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


In 2021, a “two Americas” narrative emerged: 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. Before May, 2020, 56% of deaths were in the Northeast, with 17% of the population. Subsequently, 45% of deaths were in the South, with 38% of the population. These results are important because, while some regard vaccination and other measures as matters of personal choice, the population impact is striking. After the first wave, death rates in the South were more than double those in the Northeast. If every region had the same mortality rate as the lowest region in that period, more than 418,763 COVID-19 deaths were ‘avoidable.’ These results show that population-based COVID-19 policies, including masking in certain situations, 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 including excess mortality measures as part of a comprehensive surveillance system. Official mortality counts rely on accurate and complete recording of COVID-19 as a cause of death, but COVID-19 deaths are under reported for many reasons ranging from test availability to family wishes. Indeed, the proportion of COVID-19 deaths reported as such varied markedly over time, from less than 60% in the West in some periods, 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, seroprevalence surveys, 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. Nevertheless, excess mortality estimates can be a valuable component of a comprehensive surveillance strategy for COVID-19 and other diseases.