Research Brief

COVID-19 mortality spiked among white and rural populations in U.S. during Delta and Omicron waves

People wearing surgical masks
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Racial disparities in U.S. COVID-19 deaths narrowed substantially from the first to the second year of the pandemic. While this has been touted as a major sign of progress, new research found this sharp decline mostly resulted from an increase in COVID deaths among white people, and a geographical shift in mortality from large, urban cities to rural and smaller metropolitan areas, rather than from decreases in deaths among the Black population. Similarly, a smaller decline in Hispanic-white disparities in deaths was entirely due to increases in COVID deaths among white and rural populations.

The research is published in JAMA Network Open, a subsidiary of the Journal of the American Medical Association. 

Researchers conducted statistical analyses and demographic decompositions of U.S. vital statistics between March 2020 and February 2022, comparing the Delta wave and initial Omicron wave to the initial pandemic wave. Mortality rates were standardized for age. The researchers found:

  • The proportion of COVID-19 deaths among adults residing in rural areas increased over time and peaked during the Delta wave.
  • The national disparity in COVID-19 death rates for Black compared to white adults decreased by 293 deaths per 100,000 people between the initial and Omicron waves. After standardizing for age and for racial and ethnic differences in residence across metropolitan and nonmetropolitan areas, increases in non-Hispanic white death rates explained 40.7% of this reduction, and 19.6% was explained by shifts in mortality to rural areas where a disproportionate share of white adults reside. The remainder was explained by decreases in Black death rates.
  • For Hispanic compared to non-Hispanic white adults, the national decrease in disparities was fully explained by increases in non-Hispanic white mortality and shifts in mortality to rural areas.

"These results underscore COVID's ongoing toll, even in the vaccinated era. Full protection can't rest only on vaccination or other choices that individuals can make — it also means social policies like paid sick leave, new standards for indoor air quality in workplaces and schools, and expanding and diversifying the healthcare workforce, especially in rural areas," said study author Elizabeth Wrigley-Field, an assistant professor in the College of Liberal Arts.

While there have been advancements toward racial and ethnic health equity, this study suggests this work is not finished. Efforts to promote equitable booster distribution, invest in rural health systems and address structural racism are still urgently needed, as are efforts to improve health in rural areas.

“Our findings indicate that decreases in racial and ethnic disparities in COVID were mostly explained by increases in mortality for white adults and changes in pandemic geography rather than decreases in Black and Hispanic mortality,” says study corresponding author Andrew Stokes, an assistant professor of global health at Boston University School of Public Health. “This suggests that it may be premature to celebrate reductions in disparities because they did not largely represent reductions in mortality.”

Research was funded by the Minnesota Population Center, Robert Wood Johnson Foundation, National Institute on Aging, Eunice Kennedy Shriver National Institute of Child Health and Human Development, W.K. Kellogg Foundation, Rockefeller Foundation, National Institute on Drug Abuse and Agency for Healthcare Research and Quality.

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