Background
The collateral damage associated with pandemic lockdown policies is enormous, cutting across multiple areas of physical and mental health, education, culture, religion, the economy, and the social fabric of society. In this document, we use the term ‘lockdowns’ broadly to refer to a suite of policies ranging from school and university closures, mandatory online education, health-care and travel restrictions, business closures, stay-at-home and work-from-home orders, COVID-19-related firings, and the canceling and prevention of cultural, social and religious events. Collateral public health damage has affected all segments of society, but children, low-income people, manual laborers, the elderly, and people with chronic health problems have been hardest hit, resulting in increased wealth and health inequalities.
Some of the consequences of lockdowns were immediate, such as the deterioration of cardiovascular disease outcomes and mental health, while other negative consequences, due to, for example, delayed cancer screenings and school closures, may not be realized or fully felt for decades. States, counties, and the federal government will continue to collect data and compare outcomes in states with prolonged deep lockdowns (OR, CA, MD, e.g.) versus in states that had fewer COVID-19 restrictions (SD, NE, IA, FL e.g.). Early reports indicate profound differences, with estimates suggesting that 75-80% of the excess deaths during the pandemic were not attributable to COVID-19 but to pandemic policies that led people to miss addiction treatment, to stay home when they were experiencing symptoms of a heart attack, and others.
Lockdown Philosophy
In 2006, a small group of Bush-administration health officials and computer modelers suggested lockdowns as a response to a future pandemic. Dr. Donald Henderson, a 78 year-old world-renowned epidemiologist who led the eradication of smallpox, went into action, responding that: ‘Experience has shown that communities faced with epidemics or other adverse events respond best and with the least anxiety when the normal social functioning of the community is least disrupted. Strong political and public health leadership to provide reassurance and to ensure that needed medical care services are provided are critical elements. If either is seen to be less than optimal, a manageable epidemic could move toward catastrophe.‘
Why did lab scientists such as NIH Director Francis Collins, NIAID Director Anthony Fauci and CDC Director Robert Redfield ignore the important knowledge, insights, experiences and warnings from Dr. Henderson, a public health giant?
Early in the pandemic, another preeminent infectious disease epidemiologist, Dr. Sunetra Gupta at Oxford University, voiced similar early warnings as Dr. Henderson. Why were her concerns dismissed and ignored?
Why was so much influence on public health policy accorded to Drs. Collins and Fauci? They control the largest source of infectious disease research funding in the world. How many infectious disease scientists, who should have been strong voices during the pandemic, kept quiet for fear of losing the research funding on which their livelihood depends?
Health-Care Utilization
Health-care utilization declined during lockdowns. Visits to emergency departments dropped, and childhood vaccinations plummeted. These declines likely will lead to deteriorating short and/or long-term health.
In April 2020, emergency department visits dropped by 50%. They recovered somewhat in subsequent months but were still 34% below normal at the end of 2020. How many people died because they did not go to an emergency department when they needed treatment?
A fundamental principle of public health is to consider all of health rather than focus on a single disease such as COVID-19. Why were lockdowns implemented without consideration of their negative effects on other diseases and health states? Why did the government not conduct either a formal or informal cost-benefit analysis of lockdown strategies?
Are there any systematic attempts by the CDC or NIH to collate deaths and other health consequences of deferred or missed health care during the pandemic?
Cancer
The pandemic saw a decrease in new cancer cases, but not because of less cancer. There was a significant decrease in the number of patients undergoing screening tests for cancer and thus in the number of diagnoses of cancerous and precancerous lesions during the pandemic. This inevitably means there will be more cancer deaths and later-stage diagnoses in the future. There were also decreases and delays in cancer treatments.
How many people had a cancer diagnosis delayed during the pandemic? What did the CDC and state health departments do to avoid this problem? What have they done to ensure catch ups with cancer screenings?
What will be the toll on future cancer mortality due to delayed cancer diagnoses?
