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The costs of the coronavirus pandemic are unprecedented in their dimensions:
David M. Cutler, PhD, of Harvard University discusses financial costs: the $16 trillion virus.
Lisa Cooper, MD, MPH, of Johns Hopkins University discusses the costs to communities of color in excess deaths and bereavement.
Charles R. Marmar, MD, of NYU Grossman School of Medicine discusses the mental health costs.
Recorded October 20, 2020.
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>>Hello, and welcome to Conversations with Dr. Bauchner. Once again, it is Howard Bauchner, Editor in Chief of JAMA. Last Monday, JAMA published two research letters, three viewpoints, and two editorials in some regards to summarize where we are with respect to the COVID-19 pandemic. Six of those articles will be in today's issue of JAMA, in the print issue, and once again, on our website live. And I am pleased to be joined by authors of the three viewpoints, Lisa Cooper, David Cutler, and Charlie Marmar. But before I begin with the interviews and the introductions, I just wanted to remind people of the other four articles that were the basis or also accompanied these three viewpoints. There was a research letter by Zeke Emanuel and colleagues entitled "COVID-19 and Excess All-Cause Mortality in the US and 18 Comparison Countries" in which the data are overwhelmingly clear that the US has performed less well than virtually every other country in the world with a similar economic base. And we've done poorly at the beginning of the pandemic, the middle of the pandemic, and more recently. Steve Woolf published his second research letter entitled "Excess Deaths From COVID-19 and Other Causes, March-July." The most current estimates suggest that by January 1, 2021, the US will have had more than -- more than 400,000 excess deaths related to this pandemic. It's quite possible that by the end of this year, that number will approach 500,000 deaths, exceeding the number of dead from World War II. These two research letters were accompanied by two editorials, one by Harvey Fineberg, former head of the National Academy of Medicine, "The Toll of COVID-19." And then, one by Phil Fontanarosa and me entitled, "Excess Deaths and the Great Pandemic of 2020." Welcome, Charlie, Lisa, and David. David, we'll start with you. David, you're the Otto Eckstein Professor of Applied Economics at Harvard. The title of your viewpoint was "The COVID-19 Pandemic and the $16 Trillion Virus." First, can you say something about your co-author, and can you tell us what $16 trillion means?
>> So, thank you, Howard for having me and for the -- for the questions and for your help with the publication process. My co-author is Lawrence Summers. He's the Charles Elliott University Professor at Harvard. He's also former Secretary of the Treasury. And he's a mentor of mine, actually. So, I've known him for quite a long time. We were interested in calculating the cost of COVID economically, and there are two parts to that. One is the lost output, that is, we're not -- people are not at work, so they're not producing things. For that, we took estimates from what the congressional budget office says will likely be the trend in output for the next decade, and that's about $8 trillion of lost output for the next decade. And I'll come back in a little bit to help put these in perspective for you in a second. But that's about $8 trillion over the next decade. But of course, that's not the only consequence. The fact that people are -- some people have died, many people have died. Many more under current forecasts will. Some people will have their long-term health impaired. People are suffering very high rates of anxiety and depression. About 40% of Americans report feelings of anxiety and depression. So, what we do in this second part -- so, the first half of it roughly is $8 trillion from lost output. Then, the second part is saying, "What is the economic value of the health loss?" And there we use a very familiar technique, which is called valuing statistical lives, that is, how much do we typically pay to reduce things like risks from automobile deaths or how much more do you have to pay people to work in riskier jobs? We use that to then add up the cost of the premature mortality, the morbidity from survivors with severe complications, and the mental health impairments that people are experiencing. Those are under reasonably conservative assumptions that there are deaths for another year, but none after that, and that the deaths for the next year stay at the relatively low level of a few weeks ago. So, that's the other $8 trillion. How do you think about $16 trillion? You know, it's -- it's -- obviously, it's a very high number. To put it in perspective, it's roughly about $200,000 for a family of four, you know? So, that's roughly what the loss is. Now, it's not all economic loss in terms of lost income, because for example, when a family member passes away, that is an economic loss, but it's not lost income. But on the other hand, the point of the economy is not to accumulate sheets of paper with little number signs on them and numbers after them, it's to enjoy life. And so, it's that lack of enjoyment, the sort of lost enjoyment of life, that people are experiencing in their lives that's really going on. We give a couple of markers. So, one marker is it's roughly the -- -- roughly 4 times what the Great Recession cost. It's roughly twice what we spent on all the wars in the Middle East since 9/11. And it's roughly 50 years of what people estimate will be the cost of climate change to the US. So, those are just some ways of thinking about how immense this is as an economic issue.
