COVID-19 mortality

What do we know? And how do we know it?

As the second installment in my series on the demographic impact of COVID-19 (the first, on fertility, is here), I zero in on mortality. The more we learn about the impact of the pandemic on fertility, mortality, and migration, the more I double down on my argument that COVID didn’t so much change population trends in a new direction as it did accelerate their movement down a path they were already on. This edition is a bit US-centric but I have lots of great global coverage in the coming weeks so be sure to subscribe.

Derek Thompson of The Atlantic writes about “the great metro” shrinkage, and how lower fertility, immigration, and fewer commuters combined to make a population loss of nearly 1 million for the US’s 20 largest metro areas in 2021.

I can’t write a clearer or more dramatic opening than Mike Stobbe for the AP so here you go:

“2021 was the deadliest year in US history.”

It’s incredibly hard to measure the exact number of deaths from COVID. We’ve all heard anecdotes from family and friends who’ve had loved ones die with both COVID and co-morbidities present and know the difficulty medical professionals have in disentangling the two. There are reports that US hospitals may get extra Medicare payments if the patient has COVID, meaning there might be incentives or disincentives to under- or overreport. Understanding COVID mortality also requires high data literacy, something most of us don’t have (mine is always a work in progress). Since COVID deaths are related to age, we must consider the age structure of an individual country (or state, or county) in our interpretations. That’s the reason the death rate, which measures deaths per 1,000, is higher in Japan—one of the world’s healthiest countries—than in the Democratic Republic of the Congo. Japan has more old people. And different countries measure deaths from COVID in different ways.

So how are we to ever grasp the impact of COVID on mortality? One way is to look at excess mortality, meaning deaths that wouldn’t have been expected absent the pandemic, and yes, there were spikes in excess mortality in both 2020 and 2021.

While it doesn’t necessarily isolate COVID as a cause of death, excess mortality gives a holistic view of COVID’s impact on our health because it also takes into account increases in deaths from non-COVID diseases but ones that are related to the pandemic’s impact on our lives. For example, cancers that might have been detected early were not when routine health checkups stopped during lockdowns. In the US, early data show overdoses among 14- to 18-year-olds, a group socially impacted by lockdowns, were up in both 2020 and 2021. In the US, Black, non-Hispanic men had disproportionately high excess mortality due to “deaths of despair, murders, uninfected Alzheimer’s patients, reduced health care use, and economic dislocation,” according to a study by Christopher Cronin and William Evans.

“When it comes to death, public health leadership and capacity matter.”

The bottom line: When it comes to death, public health leadership and capacity matter. The gulf in excess mortality among countries is in part because of different capacities to test, diagnose, and respond to or treat COVID-19 around the world, according to one report in JAMA. In Australia and New Zealand, mortality was below the expected number, presumably because of public health measures to limit mortality from COVID, according to a study not yet peer reviewed. In the US, the CDC provisional estimates for excess mortality between February 1, 2020 and April 26, 2022 showed 1,116,392 more people died than expected, a huge loss.

In many countries, COVID meant slower population growth (or faster depopulation) because of both excess mortality and further postponement of childbearing. Across Western Europe, East Asia, and the US—places with below-replacement fertility—I would argue that COVID didn’t reverse fertility trends, but rather accelerated movement along the path of low fertility. In the US, for example, birth in most states had already been declining since 2016.

The follow this week is Prof. Deadric T. Williams, a sociologist at the other end of my very long state of Tennessee. He Tweets on the latest scholarship in race & racism, health, and inequality and I love his feed for bringing new research to my attention.

Book travel continues! A big thanks to World Boston for inviting me to talk about 8 Billion and Counting at the GORGEOUS Boston Public Library. And I even got my 6oz lobstah roll.