We need caution, robust methods and strong evidence when quantifying the mortality impacts from the Covid-19 recession

Anja Smith | May 2020

During the last two weeks debates and discussions on the direct mortality impacts of Covid-19 relative to the mortality impacts that will flow from the recession induced by lockdown policy decisions have intensified. Newspapers and Twitter are starting to turn away from only focusing on infection rates and health system responses, to growing concerns about unemployment, business closures and the impacts on the livelihoods of ordinary South Africans. We are worried, very worried.

Lockdown responses have occurred on an unprecedented scale in many countries across the world. This recession will be unlike any other: we are facing a recession driven by health policy decisions to stabilise and protect the health system by slowing the spread of Covid-19 infections. The recession comes at a unique point in time – a point of economic weakness for South Africa when the world has never been as economically interconnected. Given this interconnected world, border closures and unprecedented global supply chain disruptions are likely to have devastating economic consequences.

As discussions and worries about the economy intensify, the media, businesses, industry associations, citizens and academics will start to refer to previous studies done on mortality impacts from economic recessions. It is worthwhile pausing to think about the minimum requirements these studies need to fulfill to be applicable to the current crisis, as well as to South Africa’s economy. A few things need to be kept in mind in scanning the literature on what the effects are likely to be in South Africa.

Only evidence from studies that used causal or semi-causal methods are worth considering. There exists a well-known and even strong correlation between health and economic development. This does not always translate into a causal relationship. We must therefore be cautious about not using evidence from purely cross-sectional studies.

Nuanced thinking is needed on the different channels through which the economy and employment will affect mortality. These channels could include suicides, road accidents, deaths due to alcohol consumption, cancer, increased hypertension and blood sugar levels due to stress and poorer diets, malnutrition due to limited calorie intake, maternal mortality through higher pregnancy rates, etc. The strength and relative importance of these channels are likely to vary according to the economic, social support and health system structures of different countries. There is a danger of cherry picking some of the possible transmission channels to support an argument in one direction or the other. It will be necessary to consider the full range of potential channels.

In presenting this evidence, we need to clearly distinguish between high-income country evidence and low- and middle-income country (LMIC) evidence. While no causal relationship may exist between recessions and mortality in high-income countries, and there may even be a relationship between recessions and reduced mortality for these countries, this is likely to be different for LMICs.

In thinking about the impacts for South Africa, it will be even more important to clearly bring to light the distributional effects of mortality. South Africa has high poverty rates and very high income and asset inequality. Some studies point to lower income people and workers, both formal and informal, as more likely to be adversely affected. The increase in deaths due to recession will not be the same across all groups.

Due to dramatic changes in the structures of economies over time, evidence from studies closer to 2020 than 1930 (the Great Depression) should be prioritised. Economies looked different in 1930 compared to 2020, and people back then were not as dependent on large corporations for sustenance as they are now.

Lastly, it important to keep in mind that policy making has become more sophisticated over time as we have learnt from previous recessions. Governments can now intervene faster, and more data is available than ever before to monitor and respond to the negative impacts. There is reason to be hopeful that we can mitigate the mortality impacts of this recession if we act fast, but also in smart, considered and flexible ways.