Vermont reported almost 3,000 more deaths from 2020 to 2023 than would have been expected were it not for the Covid-19 pandemic, according to data from the U.S. Centers for Disease Control and Prevention — but less than one-third of those deaths have been directly attributed to the virus.

The increased mortality points to a rising tide of challenges Vermonters experienced during lockdown: delayed access to health care, isolation and a worsening of the state’s decadeslong opioid crisis.

The additional deaths could also point to a hidden cause — Covid-related deaths that were not recorded as such, according to Steven Woolf, a population health researcher at the Virginia Commonwealth University School of Medicine.

Woolf’s team analyzed what researchers call “excess deaths,” or the number of deaths in a population beyond the average or the expected amount during a given time period. It’s a common technique for measuring the toll of large-scale disasters such as hurricanes, when the official death toll might be an undercount.

In the first year of the pandemic, the United States as a whole reported a death toll 23% above the expected figure, according to Woolf’s paper from 2021. Vermont itself had a death toll 8% above normal. Less than a third of those deaths that year can be attributed to officially reported Covid deaths.

But 2020 was only the beginning of Vermont’s struggles with the virus, according to CDC data. The number of excess deaths ticked up throughout 2021 and reached a peak in January 2022 during the height of the Omicron variant wave. 

Even as the state recovered and reopened in 2022, there continued to be more deaths than would have been expected, according to the CDC. The state’s death toll that year rose to 22% above the expected estimate.

It’s too soon to say how Vermont has fared in 2023, since it takes time for officials to finalize death certificates and share them with the federal government. (At the close of 2022, the state had attributed 877 deaths to Covid. As of this week, that number had risen to 967.)

Woolf’s research suggests that excess deaths early in the pandemic — particularly during those first few months of lockdown — were the most likely to be Covid deaths misattributed to other causes.

“There was confusion at the beginning about what exactly Covid-19 did,” he said. “We did not realize, at the beginning, its effect on the heart, the kidneys, many other body systems. So, understandably, I think some patients who died of Covid-19 may have been classified as deaths from heart disease or kidney failure, or some other kind of factor like that.”

Vermont takes several steps to ensure its Covid deaths are fully tracked, such as flagging Covid-like illnesses and testing people for Covid post-mortem, if necessary, Elizabeth Bundock, the state’s chief medical examiner, told VTDigger in 2022.

Woolf said the true driver of excess deaths is just as likely to be the effects of lockdown and an overburdened health care system. 

“A person who would develop chest pain and was scared to call 911 and died of a heart attack would be counted among those deaths, even though they were never infected by Covid-19,” he said. 

The number of deaths from heart disease rose about 15% in 2021 compared with 2019, according to the CDC. 

Researchers also believe the pandemic affected people with chronic health issues, along with causing or worsening mental health issues and substance use disorders, he said. Vermont Department of Health data shows that the state has seen opioid overdose deaths rise continuously since 2020. 

Conversely, deaths from non-Covid respiratory illnesses, such as influenza and chronic lower respiratory illnesses, fell during the pandemic. 

“Masking and social distancing (decreased) the spread of influenza and pneumonia … and those kinds of respiratory pathogens are very problematic for people with chronic lung disease like emphysema or asthma,” Woolf said.

Ultimately, Woolf thinks the number of deaths from Covid, compared with other causes, matters as much as the fact that “we need to develop better systems for providing health care and dealing with other health issues during public health emergencies.” 

The lack of investment in primary care meant that few people had a primary care doctor to fall back on when hospitals were too busy to visit. Primary care practices were “overwhelmed” and not ready to handle telehealth, Woolf said.

“A lot of people developed complications from diabetes and heart disease and so forth because they were not able to get their medicines,” he said. “They were not able to get their chronic conditions checked.”

The United States also has a “frail” mental health care system with too few mental health professionals, he said. Many people experiencing mental health challenges during lockdown were met with waiting lists and were stuck calling around to practices with no openings.

The toll of the pandemic does not just include deaths, Woolf said, but a broad swath of people living with health conditions brought on by the pandemic that they might live with for decades to come. 

The most obvious one is long Covid, a condition that has been demonstrated to affect almost every organ of the body, Woolf said. There are also the children who grew up under the stresses of the pandemic. 

He likened it to the famine years of the Soviet Union, which had a measurable impact on the health of generations of people. 

“Someday there will be a body of research like that about what happened to the Covid-19 generation, in terms of its ripple effects over time,” Woolf said.

Life expectancy in the U.S. was dropping even before the pandemic due to the opioid epidemic, alcohol-related deaths, suicides and cardio-metabolic illnesses such as heart disease and diabetes cropping up in young and middle-aged adults, he said. 

“The reasons for that didn’t go away during the Covid-19 pandemic. They rolled right into the pandemic,” Woolf said.

What has changed is the emphasis on infectious disease as a major public health concern. Coming up in his career, Woolf said, diseases such as polio and smallpox had been “conquered” with antibiotics and vaccines.

“People like me were taught in medical school that now we’re in a new generation, where the leading causes of death are chronic diseases, not infectious diseases,” he said. “So we’ve got that under control, and then suddenly we ended up with a virus that created mass societal changes on the scale of Covid-19.”

VTDigger's data and graphics reporter.