What is the toll in terms of longer and more expensive cancer treatment due to delayed cancer diagnoses?
Cardiovascular Disease
Both lockdowns and fear reduced hospital visits while increasing cardiovascular deaths at home.
In 2020 there was an increase in deaths from both heart disease and stroke. The increase was especially pronounced among Black, Hispanic and Asian Americans. How much of this increase was collateral lockdown damage? Why was this problem not foreseen by the health agencies and politicians implementing lockdowns?
Other Chronic Diseases
Pandemic restrictions have also had a negative impact on other chronic diseases such as diabetes and auto-immune diseases.
Diabetes care was interrupted during the pandemic. How many Americans did this affect? What will be the long-term consequences and who will be responsible for defining and collating them?
Physical exercise is important for preventing diabetes. How did closing exercise venues such as parks and gyms, affect diabetes incidence?
What were the effects of COVID-19 restrictions on people with lupus, rheumatoid arthritis, Sjögren’s syndrome, and other auto-immune diseases?
People with dementia have suffered extraordinarily during the pandemic. Why were there not more efforts to ensure the well-being of dementia patients? To what extent did isolation protocols, cessation of physical therapy, cessation of group activities and restriction of mobility contribute to increases in dementia and to dementia deaths?
Infectious Diseases and Childhood Vaccinations
Social distancing and other pandemic measures affected COVID-19 and spread of other infectious diseases.
Many older people with weakened immune systems die from commonly circulating viruses. Did lockdowns have secondary beneficial effects on the transmission and pathology of other viruses?
Children need to build up their immune systems against common viruses in order to be protected later in life. Will pandemic-era children and babies have immune systems that are less robust than their slightly older and younger cohorts?
Childhood vaccination rates plummeted in March 2020. For example, the administration of the second dose of the measles vaccine fell by more than 90%. Vaccinations rebounded later in the year but were still below baseline and the necessary catch-up did not materialize. How many American children did not get their scheduled vaccinations due to pandemic restrictions? What are the short- and long-term consequences of this?
Vaccine skepticism has increased during the pandemic because of inaccurate and overly broad messaging around COVID-19 vaccines. How has this affected childhood vaccination rates during the pandemic and how will it affect childhood vaccination rates in the future?
Mental Health
The combined effects of increased social isolation, loss of safety net services traditionally delivered in schools for young people, increased screen time, decreased addiction and therapeutic services, loss of access to religion and social events, and increased anxiety due to the pandemic and/or pandemic policies, have had a devastating toll on the mental health of Americans, including increased anxiety, depression, substance abuse and suicidal ideation. Young people and older people have suffered disproportionately due to imposed isolation.
Why were mental health and addiction services suspended without considering potential consequences of service removal?
Why were activities and sports for low-risk young people suspended without considering the harms of isolation and lack of physical activity?
Why were known harms of increased screen time for young people ignored?
Why was poor availability of mental health services not taken into account when imposing isolation on children, young adults and the elderly?
During the pandemic, why were there so few attempts to measure mental health parameters that are more sensitive than suicidality and suicide?
How will we evaluate and compare short- and long-term mental health and longevity of people in low versus high lockdown areas?
Anxiety and depression increased during the 2020 lockdowns. CDC data show that, in 2021, 37% of American high school students reported experiencing poor mental health during the COVID-19 pandemic, and 44% reported they persistently felt sad or hopeless during the past year compared to 36.7% in 2019. Why did public health authorities not consider such adverse effects? What is now being done to address and treat this problem?
There have been substantial increases in substance abuse during the pandemic, with especially devastating impacts on underserved communities. How much did social isolation, unemployment, and termination or online only availability of support groups such as Alcoholics Anonymous contribute to this?
Eating disorders increased during lockdowns, at least through the end of 2021. Why were treatment centers for eating disorders closed or virtual only for so long in many states? What are CDC and state health departments doing to alleviate this problem?
