In the US, since the beginning of the COVID-19 pandemic, we have experienced 1.02 million deaths, out of about 89 million cases. There have been about 6.4 million deaths worldwide, out of 569 million cases. These numbers, however, are almost certainly an underestimate. A Lancet study, for example, found:
Although reported COVID-19 deaths between Jan 1, 2020, and Dec 31, 2021, totalled 5·94 million worldwide, we estimate that 18·2 million (95% uncertainty interval 17·1–19·6) people died worldwide because of the COVID-19 pandemic (as measured by excess mortality) over that period.
The true mortality burden of the pandemic worldwide was likely triple the official numbers. A WHO report put the number at about 15 million. For the US the disparity was not as great, but was still significant:
For the United States, the Centers for Disease Control and Prevention (CDC) estimates that excess deaths between the weeks ending March 7, 2020 and March 5, 2022 totaled 1,105,736, 15 percent more than the 958,864 official death toll from COVID-19 over that period.
That translates to 146,872 excess deaths not officially attributed to COVID-19 during that period. What are the causes of those unaccounted for excess deaths? Some of them are likely uncounted COVID deaths. Especially early on in the pandemic, death certificates often missed the role of COVID in some deaths. Overworked coroners often took families at their word when reporting the cause of death of a family member at home. By one estimate, COVID-19 deaths were underestimated by about 20% in the US.
However, this underestimation does not account for all the excess deaths. In the US there does appear to be an increase in non-COVID deaths during the pandemic, a phenomenon coming under increased scrutiny. A PNAS study published in September 2021 found:
Thirty-four percent of the excess life years lost for males is from non–COVID-19 causes. While minorities represent 36% of COVID-19 deaths, they represent 70% of non–COVID-19 related excess deaths and 58% of non–COVID-19 excess life years lost. Black, non-Hispanic males represent only 6.9% of the population, but they are responsible for 8.9% of COVID-19 deaths and 28% of 2020 excess deaths from non–COVID-19 causes. For this group, nearly half of the excess life years lost in 2020 are due to non–COVID-19 causes.
Non-COVID deaths were increased in all groups in the US (except children) but concentrated in minorities and those with lower socioeconomic status. What were the causes of these excess non-COVID deaths? One review of the data found:
Hypertension and heart disease deaths combined were elevated 32,000. Diabetes or obesity, drug-induced causes, and alcohol-induced causes were each elevated 12,000 to 15,000 above previous (upward) trends. Drug deaths especially followed an alarming trend, only to significantly exceed it during the pandemic to reach 108,000 for calendar year 2021. Homicide and motor-vehicle fatalities combined were elevated almost 10,000. Various other causes combined to add 18,000.
These proximate causes likely relate to a few more fundamental causes. For example, delayed or deferred hospital admission or medical care likely resulted in increased deaths from heart disease and stroke. People were simply reluctant to go to the ER for fear of catching COVID there, and because hospitals were overwhelmed. Having experienced the ER during the pandemic I can tell you it was full of a lot of unhappy patients, waiting for beds in overcrowded conditions.
Other deaths are deemed “death of despair”, due to increased alcoholism and drug overdoses. Increase in motor vehicle deaths is interesting, attributed to more fast and reckless driving provoked by relatively empty roads. Increase in homicides was similarly attributed to increases in anxiety and restlessness during the pandemic.
Of course, many of the usual suspects have tried to link excess mortality to vaccines. This has been debunked, however, and in fact the evidence shows a beneficial effect of vaccination on excess mortality.
So far I have only been discussing the US. Many other countries have had a similar experience, but with great variability. Not all countries, however, have experienced excess non-COVID deaths. In the UK, for example, there was actually a decrease in non-COVID deaths during the pandemic. A study published in December 2021 found:
In England, deaths from causes other than COVID-19 have been lower than usual for 80% of the pandemic. In January to September 2021, this was equivalent to about 34,000 (or 9%) fewer deaths than we would expect, based on historical mortality patterns. This analysis explores some of the questions arising from this reduction.
The study attributes this decrease to several factors. The first is that pandemic safety procedures decreased the incidence of other infectious illnesses, such as the flu and pneumonia. The second factor was “displaced mortality” – people who would likely have died from other causes dying first from COVID. Essentially many sick or vulnerable people, who were at high risk of mortality anyway, died from COVID.
Finally, there is likely an illusory decrease in the numbers due to delayed diagnosis. There was, for example, a decrease in death from lung cancer, which is very unlikely to be real because of a lack of any plausible mechanism. Rather, epidemiologists speculate that people were simply less likely to be diagnosed with lung cancer because they were not seeking as much care.
What this likely means is that differences in health care infrastructure and income inequality likely had a significant impact on non-COVID deaths. In the US excess non-COVID deaths were heavily concentrated in the lower socioeconomic populations and minorities, in people without insurance or with less access to health care and dependent on lower quality hospitals. This data provided an important lesson to future pandemics. They do represent a significant stress on the healthcare system, revealing weaknesses. This means we need to provide much greater support for these vulnerable populations and healthcare systems in order to weather such stresses.
This data also, to some extent, validates the “flatten the curve” approach that was taken early on in the pandemic. The goal was to limit the spread of COVID, even if the eventual numbers of those infected were not reduced, in order to reduce the strain on hospitals. That strain clearly had a significant negative impact on health care and health outcomes even beyond COVID itself. This also likely means that we need to build more resilience into our health care system in order to be prepared for spikes in demand caused by pandemics or other disasters.