Although James Toussaint has never had COVID-19, the pandemic is taking a profound toll on his health.

First, the 57-year-old lost his job delivering parts for a New Orleans auto dealership in spring 2020, when the local economy shut down. Then, he fell behind on his rent. Last month, Toussaint was forced out of his apartment when his landlord—who refused to accept federally funded rental assistance—found a loophole in the federal ban on evictions.

Toussaint has recently had trouble controlling his blood pressure. Arthritis in his back and knees prevents him from lifting more than 20 pounds, a huge obstacle for a manual laborer. He worries about what will happen when his unemployment benefits from the federal government run out, which could come as early as July 31. “I’ve been homeless before,” says Toussaint, who found a room to rent nearby after his eviction. “I don’t want to be homeless again.”
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With coronavirus infections falling in the U.S., many people are eager to put the pandemic behind them. But it has inflicted wounds that won’t easily heal. In addition to killing 600,000 in the U.S. and afflicting an estimated 3.4 million or more with persistent symptoms, the pandemic threatens the health of vulnerable people devastated by the loss of jobs, homes and opportunities for the future. It will, almost certainly, cast a long shadow on American health, leading millions of people to live sicker and die younger due to increasing rates of poverty, hunger and housing insecurity.

In particular, it will exacerbate the discrepancies already seen in the country between the wealth and health of Black and Hispanic Americans and those of white Americans. Indeed, new research published June 23 in BMJ, shows just how wide that gap has grown. Life expectancy across the country plummeted by nearly two years from 2018 to 2020, the largest decline since 1943, when American troops were dying in World War II, according to the study. But while white Americans lost 1.36 years, Black Americans lost 3.25 years and Hispanic Americans lost 3.88 years. Given that life expectancy typically varies only by a month or two from year to year, losses of this magnitude are “pretty catastrophic,” says Dr. Steven Woolf, a professor at Virginia Commonwealth University and lead author of the study.

Over the two years included in the study, the average loss of life expectancy in the U.S. was nearly nine times greater than the average in 16 other developed nations, whose residents can now expect to live 4.7 years longer than Americans. Compared with their peers in other countries, Americans died not only in greater numbers but at younger ages during this time period.

The U.S. mortality rate spiked by nearly 23% in 2020, when there were roughly 522,000 more deaths than expected. Not all of these deaths were directly attributable to COVID-19. Fatal heart attacks and strokes both increased in 2020, at least partly fueled by delayed treatment or lack of access to medical care, Woolf says. More than 40% of Americans put off treatment during the early months of the pandemic, when hospitals were stretched thin and going into a medical facility seemed risky. Without prompt medical attention, heart attacks can cause congestive heart failure; delaying treatment of strokes raises the risk of long-term disability.

Much of the devastating public health impact during the pandemic can be chalked up to economic disparity. Although stock prices have recovered from last year’s decline—and have recently hit all-time highs—many people are still suffering financially, especially Black and Hispanic Americans. In a February report, economic analysts at McKinsey & Co. predicted that, on average, Black and Hispanic workers won’t recover their pre-pandemic employment and salaries until 2024. The lowest-paid workers and those with less than a high school education may not recover even by then.

And while federal and state relief programs have cushioned the impact of pandemic job losses, 11.3% of Americans today live in poverty—compared to 10.7% in January 2020. According to U.S. Census data from late May through early June 2021, 20 million U.S. adults reported having had trouble putting food on the table. Families with a limited food budget typically choose the cheapest food, rather than the healthiest, a trade-off that causes short- and long-term harm. In the short term, for example, people with low incomes are more likely to be hospitalized for low blood sugar toward the end of the month, when they run out of money for food. In the long term, food insecurity is associated with an increased risk of diabetes, high cholesterol, hypertension, depression, anxiety and other chronic diseases, especially in children.

“Once the acute phase of this crisis has passed, we will face an enormous wave of death and disability,” says Dr. Robert Califf, former commissioner of the U.S. Food and Drug Administration, who wrote about post-pandemic health risks in an April editorial in Circulation, a medical journal. “These will be the aftershocks of COVID-19.”


More illness, and faster deaths

American health was poor even before the pandemic, with 60% of the population suffering from at least one chronic condition. Four of the most common of these health issues—obesity, diabetes, high blood pressure and heart failure—were associated with nearly two-thirds of hospitalizations from COVID-19, according to a February study in the Journal of the American Heart Association.

Deaths from some chronic diseases began rising in lower-income Americans in the 1990s, says Woolf. That trend was exacerbated by the Great Recession of 2007-2009, which undermined the health not just of those who lost their homes or jobs but the population as a whole. Still, the Great Recession, and its resultant health effects, did not affect all Americans equally. Black people in the U.S. today control less wealth than they did before that recession, while the gap in financial security between Black and white Americans has widened, according to a Nonprofit Quarterly article published last year. And the unemployment rate among Black workers did not recover to pre-recession levels until 2016.

Across the board, life expectancy in the U.S. began falling in 2014, largely due to early deaths in working-age adults suffering the corrosive effects of stagnant wages, the disappearance of manufacturing jobs, unemployment, socioeconomic inequality and deteriorating neighborhoods, Woolf says. Based on what we know about how chronic stress—such as that caused by poverty, job loss and homelessness—leads to disease (for example, stress-related inflammation has been show to damage blood vessels, the heart and other organs), we can surmise that the most vulnerable suffered the most.

People who are poor tend to smoke more, have higher risks of chronic illnesses such as cardiovascular disease, diabetes, kidney disease and mental illness, and are more likely to become victims of violence. And research shows that people with low incomes live an average of seven to eight years less than those who are financially secure. The richest 1% of Americans live nearly 15 years longer than the poorest 1%.