Homicides and Domestic Violence
In the United States, the overall crime rate decreased during the first lockdown spring of 2020. Homicides later stayed constant or in some cities rose precipitously while domestic violence increased.
What proportion of these positive and negative changes were attributable to psychosocial and economic stresses of lockdowns, versus other factors such as social unrest or economic factors?
Physical Activity
General health and physical activity is important for the immune system’s ability to fight off infections, including COVID-19. Obesity is an important risk factor for COVID-19 mortality. Multiple studies have shown that physical activity and fitness decreased significantly during the pandemic including in children and young adults. Conversely, studies have demonstrated improved COVID-19 outcomes with activity for any given risk cohort. The prevalence of type 2 diabetes increased during the pandemic. Estimates of increase in Type 2 diabetes among children are as high as 182% during the first year of the pandemic, disproportionately affecting Black youth.
Why were people discouraged from going outside to exercise?
Why were beaches, basketball courts, playgrounds, and similar venues closed, preventing people from exercising and socializing in low-risk environments?
Why were many gyms closed by local and state governments?
Why were sports programs for children terminated?
In children ages 2-19, the rate of BMI increase approximately doubled during the pandemic compared to the pre pandemic period. What are the long term consequences on childhood obesity and diabetes? Was this taken into account when local governments restricted physical activity?
As of March of 2021, 42% of adults reported gaining weight during the pandemic with an average weight gain of 29 lbs. What are the long-term consequences on adult obesity, diabetes, cardiovascular disease, etc? Was this taken into account when local governments restricted physical activity?
The Microbiota and Human Immune System
Lockdowns and other social distancing measures not only affected COVID-19, but also other viruses and infectious diseases. Young children need to be exposed to viruses in order to build up the immune system that will protect them for the rest of their lives.
What effect did the lockdowns have on children’s immune systems and long term ability to fight off a variety of diseases?
The pandemic and media messaging increased use of disinfectants. What consequences does this have on our microbiota? Has it led to more gut dysbiosis (a reduction in microbial diversity)?
Gut dysbiosis is linked to an increased risk of viral hepatitis. Did use of disinfectants during the pandemic do more good than harm? Are there efforts underway at NIH to find out?
Excess Deaths
A fundamental principle of public health is concern about all aspects of health and not only a single disease. Total excess deaths is therefore an important metric when evaluating the pandemic response.
Between April of 2020 and December of 2021, excess deaths not due to COVID-19 exceeded excess deaths due to COVID-19 (29,000 vs 20,000) for ages 18-44. Why were more concerted efforts not made to anticipate and prevent non-COVID-19 excess deaths?
The US had around 170,000 excess non-COVID-19 deaths through 2021 while countries with fewer restrictions such as Sweden and Denmark had negative excess deaths during the same time period. Why did the United States focus almost exclusively on COVID-19, while Scandinavia took a more balanced approach that considered all aspects of public health? Why did most media outlets seek to discredit Sweden in 2020 for following fundamental principles of public health, leading to one of the lowest excess mortality rates in the world when measured cumulatively from the start of the pandemic until 2022?
According to CDC data, there were more than 200,000 additional American deaths at home in 2020 and more than 250,000 additional deaths at home in 2021 (provisional) compared to 2019, even while hospice deaths dropped in those years versus 2019. This can be compared to only ~19,000 COVID-19 deaths at home in 2020. What caused all these additional home deaths? How could they have been avoided?
Business Closures and Unemployment
Our pandemic response created economic problems, and public health is intrinsically linked to the economy. As people rise out of poverty their health improves, both in the short and long term. When people fall into poverty, the opposite occurs. The collateral economic harms from pandemic restrictions are of course much wider than the public health aspects discussed below, and such harms should be taken equally seriously. But, that is outside of our public health expertise and the scope of this report.
