H5N1

The quarantine economy: How COVID-19 is worsening economic inequality in America

Via Rentonomics, a report by Chris Salviati and Rob Warnock: The Quarantine Economy: How Coronavirus Is Worsening Economic Inequality in America. Excerpt:

As the quarantine economy forces hundreds of millions indoors, the ability to work from home has emerged as a key factor in determining who can and cannot continue to do their jobs. In places where shelter-in-place orders have taken effect, employees of businesses deemed “non-essential” are told to either work remotely or not work at all. 

This means that workers whose jobs require in-person interaction may be at immediate risk of losing their incomes. The option to work from home may always have been seen as a perk of certain occupations, but now it has now become crucial to the economic security of workers across the country.  

However, the ability to work remotely is far from universal. Using data from the Bureau of Labor Statistics and Census American Community Surveys, we calculate the percentage of workers who say they have the ability to work from home, broken down by income. 

We find a stark correlation between income and job flexibility; America’s lowest-earners are those who are least likely to be able to take advantage of remote working arrangements. Among workers who earn $100,000 annually or more, a majority (51.7 percent) say they can do their jobs from home. Meanwhile, remote work is possible for just 15.3 percent of those who earn $25,000 per year or less. 

The ability to work from home also varies substantially by occupation. We have previously reported that work-from-home arrangements have risen in popularity over the past decade as teleconference technology improves. But it is mostly office workers who can take advantage of these technologies and fulfill their responsibilities from any place with a strong internet connection. Some of the economy’s most common industries—such as retail, food service, and construction—require that employees show up in person because of the very nature of the work. 

There is a direct relationship between economic stability and the ability to work remotely. The chart below plots the share of workers in a given occupation who can work remotely against the share of full-time workers in that occupation who live below the poverty line. Markers are sized according to the total number of workers employed in the given occupation. 

A clear pattern emerges: most occupations cluster along either the vertical or horizontal axes. Moving up the vertical axis shows occupations with increasing capability to work remotely; for many of these jobs, poverty rates hover close to zero. For example, 86 percent of full-time software developers say that they can work from home under normal conditions, and just 1.1 percent of these workers fall below the poverty line. Similarly, just 0.5 percent of lawyers are impoverished, and 75 percent report being able to work remotely. 

Unfortunately, poverty is not so rare for other sets of American workers, even those working full-time. Moving to the right along the horizontal axis shows occupations with increasing poverty rates. Importantly, those with the highest poverty rates are those for which remote work is difficult or impossible. Maids and housekeepers, for example, are fully incapable of working from home, and face a poverty rate of 12.7 percent. Similarly, 11.3 percent of full-time cooks live below the poverty line. 

Keep in mind that the poverty threshold for an individual in 2018 was just $12,784, and for a family of four it was just $25,465. The poverty rate reflects only those facing the most extreme economic hardship, and many who fall above the poverty line still bear significant financial strain.  

As the quarantine economy forces more of the workforce to go remote, the most economically vulnerable face the greatest risk of losing their income streams. This vulnerability goes beyond the size of one’s paycheck. Workers who are unable to do their jobs remotely face a number of additional hurdles. As demonstrated in the following section, they are less likely to have paid sick leave or employer-sponsored health insurance, less likely to own homes, and more likely to be burdened by the cost of housing. 

Which Workers Are At Greater Economic Risk? 

A key component of the today’s shelter-in-place orders are the exceptions granted to workers employed in industries that are deemed “essential.” Earlier we described the general economic benefits of jobs that allow remote work. But in the quarantine economy, this concept of essentiality is an equally important factor in identifying which workers will face the greatest economic risk. 

Essentiality varies slightly from place to place, but is based on federal guidelines about what constitutes “critical infrastructure” during the coronavirus pandemic. For the most part, jobs related to manufacturing, agriculture, medicine, government services, and national defense are considered essential. Others, like education, entertainment, and some retail are non-essential. Employees of non-essential businesses are therefore prevented from working, that is, unless they can work from home. 

