Why did approximately 1.32 million more Americans die in 2020-2022 than expected?

Expected mortality in a developed — or “developed” — country like the USA is fairly easy to calculate: You just look at how many people die every year, the trend that these totals represent, and extrapolate that trend forward.

Doing this for the last 20 years prior to the Covid epidemic, we find that gross mortality totals in the USA increased by an average of .9% per year for the entire period. They rose somewhat faster in the second half of this period — 1.6% per year — mainly because of the whole “deaths of despair” phenomenon chronicled by Case and Deaton, among others. This increased rate was higher in the first half of the previous decade, and lower in the second half: in the four years prior to Covid, deaths increased by 1.2% per year.

It’s important to note that over this entire period age-adjusted mortality in the USA declined quite a bit, from 869 per 100,000 to 717 per 100,000. So annual death totals generally increase because of a combination of an aging population and a larger total population, but increase a lot less than they would otherwise because of declining mortality, when adjusted for age.

Covid of course reversed all this. It’s pretty simple to extrapolate how many deaths ought to have occurred in the USA over the previous three years if not for Covid. Using the 1.2% annual increase that we saw in the years immediately prior to the pandemic, there should have been 8.78 million total deaths in the country. How many were there in fact? As of 1/11/2023, the CDC had recorded 10.06 million deaths in 2020 through 2022. Because of data lag (a certain number of deaths in the last few weeks of 2022 haven’t been officially recorded yet by the agency) a very conservative estimate of the final number is 10.1 million, i.e., 1.32 million more deaths than would have been expected if not for the pandemic. Again, this is a conservative estimate.

So now we get this in the Washington Post:

According to the Centers for Disease Control and Prevention, the United States is experiencing around 400 covid deaths every day. At that rate, there would be nearly 150,000 deaths a year.

But are these Americans dying from covid or with covid?

Understanding this distinction is crucial to putting the continuing toll of the coronavirus into perspective. Determining how likely it is an infection will result in hospitalization or death helps people weigh their own risk. It also enables health officials to assess when vaccine effectiveness wanes and future rounds of boosters are needed.

Two infectious-disease experts I spoke with believe that the number of deaths attributed to covid is far greater than the actual number of people dying from covid. Robin Dretler, an attending physician at Emory Decatur Hospital and the former president of Georgia’s chapter of Infectious Diseases Society of America, estimates that at his hospital, 90 percent of patients diagnosed with covid are actually in the hospital for some other illness.

“Since every hospitalized patient gets tested for covid, many are incidentally positive,” he said. A gunshot victim or someone who had a heart attack, for example, could test positive for the virus, but the infection has no bearing on why they sought medical care.

Dretler also sees patients with multiple concurrent infections. “People who have very low white blood cell counts from chemotherapy might be admitted because of bacterial pneumonia or foot gangrene. They may also have covid, but covid is not the main reason why they’re so sick.”

If these patients die, covid might get added to their death certificate along with the other diagnoses. But the coronavirus was not the primary contributor to their death and often played no role at all.

Dretler is quick to add that the imprecise reporting is not because of bad intent. There is no truth to the conspiracy theory that hospitals are trying to exaggerate coronavirus numbers for some nefarious purpose. But, he said, “inadvertently overstating risk can make the anxious more anxious and the skeptical more skeptical.”

Another infectious-disease physician, Shira Doron, has been researching how to more accurately attribute severe illness due to covid. After evaluating medical records of covid patients, she and her colleagues found that use of the steroid dexamethasone, a standard treatment for covid patients with low oxygen levels, was a good proxy measure for hospitalizations due to the coronavirus. If someone who tested positive didn’t receive dexamethasone during their inpatient stay, they were probably in the hospital for a different cause.

Doron’s work was instrumental to Massachusetts changing its hospitalization reporting a year ago to include both total hospitalizations with covid and those that received dexamethasone. In recent months, only about 30 percent of total hospitalizations with covid were primarily attributed to the virus. . .

Doron acknowledges that there is a gray zone in the data in which covid might not be the primary cause of death but could have contributed to it. For instance, covid infection could push someone with chronic kidney disease into kidney failure. She and her colleagues are collecting data on this as well.Both Dretler and Doron have faced criticism from people who say they are minimizing covid. That is not at all their aim. They have taken care of covid patients throughout the pandemic and have seen the evolution of the disease. Earlier on, covid pneumonia often killed otherwise healthy people. Today, most patients in their hospitals carrying the coronavirus are there for another reason. They want the public to see what they’re seeing, because, as Doron says, “overcounting covid deaths undermines people’s sense of security and the efficacy of vaccines.”

To be clear, if the covid death count turns out to be 30 percent of what’s currently reported, that’s still unacceptably high. But that knowledge could help people better gauge the risks of traveling, indoor dining and activities they have yet to resume.

Most importantly, knowing who exactly is dying from covid can help us identify who is truly vulnerable. These are the patients we need to protect through better vaccines and treatments.

This is just an amazingly irresponsible framing of the issue from Leana Wen, the author of the piece.

There’s the traces of a good point here, which is that it may be the case that very recently there may have been some over-reporting of Covid deaths in some hospitals, given the changing profile of the disease, and the people most vulnerable.

But the way she framed that modest point comes out, intentionally or not, as sounding like the claim that Covid deaths in the USA may have been overstated by a factor of three! The extremely grim bottom line is that, while the official Covid death total for 2020-2022 is less than 1.1 million, the national excess death total over that time frame is nearly a quarter of a million people more than that already staggering figure. What exactly did all these people die of?

This point becomes even more overwhelming when you consider that not all Covid deaths have been excess deaths in the technical sense, because, given the demographic profile of the people who have died from the virus, perhaps 100,000 or so of those 1.1 million people would have died during this time frame anyway, even without the pandemic. So the difference between the excess death total officially due to Covid and the actual excess death total is probably at least 300,000 people, on top of one million or so Covid deaths that can be counted, statistically, as excess deaths.

This means, of course, that either the total number of Covid deaths has been badly underestimated over the course of the pandemic, or the secondary health effects of the pandemic have killed several hundred thousand people from causes other than Covid, or some combination of the two factors (I think the evidence suggests the first factor is overwhelmingly more powerful than the second one, but it will take many years to sort this out).

But the bottom line is that more than 1.3 million Americans died over the past three years than would not have died if not for the Covid pandemic, and it is at best recklessly irresponsible to suggest otherwise.