>> Thanks, David. I have many questions, but I want to make sure I get to -- to Lisa and Charlie, and then we'll come back. Lisa Cooper is the Bloomberg Distinguished Professor at Johns Hopkins with appointments in the School of Public Health and Medicine. Lisa, this is the second piece you've written for us this year. The title of this viewpoint -- -- the title of this viewpoint is "Excess Deaths from COVID-19, Community Bereavement, and Restorative Justice for Communities of Color." A remarkably painful year for the United States, for the world, and particularly for individuals from Black, Latinx, and Indigenous populations in the United States. Your co-author, once again, is David Williams, so could you say something about David. And then, eight months into the pandemic, how are you thinking about this vis-a-vis communities of color?
>> Yeah, thank you for having me, Howard, and -- and for, you know, allowing me to contribute to this issue. So, first of all, David Williams and I did co-author this, as we did another viewpoint for you earlier this year. And David is of the Florence Sprague Norman professor in the Johns Hopkins, Harvard Chan School of Public Health. He is a world-renowned sociologist and public health scholar. And so -- and David and I have been colleagues for many years, so it's been a great collaboration between him, you know, a preeminent social scientist, and me, a clinician and also a public health and social scientist. So, it was -- it was a difficult piece to write. I'll just be honest with you. It was one of the most painful things I've written this year and, of course, over the course of my career. And really, it's because it's so sobering, the fact that, you know, our country is going through this, but on top of that, we know that communities of color have borne the burden of excess deaths for, you know, centuries. And so, you know, one of the things we looked at was the excess deaths that were reported between 1900 and 1999, and it was -- it was close to 8 million excess deaths that were predicted in the African American community alone during that time period. And sort of the lack of progress that we've made on this issue, even though the health of the country has improved overall, that people of color continue to die at much higher rates than their white counterparts, and so, this pandemic has actually made things even worse. You know, some of the estimates now are that the death rates from COVID-19 are about 3 times higher in African Americans, Latinos, and Indigenous groups across the country. So, you know, the first thing is to basically, I think, to accept that this is going on and acknowledge that it is going on, and it is a part of a legacy of sort of social injustice, social and economic injustice, that has gone on for a long time in this country. And the pandemic has just -- has sort of magnified that. But one way to do that is for -- for us to deal with this is to first acknowledge it and then begin to think about how we can put in place a plan to restore health and wholeness, not only to the entire country, but particularly to these communities that have lost so much, you know? So, we've seen these excess rates of chronic conditions for a long time that we know are in part due to, you know, behavioral choices, but we also know that those choices in communities of color are limited based on opportunities, you know? So, we know people in those communities struggle with inadequate access to safe housing, to a good education that will allow them to become gainfully employed, to basically, you know, environments that are safe from crime and environmental toxins, access to healthy food, you know? You know, that, a lot of that has been shaped by our policies and practices that have led to this sort of segregation of people of different racial and ethnic groups into different communities and then sort of the systematic disinvestment economically in those -- in those communities. So, we have that. We've seen higher, you know, rates of diabetes, heart disease, asthma. You know, we have people who are already suffering from lack of access to healthcare as well in these communities. And then, you add to that this pandemic, and they're over-represented among frontline workers and therefore are exposed at higher rates, living in more crowded conditions, and, you know, unable to protect themselves during this time. So, we've seen that. And then, when you add to that all the police violence against these communities that has happened during this time as well, which has had a profound effect on the mental health of African Americans. You know, there's lots of data now showing that violence against unarmed people of color actually leads to 4-1/2 extra mental health days lost in those communities that we don't actually see among whites, even though I'm sure everyone is negatively impacted by what's going on, but it's just magnified in communities of color. And so, that -- that, and then, the excess deaths, that leads to people in those communities losing family members at much younger ages and producing what we know as community bereavement right now. So, we're going to have a steep climb to bring some of these communities out of where we are right now, a lot of focus on mental health and on access to primary care and on addressing sort of these broader societal issues.
