Differential COVID-19 mortality in the United States: Patterns, causes and policy implications

A "two Americas" narrative emerged in the summer of 2021: one with high demand for COVID-19 vaccines, and a second with widespread vaccine hesitancy and opposition to mask mandates. But our analysis of excess mortality shows that the U.S. has been a divided nation at least since the start of the pandemic. Through April, 2022, there were 1,335,292 excess deaths associated with COVID-19, 37% more than reported as such. After the first wave, death rates in the South were more than double those in the Northeast; 45% of deaths were in the South, with 38% of the population. While some regard vaccination and other measures as matters of personal choice, the population impact is striking. If every region had the same mortality rate as the lowest regional rate in each period, more than 418,763 COVID-19 deaths were "avoidable," more than half (58%) in the South and almost half before vaccines were available. These results show that population-based COVID-19 policies can still play an important role in protecting those most vulnerable to severe disease and death and reducing the spread of the virus. This example illustrates the importance of excess mortality measures as part of a comprehensive surveillance system. Official mortality counts rely on complete recording of COVID-19 as a cause of death, but COVID-19 deaths are under reported for many reasons. Indeed, the proportion of COVID-19 deaths reported as such varied markedly over time, and from 67% in the West to 87% the Northeast. In 2022, some regions cut back on testing making it harder to see a re-emergence of COVID-19 in those places. More extensive surveillance based on wastewater testing and other means that do not depend on testing are needed to get a more accurate picture. Excess mortality estimates are more tenuous years beyond the pre-pandemic period.