Abstract

Mortality caused by the COVID-19 pandemic has impacted indicators of Years of Potential Life Lost (YPLL) worldwide. This study aimed to estimate the YPLL due to mortality caused by COVID-19, according to sex, age group, and race/color in Brazil, from March 2020 to December 2021. Deaths caused by COVID-19 were characterized, in which the rates and ratios of standardized YPLL rates, the average number of years of potential life lost (ANYPLL), and the average age at death (AAD) were estimated and compared. Overall, 13,776,969.50 potential years of life were lost, which resulted in an average loss of 22.5 potential years not lived. A greater loss of potential years of life was identified in men (58.12%) and in the age groups from 0 to 59 years in the black (58.92%) and indigenous (63.35%) populations, while in the age groups of 60 years and over, a greater loss of YPLL was observed in the white (45.89%) and yellow (53.22%) populations. Women recorded the highest ADD, with the exception of indigenous women. White men (1.63), brown men (1.59), and black men (1.61) had the highest rates when compared to white women. Although COVID-19 has a greater impact on the elderly, it was the black and indigenous populations under the age of 60 who had the greatest loss of potential years of life.

Key words:
COVID-19; Race and ethnicity; Potential years of life lost; Intersectionality

Introduction

The World Health Organization (WHO) declared COVID-19 a severe pandemic in March 2020. Since then, Brazil has led among Latin American countries in the number of cases and deaths accumulated from this disease, ranking second in the Americas and only behind the United States and India in global terms¹1 Neiva MB, Carvalho I, Costa Filho ES, Barbosa-Junior F, Bernardi FA, Sanches TLM, Oliveira LL, Lima VC, Miyoshi NSB, Alves D. Brazil: the emerging epicenter of COVID-19 pandemic. Rev Soc Bras Med Trop 2020; 53:e20200550..

Mortality caused by the COVID-19 pandemic has had an impact on the indicators of Potential Years of Life Lost (YPLL) and Life Expectancy (LE) at a global level²2 Marois G, Muttarak R, Scherbov S. Assessing the potential impact of COVID-19 on life expectancy. PLoS One 2020; 15(9):e0238678.. The decrease in life expectancy is directly related to the increase in mortality from COVID-19³3 Schöley J, Aburto JM, Kashnitsky I, Kniffka MS, Zhang L, Jaadla H, Dowd JB, Kashyap R. Life expectancy changes since COVID-19. Nat Hum Behav 2022; 6(12):1649-1659.. YPLL is an indicator widely used to quantify the number of years of life that a population may lose as a result of premature death, considering their life expectancy. This indicator analyzes the magnitude and transcendence of deaths in terms of potential years not lived due to disease and injuries, as well as the social damage resulting from these deaths. The higher this indicator, the worse the condition of the population under analysis⁴4 Gardner JW, Sanborn JS. Years of Potential Life Lost (YPLL) - What Does it Measure? Epidemiology 1990; 1(4):322-329..

It is important to note that premature mortality is a preventable event and is therefore a reflection of the insufficiency of health policies. Understood as the expression of the social value of death that occurs in a potentially productive phase of life, mortality affects not only the individual and the group in which they are inserted, but also the community, as it is deprived of its economic and intellectual potential⁵5 Mascarello KC, Vieira ACBC, Freitas PSS, Mocelin HJS, Maciel ELN. Potential years of life lost by COVID-19 in the state of Espírito Santo and proportional mortality by age. J Bras Pneumol 2022; 48(1):e20210489..

Health research that considers race/color differences is highly significant to what was established by the World Health Organization (WHO)⁶6 Buss PM, Pellegrini Filho A. A saúde e seus determinantes sociais. Physis 2007; 7(1):77-93.

