Death rates from covid. Courtesy of Virginia Department of Health.

When the omicron variant first started sweeping across Virginia, one prominent health leader warned that “We are currently on the verge of a medical disaster in Southwest Virginia.”

Teresa Tyson, who heads the Health Wagon, a mobile health clinic, pointed out that Southwest Virginia had a large proportion of the population that wasn’t vaccinated and that the region lacked “life-saving monoclonal antibody therapies.”

That was early January. Now, COVID-19 is in retreat – although infection rates are still high so retreat is a relative word. So did the medical disaster happen?

Well, at the time, Southwest Virginia’s death rate from COVID was triple the state rate, so I guess it depends on what your definition of a medical disaster is, right? A death rate triple the state rate seems pretty disastrous to me, but one thing we’ve learned from the pandemic is that some people are pretty cold-hearted about the fate of their fellow citizens. For them, if they didn’t die and no one they knew very well died, then maybe it’s not a disaster. In an interview with The Washington Post in December, 5th District Representative Bob Good, R-Campbell County, seemed to question whether the pandemic was real because he didn’t know anyone who had died of COVID. (In his home county, 188 people have now died from COVID, according to the Virginia Department of Health.)

We recently ran a story about the public health nurses who are trying to raise the vaccination rates in Carroll County, the least vaccinated locality in the state. That prompted a reader to write in to ask why we didn’t attribute Carroll’s low vaccination rate to its large evangelical population. In response I did some number-crunching and debunked that theory – there is some connection between religious beliefs and enthusiasm (or lack thereof) for vaccines, but it’s not nearly as strong as people think. I pointed out that there are multiple counties in North Carolina that have a bigger percentage of evangelicals than Carroll does, but also a much higher rate of vaccination.

That prompted another reader to write in to ask about death rates and how they trend geographically. So that’s what I’ll deal with today.

The short version is that since the pandemic began, death rates in Southwest Virginia have run about double the state average – during the omicron surge they were, as noted, sometimes running about three times higher. WJHL-TV – which is in Johnson City, Tennessee, but covers Southwest Virginia as part of its region – has done the best reporting I’ve seen on COVID rates in that part of the state. WJHL reported last week that if Southwest Virginia were its own state, it would have the highest death rate in the country..

There are some obvious reasons for this – low vaccination rates being one of them. But low vaccination rates alone don’t explain the high death rate. Southwest Virginia had higher death rates even before vaccines were available. Why? Probably a whole confluence of reasons. Rural areas tend to be older, and COVID tends to be harsher on older people than younger ones. Older people also tend to be sicker anyway, and we know that people with comorbidities – one of those not-so-wonderful phrases we’ve learned during the pandemic – are more vulnerable. Rural areas also tend to have fewer doctors, and more people who don’t have a regular relationship with the health care system. Rural areas also tend to be poorer, which is another factor in health care outcomes. So there are lots of reasons why the death rate in Southwest Virginia is higher than the state average, not just because the vaccination rate is low (although that surely doesn’t help). Even if every locality in the state was equally vaccinated, we’d expect rural areas to have a higher death rate for some of the reasons above – so while these numbers showing a death rate double and triple the state rate are shocking, they also should not be particularly surprising.

That said, let’s look at the actual numbers.

Here are the localities in Virginia with the highest death rates since the pandemic began, as measured on a cases-per-100,000-population basis – the standard way to make sure we’re comparing the same things. According to the Virginia Department of Health, we have 27 localities where the rate is higher than 400 deaths per 100,000, so here they all are:

1. Galax: 1,144

2. Martinsville: 874

3. Alleghany County: 626

4. Buena Vista: 609

5. Danville: 604

6. Norton: 552

7. Lexington: 536

8. Nottoway County: 528

9. Smyth County: 525

10. Colonial Heights: 511

11. Shenandoah County: 494

12. Northampton County: 480

13. Patrick County: 474

14. Wise County: 470

15. Southampton County: 465

16. Page County: 464

17. Henry County: 463

18. Buchanan County: 461

19. Scott County: 458

20. Wythe County: 454

21. Carroll County: 439

22. Bath County: 437

23. Petersburg: 424

  1. Halifax County: 419
  2. Salem: 410

26. Covington: 408

27. Amelia County: 407

What should we notice from this? First, most of these are rural localities, or small cities. Six of the top 10 are west of the Blue Ridge. Almost all are from Southwest and Southside. WJHL computes the death rate for Southwest Virginia alone at  at 403 per 100,000 population.

