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President Joe Biden may have declared the coronavirus pandemic "over," but from John Felton's view as the Yellowstone County health officer in Billings, Mont., it's not over, just different.

Now, more than ever, it is a plague of the elderly.

In October, Felton's team logged six deaths due to the virus, many of them among vaccinated people. Their ages: 80s, 60s, 70s, 80s, 90s, 90s. They included Betty Witzel, 88, described by her family as a tomboy who carried snakes in her pocket as a child and grew up to be a teacher, mother of four, grandmother of nine and great-grandmother of five. And there was Nadine Alice Stark, 85, a ranch owner who planted sugar beets and corn.

Yellowstone County made the decision early in the crisis to recognize each death individually, and Felton said that is as important as ever to acknowledge the unrelenting toll on a still-vulnerable older generation, while most everyone else has moved on.

"I think about someone's grandfather — the plays they wouldn't watch, the games on the football field they wouldn't see," he said.

More than 300 people are still dying each day on average from COVID-19, most of them 65 or older, according to data from the Centers for Disease Control and Prevention. While that's much lower than the 2,000 daily toll at the peak of the delta wave, it is still roughly two to three times the rate at which people die of the flu — renewing debate about what is an "acceptable loss."

And while older Americans have consistently been the worst hit during the crisis, as evident in the scores of early nursing home deaths, that trend has become more pronounced. Today, nearly 9 in 10 COVID deaths are in people 65 or older — the highest rate ever, according to a Washington Post analysis of CDC data.

Some epidemiologists and demographers predict the trend of older, sicker and poorer people dying at disproportionate rates will continue, raising hard questions about the trade-offs Americans are making in pursuit of normalcy — and at whose expense. The situation mirrors the way some other infectious diseases, such as malaria and polio, rage in the developing world while they are largely ignored elsewhere.

S. Matthew Liao, a professor of bioethics, philosophy and public health at New York University, argued that it is possible to keep the economy open while still aggressively pursuing a national booster campaign and requiring masks in health-care settings and nursing homes, for example. But U.S. leaders have chosen not to do so, he said. That worries him.

"There's a bit of ageism, so to speak, attached to it," he said, adding, "People, even if they are older, they still have as much claim to live as me."

In an open letter published Oct. 7 in the BMJ, formerly the British Medicine Journal, Gregg Gonsalves, an associate professor at the Yale School of Public Health, and about a dozen other experts emphasized that "pandemics do not end with a flip of the switch."

"Despite the widespread belief that the pandemic is over, death and disruption continue," they wrote.

CDC Director Rochelle Walensky and other officials have justified their pandemic reset by emphasizing that Americans have more tools to fight the coronavirus than they did a year or two ago. This includes not only vaccines, booster shots and rapid tests, but antiviral pills that can be taken at home and have been shown to greatly reduce severe illness and death if taken early.

"We can now prevent almost all of the deaths that are happening," she said at a news briefing this month.

However, Walensky acknowledged that deaths among the elderly, especially those with multiple chronic conditions, is "a real challenge."

"An additional infection," she said, referring to COVID-19, "is something that may turn something they are able to stably live with to something they are not."

— — —

Epidemiologists tend to divide the pandemic into three distinct periods. In the first year, from March 2020 to March 2021, the United States experienced about 500,000 deaths. The toll was about the same the following year. In the third year, the nation is on track to lower that count significantly, to 150,000 to 175,000 deaths — barring a curveball in the form of a new variant.

That means that coronavirus is likely to rank third as a cause of death this year. By comparison, heart disease and cancer kill roughly 600,000 people each year; accidents, 170,000; stroke, 150,000; and Alzheimer's, 120,000. Flu, in contrast, kills 12,000 to 52,000.

A recent CDC report on COVID-19 mortality contained more good news — most notably, a rapid drop in deaths beginning in March that led to a relatively stable period from April through September when there were 2,000 to 4,500 deaths weekly.

But the reduced death toll has not been experienced equally among all age groups.

Unlike flu, which impacts both the very young and the very old, the coronavirus appears to put mostly older people at higher risk of severe disease and death. The proportion of deaths among those 65 or older has fluctuated from eight out of 10 in the first few months of the pandemic, to a low of six out of 10 when the delta wave struck in the summer of 2021, to a high of nine out of 10 today.

Last month, people 85 and older represented 41.4% of deaths, those 75 to 84 were 30% of deaths, and those 65 to 74 were 17.5% of deaths, according to a Post analysis. All told, the 65-plus age group accounted for nearly 90 percent of COVID deaths in the United States despite being only 16 percent of the population.

The vulnerability of older people to viruses is neither surprising, nor new. The more we age, the more we accumulate scars from previous illness and chronic conditions that put us at higher risk of severe illness.

When it comes to the coronavirus, though, deaths in Americans over 65 fell dramatically after the arrival of the original series of vaccines since seniors were the most likely to get them. But booster rates for older Americans are now lagging: According to the CDC, 98% of those ages 65 to 74 and 96% of people 75 and over completed an initial two-shot course. Those rates fall to 22% and 25% respectively for the new omicron-specific booster.

