Mandatory Public Health Measures for Coronavirus-19 Are Associated With Improved Mortality, Equity and Economic Outcomes

The impact of public health measures on the coronavirus-2019 pandemic was analyzed by comparing mandatory versus voluntary nonpharmaceutical interventions between 2 comparable European countries and among 3 U.S. states. Using an ecological retrospective cohort study design, we examine differences in mortality, economic impact, and equity. Compared to voluntary policies, mandatory shelter-in-place policies were associated with a 3- to 5-fold lower population-adjusted mortality in the U.S. model and between 11- to 12-fold lower in the European one. Voluntary shelter-in-place measures were associated with overall increased mortality cost, as measured by value of a statistical life; somewhat greater decreases in gross domestic product; and substantial negative impacts on minority communities, who experienced markedly increased mortality rates (the percentage of minority deaths was 2.3 and 4 times greater in the U.S. model and 14.5 times higher in the European one) and mortality cost (2.7- and 4.5-fold higher in the U.S. model and 11.1-fold higher in the European one). We conclude that voluntary policies are less effective than mandatory ones, based on historical precedent and the current analysis. Negative effects on health equity mirrored the increased mortality outcomes of voluntary policies, and there was no apparent economic benefit associated with voluntary measures.