & Wales, Japan, Australia, and New Zealand. It should be noted that there is also a large volume of literature that is critical of the Brenner model (see e.g. Cohen & Felson, 1979).
Brenner’s estimates are based on population figures from 1970. According to the U.S. Census bureau, the U.S. population was 205.1 million in 1970 and 327.2 million in 2018 — an increase in the population of 59.5%. So the actual increase in mortality caused by a 1% increase in the unemployment rate today (if it persisted for five years) might be closer to 58,834 lives lost. A more recent meta analysis of 42 studies conducted in 15 countries on the relationship between unemployment and all-cause mortality found that unemployment increased the risk of dying by 63% (Roelfs et al. 2011).
So how many additional deaths will be caused in the U.S. by the increase in the unemployment rate caused by government orders to shelter in place? That depends on a lot of factors including the number unemployed and the length of unemployment. The official unemployment rate in February 2020 according to the U.S. Bureau of Labor Statistics was 3.5%. Treasury Secretary Steve Mnuchin warned lawmakers of the possibility of a 20% unemployment rate from coronavirus shutdowns unless Congress passes a $1 trillion stimulus plan (although he walked the statement back the next day). New Jersey, Pennsylvania, and Minnesota all report 10- to 12-fold increases in the filing of unemployment claims last week.
The coronavirus economic crash
Two-thirds of the U.S. economy depends on consumer spending. With many states and cities moving towards various forms of lockdown, extreme social distancing, and sheltering in place (terms that were unheard of even a week ago) it is unclear whether even a massive federal stimulus will be enough to reduce the surge in unemployment that has already started in the United States.
The 2008 financial collapse shows that once the economy slows to a standstill, it takes years to bring it back up to full speed again. A study by Schularick & Taylor (2012) of recessions in 14 countries over the period 1870–2008 shows that it takes two years for a country to recover from a normal recession whereas it took 10 years to recover from the Great Depression. While a recession seems highly likely at this point, it is anyone’s guess how long it will last.
Let’s examine 3 scenarios: lower bound, mid-range, and upper bound. Following the Brenner (1976) model, these figures all reflect the estimated cumulative impact of an increase in unemployment on mortality over a five-year lag period.
Lower bound. If the unemployment rate increases by 5 points as a result of the various lockdowns, then 294,170 additional lives will be lost, not from coronavirus, but from deaths of despair.
Mid-range. If the unemployment rate increases by 16.5 points (as predicted by Treasury Secretary Mnuchin), then 970,761 additional lives will be lost to deaths of despair.
Upper bound. And if the unemployment rate increases by 10-fold — which is what we are already seeing in several states — then 1,853,271 lives will be lost to deaths of despair from government orders to lock down, shut down, and shelter in place.
The magnitude of the association between unemployment and mortality is higher for men than women and higher in early career and middle career workers than older workers (Roelfs et al., 2011, p. 849). It seems reasonable to assume that the coronavirus economic crash will also disproportionately impact the poor and working classes who lack sizable financial reserves.
A wide range of authors are now raising questions about the advisability of widespread lockdowns of indeterminate length (see: Editorial Board of the Wall Street Journal, David L. Katz, Thomas Friedman, Russell Berman, and Romer & Garber).
If government wants to minimize total fatalities from this crisis it must do better modeling. Greater use of personal protective equipment and improved medical interventions will bend the curve and should be acted upon immediately. Deaths of despair must be modeled along with deaths from coronavirus based on realistic, verifiable, independent data on prevalence and mortality rates. As it stands right now, deaths of despair from crashing the economy via lockdowns will significantly add to the final death toll and may end up surpassing fatalities from the virus itself.