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The year of COVID-19 vaccines was still a deadly one in Minnesota, with deaths from all causes in 2021 more than 15% higher than expected — mostly because of the pandemic and drug abuse.

Minnesota should have tallied 44,000 deaths in 2021 based on previous years, but the state has surpassed 51,000 reported so far and could exceed its record set in 2020 after all death certificates are recorded.

More than 5,000 COVID-19 deaths in each of the two years caused most of the excess, according to a Star Tribune analysis of available death records.

"Thank God some people survive, but too many of them don't," said Stephanie Vernier of Fridley, who lost her youngest son, Ronald, and a brother to COVID-19 in December.

The excess numbers are proof the pandemic created additional harm in Minnesota and didn't just result in deaths that otherwise would have happened from unrelated illnesses and injuries.

Further proof is that all excess deaths in the second year of the pandemic were among people younger than age 85.

In 2020, the oldest Minnesotans made up 45% of the state's COVID deaths, but that dropped to 28% last year, partly because fewer members of that generation were still alive and at risk. Total deaths among those 85 and older in 2021 were exactly as expected.

"The population that is left in 2021 that survived is a different population that is missing some of the most vulnerable people," said Elizabeth Wrigley-Field, a University of Minnesota sociologist who has studied pandemic mortality trends.

Vaccinations played a role, protecting seniors who were the earliest recipients when the shots became available in early 2021. Vaccination rates were lower among Minnesotans younger than 65, and their COVID-19 death numbers surged from 623 in the first year of the pandemic to at least 1,285 last year.

"Even in a year where you have a ton of pretty good treatments, prevention, vaccines, you still see a ton of death — and not just among really sick people in long-term care who have no way of controlling exposure," said JP Leider, a U public health researcher who has studied COVID-19 inequities. "You're seeing it in much younger people and that's very correlated with vaccination status."

Ronald Vernier was a warm-hearted medical assistant with an unmistakable laugh who worked at a Maple Grove clinic. But he mistrusted the COVID-19 vaccine so much that he was willing to lose his job if it was required, his mother said. Several relatives got coronavirus infections when they gathered in November to watch a televised fight, but he was the only one hospitalized.

"Ron was watching what he ate, he was working out," his mother said. "That's why, when he first got sick, we weren't that concerned. We were like, 'It'll go away,' but it didn't."

X-rays at Mercy Hospital in Coon Rapids were bright white in areas that should have been dark if his lungs were healthy. Vernier's breathing worsened, and he was placed on a ventilator before he died on Dec. 9 at age 42.

Excess deaths were more common among minority members, who have higher rates of chronic health problems such as diabetes and work in more front-line and customer service jobs that increase their COVID-19 risk. Deaths from all causes were 11% higher than expected last year among white Minnesotans but 81% higher among Hispanic residents and 45 to 55% higher among racial minorities.

Pao Yang and his wife, Kia Moua, were anticipating life beyond the pandemic, getting passports for a trip to Paris. But Moua, a paralegal with a master's degree, contracted COVID-19 and died at age 33 on Oct. 23 after a monthlong battle with the disease. The New Hope woman, who was waiting for more safety information before getting vaccinated, is survived by three children.

"My life is at a standstill," Yang said. "I'm just a zombie at the moment and still doing daddy duty. I'm just trying to do the best I can."

About 10% of deaths last year in Minnesota, Iowa and Wisconsin were caused by COVID-19, according to federal data. The rates were above 17% in Arizona, Nevada and Texas. Arizona had the nation's highest rate in 2021 of excess death from all causes, 40% above expectations.

Minnesota's lower rate could suggest underreporting of COVID-19 as a cause, but Leider said that was more likely a problem in 2020 when more deaths were reported in homes. Causes are murkier when deaths occur outside hospitals or care facilities, he said.

Suicides rose by 4% in 2021, accounting for little of the excess but underscoring concerns that the pandemic exacerbated depression and anxiety.

Minnesota recorded more than 1,000 deaths from unintentional opioid overdoses in a year for the first time, and that caused 9% of the state's excess in 2021. Overdose deaths had leveled off in 2018 and 2019 after efforts to reduce prescriptions of addictive painkillers, but they surged after that.

The explosion of synthetic opioids such as fentanyl might have increased deaths anyway — especially when they are mixed with other illicit drugs — but the pandemic added pressures, said Alicia Haugh, a spokeswoman for the Steve Rummler HOPE Network, an advocacy group seeking to reduce opioid abuse.

"The pandemic ushered in a lot of stress and isolation, uncertainty and loss. ... Loss of jobs, loss of the norm, and these are all factors," she said.

Gerald Green will never forget the panic on Nov. 24 as he called and texted in search of his daughter — who was expected to come home for Thanksgiving — and the anguish when police arrived at his door in Elk Mound, Wis. The 34-year-old was among three who died at a house party in Fridley after they ingested a white powder that a friend found at a bar. It was cocaine laced with lethal levels of fentanyl.

Many efforts to reduce overdoses are targeted at regular users, including test strips that identify fentanyl in substances, but first-time users and curious novices like Green's daughter remain vulnerable, he said. "The end of a beautiful life, cut short by a fatal mistake in judgment."

The pandemic might have exacerbated the opioid problem in other ways, said Dr. Ruth Lynfield, state epidemiologist. Lingering lung damage from COVID-19 might have produced "catastrophic results" in people who otherwise might have been strong enough to survive overdoses, she said.

Deaths from Alzheimer's disease declined 10% in Minnesota in 2021, reflecting the loss of seniors to COVID-19 a year earlier. However, deaths from diabetes increased 20%, while those linked to hypertension and hypertensive liver disease increased 42%. Deaths from chronic liver disease increased 36%.

Undiagnosed infections might have played a role in those excess deaths, given how often those conditions were identified in known COVID-19 fatalities. Obesity, hypertension and diabetes were underlying risks or secondary causes of 35% of COVID-19 deaths in Minnesota, according to the Star Tribune's analysis.

People avoided care for serious health problems because they feared going to hospitals or lost jobs with health benefits during the pandemic, said Dr. Hannah Lichtsinn, an internal medicine specialist for Hennepin Healthcare. That could have increased the number of non-COVID deaths.

Other people sought emergency care but didn't receive it right away last fall and winter when hospitals were "overflowing" with COVID-19 patients, she added. "We know that people did not get lifesaving care that they needed in the timeframe that could have saved their lives."

Minnesota could see fewer deaths in coming years because it lost so many people in 2021, but a decline is unlikely in 2022 because of the January omicron wave, said Dr. Jack O'Horo, a Mayo Clinic infectious disease expert. "That was quite a high peak in disease activity."

Yang feels guilty he didn't persuade his wife to get vaccinated. Vernier got vaccinated despite her own reservations after her son and brother died.

"After going through that," she said, "it kind of changes your mind."