The New York Times - USA (2020-10-25)

8 N THE NEW YORK TIMES, SUNDAY, OCTOBER 25, 2020

Tracking an OutbreakScience and Medicine

The coronavirus pandemic
caused nearly 300,000 deaths in
the United States through early
October, federal researchers said
on Tuesday.
The new tally includes not only
deaths known to have been di-
rectly caused by the coronavirus,
but also roughly 100,000 fatalities
that are indirectly related and
would not have occurred if not for
the virus.
The study, published by the
Centers for Disease Control and
Prevention, is an attempt to meas-
ure “excess deaths” — deaths
from all causes that statistically
exceed those normally occurring
in a certain time period. The total
included deaths from Covid-19, the
illness caused by the coronavirus,
that were misclassified or missed
altogether.
Many experts believe this
measure tracks the pandemic’s
impact more accurately than offi-
cial Covid-19 death reports do, and
they warn that the death toll may
continue an inexorable climb if
policies are not put in effect to con-
tain the spread.
“This is one of several studies,
and the bottom line is there are far
more Americans dying from the
pandemic than the news reports
would suggest,” said Dr. Steve
Woolf, director emeritus of the
Center on Society and Health at
Virginia Commonwealth Univer-
sity, whose own research recently
reached similar conclusions about
excess deaths.
“We’re likely to reach well over
400,000 excess deaths by the end
of the year” if current trends con-
tinue, Dr. Woolf said.
Paul Sutton, deputy director of
the division of vital statistics at

the C.D.C. and an author of the

analysis, said the study had set

out to gauge the number of deaths

that “we would not have expected

to see under normal circum-

stances.”

The results indicate that the

pandemic “is having a tremen-

dous and significant impact on

death in the country, and it may

extend well beyond those deaths

that are directly classified as

Covid deaths,” Dr. Sutton said.

The analysis highlights two dis-

turbing trends. The researchers

discovered a high percentage of

excess deaths in an unexpected

group: young adults in the prime

of life. And the coronavirus has

greatly raised deaths over all

among people of color.

Although the pandemic has

mostly killed older Americans, the

greatest percentage increase in

excess deaths has occurred

among adults ages 25 to 44, the

analysis found.

While the number of deaths

among adults ages 45 to 64 in-

creased by 15 percent, and by 24

percent among those ages 65 to 74,

deaths increased 26.5 percent

among those in their mid-20s to

mid-40s, a group that includes

millennials.

Among those in the youngest

age group, under 25, deaths were

2 percent below average.

People of color also had large

percentage increases in excess

deaths, compared with previous

years. Hispanics experienced a 54

percent increase, while Black peo-

ple saw a 33 percent rise. Deaths

were 29 percent above average for

American Indians or Alaska Na-

tive people, and 37 percent above

average for those of Asian de-

scent.

By comparison, the figure for

white Americans was 12 percent,

according to the analysis.

The report reviewed deaths

from Jan. 26 to Oct. 3 of 2020, and

used modeling to compare the

weekly tallies with those of corre-

sponding weeks in 2015 through

2019.

The researchers estimated that

299,028 more people than ex-

pected died in the United States

during that period, with 198,

deaths attributable to Covid-

and the rest to other causes.

That estimate is significantly

higher than the 216,025 coronavi-

rus deaths officially reported by

the C.D.C. as of Oct. 15. (The figure

now is nearing 221,000, according

to a database maintained by The

New York Times.)

Other researchers have also

found greater deaths over all dur-

ing the pandemic. A study pub-

lished July 1 in JAMA Internal

Medicine reported that deaths

from all causes in the United

States increased by 122,000 from

March 1 to May 30, a figure that

was 28 percent higher than the

deaths attributed solely to

Covid-19 during that period.

Dr. Woolf’s first study, pub-

lished in the journal JAMA, exam-

ined the period from March 1 to

April 25 of 2020 and found that

Covid-19 deaths represented only

two-thirds of the excess deaths in

the United States during that peri-

od.

In 14 states, including Texas

and California, more than half of

excess deaths were linked to un-

derlying health conditions unre-

lated to Covid-19. Dr. Woolf discov-

ered large increases in deaths

from diabetes, heart disease,

Alzheimer’s disease and cerebro-

vascular disease.

In New York City, for example,

deaths from heart disease in-

creased by 400 percent, and

deaths from diabetes rose by 356

percent, Dr. Woolf’s analysis

found.

A more recent paper by Dr.

Woolf and his colleagues, pub-

lished in JAMA on Oct. 12, looked

at deaths in the United States

from March all the way through

August 1. It found deaths had in-

creased by 20 percent over the ex-

pected number for that time peri-

od as well, and that only two-

thirds of the excess deaths were

attributed to Covid-19.

In many cases, patients may

have delayed seeking medical at-

tention or going to the emergency

room, either out of fear of con-

tracting the virus or because med-

ical care was not available. Sub-

stance abuse disorders and psy-

chological stress may also be play-

ing a role in excess deaths, he said.

Going forward, Dr. Woolf said,

“It’s important for people who

have these conditions to not delay

or forgo medical care because of

their fears of the virus.”

“In many cases, the danger of

not getting care is much greater

than the risk of exposure to the vi-

rus,” he said.

THE COST

Pandemic’s Toll Closer to 300,000, Researchers Say, Not All From Covid

By RONI CARYN RABIN

Moving a body to a morgue in Newark, N.J., in May. The C.D.C. is measuring “excess deaths.”

