In calculating its human toll, a pandemic is similar to a war. The most precise way public health researchers can get a handle on the impact of something like COVID-19 is to compare the number of total deaths recorded in a specific place during the pandemic with death tallies from prior years.
That analysis will yield a figure known as "excess deaths" — which simply means deaths above and beyond what would normally be expected.
That figure captures not just COVID-19 deaths, but the number of people who were unable to access health care at a moment in their lives when a chronic condition was becoming life-threatening. It also includes individuals whose primary cause of death may have been something else, but who were also infected with COVID-19.
And now that the dust has settled and the data are being tabulated, America's excess death numbers over the past year are staggering.
The importance of tabulating such a dark statistic is twofold: its record-breaking nature is due to both to our largely for-profit healthcare system, as well as government incompetence. Indeed, for decades our government ignored the warnings from public health experts that the U.S. was not properly prepared for the pandemic we are living through now.
Hindsight is 2020
It's not like no one could saw the pandemic coming. In his book "The Great Influenza", first published in 2004, John M. Barry presaged the COVID-19 crisis, describing how "hospitals, like every other industry, have gotten more efficient by cutting costs, which means virtually no excess capacity — on a per capita basis the United States has far fewer hospital beds than a few decades ago."
He continued. "Indeed, during a routine influenza season, usage of respirators rises to nearly 100 percent; in a pandemic, most people who needed a mechanical respirator would not get one."
As we have learned first-hand over the last several months, because the healthcare system was overwhelmed, getting accurate cause of death data was itself a work in progress. No doubt huge numbers of cases of COVID-19 may have been missed. In other instances, individuals may have died at home or succumbed to a chronic illness that was written off as COVID when it was not.
The one constant comparative data point is death itself from any and all causes. Like births, deaths are something we track with some precision.
Hence, one way that medical researchers can get a sense of the scale of the impact of something like COVID is to compare the total number of deaths from all causes during the pandemic and compare it with the same data point over several prior years.
Where it broke the worst
Such an "excess death" analysis will capture the collateral impact of overwhelmed healthcare systems that were under-resourced long before the pandemic. It will include the people that died as a consequence of opting not to go to the hospital for an unrelated condition for fear of catching COVID-19. While that might not count as a COVID-19 death per se, it tells us something about what happens when we permit healthcare to operate without any margin or redundancy — what is effectively a form of rationing healthcare.
According to a recently published study in the Journal of the American Medical Association, which looked at the rate of excess deaths from March 1, 2020, to Jan. 2, 2021, there were 522,368 "excess deaths," as gauged against averages over the same period from 2014 to 2019.
At the start of this year, COVID-19 deaths were reported at just over 350,186. By comparing the "excess rate" of death with the COVID-19 reported data, linked to its location, we can get some sense of where the public health system had the hardest time holding up under the once-in-a-century strain of a mass death event.
The study, produced by researchers with the Virginia Commonwealth University School of Medicine in Richmond and the Yale School of Public Health, calculated that COVID-19 accounted for 72.4 percent of the excess mortality. The balance may have been "either immediate or delayed mortality from undocumented COVID-19 infection, or non-COVID-19 deaths secondary to the pandemic, such as from delayed care or behavioral health crises."
While nationally there was a 23 percent increase in excess mortality during the pandemic, New York State, which lost close to 50,000 to COVID, saw the nation's highest spike, with a 38 percent jump in excess deaths — though Mississippi and New Jersey actually exceeded New York State on a per capita basis, according to the researchers.
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In an editorial that was published with the study, Dr. Alan M. Garber wrote of the importance of grasping the bigger picture, beyond the daily COVID dashboard. "There is no more visible or alarming manifestation of the toll of the COVID-19 pandemic than the deaths it has caused," he noted.
"The missteps in responding to an outbreak that not only could be, but largely was, predicted should not give governments confidence that they are prepared for threats that are more speculative and possibly further in the future," Garber continued. "Failure to anticipate the scale of the potential damage from such future catastrophes will only exacerbate the tendency to downplay their importance, making it less likely that governments will prepare adequately. That is why understanding the toll of a pandemic is an important step in the right direction."
In New York City, where COVID killed more than 32,000 city residents, fighting the virus inspired life-saving innovations. It also exposed long-standing healthcare disparities that left some neighborhoods more at the mercy of the highly contagious and deadly virus, according to Dr. Mitch Katz, the CEO of New York City Health + Hospitals.
NYC H+H, the nation's largest municipal hospital system, includes 11 hospitals and saw some of the highest patient death counts early on. Over the course of the pandemic, thousands of H+H workers from a myriad of job titles were sidelined by the deadly virus, which took the lives of 53 employees.
It was in the throes of this nearly unprecedented public health emergency that H+H found ways to improve patient care while at the same time reducing the exposure of staff to the deadly virus which helped to slow the spread of the virus.
"We have done a lot of work from the first wave about putting glass doors in, or glass in the walls to create a window for cameras in the patient rooms — microphones so that patients can be monitored safely without going into the room . . . and that is a positive development whether there's COVID or some other infectious disease," Dr. Katz said during a phone interview. "So, I think we learned how to make our hospitals safer for the care of patients with infectious diseases."
For Dr. Katz, one of the most sobering discoveries was how pre-existing disparities in the city's private and public hospital infrastructure left some communities so much more vulnerable during the pandemic.
"I think the fact that we had so many fewer hospital beds in Queens compared to Manhattan was one of the stark lessons," he said. "That's part of why it was so much more challenging to deal with the pandemic in Queens and Elmhurst Hospitals was because there were so few beds compared to the size of the population in Queens compared to Manhattan and other parts of New York State. The discrepancy in the number of beds I'd say was an issue."
Dr. Katz established a national reputation leading the public hospital systems in San Francisco and Los Angeles before returning home to New York. After years of experience on the frontlines of urban healthcare on both coasts, he believes that the nation's vulnerability to COVID-19 can be traced back to a steady disinvestment in public health that started during the Reagan era.
"Yes, the pandemic shows how we have to build up our public health infrastructure so that we are better prepared for what people need," he said.
As the city, state and federal governments all attempt to regroup after the death of more than a half-million and the infection of well over 30 million, Dr. Katz believes policy makers would be well advised to consult the data not just on COVID deaths per se, but on excess mortality rates referenced by neighborhoods.
"Absolutely, and I think we have some sense already of the excess mortality that occurred both among people who had COVID and didn't come forward for testing," he said. "Some of those people were undocumented immigrants or people who were very low income and feared coming forward to a hospital.
"Some of that excess mortality we know where people who were having heart attacks or other serious health conditions and didn't come forward for care because they were so frightened of catching COVID from the hospital. So, I think the excess mortality is very helpful frankly it doesn't have to be exact. We can all acknowledge there were a number of people who died and didn't have a COVID test. It's the general population trend that matters."
If America is to get well, which is the first step to escaping the undertow of this pandemic and preparing for staving off the next, we have to uplift these places where regular access to quality healthcare was a socio-economic preexisting condition that helped drive the local body count.
Our own individual health is linked to the health of our neighbor. That's not scripture. That's biology.