Analysis: Deaths surged across California in 2021. The rural High Desert took a heavy hit
Deaths attributed to COVID-19 in California spiked by more than 40% in year two of the virus while flu deaths nearly vanished and other respiratory killers plunged, as separate surges tied to blood flow, kidneys and livers, and rare and unnatural causes took the state beyond its already historic fatality 2020 toll.
San Bernardino County largely mirrored the state with its own newly unprecedented count of deaths in 2021 — and the rural High Desert carried a significantly heavier load than its share of the county population, according to a Daily Press analysis of raw data last updated March 10 in the California Vital Data system, which the state Department of Public Health compiles from death certificates and provides in anonymized form for deaths going back to 2014.
And according to the state’s initial count for the first month of this year, California remains far from a return to normalcy on the issue of mass death.
The wrong direction
Roughly 80,579 death certificates in California have listed COVID as the underlying cause, or “the disease or injury that initiated the train of events leading directly to death,” as Cal-ViDa defines it.
CDPH specifies the virus as one of 52 “rankable causes of death” formed by groups of codes in the World Health Organization’s tenth International Classification of Diseases, or ICD-10. (Editor's note: An eleventh update to the WHO classifications kicked in this year, but the U.S. hasn’t yet begun a transition away from ICD-10.)
In CalViDa’s latest count, the split among all death certificates citing COVID as the underlying cause came out to:
31,383 COVID deaths statewide in 2020
44,273 COVID deaths in 2021, a 41% spike from year one of the virus
4,923 COVID deaths in January this year
Simultaneously, the latest CalViDa count show declines in deaths from other respiratory diseases last year.
Death certificates listing an underlying cause of influenza fell by 95% statewide, from nearly 690 flu-attributed deaths in 2020 to less than 45 deaths last year.
Pneumonia deaths plunged to a less dramatic degree: Nearly 4,600 death certificates last year, a decline of more than 800 deaths or 15% from the state’s pneumonia-death count in 2020.
A broader category in CalViDa’s most specific breakdown of death causes, “Other chronic lower respiratory diseases,” also fell by about 11% last year, or 1,300 less deaths than in 2020.
It’s worth noting that future CalViDa updates will likely lead some underlying causes to increase for 2021 and January, though which causes will rise is impossible to predict, as a notable amount of deaths appear to have still been under investigation as of the latest count.
More than 5,000 deaths in January and 6,000 deaths in 2021 are currently in a category the ICD-10 describes as “symptoms, signs and abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.”
By comparison, less than 1,200 deaths are listed in this category for each year from 2014 to 2019, and less than 1,500 are in it for 2020.
The “abnormal” death count since 2021 is likely to decline as causes are determined, but by how much is unclear — the category also includes cases such as “sudden death, cause unknown,” situations “where the body…was found and no cause could be discovered,” and oddities like “findings of (substances) not normally found in blood” that don’t “point rather definitely to a given diagnosis.”
Problems beyond COVID
COVID is one part of a larger surge of excess deaths that began two years ago, and appears to go far beyond the virus itself.
Roughly 654,817 people died in California during the past two calendar years, whether or not they were a resident of the state, according to the most recent CalViDa death-certificate count.
That’s 27% higher than the prior two-year count of 541,109 deaths statewide in 2018-19.
The extraordinary increase is unexplainable by any one disease.
All-cause mortality, or the sheer number of people who died of any cause known or unknown, increased in California by an average of about 2% or 4,830 additional deaths each year during the five years leading up to 2019.
Then came 2020: A more than 18% spike in all-cause mortality — 50,000 more people than in 2019 — for a total of about 321,000 deaths statewide.
Then it got worse: About 334,000 people died in California this past year, a rise of 4% or nearly 13,000 more deaths than in 2020.
If California had maintained the 2% rate of growth in deaths that it held between 2014 and 2019, less than 550,000 people would have died statewide during the past two years, according to the Daily Press analysis.
That means more than 105,000 people who died in California between 2020 and 2021 would instead have been alive at the start of the current year. This translates to an overall excess of nearly 40,000 deaths beyond the total statewide count of COVID-attributed deaths.
So what’s fueling the unnatural rate of dying aside from the coronavirus?
A range of traditional underlying causes saw their own outsized increases in 2021.
Livers, veins, accidents and more
Deaths attributed to alcoholic liver disease rose by more than 16% or 700 additional deaths last year compared to 2020, which itself marked a 12% increase in such deaths compared to 2019. Alcoholic liver disease hadn’t increased as an underlying cause of death by more than 1% statewide over the few years prior.
Nearly 400 more deaths were attributed to cerebrovascular diseases such as strokes last year than in 2020, taking the annual count in this bloodflow-related category above 18,300 deaths.
Another 400-death increase came from essential hypertension and hypertensive renal disease, compounded by a roughly 300-death increase of deaths attributed to renal failure.
