Public Health

Over the last two years the subject of public health has dominated the pubic consciousnesses like no other period in the lifetimes of most Americans alive today.  COVID-19 has killed over 1 million Americans of over 6 million people world-wide.  Yet, despite that staggering toll, many more Americans die each year from heart disease and cancer.  While deaths from heart disease and cancer have been on a long-term decline, deaths from heart disease have risen since the start of the pandemic, possibly reflecting the direct and indirect impacts of COVID-19 on the heart.   The full long-term impact of COVID-19 on human health may not be fully understood for years. 

Cardiovascular disease and cancer, long the leading causes of death in the U.S. and Fulton County, remained the top killers in 2020 despite advances in treatment and success in reducing mortality over recent decades.  Infectious diseases jumped from the seventh leading cause in 2019 to the third leading cause  in 2020 due solely to the appearance of COVID-19.  Deaths from COVID-19 were also largely responsible for an 18% rise in the overall death rate among Fulton County residents between 2019 and 2020, from 652 to 772 deaths per 100,000. [1]

Less dramatic than the impact of the COVID-19 pandemic but of long term importance is the continued rise in deaths from the two major neurodegenerative disorders, Alzheimer's and Parkinson's.  Based on current trends, those afflictions, along with other disorders of the nervous system, are on target to surpass cancer as the second leading cause of death within the next few years if cancer death rates continue to decline. 

External causes, which include homicide, suicide and accidental death, were the fifth leading cause of death and were up in 2020 by over 40% compared to 10 years earlier.  The increase has been primarily due to a recent rise in deaths from homicide as well as deaths from car accidents and accidental poisoning.

Since the first cases appeared in March of 2020, COVID-19 has infected over 200,000 Fulton County residents, hospitalized over 11,200 and taken the lives of over 2,200.  Apart from the tragedy of each death, the virus has disrupted the lives of every resident in some way--loss of jobs or income, failed or crippled businesses, risk of eviction or foreclosure, isolation, fear, and lingering symptoms for many of those infected. 

As of this writing, the pandemic has lasted 29 months in Fulton County.  The initial "wave" in spring 2020 was subsequently dwarfed by four spikes in cases: in the summer of 2020, the winter of 2020/2021, again in late summer and early fall of 2021, and finally in winter of 2021/2022.  The last two waves were fueled first by the Delta variant, which occurred even after 45% of residents had been fully vaccinated, and then by the Omicron variant, which produced by far the largest spike in cases.  The possibility of new variants threatens to prolong the pandemic and trigger more waves of illness and death. 

At 63%*, Fulton County's full vaccination rate is trending a few percentage points above that of Georgia as a whole; however, both are below the U.S. rate. Fulton County ranks third behind Fayette and Cobb among its neighboring counties.

Health experts are now predicting that COVID-19 will circulate globally for the foreseeable future, becoming another common respiratory virus like influenza [2].  If that is the case, the one-time vaccination metrics presented here will soon become less important than the rates of boosters and possibly annual vaccination [3]. One challenge to an annual vaccination strategy is that it will be difficult to target vaccines for the current dominate variant.  Even today with influenza, after decades to develop a vaccine manufacturing and immunization strategy, the most well-matched vaccines only reach approximately 60% effectiveness.  Much less is known about the evolution of the SARS-CoV-2 virus.

The pandemic has not affected all segments of the population equally.  Older residents have been particularly vulnerable to the virus with disproportionate numbers of hospitalizations and deaths.  Residents 65 years and older have accounted for 75% of all deaths in the county despite making up only 12% of the population.  African American residents have also been disproportionately affected.  Overall, African American males 85 years and over had the highest mortality rate at just over 5,00 per 100,000, followed by African American females 85 and over at 3,900 per 100,000.  African Americans died at higher rates than Whites in every age group.  Within each age group and race, males died at higher rates than females.

African American residents have also suffered higher infection rates and higher rates of hospitalization than others through most of the pandemic.  Infections peaked much higher for African Americans in three of the fours waves.  Only in the third wave in the winter of 2020/2021 did White residents experience more infections. 