After staying at or below 4% throughout 2018, 2019, and early 2020, U.S. unemployment rose to 15% in April 2020. It gradually declined thereafter, taking until the last month of 2021 to dip below 4% again. Pre-pandemic studies show that unemployment is linked to increased mortality in men. One study estimates a 6% increased mortality risk for each percentage point increase in unemployment. Did lockdown-induced rise in unemployment increase mortality in 2020 and 2021? Does this explain some of the excess mortality seen among Americans below the age of 65?
The number of women working outside the home has steadily increased over the past decades but declined during lockdowns. Some politicians who have long championed better childcare options for working parents suddenly supported closing childcare centers and schools and leaving parents scrambling. Women disproportionately provided the necessary childcare at home. How has this affected the short- and long-term economic situation for working mothers and their families? How has it affected the mental and social health of women? How has this affected women’s career advancement and salary trajectories?
Lockdowns forced many small businesses to close permanently. How did this affect the health and well-being of small business owners and their employees? When small businesses were forced to close, much of their business was taken over by large corporations that were allowed to operate when small businesses couldn’t. Why were larger businesses provided this competitive advantage? Can this be reversed? If not, what are the long-term health consequences of having fewer small businesses?
In 2020, one pro-lockdown argument was that it was more important to save lives than to save the economy. However, a healthy economy is important for public health, especially among lower income populations. Did this view prevail because the people making it were mostly work-from-home professionals, who themselves did not suffer economically?
Housing
Many people who lost their jobs were evicted from their homes when they were no longer able to pay rent. Some people were protected by eviction moratoria.
To what extent did lockdown related home evictions or eviction moratoria exacerbate or alleviate this problem? How many Americans were evicted from their homes because of COVID-19 restrictions? How many older Americans, some of whom rely on rental income, were harmed by eviction moratoria?
Together with university closures, were house evictions one of the primary drivers of increased multi-generational living during the pandemic? How much did this increase COVID-19 mortality for older high-risk people?
In March 2020, the CARES Act temporarily prohibited landlords of federally subsidized housing units from evicting tenants for failure to pay rent during the pandemic, protecting about 25% of tenants. In September 2020, the CDC issued an agency order preventing COVID-19 related evictions. Some states implemented further prohibitions on evictions. How many people were protected by these policies? How many were able to catch up with rent, and how many were eventually evicted? How many landlords suffered economic hardship as a result?
How much did increased addiction contribute to increased homelessness?
Food Insecurity
Food insecurity increased during lockdowns, especially among families with children. With closed schools, some children lost their best source of nutritious food. In fall 2020, media outlets were full of images of thousands of people waiting in line for food in many states.
Did those implementing COVID-19 restrictions consider the fact that some people would not have enough food to eat because of lockdowns? Were there sufficient state and local remediation efforts to ensure that no American would go hungry and how well did they work?
Some school programs alleviated problems by supplying food pick-up for children in need, to be picked up by parents or other caregivers. How successful were these programs? What proportion of children in need did they reach? How many schools and districts delivered food to homes and at what cost?
Cultural and Sports Activities
Art, music, dance, theater, museums, libraries, food festivals, county fairs, sports, and other cultural activities are important for mental, emotional and social health and well-being.
Were the importance of cultural and religious activities considered when closing them?
How many children were deprived of cultural and athletic activities?
With a few notable exceptions, why were professionals working in cultural organizations not more outspoken against the closure of cultural activities? What long-term effects will these closures have on culture and society?
How many arts organizations closed their doors during the period when live performances were not allowed? What efforts are being made to revive them?
Religious Gatherings
During the pandemic, governments prevented churches, mosques, synagogues, and temples from in-person gatherings for religious worship. These closures had profound consequences on society from a multitude of perspectives. To stay within the scope of this report, we cover its public health consequences.
For many people, religious and spiritual activities are important for their mental health, whether it is partaking in mass at their church or doing yoga with a group of friends. To what extent did closing religious institutions and preventing spiritual activities contribute to increases in the nation’s mental health problems? How can religious organizations step in and help us recover?
Religious gatherings provide spiritual support as well as critical community support for emotional, mental and physical health. Why were religious gatherings closed down when many have no alternatives for social and spiritual support?
