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Health Affairs' Editor-in-Chief Alan Weil interviews Christopher Ruhm from University of Virginia who published a paper in the November 2022 issue of Health Affairs examining the mortality effects of the COVID-19 pandemic and the related economic recession.
Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;04 - 00;00;33;21
Alan Weil
Hello and welcome to A Health Podyssey. I'm your host, Alan Weil. On May 17, 2022, the United States reached the grim milestone of 1 million deaths from COVID 19. Newspapers continue to report the daily death toll, which remains near 400. As I record this episode in October of 2020 to now. While these numbers are powerful, the effect of the pandemic on mortality is more complex than can be captured in a single number.
00;00;34;02 - 00;01;01;16
Alan Weil
People die from the direct effects of being infected, but also because of strains placed on the health system which created barriers to accessing and receiving needed care for other conditions. And the rapid economic downturn which occurred as the pandemic grew, affected people's health as well. Understanding the effects of the COVID 19 pandemic on excess mortality in the United States is the topic of today's episode of A Health Podyssey.
00;01;02;05 - 00;01;28;00
Alan Weil
I'm here with Chris Ruhm, professor of public policy and economics at the University of Virginia. Dr. Ruhm published a paper in the November 2022 issue of Health Affairs examining the mortality effects of the COVID 19 pandemic and the related economic recession. He found that excess deaths in the U.S. during the first year of the pandemic were the result of both pandemic related effects and economic recession related effects.
00;01;28;13 - 00;01;44;21
Alan Weil
But these two tended to affect mortality in opposite directions. With the pandemic increasing some types of mortality, while the recession tended to reduce certain types of mortality. We'll discuss these findings in today's episode. Dr. Ruhm, welcome to the program.
00;01;45;13 - 00;01;46;27
Christopher J. Ruhm
Thanks. I'm very happy to be here.
00;01;47;04 - 00;02;11;27
Alan Weil
I'm looking forward to this conversation. As you explain the difference between just counting the number of people who died of COVID and understanding excess mortality. So let's start there, if we could. I noted in the introduction the media announcing the number of people who have died or continue to die of COVID. What do those numbers represent and how does what you did in your study differ from counting up the COVID deaths?
00;02;11;27 - 00;02;13;15
Alan Weil
As the newspapers had reported?
00;02;14;05 - 00;02;43;06
Christopher J. Ruhm
So what the newspapers report are the direct effect of COVID. The number of people who die explicitly due to COVID, or whether it's a contributory cause to their death. But it turns out there's a number of other things that could be going on. And let me give you a couple of examples. At the beginning of the pandemic, people were afraid to go to emergency rooms because they were afraid they might contact COVID.
00;02;43;06 - 00;03;07;08
Christopher J. Ruhm
Also, even if they got there, there might be delays in treatment for other kinds of things because the emergency rooms were full with COVID patients. So if I have chest pains, maybe I avoid going to the emergency room or I delay going and it turns out it's a heart attack and I die from that. So that would be a death that might not have occurred at different times.
00;03;07;14 - 00;03;29;27
Christopher J. Ruhm
So that's an example of something that's likely to indirectly increase deaths. On the other hand, if we look at something like influenza during particularly at the beginning of the COVID pandemic, people were staying home. They were they were not leaving their house. If they did leave, they were extra careful about washing hands. In many cases, wearing masks and so forth.
00;03;30;05 - 00;03;47;03
Christopher J. Ruhm
And so we might expect some other communicable diseases to actually decrease or deaths from those diseases to decrease. And excess deaths are going to take those into account. We're going to be trying to look at the total effect of COVID, but all the indirect things that go with it.
00;03;47;21 - 00;03;53;15
Alan Weil
So that's really helpful. And those examples completely ring true. They make sense to me in your paper,
00;03;54;01 - 00;04;12;19
Alan Weil
you decompose the changes in excess mortality due to pandemic effects, which sounds to me like the things you just described. You can correct me if I'm wrong, but also recession effects. So since you use those two categories, just can you provide me a little more detail on what they represent?
00;04;13;16 - 00;04;42;11
Christopher J. Ruhm
So when COVID hit, the economy went into a tailspin. So, for example, the unemployment rate went up from 3.8% to 14.4% between February of 2020 and April of 2020. GROSS Domestic Product, which is our measure of total output fell by almost a third. So the economy really collapsed, although in some ways that are unusual that we can get to.
