For months, President Donald Trump has predicted that deaths indirectly caused by stay-at-home orders would outweigh those caused by COVID-19 itself. "You're going to have suicides by the thousands," he said in late March. Health and Human Services Secretary Alex Azar offered a version of that argument in The Washington Post this month, as he backed the president's case for reopening the economy: "The economic crisis brought on by the virus is a silent killer," he wrote, one that "will likely cause tens of thousands of excess deaths" from suicides and opioid overdoses. Similarly, more than 600 physicians recently signed a letter — an effort organized by a conservative group — describing business closures as a "mass casualty incident" because of increased "alcoholism, homelessness, suicide, heart attack" and other effects.
The long-term health consequences of a significant recession, especially a prolonged one, can be serious. People who get their first jobs during a recession, for example, often suffer lifelong penalties in both income and health. As scholars who have studied "deaths of despair" in the United States, we are intimately familiar with this data. But the estimates of suicides and overdoses made by Trump and some of his supporters cannot stand serious scrutiny. In general, such deaths have been rising steadily since the 1990s, through both boom and bust periods: There is no clear-cut link to unemployment levels.
More broadly, the possible connection between unemployment levels and health outcomes has been much studied by scholars; the topic remains hotly debated, and it is possible to find results coming down on both sides. Some studies have even found that overall mortality decreases during economic downturns, even in ones as severe as the Great Depression (because, for example, people drive less and therefore get in fewer accidents, or because some economic activity, like construction, is dangerous).
We would not go so far as to predict that this will be the case in the recession we are entering. But one study that Azar cites, published by the Lancet in 2012, examined the period 1999 through 2010 and found an association between U.S. unemployment rates during the Great Recession and suicides that has not held up in subsequent years. Unemployment rose from 4.7% in the fall of 2007 to 10.0% in the fall of 2009. In one calculation, the authors found that suicide rates rose by about 1% for every additional percentage point of unemployment — translating into 1,330 additional deaths from 2007 to 2010. In another calculation, they found about four times that number of "excess" deaths during the period
If that pattern holds, and if we are now heading toward an unemployment rate upward of 25%, starting from 3.5% in February, we would expect from 10,000 to 40,000 additional suicides.
We already know, however, that the pattern does not hold.
The Lancet study used data only up to 2010, and since then the short-lived coincidence between trends in unemployment and suicide has broken — spectacularly so. From 2010 to February of this year, the unemployment rate fell from above 9% to 3.5%. Suicides therefore should have declined (or at least risen less rapidly than before the Great Recession). What happened was just the opposite. Suicides increased unabated as the recession unwound, with deaths rising from 38,672 in 2010 to 48,631 in 2018, the last year for which data is available. If the American economy was being made great again, the news didn't reach those who were destroying themselves. We obviously should not conclude that the recovery led to thousands of additional suicides.
What about opioid overdoses? Or deaths resulting from alcoholic liver disease and cirrhosis? In our recent book, "Deaths of Despair and the Future of Capitalism," we track these collectively. They rose rapidly from the mid-1990s to 2018: before, during and after the Great Recession. There were 24.6 deaths of despair per 100,000 people in 1999, 30.5 in 2007, 31.9 in 2010 and 44.4 in 2018. A key finding of our book is that short-term fluctuations in the economy are simply not related to fluctuations in deaths of despair.
Another study cited by Azar found that between 1999 and 2014, drug overdoses increased faster in counties where unemployment grew more rapidly. But geographical differences in opioid deaths do not speak to whether the total number of these deaths tracks over time with national unemployment; in fact, the authors' own data shows that total deaths and unemployment moved quite differently during the Great Recession.
Despair takes many years to take hold and build, and it is typically preceded by community destruction — declines in the institutions that hold life together, including marriage, two-arent child-rearing and church and union affiliation. What's more, many pockets of declining employment and rising hopelessness have been disproportionately targeted by pharma companies pushing their drugs. The link between unemployment and opioids or suicide in such communities cannot be used to gauge what will happen as unemployment rises there or elsewhere over just a few years. In short, we can safely dismiss confident predictions that the forthcoming recession will cause 75,000 or more new deaths of despair, or more, over the next decade — a number recently publicized by the Well Being Trust, relying on sources similar to Azar's.
There is already some fragmentary and incomplete evidence about the non-coronavirus health effects of the pandemic. The Centers for Disease Control and Prevention estimates "excess deaths" for each state by comparing weekly deaths reported since February with deaths reported in the corresponding weeks over the past three years. There are several states with few COVID-19 deaths; West Virginia had 74 and Montana 17 as of last week, for example. Yet like states with more coronavirus cases and deaths, those states have also experienced government-imposed shutdowns. If shutdowns are themselves deadly, we should see excess deaths in those states — yet there are none. Indeed, total deaths in these states are running below expected levels.
Of course, excess deaths unrelated to COVID-19 may show up as the recession continues, but we do not see them now. In fact, data for several states shows a drop in fatalities from traffic accidents — deaths in New Jersey and Nebraska are down by 10% (284 deaths vs. 184) and 21% (68 deaths vs. 86), respectively, compared with the first months of last year. The shutdown has also reduced accidents on job sites and cut pollution, another source of sickness and death.
Although many scholars have argued that recessions lead to improved health outcomes, because of fewer accidents and other changes, we would not make that claim for the unusual recession we are entering. And yes, a prolonged slump may bring some additional suicides: These effects are often found, though not consistently across different periods nor across studies. And nonessential health care has been put on hold — not as a consequence of the shutdowns but of the commandeering of facilities for COVID-19 treatment and patients' fear of infection; still, the failure to vaccinate children (for example) bodes ill, as does the likelihood that treatable conditions are going undiagnosed.
But a wave of deaths of despair is highly unlikely. Recessions are immensely costly because they disrupt people's lives, deprive them of work and income and inhibit many of the activities that make life worth living. We need to find safe ways of getting back to work. But we should not scare ourselves with nightmares about tens of thousands of additional suicides or drug overdoses.
Case is the Alexander Stewart 1886 professor of economics and public affairs emeritus at Princeton University. Deaton, who was awarded the Nobel Prize in 2015, is professor emeritus at Princeton and presidential professor of economics at the University of Southern California. They are the co-authors of "Deaths of Despair and the Future of Capitalism." This piece was written for The Washington Post.
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