According to the CDC, non-Hispanic Black persons are over twice as likely to be hospitalized for COVID-19 than non-Hispanic Whites and are 1.7 times as likely to die [4].  Studies indicate that the disproportionate impact of the disease on Black persons has several likely causes related to characteristics of the Black community, each highlighting persistent health disparities: 1) higher prevalence of diabetes, cardiovascular disease, and other underlying conditions, 2) higher likelihood of being front-line industry or essential workers, and 3) less access to healthcare in an out-patient setting and, therefore, less likelihood of early treatment [5][6].

While rates of infection have been higher among Black residents since the beginning of the pandemic, the discrepancy became larger after vaccines became available, likely due to higher vaccination rates among non-Black residents. As of mid-summer 2022, barely half of Black residents were fully vaccinated while 65% of White and 83% of Asian residents were fully vaccinated.

Chronic diseases are conditions that last a year or more and that require on-going medical treatment or limit daily activities.  Heart disease, cancer and diabetes are the major chronic diseases and are he leading causes of death and disability in the U.S.  They are also the major drivers of healthcare costs [7].

The declining cancer death rates among Fulton County residents largely reflect the national trend.  The decline is largely attributable to progress in the treatment of two of the most common cancers--lung and melanoma.  A steady decline in smoking rates among Americans has also played a large role in reducing deaths from lung cancer.  Progress has been slower in the treatment of other common cancers such as breast cancer and colon and rectal cancers.

While cancer death rates have fallen and continue to fall for all racial groups, disparities remain.  As of 2020, the rate of death from all cancers for Fulton County residents was about 60% higher for Blacks than for Whites. That disparity is much larger than it is for the state of Georgia and for the U.S. and is due more to an unusually low death rate among Whites in Fulton County than to an unusually high death rate among Blacks. 

Geographic disparities in cancer deaths are evident and correlate with racial and socioeconomic residential distributions.  As measured by hospital discharge rates, cancer rates are highest in areas of the county with a high proportion of Black residents, particularly in low-income neighborhoods.

Since 1950, age-adjusted death rates from cardiovascular disease in the U.S. have declined 60%, representing one of the most significant public health successes of the 20th century [8].  However, cardiovascular disease remains the number one killer among all causes of death and the rate of decline as slowed in recent years.  Furthermore, there is evidence that the long-term effects of COVID-19 include and increase in the risk of cardiovascular disease, even among those whose illness did not require hospitalization [9]. Problems associated with COVID-19 during the 12-month period following the infection include increased risk of stroke, of blood clots in the legs and the lungs, and of heart failure and heart attacks. Rates of death from cardiovascular disease in Fulton County did in fact increase during the pandemic, rising in 2020 and even more in 2021. Only time will tell how persistent the heightened risks will be.

Cardiovascular disease continues to be more prevalent among Blacks than other racial groups.  In 2020, deaths rate among black Fulton County residents was over 60% higher than for white residents.

[1] Georgia Department of Public Health. Online Analytical Statistical Information System.

[2] Marks P, Woodcock J, Califf R. "COVID-19 Vaccination—Becoming Part of the New Normal". JAMA. 2022;327(19):1863–1864. doi:10.1001/jama.2022.7469

[3] Rubin R. "Challenges of Deciding Whether and How to Update COVID-19 Vaccines to Protect Against Variants." JAMA. 2022;327(23):2273–2275. doi:10.1001/jama.2022.9367

[4] Centers for Disease Control and Prevention. 2020.  "Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity." Accessed August 4, 2022.

[5] Centers for Disease Control and Prevention. 2020.  "Characteristics Associated with Hospitalization Among Patients with COVID-19 — Metropolitan Atlanta, Georgia, March–April 2020.",  Accessed August 4, 2022.

[6] Economic Policy Institute. 2022. "Black workers face two of the most lethal preexisting conditions for coronavirus—racism and economic inequality". Accessed August 4, 2022.

[7] Centers for Disease Control and Prevention. 2022.  "About Chronic Diseases". Accessed on August 4, 2022.

[8] Centers for Disease Control and Prevention (CDC). Decline in deaths from heart disease and stroke--United States, 1900-1999. MMWR Morb Mortal Wkly Rep. 1999 Aug 6;48(30):649-56. PMID: 10488780.

[9]  Yan Xie, Evan, Xu, Benjamin Bowe, Ziyad Al-Aly. 2022. Long-term cardiovascular outcomes of COVID-19. Nature Medicine. March 2022, Vol. 28