Excess Mortality as a Canary in the Coal Mine for COVID Disparities

by JP Leider and Elizabeth Wrigley-Field

Minnesota has been in the news in recent months, for all the wrong reasons. The murder of George Floyd by a Minneapolis police officer in the midst of a seemingly uncontrollable COVID-19 pandemic again shone a light on the tremendous disparities and inequities present in the state. The governor of Minnesota, Tim Walz, noted that Minnesota is one of the healthiest places to live, but only if you are white.

It’s true – by most every metric, white Minnesotans are better off than Black, Native, and Latino Minnesotans. This appears especially the case in the context of COVID-19, especially around excess mortality, both deaths directly attributable to the disaster and those caused by it indirectly. Disasters of any type inevitably produce excess mortality.

Examining excess deaths alongside COVID-19 mortality by race and ethnicity offers a fuller picture of deaths attributable to the pandemic, highlighting otherwise hidden disparities and sharpening hypotheses about why mortality has grown. Consider these two maps. The first one shows COVID-19 mortality by county through the beginning of August in Minnesota. The second shows excess mortality, measured as averaged year-to-date total mortality for 2017-2019 compared to 2020. The height of a county is the count of deaths; the color is deaths per 100,000 population. What’s clear is that measures of COVID-19 and excess mortality paint a different picture of the pandemic. Excess mortality reveals a broader impact across the state than confirmed COVID-19 deaths, but however it’s measured, the pandemic is hitting the Twin Cities metro area particularly hard.

COVID-confirmed and Excess Mortality in Minnesota, 1/1/2020 – 8/04/2020, Counts and Rates

The map shows total COVID-confirmed deaths (left) and excess mortality (right, comparing 2020 to 2017-2019 average, year-to-date), excluding external causes of death. The “height’”of each county is relative to the count of COVID deaths or excess deaths. Height is visualized as flat for counties with fewer than 10 total excess deaths in 2020 compared to YTD 2017-2019 average. Eleven Minnesota counties have fewer than -10 excess deaths in 2020 compared to YTD 2017-2019 average.

Source: Author analysis of Minnesota Department of Health death records

Early in the pandemic, the popular press noted note that about 80% of COVID deaths in Minnesota were from white Minnesotans – and that 79% of Minnesotans are white. That observation suggests COVID-19 disparities are much more modest than they are in reality. Minnesota’s superficially small racial disparities in COVID mortality may be attributable to the interaction between two factors: the age distribution of Minnesotans by race/ethnicity and the spread of COVID through disproportionately White nursing homes and long term care facilities (LTC). Minnesota’s non-Hispanic White population has a similar median age to the whole US, 42 in Minnesota vs. 43 in the US, but for non-Hispanic Blacks the median age is 27 in Minnesota vs. 34 in the US. Minnesota’s nursing homes are approximately 91 percent non-Hispanic White and only 3 percent non-Hispanic Black. This distinctive age distribution combined with the natural history of COVID-19 in the state suggests White Minnesotans are experiencing the worst of COVID-19. Not so.

Once one accounts for the age distribution of the state, the “gap” between excess mortality and COVID-19 mortality highlights profound racial disparities (Figure 2). For Native Americans, the gap is large and growing, representing more than 112 excess deaths per 100,000 people, beyond COVID-19 deaths. These deaths represent a large mortality burden excluded from COVID-19 confirmed counts. For Blacks, this gap between excess and confirmed-COVID mortality is two-thirds of that size, at 75 deaths per 100,000, and for Asian Americans and Latinos it is 49-52 deaths per 100,000, respectively. Indeed, until early May, despite COVID mortality among Latinos, total mortality for this population was below the 2017-2019 year-to-date average, suggesting a possible broad protective effect of stay-at-home policies. For whites alone, the gap is negligible, at only 7 deaths per 100,000—suggesting that confirmed COVID-19 deaths reflect a good summary of the overall excess mortality burden in this period for Whites alone.

Source: Author analysis of Minnesota Department of Health death records

In Minnesota, cumulative COVID-19 mortality and excess mortality (Figure 2) also vary dramatically by place of death and LTC residence. The greatest number of deaths are associated with LTC facilities, and for LTC residents, excess mortality is driven by COVID-19 deaths, which account for 83% of the excess 20 LTC deaths per 100,000 people in the state. In contrast, deaths at home and in hospitals evince strikingly divergent patterns of COVID-19 and excess mortality. Deaths to causes other than COVID-19 appear to have shifted from hospital to home.

Source: Author analysis of Minnesota Department of Health death records

The low rate of confirmed COVID deaths, and high rate of other deaths, at home suggests one of two possibilities. One is that some portion of the excess deaths are unconfirmed COVID deaths; the other is that hospital avoidance has increased deaths to causes other than COVID among Minnesota residents who avoid hospitalization even when they are close to death. This phenomenon is highly differential between White Minnesotans and Black, Latino, and Native Minnesotans, with much worse outcomes for Minnesotans of color.

While at first glance, Minnesota appears to only have superficial disparities in mortality given profound disparities in COVID spread among communities of color, age-adjusting COVID mortality and, especially, excess mortality shows that the pandemic is hitting communities of color across the state particularly hard. This compounds the disproportionate economic toll of the pandemic in these same communities.

In our view, Minnesota has been more transparent than most states or the federal government in its attempts to control COVID and COVID’s impact across the state. But more can be done to show the impact on all Minnesotans, and to provide more substantive policy interventions and social support to meet the profound need in the state.

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Jonathon P. Leider

Jonathon P. (JP) Leider is an independent consultant in the public health and health policy space, as well as a Senior Lecturer at the University of Minnesota and Associate Faculty at the Johns Hopkins Bloomberg School of Public Health. He has active projects and collaborations with foundations, national public health organizations, public health researchers and academics, and public health practitioners. His current projects focus on public health systems, the public health workforce, and public health finance. He holds a PhD in Health Policy and Management from the Johns Hopkins Bloomberg School of Public Health. [Full bio]



Elizabeth Wrigley-Field

Elizabeth Wrigley-Field is an Assistant Professor in Sociology at the University of Minnesota, where she is also affiliated with the Minnesota Population Center. Substantively, she specializes in racial inequality in mortality and historical infectious disease. She is also a quantitative methodologist, developing models designed to clarify relationships between micro and macro perspectives on demographic relationships.