Excess Deaths From COVID-19, Community Bereavement, and Restorative Justice for Communities of Color

The number of reported deaths from coronavirus disease 2019 (COVID-19) in the US was nearly 205 000 on September 28, 2020.¹ A month earlier, on August 13, 2020, a New York Times analysis of estimates from the Centers for Disease Control and Prevention reported that across the US, at least 200 000 more people had died than expected (based on rates in the past 5 years), between March and late July, and that these estimated deaths were approximately 60 000 higher than the number of deaths that were directly linked to the coronavirus.²

In this issue of JAMA, Woolf et al³ corroborate these findings in their analysis of data from the National Center for Health Statistics, confirming that due to incomplete and undocumented data, the number of publicly reported deaths from COVID-19 likely underestimates the actual death toll. The authors estimated that between March 1 and August 1, 2020, a 5-month period, there were 225 000 excess deaths. Of these deaths, they estimate that 65% can be attributed to COVID-19 and the remaining 35% to other conditions, such as diabetes, heart disease, Alzheimer disease, and cerebrovascular disease. By the end of the year it is likely that the total number of excess deaths in 2020 in comparison to the previous years will be greater than 400 000—primarily attributable to the COVID-19 pandemic.

The implications of these excess deaths are sobering for the entire country, yet are even more profound for communities of color. Whether these excess deaths are due to nonrespiratory complications of COVID-19 or societal disruptions that reduced or delayed access to health care and worsened other social determinants of health, it is certain that individuals living in the US who are Black, Indigenous, Latino, or Pacific Islander have the highest per capita hospitalization and death rates. On August 18, 2020, the American Public Media Research Lab reported that individuals who are Black, Indigenous, Latino, or Pacific Islander have experienced higher death rates than individuals who are White or Asian, and that if they had died of COVID-19 at the same rate as White US residents, about 19 500 Black, 8400 Latino, 600 Indigenous, and 70 Pacific Islander individuals in the US would still be alive.⁴ As startling as these numbers are, the reality is likely worse because these numbers do not include the excess deaths that Woolf et al³ have estimated or projections for all of 2020.

Communities of color have borne the burden of excess deaths from health disparities for generations. In a recent review article, Jackman and Shauman⁵ estimated that almost 7.7 million excess deaths occurred among Black individuals from 1900-1999. Although excess deaths were highest in the early decades of the 20th century, in subsequent decades, excess deaths declined only modestly. Over the course of the century, these excess deaths began to occur among older Black persons in the prime of life, with devastating effects on the economic and social well-being of their families and communities. Of particular concern, the number of excess deaths in the last decade of the 20th century was almost as high in the first decade.

The COVID-19 pandemic has further compounded health, social, and economic disparities in communities of color. The effects of 2020 will be felt for years to come; however, critical steps can be taken to interrupt the course and reduce further harm. The first step is to recognize and acknowledge the sources of ongoing harm and excess deaths, and the second is to implement a plan for restorative justice and healing. There are many sources of these ongoing harms and excess deaths among people of color in the US. Structural racism has produced a legacy of inequitable access to social and economic resources, including healthy food, a high-quality education, gainful employment opportunities, safe physical and social environments, and high-quality health care.⁶ The psychological stress associated with exposures to adverse social determinants, as well as pervasive experiences of interpersonal discrimination in society, have produced negative effects on biological processes and poor physical and mental health of people of color.

The manifestations of these harms are seen in higher rates of infant mortality among African American and Native American infants, higher rates of asthma and obesity among African American children, higher rates of pregnancy-related complications and deaths among Black women, and earlier onset of multiple chronic conditions such as obesity, hypertension, heart disease, diabetes, and cancers among Black, Latino, and Native American adults, leading to premature death and disability. Many of these so called pre-existing conditions are the direct result of policies and practices enabled by structural racism. This is not to dismiss that individuals bear responsibility to engage in behaviors that enhance their own health, but these individual responsibilities must be understood in the context of opportunities that exist within communities in which many people of color live.

The economic fallout from COVID-19 has also affected communities of color more severely than other communities and will likely have lasting effects. Higher rates of prepandemic unemployment or underemployment, overrepresentation in low-paying jobs that have been reduced or eliminated due to the economic depression, and lack of family wealth have compounded financial burdens and will lead to increased evictions, homelessness, and food insecurity. The loss of income from prolonged closures and increased costs of operating with new safety protocols will affect small businesses and hourly workers, who are disproportionately people of color, to the greatest degree.