MIKE SEGAR/REUTERS

Weathered, wiry and in his
early 60s, the man stumbled into
the clinic, trailing cigarette smoke
and clutching his chest. Over the
previous week, he had had fleet-
ing episodes of chest pressure but
stayed away from the hospital.
“I didn’t want to get the corona-
virus,” he gasped as the nurses
unbuttoned his shirt to get an
EKG. Only when his pain had be-
come relentless did he feel he had
no choice but to come in.
In pre-pandemic times, patients
like him were routine at my Bos-
ton-area hospital; we saw them al-
most every day. But for much of
the spring and summer, the halls
and parking lots were eerily
empty. I wondered if people were
staying home and getting sicker,
and I imagined that in a few
months’ time these patients, once
they became too ill to manage on
their own, might flood the emer-
gency rooms, wards and I.C.U.s, in
a non-Covid wave.
But more than seven months

into the pandemic, there are still

no lines of patients in the halls.

While my colleagues and I are

busier than we were in March,

there has been no pent-up over-

flow of people with crushing chest

pain, debilitating shortness of

breath or fevers and wet, rattling

coughs.

“It’s so weird,” a colleague re-

marked recently. “It’s like those

people have vanished.”

I remembered my colleague’s

observation when I read a recent

study that suggested why those

patients have never returned.

Researchers from Sound Physi-

cians, a national medical group of

almost 4,000 doctors specializing

in hospital medicine, critical care

and emergency medicine, and the

Dartmouth Institute for Health

Policy and Clinical Practice gath-

ered admissions data from more

than 200 hospitals in 36 states and

compared differences in patient

characteristics, diagnoses and

mortality rates between February

and July of this year with the same

time period last year. The re-

searchers found that by mid-

April, non-Covid admissions to

hospitals had dropped by almost

half.

But surprisingly, even months

later, as coronavirus infection

rates began falling and hospitals

were again offering elective

surgery and in-person visits to

doctor’s offices, hospital admis-

sions remained almost 20 percent

lower than normal.

“We found it staggering that

such a high number of patients

who might have been hospitalized

for serious issues just kind of dis-

appeared,” said Dr. John D. Birk-

meyer, lead author of the study,

chief clinical officer of Sound Phy-

sicians, and adjunct professor of

health policy and clinical practice

at the Dartmouth Institute for

Health Policy and Clinical Prac-

tice. “You have to wonder, ‘Where

did they all go?’ ”

Some experts have pointed to

patients’ overwhelming fear of

contagion as a reason for the drop

in the numbers seeking hospital

care. But the patients in the study

who had the greatest persistent

drop in hospitalization were those

with acutely worsening asthma or

emphysema, pneumonias, sepsis,

strokes and even heart attacks, all

illnesses where hospitalization is

generally not optional.

And those who were hospital-

ized were not necessarily Covid-

holdouts, so fearful of contagion

that they came only when they

were at death’s door. Analyzing

hospital mortality rates, Dr. Birk-

meyer and his colleagues found

that apart from a small bump dur-

ing the early weeks of the pan-

demic, hospitalized patients with-

out Covid-19 were not dying more

than they were before.

Moreover, as the pandemic

wore on, fears of getting infected

at the hospital may have begun to

dissipate. By June, patients were

going back to their doctors’ of-

fices, with some specialists like

dermatologists experiencing

more demand for in-person visits

than previously. “If dermatology

visits are higher than pre-Covid

levels,” said Jonathan Skinner,

senior author of the study and a

professor of economics at Dart-

mouth College, “I can’t imagine

people not showing up at a hospi-

tal if they are having a stroke.”

The most likely explanation for

persistent lower hospitalization

rates “may simply be that fewer

patients are getting sick in the

first place,” Dr. Birkmeyer pos-

ited. Statewide stay-at-home or-

ders aimed at curbing the corona-

virus resulted in a dramatic drop

in human activity and a concomi-

tant improvement in air quality

across the country. Poor air qual-

ity is linked not only to respiratory

diseases like asthma and emphy-

sema but also to other illnesses

like strokes and heart attacks.

Research over the years has

also shown that during recessions

and periods of higher unemploy-

ment, people may at least tempo-

rarily adopt healthier behaviors.

Individuals may smoke and drink

less, get more exercise, improve

their diet, lose weight and have

less stress related to work or com-

muting.

Recent public health efforts to

promote wearing masks and fre-

quent hand-washing have also

probably lowered the transmis-

sion rate of other viruses and bac-

teria that can be responsible for

colds, pneumonias and the life-

threatening infections or exacer-

bations of asthma and emphyse-

ma. “People keep saying, ‘Hey, I

don’t remember the last time I had

a cold,’ ” Mr. Skinner noted. “It’s

because no one is hugging or

shaking hands, and everyone is

washing their hands.”

The published study followed

hospitalization trends only

through July, but the researchers

have continued to gather data

which shows that depressed hos-

pital admission rates are persist-

ing into the fall. While both Dr.

Birkmeyer and Mr. Skinner con-

cede that more work needs to be

done, their study makes clear that

the pandemic has had significant

public health and public policy im-

plications beyond those directly

related to Covid-19.

“All of the things we are doing to

reduce Covid shouldn’t necessar-

ily disappear once we have a vac-

cine,” Mr. Skinner reflected.

He added: “Someday, when

Covid is an answer on ‘Jeopardy!’,

I hope that we won’t have forgot-

ten the important beneficial ef-

fects of reducing pollution and

stress on our health in general.”

DOCTORS

Hospitals Still Eerily Empty of Non-Covid Patients: ‘It’s Like Those People Have Vanished’

By PAULINE W. CHEN, M.D.

Experts think staying

home has lessened

serious conditions.

Dr. Pauline W. Chen, the author of
“Final Exam; A Surgeon’s Reflec-
tions on Mortality,” is a physician
who practices in Boston.

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