Tag Archives: health

How many deaths from COVID-19 are acceptable?

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With a downturn in COVID-19 cases and deaths in the United States, officials and others are considering how many COVID deaths are acceptable moving forward:

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Implicit in a decision to drop the last remaining safety rules is a willingness to abide the current mortality rate. Over the last week, COVID-19 has claimed an average of 626 lives in the U.S. each day. That’s fewer than the roughly 1,900 who die of heart disease and the 1,650 who die of cancer each day, on average, but well above the 147 are lost to influenza and pneumonia combined.

For public health experts, the calculus is more explicit. Mortality and morbidity — the words their profession uses for death and illness — are on one side of the equation, and tools like seat belts, blood pressure medication, smoking-cessation programs and vaccines are on the other.

Those tools vary in cost, intrusiveness and political acceptability. Despite public health campaigns and legal mandates, Americans continue to drive drunk and leave seatbelts unfastened. Tobacco kills more than 480,000 people a year in the United States, yet 34.2 million adults continue to smoke. Diabetes claims more than 100,000 lives a year, but efforts to discourage the sale and consumption of sugary drinks — a significant contributor — have met fierce resistance.

At some point, all efforts to limit preventable deaths will hit the hard wall of funding constraints, medication availability, and people’s willingness to take steps to protect themselves and others. That’s where the number of deaths that is “acceptable” comes into focus…

The CDC and other federal agencies are still deciding on the criteria they’ll use to determine when the pandemic has ended. There’s still time — Dr. Rochelle Walensky, the agency’s director, said as recently as last week that we’re not there yet.

What I would highlight here as a sociologist:

  1. The relative risk of different illnesses or behaviors are not just determined by numbers. The first paragraph cited above highlights the number of people who die each day in the US due to different conditions. But, this does not mean each of these illnesses is experienced the same nor is thought of as the same kind of threat. See earlier posts on the acceptable deaths due to driving (and pedestrians).
  2. Decisions like these are made by a constellation of actors with a variety of interests. The public is involved in how leaders think the public will perceive changes, pressure the public can place on officials to make particular decisions, and in how the public responds. This is a process with numerous organizations and institutions involved.

Declaring an end to the COVID-19 pandemic is not easy nor is addressing the illness beyond the official end of a pandemic. Like much involving health, policies and behavior depends on social conditions and influences.

Deaths and COVID-19 by groups, communities in Cook County

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COVID-19 is big in its effects but I am surprised we have not seen more coverage all over the place about who specifically is affected more within regions and big cities. WBEZ looks at recent data in Cook County, Illinois:

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In the earliest weeks of the pandemic, Chicago’s Black residents were dying of COVID-19 at alarming rates. More recently, in the few weeks since the arrival of the omicron variant, Black Chicagoans are again dying at much higher rates than their Asian, Latino and white counterparts, shows a WBEZ analysis of data on COVID-19 related deaths from the Cook County Medical Examiner’s Office.

Since Dec. 7, 2021, the date when the state’s first omicron case was found in Chicago, the city’s Black residents are dying at rates four times higher than Asians, three times higher than Latinos and nearly two times higher than white residents, according to WBEZ’s analysis. A total of 97 Black Chicagoans died of COVID-19 during the seven-day period ending Jan. 9, 2022 — more than at any point since May 11, 2020.

Black Chicagoans aren’t the only demographic that has been particularly vulnerable since the arrival of omicron. Older suburban Cook County residents have also seen their seven-day COVID-19 death totals reach levels not witnessed in more than a year. According to WBEZ’s analysis, a total of 181 suburban Cook County residents 60 years and older died from COVID-19 during the week ending Jan. 9, 2022. That’s the highest seven-day total for that group since Dec. 24, 2020…

While several communities on Chicago’s South and West sides have been hit hard by COVID-19, the pandemic’s death toll has also weighed heavily in various parts of suburban Cook County. WBEZ’s analysis finds some of the county’s highest COVID-19 death rates in parts of northwest suburban Niles, Norridge and Lincolnwood, southwest suburban Palos Heights, Chicago Ridge, Oak Lawn and Bridgeview; and south suburban Hazel Crest, Markham, Harvey, Robbins and Country Club Hills.