00;04;42;11 - 00;05;07;11
Christopher J. Ruhm
But we'd expect that might have effects on deaths. Most people might think they'd be positive. They'd increase deaths. It turns out that's not always the case, but that's what I'm referring to as the recession effect. The pandemic effect was sort of everything else. So is the direct effect of COVID. It was effects of strains on the medical system, its effects on individual behaviors.
00;05;07;13 - 00;05;18;10
Christopher J. Ruhm
So I talked about that people might isolate themselves, but also it turns out there are changes in sort of risk taking behavior. So it's all of those things put together.
00;05;18;18 - 00;05;39;01
Alan Weil
Okay. I'm going to have a lot of questions about those. But before we get to them, let's just start with the findings. You look at the mortality effects, you decompose them by pandemic and recession. You have some variability across different categories. Can you just give me the top line results from the work?
00;05;39;20 - 00;06;12;08
Christopher J. Ruhm
Sure. So overall, and this is all in the first year of the COVID pandemic. So that's basically March 2020 through February 2021, there were a 665,000 excess deaths. So about two thirds of a million excess deaths. It turns out the recession effect reduced the number by almost 40,000, about 38,000. And the pandemic effect increased it by a bit over 700,000.
00;06;12;08 - 00;06;25;15
Christopher J. Ruhm
So what we had was 665,000 plus or minus deaths, a slightly smaller number than we would have had if there hadn't been the recession effect coming in.
00;06;26;06 - 00;06;42;18
Alan Weil
Okay. So that's a big number. That's a lot of people. You also did some disaggregation by race, sex and age. I won't ask you to read through all the tables in the paper. People can do that on their own. But can you provide me with some of the highlights of differences across those categories?
00;06;42;22 - 00;07;14;15
Christopher J. Ruhm
Sure. So if we looked by sex a slightly bigger affect for males and females, but pretty similar. Pretty similar when we looked at, for example, race and ethnicity, quite different there. So there it was blacks, Hispanics and other non-whites who had the much larger increases. This is in percentage terms. And then non-Hispanic whites had the smallest increases and deaths.
00;07;14;15 - 00;07;49;28
Christopher J. Ruhm
This is, again, in relative terms. When we look at age groups, what we found was smaller increases for the young. So for those under the age of 25, which maybe isn't completely surprising given that they're less likely to die in general, but turns out some quite different pandemic and recession effects by age. What we find there is that the recession effect, which reduces deaths in percentage terms, that has the biggest effect for relatively young individuals.
00;07;49;28 - 00;08;15;18
Christopher J. Ruhm
So those less than 25 and 25 to 44 and we can get into this later when we talk about causes of death. But that has to do with the kinds of risky behaviors that they're engaged in. So compared to the other groups, there's this relatively large reduction in recession deaths for the young, which is part of the reason why they have a smaller increase overall.
00;08;15;18 - 00;08;21;03
Christopher J. Ruhm
Although they do also have a smaller increase in pandemic deaths as well.
00;08;21;21 - 00;08;58;00
Alan Weil
So it sounds like the general categories where the burden was highest are consistent with what we have heard about COVID deaths in general, that older people are more vulnerable, that non-whites definitely had higher death rates than whites for a variety of reasons. And yet this adds to the literature, because you're not just, again, counting the COVID deaths, you're looking at a combination of responses that can push their way through the health care system, through people's behavior in quite a number of different ways.
00;08;58;04 - 00;08;59;19
Alan Weil
So the right way to think about it.
00;08;59;20 - 00;09;28;23
Christopher J. Ruhm
Yeah, that's correct. So when we're just looking at the overall number, we're not taking account of the changes in the economy and how that plays through, which can be relevant directly for what we might think happens as the COVID pandemic evolves over time, it's relevant for thinking about policies that we might want to address it, and it's potentially relevant for the future.
00;09;28;23 - 00;09;40;20
Christopher J. Ruhm
You know, and unfortunately, this may not be the last pandemic that we have. It does also quite come into play when we look at causes of death. So you know what people are dying of during the pandemic.
00;09;41;02 - 00;10;13;04
Alan Weil
Well, I want to go deeper into both of those topics. The economic effects and the causes of death. We'll dive into those topics after we take a short break. And we're back. I'm speaking with Chris Ruhm about the pandemic and recession effects on mortality in the first year of the COVID pandemic in the United States. Before the break, we got sort of the top line.
