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Amy Barnhorst MD
Amy Barnhorst MD

The Hidden Cost of COVID Shutdowns

It's not just in dollars; eventually, it will be in lives too.

Some leaders are calling for an end to stay-at-home orders to save the economy, while public health experts argue this will result in a surge of COVID deaths. The implication is that we have to choose between a financial crisis and a public health crisis, and that lives are more important than money. But economic crises are public health crises. Unemployment, lack of education, poverty, and homelessness kill people, too.

These factors, known as the social determinants of health, worsen mental and physical health, and increase mortality. But they kill people much more slowly than an infectious virus, and in quiet coordination with other factors; they’re rarely named as a direct cause of death. It’s understandable that we push them out of our minds when faced with a more immediate and identifiable foe.

Lack of education is one such killer. The COVID shutdowns have changed schooling across America, with teachers struggling for competence at online content delivery, and parents acting as poorly trained and highly frustrated homeschoolers. Many schools lost weeks of learning time to the transition. But with a hastily planned curriculum, technological barriers, and a lack of personal connection to teachers and school supports, students are the big losers. Those who were hanging on to their education by the thinnest threads will be the first to fall off.

Dropping out of school won’t be immediately fatal. But lower levels of education are associated with obesity, increased rates of smoking and drinking, and less physical activity. All of these are risk factors for cardiovascular disease, the number one killer of Americans. The effects will take decades to accumulate, and even then, it won’t be easy to trace a patient’s lung cancer directly back to the COVID crisis. But when we zoom out and look at large groups of people over time, poor education and poor health go hand in hand.

Other childhood opportunities may also be diminished by parents' new economic circumstances. Jobless rates have reached an unprecedented high, and while unemployment payments and stimulus checks may bolster people for a few months, the money will run out before the jobs come back. When the emergency orders against evictions and foreclosures expire, people without jobs will become people without housing. We’re likely to see a new wave of homeless families and all the health problems that accompany this.

Homeless people die, on average, about 20 years sooner than people with housing. If you’re homeless, it’s hard to get to the doctor, pay for your medications at the pharmacy, and manage to take them regularly without them being lost or stolen. This may account for the elevated death rates among the homeless from things like infections, cancer, and heart disease. And homelessness introduces new mortal threats, like tuberculosis, assault, and hypothermia.

Without jobs, many people will also lose their health insurance. Sure, they can enroll in coverage provided by the Affordable Care Act, but coverage doesn’t get you an appointment with a new doctor before prescriptions run out. Nor does it keep the cost of medications affordable. People will go without their inhalers, their insulin, and their chemotherapy. With even a month-long delay in care, they will get sicker. The cause of their eventual death won’t be recorded as “loss of insurance due to COVID shutdowns”. It will just say “diabetes”.

As social isolation, chronic health conditions, unemployment, and economic stress increase, so does the risk of suicide. That risk is enhanced by alcohol and depression, which also fuel each other; people often self-medicate their depression with alcohol, which is itself a depressant that diminishes impulse control and judgment. It doesn’t help that heavy drinkers are more likely to have access to the most lethal of suicide methods, firearms, ensuring that a suicide attempt won’t be likely to result in a second chance. Suicide rates had already been climbing for a decade in the United States before COVID, but our interventions to quell the new epidemic may inadvertently fuel an old one.

Alcohol sales, like firearm sales, are booming during the shutdowns. Beyond increasing suicide risk, drinking can cause liver damage, anemia, and cancer. Its effects are so detrimental and its use so common that alcohol is the third-highest preventable cause of death in the US.

Alcohol also contributes significantly to cardiovascular disease, the most common cause of death in our country, but perhaps more surprisingly, so does depression. People with depression are about twice as likely to have a heart attack, and five times more likely to die from it in the following months. Unemployment and poverty contribute to both alcohol use and depression, and alcohol use and depression, in turn, increase cardiovascular disease. But by the time someone dies of a heart attack, few will attribute it to them having lost their job a decade ago.

This is not an argument that the public health threat from the economic shutdown is worse than that from the coronavirus epidemic. It’s is just harder to see, and therefore easier to ignore. Social determinants of health play off one another to enhance and amplify risk, working silently through surrogate assassins, like heart disease and cancer. Their effects are best quantified in large groups over long periods of time, and that kind of research is difficult to do. Most of us would reasonably choose a possible future death from one of many chronic illnesses than death from COVID in the next month.

Image by Leroy Skalstad from Pixabay
Reinstatement of workers in carefully redesigned workplaces could slow the downward slide for millions of Americans.
Source: Image by Leroy Skalstad from Pixabay

But as we weigh re-opening measures, we need to keep in mind that this is not just a tradeoff between lives lost now and money lost later. It’s also between lives lost now and lives lost later. The people most affected will be those whose position on the socioeconomic ladder was tenuous, to begin with, and are now being pushed down into a slippery zone where one loss begets another in a destructive and irreversible chain reaction. Like the virus, the economic consequences of the shutdowns will disproportionately affect the most vulnerable—people living just above the poverty line, people with chronic medical and mental illness, people of color from poorer communities. They will also be the ones with the least say in all this.

For those who can work from home, afford a laptop for every kid, and pay the delivery fees for takeout and grocery delivery, not reopening for an extended period is the obvious choice. We can avoid almost any coronavirus exposure risk by sacrificing relatively little. But for others who depended on their income from retail, restaurants, or hospitality work, a well-planned and cautious return to business might be a risk worth taking to stave off the specter of decline looming over their futures. Haircuts may not be essential for people getting them, but they're certainly essential for hairdressers.

We’ve stayed home these last few weeks to protect others as well as ourselves, let’s continue to work for the collective good as we think about reopening. With the vast amount of coronavirus knowledge gained in the time we bought with the shutdowns, leaders can orchestrate a safe plan to restore low-risk workers in carefully redesigned workplaces. This plan must be based on scientific evidence, as well as on risk-benefit analysis, and it needs to be adjusted as new information emerges. We also need testing and contact tracing, and a way to support those who give up a paycheck to self-isolate after an exposure. Failure of leadership to do this will result in desperate people making reckless decisions in a bid to save their livelihoods. A cautious loosening of stay-at-home orders could bolster the economy and slow the downward slide for millions of Americans while keeping infection risk at a minimum.

The coronavirus is not going away any time soon, and each week of shutdowns pushes more people into unemployment and poverty, and the health problems they bring. Getting people back to work is not without risk, but it will save more than just money.

About the Author
Amy Barnhorst MD

Amy Barnhorst, MD, is Vice Chair for Community Mental Health in the Department of Psychiatry at the University of California, Davis.