The true toll of the COVID-19 pandemic on many communities of color is worse than previously known.
Betsy Ladyzhets, MuckRock’s Documenting COVID-19 project; Shaena Montanari, Arizona Center for Investigative Reporting; and Rachel Monahan, Willamette WeekIt’s not always easy to identify a COVID-19 death.
Incorrect death certificates add to the racial and ethnic health disparities exacerbated by the pandemic, which stem from long-entrenched barriers to medical care, employment, education, housing and other factors.
Experts point to several reasons for increased inaccurate death certificates among non-white Americans. These include resources available for death investigations, the use of general or unknown causes on death certificates, and how the race and ethnicity fields of these certificates are filled out. As a result, researchers often use excess deaths, a measure of deaths that occur above what demographers expect to see in a given time period based on past trends, to examine the pandemic’s overall impact. Nationwide, more than 280,000 excess deaths since 2020 have not been attributed to COVID.
Garbage codes were a “pretty big problem” before the pandemic, said Laura Dwyer-Lindgren, leader of the U.S. Health Disparities team at the University of Washington’s Institute for Health Metrics and Evaluation. Past analyses going back to the 1990s have found these codes have historically been used more among non-white people.
Another potential source for undercounting: Race and ethnicity are not always correctly reported on death certificates, especially if the investigator filling out such a certificate is a different race than the person who died. These errors are particularly common for Native Americans, like Mary-Katherine McNatt, a public health expert at A.T. Still University whose research focuses on health disparities.
Thanks to these efforts, Arizona’s Native American communities became “pockets of high vaccine areas,” McNatt said. The vaccinations contributed to a sharp decline in COVID deaths and overall excess deaths: In Navajo County, the COVID death rate for Native Americans almost halved between 2020 and 2021, according to analysis of CDC data. In Apache County, the rate dropped by 36%.
Despite the vaccination success for this Native American community, legacies of racism and colonialism contributed to continued health problems in 2021, said Emerson, the UNC expert. He pointed to issues such as a lack of clean water and intergenerational households as sources of coronavirus spread in the region.
Despite its high COVID vaccination rate – more than 80% of residents are fully vaccinated, according to CDC data – Multnomah County saw a stark increase in excess deaths from 2020 to 2021. These deaths were disproportionately located in communities of color, particularly Native American, Black and Pacific Islander communities.
The Multnomah County Health Department acknowledged it doesn’t routinely analyze local death data or compare Multnomah to other counties. County programs to investigate deaths often “rely on part-time investigators with limited forensic training,” said a spokesperson for the Oregon State Police, which oversees the medical examiner’s office.
For the remaining 239 Texas counties, elected Justices of the Peace are responsible for investigating deaths. These JPs do not need any medical training to take on their jobs. In fact, the only training they receive for tracking down deaths outside medical settings is a two-hour course from a medical examiner, according to reporting by the Texas Observer.
Several counties on or near the state’s border with Mexico, such as Zavala, assigned less than half of their excess deaths to COVID in 2021 – a clear signal of underreporting. Another border country, Presidio, also fits this pattern. JPs are primarily responsible for investigating deaths that occur at home or otherwise outside medical settings. These at-home deaths are more common in rural areas, Stokes said, in part because rural communities have less access to health care. Between 2005 and 2022, 183 rural hospitals have closed across the country, according to a study by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina Chapel Hill.
Matagorda County’s JP office, aided by an attentive small county hospital staff, continued to conduct thorough death investigations throughout the pandemic. According to the Boston University analysis, this county had more official COVID deaths in 2021 than it did excess deaths, indicating a high accuracy of reporting.
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