Counting for Accountability in a Time of Catastrophe: COVID-19 and Other Deaths, Cohorts, Color Lines, and Dollar Signs

Counting our dead—with accuracy and for accountability—is core to public health. For COVID-19, can we do right by those harmed and hold accountable those who have exacerbated the pandemic’s devastating—and inequitable—lethality?

The deluge of COVID-19 data in the United States has been both astounding and inadequate. Between myriad rapidly constructed public health agency data dashboards, news media data-driven visual and in-depth reporting, and citizen science Web-based COVID-19 trackers to highlight inadequately reported risks by racialized groups, gender, and occupation, we are awash in both data—and exposed data gaps.

But will this data frenzy let us tally the true toll of COVID-19? Motivated by my own work wrestling with COVID-19 data for health justice in the United States, ^{1 , 2} I raise three urgent concerns that have global implications.

INEQUITABLE UNDERESTIMATES OF COVID-19 MORTALITY

To the extent that classification of COVID-19 deaths depends on access to being tested or hospitalized for COVID-19, in the US context this will lead to systematic undercounts of COVID-19 deaths among workers in low-wage jobs who lack health insurance and among elders who lack access to adequate care. Together, such undercounts will be concentrated among the Black, Indigenous, and Latinx populations. Analyzing excess deaths helps, but does not resolve, this problem. ²

Related, if people who survive COVID-19 develop post-acute sequelae of SARS-CoV-2 infection (i.e., experience persistent symptoms and poor health after acute COVID-19 illness) or COVID-19–related organ damage, will their eventual death certificates list COVID-19 as an underlying or significant contributing cause of death?—or omit it altogether? If the answer depends on quality of medical records, socially biased undercounts are bound to occur.

INEQUITABLE IMPACTS ON OTHER CAUSES OF DEATH

COVID-19 is already disproportionately killing people diagnosed with cancer, cardiovascular disease, and diabetes—all diseases that are marked by inequities. If this results in drops in deaths for these other causes, will this lead to facile interpretations implying that rates and inequities in these other causes of death are “declining”?

Conversely, what about selection effects induced by COVID-19? Will those left alive (comprising the numerators and denominators for other outcomes) skew toward better health profiles? Will it be recognized that any contingent gains in non–COVID-19 mortality rates and reductions in inequities come at the expense of decimation by COVID-19? More broadly, how will socially patterned birth cohort effects, conditioned on people’s chronological age during the brutal first years of the pandemic, affect future mortality rates and their inequities?

INEQUITABLE MORTALITY IMPACTS OF PANDEMIC POLITICS

Consider too the mortality impacts of the profoundly racialized economic and social devastation wrought by the pandemic above and beyond COVID-19 mortality inequities ^{1 , 2} Will analyses address or ignore the causal role of wealthy elites, including politicians and their billionaire enablers, who have prioritized profits over people, stoked COVID-19 denialism, and opposed coherent, compassionate, and equitable COVID-19 policies? ²

I fear the latter. The overwhelming neglect of the continued impact of Jim Crow on contemporary US mortality rates starkly reveals how individualistic whitewashing (aptly encoding White supremacy) can render institutional and individual memory short, even as embodied risk lives on. The mass protests against structural racism in 2020, sparked by horrific police violence in conjunction with COVID-19 inequities²—and echoed in the equity declarations of the new Biden–Harris administration—demand better.

Minimally, a permanent asterisk—and corresponding footnote caveat about data limitations and sociopolitical context—should be affixed to any mortality estimate potentially affected by the COVID-19 pandemic. Beyond this, any true reckoning of the COVID-19 pandemic’s toll, both current and forthcoming, must have at its core the entwined impacts of color lines and dollar signs. Anything less would be a betrayal of the public trust that public health must earn. Time to step up and start implementing accountability science for health justice now!