7 Carvalho AI. Determinantes sociais, econômicos e ambientais da saúde. In: Fundação Oswaldo Cruz. A saúde no Brasil em 2030: prospecção estratégica do sistema de saúde brasileiro: população e perfil sanitário. Rio de Janeiro: Fiocruz; 2013. p. 19-38.^-88 Chapman AR. The social determinants of health, health equity, and human rights. Health Human Rights 2010; 12(2):17-30. when classifying racism as one of the social determinants of the health-disease process and by the National Policy for Comprehensive Health in the Black Population⁹9 Brasil. Ministério da Saúde (MS). Portaria nº 992, de 13 de maio de 2009. Institui a Política Nacional de Saúde Integral da População Negra. Diário Oficial da União; 2009. which, in one of its specific objectives, encourages studies and research on racism and health as one of the ways to shed light on racial inequities and promote equity in health¹⁰10 Araújo EM, Costa MCN, Hogan VK, Mota ELA, Araújo TM, Oliveira NF. Diferenciais de raça/cor da pele em anos potenciais de vida perdidos por causas externas. Rev Saude Publica 2009; 43(3):405-412.. It is worth noting that, in the present study, race/color was analyzed from a historical¹¹11 Almeida S. Racismo Estrutural - Coleção Feminismos Plurais. 1ª ed. Coord.: Ribeiro D. São Paulo: Ed. Jandaíra; 2019. and intersectional sociopolitical perspective.

Although the relationship between race/color and health is an important marker of the lack of equity between population segments, the study of this issue is still incipient, and the simultaneous use of the variables of race/color and gender as units of analysis is even rarer¹²12 Krieger N, Fee E. Man-Made Medicine and Women's Health: The Biopolitics of Sex/Gender and Race/Ethnicity. In: Fee E, Krieger N, editors. Women's Health, Politics, and Power: Essays on Sex/Gender, Medicine, and Public Health. Amityville: Baywood Publishing Company, Inc; 1994. p. 1-359..

To overcome this gap, some approaches to health inequalities in contemporary society have sought to understand the structuring and dynamics of processes of oppression and discrimination. The theoretical and methodological perspective of intersectionality expands explanations through social markers of differences (gender, race/color, age, among others), understood as categories that overlap, but do not merge, without precedence or prominence between them in the constituent analyses of the social determinants of health. Intersectionality highlights the interconnection between the dimensions of social inequality. Therefore, groups with multiple vulnerabilities in relation to life experiences and opportunities must be considered in both the development of social policies¹³13 Caiola C, Docherty SL, Relf M, Barroso J. Using an Intersectional Approach to Study the Impact of Social Determinants of Health for African American Mothers Living With HIV. Advances Nurs Sci 2014; 37(4):287-298.

14 Hankivsky O, Christoffersen A. Intersectionality and the determinants of health: a Canadian perspective. Crit Public Health 2008; 18(3):271-283.^-1515 Luiz OC, Couto MT, Oliveira E, Separavich MA. Inequality in health, social determinants, and intersectionality: a systematic review/Desigualdade em saúde, determinantes sociais, e interseccionalidade: uma revisão sistemática. Braz J Health Rev 2020; 3(5):11827-11841. and the production of knowledge.

One study¹⁶16 Xu JJ, Chen JT, Belin TR, Brookmeyer RS, Suchard MA, Ramirez CM. Racial and Ethnic Disparities in Years of Potential Life Lost Attributable to COVID-19 in the United States: An Analysis of 45 States and the District of Columbia. Int J Environ Res Public Health 2021; 18(6):2921., conducted in the USA, estimated YPLL by states and race/color in the country, reporting great variability per unit studied in terms of the magnitude of racial/ethnic disparities, suggesting that they are most often driven by social determinants of health. From this perspective, the use of the YPLL indicator is important because it enables a measurement of social inequalities regarding deaths when comparing different population segments¹⁰10 Araújo EM, Costa MCN, Hogan VK, Mota ELA, Araújo TM, Oliveira NF. Diferenciais de raça/cor da pele em anos potenciais de vida perdidos por causas externas. Rev Saude Publica 2009; 43(3):405-412., since mortality from COVID-19 shows not only a very strong risk stratification by age and clinical factors, but also by socioeconomic factors¹⁷17 Ioannidis JPA. Global perspective of COVID-19 epidemiology for a full-cycle pandemic. Eur J Clin Invest 2020; 50(12):e13423..

