January 26, 2022

Indirect consequences of COVID-19 are contributing to a significant number of deaths in the United States, especially among communities of color and young people, according to epidemiologists at the UNC Gillings School of Global Public Health.

When analyzing deaths that occurred in 2020, a recent study published in the American Journal of Public Health found that indirect effects of the pandemic – such as social isolation, economic insecurity and barriers to health care access – accounted for 16% of excess deaths. Such estimates suggest that the toll of the pandemic is being greatly underreported because these deaths are not being captured in official COVID-19 surveillance data.

Lauren Zalla

Lauren Zalla

Grace Mulholland

Grace Mulholland

“Since most reports of pandemic-related mortality focus on deaths caused by COVID-19, we wanted to find out how many additional deaths are caused by the indirect effects of the pandemic,” said Lauren Zalla, MS, doctoral researcher in epidemiology and biostatistics. “But it was equally important to us to study how those deaths are distributed – who is more likely to die from the social and economic effects of the pandemic? We expected to see disparities, but what we found was even more dramatic than expected.”

Dr. Lindsay Filiatreau

Dr. Lindsay Filiatreau

Dr. Jess Edwards

Dr. Jess Edwards

Zalla led the study along with fellow doctoral researcher Grace Mulholland, MSPH; Lindsey Filiatreau, PhD, a recent graduate of the epidemiology doctoral program and current postdoctoral scholar at Washington University in St. Louis; and Jess Edwards, PhD, assistant professor of epidemiology at the Gillings School.

COVID-19 has magnified the burden of health inequity that Americans experience, borne out by higher rates of cases, hospitalizations and death among historically underserved populations. As the country grapples with concurrent crises of systemic racism and economic turmoil, the pandemic’s indirect effects have seen similar disparities in distribution.

By modeling the expected number of deaths that might have happened in 2020 had the pandemic not occurred and subtracting it from the number of actual deaths that occurred in 2020, the study team found that U.S. mortality was 17% higher than expected in 2020.

This increase in mortality, known as “excess deaths,” is a net measure of the deaths that were caused by the pandemic, offset by decreases in influenza, traffic fatalities and other deaths that might have occurred in the absence of lockdowns and social distancing.

Of all excess deaths that happened in 2020, only 84% were directly attributed to COVID-19. The remaining 16% represent deaths due to the indirect effects of the pandemic. Some of these deaths may be due to undiagnosed COVID-19, but mortality data collected during the pandemic suggest that a larger portion of these deaths are consequences of COVID-19’s broader impact on the U.S.

“In the past year and a half, we have seen increases in deaths due to chronic, manageable diseases like diabetes because of the strain the pandemic has placed on our health care system,” the study team noted. “We have also seen increases in suicide, homicide and drug overdose deaths, many of which may be related to secondary effects of the pandemic like social isolation, loss of wages and housing insecurity.”

When modeling by race and ethnicity, the study found that indirect effects of the pandemic were responsible for 32% of excess deaths among Black Americans, 23% of excess deaths among Native Americans, 16% among Hispanic and Asian Americans, and 11% among white Americans.

The study also found that more than 60% of excess deaths among people ages 15 to 44 were not captured in official surveillance data on deaths from COVID-19. Deaths of people 55 and older were much more likely to be directly attributed to COVID-19.

Those who identify as Black, indigenous or people of color (BIPOC) have faced greater economic hardship, disruption of medical care, and employment and housing insecurity. Younger people, who are often considered to be at less risk of death due to COVID-19, have been isolated from school and social support systems and are more likely than older Americans to have lost jobs and been excluded from economic assistance services.

The study results emphasize that the magnitude of health inequity in pandemic-related mortality can’t be measured by simply analyzing the number of deaths attributed to COVID-19. Without applying a framework of equity in public health surveillance, the unseen consequences of the pandemic may continue to claim lives and perpetuate systemic inequities.

“If we don’t know who is dying as a result of the pandemic, we can’t target public health policies and programs appropriately to prevent those deaths,” said the researchers. “This research reveals that we need to do a better job of tracking and reporting all pandemic-related deaths, not just deaths directly caused by COVID-19.”

In the future, the research team plans to conduct a study to look at disparities in excess mortality from specific causes of death to better understand the pathways through which the pandemic has impacted mortality differently in different population groups.

Read the full paper online.

Contact the UNC Gillings School of Global Public Health communications team at sphcomm@unc.edu.

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