May 2, 2021

COVID-19

Was COVID-19 the only culprit behind the extraordinary increase in deaths last year?

Leading causes of death in 2020

Read Time 4 minutes

JAMA recently published an article tabulating provisional estimates of the leading causes of death in the U.S. in 2020. As shown in the Table below, the results indicate an 18% increase in the number of deaths in 2020 compared with 2019, and COVID-19 was the third leading cause of death, behind heart disease and cancer.

Table. Number of deaths for leading causes of death, U.S., 2015-2020.

I don’t think it will come as a shock to most people that the number of total deaths increased in 2020 compared with 2019. What may be surprising, however, is that most (7-in-10) other leading causes of death also increased. In other words, the 18% increase in deaths was not all due to COVID-19. A few things stand out to me when comparing the number of deaths in 2020 to 2019. I’ll expand on them below, but first here’s a brief overview of each cause of death:

  • The total number of deaths in 2020 was 3.4 million compared with 2.9 million in 2019, which is over 500,000 more deaths and an 18% increase. Did COVID-19 account for all of the increase? No, since COVID-19 accounted for nearly 350,000 deaths, leaving nearly 160,000 additional deaths in 2020 to account for. 
  • Heart disease accounted for nearly 32,000 more deaths, a 5% increase, which is actually the largest increase in heart disease deaths since 2012. The authors speculate that increases in other leading causes of death, especially heart disease, Alzheimer’s disease (AD), and diabetes may be due to disruptions in health care that hampered early detection and treatment.
  • Cancer deaths were flat. This is a bit puzzling to me. If increases in causes of disease-related deaths are due to disruptions in health care, why didn’t we see an uptick in cancer deaths? It could be that cancer care was deemed more essential, and therefore less disrupted than care for more chronic diseases. 
  • Unintentional injuries, in which automobile accidents, falls, and drug overdose deaths typically make up the bulk of this number, account for nearly 20,000 more deaths, an 11% increase. This is surprising to me considering the fact that most people must have driven far less due to COVID-19 in 2020.
  • Stroke accounted for over 9,000 more deaths, a 6% increase, which is in line with the numbers on heart disease above.
  • There were about 5,000 fewer deaths from chronic lower respiratory diseases (CLRD), a 3% decrease. 
  • AD accounted for nearly 12,000 more deaths, a 10% increase. This is the most surprising finding to me.
  • Diabetes accounted for more than 13,000 additional deaths, a 15% increase, which was the largest relative increase in deaths out of all the leading causes (outside of COVID-19, of course). Diabetes death is tricky because it’s difficult to distinguish between a death from diabetes that is not related to another disease compared to a “pure” diabetic death. Nearly 98% of older American adults with type 2 diabetes have at least one comorbid condition and nearly 90% have at least two comorbidities, so it’s extremely difficult to disentangle the difference between diabetes as an underlying cause vs a contributing cause of death.
  • Influenza and pneumonia accounted for nearly 4,000 additional deaths, an 8% increase. While this fluctuation is in line with previous years, it still really surprises me, given how much people went into isolation. Many of the recommendations for COVID-19—staying at home, social distancing, frequent hand-washing, wearing masks—presumably should also mitigate the transmission of influenza and pneumonia as well. I would have expected deaths from influenza to have been almost negligible. 
  • Kidney disease deaths were relatively flat, accounting for 700 more deaths and less than a 2% increase.
  • There were almost 3,000 fewer suicides, a 6% decrease. This cuts against the grain of the narrative of how much mental health has flared up during COVID-19. Could this mean that there has been a huge increase in depression, anxiety, etc., but has not translated to actual suicide?