In general, the most severe cases of COVID-19 occur in the elderly, due to the higher prevalence of comorbidities in this group¹⁸18 Liu K, Chen Y, Lin R, Han K. Clinical features of COVID-19 in elderly patients: A comparison with young and middle-aged patients. J Infection 2020; 80(6):e14-e18.^,1919 Yang J, Zheng Y, Gou X, Pu K, Chen Z, Guo Q, Ji R, Wang H, Wang Y, Zhou Y. Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis. Int J Infectious Dis 2020; 94:91-95.. Furthermore, deaths from COVID-19 represent a more substantial proportion than those reported from other diseases, such as H1N1²⁰20 Hanlon P, Chadwick F, Shah A, Wood R, Minton J, McCartney G, Fischbacher C, Mair FS, Husmeier D, Matthiopoulos J, McAllister DA. COVID-19 - exploring the implications of long-term condition type and extent of multimorbidity on years of life lost: a modelling study. Wellcome Open Res 2021; 5:75. influenza, even after adjusting for age and comorbidities²¹21 Salinas-Escudero G, Toledano-Toledano F, García-Peña C, Parra-Rodríguez L, Granados-García V, Carrillo-Vega MF. Disability-Adjusted Life Years for the COVID-19 Pandemic in the Mexican Population. Front Public Health 2021; 9:686700..

In the case of COVID-19, a low YPLL in terms of general mortality from this cause would be expected, as the natural history of COVID-19 predicts a higher proportion of deaths among the elderly with comorbidities, although young people and children are also highlighted in the profile of morbidity and mortality. However, studies have shown a higher incidence among people in socially vulnerable scenarios²²22 Santos RV, Bastos JL, Kaingang JD, Batista LE. Cabem recomendações para usos de "raça" nas publicações em saúde? Um enfático "sim", inclusive pelas implicações para as práticas antirracistas. Cad Saude Publica 2022; 38(3):e00021922.^,2323 Campos MR, Schramm JMA, Emmerick ICM, Rodrigues JM, Avelar FG, Pimentel TG. Carga de doença da COVID-19 e de suas complicações agudas e crônicas: reflexões sobre a mensuração (DALY) e perspectivas no Sistema Único de Saúde. Cad Saude Publica 2020; 36(11):e00148920..

Given the lack of scientific production that seeks, specifically, to evaluate YPLL according to ethnic-racial and gender groups from the viewpoint of shedding light on risk factors distributed unequally in the country, the present study aims to estimate YPLL due to COVID-19, according to sex, age group, and race/color in Brazil, from March 2020 to December 2021.

Methodology

This descriptive study characterized the deaths caused by COVID-19, in which the rates and ratios of YPLL standardized rates, using the direct method; the average number of years of potential life lost (ANYPLL); and the average age at death (AAD) were estimated and compared. Social markers of differences among gender, age, and race/color (black, brown, white, indigenous, yellow, and black) of residents in Brazil who died from COVID-19, in the period from 2020 to 2021, were considered. The black and brown populations were also evaluated together, called the black category.

The 628,689 deaths from COVID-19 were extracted from the Mortality Information System (SIM) database²⁴24 Brasil. Ministério da Saúde (MS). DATASUS. SRAG 2021 e 2022 - Banco de Dados de Síndrome Respiratória Aguda Grave - incluindo dados da COVID-19 [Internet]. 2021 [acessado 2022 set 19]. Disponível em: https://bit.ly/3tKOgEa
https://bit.ly/3tKOgEa... of the Department of Informatics of the Unified Health System (DATASUS). Population data²⁵25 Brasil. Ministério da Saúde (MS). DATASUS. População residente. Projeção da População das Unidades da Federação por sexo e grupos de idade: 2000-2030 [Internet]. 2022 [acessado 2022 set 19]. Disponível em: https://datasus.saude.gov.br/populacao-residente.
https://datasus.saude.gov.br/populacao-r... were obtained through the Brazilian Institute of Geography and Statistics (IBGE), also available on DATASUS. When simultaneously considering the notification of cases according to sex, age group, and race/color, a loss of 2.7% of data referring to deaths was observed, totaling 611,705 cases. However, the SIM database showed good consistency, given the 97.3% comprehensiveness of the variables selected for this study.

