Covid-19 deaths in the United States: Reinforcing the notion of ‘two Americas’

The notion of Covid-19 causing two Americas was on many minds in the summer of 2021. The Washington Post and LA Times both wrote about it; Dr. Anthony Fauci mentioned it in an interview. One America had high demand for Covid-19 vaccines, the other had widespread vaccine hesitancy and opposition to mask and vaccine mandates.

This narrative helped shape the understanding of what happened as well as what the country should be doing now to control the pandemic.

But Covid has been dividing the nation since the start of the pandemic. Our recent analysis of Covid-19 deaths by region, published in PLoS One, supports the two Americas idea.

While some regard vaccination and other measures as a matter of personal choice, the population impact of anti-Covid strategies is quite striking. After the first wave of the pandemic, from March to May 2020, death rates in the South were more than double those in the Northeast, the region with the fewest deaths. Nearly 320,000 deaths might have been avoided between June 2020 and September 2021 — 62% of them in the South — had protective measures been more strongly employed.

Such a large number of avoidable Covid deaths is clearly a tragedy, placing the U.S. with Russia, Brazil, and Mexico in terms of per-capita Covid-related deaths. But the lower rates in the Northeast also demonstrate the potential impact of population-oriented preventive strategies and other lessons for how the country proceeds in 2022.

We analyzed how Covid-19 death rates changed from early 2020 to late 2021 in four regions of the U.S. To avoid problems of undercounting, we focused on the CDC’s metric of excess deaths — the difference between total deaths and what would have been expected based on earlier time periods. Similar to the WHO’s new estimates, this approach doesn’t depend on Covid-19 having been correctly diagnosed and reported as a cause of death.

Between January 2020 and September 2021, there were 895,693 excess deaths associated with Covid-19, 26% more than the 710,999 reported to health departments during this time. Although the official total is now closing in on 1 million deaths, that milestone occurred in December 2021. If the current rate of undercounting holds, there have been approximately 1.25 million Covid-related deaths in the U.S. as we write this.

More than 40% of these deaths occurred during just five months, from October 2020 through February 2021. In the early months of the pandemic, approximately 56% of deaths were in the Northeast, where 17% of the population resides. Later on, the burden shifted to the South, where 38% of the population resides, with 48% of deaths.

Source: Authors’ calculations based on CDC data

We also calculated how many deaths could have been avoided if each region had the same Covid-19 mortality rate as the Northeast, which had the lowest rate after June 2020. Between then and September 2021, more than 316,234 deaths could have been avoided. Of those, 60% were in the South.

Regional differences in Covid-related deaths didn’t emerge in the summer of 2021 — they have been strong throughout the pandemic. These differences are likely to be due in part to higher transmission resulting from differences in mask use, school attendance, social distancing, and other behaviors, not just differences in vaccine coverage.

We say this because, while vaccines have saved many lives, the major differences in Covid-related deaths emerged well before vaccines became widely available. Indeed, 63% of the avoidable deaths in the U.S. occurred by the end of February 2021, when the vaccine rollout was just beginning and before the Delta variant became dominant.

Weather is not likely a contributor to these regional differences because the South has had dramatically higher Covid-19 mortality than the Northeast during all seasons. Residents of the Northeast may have carried some natural immunity into the summer of 2020, but by July 2020 the proportion of the population with antibodies to SARS-CoV-2, the virus that causes the disease, were higher in the South (37.9%) than in the Northeast (17.5%), so natural immunity cannot explain the differences since then.

Recent analyses have shown how vaccines have saved more than 2 million lives in the U.S. Given that vaccine uptake is lagging in the same areas where Covid deaths are highest, the geographical differences we found will likely continue.

Although our analysis was primarily historical, it has two important implications for the Omicron BA.2 wave the country is now experiencing.

First, our analysis shows that the proportion of deaths reported as being due to Covid-19 varied markedly over time, dropping to less than 60% in the West during some periods, and overall was lowest in the West (72%) and South (76%) compared to the Midwest (83%) and Northeast (92%). As some regions cut back on testing because of the sense that the pandemic is “over,” undercounts of deaths — and likely cases and hospitalizations as well — will make it harder to see a re-emergence of Covid-19, particularly BA.2 and other variants, in those regions. More extensive surveillance based on wastewater testing, seroprevalence surveys, and other means that do not depend on the availability of test sites and individuals’ decisions to be tested are clearly needed to get a more accurate sense of what is happening.

Second, with vaccine and booster coverage lagging, especially in rural areas and the regions of the country that have experienced high Covid-19 mortality, there is still a need for comprehensive, population-based pandemic policies, such as wearing masks in crowded closed spaces. The 2020-style lockdowns are no longer necessary, but our analysis shows that the less-restrictive measures adopted since the summer of 2020, especially in the Northeast, can still play important roles in protecting those who are most vulnerable to severe disease and death and in reducing the spread of the virus.

After two years, everyone is tired of Covid-19. It is tempting to decide that control measures should be abandoned. But the U.S. — and other countries — will continue to experience waves of Covid-19. Temporary and targeted mitigation, especially in communities that don’t have high vaccination rates, can help shorten these waves.

If all communities had done this throughout the pandemic, hundreds of thousands of our family members, neighbors, and friends would still be alive.

Michael A. Stoto is a statistician and professor of health systems administration and population health at Georgetown University. Samantha Schlageter is a graduate of Georgetown’s Health Care Management and Policy Program. John Kraemer is an epidemiologist and associate professor of health systems administration at Georgetown University.