Indian air pollution: Loaded dice

Via The Lancet Planetary Health: Indian air pollution: loaded dice. Excerpt:

India is once again at the centre of heated discussions due to its toxic air and the disproportionately high mortality and disease burden this is causing. 

In November, the air in Delhi, India's capital, was so noxious that authorities declared a public health emergency and ordered the closure of schools in the city and surrounding suburbs for several days. All dirty fuel-based industries—ie, those powered by coal and diesel—were also ordered to be closed by the Supreme Court mandated Environment Pollution Prevention and Control Authority. 

Delhi's toxic air, choked with smoke, partly from farm fires in neighbouring states, industrial and vehicular pollution, and road dust, is familiar to all those who live in the city. The toxicity shoots up every winter due to several factors, including lower wind speeds, festival fireworks and crop residue burning by farmers in neighbouring states. 

Despite the well-documented health impacts, the situation has not improved. 

A recent study showed that India's toxic air—particulate matter and household air pollution—claimed 1·24 million lives in 2017. That is 12·5% of the deaths recorded that year in India. Delhi was shown to have the highest level of annual population-weighted mean PM2·5 (particulate matter of diameter <2·5 μm) pollution in 2017, followed by Uttar Pradesh, Bihar, and Haryana in north India, all with mean values greater than 125 μg/m³. 

Delhi's toxic air regularly makes front page news, but the problem is much more widespread. For example, a 2018 report on the worlds most polluted cities noted that “of the cities included in South Asia… although Delhi typically receives most media coverage as one of the world's ‘pollution capitals’… [it] ‘only’ ranks 10th for annual PM2·5 concentration. Other cities across Northern India and Pakistan have a higher recorded annual PM2·5 level, with nearby Gurugram narrowly resulting in the highest annual concentration of any global city recorded during 2018.” In 2018, the average air pollution level in Gurugram was over 13 times the WHO guidelines. 

Differential impacts 

Polluted air does not impact everyone equally; the poor and those forced to work outdoors suffer more. A 2011 paper which investigated the human health impacts from urban air pollution in India concluded that such pollution is especially harmful to poor people. “About 74% of the population with low income is exposed to annual 24-hourly average PM10 concentration levels above 150 μg/m³, compared to about 58% each for those with medium or high income. The safe level standards for residential areas are up to 60 μg/m³”, the paper noted. 

More affluent Indians are now seeking to protect themselves by installing air purifiers, remaining indoors in more “protected air” and venturing outdoors with masks on. In contrast, a cycle-rickshaw ride through the Rajendra Nagar Industrial area in Ghaziabad, adjacent to Delhi, gave a glimpse of the risks faced by extremely poor Indians, working outdoors, with few other work choices and no protection. 

Vijay Singh, around 40, knows it is a tough life pedalling a rickshaw through some of the most polluted patches of the city. 

“Yes, I have breathing problems. It is getting worse. I cough a lot. I don't go to a doctor unless I feel really bad. I can't afford to take time off. I don't feel comfortable wearing a mask when I cycle. I know the air is very polluted here, but what can I do?” Singh told The Lancet Planetary Health. 

Dr Arvind Kumar, a chest surgeon at Delhi's Ganga Ram Hospital and chairperson of the NGO the Lung Care Foundation, explains that “Air pollution affects anyone and everyone who breathes. Prime Minister Narendra Modi, and a sweeper on the street, both breathe about 25 000 times a day. However, the economic difference allows one to control the quality of air that goes into one's lungs. An economically deprived person living in a shack or by the roadside has no access to any technology device which can in any way influence the quality of air.” 

“Air purifiers can help some people, to some extent but at a heavy cost and no one can remain locked up in air purified rooms 24/7. Air purifiers have mechanical filters which need to be replaced if the ambient air is too dirty. This is expensive and furthermore, domestic air purifiers can't deal with noxious gases, only particulate matter”, says Kumar. 