The last two years have also marked a surge of deaths attributed to accidents.
Death certificates in CalViDa’s Motor Vehicle Accidents category rose by 11% in 2020 to about 4,500 deaths. Then they surged by another 10% last year, to just under 5,000 car-accident deaths.
With that, while they didn’t increase in 2021, “accidental poisonings” also have spiked in the past two years. This ICD-10 category includes mistaken overdoses and “accidents in the use of drugs, medicaments and biological substances in medical and surgical procedures.” It rose by more than 48%, or 3,000 additional deaths, to nearly 9,400 accidental-poisoning deaths statewide in 2020. Such deaths remained at an outsized level of about 9,300 last year.
The most specific breakdown provided by CalViDa accounts for 113 separate potential underlying causes of death. Even then, the ICD-10 is too vast to cover everything.
In turn, health authorities group the rarest causes of death into one category dubbed, “All other diseases (Residual).” This category mixes myriad unique ailments ranging from “systemic atrophies primarily affecting the central nervous system” to inflammation throughout the body to various “diseases of the blood and blood-forming organs.”
Between 2014 and 2018, these deaths remained at a stagnant up-and-down in the area of 24,000 deaths in California, then ticked up to just above 25,000 in 2019.
In 2020, the uncommon-cause category spiked by more than 12% to about 28,250 deaths.
Then, “all other diseases” surged another 4% to a total of more than 29,350 deaths last year, as of CalViDa’s latest count.
Diseases of the heart, which remain the top cause statewide among CalViDa’s “Rankable Causes of Death,” rose 7% in 2020 to a record-high of about 66,800 deaths in 2020, then fell slightly last year while remaining about 1,500 deaths higher than any pre-2020 year.
Deaths primarily attributed to the many forms of cancer, second-highest among rankable causes, were virtually unchanged from pre-COVID counts in the past two years, though a remarkable shift saw cancer deaths plummet in hospitals while skyrocketing in peoples’ homes.
High Desert, heavy burden
Each statewide trend of the past two years is reflected in the U.S.’s largest county by square mile, San Bernardino County.
When broken down by place of residency, rather than place of death, the latest CalViDa data shows about 19,600 San Bernardino County residents died last year.
That’s a slight uptick from about 19,420 deaths in 2020, and a movement in the opposite direction of normalcy: The county logged just above 14,800 deaths among its residents in 2019, and usually recorded between 100 and a few hundred additional deaths per year up to that point.
A closer look reveals the dying has fallen disproportionately on residents in the rural, economically-strained High Desert.
People who live in the High Desert represented roughly 22% of San Bernardino County’s population as of the 2020 U.S. Census count.
But in the past two years, they accounted for about 31% of all deaths among county residents – about 5,938 in 2020 and 6,142 in 2021 – according to a Daily Press analysis of CalViDa data isolated to deaths among residents at 30 zip codes in High Desert communities.
The High Desert’s three most populous cities account for about 61% of these deaths.
Victorville residents: about 1,480 in 2020 and 1,541 in 2021
Apple Valley residents: about 1,098 in 2020 and 1,201 in 2021
Hesperia residents: about 1,087 in 2020 and 1,047 in 2021
Yet, accounting for differences in population, the highest rate of deaths per 100,000 residents among High Desert communities with at least 5,000 residents came in:
Yucca Valley: more than 2,300 deaths per 100,000 each year (513 deaths in 2020; 500 in 2021)
Barstow: more than 2,000 deaths per 100,000 each year (510 in 2020; 524 in 2021)
Lucerne Valley: more than 2,150 deaths per 100,000 each year (115 in 2020; 130 in 2021)
Twentynine Palms is the only area of the High Desert to log a death rate lower than that of the broader county and state in both of the past two years, with about 709 and 776 deaths per 100,000 residents in 2020 and 2021, respectively.
As is the case in statewide data, COVID plays a notable role in the unprecedented level of dying in the High Desert since 2020 but is far from the only factor.
Victorville, Apple Valley and Hesperia are more prominent on this front. The three cities accounted for more than 68% of COVID deaths in the High Desert.
The region also demonstrates how much worse last year was for the virus death-count. Less than 11 deaths among Twentynine Palms residents were attributed to COVID in 2020 — CalViDa discloses only “<11” for totals between 1 and 10 to protect the dead from being identified — but in 2021, the city’s COVID-attributed deaths more than doubled to 26 residents.
Overall, roughly 6,663 deaths among San Bernardino County residents in the past two years were attributed to an underlying cause of COVID in the latest CalViDa count — 2,758 in 2020 and 3,525 in 2021.
High Desert residents made up about 28% of those COVID-attributed deaths.
‘Social determinants’
Numerous factors could play into these disparities.
According to Josh Dugas, director of San Bernardino County’s public health department, a central challenge stems from “social determinants of health,” which the U.S. Centers for Disease Control and Prevention defines as “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.”
