key: cord-0820866-3i43x17v authors: Bhatia, R. title: Quantitative Estimation of Covid-19 Related Unemployment On Suicide and Excess Mortality in the United States date: 2020-05-08 journal: nan DOI: 10.1101/2020.05.02.20089086 sha: 95ccbe33a951decc808ca6c6bfc790ba3acef8a4 doc_id: 820866 cord_uid: 3i43x17v Introduction: To date, reducing virus transmission to mitigate demand on health care systems has been a singular objective of Covid-19 policy action. This aim has driven widespread and rapid application of untested policies to control contagion, including the deployment of non-pharmaceutical interventions (NPIs), including travel restrictions, bans on gathering, and community-wide lockdowns. Risk models, public health experts and political leadership alike have given almost no attention to related, anticipated, and predictable societal and health impacts likely to result from behavioral responses to Covid-19 combined with the application of NPIs. Methods: This analysis demonstrates a standard risk assessment approach to quantify the impacts of Covid-19 unemployment in the United States on suicide and all cause mortality. Results: Applying observational epidemiological data to the population recently unemployed predicts 7444 deaths from suicide in the coming year and 556,000 avoidable deaths from all causes over the next ten years. Discussion: Indirect health impacts of societal responses to Covid-19 are likely and quantifiable. Decision-makers can now include indirect health impacts into their policy making calculus for Covid-19 to strike a balance between the benefits and costs of mitigation. A full trade-offs analysis of alternative planning scenarios will likely reveal multiple unconsidered ethical challenges that need transparent public discussion and solution. Optimal health requires the fulfillment of multiple human needs. Among them are safety and protection, a sustainable livelihood, social relationships, meaning and purpose, and freedom and autonomy. Health is a need in itself as well as the product of the fulfillment of human needs. The Chilean economist Manfed Max-Neef astutely pointed out that society often does something to singularly satisfy one need but, tragically, in doing so, undermines several others.(1) Optimal social decisions are: holistic and multi-objective, considering the impacts of multiple needs simultaneously; forward looking understanding that actions cause reactions; equitable, understanding that impacts can fall on different groups unequally; participatory, valuing diverse perspectives and consensus; and transparent, upholding democratic ideals. (2) To date, reducing transmission of the Covid-19 virus in order to both avoid death and mitigate demand on health care systems has been a singular aim of policy action. The spectre of overwhelmed tertiary health care (e.g. ventilator rationing) forecast by influential modeling institutes, has driven widespread and rapid application of rarely used policies to control contagion, including the deployment of non-pharmaceutical interventions (NPIs), including travel restrictions, bans on gathering, and communitywide lockdowns. (3) Risk models, public health experts and political leadership alike have given less attention to indirect health impacts likely to result from behavioral responses to Covid-19 and the application of NPIs, despite their being both predictable and severe. Such anticipated secondary effects include fear and anxiety, deferred or delayed health care, social isolation, business closures, unemployment, bankruptcies, foreclosures, and homelessness. (4) Available economic and risk assessment methods could help evaluate and quantify these secondary health impacts. Quantification of the indirect health impacts are also possible.(5) The needs of optimal policy making as well as pandemic response plans require including these indirect impacts on decision-making scales. Outcomes that might help balance our collective response to Covid-19 and might lead to policy countermeasures, such as income support. One early and visible consequence of the response to the pandemic has been widespread unemployment. Unemployment results both from individual-level changes in consumer behavior as well as governmental restrictions on mobility and economic activities. As of April 30th 2020, in the United States, thirty million Americans have become newly unemployed due to the combined public, private, and governmental responses to the Covid-19 pandemic. A similar situation exists in many other countries. A substantial literature now exists on the associations among unemployment and poor health. A review of studies conducted following the great recession of 2007 found that unemployment may contribute to hunger, the loss of housing, declines in birthweight, increased symptom reporting, substance abuse, disability, medication use, and hospital visits, and untimely deaths due to suicide.(6) Study of suicide conducted in the aftermath of the great recession, observed that a 1% increase in the unemployment rate translated into a nearly 1% increase in the suicide rate in the US.(7) Between 2007 and 2010, the authors estimated that the recession produced an extra 4750 excess suicide deaths. In 2017, the U.S. age-adjusted suicide rate was 14.0 per 100,000 population, with rates varying by state. Unemployment rates have increased from 3.8% to over 20% in the US in the months following Covid-19. A simple extrapolation of the observational data from the 2007 post recessionary period predicts an excess 7444 deaths from suicide in the coming year. