The Atlantic

In a matter of weeks, the coronavirus has gone from a novel, distant threat to an enemy besieging cities and towns across the world. The burden of COVID-19 and the economic upheaval wrought by the measures to contain it feel epochal. Humanity now has a common foe, and we will grow increasingly familiar with its face.

Yet plenty of this virus’s aspects remain unknown. The developing wisdom—earned the hard way in Wuhan, Washington, and Italy—has been that older people and sicker people are substantially more likely to suffer severe illness or die from COVID-19 than their younger, healthier counterparts. Older people are much more likely than young people to have lung disease, kidney disease, hypertension, or heart disease, and those conditions are more likely to transform a coronavirus infection into something nastier. But what happens when these assumptions don’t hold up, and the young people battling the pandemic share the same risks?

The world is about to find out. So far, about one in 10 deaths in the United States from COVID-19 has occurred in the four-state arc of Louisiana, Mississippi, Alabama, and Georgia, according to data assembled by the COVID Tracking Project, a volunteer collaboration incubated at The Atlantic. New Orleans is on pace to become the next global epicenter of the pandemic. The virus has a foothold in southwestern Georgia, and threatens to overwhelm hospitals in the Atlanta metropolitan area. The coronavirus is advancing quickly across the American South. And in the American South, significant numbers of younger people are battling health conditions that make coronavirus outbreaks more perilous.

The numbers emerging seem to indicate that more young people in the South are dying from COVID-19. Although the majority of coronavirus-related deaths in Louisiana are still among victims over 70 years old, 43 percent of all reported deaths have been people under 70. In Georgia, people under 70 make up 49 percent of reported deaths. By comparison, people under 70 account for only 20 percent of deaths in Colorado. “Under 70” is a broad category, not really useful for understanding what’s going on. But digging deeper reveals more concerning numbers. In Louisiana, people ages 40 to 59 account for 22 percent of all deaths. The same age range in Georgia accounts for 17 percent of all deaths. By comparison, the same age group accounts for only about 10 percent of all deaths in Colorado, and 6 percent of all deaths in Washington State. These statistics suggest that middle-aged and working-age adults in the two southern states are at much greater risk than their counterparts elsewhere; for some reason, they are more likely to die from COVID-19.

All data in this stage of the pandemic are provisional and incomplete, and all conclusions are subject to change. But a review of the international evidence shows that, as far as we know, the outbreaks currently expanding in the American South are unique—and mainly because of how many people in their working prime are dying. Spain’s official accounting of the pandemic last week showed that deaths among people under 70 years old make up only about 12 percent of total deaths in the country. Case-fatality rates around the world are notoriously tricky because they are based in part on the extent of testing, but a recent study of the outbreak in Wuhan, China, found a case-fatality rate of 0.5 percent among adults ages 30 to 59. The current estimate of fatality rates in the same age range in Louisiana is about four times that.

Tricia Neuman, a senior vice president at the Kaiser Family Foundation, says this analysis points to the underlying issues that might complicate or worsen the pandemic in the South. “Due to high rates of conditions like lung disease and heart disease and obesity, the people living in these states are at risk if they get the virus,” Neuman told me. These aren’t “people who are sick, but these are people who have underlying comorbidities that put them at higher risk of serious illness if they get infected.”

The KFF analysis doesn’t include potential complications from hypertension—which is also suspected to be driving coronavirus-linked hospitalizations—but the data are predictable on that front. If you define Oklahoma as part of the South, southern states fill out the entirety of the top 10 states in percentage of population diagnosed with hypertension by a doctor. Southerners are more likely to suffer from chronic diseases than other Americans—even as Americans are more likely to suffer from chronic diseases than citizens of other countries with comparable wealth. According to Neuman, these estimates don’t include people with cancer or who are immunocompromised—groups that are also at high risk for serious illness from COVID-19. And cancer mortality rates are highest in southern states.

These differences are not innate to southerners; they are the result of policy. Health disparities tend to track both race and poverty, and the states in the old domain of Jim Crow have pursued policies that ensure those disparities endure. The South is the poorest region in the country. The poor, black, Latino, or rural residents who make up large shares of southern populations tend to lack access to high-quality doctors and care. According to the State Health Access Data Assistance Center, Mississippi, North Carolina, Texas, Florida, Georgia, and Louisiana all spend less than $25 per person on public health a year, compared with $84 per person in New York. Nine of the 14 states that have refused to expand Medicaid to poor residents under the Affordable Care Act are in the South. And many of those states are led by Republican leaders who have imitated President Donald Trump’s dallying and flip-flopping, and now find themselves flat-footed.

The slow response from those governors will be even more ruinous in a region with so many challenges. Chronic disease and the apparent increased risk for younger people from COVID-19 are only part of the story in the South. Other factors could complicate its pandemic response. Advocates have drawn attention to the extreme vulnerability of people in prison to the coronavirus—and the South incarcerates a larger proportion of its population than anywhere else in the United States. A federal prison in Louisiana has already seen a spike in COVID-19 cases this week. Also, a global fear in this pandemic is that it will sicken health professionals and doctors, and leave them unable to contend with waves of hospitalizations. Southern states have some of the lowest ratios of active physicians to patients in the country.

In all, the South seems likely to be a new kind of battleground, one in which distancing and isolation are going to be especially important in stopping the virus. Centuries of policy gave the pandemic a head start—and younger targets—in the South. Now there are mere days to change course.


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