COVID-19: Will the disease or the cure cause more death?

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There have been increasing statements in the media to the effect that, for the COVID-19 pandemic, “the cure is worse than the disease,” and that the economic impact of the drastic and widespread quarantines will cause a severe recession that will result in excess deaths. This is very unlikely, as the overall U.S. mortality from unchecked COVID-19 would likely exceed the mortality from an economic recession resulting from the public health measures used to contain its spread.

The currently available medical interventions are limited. There are no known vaccines or proven medication regimens for COVID-19. Travel restrictions initially slowed the spread of the infection to the U.S. But, the limited number of tests prevents widespread case identification, and the very limited public health workforce at the local level makes contact tracing with multiple infections virtually impossible. The remaining strategies which focus on reducing population spread have been employed globally with varying success. These include an array of options ranging from individual case isolation to nationwide “lockdowns.”

The worst-case projections are truly frightening. The U.K.’s Imperial College estimates that 2.2 million Americans will die from COVID-19 and that hospital bed demand will be 30 times greater than supply, if no public health measures are taken. The college’s modeling shows that mortality could be reduced by as much as 90 percent based on the intensity and speed with which five non-pharmaceutical measures are implemented. Even with more hopeful assumptions for infectivity and mortality, the anticipated number of deaths for unchecked COVID-19 is striking. Assuming a best-case scenario similar to a typical influenza outbreak, if 20 percent of the roughly 330 million disease-naive people in the United States became infected, and 0.1 percent died, this would still result in 66,000 deaths from unchecked COVID-19. This would create an overwhelming burden for our hospitals.

Historical context

These numbers contrast with the historical mortality from economic downturns. Studies of the U.S. Great Depression (1929-1933), Great Recession (2007-2009), and other periods of worsening economic conditions, demonstrate that mortality actually decreases during periods of economic downturn. In a 2009 publication, Berzruchka writes that, “economic recessions have paradoxical effects on the mortality trends of populations in rich countries. Contrary to what might have been expected, economic downturns during the 20th century were associated with declines in [all-cause] mortality rates.” Ruhm has shown a procyclical relationship between the economy and mortality – meaning that overall mortality increases during economic expansion and decreases during decline.  Statistically, a one-percent increase in unemployment decreases the predicted death rate by 0.5 percent. A 2009 descriptive analyses of associations in health indicators and economic activity for the period of 1920-1940 found that population health evolves better during recessions than expansions.

Mortality from suicide is a notable exception, as it is countercyclical, and increases during economic downturn. However, this increased mortality from suicide does not outweigh the net decrease in overall societal mortality. These mortality findings only apply to higher-income countries. Countries with an annual GDP of less than approximately $5,000 to $10,000 per capita (in 2009 dollars) would expect to see mortality improvements with economic growth.

Several factors may explain these counterintuitive trends. There are fewer traffic and industrial accidents when there is less economic activity, as people are not commuting or performing work. People also have less work-related stress, during times of economic downturn, which might exacerbate health conditions. In addition, without disposable income, people are less likely to engage in behaviors associated with poor health conditions, including drinking and smoking. Consequently, decreases in obesity and cardiovascular disease are often seen during an economic recession. Moreover, people are often home spending time with families and friends and are more physically active during an economic downturn compared to a period of economic expansion.

The disease is more deadly

Public health decisions in the face of the uncertain impact of a new threat are complicated, but when lives are at stake, public health leaders usually recommend the most conservative course to prevent deaths. Our current limited understanding of the transmission, infectivity, presentation, and fatality of COVID-19 has made choosing the best interventions to reduce mortality even more difficult. But watching the horrors of the impact of the thousands of patients overwhelming the hospitals and healthcare workers in Italy, Spain, and New York, is ample evidence that this pandemic requires drastic interventions.

It is clear from historical precedent that the “cure” of public health strategies to suppress COVID-19 will result in significantly less mortality than any potential mortality caused by a resultant economic downturn.

Craig Goolsby and Thomas Kirsch are emergency physicians. Raphaelle H. Rodzik and Nicole Dacuyan-Faucher are epidemiologists. Keke Schuler is a psychologist.

Image credit: Shutterstock.com

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