In cities with clean air, cycling is healthy. But not so in polluted cities. Rahul Goel, lead author of a 2015 study concerned with on-road PM2·5 pollution exposure in Delhi, says “We found that a person who is cycling or in an auto rickshaw is exposed to 2·5 times more particulate matter (PM2·5) pollution than someone who is in an air conditioned car with the windows rolled up or someone who is travelling in an air conditioned train. It gets worse if you factor in the physical exertion involved in cycling, for example. When you are cycling, you inhale up to three times more air. So, for the same distance travelled, a cyclist inhales a total dose of polluted air eight times more than someone in an air conditioned car.”

Samoa measles: Desperate and anxious parents vent frustration on help line community

Via Talamua On-line News: Desperate and Anxious Parents Vent Frustration on Help Line Community. Excerpt:

APIA, SAMOA – 11 DECEMBER 2019: Parents in desperate need of help for their children amidst the measles crisis have kept the 24 hour Free Help Line number 800-7874 operated by Samoa Victim Support Group busy.  

The calls according to SVSG range from assistance required for their children’s burial such as clothes; others required assistance with diapers, milk, and food to care for their children recovered from the measles and have been discharged from the hospital. 

“Even through the phone, we could hear the desperation in the voices of the parents; most have been caught off guard by the turn of events and needed someone to blame, hence they vented their frustration towards the whole situation through the Help Line.”

SVSG is not blaming these people as most of the callers are families and parents of children victims of the measles from underprivileged families. 

“Some just couldn’t afford a bus fare to travel to town to seek assistance which is what makes the Help Line more convenient.” 

Grieving solo mother 

On Wednesday, the SVSG Measles Outreach assisted a grieving single mother whose 4 year old son lost his battle with the measles.  The mother walked from the hospital to the SVSG office for help in getting a white suit for her son.  

“Through the kind donations we have received for the Measles Outreach, we were able to provide for this mother’s request.  It really breaks the heart to see the pain and the sorrow through the eyes of this mother; but it has been a sight now becoming a norm to us as the Measles Outreach continues through the villages.”  

Later on the same afternoon, SVSG received a call on the Help Line from a 65 year old grandmother. She needed milk, diapers and food for her 2 grandchildren who have just been discharged from the hospital. 

“The mother of the 2 grandchildren is 9 months pregnant and as such, she could not take care of her young ones recovering from the measles.”  

It was late at night when the grandmother was presented with the donations of a carton of milk, a packet of diapers, a bag of rice, boxes of noodles and toiletries. The relieved smile from the grandmother when presented with the donations was reward for a long day’s work.  

The next day, a father of 5 children from called the Help Line twice during the government shut down period from 6am – 5pm, desperate for food for his children. 

“Apparently, 3 of the children have been hospitalized due to the measles, including a 1 month old baby.  Fortunately, all the 3 children have recovered and continued to take medication at home.” 

It’s not just poor white people driving a decline in life expectancy

Via The New York Times: It’s Not Just Poor White People Driving a Decline in Life Expectancy. Excerpt:

As the life expectancy of Americans has declined over a period of three years — a drop driven by higher death rates among people in the prime of life — the focus has been on the plight of white Americans in rural areas who were dying from so-called deaths of despair: drug overdoses, alcoholism and suicide.  

But a new analysis of more than a half-century of federal mortality data, published on Tuesday in JAMA, found that the increased death rates among people in midlife extended to all racial and ethnic groups, and to suburbs and cities. And while suicides, drug overdoses and alcoholism were the main causes, other medical conditions, including heart disease, strokes and chronic obstructive pulmonary disease, also contributed, the authors reported.  

“The whole country is at a health disadvantage compared to other wealthy nations,” the study’s lead author, Dr. Steven Woolf of Virginia Commonwealth University, said. “We are losing people in the most productive period of their lives. Children are losing parents. Employers have a sicker work force.”  