What can we take away from all of this? The data certainly makes a compelling case that there was a substantial increase in deaths from 2019 to 2020 and most of the increase can be attributed to COVID-19. This may seem obvious today, but many pundits this time last year made the case that all COVID-19 deaths were “canceling out” other deaths, so there would be no increase in overall mortality. To put the overall increase in deaths into context, let’s exclude COVID-19 deaths and compare annual deaths. There’s still an excess of 160,000 deaths in 2020 compared with 2019. Even after excluding COVID-19 deaths, it’s the largest year-over-year increase since at least 2015. The relative and absolute increase in the number of deaths from heart disease, unintentional injuries, diabetes, AD, and stroke in 2020 were all the largest since at least 2015. What’s going on here?

The authors speculated that increases in other leading causes of death, especially heart disease, AD, and diabetes may be due to disruptions in health care that hampered early detection and treatment. They also suggested the increases may indicate an underreporting of COVID-19, especially during the beginning of the pandemic, leading to an underestimation of COVID-19 mortality. Both of these factors may have contributed, but I’m not convinced they can fully explain the data presented. If that were the case, why didn’t the number of deaths from cancer, CLRD, and kidney disease increase?   

As I alluded to above, the increase in unintentional injuries is very surprising when most people drove less frequently due to the pandemic. The number of automotive fatalities in the U.S. typically approaches nearly 40,000 deaths annually, which accounts for about one-quarter of all deaths from unintentional injuries. According to the authors, and the New York Times citing CDC data, increases in unintentional injury deaths were largely driven by drug overdoses. This increase may be due in part to an increase in social isolation and a decline in mental and emotional health during the pandemic. In fact, even before the pandemic, I wrote about the increase in deaths of despair —drug overdoses, suicides, and alcohol-related diseases—-contributing to the three consecutive years of decline in life expectancy in the U.S. Drug overdoses alone increased by nearly 400% (from 6.7 deaths/100,000 to 32.5) in midlife between 1999 and 2017. Here’s what’s even more surprising: the National Safety Council estimates that more than 42,000 automobile deaths occurred in 2020, up 8% from 2019, despite estimates that the overall number of vehicle miles traveled decreased by 13%.

I’m left with more questions than answers at the moment and believe these data are worthy of further exploration. To be continued …

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20 Comments

  1. Though I expect we will learn more and even different things related to the above excellent e-mail, here are my thoughts on what you wrote.

    About the surprising deaths in autos: Those who WERE driving were more stressed, more reckless and/or more high or drunk.

    “Diabetes accounted for more than 13,000 additional deaths, a 15% increase, which was the largest relative increase in deaths out of all the leading causes (outside of COVID-19, of course). Diabetes death is tricky because it’s difficult to distinguish between a death from diabetes that is not related to another disease compared to a “pure” diabetic death. Nearly 98% of older American adults with type 2 diabetes have at least one comorbid condition and nearly 90% have at least two comorbidities, so it’s extremely difficult to disentangle the difference between diabetes as an underlying cause vs a contributing cause of death.”

    Excellent point. So excellently written and expressed. I expect in the coming years, diabetes is going to just explode even more. That is, unless something different is done – some mass campaign to curb our sugar intake. The reason I think it will increase is that people ate more sugar than ever during the pandemic. We went in the exact wrong direction.

    “Kidney disease deaths were relatively flat, accounting for 700 more deaths and less than a 2% increase.”

    I did one volunteer event with the NKF and one educational session. Ever since, I get their emails and they have done an outstanding job educating, encouraging advocating for, and protecting their members.

    • My thoughts are very much so the same in regard to the MVA deaths and diabetes.

      Following up on your statement about sugar intake increasing significantly and adding in alcohol consumption, this would also have an affect on cardiovascular conditions, and may be another explanation to the increase. However, it is certain that hospitals may have been disrupted and individuals may be afraid to leave their homes to find help when it may be too late.

      I’d like to add that with the mention of :

      “The authors speculated that increases in other leading causes of death, especially heart disease, AD, and diabetes may be due to disruptions in health care that hampered early detection and treatment. “””They also suggested the increases may indicate an underreporting of COVID-19, especially during the beginning of the pandemic, leading to an underestimation of COVID-19 mortality.””” Both of these factors may have contributed, but I’m not convinced they can fully explain the data presented. If that were the case, why didn’t the number of deaths from cancer, CLRD, and kidney disease increase?“

      Their may be an underestimation of COVID19 cases, however it may also be that there also was an overestimation of COVID19 being confirmed as the cause of death. This would be an interesting area to see if we will have information on this in the future.