To minimize further loss of life ahead of a feared winter surge, the White House announced Tuesday that it was launching a six-week push to increase booster uptake in seniors and other groups that have been disproportionately affected.

"The final message I give you from this podium is that please, for your own safety, for that of your family, get an updated COVID-19 shot as soon as you're eligible, to protect yourself, your family and your community," Anthony S. Fauci, the president's chief medical adviser, said during the briefing, billed as his last before he retires next month.

— — —

The issue of age and the pandemic has been a source of tension throughout the pandemic.

When hospitals were hit with a crush of patients in the spring of 2020, some of the debates about allocating scarce resources centered on age. In documents drafted by some medical institutions, "stage of life," a proxy for age, was sometimes recommended to be used as a tiebreaker in decisions about who should get a ventilator or a bed.

A number of experts, including Liao, expressed discomfort with such rankings. "I really disagree with that view," he said. "You can imagine a 70-year-old who can do everything — can enjoy friendship, read books and go to movies."

Jo Rowland, parish nurse at the Harvest Church in Billings whose job includes supporting congregation members and their families through COVID illness and death, said society failed many of its elderly in another way, too: through safety protocols at the beginning of the pandemic that left them to die alone.

As more continue to fall victim to the virus, she said, we need to be more thoughtful about how to celebrate their lives and treat their deaths with dignity. "It's a different type of grief losing an older person," she said.

While some fault COVID-19 policies for not doing enough to protect the elderly, others criticize age-based policies implemented elsewhere. In the United Kingdom, for example, a matrix of recommendations based on age left some seniors feeling they were being discriminated against. Even as stores and restaurants began to open in the summer of 2020, the National Health Service still advised people 70 and older to stay home or "shield." In Colombia, the government sought to protect older people by closing centers that offered activities for them through August 2020. The policies became controversial for restricting freedom of movement.

Elfriede Derrer-Merk, a geriatric nurse from the University of Liverpool, and others wrote in a journal article in August that many older people felt angry and frustrated that their individuality was ignored.

The "undifferentiated way in which especially the role of age as a risk factor was discussed, and the inclusion of all people above the age of 65 into one homogeneous risk group, often neglected … the diversity of older people and their characteristics and thus drew criticism for fueling ageism in society," the authors wrote.

— — —

Tara Swanigan's father was in the first wave of deaths that occurred in 2020.

Charles Krebbs had celebrated his 75th birthday shortly before he was infected in July. He had retired from his job as an appraiser in Phoenix and was spending his time reading, gardening, picking up his grandson from school and accompanying him to his football games. He was strong and extraordinarily healthy, Swanigan recalled, but the virus nonetheless ravaged his lungs and he had to be put on a ventilator. He died that August.

Swanigan said she was heartened to hear about Biden's campaign to encourage older Americans to get booster shots. But she and other members of Marked by COVID, a nonprofit founded by two women who lost parents to the virus, advocate for more protections for people who are vulnerable, such as additional coronavirus testing. She continues to be shocked by how callous some people have been when she has talked about her father's death. "Well, your dad was super old," she recalled one man telling her on social media.

"For seniors and the immunocompromised, it's almost like we're saying, 'You don't matter. We'd rather just not be inconvenienced,'" she said.

Masks are a particular pain point.

"I was hugely disappointed when they took away the mask mandates for airplanes and other public transportation," she said.

Given the minimal disruption to daily life from face coverings, and their major impact on curbing transmission, according to studies, she does not understand why public health leaders have stopped promoting their use.

Even one of the most recognizable seniors during the pandemic, Fauci, the National Institutes of Health scientist who is 81, no longer wears a face covering in many public appearances. In pictures from 2020, Fauci was always seen with a mask. Even when he threw the ceremonial first pitch that year on MLB Opening Day between the New York Yankees and the Washington Nationals, and was outdoors and 60 feet away from another human being, he was masked.

But last month, when the infectious-disease doctor accompanied TV host Stephen Colbert to a Walgreens in New York City to get a booster shot, neither wore a face covering.

Fauci, through his office, declined to comment on that decision. But in a White House briefing on Tuesday, he talked about face coverings as just one of "multiple interventions and multiple actions" people can take to protect themselves, saying each individual should evaluate their own risks, as well as those of the people around them.

Given the scripted nature of such photo opportunities, the decision to forgo masks horrified Andrew Noymer, a public health professor at the University of California at Irvine. "The message is 'don't bother masking,'" he said in an interview. "We have given up, and the fact we've given up means we don't care about a certain amount of deaths."

Noymer, who studies COVID-19 mortality, argued that the notion that we can prevent almost all deaths given the pullback of mitigation policies is disingenuous.

"I don't think they are being totally candid" about the number of deaths the country will face, he said of U.S. officials. "I think it is bleak, and I am trying to steel myself for the winter to come."

The Washington Post's Fenit Nirappil contributed to this report.

previous coverage

• COVID is no longer mainly a pandemic of the unvaccinated. Here’s why.
• California’s ‘tripledemic’ of viruses is on the rise. Here’s how to care for a sick loved one

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