Association between urban shrinkage and excess mortality during the COVID-19 pandemic

Abstract

As the COVID-19 pandemic exposed and amplified structural vulnerabilities in cities, understanding how urban shrinkage exacerbates public health risks has become increasingly urgent. This study examines the relationship between urban shrinkage and excess mortality in 1,142 US counties during the COVID-19 pandemic (March 2020–February 2023). Using Kruskal–Wallis tests and mixed-effects models, we analyzed how different patterns and degrees of urban shrinkage influenced monthly excess deaths per 100,000 population and the frequency of mortality peaks. The results indicate that shrinking counties showed 165% higher excess deaths and 142% more mortality peaks than growing counties. Notably, counties experiencing simultaneous declines in both population and gross regional domestic product demonstrated worse outcomes than those with only one dimension of shrinkage. Furthermore, excess deaths increased proportionally with the severity of demographic and economic contraction. Socioeconomic disadvantages prevalent in shrinking counties—including lower income levels, higher proportions of older adults, lower educational attainment and higher unemployment rates—were also associated with elevated excess deaths. These findings underscore the need for place-based public health strategies tailored to address the structural vulnerabilities faced by shrinking and socioeconomically disadvantaged communities. Shrinking US counties faced 165% higher COVID-19 excess mortality than growing areas, exacerbated by combined population and economic decline. Structural vulnerabilities in shrinking regions underscore the need for targeted health interventions addressing socioeconomic disparities.