>> We gave Charlie all of mental health of the country, but before we go on, Charlie -- Lisa, 2 years ago, we published a piece from Otis Brawley called "Cancer Justice." And -- -- Otis talked about, "We need no new technology to collapse the screening rates for Black Americans for colorectal cancer, prostate cancer, and mammography." Certain communities have done it, we haven't done it nationally. But these are three diseases that are usually changed if people are appropriately screened. Do you think it will be different this time? Do you think something is fundamentally different so that in 2022, 2023, 2024, we won't look back and we'll say, "Another lost opportunity," or lack of progress. Do you think it will be different this time, Lisa?
>> Well, you know, I certainly hope so. You know, in order to do the kind of work that I do, I think I have to be an optimist. And so, to me, I think one thing that feels different this time is just a greater recognition among people outside of these communities of how severe this problem is and the fact that it's something that impacts not only them, but the whole country, you know, because you can see now that our economy has been shut down, and, you know, kids can't go to school anymore, and a lot of this is because of the inequities we have. We actually -- our population and our morbidity and mortality in this country from many diseases that are treatable look like a country that's a developing country, and that's in large part because we don't really invest in our social -- -- our safety net and our social services in this country, and we don't protect the most -- people who are the most vulnerable in our society. And I think it's really manifested in this COVID pandemic. And now, because so many people have been affected by it, we can see how interconnected we are. And hopefully, we won't forget about that when this moment passes.
>> Charles Marmar, Charlie is a Lucius Littauer Professor of Psychiatry at NYU. We gave Charlie all of the US mental health to talk about. The title of his viewpoint is "Mental Health Disorders Related to COVID-19-Related Deaths." Charlie and his co-authors -- Charlie particularly is a world-renowned expert in post-traumatic stress disorder. Charlie, can you say something about your two co-authors and then talk about what you and they have written about with respect to this viewpoint?
>> With pleasure, Howard, but let me just start by thanking -- first of all, thank you for welcoming us to this conversation and to the JAMA pieces. And I would say also perhaps more deeply, Howard, thank you and JAMA for your leadership in conveying accurate and timely information about COVID. We live in an age of profound disinformation, and I think JAMA, perhaps more than any other medical journal internationally, has been an antidote to fake news in this area. It's been profoundly important. So, I wanted to just start by thanking you and the journal for that. With respect to my co-authors, I have an enormous pleasure and privilege to have a wonderful faculty at NYU, and Naomi Simon, who is my Vice Chair for Faculty Development in the Department of Psychiatry at NYU is an internationally-recognized leader in the understanding of normal and complicated or pathological bereavement, which is the central focus of our article. And Glenn Saxe, who is a professor at NYU and previous Chair of the Child Psychiatry Department here, is a renowned expert in childhood trauma. So, I'm just very privileged to work in such an enriched environment and to have such wonderful colleagues. Now, with respect to the topic on hand, the impact of COVID, there are two very broad dimensions to the impact of COVID on the mental and emotional health of Americans and perhaps all citizens of the world. The first is more narrowly defined and was more the subject of our article, which is the large number of deaths which have profoundly impacted American families. So, just by rough estimate, the numbers that we understand are at least actually 300,000 -- as you mentioned, perhaps soon, more than 400,000 deaths -- can be directly or indirectly attributed to COVID. Now, for each -- we know from previous research that for each death in a family, given average family network sizes, on average, nine people are profoundly impacted by that loss in terms of their personal grief, mourning, and risk for psychiatric complications. So, alone from the 300,000, 400,000 deaths, we have 3 to 4 million Americans who are recently bereft. And that's over a relatively brief period of 6 or 7 months. So, it's unprecedented, even compared to times of war. Second, among those who do experience a family loss of a beloved grandparent, parent, sibling, child, or other close family member, we know that roughly 1 in 10 will experience an abnormal, prolonged, pathological form of grief called PG, prolonged grief, which is characterized by persistent, unremitting painful experiences of the loss, inability to accept the reality of the loss, constant yearning, searching, and pining for the person who has died, inability to restore a sense of hope and optimism for going forward in life, loss of energy and pleasure, feelings of depression, and increased use of alcohol and drugs. And unfortunately, increased suicidal thoughts and suicidal intentions. So, that's 10% of 3 to 4 million people. So, that is an epidemic of pathological grief, which is a downstream consequence of the pandemic, and this is a worldwide phenomenon, so it's very profound. Now, what can -- the second dimension to this problem is one that David Cutler alluded to, which is that setting aside for a moment those most profoundly affected by losing someone close to them, whether we have or have not lost a family member, we are all affected by the stress and uncertainty and ambiguity of COVID. Economic uncertainty, social uncertainty, social unrest, worries about our health, worries about protecting the health of our parents and our children, the list goes on and on. So, there is a second kind of psychological epidemic, which is one of anxiety, depression, and difficult to manage uncertainty. And complicated by the fact that it will take an uncertain amount of time to have a safe and effective vaccine and safe and effective and well-confirmed treatments for the disease. So, taken altogether, 30% to 40% of the general population are burdened with stress, anxiety, and depression, and a subgroup of 3 to 4 million Americans are deeply burdened by loss, and some of those quite severely. I'm also happy, Howard, to talk about what we can do on a more optimistic note very briefly. We adopt a three-point approach to that, which is education, treatment and primary care, and specialty care. But that's the scale of the problem.
