The Health Consequences of Urban Scaling

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COVID-19 is the most severe health emergency since the 1918 influenza pandemic. However, the impacts of the pandemic have been severely underestimated. First, a number of deaths directly caused by COVID-19 have not been coded as such due to differences in testing capacity, knowledge of clinical manifestations, etc. Second, the pandemic has also had indirect consequences of health, including potential increases or decreases in mortality due to the mitigation measures designed to control the pandemic. Both the direct and indirect impacts of the pandemic have been unequally distributed, as individuals of low socioeconomic status and racial/ethnic minoritized populations have suffered the highest burden of the direct and indirect impacts of the pandemic. These inequalities may be wider in larger cities, as they tend to concentrate both wealth and poverty. However, larger cities also tend to have a healthier population. The overall objective of this study is to examine excess mortality and inequities in excess mortality during 2020 and 2021 in US metropolitan statistical areas (MSAs), and to explore factors driving excess mortality and its inequities. We will leverage expertise and data acquired through the parent grant and will mentor a set of diverse trainees to uncover inequities and predictors of these inequities in excess mortality that will allow for a better of understanding where and why health inequities are wider and whether these inequities stemmed from direct or indirect impacts of the pandemic. Specifically, we aim to (1) describe excess mortality in the 392 MSAs of the US during 2020 and 2021, and to quantify direct (COVID-19) vs indirect impacts of the pandemic; (2) measure inequities in excess mortality by race/ethnicity and education in 392 MSAs during 2020 and 2021, and to quantify the contributions of direct and indirect impacts of the pandemic on these inequities; and (3) study the association between city size, city-level income inequality, and city-level racialized residential segregation on excess mortality and on inequities in excess mortality, and to examine the differential contribution of these factors to the direct and indirect impacts of the pandemic. In summary, the proposed study will fill significant gaps in our knowledge regarding the unequally distributed impacts of the COVID-19 pandemic in urban areas of the US, with a special emphasis on understanding these impacts across the continuum of urbanization, with a focus on social inequality.