      I simply wanted to add to your well articulated comment.

      Hope all is well.

  2. COVID aside, so many people die with comorbidities, I’m skeptical of any consistency at a national level with which cause of death is ascribed … and even more skeptical of statistics teased out of such data.

  3. It would be interesting to see this data with a breakdown by state to see if there are differences in these trends, especially since there have been some reports of irregular reporting for some states.

  4. How many more deaths would we have expected in 2020 vs 2019 due to the boomer age cohort aging? It looks like there are supposed to be ~2M more people ≥65 each year for the next several years, and the people at the upper end of the age distribution are going to die of _something_.

    Instead of a comparison of 2019 vs 2020, a baseline should be vs expected growth in mortality vs 2020. The excess mortality from SARS-CoV2 will still be there, but it might be somewhat lower given the age distribution of the dead (the large majority ≥65).

  5. Definitely interesting, like you I found some of these are surprising. The accidental deaths and suicide numbers go against the grain of prevailing narratives. But perhaps the excess in accidental deaths are driven not by auto accidents but by overdoses? Which could explain why suicides are down a little bit despite declining mental health. Perhaps it is just a nuance in classification between accidental overdose and suicide?

  6. More than 2/3 of Americans are either overweight or obese. And the numbers are rising. By 2030, more than half of the country is expected to be clinically obese. This makes people more vulnerable to viral infections, heart disease, diabetes and all of the other major killers.

    Combining the obesity epidemic with the tendency of Americans to be sedentary (the story of 2020), in particularly deadly. It may have been necessary to slow the spread of Covid, but it had many bad repercussions. We stopped taking walks outdoors, stopped leaving our homes to take classes and visit friends, stopped going to the grocery store.

    People talk about being concerned that pandemics could overwhelm our national health care system. But even before the pandemic, due to the raging epidemic of obesity, our health, as a country, has been heading off of a cliff.

    • Especially since there have been articles written such as this headline in Scientific American last week: “Flu Has Disappeared Worldwide during the COVID Pandemic.” Difficult to explain the excess influenza deaths, indeed. Misdiagnoses?

  7. Another worthwhile analysis would be a correlation in the rise in healthcare costs per type (insurance, Medicare and other publicly provided insurance, in and outpatient care, 10-Q profitability of healthcare-associate companies, pharmaceutical companies advertising of pharmaceutical companies, doctor’s visits, sporting good sales, fast food sales, junk food sales, franchising for fast and junk-food restaurant’s, the10-Q stated profits of companies that make the foods that are killing people, and if there one, and index of how well gyms fared across the same period of measurement), against these sad and troubling numbers.

    We hold re-opening restaurants and churches sacrosanct as the victims of the plague, while we die every younger in increasing numbers Y-on-Y and never a homily on this issue, taking better care of the gift of life God has given us.

    Lastly, I’d like to see the same kind of stats comparing our nation against other, and then an analysis combating developed, developing, and under-developed counties.

    I think of, and cheer on plans of actions for infrastructure improvements, a resurrection of our National industrial capacity, and a return of our troops (a whole different set of sad and troubling comparative stats, no doubt), but nary a word on how we could do either without people. How about a plan for the robustness of the health of the people? Thank you for your work.

  8. Peter

    You may find this graph useful (this is England & Wales mortality for 2020 vs 2019): https://www.giantpygmy.net/gp/data/uploads/img/blog/2021/controller-2021-01-26-stateofemergency-pcr-06-all-deaths-vs-positive-pcr-cases.png

    From the same report (regarding the situation in the UK):
    https://www.giantpygmy.net/gp/index.php?id=blog&post=state-of-emergency-rt-pcr-the-pandemic-machine

    “The rising mortality in November and December shouldn’t surprise anyone after the government imposed increasingly draconian, hope-sapping lockdowns on an already beleaguered and frustrated population, having made 70,000 households homeless, bankrupted businesses, destroyed incomes and restricted medical procedures, screenings and checkups for non-COVID-19 patients. The BMA estimates that between April and November 2020 there were 2.57 million less elective procedures and 18 million less outpatient attendances.”

