Ask Dr. Halverson: What is the true impact of the Great Pandemic?

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By Dr. Halverson

Every day, new tallies of cases, hospitalizations and deaths from COVID-19 are reported by universities and the media. Are they accurate and do they represent the true impact of this disease on our nation and the world? The highly respected Journal of the American Medical Association (JAMA) devoted its entire Oct. 12 weekly publication to this topic. Several sobering facts were clearly articulated.

• The mortality of COVID-19 is underestimated by the daily death count.

Because fatality counts from death certificates are at any moment incomplete, and the listed causes of death reflect varying degrees of uncertainty by the certifying physician, it is important to consider other ways to estimate the number of deaths due to a condition such as COVID-19. One useful metric for this purpose is the number of deaths in excess of the number expected in a specified period of time. The National Vital Statistics System has been our gold standard for this in the United States since 1960. The number of deaths in the United States over the course of a year shows a highly regular wave pattern, increasing in the winter months and declining in the summer. When an abrupt event arises, such as a war or epidemic, the excess mortality can be a revealing indicator of the death toll from that event.

In the JAMA issue, researchers updated their estimate of excess deaths in recent months in the United States. From March through July, the United States experienced more than 225,000 excess deaths, a 20% increase over expected deaths during that time period. COVID-19 death estimates were approximately 150,000, or two-thirds of total deaths.  

Importantly, a condition such as COVID-19 can contribute both directly and indirectly to excess mortality. The direct contribution occurs among individuals who are infected. The indirect contribution relates to circumstances of choices due to the pandemic: For example, a patient who develops symptoms of a stroke is too concerned about COVID-19 to go to the emergency department and a potentially reversible condition becomes fatal. In addition, when a portion of excess mortality may be attributable to a COVID-19-related condition, such as pneumonia, some deaths recorded as due to pneumonia, without mentioning COVID-19, probably represent missed COVID-19 diagnoses. Over time, further analyses of mortality patterns, which are ongoing, will better illuminate the direct, indirect and missed counts of deaths attributable to COVID-19.

• Certain groups of people bear a disproportionate burden of the pandemic.

One of the striking epidemiological features of COVID-19 is the steep shift toward more severe outcomes with increasing age. In the United States, the disease has also disproportionately affected African-American persons, Latinx persons and American Native or Alaska Native persons. As of Aug. 18, for example, JAMA reported that COVID-19 hospitalization rates among Black or African-American persons were 4.7 times higher, and the death rate from COVID-19 was 2.1 times higher than  white, non-Latinx persons.


• Deaths attributable to COVID-19 are just a partial representation of its health burden.

According to the JAMA publication, it is critical to consider that for every death, an estimated nine family members are affected, such as with extreme grief or symptoms of post-traumatic stress disorder. In other words, approximately 2.5 million people could develop major mental health needs. This does not account for the thousands of health care workers in hospitals and nursing homes who have been witness to the unimaginable morbidity and mortality associated with COVID-19. It is difficult to fully comprehend the lasting emotional and psychological effects of the greatest number of excess deaths to occur within a single year in the United States since World War II.

• The economic cost of COVID-19 is enormous.

COVID-19 has disrupted our lives in many ways beyond just health and well-being.  Schools, workplaces and restaurants have been closed. Conferences, exhibitions, musical and theater events, travel and sporting contests have been canceled. According to JAMA, the economic cost of COVID-19 represents the greatest threat to prosperity and well being that the United States has encountered since the Great Depression. The economic cost thus far exceeds an estimated $16 trillion, nearly an entire year of the nation’s economic output. Approximately half of that is due to lost gross domestic product and the remaining half is attributable to health loss, of which nearly one-fifth is due to mental health impairment. 


When you see specific numbers of cases, hospitalizations or death counts, remember this: The true number of reported cases and deaths is likely higher. Like the stopped clock that is exactly right twice each day, the specific number reported on a given day may have been, or will be, exactly correct at some point in time. A general indication of the death toll from COVID-19 and the excess deaths related to the pandemic are sufficiently mortifying and motivating. Few people will forget the Great Pandemic of 2020, where and how they lived, how it substantially changed their lives, and for many, the profound human toll it has taken.

Stay informed, stay committed, stay safe and stay well.


— Dr. Jim Halverson is a longtime Ojai physician who writes a weekly column on COVID-19 for the Ojai Valley News.


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