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Graphic detail Vulnerability to covid-19
→ Risk factors for covid-19 are highest in the South and Appalachia
United States, predicted covid-19 case-fatality rate, %
Dixie in the
crosshairs
The South is likely to have America’s
highest death rate from covid-19
merica does not face one covid-19 cri-
Asis, but rather dozens of different ones.
A few places have been walloped; others re-
main unscathed. So far, sars-cov-2 has
claimed most of its victims in areas where
it has spread the fastest. Lockdowns have
geographically contained most outbreaks.
However, once social distancing is relaxed,
the virus will accelerate its spread, and
could infect a majority of Americans. If
that happens, the places it hits hardest may
not be those it struck first. Instead, the vul-
nerability of local populations will deter-
mine its death toll in each region.
Covid-19’s true infection-fatality rate
(ifr, the share of infected people who die)
is unknown, because most carriers are not
tested. However, testing is more common
for people whose cases are bad enough to
endanger their lives: in New York 67% of
people with covid-19 on their death certifi-
cate had tested positive. If the share of peo- 100,000 people
The Economist April 25th 2020 81
0 2 4 6 8
Max 8.7 No data
One-third of residents in thinly populated
Albany County, Wyoming are university students
New York’s high population
density made it particularly
vulnerable to covid-19
Florida’s Sumter County, home to
a huge retirement community, has
the highest median age in America
Sources: US Census Bureau; New York Times; Covid Tracking Project; Global Health Data Exchange
University of Washington; Google Health; Unacast; The Economist; *Logarithmic transformation
ple without grave symptoms who still get ict which places not yet ravaged by the vi-
tested were similar everywhere, places
rus will suffer most if it arrives in earnest.
with high case-fatality rates (cfrs)—the Some factors that affect viral spread also
death rate among people testing positive— predict the cfr. It tends to be higher in cit-
would be likely to have high ifrs as well. ies than in rural areas, and lower where so-
In fact, testing practices vary widely. cial distancing, as measured by traffic to
And given two states with the same rate of workplaces and transit stations, is greater.
infections and deaths, one that tests only One explanation is that health-care quality
the severely ill will report a higher cfrthan drops when caseloads surge. Places with
will one that tests more broadly. However, few intensive-care-unit (icu) beds also
within any given state, testing protocols have high cfrs, bolstering this hypothesis.
are likely to be more uniform. As a result, However, demography is just as impor-
we have built a model to identify the traits tant. Places with older residents and more
shared by counties with cfrs far above or diabetes, heart disease and smoking have
below their own state’s average—and pred- higher cfrs. Race and income also play a
role. Counties with lots of poor or black
Impact of one-standard-deviation increase on people tend to have more health problems,
less social distancing and fewer icu beds.
covid-19 case-fatality rate, % points
Yet cfrs in such areas are even higher than
-0.5 0 0.5 1 you would expect from these factors alone.
Median age Together, these variables leave a geo-
graphic footprint. If covid-19 does infect
Population density*
most Americans, the highest death rates
Prevalence of heart disease, will probably not be in coastal cities—
diabetes and smoking whose density is offset by young, healthy,
Share of population 95% confidence well-off populations and good hospitals—
that is African-American
but rather in poor, rural parts of the South
Amount of social distancing
and Appalachia with high rates of heart dis-
three weeks prior
ease and diabetes. Worryingly, the three
Median income* states that announced plans this week to
ICU beds per relax their lockdowns (Georgia, Tennessee
and South Carolina) are all in this region. 7