I am sure there are already and will continue to be many academic studies that examine these differences. Even as COVID-19 has impacted many, the impacts of COVID-19 are not distributed evenly. It arrived at a time of inequality, including in health outcomes and experiences, and it exacerbated issues.

At least in the Chicago area, data on this topic is available online. For example, I have tried to keep track of the disparate effects of COVID-19 in DuPage County where there are significant differences across racial and ethnic groups, age groups, and communities (earlier post here).

The health costs of initial urbanization and industrialization

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In Extra Life: A Short History of Living Longer, Steven Johnson briefly summarizes how the development of big cities around the world in roughly the last two centuries often came at a high cost regarding health. After discussing the first life tables developed in England:

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How could any economy that was creating more wealth than any other place on earth produce such devastating health outcomes? The answer that Farr proposed with epidemiological data was similar to the one Marx and Engels were forming at the same time using political science: the mortality rates were plunging because the defining characteristic of being “Advanced” at that moment in history was industrialization, and industrialization seems to come with an unusually high body count in its initial decades, wherever it happens to arrive. The twentieth century would go on to show the same trends happening around the world whenever people left their agrarian lifestyle and crowded into factories and urban slums, even in economies where communist planners were driving the shift to an industrial economy…

The data told an incontrovertible story: industrial cities were killing people at an unprecedented rate. (73-74)

As Johnson goes on to note, this trend did not necessarily last as many cities and the millions living there became healthier over time. But, that transition period in Liverpool and other industrializing cities, whether in the 1800s or in more recent decades with the development of megacities around the globe, comes at a significant cost.

Even though I have not emphasized the health aspects of this in the past, this is part of the reason that I link the beginnings of sociology, urbanization, and industrialization in my courses. The population shift to big cities plus a new economic and production structure are noteworthy enough. But, these are connected to seismic shifts in societal structures and relations. People had lived in relatively small communities for thousands of years and this was shifting to significantly different kinds of communities, governments, and interaction. Sociology as a discipline emerges at this time to help explain and understand these changes. As noted above, Marx was seeing all of this happen and expressedt his concerns of what it all meant.

And all of this affected the human body in significant ways. This shift required poor health and death for many. We may look now and think it turned out okay – and life expectancy around the globe has increased dramatically – but it influenced bodies and social structures in profound ways.

Doctors connecting health and land use policies

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A recent document from the American Medical Association and the Association of American Medical Colleges asks doctors to address health inequities by prioritizing structural conditions. Here is one example involving land use which first asks the conventional question and then highlights a health equity perspective:

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How can we promote healthy behavior?

How can we democratize land use policies through greater public participation to ensure healthy living conditions?

The second perspective highlights a structural perspective in two ways.

  1. Healthy behavior leans more toward an individualistic perspective. A person who has health concerns should adapt their behavior in order to be more healthy. In contrast, healthy living conditions suggests there is a broader context for the individual’s health. Healthy living conditions can help lead to healthier individuals.
  2. With healthy living conditions in mind, the new question highlights two ways that healthy living conditions come about: land use policies and greater public participation. This likely refers to research and experiences certain communities have with decisions made about where to locate land uses – ranging from coal power plants to landfills to manufacturing facilities with toxic output and more – that then affect health. Such decisions involve power, race/ethnicity, and social class as well as decision-making processes.

More broadly, land use in the United States is often determined by zoning and profit-seeking. Zoning often has the goal of protecting single-family homes. Land and location can be turned into money. Health is not a primary concern in all of these decisions even as it can lead to better health outcomes for some compared to others.

h/t Conor Friedersdorf in The Atlantic.

Reminder: only about one-third of American adults have a college degree

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Coverage of a recent study about life expectancy and education provided this reminder about education levels in the United States:

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About one-third of Americans have a four-year college degree, and they are living longer and more prosperous lives while the rest face rising death rates and declining prospects, said researcher Angus Deaton, a professor at the University of Southern California’s Center for Health Policy and Economics.

According to QuickFacts from the Census with July 1, 2019 estimates, 32.1% of American adults have a bachelor’s degree or higher.