Many religious institutions provide essential services such as funerals and weddings. Marriage can also increase family income. How will we measure whether social bonds that help society function were weakened in the long-term by failing to observe such rituals?
The Environment
A healthy environment is important for long term public health and well-being.
With work-from-home orders, less car traffic reduced street congestion and air pollution in cities in 2020. What benefits did this have on asthma and other respiratory conditions? Are there ways to achieve similar improvements in air quality without pandemic lockdowns?
Did mask requirements, COVID-19 fears, and public transit restrictions push people from public transportation to increased car use? In the long run, will such fear reduce public transit use and increase traffic congestion and air pollution in large cities?
The pollution from billions of disposable face masks has harmed birds and other wildlife. What is being done to mitigate this problem? Are there other negative public health consequences from this environmental damage such as increased microplastics in the environment for humans?
Despite no evidence that COVID-19 is spread by fomites, hundreds of millions of people increased their use of disinfectants. What are the environmental effects of increased disinfectant exposures?
Community-Wide Suppression
The World Health Organization’s October 2019 publication “Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza” stated that “home quarantine of exposed individuals to reduce transmission is not recommended because there is no obvious rationale for this measure, and there would be considerable difficulties in implementing it.”
In a Johns Hopkins document, “Preparedness for a High-Impact Respiratory Pathogen Pandemic”, the authors stated in September 2019 that “In the context of a high-impact respiratory pathogen, quarantine may be the least likely NPI to be effective in controlling the spread due to high transmissibility.” They also stated that “During an emergency, it should be expected that implementation of some NPIs, such as travel restrictions and quarantine, might be pursued for social or political purposes by political leaders, rather than pursued because of public health evidence.”
On January 24, 2020, NIH/NIAID Director Dr. Anthony Fauci told reporters, “That’s something that I don’t think we could possibly do in the United States, I can’t imagine shutting down New York or Los Angeles, but the judgement on the part of the Chinese health authorities is that given the fact that it’s spreading throughout the provinces…it’s their judgement that this is something that in fact is going to help in containing it. Whether or not it does or does not is really open to question because historically when you shut things down it doesn’t have a major effect.”
Why did Dr. Fauci later change his positions to become a proponent of school closures and other pandemic restrictions?
On March 21, 2020, Dr. Michael Osterholm, Director of the Center for Infectious Disease Research and Policy, and subsequent COVID-19 advisor to President Biden, advocated against lockdowns and for focused protection in an Op-Ed published by the Washington Post. Why did he later advocate for lockdowns in the New York Times while criticizing focused protection?
In March 2020, more than 800 epidemiologists and other medical professionals sent a letter to Vice President Pence, warning that “Mandatory quarantine, regional lockdowns, and travel bans have been used to address the risk of COVID-19 in the US and abroad. But they are difficult to implement, can undermine public trust, have large societal costs and, importantly, disproportionately affect the most vulnerable segments in our communities.” Why did the Vice President and other government officials ignore this letter?
Why did some public health scientists reverse previous positions when federal and state governments implemented lockdowns in the spring of 2020, while others did not? One example was changing levels of evidence expected for safety and efficacy of COVID-19 vaccines depending on which administration was in the White House.
In October 2020, tens of thousands of scientists and medical professionals signed the Great Barrington Declaration, advocating for focused protection instead of school closures and other lockdown measures. Why did the NIH director attempt to reduce support for this document rather than encourage debate at a time when debate was critical?
Why did some highly influential public health scientists believe that SARS-CoV-2 could be permanently suppressed or eradicated when epidemiologic history did not support this conclusion?
Community-wide efforts can partially and temporarily suppress community spread, prolonging the length of the pandemic and, therefore, prolonging the period of time that older vulnerable people must isolate to protect themselves. Why did the CDC and state health departments not consider fatigue when advocating for community suppression rather than focused protection? How many additional COVID-19 deaths resulted from this failure?