Deaths caused by COVID-19 were classified according to the International Classification of Diseases (ICD-10) as B34.2 - coronavirus infection of unspecified location - recommended by the WHO²⁶26 Brasil. Ministério da Saúde (MS). Guia de Vigilância em Saúde. Volume único 9 [Internet]. 3a ed. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/guia_vigilancia_saude_3ed.pdf.
https://bvsms.saude.gov.br/bvs/publicaco... . The criteria adopted are based on the identification codes recommended by the Ministry of Health (2020): i) U07.1 - COVID-19, identified virus; ii) U07.2 - COVID-19, unidentified virus, clinical-epidemiological; iii) U04.9 - SARS; SRAG; iv) B34.2 - coronavirus infection of unspecified location. The first two (U07.1 and U07.2) were defined by the WHO and were adopted as official markers for the pandemic in Brazil. Code U0.49 is common to designate suspected cases (which require subsequent confirmation), and B34.2 is still the most used code to identify deaths from COVID-19²⁶26 Brasil. Ministério da Saúde (MS). Guia de Vigilância em Saúde. Volume único 9 [Internet]. 3a ed. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/guia_vigilancia_saude_3ed.pdf.
https://bvsms.saude.gov.br/bvs/publicaco... .

To characterize COVID-19 mortality in Brazil, during the period studied, the following variables were analyzed: sex, age group, race/color, marital status, education, place of occurrence and occupation.

To estimate YPLL, the same variables were used. The gender variable was classified as male and female. Age was considered in age groups with 5-year intervals, ranging from 0 to 80 years and over. The race/color analyzed was that recorded on the death certificate, while for the population, census data based on self-reporting was used.

In the data analysis, the following indicators were used: absolute number and average number of YPLL; percentage distribution of YPLL; age at which, on average, deaths occurred; YPLL rate per 100,000 inhabitants, and the rate ratio, taking the white female population as a reference. For age-standardized estimates, the direct method was adopted and, as a standard, the World Standard Population²⁷27 Ahmad OB, Boschi-Pinto C, Lopez Christopher AD, Murray JL, Lozano R, Inoue M. Age Standardization of Rates: A new WHO standard. Geneva: WHO; 2001.. The population projection calculated by IBGE for 2020 corresponds to the total population of Brazil without detailed segmentations by race/color. For this reason, the projection of the age groups, by sex and race, of the Brazilian population in 2020 was made based on the proportions observed in the most recent Demographic Census²⁵25 Brasil. Ministério da Saúde (MS). DATASUS. População residente. Projeção da População das Unidades da Federação por sexo e grupos de idade: 2000-2030 [Internet]. 2022 [acessado 2022 set 19]. Disponível em: https://datasus.saude.gov.br/populacao-residente.
https://datasus.saude.gov.br/populacao-r... . Therefore, the percentages of the white, black, yellow, brown, and indigenous population in each of the 2010 age groups were used to estimate these same groups within the 2020 population projection carried out by IBGE.

The total YPLL value was obtained by summing the YPLL in each age group, sex, and race/color, applying the formula: YPLL=Σa _i d _i , where: a _i represents the difference between the limit age and the midpoint of each group age, assuming uniform distribution of deaths occurring in each group; d _i is equal to the number of deaths due to a specific cause in this same age group (Equation 1)²⁸28 Romeder JM, Mcwhinnie JR. Potential Years of Life Lost Between Ages 1 and 70: An Indicator of Premature Mortality for Health Planning. Int J Epidemiol 1977; 6(2):143-151..

To calculate the average number of YPLL, an expression of the number of years that, on average, each death caused by COVID-19 took away from a person (years not lived), the total number of YPLL was divided by the number of deaths caused by COVID-19 (Equation 2).

The expected YPLL was defined as the ratio between the total YPLL and the standard population multiplied by the evaluated population (Equation 3).

The standardized YPLL rate is calculated based on the ratio of the expected YPLL to the standard population times 100,000 (Equation 4). The rates per 100,000 inhabitants corresponded to the YPLL accumulated between 2020 and 2021.

The standardized rate ratio was calculated considering the standardized YPLL rate by race/color category and the reference standardized YPLL rate (white race/color category) (Equation 5).

