key: cord-0983202-n1cfumeg
authors: Kim, Daniel
title: Minimizing Public Health Consequences of the COVID-19 Pandemic: Let's Consider the Threat of a Triple Recession
date: 2022-01-19
journal: Lancet Reg Health Am
DOI: 10.1016/j.lana.2021.100176
sha: c46ca77fc9c21350f2b0622c2d597c92a6afd7fd
doc_id: 983202
cord_uid: n1cfumeg

nan

According to the National Bureau of Economic Research, the economic recession in the United States brought on by the coronavirus pandemic in 2020 lasted just two months-the shortest recession in American history. 1 While an index of economic activity currently points to the economy as 85% "back to normal", 2 the economic recovery has been prolonged and is far from complete, particularly for employment (with between 4 and 5 million fewer jobs than expected), the reopening of retail businesses, and in-person consumer activities. Recent surges in inflation not witnessed in nearly four decades have also sparked concerns that increases in the cost of living may impose higher levels of financial strain among Americans during the pandemic. 3 As of January 2022, the pandemic has not relented, with a dramatic rise in cases and hospitalizations due to the highly transmissible Omicron variant of the coronavirus.

It is difficult to fathom the nation as a whole can be considered largely back to normal when society still feels fractured on many levels. In addition to the current Omicron wave that has aggravated the economic downturn, the nation's societal picture may be characterized by two other recessions-a social/social capital recession and an education/human capital recession. Critically, all three recession types could have spillover effects and generate short-term effects (e.g., occurring within one year after exposure) and long-term negative consequences (e.g., occurring one year or later after exposure) on the well-being of the American population (Table 1) . While the health impacts of social, economic, and education disruptions are increasingly being studied on an individual basis, no empirical investigations have yet applied the label of social or education recessions or considered the concurrent impacts of these three recession types during the pandemic. Through jointly acknowledging, describing, and surveilling these social and economic phenomena (reflecting upstream social determinants of health including social capital with the capacity to shape downstream lifestyle risk factors such as diet and exercise, levels of social support, and affective states and feelings of social isolation at the household and individual level), 4 more attention can be brought to policymakers to implement effective policy solutions to avoid and mitigate adverse public health sequelae from the pandemic.

The notion of a social recession was first raised by U.S. Surgeon General Dr. Vivek Murthy and Dr. Alice Chen at the start of the pandemic-warning of the health dangers of a fraying of communal bonds due to social distancing. 5 Indeed, we have literally socially receded away from each other and into our homes to reduce transmission. Now nearly two years into the pandemic, we are still physically distancing with less faceto-face contact. And even now, the nature and frequency of social activities including communal celebrations such as graduations, weddings, and cultural gatherings as well as normative child enrichment experiences are diminished. Most recently, the rapid spread of the Omicron variant resulted in fewer family gatherings during the winter holidays. A decline in face-to-face social activities can lead to social isolation and loneliness, a known risk factor for both depression and mortality. 6 Importantly, evidence suggests that levels of social isolation have risen since the pandemic began. 7 Moreover, the economic downturn has been accompanied by escalating income and wealth inequality-with growing chasms between the 'haves' and the 'have-nots' capable of further deepening levels of social recession.