That some Americans’ life spans were decreasing has been well established. But the level of detail in Tuesday’s study was new, as was the rich analysis of the geography of the declines. Health experts say the full effect was startling.

The increase in deaths among people in midlife highlighted the lagging health measures in the United States compared with other wealthy nations, despite the fact that the United States has the highest per capita health spending in the world, noted an editorial that accompanied the study. 

“Mortality has improved year to year over the course of the 20th century,” said Dr. Samuel Preston, a demographer at the University of Pennsylvania. “The 21st century is a major exception. Since 2010 there’s been no improvement in mortality among working-aged people.”  

While the total number of excess deaths — meaning the number of deaths that would not have happened if the mortality rate had continued to improve — is small, at 33,000, deaths in younger people have a much bigger effect on national life-expectancy estimates than deaths of people in their 80s or 90s. 

Death rates are actually improving among children and older Americans, Dr. Woolf noted, perhaps because they may have more reliable health care — Medicaid for many children and Medicare for older people.

According to the new study, the death rate from 2010 to 2017 for all causes among people ages 25 to 64 increased from 328.5 deaths per 100,000 people to 348.2 deaths per 100,000. It was clear statistically by 2014 that it was not just whites who were affected, but all racial and ethnic groups and that the main causes were drug overdoses, alcohol and suicides.

NSW bushfires: Doctors sound alarm over 'disastrous' impact of smoke on air pollution

Via The Guardian: NSW bushfires: doctors sound alarm over 'disastrous' impact of smoke on air pollution. Excerpt:

A Sydney GP working in the suburbs hardest hit by bushfire smoke plaguing New South Wales has said she is devastated for her patients, many of them unable to afford air filters, air conditioning or masks.  

Dr Kim Loo works in Riverstone, which along with Richmond and St Marys on Tuesday recorded some of the highest levels of ultra-fine PM2.5 particles, small enough to enter the lungs and bloodstream. On Tuesday afternoon, the 24-hour average index for Rouse Hill stood at 430, with anything above 200 rated “hazardous”. 

Levels ranged as high as 2,200 in some Sydney suburbs on Tuesday. Bathurst, Orange, Armidale and Goulburn also experienced hazardous air quality. 

“My poor patients, many live on the margins of poverty,” a tearful Loo told Guardian Australia. “They live in houses that aren’t sealed. I know there are guidelines telling people to stay inside if they have certain health conditions, but that’s no good if your house isn’t sealed and you can’t afford an air filter. 

“It is disastrous and it’s unprecedented. We have no experience dealing with this for such a long period. I have patients on oxygen for lung disease and they’re on it for 16 hours a day and they can’t go outside at all now. They’re isolated.” 

Loo is also angry. For several years she has been travelling to Canberra to talk to federal politicians, warning them of such a situation due to climate change. She has had meetings with state politicians as well.  

“And then I get really upset and it makes me so sad, because what climate change does is amplify social inequity,” Loo said as she drove to her clinic to face another day of treating smoke-affected patients. “People who can afford to filter their air and live in places where trees aren’t burning, or to fly somewhere else when the smoke gets bad, don’t feel the brunt of this. The people on the margins walk to my surgery, they don’t own a car. They can’t pay for food, let alone smoke masks.” 

In the week to 6 December, about 1,140 people presented to NSW emergency departments, 25% more than the usual weekly average. The largest increases have been in South Western Sydney Local Health District, which serves a region particularly affected by smoke. NSW Ambulance fielded about 2,330 calls in the same period, about 30% more than the average for a week. Hospitals are so far managing to cope with the demand.  

The vice-president of the Australian Medical Association, Dr Chris Zappala, is a respiratory physician and he said the weeks of relentless bushfire smoke were taking a toll on people’s sense of well-being. Many people were cutting back on normal activities such as exercise because of smoke inhalation and irritation to their eyes and respiratory system, he said.  

