Graphic detail Vulnerability to covid-19
Risk factors for covid-19 are highest in the South and Appalachia
Predicted covid-19 case fatality rate, %
Dixie in the
crosshairs
The South is likely to have America’s
highest death rate from covid-19
A merica does not face one covid-19 cri-
sis, but rather dozens of di erent ones.
A few places have been walloped; others re-
main unscathed. So far, the disease has
claimed most of its victims in areas where
it has grown the fastest. Lockdowns have
geographically contained most outbreaks.
However, once social distancing is relaxed,
sars-cov-2 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-
cates had tested positive. If the share of
One-third of residents in thinly-populated
Albany County, Wyoming are university students
Florida's Sumter County, home to
a huge retirement community, has
America's oldest population
Sources: The Economist; US Census Bureau; New York Times; Covid Tracking Project; Global Health Data Exchange; University of Washington;
Google; Unacast *Logarithmic transformation †Increase in predicted CFR associated with a one-standard-deviation increase in each variable
people without grave symptoms who still
get tested were similar everywhere, places
with high case-fatality rates (cfrs)—the
death rate among people testing positive—
would be likely to have high ifrs as well.
In fact, testing practices vary widely.
And given two states with the same rate of
infections and deaths, one that tests only
the severely ill will report a higher cfr than
will one that tests more broadly. However,
within any given state, testing protocols
are likely to be more uniform. As a result,
we have built a model to identify the traits
shared by counties with cfrs far above or
below their own state’s average—and pred-
Impact on covid-19 case-fatality rate†, % points
-0.5 0 0.5
Median age
Population density*
Prevalence of heart disease,
diabetes and smoking
Share of population
that is African-American
95% confidence
Amount of social distancing
three weeks prior
Median income*
ICU beds per
100,000 people
The Economist April 25th 2020 81
0 2 4 6 8
Max 8.7 No data
New York’s high population
density made it unusually
vulnerable to covid-19


ict which places not yet ravaged by the vi-
rus will su er most if it arrives in earnest.
Some factors that a ect viral spread also
predict cfrs. They tend to be higher in cit-
ies than in rural areas, and lower where so-
cial distancing, as measured by tra c to
workplaces and transit stations, is greater.
One explanation is that healthcare quality
drops when caseloads surge. Places with
few intensive-care-unit (icu) beds also
have high cfrs, bolstering this hypothesis.
However, demography is just as impor-
tant. Places with older residents and more
diabetes, heart disease and smoking have
higher cfrs. Race and income also play a
role. Counties with lots of poor or black
people tend to have more health problems,
less social distancing and fewer icu beds.
1 Yet cfrs in such areas are even higher than
you would expect from these factors alone.
Together, these variables leave a geo-
graphic footprint. If covid-19 does infect
most Americans, the highest death rates
will probably not be in coastal cities—
whose density is o set by young, healthy,
well-o populations and good hospitals—
but rather in poor, rural parts of the South
and Appalachia with high rates of heart dis-
ease and diabetes. Worryingly, the three
states that began relaxing their lockdowns
this week (Georgia, Tennessee and South
Carolina) are all in this region. 7