California’s deadliest spring in 20 years suggests COVID undercount

Reviewed by Emily Henderson, B.Sc.Sep 21 2020

The first five months of the COVID-19 pandemic in California rank among the deadliest in state history, deadlier than any other consecutive five-month period in at least 20 years.

And the grim milestone encompasses thousands of "excess" deaths not accounted for in the state's official COVID death tally: a loss of life concentrated among Blacks, Asians and Latinos, afflicting people who experts say likely didn’t get preventive medical care amid the far-reaching shutdowns or who were wrongly excluded from the coronavirus death count.

About 125,000 Californians died from March through July, up by 14,200, or 13%, from the average for the same five months during the prior three years, according to a review of data from the state Department of Public Health.

By the end of July, California had logged about 9,200 deaths officially attributed to COVID-19 in county death records. That left about 5,000 "excess" deaths for those months — meaning deaths above the norm not attributed to COVID-19. Deaths tend to increase from year to year as the population grows, but typically not by that much.

A closer look at California's excess deaths during the period reveal a disturbing racial and ethnic variance: All the excess deaths not officially linked to COVID infection were concentrated in minority communities. Latinos make up the vast majority, accounting for 3,350 of those excess deaths, followed by Asians (1,150), Blacks (860) and other Californians of color (350).

The overall number of excess deaths across all races and ethnicities was ultimately tempered because, compared with the three prior years, there were actually 383 fewer deaths among white Californians than would be expected in the absence of COVID-19. In addition, California Healthline adjusted the overall numbers to reflect more than 320 COVID deaths that could not be categorized by race or ethnicity because that information was missing from state records.

Several epidemiologists interviewed said they believe a sizable portion of the excess deaths among people of color did, in fact, stem from COVID infections but went undetected for a variety of reasons. Among them: a shortage of coronavirus tests in the early months of the pandemic; an uneven strategy for how and when to administer those tests, which persists; and inadequate access to health care providers in many low-income and immigrant communities.

Dr. Kirsten Bibbins-Domingo, chair of the Department of Epidemiology and Biostatistics at the University of California-San Francisco, is among those who suspect the excess deaths reflect a COVID undercount in minority communities. She noted that several chronic health conditions that disproportionately affect Blacks and Latinos — including diabetes, high blood pressure and heart disease — also place them at higher risk for severe complications from COVID-19.

In addition, Bibbins-Domingo said, the prolonged shutdown of medical offices in the early months of the pandemic — and with them non-urgent surgeries and routine medical care — likely accelerated death among people with those chronic conditions.

"Shutdowns always come at a cost," she said. "It is our most marginalized communities that experience the cost of a shutdown."

According to state Department of Public Health data, deaths in California attributed to diabetes rose 12% from March through July when compared with the average for the same period over the past three years. In addition, deaths attributed to Alzheimer's disease rose 11%.

"Dementia is also a disease where we have racial, ethnic minorities already at greater risk," said Andrea Polonijo, a medical sociologist at the University of California-Riverside. "Now that we have the pandemic, they’re more socially isolated. Social isolation we know can cause deeper cognitive decline."

It's hard to determine whether a death is due to COVID-19 if the victim never sought medical care, said Jeffrey Reynoso, executive director of the nonprofit Latino Coalition for a Healthy California. Latinos in California are less likely to have health insurance, he said. They may face language barriers if their medical provider — or contact tracer — does not speak Spanish. Latino immigrants working in the U.S. without authorization may hesitate to visit the doctor.

"Immigration is definitely a driver in creating a fear and a mistrust of systems, and that includes our health care system," Reynoso said.

Polonijo said the fact that Latinos make up the bulk of the excess deaths correlates with their dominant role in farming, meat processing, manufacturing and food service, jobs all deemed essential during the pandemic.

"This population is also more likely to live in more crowded conditions," she said. "So not only are they exposed at work, but they are bringing disease home and with it the possibility of spreading it to their family, bringing it to the community."

Bibbins-Domingo noted that, while a major portion of COVID deaths overall have occurred among seniors and nursing home residents, a disproportionate number of the state's excess deaths are of working-age adults.

"The excess deaths that we’re seeing in communities of color and in low-income communities are deaths that are occurring at younger ages," she said. "These are deaths that are occurring in these ages from 20 to 60, generally speaking — the ages when people would be out working."

Kathy Ko Chin, president of the Oakland-based Asian & Pacific Islander American Health Forum, said Asian Americans also tend to be overrepresented in essential worker occupations, noting that a large proportion of the state's nurses are Filipino. In addition, she said, government officials have not done enough to translate COVID educational materials into the many languages spoken by California's Asian Americans. The Trump administration's rhetoric on immigration during the past four years, she added, has had a "chilling effect” that has kept many foreign-born Asian Americans from visiting a doctor.

“People were really, really scared,” Chin said.

Counties in Southern California and the largely rural Central Valley — places with a high proportion of Latino residents — tended to have high rates of excess deaths from March to July. Among counties with at least 100,000 people, Kings County, an arid expanse north of Los Angeles that is home to industrial-scale agriculture, had the highest rate of excess deaths per capita.

Officials at the Kings County Department of Public Health did not return a message seeking comment.

Bibbins-Domingo and others said it is important for state and county health officials to take a hard look at their excess death numbers. Excess deaths matter, she said, because they expose shortcomings in health care delivery. In addition, local and state responses to COVID-19 are grounded in data; if that data is inaccurate, the responses may be misguided.

"Deaths are important because they also help us to understand how much severe COVID is there in the community that we have to worry about," Bibbins-Domingo said. "I think when we undercount that, we both fly blind for the overall pandemic management, and we might fly particularly blind in understanding the impact of the pandemic in particular communities."

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.