We now have fatality data for 2022, which should be mostly complete. Fatalities for the year still ran well above pre-pandemic levels but were down from 2020 and 2021.
Prior to the pandemic, there were about 2.8 million fatalities each year in the US. For many years, fatalities have grown consistently at a little over 1% each year. There were slight variations, mostly based on the severity of flu seasons.
But in 2020, fatalities jumped by slightly over 19% to just under 3.4 million and then another 2.4% in 2021, taking total fatalities to nearly 3.5 million. In 2020 and 2021, there were about 1.1 million more fatalities than the trend at the pre-pandemic rate.
In 2022, total fatalities fell by just over 5% to 3.26 million. However, that is still about 11%, or 328,000 deaths, above what we would expect based on the pre-pandemic rate.1
According to the CDC, about 245,000 people died in 2022 after being diagnosed with COVID. So, like in 2021, there were more deaths excess than fatalities related to COVID. This phenomenon has been observed in other countries as well and has prompted much discussion as to the cause of the excess deaths apparently not related to COVID. I think the most likely explanation is that the postponement of routine screenings for other diseases like cancer is catching up with us.
One piece of good news is that most of the excess deaths in 2022 occurred early in the year as we were coming out of the winter flu season. During the spring and early summer, fatalities were back at or below base line levels before ramping back up with the fall/winter flu season. Hopefully this trend will continue in 2023 and we can finally get back to a “normal” fatality rate.
“Mortality Displacement” & “Years of Life Lost”
As I have mentioned in previous posts, there are two aspects of the pandemic that will ultimately affect our understanding of the fatality toll of COVID.
The first is mortality displacement. Mortality displacement is an epidemiological/demographic concept that describes the phenomenon where an extraordinary event delays or accelerates fatalities that would otherwise have occurred in another time period.
Because the vast majority of COVID victims have been elderly and/or ill, there likely has been a significant displacement of fatalities that would have otherwise occurred over the next several years. This is particularly likely with regard to the fatalities which occurred in nursing homes. The average life expectancy in a skilled nursing facility is less than two years.
Also, there was an unusually small increase in 2019. Therefore, we probably went into 2020 with a larger vulnerable cohort than normal.
I thought we might start seeing some effect of displacement by now. But other than a few brief weeks in the spring and early summer last year, that has not been the case. The seemingly never-ending emergence of new variants has kept the pandemic lingering on for longer than previous epidemics. When you add to that, what appears to be collateral fatalities indirectly caused by behavior changes in reaction to COVID, I am beginning to doubt we will see whatever mortality displacement has or will take place in the data. I am now expecting that there will be a gradual reversion to the mean and maybe a few years of even running slightly below the mean, but I have less confidence we will see much more than that.
Second, epidemiologists and actuaries distinguish between “lives lost” and “years of life lost” (YLL). Years of life lost is a calculation which compares the age of the decedent to their life expectancy. For example, if an 84-year-old person died of COVID, the assumption would be that they lost 6.1 years of life because that is the life expectancy of the average 84-year-old person based on the current life tables. Conversely, the life expectancy of a 5-year-old is 79.8 years, so the death of 5-year-old is equal 79.8 YLL.
Again, because COVID fatalities have been very concentrated among the elderly, its toll in terms of years of life lost has been relatively less than other pandemics. Most pandemics, and especially flu pandemics, tend to have a high fatality rate among children, as well as the elderly. Thankfully, COVID almost entirely spared children. So, we would expect the years-of-life-lost to be something substantially lower than the absolute increase in fatalities.
In the last year, there has been considerable academic debate about the YLL lost due to COVID and COVID's effect on life expectancy generally. This paper discusses the difficulty in attempting to tease out the affect of COVID from other factors and contrasts two studies, one which found the average YLL of COVID at 16 years while another came in at 1.3 years. The second study attempted to control for co-morbidities.
Previously, I mentioned this Northwest University study of 2 million patients in the Midwest over the course of the pandemic. The study found that the fatality rate for COVID among the entire population studied was .23% (23/100 of one percent) but the YLL of individual COVID victims was about 13 years. This result highlights stark difference between the effect on the overall population and the effect on specific individuals.
I don’t know that we will ever sort out what the true toll of COVID was on mortality in the US, much less the rest of the world. But there is no doubt that life expectancy is dropping in the US and that Americans are not living as long as those in other rich countries. There are many likely causes for our poor life expectancy other than COVID, such as widespread obesity and lack of access to primary care by lower income families, especially recent immigrants.
To some extent, I think our national obsession with COVID caused us to take our eye off some of the more chronic healthcare problems in our country. Smoking still kills about half a million people every year. This study found that obesity causes nearly 500,000 excess deaths every year, roughly the same amount the CDC has attributed to COVID. Cancer and heart disease still cause, by far, the most fatalities in the US. Drug overdoses are up, as are homicides and suicides. Hopefully, we can begin to getting back to attempting to address some of our other chronic health issues.
Note 1 - The CDC continues to show excess deaths at higher levels than I am calculating. They show the excess deaths for 2020, 2021 and 2022 at 19%, 21% and 15%, respectively. According to their website, this is based on some algorithm they have developed to predict what fatalities would have been without the pandemic. But their results suggest that without the pandemic, the increase in fatalities would have been much lower than the historical average of 1.3%. I have written to the CDC several times asking why their algorithm would have produced that result but have not received any answer.