    The question, that doesn’t seem to have been dealt with on this site, is “what is a COVID-19 death”? Which again, leads us to the Corman-Drosten RT-PCR test and the intentionally high cycle thresholds they were run at (up to between 35 and 45) to achieve a positive result (35+ ct = 97% false positive rate).

    So if a COVID-19 death is based on the official 28 – 30 days after a likely false positive PCR test – then what really does that mean?

    Finally, let’s put SARS-CoV-2 in some proper context. The initial (scary) 3.4% IFR (infection fatality ratio) has now been scaled back to 0.15%. So we’re getting in line with the seasonal flu ( https://off-guardian.org/2021/04/21/covids-ifr-just-keeps-dropping/ )

    Another useful graph:
    https://www.giantpygmy.net/gp/data/uploads/img/blog/2021/controller-2021-01-26-stateofemergency-pcr-7-03-inluenza-who-2020.png

    The health outcomes from the “deadly pandemic” are not so much from the SARS-CoV-2 virus, but from the response to it – i.e not using field-tested treatments (see https://c19early.com/ ) and the lockdown policies that meant all things non-COVID went onto the back-burner.

    aiP

  9. I built a Z-score from CDC’s 2017 – 2019 mortality data, in order to compare last year’s and this year’s excess deaths to the three previous years’ average and standard deviation. Interestingly enough, at present (beginning of May ’21) it shows a Z-score of about -2 right now; that would be negative excess deaths. The data always changes, and it’s too early to draw any conclusions, but if it continues this way, we might end up with a “canceling out” to some degree this year of last year’s deaths. I guess a case like that could be explained by a certain number of very fragile people dying last year instead of this year, as they would have without COVID and the stressed medical system.
    -C’s husband, Dave

  10. Peter, can you check the SIDS deaths in 2020? I heard that they declined by a huge margin in the first half of the year when parents quite bringing kids in for the “well baby check-ups.” Are pediatric check-ups killing our kids?

    Same with cancer. Are the chemo/radiation appointments killing more people than are being helped? Perhaps the treatment is worse than the disease?

    Will this be the 3rd year in a row of declining life expectancy?

  11. “it’s the largest year-over-year increase since at least 2015.”

    Well, even if its buried in the article, at least you do mention that it’s most likely a meaningless statistical fluctuation. It’s especially evident when at least half the data goes against “what you thought” should have happened.

  12. Regarding the auto related increases in 2020, this is precisely what was predicted by the folks whom have long been arguing that it’s speed that kills. Since traffic has a calming effect, speeds on average were way up despite fewer total road miles travelled. Charles Marohn, an engineer and former city planner, lays out this argument far more clearly (and with more data) than I’m making it here. https://www.strongtowns.org/journal/2020/8/21/time-to-end-traffic-fatalities

  13. Thanks for sharing this as I have a few acquaintances that express there was no change in the death rate as part of their denial of Covid’s threat.
    I do wonder if the increased mortality was in part due to the manner Covid overwhelmed the healthcare system. If ER’s and ICU’s were at capacity, it likely led to delays in care for cardiac, stroke and unintended accidents. The purpose of the lockdowns was to reduce the spread and keep from burdening the critical ICU capacity, which didn’t necessarily occur. If true, it would be in the data with a deeper dive,
    Thanks again as actual data is always better than anecdotal evidence.

  14. If 10 people get a virus and one person dies there’s a 1% Fatality rate.

    If one million people get a virus and 10000 people die, that’s also 1% fatality rate. 99% chance of recovery.

    Something that could have been anticipated is a more contagious variant that infects more people more quickly.

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