The Centers for Disease Control and Prevention (CDC) announced last week that the United States had passed a grim milestone: over 200,000 Americans have now died from COVID-19. But research from Boston University School of Public Health finds that the true number of losses could be much higher.
That analysis, available on medRxiv ahead of peer-reviewed publication, took a close look at the number of US deaths between February and September 2020 that are characterized as in excess of the number of deaths that would be expected in a normal year. Researchers discovered that for every 100 excess deaths directly attributed to COVID-19, there were another 36 excess deaths-also likely caused by COVID-19, but in a less obvious manner.
BU researchers, who teamed up with collaborators from the University of Pennsylvania, and the Robert Wood Johnson Foundation, found more of these additional deaths in US counties that have greater income inequality, high percentages of non-Hispanic Black residents, less home ownership, and high population density. The data suggests that higher mortality rates are inextricably linked with socioeconomic disadvantage and structural racism.
Looking at where the most excess deaths occured is a better measure of the pandemic's disproportionate effect on communities than simply tallying up the total number of COVID-19-related deaths, according to the study's lead author Andrew Stokes, a BU School of Public Health assistant professor of global health. "Excess deaths include COVID deaths that were ascribed to other causes, as well as the indirect consequences of the pandemic on society," he says.
Indirect consequences could include people being afraid to go to the hospital for another condition for fear of catching the coronavirus, or a number of other issues caused or exacerbated by COVID-19's economic and mental health impacts, such as loss of health insurance after layoffs, inability to afford medications after pay cuts, or the skyrocketing rates of depression in America's adults, a condition that negatively impacts many aspects of health.
For their analysis, Stokes and his collaborators looked at county-level mortality data from the National Center for Health Statistics (NCHS) for 1,021 counties with 10 or more COVID-19 deaths from February 1 to September 23. Although previous studies have estimated excess deaths at the national and state levels, this is the first study to examine the question at the county level, allowing researchers to better examine how patterns of excess deaths vary by demographic and sociostructural factors.
"Our results focus important attention on the disparate impact of the COVID-19 pandemic on low-income and minority communities which have historically experienced high death rates," says study coauthor Irma T. Elo, UPenn professor and chair of sociology. Those disproportionate death rates "are now further exacerbated by the current pandemic."
As a baseline for comparison, the researchers compiled CDC data from 2013 to 2018 to estimate how many deaths each county would have expected to have during this period if not for the COVID-19 pandemic.
They found that, for the 249,167 total excess deaths in these 1,021 counties, there were 183,686 deaths directly assigned to COVID-19 on death certificates, and another 65,481 excess deaths not officially assigned to COVID-19. This means 26 percent of all excess deaths were not directly attributed to COVID-19-or, viewed another way, that actual excess deaths were 36 percent higher than the number that has been officially attributed to COVID-19.
"Counties with high levels of COVID-19 mortality also had exceptionally high levels of mortality in 2020 from other causes of death," says the study's senior author Samuel H. Preston, UPenn professor of sociology. "This result suggests that the epidemic is responsible for many more deaths than are attributed to COVID-19 alone."
While most counties saw more deaths than would have been expected in a normal year, some saw fewer deaths than normal. Combining that with demographic and structural factors gathered by US Census data, the researchers suggest that the communities identified as the ones hit hardest by the COVID-19 pandemic have likely lost even more lives than official numbers show.
"Racial and socioeconomic inequities in US mortality have widened significantly as a result of the COVID pandemic," says study coauthor and BU research fellow Dielle Lundberg (SPH'19). "To protect public health, policymakers must act decisively to address structural racism and reduce income inequality."
The study was also coauthored by Katherine Hempstead of the Robert Wood Johnson Foundation, and was funded by the Robert Wood Johnson Foundation.