Now, here’s some more context: The U.S death rate is 279.84, so as long as that list is, there are a lot more Virginia localities that are still above the national death rate. That would include Roanoke (323) and Lynchburg (315). It’s actually easier to count the localities in Virginia that are below the national death rate.

The state’s lowest death rate is Loudoun County, at 83 per 100,000, followed by Williamsburg with 85 per 100,000. The rates in the urban crescent are all below the national average with just one exception – Portsmouth at 315. There are some localities in Southwest and Southside, though, that come in under the national average:

Botetourt County: 265

Prince Edward County: 261

Giles County: 258

Craig County and Roanoke County: 256

Radford: 247

Brunswick County: 243

Lunenburg County: 228

Highland County: 227

Cumberland County: 221

Montgomery County: 138

So we can’t say that Southside and Southside have death rates uniformly higher than the national rate, just that most localities there do. Some of these exceptions are understandable – Highland is small so statistics there can swing wildly, Montgomery County and Radford are home to major universities that have had vaccine mandates. But other places, such as Cumberland County, have apparently just had good luck, or are doing something right. However, all those, with the exception of Montgomery County, are still higher than the state rate of 206 per 100,000. 

Now for more context: The country most like the United States culturally, and the closest to us geographically, is Canada. In Canada, the death rate is 95.18 deaths per 100,000, according to the World Health Organization. If we were Canadian, we might have more hockey teams and poutine on more restaurant menus. But we might have a much, much lower death rate, too. Only two localities in Virginia – Loudoun County and Williamsburg – have death rates lower than the Canadian average. In the United States, we see some of the highest death rates in rural areas. In Canada, we see some of the lowest. In Nova Scotia, the death rate is just 19 per 100,000. In Newfoundland and Labrador, it’s 12. In Prince Edward Island, just 9. Even the province with the highest rate – Quebec at 161 – is pretty darned low by American standards.

In some ways, this makes the recent trucker protests in Canada more understandable. That country has done a much better job than we have in holding down deaths, and the virus in general, so maybe it’s natural that some people would rebel at restrictions when they don’t see a big problem that those restrictions have presumably prevented. It’s harder to understand why people in American localities with such a high death rate would be so reluctant to get vaccinated. Surely they see all the tragedies around them? Why aren’t they reacting by lining up to get vaccinated? I’m inclined to think that this is fundamentally a cultural difference between Americans and the rest of the world.

In parts of Europe, the COVID death rates are lower still: 73.47 in Denmark, 42.15 in Finland, 28.84 in Norway, which means even our lowest localities have death rates that are more than twice as high as Norway’s and about twice as high as Finland’s. In the industrial heart of Europe, the death rate is 145.82 in Germany. Sweden, which famously took a more hands-off approach to COVID restrictions, has a death rate of 163.18, not much different from places that imposed stricter lockdowns. By those international measures, our highest death rate localities are simply off the Western scale. Attributing those high death rates in Southwest Virginia and even Southside Virginia simply to older communities feels unsatisfactory. Ultimately the question to me seems to be not why Southwest Virginia’s death rate is higher than either the state or national rate – that seems perfectly explainable – but why any of those rates are so much higher than so many other countries. Feel free to discuss that amongst yourselves.

So which countries do our death rates compare to?

How about Italy, which had a gruesome COVID-19 death wave early on? Nope. Its death rate is lower than the American rate now – 256.85.

What about Brazil, another country that for a time seemed overwhelmed by the virus? Nope. Its death rate is 302.52, so higher than the American rate but still lower than most Virginia localities.

Do you really want to know? You don’t. How about Bulgaria, which has the highest rate in Europe at 503.46? Even Bulgaria would fall below 10 localities in Virginia. And then there’s Peru, where the death rate is 634.21, which puts it slightly higher than Alleghany County but still below Martinsville and Galax. The overall Southwest Virginia rate would be just below Montenegro, which stands at 423.21.

Surely we are more advanced than Montenegro and Bulgaria and Peru – yet when it comes to matters of life and death, apparently not. That WJHL report that said if Southwest Virginia were a state it would have the highest rate in the country? What if Southwest Virginia were its own country? Well, it wouldn’t have the highest death rate in the world – just one of the highest. 

Yancey is editor of Cardinal News. His opinions are his own. You can reach him at