Consider also the possibility of an education/human capital recession, particularly among children and young adults. In the previous school year, most K-12 schools shifted to remote/hybrid learning, and at least 25 million school children in the United States were physically out of school for more than 13 consecutive months between March 2020 and June 2021. 8 Learning has likewise been disrupted this school year, with frequent new cases and outbreaks requiring students to quarantine at home-and with an estimated 1 out of every 6 public schools in the U.S. in December 2021 operating at still under 50% of their in-person learning capacity during the same month prior to the pandemic in 2019. 9 Furthermore, due to the Omicron surge, the public school districts for the cities of Chicago and Detroit canceled classes and went remote in early January, respectively. The Omicron wave is anticipated to lead to a substantial additional number of school closures and shifts to remote learning across the country, and there remains the risk of similar impacts on education from future waves and variants during the pandemic. Remote learning and school closures have the effect among students of: 1) reduced in-person contact, with consequences of a social recession at an early life stage when social development and peer influences are crucial; 2) impeded cognitive and socioemotional development and learning potential; and 3) food insecurity and lack of access to social and clinical services including special education, physiotherapy, occupational therapy, psychology, and speech and language services. 8 Education, including early child education, is a powerful determinant of health, linked to adult socioeconomic position, cognitive function, and all-cause mortality. 14 Economic recessions may further hinder education/ human capital and impede socioeconomic mobility if austerity measures are undertaken that reduce spending on education and job training programs, although such measures can be averted through appropriate policy architecture and government choice. 15 While health impacts of an education/human capital recession may not manifest for decades, social and economic investments are vital to avert its deleterious sequelae. One common mechanistic pathway for health impacts of these recessions is that each recession type can plausibly induce stress. Emerging research suggests that the pandemic can also be understood as a traumatic event that elicits post-traumatic stress disorder (PTSD)like responses and influences mental health states including depression. 16 All three recession types may represent principal sources of this trauma during the pandemic. In the year 2020 compared to 2019 in the U. S., the percentage increases in the estimated prevalences of major depressive and anxiety disorders exceeded 

25%. 17 Furthermore, the national average of weekly emergency room visits for suspected suicide attempts among teens climbed by nearly 40% in February and March of 2021 compared to the same respective months in 2019, prompting the U.S. Surgeon General to declare a youth mental health crisis exacerbated by the pandemic. 18, 19 In addition, we have yet to fully grieve for fellow Americans who have died from COVID-19, with over 840,000 lives lost to date, 20 and an anticipated cumulative total of more than 1 million coronavirus deaths during the pandemic by later this year. The prospects for a tsunami of PTSD and other mental health disorders will only mount as the pandemic persists for several years and preventive steps fail to be taken. Over the long term, these recessions could exact a substantial toll on the average life expectancy of Americans by influencing chronic disease mortality as well as deaths of despair in young and middle-aged adults-namely, mortality from gun homicides/suicides, drug overdoses, and alcoholic liver disease. 21 During the pandemic thus far, there is growing evidence of surges in each of these diseases of despair over and above pre-pandemic levels. For example, there were an estimated greater than 100,000 drug overdose deaths in the U.S. during the 12-month period ending in April 2021, a 28.5% increase over the same period a year earlier. [22] [23] [24] [25] Additionally, it is important to consider the possibility that each recession type may differentially affect segments of the population. For example, low-income and marginalised populations have been the hardest hit by COVID-19 infections and mortality, 26 While the 'backto-normal' economic index captures multiple aspects of the economy, it does not account for distributional impacts, nor does it directly incorporate inflation increases that effectively raise the cost of living (e.g., cost of food and rent), particularly among those of low income, thereby increasing levels of financial hardship. Although the American Rescue Plan provided federal unemployment insurance (UI) supplements through early September 2021, over half of states halted these benefits prematurely. Evidence suggests that financial hardship during the pandemic, especially among those unemployed, could adversely affect mental health and contribute to food and housing insecurity. 27 Emerging research further demonstrates that rural regions in the U.S. may be particularly vulnerable to pandemic-related economic shocks. 28 During the last academic year among urban public schools, which largely serve lowincome students of color, those that went strictly remote experienced greater declines in kindergarten enrollment. 29 Meanwhile, low-income students are more likely to attend schools that cannot afford adequate school-based precautions against transmission, leading to higher rates of absenteeism and school closures. A recent U.S. nationally-representative study found that children from lower-income families and older children/adolescents were more likely to report mental health problems related to school closures. 30 Survey evidence also supports that those unemployed and with lower income levels have just barely recovered from spikes in social isolation suffered earlier in the pandemic. 7 As a result of subpopulations being differentially affected by these recessions, inequities in health care access and utilization are only likely to be magnified. For example, socially-isolated individuals have been identified as receiving fewer preventive services. 31 Likewise, socioeconomically-disadvantaged and other marginalised subpopulations are known to have lower access to quality health care, leading to worse health outcomes. 32 With these population groups including those who have lost employment during the pandemic being disproportionately affected by economic, social, and education recessions during the pandemic and thus having a greater need for health care, the lower access to and utilization of health care in these subpopulations will exacerbate health inequities. Moreover, rural-urban differences in vulnerabilities to social and economic shocks during the pandemic will plausibly be compounded by rural-urban differences in health care facilities (e.g., tertiary care centers concentrated in large urban areas), hence giving rise to even wider ruralurban inequities in health.