00;10;13;04 - 00;10;40;17
Alan Weil
I'm really intrigued by the economic side of the equation. Maybe that's not fair for a health policy journal. But I have to say, you know, the sort of the conventional wisdom I thought was the economy turns down. People have hardship. They can't afford things. They go without health care and they get depressed because they don't have a job and deaths go up.
00;10;40;21 - 00;10;50;27
Alan Weil
But as I gather it from the literature, actually mortality declines in an economic downturn. Can you just help me understand this?
00;10;50;28 - 00;11;13;08
Christopher J. Ruhm
Sure. And you know, and I want to be clear here and we can talk about this more as we go on the evidence we have is coming from sort of changes in economic conditions that we've seen over, say, the last few decades, the last three or four decades. Whether how well they fit in this case is something we should talk about.
00;11;13;08 - 00;11;37;15
Christopher J. Ruhm
But with that said, the evidence is now quite clear that in a typical economic downturn, deaths decline. They don't go up, they decline. And there's a number of reasons for this. But let me give you one of the strongest patterns that we see. And we see this in the US, but we see this across the world, across time periods.
00;11;37;25 - 00;12;03;10
Christopher J. Ruhm
If you look at traffic fatalities, traffic fatalities decline quite sharply in recessions. And again, we'll talk about how well that applies in this case. But, you know, in general, the simplest reason there you can think about is people are driving less. When people are driving less, there's less you know, there's less risk of death. But also, if you think about driving less but also less production, there's less air pollution.
00;12;03;17 - 00;12;25;28
Christopher J. Ruhm
And pollution is an environmental risk and people die from it. So we have lower levels of pollution deaths fall. And then we also have some evidence of life style changes. People have more time available, so they might be more likely to cook meals at home rather than going out to eat. And those home cooked meals might be healthier.
00;12;26;07 - 00;12;51;00
Christopher J. Ruhm
So there's a number of of reasons, and we are seeing these patterns pretty consistently. Now, I want to emphasize this relates to two deaths and to physical health. The literature suggests that mental health declines. And so one of the strong pieces of evidence we have of that and this is, again, in a typical recession, is that suicides increase.
00;12;51;20 - 00;12;59;00
Christopher J. Ruhm
So among people who study this disease, this is pretty well known now. But the general public probably isn't that aware of this.
00;12;59;20 - 00;13;23;04
Alan Weil
Well, right. Because I remember people saying, you know, the cure is worse than the disease the shutdowns are causing more deaths due to suicide than COVID is causing. You referenced that in your paper. I gather if you look at the numbers, that's really not true, although it does have a little surface appeal. What is your take on whether the cure was worse than the disease?
00;13;24;02 - 00;13;43;24
Christopher J. Ruhm
Yeah, I think that's wrong. I think for one thing, we need to remember at the beginning of COVID, we didn't know exactly how it was transmitted. So we didn't know all the best means of avoiding that. We did not have vaccines. We did not have, you know, a lot of the drugs we have now that can treat it.
00;13;44;04 - 00;14;13;02
Christopher J. Ruhm
And so we were in a situation where people were at high risk of death if they got COVID and stopping. That was sort of job number one. And then when we add to that this argument, well, when the economy declines, then that could be deadly. It turns out that's just not true. Now, that does not say that there's not all sorts of issues with economic declines and with some of the other things that went on.
00;14;13;02 - 00;14;29;20
Christopher J. Ruhm
For example, we know that students have suffered from school closings. So there's definitely costs to this. But the notion that, you know, we would not have had a large increase of deaths if we hadn't taken these measures, I just think is completely wrong.
00;14;30;08 - 00;15;01;02
Alan Weil
Okay. That's very helpful. And what if what I hear is that there's not just is the conventional wisdom around economic growth or contraction wrong, but that the magnitude is so different here that the pandemic deaths are so much greater than any possible savings, if you will, or in in related to economic conditions, that when the pandemic is yielding death rates this high, that just has to be the focus.
00;15;02;08 - 00;15;04;23
Alan Weil
At least that's how I interpret what you just said.
00;15;05;08 - 00;15;37;09
Christopher J. Ruhm
Yeah, I mean, that's absolutely my view as well. I mean, you know, if I'm estimating that on the order of 38,000 lives were saved actually due to the downturn. But we're comparing that to 700,000 plus pandemic deaths. So even if those numbers are wrong, you know, even if they're there, they're in the wrong direction and by a magnitude of, you know, two or three or four or five, we're still talking that, you know, we had a deadly pandemic.