“Poverty causes a lot of cancer and chronic disease, and this pandemic has caused a lot more poverty,” says Dr. Otis Brawley, a professor at Johns Hopkins University who studies health disparities. “The effect of this pandemic on chronic diseases, such as cardiovascular disease and diabetes, will be measured decades from now.”


Life-altering evictions during COVID-19

Being evicted, too, erodes a person’s health in multiple ways, and once the federal eviction moratorium, which has helped an estimated 2.2 million people remain in their homes, expires June 30, many people could find themselves homeless. Without protection from evictions, “millions of Americans could fall off the cliff,” says Vangela Wade, president and CEO of the Mississippi Center for Justice, a nonprofit advocacy group.

Some landlords have found ways to evict tenants despite the federal ban. James Toussaint’s annual lease expired during the pandemic, leaving him to rent on a month-to-month basis. While some states require landlords to show “just cause” for eviction, Louisiana landlords can evict tenants for any reason once their annual lease has expired. In May, a judge ordered Toussaint—who is Black—evicted from his New Orleans home, giving him just two weeks to vacate the premises. His family was unable to take him in. “I’ve got family, but everybody has their own issues and problems,” Toussaint says. “Everyone is trying their best to help themselves.”

Toussaint is now renting a room in a boarding house with no kitchen and a shared bathroom for $160 a week. Although he’s fully immunized, he bought cleaning supplies with his own money to sanitize the bathroom, which he says is often too dirty to use.

Sharing communal space is often unsanitary and increases the risk of being exposed to the coronavirus, says Emily Benfer, a visiting professor at Wake Forest University School of Law. Even moving in with family poses risks, she says, because it’s impossible to isolate or quarantine in crowded homes—and while some 65.6% of U.S. adults are vaccinated, that still leaves a huge portion of the 18-plus population that is not. Benfer co-wrote a November study that found COVID-19 infection rates grew twice as high in states that lifted moratoriums on evictions, compared with states that continued to ban them.

People who are evicted often move into substandard housing in neighborhoods with higher crime rates. These homes are sometimes plagued by mold and roaches, lack sufficient heating or have plumbing that doesn’t work. Landlords have no incentive to make repairs for tenants who are behind on their rent, Benfer says. In fact, tenants who request repairs or report safety hazards risk eviction.

A growing body of evidence shows that eviction is toxic to health, causing immediate and long-term damage that increases the risk of death. Studies show that evicted people are more likely to be in poor general health or have mental health concerns even years later.

About 14% of tenants in the U.S. have fallen behind on rent—double the rate before the pandemic. Rates are even higher among minorities; nearly a quarter of Black tenants and 16% of Hispanic renters are behind on rent. “This singular event alters the course of one’s life for the worse,” Benfer says. Without intervention to prevent mass evictions when the moratorium ends, “it will be catastrophic for generations to come.”

Even before last year, tenants with children were more likely to be evicted than others, but the pandemic has made life especially difficult for women and families with kids. With schools and nearly half of child care centers closed, many women have struggled to hold a job while taking care of children; some have found it impossible. More than 2.3 million women dropped out of the labor force between February 2020 and February 2021, compared to 1.8 million men, according to the National Women’s Law Center. As a result of this exit and the loss of income, households with children are more likely to have trouble affording food and paying rent than other households, according to an analysis of U.S. Census data by the Center on Budget and Policy Priorities.

The health harms that result from evictions can be measured at every stage of life: Kids who are evicted are at greater risk of lead poisoning from substandard housing. They’re also more likely than others to be hospitalized. When pregnant women are evicted, their newborns are more likely to be born early or very small and have a higher risk of dying in the first year. Women who are evicted are more likely to suffer sexual assault.

Evicted adults in general report worse mental health and are more likely to be hospitalized for a mental health crisis, studies show. They also have higher mortality rates from suicide. Although the causes of addiction are complex, research shows that counties with higher eviction rates have significantly higher rates of drug- and alcohol-related deaths.

And during the pandemic, so-called deaths of despair increased significantly. Fatal drug overdoses spiked 30% from October 2019 to October 2020. And the bad habits that many Americans developed during lockdowns and their aftermath—smoking more, drinking more and gaining weight—increase the risk of chronic disease in the future.

Jennifer Drury, 40, has struggled with substance abuse, particularly prescription painkillers, since her 20s. In recent years, she was the mend and managed to stay sober. She blames the isolation and stress of the pandemic for causing her to relapse—and leading several of her friends to fatally overdose. “Idle time is not good for addiction,” says Drury, who fell behind on rent and was evicted from her previous home. She says drug dealers are never far away, especially at the New Orleans motel where she and her husband are now staying. “Drug dealers don’t care about pandemics.”


Don’t forget recent history

Toussaint, who in the past spent a two-year stretch living on the street, says he’s determined not to return there. He hopes to apply for disability insurance, which would provide him with an income if his arthritis prevents him from finding steady work.

Woolf says he hope that Americans won’t forget about the suffering of people like Toussaint as cases of COVID-19 decline. “My worry is that people will feel the crisis is behind us and it’s all good,” Woolf says. His research connecting four decades of declining economic opportunity with falling life expectancy shows “we are in really big trouble, and that was true before we knew a pandemic was coming.”

The pandemic doesn’t have to doom a generation of Americans to disease and early death, says Dr. Richard Besser, president and CEO of the Robert Wood Johnson Foundation. By addressing issues such as poverty, racial inequality and the lack of affordable housing, the country can improve American health and reverse the trends that caused communities of color to suffer. “How the pandemic will affect people’s future health depends on what we do coming out of this,” Besser says. “It will take an intentional effort to make up for the losses that have occurred over the past year.”


KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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