Zero (0) and 87.9 years were stipulated, respectively, as lower and upper limits to calculate the YPLL. The upper limit of 87.9 years was taken as a parameter for life expectancy based on the projections observed in the studies by Zhang and Rasali²⁹29 Zhang LR, Rasali D. Life expectancy ranking of Canadians among the populations in selected OECD countries and its disparities among British Columbians. Arch Public Health 2015; 73(1):17. and the Global Burden of Diseases (GBD)³⁰30 Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease Study 2017 [Internet]. 2018 [cited 2022 ago 19]. Available from: https://www.healthdata.org/policy-report/findings-global-burden-disease-study-2017.
https://www.healthdata.org/policy-report... .

The age at which, on average, death occurred was obtained by adding the ages at which deaths occurred, divided by the total number of deaths in each age group, according to sex and race/color⁶6 Buss PM, Pellegrini Filho A. A saúde e seus determinantes sociais. Physis 2007; 7(1):77-93.^,2828 Romeder JM, Mcwhinnie JR. Potential Years of Life Lost Between Ages 1 and 70: An Indicator of Premature Mortality for Health Planning. Int J Epidemiol 1977; 6(2):143-151.. For a better understanding of the calculations carried out in the research, consider the following equations:

The number of deaths caused by COVID-19 and the standardized YPLL rates were graphically represented by tables and age pyramids. To store the data and execute the statistical procedures of this research, the R³¹31 R Core Team. R: A language and environment for statistical computing [Internet]. 2022 [cited 2022 ago 19]. Available from: https://www.R-project.org.
https://www.R-project.org... computational and statistical language and the Calc spreadsheet were used.

Given the scope of the study that used secondary data in the public domain, in accordance with Resolution No. 466/12 of the CNPb and Resolution No. 510/2016 of the Brazilian National Council for Ethics in Research (CNPb), the present study did not require approval from a Research Ethics Committee.

Results

Mortality due to COVID-19 in Brazil

In the period spanning January 2020 to December 2021, there were 628,689 deaths caused COVID-19 in Brazil. Of these, 275,970 (43.89%) occurred among women and 352,654 (56.09%) among men. The average age of the male population (65.33±15.61) who died from COVID-19 in Brazil was lower than the average age observed among the female population (67.66±16.02). When considering deaths according to race/color, it was observed that the highest average age of death occurred in the yellow population (69.88±15.00), followed by the white population (67.43±15.69). The lowest average age of death was observed among the brown population (64.90±15.98), followed by the black population (64.96±15.86) and indigenous people (64.92±21.26), with a lower average indicating an earlier occurrence of death.

The yellow population showed less variability concerning the average age of death (CV=21.47%), while the indigenous population showed greater variability concerning the average age of death (CV=32.75%), which represents a greater variation of the occurrence of deaths between age groups in this population (Figure 1).

The highest proportion of deaths caused by COVID-19 occurred among married people (44.25%), followed by widows (19.12%) and single people (17.66%). Regarding the place of death, those occurring in a hospital environment predominated (91.25%) (Table 1). The average underreporting of the occupation variable was 15.90%. The occupational categories of retired person (24.30%) and housewife (14.30%) were the most commonly reported (data not shown).

Regarding the absolute number of deaths, for which there was a simultaneous recording of the variables of age group, sex, and race/color, a total of 611,705 deaths were observed. When representing these deaths graphically, an inverted age pyramid pattern was evident with a greater magnitude of deaths among people aged 60 and over and male (Figure 1).

The results observed in the age pyramids (Figure 1) are represented proportionally. In the age groups from 0 to 59 years of age, a higher proportion of deaths was found among black people (34.46%) and indigenous people (33.13%). In the age groups of 60 years and over, the yellow (77.96%) and white (70.82%) populations showed the highest proportions. A higher proportion of deaths was found in the 0 to 19 years age group among indigenous people (4.61%), whereas in the 0 to 4 years age group, the proportion was 3.33%, when compared to the other categories (Table 2).

