Although James Toussaint has never had covid, 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 recently has 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.

Toussaint worries about what will happen when his pandemic unemployment benefits run out, which could happen as early as July 31.

“I’ve been homeless before,” said Toussaint, who found a room to rent nearby after his eviction. “I don’t want to be homeless again.”

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 United States 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 Brown Americans and those of white Americans. Indeed, new research published Wednesday in the 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,” said 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 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 said. 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 Brown Americans. In a February report, economic analysts at McKinsey & Co. predicted that, on average, Black and Brown 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 with 10.7% in January 2020. A federal eviction moratorium, which has helped an estimated 2.2 million people remain in their homes, expires June 30. Without protection from evictions, “millions of Americans could fall off the cliff,” said Vangela Wade, president and CEO of the Mississippi Center for Justice, a not-for-profit advocacy group.

Being evicted erodes a person’s health in multiple ways. “Poverty causes a lot of cancer and chronic disease, and this pandemic has caused a lot more poverty,” said 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.”

Nineteen million adults recently have had trouble putting food on the table. The inability to afford healthy food — which is usually more expensive than salty, starchy fare — can cause both short-term and long-term harm. People with low incomes, for example, 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,” said Dr. Robert Califf, former commissioner of the 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.”

Less Wealth, Poorer Health

American health was poor even before the pandemic, with 60% of the population suffering from a chronic condition, such as obesity, diabetes, high blood pressure or heart failure. These four conditions were associated with nearly two-thirds of hospitalizations from COVID, 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, Woolf said. That trend was exacerbated by the Great Recession of 2007-09, 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.

Researchers have developed a better understanding in recent years of how chronic stress — such as that caused by poverty, job loss and homelessness — leads to disease. Unrelenting stress causes inflammation that can damage blood vessels, the heart and other organs.

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%.

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.

The stress of the pandemic also has led many people to smoke, drink and gain weight, increasing the risk of chronic disease. Fatal drug overdoses spiked 30% from October 2019 to October 2020.

Jennifer Drury, 40, has struggled with substance abuse, particularly prescription painkillers, since her 20s. 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,” said Drury, who fell behind on rent and was evicted from her previous home. She said 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.”

Women Losing Ground

The American Rescue Plan, which provides $1.9 trillion in pandemic relief, was designed to help displaced workers and cut child poverty rates in half. The actual benefits of the law may prove less sweeping.

Twenty-five states have opted to cut off additional federal unemployment payments, citing concerns that such generous benefits pay people more to stay home than to work.

Many women say they would like to return to work but have no one to take care of their children. Nearly half of child care centers have closed and others have reduced the number of children they serve.

The Federal Reserve Bank of Minneapolis concluded that “economic recovery depends on child care availability.” A March report from the National Women’s Law Center estimates “women have lost a generation of labor force participation gains,” which could leave them and their children financially disadvantaged for years.

Ruth Bermudez is one of millions of women who have left the workforce in the past year. Bermudez, who was laid off from her job as a behavioral health caseworker in New Orleans last year, said her child care needs have prevented her from finding work. The care of her 6-year-old daughter became her full-time job after the pandemic closed schools.

Although her daughter has returned to class, Bermudez said school shutdowns due to covid outbreaks have been frequent and unpredictable.

“I had to be the teacher, the lunch lady, the school bus driver, all at one time,” said Bermudez, 27. “It is exhausting.”

Life-Altering Evictions

James Toussaint had just two weeks to find a new place to live after a judge ordered him evicted. His family was unable to take him in.

“I’ve got family, but everybody has their own issues and problems,” said Toussaint, who had to throw away all his clothes and furniture because they had become infested with bedbugs. “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. He’s had to buy cleaning supplies with his own money in order to sanitize the bathroom, which he said is often too dirty to use.

Sharing communal space is often unsanitary and increases the risk of being exposed to the coronavirus, said Emily Benfer, a visiting professor at Wake Forest University School of Law. Even moving in with family poses risks, she said, because it’s impossible to isolate or quarantine in crowded homes.

Benfer co-wrote a November study that found COVID infection rates grew twice as high in states that lifted moratoriums on evictions, compared with states that continued to ban them. About 14% of tenants have fallen behind on rent — double the rate before the pandemic.

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.

Property owners have filed for more than 372,000 evictions during the pandemic in just the five states and 29 cities tracked by Princeton University’s Eviction Lab. 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.

“This singular event alters the course of one’s life for the worse,” Benfer said. “If we don’t intervene” to prevent mass evictions when the moratorium ends, “it will be catastrophic for generations to come.”

Eviction’s harms can be measured at every stage of life:

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, Benfer said.

Kids who are evicted are at greater risk of lead poisoning from substandard housing, Benfer said. They’re also more likely than others to be hospitalized.

Evicted adults 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.

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 said. In fact, tenants who request repairs or report safety hazards risk eviction.

Although middle-class Americans take their kitchens for granted — and rely on them to cook healthful meals — more than 1 million homes lack complete kitchens, according to the U.S. Census Bureau.

New Orleans doesn’t require that rental units include stoves, said Hannah Adams, also a lawyer with Southeast Louisiana Legal Services. Toussaint’s new room is equipped with a microwave and small refrigerator, but no sink, oven or stove. He washes dinner dishes in the bathroom. His landlord doesn’t allow residents to have electric hot plates, so most of his meals involve cold cereal, deli sandwiches or meals he can heat in the microwave. His doctor has urged Toussaint, who is borderline diabetic, to lose weight, eat less salt and starch, and stop smoking.

Toussaint, who lived on the street for two years, said 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 said he hopes Americans won’t forget about the suffering of people like Toussaint as cases of COVID decline. “My worry is that people will feel the crisis is behind us and it’s all good,” Woolf said. 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, said 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 said. “It will take an intentional effort to make up for the losses that have occurred over the past year.”