How then can our society best circumvent the adverse health repercussions of these recessions? First, expert consensus must be reached on defining and measuring these recessions, ideally using a comprehensive dashboard of validated social, economic, and human capital indicators-whilst considering new relevant terminology. For instance, the term economic micro-recession might more aptly describe the chronically depressed U.S. economy juxtaposed with upswings in the cost of living. Consensus on this dashboard of indicators should be reached following the formation of a national interdisciplinary expert panel that includes epidemiologists, economists and other social scientists, education researchers, and policymaking experts. Such a dashboard of indicators would likely need to be revised and refined over time. Many of these indicators could be leveraged from existing federal surveys and administrative data such as the Civic Engagement Supplement to the Current Population Surveys, 10 the CDC's Behavioral Risk Factor Surveillance System, 12 and the U.S. Census Bureau's Household Pulse Survey, 11 while other data sources such as the U.S. School Closure and Distance Learning Database 9 would require new or expanded surveillance efforts (Table 1) . For example, to monitor for a social recession, the multidimensional construct of social capital could be captured using multiple existing measures of informal and formal social ties, civic engagement, and trust in institutions. 33 Second, we must ensure proper surveillance of health impacts of these recessions through representative surveys and administrative data that capitalize and expand upon existing governmental data, and that allow for disaggregation by race/ethnicity, gender, and socioeconomic position in order to accurately identify health inequities. Third, we should investigate the extent to which these recessions interact with each other in their impacts, including among vulnerable populations, that may experience multiple types of recessions concurrently. Fourth, we need to identify public policies that can minimize harmful health impacts of these recessions. A 'health-in-all-policies' approach-a comprehensive strategy in which health policy considerations permeate multiple public sectors with ties to health-could ultimately be more cost-effective. 34 Specific candidate policy interventions might include UI supplements (similar to those provided in the Coronavirus Aid, Relief, and Economic Security Act of 2020 and the American Rescue Plan Act of 2021) and other income support programs such as higher state and local spending on welfare and the Supplemental Nutritional Assistance Program (SNAP); increases in the minimum wage level; tax policies to temper increases in income/ wealth inequality; and greater education spending in low-income and marginalised communities 4,33 ( Table 1) . The Biden administration's Build Back Better Plan, currently under consideration by the U.S. Congress, includes several policy provisions such as a federal universal prekindergarten program and subsidies for child care 35 that could serve to stimulate economic and human capital recovery both during and after the pandemic. Furthermore, the expanded child tax credit implemented in 2021 has been shown to substantially reduce child poverty and food insecurity including keeping 3.8 million children out of poverty. 36, 37 Extending the expanded child tax credit into 2022 and beyond could also improve economic security such as by countering the recent rises in the cost of living (Table 1) . Last, we should implement and evaluate these policies in a timely manner that can inform future policy implementation to optimize effectiveness.

Since its onset, the COVID-19 pandemic has posed numerous health and economic, social, and human capital challenges that have uprooted major facets of society. Anticipating and addressing the triple threat of pandemic recessions are not only feasible-but essential to curtail their public health sequelae during and in the aftermath of a once-in-a-century traumatic event.

The author declares no conflicts of interest.

The author has received grants from the U.S. National Institutes of Health for research on social and economic determinants of health. The funding sources had no role in the writing of the manuscript or the decision to submit it for publication.

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