Sheltering in Place and the Likelihood of Nonnatural Death

Ralph Catalano; M. Maria Glymour; Yea-Hung Chen; Kirsten Bibbins-Domingo


Am J Epidemiol. 2021;190(6):1075-1080. 

In This Article

Abstract and Introduction


Increasing hospitalizations for COVID-19 in the United States and elsewhere have ignited debate over whether to reinstate shelter-in-place policies adopted early in the pandemic to slow the spread of infection. The debate includes claims that sheltering in place influences deaths unrelated to infection or other natural causes. Testing this claim should improve the benefit/cost accounting that informs choice on reimposing sheltering in place. We used time-series methods to compare weekly nonnatural deaths in California with those in Florida. California was the first state to begin, and among the last to end, sheltering in place, while sheltering began later and ended earlier in Florida. During weeks when California had shelter-in-place orders in effect, but Florida did not, the odds that a nonnatural death occurred in California rather than Florida were 14.4% below expected levels. Sheltering-in-place policies likely reduce mortality from mechanisms unrelated to infection or other natural causes of death.


As coronavirus disease 2019 (COVID-19) infections and hospitalizations increase in the United States and elsewhere, debate over the prudence of shelter-in-place mandates has intensified.[1,2] The debate includes claims that the intervention has induced unintended adverse health effects.[3] The "Great Barrington Declaration," for example, justifies opposition to sheltering in place by citing "devastating effects on short and long-term public health.[2,4]" The literature includes claims that the harms of lockdown include increases in deaths not just from impeded access to health care but also from suicide[5] and intrafamily violence.[6] Assessing the accuracy of these claim would seem important if for no other reason than to improve the explicit or implicit accounting of costs presumed to inform the choice whether or not to impose sheltering in place.

Although clinical anecdote[7] supports the intuition of increased non-COVID-19 mortality during sheltering-in-place, the scholarly literature reports mixed findings.[8–10] These divergent results likely arise, at least in part, because the observed populations varied in the fraction at risk of what the US Centers for Disease Control and Prevention term "natural" death or that "due solely or almost entirely to disease or the aging process".[11] Although information characterizing deaths varies among states, all death certificates in the United States use a "manner of death" classification that includes "natural death".[11] Based on data from the last decade, natural deaths account for approximately 89% of deaths in the United States.[12]

The observed populations also likely varied in the fraction at risk of "nonnatural" deaths. How sheltering in place affects these deaths remains, however, even less clear than how it affects natural deaths. As noted above, anecdote implies that suicides[5] and death due to intrafamily violence[7] increased with sheltering in place. Other reports, however, suggest decreases in such nonnatural deaths as those by accidents,[13] stranger-on-stranger violence,[14] and medical error.[15] Taken together, these reports raise an important, question: What has been the "net effect" of sheltering in place on nonnatural deaths? Answering this question requires an estimate of the association between sheltering in place and the incidence of nonnatural deaths. The peer-reviewed literature, however, includes no attempts to estimate that association. We have attempted such an estimate using data from 2 US states. We used time-series methods to compare nonnatural deaths in California, the first state to begin and among the last to end sheltering in place in early 2020, with those in another large state, Florida, where sheltering in place began late and ended early.

California and Florida responded very differently to the emerging epidemic in early 2020. Large employers, primarily in the technology sector, began telling their California workers to stay at home effective March 8.[16] Counties in the San Francisco Bay Area issued stay-at-home orders effective March 17,[17] and the Governor issued similar orders for the remainder of the state on March 19.[18] California began reopening on May 15.[19] Florida mandated sheltering in place effective April 3 and reopened on May 1.[20,21] Data that indirectly measure the behavior of households suggest that the citizens of both states reduced mobility and social contacts when shelter-in-place orders were in effect and increased both when orders were removed.[22]