Years of Potential Life Lost (YPLL) due to COVID-19 in Brazil

In the first two years of the pandemic, 13,776,969.5 potential years of life were lost, with emphasis on the white population, which totaled 7,276,666.8 potential years of life (52.8%). The percentage distribution of age-standardized YPLL, according to age group and race/color, shows that there was a greater proportion of YPLL in the age groups from 0 to 59 years in the black (58.92%) and indigenous (63.35%) populations, while in the age groups of 60 years and over, a greater YPLL was observed in the white (45.89%) and yellow (53.22%) populations (Table 3).

With regard to YPLL rates per 100,000 inhabitants, according to sex, age group, and race/color, an inverted pyramid pattern was also observed, with higher rates in the older population, regardless of sex and race/color. However, the indigenous population presented the highest rates in the oldest and youngest age groups (Figure 2).

In the period analyzed in this study, the average age at which deaths from COVID-19 occurred was 65.4 years, which was higher in the yellow population (68.5 years). The average ANYPLL in the general population was 22.5 years, with the highest record of this indicator appearing in the indigenous population (24.3) - data not shown.

The analysis by sex and race/color revealed that, proportionally, men showed the highest YPLL. By contrast, with the exception of indigenous race/color, women recorded the highest average age of death and the lowest rates of YPLL. Taking the YPLL rates of the white female population as a reference, the highest YPLL rate ratios were observed among white men (1.63), black men (1.61), brown men (1.60), and black and brown men (1.59); that is, all of these categories showed approximate rate ratios of above 60.0% (Table 4). It is important to highlight the fact that black women present rates 12.0% higher than white women.

Furthermore, when observing the rate ratio, it is possible to state that yellow women had a lower YPLL due to COVID-19, considering that the rate ratio (0.39) denotes a reduction of 61.0% (Table 4).

Discussion

The analysis of YPLL due to COVID-19, according to sex, age group, and race/color, showed a large YPLL for the Brazilian population. The white population lost 6.50% more potential years of life when compared to the black population; however, this result may be due to the greater longevity of the white population and the underreporting of the variables selected for this research.

Other aspects of inequalities in mortality due to COVID-19 observed in our findings refer to the higher proportion of deaths from this cause among black and indigenous people aged 0 to 59 years. Indigenous people in the age group of 0 to 4 years had a higher proportion of deaths (3.33%) when compared to other race/color categories, while in the yellow and white population, higher proportions of deaths were observed in the groups over 60 years of age. Furthermore, black and indigenous men and women showed the highest YPLL averages. All of these aspects indicate earlier mortality in vulnerable groups.

In the Brazilian context, early mortality and YPLL due to COVID-19 unequally affect groups according to race/color and gender. The most significant impact of premature deaths resulting from the pandemic on black and indigenous populations is due to the combination of structural racism, social inequities, and weaknesses in health systems.

To date, there are few studies that address YPLL due to COVID-19 around the world. One study³²32 Castro APB, Moreira MF, Bermejo PHS, Rodrigues W, Prata DN. Mortality and Years of Potential Life Lost Due to COVID-19 in Brazil. Int J Environ Res Public Health 2021; 18(14):7626. on mortality and YPLL due to COVID-19 in Brazil, for the period from February 16, 2020, to January 1, 2021, showed that 47.90% of deaths occurred in the population under 60 years of age, a high proportion that suggests, as in our study, the prematurity of deaths. It is important to highlight that this study extended the period of analysis in relation to the one mentioned above and evaluated, to date, the two years that concentrated the highest number of cases and deaths due to the pandemic in Brazil.

In this study, the average age at which deaths caused by COVID-19 occurred was 65.4 years, and the average ANYPLL in the general population was 22.5 years. In an analysis of YPLL covering 17 countries, considering the period from January to August 2020, it was observed that, in general, men had a higher YPLL rate and greater loss of potential years of life than women, who, on average, died two years younger. In most countries, the highest proportion of YPLL was observed in people over 60 years of age³³33 Ugarte MP, Achilleos S, Quattrocchi A, Gabel J, Kolokotroni O, Constantinou C, Nicolaou N, Rodriguez-Llanes JM, Huang Q, Verstiuk O, Pidmurniak N, Tao JW, Burström B, Klepac P, Erzen I, Chong M, Barron M, Hagen TP, Kalmatayeva Z, Davletov K, Zucker I, Kaufman Z, Kereselidze M, Kandelaki L, le Meur N, Goldsmith L, Critchley JA, Pinilla MA, Jaramillo GI, Teixeira D, Goméz LF, Lobato J, Araújo C, Cuthbertson J, Bennett CM, Polemitis A, Charalambous A, Demetriou CA. Premature mortality attributable to COVID-19: potential years of life lost in 17 countries around the world, January-August 2020. BMC Public Health 2022; 22(1):54..

