COVID-19 is the big story in mortality statistics – but not the only one

Numbers tell stories. And this year, few stories will be bigger than the end-of-year statistics showing the top causes of death for Americans.

For years, the data has shown heart disease as the No. 1 killer, followed by cancer, accidents, chronic lower respiratory disease and stroke. In a normal year, such statistics are a place to watch long-simmering trends slowly emerge.

But this is 2020.

Figures take time to tally, and final mortality numbers for 2019 – before the pandemic – aren't due until later this month. They likely still will show heart disease and stroke among the country's top causes of death. But whatever the dataset, talk of COVID-19 will dominate because of its current grisly toll.

As of mid-December, COVID-19 already has killed more than 300,000 people in the United States, according to the Johns Hopkins Coronavirus Resource Center. The Centers for Disease Control and Prevention predicts more than 330,000 COVID-19 deaths by year's end.

For perspective, in 2018 – the most recent year for which data is available – heart disease was the cause of death for about 655,000 Americans; cancer for 599,000; accidents 167,000; chronic lower respiratory disease 159,000; and stroke nearly 148,000.

So, when CDC researchers do a final accounting of deaths next year for 2020, COVID-19 is expected to be the No. 3 cause of death.

But those numbers are not the whole story, experts say.

For starters, the true toll of COVID-19 might not be reflected in the CDC numbers. Dr. Steven Woolf, director emeritus at the Center on Society and Health at Virginia Commonwealth University in Richmond, has led research suggesting that for every two deaths attributed to the disease, it has probably caused a third death. Those deaths could be from underreported COVID-19, or they could be non-coronavirus deaths that are the result of hospitals being overwhelmed, people not seeking emergency care or other indirect causes.

Once these "excess deaths" are factored in, COVID-19 fatalities might hit 400,000, Woolf said, although it's hard to tell.

"Our treatments for COVID have improved as the year has gone on," he said. "And people who are hospitalized have a better chance of being discharged alive than was the case earlier in the year. So that's good."

But the pandemic isn't under control, "so all bets are off in terms of how much higher this can go."

Dr. Mitchell Elkind, a neurologist at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center in New York City, said the number of excess deaths reveal a broad ripple effect from the coronavirus.

"Either it's causing problems with the treatment of other conditions because hospitals are overwhelmed, or people are staying home and aren't coming in when they have heart attacks and strokes and other emergencies," said Elkind, who also is president of the American Heart Association.

The headline-grabbing numbers also don't always tell the story for all the subpopulations, Elkind said, and COVID-19 has been particularly deadly in Black, Hispanic and American Indian communities. Preliminary data from researchers at the University of Southern California showed COVID-19 was likely to reduce overall life expectancy in the U.S. to 2003 levels – with Black and Latino people seeing much larger declines than their white peers.

Another critical factor obscured by counting overall deaths is the broader harm from any particular disease, Elkind said.

"Measuring mortality is important, but it's not the only measure of disease burden," he said. For example, even though stroke has ranked behind heart disease as a leading cause of death for years, it's still a major cause of long-term disability.

Although attention to a problem sometimes leads to action, disease statistics don't always correlate with research funding, both Elkind and Woolf said. Some health issues get support that's disproportionate to the harm they cause.

"A simple example of this would be tobacco use," said Woolf. Smoking-related illnesses cause more than 480,000 deaths a year, "yet resources going toward helping people to stop smoking have been inadequate, given the scale of that problem."

But he and Elkind said they hope COVID-19's grim toll this year would lead to investments to prepare for the next pandemic, which both called inevitable.

"I think that's the big story – that we need better public health here," Elkind said.

It was telling that on a recent call, he and his colleagues in the U.S. were asking their Chinese counterparts about their efforts to study large numbers of coronavirus patients. The Chinese doctors said that wasn't really an issue for them – because they don't see that much of the disease now.

"It was pretty disconcerting," Elkind said.

Woolf agreed. "This failure to control the pandemic is a uniquely American thing," he said. "No country has had as many deaths. And even when you adjust for population size, our mortality rates are horribly high."

Meanwhile, Woolf said, "the major killers in our lives are not going away. We still have an opioid epidemic. We still have heart disease and stroke. We still have cancer and chronic pulmonary disease, and we need to continue to battle those conditions as well. And mortality is just the tip of the iceberg."

It's also important to remember, he said, that the ultimate story behind each of those numbers is a person – "a father, a mother, sister, brother. And just like their loved ones, physicians anguish over lives that are lost unnecessarily."

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