>> We'll come back to the treatment. I'd like to depart some optimism. David, how does the $16 trillion relate to what -- what Lisa just talked about? Disenfranchisement of an entire community for centuries manifests acutely, once again acutely, during this pandemic. You're the applied -- applied economic, so you must think about this in terms of human beings, not just theoretical economics. What's the $16 trillion mean vis-a-vis what Lisa just talked about?
>> Actually, what Lisa talked about is quite relevant here in the sense that the lost output, the lost value to society of having historical levels of segregation and historical levels of inequality, are really just immense. So, for example, the consequences of people not living their full lives or people not being able to live to their fullest extent, those are very, very big numbers. And, you know -- you know, there's -- you know, people have often done these calculations about, you know, for example, if women are paid 79 cents on the dollar for men, what is the output that we're not having because women are not earning those 21 cents that men are? And one could do the same thing for racial and ethnic minorities, Blacks and Hispanics and other minority groups, and the numbers would be immense as well. You sort of pick it up in things like people who don't -- who don't live their -- who don't go on to do the kinds of things that they would want to do in life or people who are shut out of institutions that they ought not to be shut out to -- shut out of. So, those are really very big costs that -- in some ways, that we did not -- with the specifics on the $16 trillion, we did not allocate it by group because we just calculated the national number. But surely, that number is greater per person in lower SES groups and racial minority groups because the economic loss is greater there, as well as the health loss.
>> David, if society returns to some semblance of normal late next year, you know, schools -- schools are in person again next year, is the economic challenges a year, 2 years, or 3 years, or 4 years?
>> The estimates from the Congressional Budget Office are that for the next decade, we will not reach the level of economic output that we would have absent COVID-19. So, that's a very big period of time. It will depend a lot on actions that we take, both as a society and as a government. So, if we do nothing now, nothing to address the virus, nothing to address the fact that people are still out of work, then things will stop their upward trajectory and go back down and get worse. On the other hand, if we do things to both address the path of the virus -- Larry Summers and I call for devoting at least 5% of any new bill passed to testing so that once you test people, they can isolate, and then you can stop the spread of the virus. And in addition to helping support people who it's not safe for them to go to work now and their employers are not having people --
>> Excuse me. Someone -- is there someone communicating -- there's other -- there's another voice in the background, so if people could be careful about turning that off. Sorry, David. Go ahead.
>> So, if we can support those people, then we can get the economy going better again. The worry is that we will be held up by paralysis, and that will make any recovery be less rapid, and that we won't get the virus under control, and that's going to make everybody be fearful about going back to work.
>> Lisa, when you hear Charlie talk about bereavement, nine affected people for each death -- and you already mentioned when you talked that there's emerging data about the mental health within particularly Black communities. I've seen some of the data. How do you think about it vis-a-vis Charlie's comments about bereavement, mental health needs, post-traumatic stress disorder?