“There is no question that there is a quality of life and mental health cost from the confinement, and the worry that this prolonged period of smoke exposure causes,” Zappala said. “I had a mother of younger kids telling me her children were not allowed out to play at school, and the kids were experiencing boredom and agitation and other effects of prolonged confinement. People are appropriately not going out to exercise as much and it’s just a constraining, unhappy time.”

Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: An observational study

Via The Lancet Public Health: Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational study. The summary: 

Background 

Low socioeconomic position is consistently associated with increased risk of premature death. The aim of this study is to measure the aggregate scale of inequality in premature mortality for the whole population of England. 

Methods 

We used mortality records from the UK Office for National Statistics to study all 2 465 285 premature deaths (defined as those before age 75 years) in England between Jan 1, 2003, and Dec 31, 2018. Socioeconomic position was defined using deciles of the Index of Multiple Deprivation: a measure of neighbourhood income, employment, education levels, crime, health, availability of services, and local environment. We calculated the number of expected deaths by applying mortality rates in the least deprived decile to other deciles, within the strata of age, sex, and time. 

The mortality rate attributable to socioeconomic inequality was defined as the difference between the observed and expected deaths. We also used life table modelling to estimate years-of-life lost attributable to socioeconomic inequality. 

Findings 

35·6% (95% CI 35·3–35·9) of premature deaths were attributable to socioeconomic inequality, equating to 877 082 deaths, or one every 10 min. The biggest contributors were ischaemic heart disease (152 171 excess deaths), respiratory cancers (111 083) and chronic obstructive pulmonary disease (83 593). 

The most unequal causes of death were deaths due to tuberculosis, opioid use, HIV, psychoactive drugs use, viral hepatitis, and obesity, each with more than two-thirds attributable to inequality. Inequality was greater among men and peaked in early childhood and at age 40–49 years. 

The proportion of deaths attributable to inequality increased during the study period, particularly for women, because mortality rates among the most deprived women (excluding cardiovascular diseases) plateaued, and for some diseases increased. A mean of 14·4 months of life before age 75 years are lost due to socioeconomic inequality. 

Interpretation 

One in three premature deaths are attributable to socioeconomic inequality, making this our most important public health challenge. Interventions that address upstream determinants of health should be prioritised.

It’s no surprise that Canada’s life expectancy has plateaued

The Tyee has published my article It’s No Surprise that Canada’s Life Expectancy Has Plateaued. Excerpt:

When a strange, ugly, and fatal disease hits, it gets a lot of attention. Ebola in the Democratic Republic of the Congo has so far sickened a little over 3,000 people and killed over 2,000 of them. The world has watched in morbid horror.  

Meanwhile measles has killed over 5,000 people in the DR Congo, almost all of them children under five. A quarter-million more fell ill. No one much cares.  

Similarly, any slow, insidious threat to public health is easier to ignore than a sudden, obvious one. And that is why political decisions taken in the 1970s and ’80s, and being taken today, have caused a public health disaster in North America. 

We’ve known for a long time that inequality is harmful to health and life expectancy, even for the rich, who die young thanks to the stress of keeping the rest of us poor. 

But for decades it’s been possible to ignore that grim fact by pointing to ever-increasing life expectancy as an indication all was well. Americans could brag about how much they spend on health care. Canadians could point to medicare as a major reason why we spend less on health care and still live longer than they do.

It’s getting harder, however, for either country to claim bragging rights. According to a new report published in the Journal of the American Medical Association, the U.S. once did have a lot to be proud of. “Between 1959 and 2016, U.S. life expectancy increased by almost 10 years, from 69.9 years in 1959 to 78.9 years in 2016, with the fastest increase... occurring during 1969-1979.” 

But even in the 1970s, changes were under way: wages began to stagnate, and right-wing media and think tanks in both the U.S. and Canada began to criticize “big government” for high taxes and over-regulation. That made sense to some workers whose income didn’t quite cover their expenses anymore. 

