Covid-19 was the leading cause of death for young adults in Texas in summer and late fall of 2020.
A majority of Covid-19 deaths among Texans ages 25-44 were among Hispanic residents, highlighting ongoing disparities.
In this Inside Medicine, I’m summarizing new research that I was privileged to lead with a team that included a resident physician, an undergraduate student, and a fellow faculty member here at Harvard as well as a phenomenal team I frequently join forces with at the Yale School of Medicine. Our new paper was published today in JAMA Internal Medicine.
New data show that Covid-19 was the 2nd leading cause of death among Texas residents ages 25-44 from the start of the pandemic in March 2020 through December 2020. During the summer months (June-August), Covid-19 was the leading cause of death in this age group, surpassing the death toll from the typical leading causes of death, which are unintentional drug overdose, accidents, assaults, heart disease, cancer, and suicide. During the peak of the 2020 outbreak, Covid-19 was killing more Texans ages 25-44 per month than HIV/AIDS killed per month during the worst years of the AIDS crisis in the United States. Monthly AIDS deaths in this age group peaked at around 352 deaths per million adults ages 25-44 in Texas in 1994. In July of 2020, 404 Covid-19 deaths per million occurred in that demographic.
As if that were not disturbing enough, the disparities we unearthed were staggering. Among Hispanic residents in Texas, Covid-19 was far-and-away the leading cause of death during the pandemic period covered in our study. In fact, for that demographic, Covid-19 was the leading cause of death for the entire year of 2020, even though there was only one Covid-19 death prior to April. (Meanwhile, deaths from the usual leading causes occurred at their usual rates in January, February, and March, and therefore had a “head start” on Covid-19). Nevertheless, Covid-19 killed 20% more Hispanic residents ages 25-44 in Texas than the next most common cause (accidents) for the whole calendar year.
But even that does not encapsulate how bad things really got. At the height of the 2020 outbreak in Texas (July), Covid-19 killed 3.8-times as many Hispanic adults aged 25-44 as accidents killed, and 4-times as many as the number that died by unintentional drug overdose. These staggering burdens are illustrated in the graphics below.‡
The animation above shows the leading causes of death for Texans ages 25-44 from 2017 through 2020.
The red lines are Covid-19.
Left panel: Hispanic; Middle panel: Black; Right panel: White.
Anyone who reads our manuscript in JAMA Internal Medicine might notice that the graphs we created for Inside Medicine and displayed above appear a bit different from those we presented in the medical journal. In the journal, we grouped the data by quarter so that we could make stronger statistical conclusions. But here, I’m showing you how things played out in each month of 2020. By doing that, we can see that Covid-19 was also the leading cause of death among Black Texas residents in July, and the 2nd leading cause of death in December of 2020 for the demographic. The graphs above also show that for White Texas residents, a far lower mortality burden owing to Covid-19 was recorded than among Hispanic or Black residents. In fact, among White Texas residents, Covid-19 only cracked the top five leading causes of death during one month, December, coming in at #5 behind accidents, suicide, unintentional overdoses, and cancer.
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Why did we do this work? The impetus for this study was two-fold. First, we wanted to follow up research that some of us published a year ago in the Journal of the American Medical Association’s main imprint that highlighted the unexpectedly high increase in all mortality among adults ages 25-44 in the United States. But at that time, some critics noticed that only 38% of the increase in deaths from all causes in the United States had been directly attributed to Covid-19 (though we thought that some downstream complications and lack of testing might have meant that Covid-19 was being undercounted at that time). But could other causes, like drug overdoses, assaults, and accidents also have gone up during 2020? Indeed, that’s what we found in another research manuscript we published earlier this year, also in JAMA. But that research covered all age groups in the US. We couldn’t yet drill down into the young adults because the data were not (and are still not) entirely available. But we remained worried that Covid-19’s effect on young adults was still not fully appreciated by our colleagues or the public. So, we decided to chase down data for a handful of states. We ultimately chose to study Texas because of its size, diversity, and its relatively lax attitudes about Covid-19.
Texas’s diversity was indeed another reason for putting that state under the microscope. We wondered whether racial/ethnic disparities had masked the situation in our earlier paper describing the increase in deaths among young adults nationwide. For example, we wondered whether among White people, unintentional drug overdoses and accidents had increased somewhat (which would impart a large numeric contribution, because White people account for a majority of the US population), while the contribution from Covid-19 to the overall mortality increase in young adults was largely a result of catastrophic spikes among Hispanic and Black people, who still remain in the minority of the US population. If other states turn out to parallel our findings in Texas, that hypothesis will be confirmed.
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Right now, it looks to me like the reason that our previous study found that “only” 38% of the increase in deaths among US adults ages 25-44 early in the pandemic was directly due to Covid-19, is that by-and-large, the younger White population was able to avoid Covid-19. (White people were much more likely to be able to work from home, for example). Indeed, younger White adults (like all races) experienced increases in overdose deaths last year, but relatively fewer Covid-19 deaths. Those overdose numbers among White people add up quickly on a national scale, appearing to tip the scale away from Covid-19 as the explanation for the majority of extra deaths last year, because White people remain the majority. Meanwhile younger Black and Hispanic adults had increases in overdoses too, but at times, as we saw in Texas, experienced far, far more Covid-19 deaths.
If it were not for effective vaccines, the Covid-19 mortality disparities would have been expected to eventually narrow to some degree. You can only outrun this virus for so long. But how things play out from here—whether the disproportionate mortality burdens will become smaller or larger—hinges mostly on vaccine uptake. Maximizing vaccine uptake, we all know, continues to depend on better educating the public and assuring that everyone who needs a Covid-19 vaccination has access.
‡Special thanks to Dr. Kristen Panthagani for data visualization created for this Inside Medicine article. I also wish to thank my co-authors on the JAMA Internal Medicine Study: Mr. Alexander Junxiang Chen, Dr. Max Jordan Nguemeni Tiako, Dr. Chengan Du, Dr. Shu-Xia Li, Dr. Harlan Krumholz, and Dr. Michael Barnett.
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