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 8, 2020. Excess death from all causes is a commonly used summary measure of health impact. A meta-analysis of 40 studies, primarily in OECD countries and involving 20 million subjects, estimated an average 63% increase in all-cause mortality in unemployed working aged people. (8) The effect of unemployment on the death rate persists for at least 10 years with higher death rates in the immediate period following unemployment. Excess mortality from unemployment is highest in the younger and middle age groups. Applying age-specific hazard ratios from the above published work to 2019 data on the composition of the current labor force from the Bureau of Labor Statistics and 2017-2018 age specific death rates from the US National Bureau of Health Statistics, produces the results in the table below ( Table 1 ). The methodology estimates 556,000 avoidable deaths due to the effects of unemployment over the next ten years. This article demonstrates the feasibility of quantifying several indirect health impacts of societal responses to Covid-19. The risk assessment methodology, though simple, is realistic and conceptually sound. Inclusion of a broader range of scenarios, consideration of uncertainties, and sensitivity analysis would improve the estimates. Additional considerations could be factors that might cause the impact of this recession to be more or less severe and countermeasures to mitigate the impact of unemployment. Similar methods could predict additional indirect health impacts, including those on health related quality of life and health care utilization. Wise social action to protect public health should be precautionary. However, it also should be balanced and holistic. This means considering the direct and indirect health impacts, health impacts in the short term and long term, as well as how health impacts are distributed in various sub groups of the population. The Community Mitigation Guidelines to Prevent Pandemic Influenza--United States recognizes these principles. "To be effective, these measures must be implemented early and strategically targeted, layered, and tailored to pandemic severity, and their public health benefits must be balanced against economic and social costs." (8) Pandemic planning guidelines also anticipate that the application of NPIs may disproportionately hurt the most vulnerable and may raise difficult ethical questions. For example, school closure might disproportionately impact lower income families who have less access to other educational resources. (9) In the case of Covid-19 specifically, the prevention of deaths among the elderly population might come at the expense of delayed deaths in the working age population resulting from secondary unemployment. Those most able to tolerate lockdowns, such as the retired and those working in the knowledge economy, might have more political influence than those whose day to day livelihood requires a physical presence at work. In the face of uncertainty and threat, precautionary and decisive action is reasonable. Yet, quickly, decision-makers must find ways to strike a balance between the benefits and costs of alternative courses of action. The needed monitoring and evaluation tools must . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 8, 2020. . https://doi.org/10.1101/2020.05.02.20089086 doi: medRxiv preprint measure not only infection and hospital capacity but also must measure the costeffectiveness of individual NPIs for mitigating pandemic impact on virus transmission, hospitalizations, and deaths. Furthermore, monitoring and evaluation must also enumerate and quantify, where possible, the secondary health impacts of NPIs, such as social isolation, hunger, homeless, and delayed primary care. Pandemic guidelines anticipate that NPIs might need to be implemented swiftly but also dictate that the public should be involved in the pandemic response both in advance of implementation and in ongoing ways. Given the scope of social disruption and the need to balance multiple and competing social interests, decision-making must be more transparent and participatory. Hard to anticipate, novel effects of societal Covid-19 responses, are also coming into view. Migrant workers are left without employment or shelter on roads home. People are becoming fearful of others, with concerning implications for social trust. Sadly, these effects may create new health inequalities and political divisions. Overall, public health planning and action to contain and mitigate Covid-19 might benefit from a more holistic policy framework, greater transparency and public participation. In places where Covid-19 response has led to significant economic and social disruption, policy leaders might develop indicators and tools to monitor these effects. Ambulatory care visits for mental health concerns, demand for food and housing assistance, and trust in people and institutions might be early indicators of social distress. Longer term income support, universal health insurance coverage and other policy interventions may be warranted to mitigate the indirect health impacts of Covid-19 response. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 8, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 8, 2020. . https://doi.org/10.1101/2020.05.02.20089086 doi: medRxiv preprint Human scale development: An option for the future US) Committee on Health Impact Assessment. Improving Health in the United States: The Role of Health Impact Assessment Memish Ziad A. 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