Black, Latino, and Native American individuals also experience barriers to care and disparities in health care quality that are likely to be exacerbated in the pandemic response period. Due to higher rates of unemployment and poverty, the number of uninsured and underinsured persons will likely increase in these communities. Access barriers have already increased, due to the accelerated transition to telemedicine, ongoing underresourcing of safety-net clinicians and health care centers that reduces their ability to meet the demands of necessary changes in care delivery, and existing disparities in internet access and digital literacy. If efforts to repeal the Affordable Care Act are successful, COVID-19 survivors, and persons with other chronic conditions, will be at risk for losing their health insurance coverage or losing coverage for preexisting conditions, exacerbating disparities in access to care. Additionally, bias and stigma due to higher rates of COVID-19 infections and complications may further exacerbate existing disparities in quality of health care.

The epidemic of police violence against individuals of color in the US has also been spotlighted over the past several months and has resulted in widespread protests and calls for justice. Data show that police in the US kill an average of 300 Black individuals, approximately 20% of whom are unarmed, each year.⁷ Several studies have shown negative mental health spillover effects of police violence among Black persons. In a national study, 49% of 103 710 Black adult respondents were exposed to at least 1 or more police killings of unarmed Black individuals in their state of residence within 3 months of completing the survey.⁸ Black respondents experienced an average of 4.1 poor mental health days in the preceding month; for each additional police killing of an unarmed Black person in the preceding 3 months, Black respondents reported more poor mental health days. This effect was not observed among White respondents in the same states. Thus, the heightened attention to police violence perpetrated against individuals of color in 2020 will continue to have negative mental health spillover effects in the postpandemic period.

Racial disparities in life expectancy also mean that Black individuals in the US are exposed to more family deaths than White individuals, from childhood through adulthood. In a nationally representative study, Umberson and colleagues⁹ estimated racial differences in exposure to the death of family members at different ages, beginning in childhood. Their results confirmed that Black persons are significantly more likely than White persons to have experienced the death of a mother, a father, and a sibling from childhood through midlife. Additionally, between young adulthood and later life, Black persons were more likely than White persons to have experienced the death of a child and of a spouse. The authors suggested that more frequent and earlier exposure to family member deaths could contribute to cumulative health disadvantage across generations. The excess deaths of the COVID-19 pandemic could heighten these existing vulnerabilities among persons of color, contributing to deep and prolonged “community bereavement.”

Communities of color have grieved excessive losses of life for centuries. It is time to recognize that this grief compounds the emotional pain, physical illness burden, economic hardship, and injustice these communities continue to endure. It has been more than 50 years since the civil rights movement, yet racial tensions are higher than they have been in decades, and many still find it difficult to acknowledge historical and current injustices against people of color. There is much work to be done to achieve a national reawakening. The time is long overdue to implement a plan for restorative justice.¹⁰ Such a plan ought to include recognizing the sacrifices and contributions these communities have made for and to the US and creating opportunities, through investments in early childhood education, financial assistance for higher education and vocational training, debt forgiveness for student loans and expanded employment opportunities. It should include societal investments in affordable housing and healthy neighborhood environments; policies that ensure fair and equitable access to loans for mortgages and businesses, transparent and equitable public safety and criminal justice practices, and universal access to health care; and resources to strengthen the health care system’s ability to address social needs and deliver primary care and mental health care more effectively. Persons with lived experiences who are from communities of color should have opportunities to lead the development of restorative justice initiatives.

Lives lost can never be replaced, yet healing and renewal are possible for those who remain, through acknowledgments of the harm created by centuries of injustice, commitments to rectifying past wrongs, and changes that restore all individuals and communities, but especially those that have lost the most, to a state of health and wholeness.

Corresponding Author: Lisa A. Cooper, MD, MPH, Johns Hopkins Center for Health Equity, 2024 E Monument St, Ste 2-500, Baltimore, MD 21287 (lisa.cooper@jhmi.edu).

Published Online: October 12, 2020. doi:10.1001/jama.2020.19567

Conflict of Interest Disclosures: None reported.