The greatest loss of YPLL in the age groups of 60 years and over occurred in the white and yellow populations. Although unadjusted mortality from COVID-19 is higher in the white population, it must be considered that this group has a higher proportion of elderly people, due to greater longevity expressed by better socioeconomic conditions, and possibly due to the privileges arising from their racial affiliation, hence the need for age-standardized data in the analysis³⁴34 Nisida VC, Cavalcante LA. Racismo e impactos da COVID-19 na população da cidade de São Paulo. RBDU 2020; 6(10):151-174.. Because they are younger, it was expected that the black and indigenous populations would die in smaller numbers. However, standardization revealed that there was a greater chance of death among these populations.

In this sense, the oldest ages at which, on average, deaths from COVID-19 occurred were observed in yellow (69.4) and white (67.5) women; by contrast, the lowest were found in indigenous women (63.2) and black men (63.5). Yellow and white women died at an older age than did indigenous women and black men. These two categories are similar in terms of social and health indicators, which could impact the difference in the average age of death due to COVID-19.

The highest YPLL rates were observed in white men (7,253.9), followed by black men (7,182.3). The difference in YPLL rates between white and black men was close to 1.0%. It is possible that, among the 2.7% of underreporting of the race/color variable, there was an even greater underreporting of the black race/color. The lowest YPLL rates were observed among women (1,714.8) and yellow men (3,712.1), a predicted finding given the living conditions of these populations.

In the United States, mortality from COVID-19 has increased the contrasting life expectancy between blacks and whites. In 2020, it was observed that all groups considered minorities suffered significant losses in life expectancy and an increase in YPLL. Among black men, mortality under the age of 60 corresponded to 31.9% of YPLL due to COVID-19, as compared to 18.4% for white men. Among women, the proportions represented 14.7% for white women and 27.2% for black women³⁵35 Aburto JM, Tilstra AM, Floridi G, Dowd JB. Significant impacts of the COVID-19 pandemic on race/ethnic differences in US mortality. PNAS 2022; 119(35):e2205813119.. The panorama of racial inequality in mortality in the United States could be as deadly as COVID-19³⁶36 Wrigley-Field E. US racial inequality may be as deadly as COVID-19. PNAS 2020; 117(36):21854-21856.. Structural racism expressed in economic suppression, racial residential segregation, and inequalities in health care resulted in worse health outcomes for the black population, producing a succession of negative economic effects upon future generations³⁷37 Gillispie-Bell V. The Contrast of Color. Obstetr Gynecol 2021; 137(2):220-224..

In Brazil, the scale of inequality in mortality among marginalized groups before and during the pandemic is similarly shocking. Historical inequalities are exacerbated during a public health crisis, and the COVID-19 pandemic deepened social inequalities¹⁷17 Ioannidis JPA. Global perspective of COVID-19 epidemiology for a full-cycle pandemic. Eur J Clin Invest 2020; 50(12):e13423.. Therefore, health and social protection policies must minimize the direct and indirect impacts of a pandemic and contain long-term losses³⁸38 Pifarré i Arolas H, Acosta E, López-Casasnovas G, Lo A, Nicodemo C, Riffe T, Myrskylä M. Years of life lost to COVID-19 in 81 countries. Sci Rep 2021; 11(1):3504.. Specific policies are criticized, but they are highly effective in tackling social inequities.

The indigenous population presented data with greater variability concerning the average age of death. The distribution of the occurrence of deaths in different age groups in the indigenous population is justified by the greater relative variability of age, which denotes inequality in the occurrence of deaths according to age group, as deaths due to COVID-19 are expected to occur in more advanced age groups.