00;15;37;09 - 00;15;39;25
Christopher J. Ruhm
We just had to get that under control first.
00;15;40;13 - 00;16;05;22
Alan Weil
And then you have made reference to what people died of. You've also made reference to traffic fatalities and that that's based on sort of historical data. What more can you say? Because one of the insights that your work brings is that if you want to understand the effects on mortality, you can't just look at COVID deaths, things, you know, coded for that reason.
00;16;05;28 - 00;16;09;24
Alan Weil
So what else can you say about causes of death during that first year?
00;16;10;10 - 00;16;33;10
Christopher J. Ruhm
The results are quite interesting. I mean, some of them are not surprising. So for example, other than COVID, which is of course, the dominant factor, but deaths from heart disease went went up. And they were the largest sort of numerical increase. But of course, there's lots of deaths from heart disease. So in percentage terms, those weren't that high.
00;16;33;17 - 00;16;53;29
Christopher J. Ruhm
On the other hand, and I mentioned this kind of early on, deaths from influenza, well, they almost disappeared. They went down probably on the order of 75%. So those are and those are maybe not that surprising. Some of the more surprising results are when we get to what we refer to as external causes of death or non disease causes of death.
00;16;54;07 - 00;17;23;25
Christopher J. Ruhm
So the biggest one is that vehicle fatalities went up quite dramatically during this period. And as I mentioned, typically in recessions they go down. But what happened here is that it appears that people were driving faster. They were they were driving more dangerously. And so even though Miles driven fell quite dramatically at the beginning of the pandemic, vehicle fatalities went up quite a lot.
00;17;24;18 - 00;18;01;07
Christopher J. Ruhm
Drug fatalities also went up a lot. Now that is an unusual case in that both the recession effect and the pandemic effect were increasing drug deaths. So they were both going in the same direction. Deaths related to alcohol and homicide also went up, but surprisingly, suicides to the two, the best we can estimate didn't increase. And if anything decreased slightly, some of that may be there were some trends going on before the pandemic started that are hard to fully capture.
00;18;01;16 - 00;18;13;27
Christopher J. Ruhm
But there is certainly no evidence of an increase in suicides, which is sort of goes against a lot of the predictions and even a lot of what people were saying without, I think, carefully looking at the evidence.
00;18;14;15 - 00;18;40;26
Alan Weil
Yeah. So all of these suggest a really complex response, right? That as complex as the disease was, the effect on people's mortality was even another layer of complexity. You've given some really helpful examples in how that could play out. I wonder, as we come toward the end of our conversation, if you could talk a little bit about the implications of this work.
00;18;41;04 - 00;19;03;08
Alan Weil
And I'm going to ask you to think about it with me in two dimensions. One is speculative, which is this is from year one of the pandemic, as you mentioned. Is there work underway to look over a longer period? Could the results change if they did? What might you expect?
00;19;03;09 - 00;19;33;21
Christopher J. Ruhm
Yeah, absolutely. I mean, that's a great question's actually something I've been working on, looking at how deaths from the pandemic kind of are evolving over time. One, so there's sort of these offsetting effects. We would hope that as time goes on, the pandemic deaths to climb. And there's a lot of reasons for that. One is, you know, probably the most important is we have better ways to deal with it.
00;19;33;21 - 00;20;01;29
Christopher J. Ruhm
And I'm talking particularly immunizations here, which, you know, which save lives. But also, there's medications we just know a lot more about, you know, how to deal with it. And, you know, and a lot of the health system strains may be less as well. So all those things would lead us to think we'd see lower numbers of deaths that we may be offset a bit by the fact that the economy really pretty much has fully recovered at this point.
00;20;02;07 - 00;20;30;11
Christopher J. Ruhm
And so those kind of benefit benefits and the benefits in terms of deaths of the you know, of the recession are going to disappear. And so we might not see deaths falling as much as we would have if it were not for these recession effects disappearing. But still, you know, I again, think the dominant effect is going to be that, you know, kind of what's referred to here as the pandemic effect.
00;20;30;17 - 00;20;54;08
Christopher J. Ruhm
There are all sorts of reasons that those deaths should decline over time. What's a little harder to know are on some of these kind of deaths related to risky behaviors that we were just talking about. We're sort of in an unknown situation here in terms of, say, if people change their driving behavior or some of these other things.