For a good segment of Americans, college is the expected path that follows after high school and also leads to future opportunities, particularly regarding jobs. But, many American adults did not or do not follow that path and this has all kinds of consequences. At the least, it can provide a reminder to current college students and instructors that college is an opportunity and/or blessing, not just something to be endured for later outcomes. More broadly, that degree can separate workers in the job market, lead to subsequent educational opportunities, and, as this study suggests, interact with health.

The suburban lawn and patio as protection against COVID-19

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If people gather for Thanksgiving, experts are advising they meet and eat outside. Here is one example:

How much safer is an outdoor meal than an indoor meal?

Much, much safer. Almost all transmission of this virus happens indoors.

Even if people are close together?

Eating outdoors doesn’t mean you’re invincible. Still try to stay six feet apart. If you huddle together around a cramped table and have close, face-to-face conversations with the people next to you, you could absolutely infect them.

This is time for the patio or lawn, found in millions of single-family homes and in many suburbs, to shine. The lawn does not just have to be a status symbol; it can confer health benefits by allowing people to spread out.

This is not the first time that the suburban lawn was said to boost health. In the gathering urbanization of the nineteenth century, suburban lawns provided space away from polluted and noisy cities. Listening to the radio the other day, I again heard mentioned how River Forest, Illinois was intentionally built with features meant to highlight nature.

Before COVID-19, the suburban lawn was also said to aid good health. It helps people get outside to work and move around (canceled out by the use of gas-powered equipment?). It encourages kids to play in a safe space. Depending on the season and/or weather, the patio and yard can act as an outdoor extension of private living space.

Now, the lawn and patio can be a private spot away from COVID-19. Outsiders are not welcome. The fresh air, breeze, and distance can limit transmission. Nature, or “nature” in many suburban settings, can serve as an oasis. All that lawn and patio maintenance can be put to use. And, hopefully, people can stay COVID free.

A health example of choosing between a dichotomous outcome or a continuum

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When I teach Statistics and Research Methods, we talk a little about how researchers make decisions about creating and using categories for data they have. As this example of recommendations about fertility notes, creating categories can be a tricky process:

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Being 35 or older is labeled by the medical community as “advanced maternal age.” In diagnosis code speak, these patients are “elderly,” or in some parts of the world, “geriatric.” In addition to being offensive to most, these terms—so jarringly at odds with what is otherwise considered a young age—instill a sense that one’s reproductive identity is predominantly negative as soon as one reaches age 35. But the number 35 itself, not to mention the conclusions we draw from it, has spun out of our collective control…

The 35-year-old threshold is not only known by patients, it is embraced by doctors as a tool that guides the care of their patients. It’s used bimodally: If you’re under 35, you’re fine; if you’re 35 or older, you have a new host of problems. This interpretation treats the issue at hand as what is known as a “threshold effect.” Cross the threshold of age 35, it implies, and the intrinsic nature of a woman’s body has changed; she falls off a cliff from one category into another. (Indeed, many of my patients speak of crossing age 35 as exactly this kind of fall, with their fertility “plummeting” suddenly.) As I’ve already stated, though, the age-related concerns are gradual and exist along a continuum. Even if the rate of those risks accelerates at a certain point, it’s still not a quantum leap from one risk category to another.

This issue comes up frequently in science and medicine. In order to categorize things that fall along a continuum, things that nature itself doesn’t necessarily distinguish as being separable into discrete groups, we have to create cutoffs. Those work very well when comparing large groups of patients, because that’s what the studies were designed to do, but to apply those to individual patients is more difficult. To a degree, they can be useful. For example, when we are operating far from those cutoffs—counseling a 25-year-old versus a 45-year-old—the conclusions to draw from that cutoff are more applicable. But operate close to it—counseling a 34-year-old trying to imagine her future 36-year-old self—and the distinction is so subtle as to be almost superfluous.

The trade-offs seem clear. A single point where the data turns from one category to another, an age of 35, simplifies the research findings (though the article suggests they may not actually point to 35) and allows doctors and others to offer clear guidance. The number is easy to remember.

A continuum, on the other hand, might better fit the data where there is not a clear drop-off at an age near 35. The range offers more flexibility for doctors and patients to develop an individualized approach.

Deciding which is better requires thinking about the advantages of each, the purpose of the categories, and who wants what information. The “easy” answer is that both sets of categories can exist; people could keep in mind a rough estimate of 35 while doctors and researchers could have conversations where they discuss why that particular age may or may not matter for a person.