It wasn’t a coincidence that, as the JAMA report says, “Life expectancy began to advance more slowly in the 1980s and plateaued in 2011... The National Center for Health Statistics reported that U.S. life expectancy peaked (78.9 years) in 2014 and subsequently decreased significantly for three consecutive years, reaching 78.6 years in 2017.”

Life expectancy and mortality rates in the United States, 1959-2017

Via JAMA, the big story of the week, if not the year: Life Expectancy and Mortality Rates in the United States, 1959-2017. The abstract:

Importance  US life expectancy has not kept pace with that of other wealthy countries and is now decreasing.  

Objective  To examine vital statistics and review the history of changes in US life expectancy and increasing mortality rates; and to identify potential contributing factors, drawing insights from current literature and an analysis of state-level trends.  

Evidence  Life expectancy data for 1959-2016 and cause-specific mortality rates for 1999-2017 were obtained from the US Mortality Database and CDC WONDER, respectively. The analysis focused on midlife deaths (ages 25-64 years), stratified by sex, race/ethnicity, socioeconomic status, and geography (including the 50 states). Published research from January 1990 through August 2019 that examined relevant mortality trends and potential contributory factors was examined. 

Findings  Between 1959 and 2016, US life expectancy increased from 69.9 years to 78.9 years but declined for 3 consecutive years after 2014. The recent decrease in US life expectancy culminated a period of increasing cause-specific mortality among adults aged 25 to 64 years that began in the 1990s, ultimately producing an increase in all-cause mortality that began in 2010. During 2010-2017, midlife all-cause mortality rates increased from 328.5 deaths/100 000 to 348.2 deaths/100 000. By 2014, midlife mortality was increasing across all racial groups, caused by drug overdoses, alcohol abuse, suicides, and a diverse list of organ system diseases. The largest relative increases in midlife mortality rates occurred in New England (New Hampshire, 23.3%; Maine, 20.7%; Vermont, 19.9%) and the Ohio Valley (West Virginia, 23.0%; Ohio, 21.6%; Indiana, 14.8%; Kentucky, 14.7%). The increase in midlife mortality during 2010-2017 was associated with an estimated 33 307 excess US deaths, 32.8% of which occurred in 4 Ohio Valley states.  

Conclusions and Relevance  US life expectancy increased for most of the past 60 years, but the rate of increase slowed over time and life expectancy decreased after 2014. A major contributor has been an increase in mortality from specific causes (eg, drug overdoses, suicides, organ system diseases) among young and middle-aged adults of all racial groups, with an onset as early as the 1990s and with the largest relative increases occurring in the Ohio Valley and New England. The implications for public health and the economy are substantial, making it vital to understand the underlying causes.

US: Flint’s children suffer in class after years of drinking the lead-poisoned water

Via The New York Times: Flint’s Children Suffer in Class After Years of Drinking the Lead-Poisoned Water. We are just beginning to face similar problems in Canada. Excerpt:

FLINT, Mich. — Nakiya Wakes could not understand how her wiry, toothy-grinned 6-year-old had gone from hyperactive one school year to what teachers described as hysterical the next. Then, in 2015, the state of Michigan delivered a diagnosis of sorts: Ms. Wakes’s neighborhood’s water — which her son, Jaylon, had been drinking and bathing in for more than a year — was saturated with lead, at some of the highest levels in the city. 

Jaylon would cycle through two schools, receive 30 suspensions and rack up 70 unexcused absences. In one of Ms. Wakes’s clashes with Flint Community Schools, she delivered administrators a warning: “You can’t keep suspending him because soon, you’re going to have to suspend the whole school system.” 

Five years after Michigan switched Flint’s water supply to the contaminated Flint River from Lake Huron, the city’s lead crisis has migrated from its homes to its schools, where neurological and behavioral problems — real or feared — among students are threatening to overwhelm the education system.  