00;20;54;16 - 00;21;21;28
Christopher J. Ruhm
Is that going to be persistent in ways that we don't fully understand? The evidence in this paper is good news for drug deaths in the sense that as the economy improves, we would expect those to fall. But I will tell you if we kind of look at the provisional data from year two, we're actually not seeing the declines in drug deaths that we might hope to see.
00;21;22;03 - 00;21;37;12
Christopher J. Ruhm
There is some evidence that maybe they're now starting to turn down a little bit. But so, you know, so there are some things we can predict. And then there's a lot I think we're just going to have to wait and see and look and learn from what we actually see in the data.
00;21;38;02 - 00;22;09;00
Alan Weil
Yeah. Having driven down your way just yesterday, I'm going to say I'm not sure that people are driving any better now than they were a couple of years ago. But of course, that's just anecdotal. It'll also, I think, be interesting to see if some of the other health causes of death come back down closer to what you would predict after all the examples you gave of not going to the emergency room or the emergency room being full, even with ongoing deaths without those spikes, hopefully those become a bit more normalized.
00;22;09;10 - 00;22;49;13
Alan Weil
And then the other forward looking question I just have for you, you already mentioned the notion that given the twentyfold ratio between the increase in mortality due to pandemic effects relative to the reductions in mortality due to economic effects, you've got to make reducing COVID deaths a job one. But if you think about the future of pandemic preparedness from a sort of system and buffers against some of these effects that you measured, how would you think differently about preparing for the next pandemic as a result of this work?
00;22;49;13 - 00;22;52;20
Alan Weil
And work of this nature than before you did this work?
00;22;53;25 - 00;23;24;00
Christopher J. Ruhm
Yeah, that's a great question. And I do want to be clear that the nature of the pandemic is going to influence the response that, you know, that is appropriate. So we could have another highly infectious disease, but that is much less deadly. And then we might want to think differently. But certainly if we have something like another COVID and what I mean is something that's highly infectious but also, you know, has a high fatality risk.
00;23;24;25 - 00;23;53;07
Christopher J. Ruhm
I think, you know, the notion that in at least at the beginning, stopping, you know, taking the public health measures to stop the pandemic, I mean, that just has to be job one. Now, having said that, one of the things that I think was done fairly well, but maybe we could do better in the future, is providing the various kinds of income support that were given that really mitigated many of the typical effects of a recession?
00;23;53;18 - 00;24;17;18
Christopher J. Ruhm
That was actually those made a lot of sense. I do think that in the future or those efforts could be more targeted. So there were, you know, frankly, a lot of people who got those, a lot of people and some companies that got that financial support that probably didn't need it. And so it made it quite expensive and, you know, possibly has played a role in the inflation that we're seeing right now.
00;24;17;18 - 00;24;56;22
Christopher J. Ruhm
So I think we could have been a bit more targeted. Again, I want to emphasize, it's hard when, you know, when you're in a crisis, you're not going to get it. All right. But I think we could have done a bit better there. The other piece is to realize that some of these indirect effects on things like risky behaviors, you know, making sure with the traffic fatality example, making sure that we are enforcing speed limits, you know, are having public health messages related to driving safely, but also making sure if somebody is in a drug treatment program that we can keep that available to them so that some of those kinds of things.
00;24;57;00 - 00;25;07;14
Christopher J. Ruhm
And again, you know, I want to emphasize, it's really hard when you're in a crisis period, but these are some of the things we can try to do when we're you know, when we're preparing for what might occur in the future.
00;25;08;12 - 00;25;33;03
Alan Weil
Well, and as you say, I mean, there's a lot of uncertainty and it is a crisis. But your work reminds us that there are causes of death in a pandemic that are not just directly related to the pandemic itself and to try to buffer against some of those is worthwhile, even as we're putting our focus on COVID or whatever the next might be.
00;25;33;04 - 00;25;51;19
Alan Weil
So I think the broadening of the lens around what the dynamics are feels like a very important contribution for that and for explaining the paper, doing the paper and allowing us to publish it. Dr.Ruhm, thanks for all of this work and for being my guest today on A Health Podyssey.
00;25;52;09 - 00;25;53;26
Christopher J. Ruhm
Well, thanks so much. It's my pleasure.
00;25;55;20 - 00;26;09;05
Alan Weil
And thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about A Health Podyssey.