The high proportion of deaths in the 0 to 19 age group among indigenous people, the highest record of YPLL in this population and years not lived by women of this ethnic group reveal the socioeconomic and environmental vulnerability resulting from constant political attacks on the rights of this population. Indigenous territories are also marked by the phenomenon of exclusionary urbanization, which translates into peripheralization, poverty, violence, racism, and a general lack of sanitation, as well as by diminished and difficult access to health services, whose delay in diagnosis and treatment increases the probability of death due to COVID-19. In effect, the pandemic represents a threat of genocide against indigenous peoples³⁹39 Cunha AA, Nazima MTST, Castilho-Martins EA. Covid-19 among the Brazilian Amazon indigenous people: factors associated with death. Saude Soc 2022; 31(2):e210368en.

40 Rodrigues D, Albertoni L, Mendonça SBM. Antes sós do que mal acompanhados: contato e contágio com povos indígenas isolados e de recente contato no Brasil e desafios para sua proteção e assistência à saúde. Saude Soc 2020; 29(3):e200348.^-4141 Silva MG, Pereira PMB, Portela WF, Daros GC, Barbosa CRA, Vanassi BM, Parma GOC, Bitencourt RM, Iser BPM. Epidemiology of COVID-19 Among Indigenous Populations in Brazil. J Racial Ethn Health Disparities 2022; 9(3):960-966..

Disparities in COVID-19 mortality data in Brazil are acute and exacerbated by social inequities. Many early deaths may have occurred due to the negligence of the federal government in force at the time; poor national coordination of the health system; denial of science; disrespect for the guidelines of national and international organizations; delay in negotiation, acquisition, and insufficient distribution of vaccines; fragility in the production and dissemination of data from information systems; distribution of technologies with no scientific basis; the lack of attention to traditional territories, peoples, and communities; and limited investment in technologies and measures to overcome the health crisis⁴²42 Silva SA. Pandemia de COVID-19 no Brasil: o acesso e a qualidade dos serviços de saúde como determinante social. Rev Contexto Geogr 2021; 6(11):56-76..

Study limitations

This study was conditioned by the availability and quality of data and the process of coding deaths attributable to COVID-19. The main limitation of the present study corresponds to the comprehensiveness of the data. While variables such as race/color, age, and sex showed excellent comprehensiveness (above 90%), variables such as education and professional categories showed a comprehensiveness of below 90% (Table 1). There were approximately 16,984 deaths that did not have sufficient data regarding the eligible variables to carry out this study. In this sense, these results may be underestimated.

Final considerations

In Brazil, 628,689 deaths due to COVID-19 were recorded in Brazil between March 2020 and December 2021, with a higher proportion of deaths among black and indigenous people. An average age at which death occurred was around 65.4 years, which corresponded to an average of 22.5 years not lived in the general population.

Considering race/color, a higher average ANYPLL was noted among indigenous and black people. Men showed the highest YPLL Women recorded the highest average age at death (ADD), with the exception of indigenous women. White, brown, and black men had higher YPLL rates than did white women. The lowest average age of death was observed among mixed-race people, followed by the black and indigenous categories.

The white population showed a low percentage of YPLL when compared to the black population; however, this result may be due to an underreporting of the variables selected for this research.

The fact that the yellow and white populations had a higher proportion of deaths in age groups over 60 years of age - which is to be expected, unlike what was observed in the black and indigenous populations - reveals a certain aspect of inequality in the distribution of deaths due to COVID-19. This was corroborated by the higher average ANYPLL among the black and indigenous populations.

These findings point to the need for political interventions on the social determinants of health, so that, during a public health crisis, coping strategies and impacts on early mortality in marginalized groups can be mitigated.

An expanded assessment of the health impact of COVID-19 must consider the YPLL and the disability burden associated with the disease. Social protection policies linked to preventive and emergency health policies make it possible to mitigate the context of socioeconomic inequity and early mortality. It is recommended that research be developed that aims to establish a relationship between inequities and ethnic-racial and gender aspects in the context of the pandemic in developing countries.

References

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