• The official COVID-19 mortality count in the United States has surpassed 660,000, but inaccuracies in cause of death reports hide the true impact of the pandemic.
• Researchers at Boston University and the University of Pennsylvania recently explored healthcare factors at the county level that explained why 20% of excess deaths in 2020 were due to COVID-19.
• Their study found that most of these excess deaths occurred in areas affected by racial and social injustices.

A recent study suggests that authorities did not factor excess deaths into COVID-19 death tolls in 2020. The authors define “excess deaths” as the number of mortalities beyond what would have been expected compared with the average at the same time of year over the previous 5 years.

They pinpointed several healthcare and socioeconomic factors involved in excess deaths not attributed to COVID-19.

Dr. Andrew Stokes, Ph.D., a professor of global health at the Boston University School of Public Health (BUSPH), led the recent study. He and his team have now published their findings in JAMA Network Open.

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Disproportionate burden

In an earlier study, the researchers showed that COVID-19 directly or indirectly contributed to 1 in 5 excess deaths in the U.S. in 2020. This figure varied by county.

They revealed that more excess deaths were likely to be missing from death certificates in counties with worse socioeconomic and health indices. They did this by comparing missing COVID-19 deaths in the top 25% of counties versus the lowest 25% of counties.

For example, 24% of deaths were likely to be missing in counties with the highest rates of diabetes (top quartile) compared with 9% in counties with the lowest rates of diabetes (lowest quartile).

The researchers also found that missing COVID-19 deaths were higher in counties with higher proportions of non-Hispanic Black populations (23% vs. 14%) and Hispanic populations (18% vs. 9%).

Dr. David Williams, Ph.D., is the Florence Sprague Norman and Laura Smart Norman Professor of Public Health at the Harvard T.H. Chan School of Public Health and a professor of African and African American Studies at the Harvard Faculty of Arts & Sciences.

During a podcast with The Brain Architects, Dr. Williams explained:

“We are seeing in multiple states [that] more than half of all deaths from the coronavirus are African American, and in virtually every state, the percent of deaths of African Americans who die from the coronavirus [is] larger than the percent of African Americans in the population in that state.”

Dr. Williams was not involved with the recent study.

Dr. Vickie Mays, Ph.D. — who was also not involved with this study — is a professor of psychology and the director of the UCLA Center for Research, Education, Training, and Strategic Communication on Minority Health Disparities.

During the virtual panel Confidence in Crisis: Strengthening Medical Trust in the Black Community Q&A, Dr. Mays discussed social difficulties that many Black people face as risk factors for COVID-19.

“The three top things that we can see are related to social determinants of health relative to being at risk [of COVID-19] are what we’re calling the ‘threats to survival’ and ‘stresses and strains.’ People, for example, with income insecurity, people with food insecurity, and people with housing insecurity were more likely to develop COVID-19.”

Dr. Mays’ BRITE Center also mentions that African American people comprise a larger proportion of essential workers with an increased risk of infection.

Measuring mortalities

Dr. Stokes and fellow researchers used data from the U.S. National Center for Health Statistics. This information included COVID-19-related and all-cause deaths in U.S. counties throughout 2020.

The team also assessed data from the Centers for Disease Control and Prevention (CDC)’s WONDER database and the U.S. Census Bureau.

The study covered 2,096 counties with over 319 million residents. Roughly 11% of this population had no health insurance.

Obstacles to accuracy

Speaking with Medical News Today, Dr. Mays mentioned several challenges to obtaining accurate cause of death assessments.

“Not every death gets an autopsy,” she explained. “Not every county has the kind of resources and time, particularly if you think about what the medical examiners and the coroners are faced with.”

Dr. Mays added that “there is a correlation between whether or not the locale that you’re in is a big believer in COVID-19 or if there are political reasons that COVID-19 is not supported.”

Dr. Mays also referred to another study led by Dr. Stokes, which sees inequities in deaths attributed to COVID-19 as evidence of structural racism. According to that research, such disparities have “contributed to vulnerability during the pandemic.”

Reduced access to healthcare may be skewing COVID-19 death counts downward. Rural areas and communities with large historically marginalized populations tend to have fewer testing sites as well, according to Dr. Williams.

Dr. Williams also said that Black people have been less likely to undergo testing when they experience the same COVID-19 symptoms as white people.

The study’s results

The study indicates that counties with more uninsured residents, fewer primary care doctors, and more at-home deaths showed a higher percentage of excess deaths.

• In counties with the highest proportion of people without health insurance, 27% of excess deaths were estimated to be due to COVID-19 compared with -5% in the counties with the lowest numbers without health insurance.
• In counties with the lowest number of primary care physicians per resident, 20% of excess deaths were considered to be due to COVID-19 compared with 0% in counties with the highest proportion of primary care physicians.
• More deaths at home led to an estimate of 34% of excess deaths due to COVID-19 compared with 17% in counties in the lowest quartile of deaths at home.

People with no health insurance or access to a doctor could be less likely to undergo testing for or have their deaths coded accurately as COVID-19.

Dr. Stokes says that this underscores the need to increase funding for the U.S. death investigation system, which certifies home deaths.

Study co-author Dielle Lundberg is a research fellow in the Department of Global Health at BUSPH. Lundberg says that “expanding access to healthcare is thus a priority not only for health equity, but for data integrity.”

Dr. Mays is currently working with legislators to draft a bill requiring clearer ethnicity data on people affected by COVID-19. She and others working for public health organizations hope to use this information to understand and respond to the pandemic’s impact on historically marginalized communities.

It is worth noting that the recent study did have certain limitations. For instance, Dr. Stokes and his co-authors were limited to using provisional data.

Also, the county-level information did not break down age, race, ethnicity, or gender data. The team was also unable to adjust for all factors with the potential to influence the findings.

‘We are all connected’

This study concludes that inaccurate cause of death reporting might be concealing COVID-19’s true impact on vulnerable populations. This could lead to insufficient policy responses.

Dr. Stokes believes that “accurate and timely mortality surveillance is critical to a well-functioning and equitable public health system.”

During his The Brain Architects interview, Dr. Williams emphasized that when one segment of the population is affected disproportionately, all of society suffers.

“It is about all of us,” he said. “We are all connected. Higher rates of death for one population affects the entire profile and the entire risk for all of the population.”

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