>> Well, you know, I think it just makes the case even more strongly that -- that we have to work on equity because I think -- you know, when a group has been disproportionately impacted -- so, we're talking about how everyone across the country has been impacted. We're talking about families that have lost loved ones. But when you think about the scope of it, the number of families and the number of people in communities of color that are affected is much greater proportionately. So, you're talking about people who, many of them were already probably in a precarious position because of, you know, the inequities in our society, so many of them were already sort of living economically on the edge, struggling with, you know, getting their basic needs met, you know, making sure they actually had healthcare and all of that. And now, they've sort of been pushed off the ledge. And so, it's like -- it's even more profound at this point in time, so we're going to need to do some of the restorative things that we're talking about for everyone, but we're really going to need to pay particular attention to those groups that have been the hardest hit, you know? So, I think it just really makes the case for the fact that we -- we have an overwhelming problem here. But also, the fact that if we try to take a one-size-fits-all approach, that we may not get the result we're aiming for because there are certainly certain groups that are going to need more to get back on track. And a lot of these communities didn't have, for example, the family wealth that could serve as a cushion at a time like this because, again, you know, of these sort of years and years of economic inequality that have sort of prevented people from building up that kind of a safety, like, net for a crisis like this.
>> If I made you and David -- -- if I put you in charge of equity for the country -- you don't have quite a blank check, but you have a lot of money to spend, some of that $16 trillion that that David mentioned, how would you start, Lisa?
>> Well, you know, I'm just thinking about the interventions that I -- that have shown -- been shown to be -- to have an effect, you know, on health, and the ones that are actually most promising are on early childhood development and education and on income inequality, so providing a living wage to people who are young adults. And so, I think I would start with those two areas with really focusing in on young children and their development and investing in education and then in making sure people have a living wage because then they -- then they can afford to pay for safe housing, you know? Affordable housing would be part of that, but I think income inequality and early childhood education would be where I would focus. And then of course, on universal coverage for healthcare, you know? Well, I am a pediatrician, so whenever anyone mentions early education, I'm always very supportive. But this issue about income inequality, it's amazing that we're stuck on discussing a minimum wage of $15 an hour. In many cities, that keeps you below the poverty line, and you can't get housing. I just can't understand why, unlike most other countries, we somehow can't move that -- not in everywhere in the country, but in certain areas to $20 or $25 an hour to give people living wages. I don't -- I just don't need to see the wealthy get wealthier. That's just not, to me, the future of the country. Charlie, you, you know we're facing a mental health pandemic. And my lord, no one really knows what's going to happen over the next 6 to 8 to 10 weeks. The number of new cases over the last 2 weeks have been very, very discouraging, back up into the 50, 60, 70,000 range. Deaths have remained below 1000, but still concerning. How do we prepare for the coming mental health pandemic or the one that's already here, but has not yet surfaced in terms of requests for more help. What is it that we need to do going into 2021?
>> Wonderful. I think we need to take a three-pronged approach. The first is -- and this podcast is a beautiful example of that, we need -- at the base of the pyramid, we need a broad, honest, open dialogue with the American people and in the international community about what the nature of the problems are, what the risks are, how to recognize when you're managing or not managing the stress, anxiety, and depression related to this ongoing pandemic threat, and where to find resources. So, that's -- the first approach is education at the deepest level, real, accurate, timely, honest information, which gets to all communities, including the Black and Latinx and Indigenous communities and others. Second level of approach, and it's important to remind our listeners, Howard, because this is largely a medical audience, that the frontline for mental health is not psychiatry and medicine. It never has been. It's pediatrics and primary care. Seventy percent of all children, adolescents, and adults with psychiatric difficulties are managed in pediatrics and primary care. So, it's very important for our family doctors to be educated about the nature of normal and pathological grief, normal and traumatic stress, alcohol and drug misuse, and suicidal risk because that is where the initial safety net is. And then finally, for those -- the subset of people, which is more of a minority, who maybe had psychiatric vulnerabilities or illnesses pre-COVID and then have had them complicated, someone who has had a history of bipolar disorder and now has lost a family member, they're at much greater risk, and those usually require tertiary specialized child adolescent and adult psychiatric care with a sophisticated psychotherapy, pharmacotherapy, and other approaches. So, that's how we think about it. But it's very important to remind our listeners that for the majority of people, the approach is education and family medicine. Those are the frontlines to manage the psychiatric crisis.