One of those determinants, Dugas says, is “access to affordable and quality healthcare.”
“The High Desert is so large, in such a vast area,” he told the Daily Press, “and transportation being sometimes an issue, it may be challenging for people to find preventative care and be able to get regular business with a qualified medical professional outside of just showing up to the emergency room.”
Aside from sheer access, Dugas cited lower rates of health-insurance coverage as another problem. He linked this to broader lags in unemployment and personal income.
Raw joblessness among High Desert residents sat at about 7.4% in December 2021, notably worse than the non-seasonal rates of 5.2% in San Bernardino County as a whole and 5% in all of California, a previous Daily Press analysis of state data found. It matched a yearslong disparity: In July 2010, as the manmade financial crisis of 2007-09 peaked in its ravage on workers, unemployment hit 17.2% in the High Desert versus 14.5% in the county and 12.7% statewide.
Dugas, a 20-year veteran of San Bernardino County’s health department who was appointed director last August, also pointed to barriers presented by the jobs of some residents who are employed.
“Many people in the High Desert commute,” he said. “Commuting, just by its nature, leads usually to a more sedentary lifestyle where people are maybe not as active. If you have a long commute, maybe when you get home you’re not as eager to exercise or get that physical activity that’s needed.”
Another factor Dugas cites is infrastructure for public recreation and its role in encouraging active lifestyles.
“Walkable sidewalks, parks,” he said. “Not that they don’t exist, but some areas of the High Desert, there’s dirt roads, things along those lines which, not that you can’t walk on them but it may deter people from getting out there and exercising.”
Death and severe disease in COVID patients has been associated with lower levels of exercise and less healthy diets prior to infection. On the latter issue, Dugas says the High Desert is one of multiple areas in the more than 20,000 square-mile county that equate to “food deserts.”
“It’s challenging to obtain not food, but healthy food. That usually leads to people eating unhealthier foods, higher salt content, fat, fast-food type foods,” he said. “That can help contribute to things like diabetes, obesity, there’s so many things that can contribute to.”
So what is the county doing to combat these disadvantages, and the broader elevation of deaths that has continued since 2020?
Dugas referenced an initiative dubbed Vision2BActive, meant to encourage exercise through social-media challenges, and a separate initiative to help residents access resources for healthier food and recipes. He also pointed to Community Vital Signs, an effort between the county and community leaders “to establish a health improvement framework by using data to help set goals and priorities for action,” it stated in a report published last March.
Dugas encouraged High Desert residents to seek check-ups or any form of primary care at one of two Federally Qualified Health Centers in Hesperia and Adelanto, where he says “they can come get ultimately, depending on their income-level, free healthcare, and we’re eager to see them and help them out.”
“Anyone can go, but it primarily focuses on lower-income, undocumented individuals,” he said. “Especially preventative care in nature, to try to keep people out of – you know, we try to treat things before they get to the emergency room, and help improve their overall lifestyle.”
As for the issue persisting beyond the county-level – historic rates of dying for the last two years – Dugas called it “a million-dollar question.”
“It’s hard to predict what COVID is going to look like. It’s giving every indication now that it’s becoming more normalized. We can’t predict future variants or any of those things,” he said Wednesday. “We’re gonna continue to put resources into that, to helping people receive vaccinations and provide testing options to help protect people from COVID.”
“When it comes to the many other negative health impacts,” Dugas continued, “my goal being relatively new to this position, and the department’s goal and the county’s goal, is to reengage and reevalute and find ways to – my goal would not be to get back to where we were, but hopefully show continued improvement in some of the negative outcomes as we move into the future.”
A new phase
State and federal officials have recently shifted their public tone to suggest some of the mandates and restrictions they’ve imposed through emergency orders since 2020 will soon be a thing of the past. On Feb. 25, California Gov. Gavin Newsom issued a new executive order that he touted as a rollback of “all but 5 percent of COVID-19 related executive provisions,” though it also issued four-month extensions on dozens of emergency measures including suspended regulations of various agencies and healthcare providers. Days later he announced his mask mandate for K-12 schools would end March 12.
Yet, expected death numbers are still much higher than pre-pandemic years. The initial January 2022 count of all-cause mortality, which may become higher as CalViDa often raises its initial counts in monthly updates, came out to almost 33,400 deaths across California — a sizable decline from more than 48,000 deaths in the same month a year ago, but still 30% higher than the number of deaths statewide in January 2020.
Charlie McGee covers California’s High Desert for the Daily Press, focusing on the city of Barstow and its surrounding communities. He is also a Report for America corps member with the GroundTruth Project, an independent, nonpartisan, nonprofit news organization dedicated to supporting the next generation of journalists in the U.S. and around the world. McGee may be reached at 760-955-5341 or cmcgee@gannett.com. Follow him on Twitter @bycharliemcgee.
This article originally appeared on Victorville Daily Press: Analysis: A 2021 death surge in California hit heavy in High Desert