More broadly, learning more about continuums and considering when they are worth deploying could benefit our society. I realize I am comfortable with them; sociologists suggest many social phenomena fall along a continuum with many cases falling in between. But, this tendency toward continuums or spectrums or more nuanced or complex results may not always be helpful. We can decry black and white thinking and yet we all need to regularly make quick decisions based on a limited number of categories (I am thinking of System 1 thinking described by behavioral economists and others). Even as we strive to collect good data, we also need to pay attention to how we organize and communicate that data.

During COVID-19, wealthier people now less mobile than poorer people

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Researchers found changes in mobility patterns among Americans of different income levels during COVID-19:

woman in yellow tshirt and beige jacket holding a fruit stand

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Writing in the journal PNAS, researchers from several California universities describe how they used anonymized cell phone location data and census info to show a dramatic reversal in how mobile Americans have been this year. Before Covid-19 struck, rich Americans moved about more than poor Americans—they can always afford to travel. But between January and April, that flipped. Rich folk are now far more likely to stay completely at home than poor folk: The study found that 25 percent more high earners stayed completely at home during the pandemic, compared to the number of them who had stayed home before. That increase was only 10 percent among low earners. And that has major implications for how we as a nation can fight the pandemic.

“In the early stages of the Covid-19 pandemic, there was a clear mobility response across the board,” says University of California, Davis environmental economist Joakim Weill, lead author on the paper. “In the US, everyone started to stay at home more. But we also found that there is a clear differential between wealthier communities and poor communities, where individuals in wealthier neighborhoods tended to stay at home much more than people in poorer neighborhoods.”…

Close to half of the wealthiest Americans stayed completely at home on weekdays in April, compared to less than 40 percent of low-earners. The poor traveled farther distances on average: In the same month, people who live in lower-income areas traveled between 5 and 6 kilometers, while the rich traveled closer to 4. The rich nearly halved their visits to recreational and retail areas in April, while the poor cut their visits by only a quarter—perhaps because their jobs required them to return to work there.

To be clear, the researchers can’t definitively say why the data shows this dramatic discrepancy, but they can begin to speculate. For one, essential workers often earn lower incomes, like clerks at grocery stores and pharmacies. Indeed, the US Bureau of Labor Statistics has found that among Americans 25 and older with less than a high school diploma, just 5 percent teleworked in June. On the other hand, 54 percent of Americans with a bachelor’s or more advanced degree were able to work remotely.

Social class is connected to mobility, health, and a whole lot of factors in social life. The anonymized cell phone data also seems to align with other patterns: those who can leaving certain big cities as well as differences in COVID-19 cases across communities and racial and ethnic groups.

As the article goes on to note, the fact that anyone can contract COVID-19 is not the same as saying everyone has the same likelihood of contracting COVID-19. Those with resources have more options in how to respond to crises plus more options when it comes to treatment. These differences are generally present regarding health but a large pandemic reveals some of the underlying patterns that deserve attention.

When communities resist and protest COVID-19 testing and treatment sites

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NIMBY attitudes can be present even – or maybe especially – during pandemics:

Last week, residents in Darien, Connecticut, a tony exurb of New York City, successfully lobbied to shut down plans for a coronavirus testing site, despite surging demand. The reason? Complaints from neighbors. As it turns out, the “Not In My Backyard” impulse to block new development — which has been implicated in the severe affordability crisis affecting cities from coast to coast — translates far too neatly into blocking certain measures needed to stop the spread of the virus.

In a similar case in Ewing, New Jersey, a local landlord issued a cease-and-desist letter to the operator of a coronavirus testing center amid complaints about congestion in the parking lot. As The Trentonian reported, one resident who wanted to be tested in order to protect his three-year-old child wasn’t subtle about how he felt about the decision: “It blows my f**king mind.”

Community resistance from neighbors of testing sites is a rerun of the fierce NIMBY reaction to potential coronavirus quarantine sites. Back in February, California began looking for a place to shelter Americans returning from abroad with the virus and settled on an isolated medical campus in Costa Mesa. But after local residents complained, city officials sought and received a court injunction to stop the project.