>> David, so unemployment is way up. I'm assuming that the number of uninsured is going to approach 35 or 40 million at some point, unless we do something. State budgets are in shambles. I actually think they'll manage this year because of rainy day funds and some manipulation probably of their budgets. In 2021, that will not be true, because the rainy day funds will have been spent, and they won't be able to keep pushing -- -- pushing payments into the future. And because states spend so much on Medicaid, that will become an issue in 2021, 30% to 35% of state budgets go to Medicaid. Is there enough money to borrow? Can we borrow enough money? Or do economists then get worried that -- that we have too big a deficit. This always drives me a little crazy, because sometimes we seem like we can spend an ungodly sum of money, and then other times, I hear about deficits, and I can't figure it out.
>> At the moment, we can borrow. If you look at the people with money in the world, they're willing to lend it to the US government that is for essentially no interest. They're looking for a safe place to put the money. So, there's no problem at the moment in our physical capacity to borrow. Interest rates are and remain very low. At some point, debt has to be paid back --
>> -- and so, a big issue, "Will be how do we go about doing that?" My guess is that what we're going to start to see next year are calls for austerity.
>> You know, we need austerity in -- -- Medicare funds, and we need austerity and Medicaid funds, and we need austerity in funds for lower-income populations, and so on. And I think partly that will be true worry, about how much debt we can afford, and partly that will be depending on who's the president and the makeup of the congress and attempt to try and avoid any new spending. I think the reality is that we will do better to spend more now, get the economy going, get people -- and control the virus so people can get back to work. And then, come back and say, "Okay, let's think about how we're going to deal with the paying back of it all." Then, we would jumping too quickly. So, I don't know about -- I'm not an MD, but it's a little bit like, sometimes, you have to treat the patient with something that's too much for the long-term because you have to get them over the short-term health impairment.
>> Lisa, I want to -- I want to give you the final word. It's been a painful search for equity in the United States, in healthcare and in society in general. It's been elusive for centuries. It's a -- it's just been elusive. Are you optimistic that it will be different this time?
>> I have to be. You know, I -- there are days when I wake up and wonder, you know, whether I've actually lost it and whether I'm living in a fantasy, you know, by believing this, but I have to believe that. I do think that we're going to have to get creative about this. I think there's a lot of fear circulating among people that somehow if one group of people gets something, that means the other group is going to suffer more, and I think there's a lot of fear about that. I think everyone's sort of in, like, defense mode right now. And I think one thing that will help us is to really understand that, you know, we are kind of all in this together, and we're not going to -- no one's going to succeed unless we all do, you know? And I think that's the -- sort of the thinking that needs to shift in our society away from this sort of "us against them" and "this group against that group" to really thinking about the fact that in order for us to all, like, succeed and get better, we have to work together. And it may mean that, you know, it's a give and take. It's like, as if -- like, if it was your immediate family, you know, would you basically starve one of your children because, you know, you were afraid that you wouldn't get something to eat? Or would you try to make the best of what you had? And would you make sure that everyone had a chance, especially the person or the groups that had been left behind for, you know, for whatever reason, which we know that there are many reasons. But I think if we can get a shift in attitudes around that, like we are in this storm. We're not all in the same boat, but we're all in the same storm. And that it's really going to be -- we all -- in order for any of us to actually succeed, we all have to sort of succeed. We can't leave anyone out of this.
>> This is Howard Bauchner, Editor In Chief of JAMA. It's been Conversations with Dr. Bauchner. I have been talking with three remarkably distinguished scholars. David Cutler and Larry Summers have written a viewpoint entitled "The COVID-19 Pandemic and the $16 Trillion Virus." Naomi Simon, Glenn Saxe, and Charles Marmar have written a viewpoint entitled "Mental Health Disorders Related to COVID-19-Related Deaths." Lisa Cooper and David Williams have written a viewpoint, "Excess Deaths From COVID-19, Community Bereavement, and Restorative Justice for Communities of Color." And I really want to acknowledge Harvey Fineberg, former President of the National Academy of Medicine, who's written an editorial that has summarized the toll of the COVID-19 pandemic. He's talked about the two research letters that I mentioned earlier, as well as these three viewpoints. Charlie, David, Lisa, thank you so much for joining me today. And please, stay healthy. Thanks so much.
>> Thank you.
>> Thank you so much.
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