key: cord-0961400-oy8drsj5 authors: Mena, G. E.; Aburto, J. M. title: The unequal impact of the COVID-19 pandemic on life expectancy across Chile date: 2021-12-09 journal: nan DOI: 10.1101/2021.12.08.21267475 sha: ecab4c24c19f01f8cc6d53e2ac55de87a154cce9 doc_id: 961400 cord_uid: oy8drsj5 Objectives: To quantify the effect of the COVID-19 pandemic on life expectancy in Chile categorized by rural and urban, and to correlate life expectancy changes with socioeconomic factors at the municipal level. Design: Retrospective cross-sectional demographic analysis using aggregated data. Setting: Vital and demographic statistics from the national institute of statistics and department of vital statistics of ministry of health. Participants: Aggregated national all-cause death data stratified by year (2000-2020), sex, and municipality. Main Outcome measures: Stratified mortality rates using a Bayesian methodology. With this, we assessed the unequal impact of the pandemic in 2020 on life expectancy across Chilean municipalities for men and women and analyzed previous mortality trends since 2010. Results: Life expectancy declined for both men and women in 2020. Urban areas were the most affected, with males losing 1.89 and females 1.33 in 2020. The strength of the decline in life expectancy correlated with indicators of social deprivation and poverty. Also, inequality in life expectancy between municipalities increased, largely due to excess mortality among the working-age population in socially disadvantaged municipalities. Conclusions: Not only do people in poorer areas live shorter lives, they also have been substantially more affected by the COVID-19 pandemic, leading to increased population health inequalities. Quantifying the impact of the COVID-19 pandemic on life expectancy provides a more comprehensive picture of the toll. • We show that COVID-19 led to declines in life expectancy in Chile greater than a year in magnitude. These declines correlated with poverty levels, indicating that socially deprived populations were hit the hardest. • We also show that inequality in life expectancy between municipalities increased due to excess mortality among the working-age population in socially disadvantaged municipalities. • The main limitation is that our estimates depend on accurate small-area stratified population estimates. We implemented several estimates and showed that our findings are robust to the choice of them. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. Most Latin American countries experienced substantial progress in reducing premature mortality while increasing health standards over the last century and into the first fifteen years of the twenty-first century. 1, 2 But this progress has been reversed, as Latin American countries have been severely affected by the COVID-19 pandemic. 3 The region became the hotspot of the pandemic in June 2020 and by May 2021 more than one million COVID-19 deaths have been reported. 4, 5 After decades of sustained improvements in life expectancy, leading to levels comparable to low mortality countries, Chile experienced losses in this indicator in 2020 due to increased excess mortality during the COVID-19 pandemic (11 months for women and 1.3 years among men). 6 While national figures are important and informative, they conceal heterogeneity at the subnational level, which can be substantial. Emerging evidence from Latin American countries suggests that the COVID-19 pandemic has disproportionately affected disadvantaged groups with low socioeconomic status as well as indigenous people, with large regional variation. [7] [8] [9] [10] In Chile's capital, Santiago, areas with low socioeconomic status experienced poorer health interventions, and substantial excess mortality coupled with higher number of deaths and infection fatality rates at younger ages. 7 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint showed higher mortality from COVID-19. 8 It is unclear, however, what the net effect of increased mortality has been on life expectancy at a more granular level of geography and by population subgroups in Chile. In this context of persistent and pervasive health inequalities, varied mortality impacts by age and sex, and regional variation, it is imperative to analyze how has life expectancy been affected differently across Chile. Due to the heightened risk to COVID-19 and mortality of disadvantaged populations, most deprived areas may have experienced greater losses in life expectancy, especially among men. Similarly, since rural and urban areas may be affected differently, and mortality increased among young working-age men, we hypothesize that younger age excess mortality will have a substantial effect on life expectancy losses potentially increasing disparities at the municipality level. This hypothesis is supported by evidence from Chile's capital suggesting that urban and more crowded areas have experienced worse health outcomes during the pandemic. 7, 11 Alternatively, since death rates increased exponentially with age and losses in life expectancy in low mortality countries have been attributed mostly to mortality above age 60, 6 another hypothesis is that the pandemic in 2020 was such a strong shock that excess mortality differentials decreased, leading to reducing inequalities between municipalities. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint by sex using a powerful Bayesian methodology. 12 We contextualize our results with past trends of progress and disparities in life expectancy, and categorize our findings by urban vs non-urban areas. Our study is a step towards explaining the varied impacts of the pandemic by analyzing trends in life expectancy over age at a more granular level and by correlating life expectancy losses with indicators of poverty in Chile. We used data on births and deaths by age, sex and municipality from publicly available vital statistics. 13 These data were complemented with official population counts by age (single years is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint for 2017 onwards. The first one assumes that population counts remain fixed for years 2018,2019 and 2020. In the second one, we projected forward the population using the cohort component method 16 with 2017 as baseline assuming zero migration. We also used census data to classify municipalities as urban or non-urban. (See Supplementary Tables 1-3 ). 17 Data on poverty and crowdedness were taken from the CASEN survey by the Chilean Ministry of Social Development and Family. 18 Age specific death rates for each municipality by sex were estimated implementing a recently developed methodology 12 based on a hierarchical Bayesian model 19 using population and death counts. 17 There are two main advantages to this Bayesian methodology: first, by sharing information across global variables, it is possible to smooth out the noisy estimates that would otherwise be obtained if we relied only on empirical counts. This is important because of the increased likelihood of low death counts on each strata in small municipalities. Second, by appealing to the Bayesian methodology we obtain credible intervals for each of our estimates. Life tables were calculated using the age specific death rates estimated in the Bayesian procedure following standard techniques. 16 From these, period life expectancy at birth, CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint misreporting and coverage across municipalities, as well as systematic age overstatement. 