The contamination of this long-struggling city’s water exposed nearly 30,000 schoolchildren to a neurotoxin known to have detrimental effects on children’s developing brains and nervous systems. Requests for special education or behavioral interventions began rising four years ago, when the water contamination became public, bolstering a class-action lawsuit that demanded more resources for Flint’s children. Sign Up for On Politics With Lisa Lerer A spotlight on the people reshaping our politics. A conversation with voters across the country. And a guiding hand through the endless news cycle, telling you what you really need to know.

That lawsuit forced the state to establish the $3 million Neurodevelopmental Center of Excellence, which began screening students. The screenings then confirmed a range of disabilities, which have prompted still more requests for intervention. 

The percentage of the city’s students who qualify for special education services has nearly doubled, to 28 percent, from 15 percent the year the lead crisis began, and the city’s screening center has received more than 1,300 referrals since December 2018. The results: About 70 percent of the students evaluated have required school accommodations for issues like attention deficit hyperactivity disorder, also known as A.D.H.D.; dyslexia; or mild intellectual impairment, said Katherine Burrell, the associate director of the center.  

“We have a school district where all that’s left are damaged kids who are being exposed to other damaged kids, and it’s causing more damage,” said Stephanie Pascal, who has taught in Flint for 23 years.

Effect of economic recession and impact of health and social protection expenditures on adult mortality

Via The Lancet Global Health, an important study: Effect of economic recession and impact of health and social protection expenditures on adult mortality: a longitudinal analysis of 5565 Brazilian municipalities. The summary:

Background 

Economic recession might worsen health in low-income and middle-income countries with precarious job markets and weak social protection systems. Between 2014–16, a major economic crisis occurred in Brazil. We aimed to assess the association between economic recession and adult mortality in Brazil and to ascertain whether health and social welfare programmes in the country had a protective effect against the negative impact of this recession. 

Methods 

In this longitudinal analysis, we obtained data from the Brazilian Ministry of Health, the Brazilian Institute for Geography and Statistics, the Ministry of Social Development and Fight Against Hunger, and the Information System for the Public Budget in Health to assess changes in state unemployment level and mortality among adults (aged ≥15 years) in Brazil between 2012 and 2017. Outcomes were municipal all-cause and cause-specific mortality rates for all adults and across population subgroups stratified by age, sex, and race. 

We used fixed-effect panel regression models with quarterly timepoints to assess the association between recession and changes in mortality. Mortality and unemployment rates were detrended using Hodrick–Prescott filters to assess cyclical variation and control for underlying trends. We tested interactions between unemployment and terciles of municipal social protection and health-care expenditure to assess whether the relationship between unemployment and mortality varied. 

Findings 

Between 2012 and 2017, 7 069 242 deaths were recorded among adults (aged ≥15 years) in 5565 municipalities in Brazil. During this time period, the mean crude municipal adult mortality rate increased by 8·0% from 143·1 deaths per 100 000 in 2012 to 154·5 deaths per 100 000 in 2017. An increase in unemployment rate of 1 percentage-point was associated with a 0·50 increase per 100 000 population per rter (95% CI 0·09–0·91) in all-cause mortality, mainly due to cancer and cardiovascular disease. 

Between 2012 and 2017, higher unemployment accounted for 31 415 excess deaths (95% CI 29 698–33 132). All-cause mortality increased among black or mixed race (pardo) Brazilians (a 0·46 increase [95% CI 0·15–0·80]), men (0·67 [0·22–1·13]), and individuals aged 30–59 years (0·43 [0·16–0·69] per 1 percentage-point increase in the unemployment rate. 

No significant association was identified between unemployment and all-cause mortality for white Brazilian, women, adolescents (aged 15–29 years), or older and retired individuals (aged ≥60 years). In municipalities with high expenditure on health and social protection programmes, no significant increases in recession-related mortality were observed. 

Interpretation 

The Brazilian recession contributed to increases in mortality. However, health and social protection expenditure seemed to mitigate detrimental health effects, especially among vulnerable populations. This evidence provides support for stronger health and social protection systems globally.