As the need for quarantine sites expanded, so did the NIMBY backlash. Finding sites that won’t suffer the same fate has proven to be a major hurdle as the federal government attempts to manage the crisis. Back when the focus was still on returning cruise ship passengers, officials in Alabama went to the mat to keep passengers of the Diamond Princess cruise ship out of a local FEMA facility, eventually forcing the federal government to scrap the plan altogether. Similar fights have played out from Seattle to San Antonio, potentially undercutting the response to the coronavirus at key early stages. As a result, the federal government largely shifted quarantining efforts to military bases, where complaining neighbors hold less sway…

At first glance, it might seem like efforts to block potentially life-saving public health screenings and complaints about community character have little in common. But in both cases, the formula is the same: Whether out of an understandable fear of the unknown or a selfish desire to shift the burden elsewhere, local impulses are given veto power over broader social needs. Under normal conditions, the inability to constructively manage this means higher rents. In a public health emergency, it could be lethal.

In addition to what is in the last paragraph quoted above, I am struck by the resistance to facilities and sites that would be home to temporary concerns. It is one thing to object to a long-term health facility (see recent posts about a drug treatment facility in the western suburbs of the Chicago area here and here) but another to resist something that is needed now and presumably not permanent. Of course, this could be part of the fear: if a site treats COVID-19, could it then later be turned into a more permanent fixture in the community?

The logical extension of the NIMBY claims would be to push COVID-19 treatment sites or testing facilities to communities that could not resist it. When this plays out in areas like housing or unwanted land uses, this means that communities with less wealth and political power tend to become home to land uses that wealthier communities refuse. If such a pattern occurs here (and there is evidence that health differs dramatically by location in the United States), it could be evidence that pandemics further locational and health inequalities.

Infectious diseases in urban and suburban life

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Americans already have a predilection for suburban life; might a global pandemic push even more people out of cities and to the edges of metropolitan regions? One take regarding safety in suburban life:

As maps like this show, major metropolitan areas are bearing the brunt of the Covid-19 infections spreading across North America. And that makes sense: Though there’s no way to know for sure how the virus arrived, it almost certainly came by way of an international flight to a major airport (or several of them). But while infectious disease spreads faster where people are more densely clustered — hence the strategy of social distancing to contain the coronavirus — that doesn’t necessarily make suburban or rural areas safer, health experts say…

That is not to say that cities aren’t Petri dishes — they are. Relative to rural areas, urban centers do provide stronger chains of viral transmission, with higher rates of contact and larger numbers of infection-prone people. And historically, urbanites paid a price for this vulnerability…

Modern transportation networks have made the population shield that rural areas once provided much more porous. Now that humans and freight can travel from, say, Hong Kong to Los Angeles in less than 13 hours — and arrive by vehicle to somewhere sparsely populated hours after that — outbreaks can happen just about anywhere. New pathogens tend to arrive sooner in global hubs, but that doesn’t mean they can’t quickly reach rural locales and proliferate from there, says Benjamin Dalziel, a professor of mathematics at Oregon State University who studies population dynamics…

But while the CDC recommends decreasing social contact to limit the spread of the virus, that’s just as doable in a downtown apartment as a countryside manor. Says Viboud: “If you’re staying at home and limiting outside contact, you’d achieve the same purpose.”

Three thoughts come to mind:

  1. This highlights the connectedness of cities and suburbs today, even if there is significant physical distance separating communities. The rate at which people travel around the world, to other regions, and throughout regions is high compared to all of human history and is relatively easy to do. Cities and suburbs are not separate places; they are parts of interdependent regions that are highly connected to other places.
  2. Safety and health was a part of creating the suburbs in the United States but it is hard to know how this might matter in the future. Given all the reasons people now settle in the suburbs, would avoiding communicable diseases be a top factor? I would think not, particularly compared to factors like housing prices or amenities (schools, quality of life, etc.), or demographics.
  3. If particular places are not that much safer, does the sprawl of American life then limit the response to any illness? Imagine the Chicago region with dozens of hospitals that need to be equipped spread throughout the region as opposed to that same number of people packed into a smaller area where it is easier to get supplies and people to medical facilities. Or, the need to supply grocery stores throughout a huge region.