Since COVID-19 claimed its first life in Minnesota, the pandemic has caused the total number of deaths in the state to swell nearly 20% above normal.
In just seven weeks, the additional fatalities have cut into generations and communities, taking more than 1,000 people who otherwise would likely be alive today.
The impact is greatest among those 65 and older, where there have been 25% more deaths than expected, according to a Star Tribune analysis of death records since 2015. It has also taken a significant toll on people of color, who are dying in disproportionate numbers.
Compared with five-year averages, the pace of excess deaths has been on the rise, hitting 25 to 30% above the average of 435 deaths each week through early May, the most recent period for which death records can be analyzed.
While death totals typically go up gradually each year, most of the increase in 2020 was attributable to the new coronavirus.
"We expect that deaths, and we've seen that the deaths, have been rising slowly year over year as our population ages," said Susan Brower, Minnesota state demographer. "But to see this level of increase in such a short period of time is unusual."
It is the type of mark left by a pandemic, a major natural disaster, or war.
"We could see slower population growth and continued mortality because of what we are experiencing," said Brower.
There is concern that deaths could soar above average from causes that go beyond coronavirus infection.
"We are experiencing a pandemic that impacts not only people's health but their ability and desire to access health care," said Brower. "What we may see is excess or higher levels of deaths because of the secondary impact."
The fear of going to the emergency room could lead to more fatalities from heart attacks or strokes, while the lack of periodic primary care checkups sets the stage for deaths from uncontrolled diabetes or asthma.
Nearly 80% of the excess deaths in Minnesota were caused by COVID-19, according to the Star Tribune analysis. It is too early to determine whether deaths from other causes were unusually high.
However, there has been a 26% jump in the number of drug overdose-related deaths in 2020, but due to a lag in reporting the actual increase may be higher.
Homicides and suicides so far this year are close to last year's patterns.
Elderly hard hit
Throughout most of the pandemic in Minnesota, nine of every 10 COVID-19 deaths have been among those 65 and older.
They succumb to heart attacks, strokes or a combination of many factors that is sometimes described as "failure to thrive." But most die from lung failure, such as acute respiratory distress syndrome, a condition where fluid builds up in the lungs' air sacs, depriving the body of oxygen.
Most of the deceased also had underlying health conditions, such as heart disease, kidney disease, diabetes or obesity. Those diseases make it more difficult for the body to respond to a respiratory illness.
"The organ that is attacked is your lungs," said Dr. Roberta Meyers, a geriatrician with Hennepin Healthcare. "It is like flu but like a flu that is way worse."
But even with their pre-existing illnesses, many who died from COVID-19 were otherwise not on the verge of death. "The virus was the proximate cause of death for many of these people," said Meyers. "Had they not gotten the virus they would probably have lived on."
If it were a situation where "they would have died anyway," the weekly number of deaths in 2020 for those over 65 would be closer to the average of 285. Instead, there have been 355 deaths per week on average since Minnesota saw its first COVID-19 death in mid-March.
"There are some who say that this just impacts old people. Who cares? Old people just die," said Adam Suomala, executive director of the Minnesota Leadership Council on Aging. "There is some social acceptance that an older life is worth less than a younger life."
In some ways, state policy mirrored societal attitudes, according to Suomala.
"Why is it that there was a rush to do planning around personal protective equipment and testing in hospital systems but not in long-term care services and supports, or certainly not to the same prioritization?" he said.
As Minnesota gradually opens up businesses, houses of worship and outdoor activities, Suomala said there needs to be an awareness that social distancing is still needed to protect the elderly.
If the virus is spreading widely in the community, it is likely that it still can make its way into nursing homes or assisted-living facilities, even with strict visiting restrictions. Caregivers, cooks, janitors and administrators come and go each day, potentially bringing in the virus with them even if they don't have symptoms.
"I would hope they continue to listen to the governor's calls for masking and all of the infection control practices in place," Suomala said.
Toll on people of color
Black Minnesotans and members of other communities of color also have been hard hit.
Although 6% of the state's population is black, they comprise 23% of all confirmed COVID-19 cases and 20% of hospitalizations, according to the state Department of Health.
Among all people of color, those between ages 30 and 64 have been affected significantly. This group represents 16% of the state's population but accounts for 32% of the COVID-19 deaths, as of death records reviewed by the Star Tribune through the first week of May.
"While the virus doesn't discriminate, our society does," said Dr. Nathan Chomilo, a pediatrician and founding board member of Minnesota Doctors for Health Equity. "We already have these deep racial disparities. When something like COVID comes, it stresses a system that already has racist outcomes."
Chomilo pointed to inequities in childhood nutrition, education, employment opportunities and exposure to pollution as factors that affect health.
Many people of color work in jobs that are deemed essential and can't be done from home, increasing the likelihood of exposure, he said.
Access to care and resources is also a factor, including a lack of testing among communities of color.
"That is certainly something that has improved over the last month," Chomilo said. Testing should be considered a scarce resource, just like personal protective equipment, ventilators and ICU beds.
"Some part of the supply chain in another part of the world gets interrupted and then we are back at square one, and then we have to look back at how things are prioritized," he said.
"We continue to have a lot of work to do to live up to some of these ideals that we have in Minnesota that we are failing."