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How many people have died so far from the COVID-19 pandemic? This is actually a challenging question to answer, and there are several different approaches that can be taken. Different methods have different strengths and weaknesses, but they are all legitimate.

The World Health Organization (WHO) has the current total cases at over 14.5 million, and deaths at 607,000. The CDC calculates that the total number of cases in the US is 3.8 million, with over 140,000 deaths. The CDC details the limits of this data, however:

However, counting exact numbers of COVID-19 cases is not possible because COVID-19 can cause mild illness, symptoms might not appear immediately, there are delays in reporting and testing, not everyone who is infected gets tested or seeks medical care, and there are differences in how completely states and territories report their cases.

You may notice that all of these factors would tend to underestimate the number of COVID-19 deaths. Is there any way figures might be overestimated? Potentially – the numbers are based on death certificates which indicate the cause of death, which is determined by the doctor or coroner. If COVID-19 is listed as a causal factor in the reported death, it is counted. Doctors may list COVID-19 on the certificate if a patient died with COVID-19, even if it was not directly from COVID-19 (if they had a heart attack while suffering from the illness, for example). Also, some people may die from a respiratory illness that clinically looks like COVID-19 even though that particular virus was not confirmed by testing.

But there is little reason to think there is any significant overcounting of COVID-19 deaths. If someone is very ill from COVID-19 and they die, it is highly likely they would not have died if they were not sick from the virus. And during a pandemic, if you have an illness that clinically looks like the pandemic illness, statistically it’s a good bet that is what you have. So while it is possible there may be some overcounting, it is likely minimal and dwarfed by the underreporting. This is why most experts agree that, if anything, we are underestimating the death toll from this pandemic.

Another way to approach this question is to count so-called excess deaths. This is simply a comparison of the historical baseline death rate of a region or population compared to the actual death rate during the pandemic. It is likely that any excess deaths are either directly or indirectly due to the pandemic. This method has been used to estimate total deaths from a hurricane or other natural disaster, for example.

There have been a number of studies looking at this question. One study published in JAMA, for example, found that in the US:

…the number of deaths due to any cause increased by approximately 122 000 from March 1 to May 30, 2020, which is 28% higher than the reported number of COVID-19 deaths.

Another study looking at the early months of the pandemic in the US found that 35% of excess deaths were attributed to causes other than COVID-19, including heart disease, stroke, other pneumonia, and diabetes. The authors speculate that the number of excess deaths not attributed to COVID was higher early in the pandemic because of lack of familiarity and diagnostic testing. We now know, for example, that the illness is not purely a respiratory illness, and can cause vascular effects leading to strokes and heart attacks.

Unfortunately, we do not have good data for the entire world. In order to calculate excess deaths you need a good baseline, and you need adequate reporting of current deaths, and many countries lack this. However, data from other countries with adequate reporting has been varied but on average similar. In the UK, as of June 5th, they had 51,804 official COVID-19 deaths, but also 12,729 other excess deaths, or about 20% of the total. In Spain the percent of excess deaths not attributed to COVID-19 is 40%, Italy 33%, Netherlands 38%, but France only 3%.

So what is going on? Should we count any of these excess deaths from other causes as actually being from the pandemic? There is no way to objectively answer that question, but here are the possibilities. One is that the excess deaths are mostly directly due to COVID-19 but are simply missed or incorrectly labeled deaths. These may be people who died at home and were never tested and the cause of death is simply listed as heart failure or some other proximal cause without any link to COVID being noted, even though that was a contributing cause. They may be deaths not properly attributed for other reasons.

At the other end of the spectrum we might speculate that most of the excess deaths not attributed to illness with COVID-19 were from other causes entirely, but related to the effects of the pandemic. For example, people have been fearful of going to the ER. Hospitals have been admitting fewer strokes and heart attacks overall. There is no reason to think there is a real drop in the incidence of stroke, and so it is likely that people are just staying away. This will have an obvious negative effect on the outcome of these serious conditions. Further, we may be seeing the effect of hospital and other health care resources being overwhelmed. When the ICUs are full of COVID-19 patients, patients with other serious but unrelated medical problems may not get the care they would have outside the pandemic.

As a side note, we are seeing fewer deaths from homicides and car accidents during shutdowns, and this is obscuring some of the rise in excess deaths from other causes.

Wherever the reality is across the spectrum from direct to indirect effects of the pandemic, the total excess deaths is an important and informative number to follow. First, it shows that we are clearly not overestimating the number of COVID-19 deaths. If anything we are undercounting such deaths – the only question is, by how much? But further, the excess deaths show the total impact of the pandemic. We can argue about the relationship between the pandemic and excess deaths that cannot be tied to illness with COVID-19, but in the end what matters is the excess deaths. It is reasonable to consider this a part of the total burden of the pandemic. Teasing apart the exact causes is important in order to know how to mitigate the effects of the pandemic, but does not reduce the impact of the pandemic itself.

The pandemic is also not over yet, and in fact the worst may yet to be seen. There is a clear increase in anxiety and depression during the pandemic and the resulting economic hardships. Mental health experts are warning of a potential surge in suicides; although this has not manifested yet, the reporting and effects may simply be lagging.

It will likely be years before we can calculate the total impact of the COVID-19 pandemic, but the excess deaths we can calculate are already telling a pretty consistent story.

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Posted by Steven Novella

Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.