22 Delays in recording deaths may lead to incompleteness issues especially in urban areas. Our results on life expectancy declines and mortality inequalities may be considered a lower bound because of these issues. The effect of systematic age overstatement is likely to affect our results too. However, there is no information on what the age pattern of overstatement is during the pandemic. To mitigate these inaccuracies and their effects on our life expectancy estimates, we used a hierarchical Bayesian model that helped to retrieve a reasonable mortality profile across regions. Another limitation is that because of the low number of deaths observed in some municipalities, the degree of uncertainty around the estimates was very high, not allowing us to include them in our analysis with confidence. We excluded municipalities by sex with less than is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint biased. We studied the effect of alternative population estimates in final outcome measures, as described in the Supplement (Figures 3-17) . Men and women from both urban and non-urban areas experienced is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint increases in mortality below age 65 are apparent in our results, especially among men in urban areas. pandemic in 2020 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint Urban areas that are exposed to higher poverty or social disadvantages experienced larger losses in life expectancy during the COVID-19 crisis in 2020 in Chile. Our results reveal that losses were unevenly shared across municipales, over age, and by sex, leading to increasing inequality in life expectancy across regions in Chile. Moreover, consistent with previous research on increased mortality at younger ages in 2020 in deprived municipalities in Chile's capital, 7 our research shows that working age mortality was one of the main drivers of increasing inequality in life expectancy across Chile. Analysis of life expectancy in 2020 compared with the previous five years ( show that poorer urban municipalities suffered a double burden. Not only did they show lower levels of life expectancy but they also experienced greater losses in life expectancy. This is consistent with previous research documenting larger mortality increases for the lower educated groups in Chile's capital. 23 Furthermore, when we disaggregate by age groups, we observe that the association between life expectancy for working age individuals (between ages 20 and 65) and levels of poverty became stronger compared to previous years. This is a surprising finding given that previous evidence had documented a positive association between income and life expectancy at retirement. 24 This suggests that even if the burden of mortality during the COVID-19 crisis has been concentrated at older ages, 25 contributing substantially to life expectancy declines during 2020, 6 inequalities in life expectancy were largely driven by increased mortality in working ages at higher levels of poverty. A . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint potential explanation is that the working age population's availability to work from home and be less exposed to heightened risk of COVID-19 and its consequences varies across municipalities. Deprived populations in Chile's capital experienced higher fatality rates as a consequence of worse baseline individual health status and to an overwhelmed healthcare system. 7 Similarly, evidence from the US suggests that those individuals with less availability to work from home had higher death rates compared to those that could afford working from home in 2020. 26 An open question is whether this sudden increase in inequality amounts to a shock that will be followed by a recovery to pre-pandemic levels, or whether these changes will persist in the is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint from COVID-19 mortality as well as the indirect effects through other pathways of diseases and conditions. 29 Our research, in this sense, provides a first outlook by focusing on all-cause mortality. As shown by our results, the case of Chile underscores the dire widening of an already large mortality gap between those living in deprived conditions and those living with higher income during the COVID-19 crisis. Evidence shows that the health consequences of external shocks such a pandemic or an economic crisis are not spread equally across social deprivation levels. 30 The COVID-19 pandemic reminds us of the ever-present risk of such events, whose cumulative effect may partially explain the ever-existing gaps in mortality. Therefore, the way that this crisis has exposed the vulnerabilities of socially deprived populations is a call to challenge the monolithic view of a country's demographics in the design of social security systems. New strategies incorporating a public health perspective that considers widening inequalities should be implemented to minimize the effects of the COVID-19 pandemic on the health status of the Chilean population both immediately and in the long term. We are grateful to Alberto Palloni for comments on earlier versions of the manuscript, and to Monica Alexander and Ameer Dharamshi for sharing their code related to reference 12. . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint The World health report : 2000 : Health systems : improving performance Latin American convergence and divergence towards the mortality profiles of developed countries COVID-19 mortality. Evidence and scenarios Demographic Centre (CELADE)-Population Division of ECLAC Covid-19 hot spots appear across Latin America Latin America and the Caribbean surpass 1 million COVID deaths -PAHO/WHO | Pan American Health Organization Quantifying impacts of the COVID-19 pandemic through life expectancy losses Socioeconomic status determines COVID-19 incidence and related mortality in COVID-19 and Indigenous peoples in Chile: vulnerability to contagion and mortality Exploring excess of deaths in the context of covid pandemic in selected countries of Latin America Socioeconomic inequalities associated with mortality for COVID-19 in Colombia: a cohort nationwide study OECD. 1. The COVID-19 crisis in urban and rural areas | OECD Regional Outlook 2021 : Addressing COVID-19 and Moving to Net Zero Greenhouse Gas Emissions | OECD iLibrary A Flexible Bayesian Model for Estimating Subnational Mortality Measuring and Modeling Population Processes Health Affairs supplement Bayesian Data Analysis Measuring and Explaining the Change in Life Expectancies Measurement of Inequality of Incomes Estimation of older-adult mortality from information distorted by systematic age misreporting COVID-19 and the worsening of health inequities in The cost of uncertain life span Assessing the age specificity of infection fatality rates for COVID-19: systematic review, meta-analysis, and public policy implications Estimated Mortality Increases During The COVID-19 Pandemic By Socioeconomic Status, Race, And Ethnicity: Study examines COVID-19 mortality by socioeconomic status, race, and ethnicity Changes in inequality of mortality in 2020 with respect to recent history were stronger in younger age groups. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprintThe copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint 24 . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprintThe copyright holder for this this version posted December 9, 2021. ; https://doi.org/10.1101/2021.12.08.21267475 doi: medRxiv preprint