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Not Just How, but Who: Tracing the Indirect Deaths Caused by Covid-19

Calculating how many people were killed by Covid-19, whether directly or indirectly, could influence policy and help address structural inequities.



Staff with Ampla Health Care conduct Covid-19 testing at a drive-through site in Yuba City, California, on Friday, March 27, 2020. The site was provided with protective gear from Direct Relief. (Photo by Renée C. Byer/ZUMA Wire)

Covid-19 will most likely cause the deaths of many who never contracted it at all, or who contracted it and recovered from it.

When it comes to estimating the lives claimed by the novel coronavirus, there are two considerations, said Dr. Satchit Balsari, a Harvard professor of emergency medicine and fellow at the university’s FXB Center for Health and Human Rights.

There are the deaths caused by the infectious disease itself, which perhaps should be straightforward but aren’t, as overwhelmed coroners struggle to keep up with the mounting death toll.

But then there are the deaths caused by what Dr. Balsari called “Covid-19, the global pandemic and its impact on our society.”

“You need to understand the virus and its contagion, its transmission and the morbidity and mortality it causes,” Dr. Balsari said. “And then there is the larger impact of the disease on our society and all the deaths that result thereof. Not counting those deaths is hardly an option.”

Dr. Balsari knows what he’s talking about. He’s one of the authors of a now-influential study that found that the death toll after Hurricane Maria was considerably higher than official estimates suggested – approximately 4,600.

Roughly one-third of those deaths, the study authors found, were caused by a lack of access to health care.

A new kind of disaster

When it comes to calculating the impacts of a large-scale emergency like Covid-19, researchers are in new territory, said David Eisenman, a professor of medicine and public health at UCLA. “The model for prior disasters has been natural disasters – geological disasters, weather-related disasters,” he said.

Dr. Eisenman explained that natural disasters tend to shut down vital health care services, such as hospitals and pharmacies. They can also cut off supplies of electricity and running water, compromising sanitation and depriving people of heat, air conditioning, and the power required to keep a medical device running.

But while the hospitals are open and power – with the exception of some areas that have experienced natural disasters in recent weeks – is on, Dr. Eisenman said Covid-19 does seem to be causing indirect deaths.

“We are seeing reports now that there is excess mortality in cities around the world, beyond what is directly attributable to Covid-19,” he said. “We’ll need a lot more information, but it is completely consistent with every other disaster.”

“When we think about a pandemic like this, we don’t have that sort of destruction of the infrastructure…but at the same time, our health care system is completely overwhelmed,” said Kimberly Shoaf, a professor of public health and family and preventative medicine at the University of Utah.

And yet hospitals are reporting decreased numbers of patients with heart attacks, and appendicitis, according to the Washington Post.

“All of us in the emergency departments have been talking about ‘Where are all the patients? Where are all the normal emergencies?’” Dr. Balsari said. “While our floors and ICUs are full, because patients come in with Covid-19…we’re not seeing these Covid patients on top of the normal ER volume. We’re actually not seeing high emergency room volumes at all.”

But even interruptions to basic primary care are dangerous, Dr. Shoaf explained.

“For example, our clinics have moved a lot to virtual visits as opposed to in-person visits,” she said. “Triaging is occurring, but that doesn’t mean we think this is all hunky-dory and everything’s fine.”

Dr. Shoaf’s own mother, who lives in an assisted living facility recently developed a significant health issue after a virtual consultation with a geriatrician, who told her she didn’t need to be urgently seen.

The challenges of counting

Even capturing direct deaths – those caused by complications of Covid-19 or by a combination of the disease and an underlying condition –may be difficult.

A medical examiner may not always get enough information to make a diagnosis, or may decide not to do an autopsy. “If you’re getting thousands of excess deaths in a month, coroners can’t keep up with that caseload,” Dr. Eisenman said.

But at least, Dr. Balsari said, those deaths are relatively straightforward. As a counterexample, he described a theoretical 60-year-old patient who, fearing exposure to Covid-19 at a hospital, lets his angina go untreated for weeks, eventually dying of a heart attack.

“At what point do you stop attributing these deaths to this large federal emergency?” He asked. “I think we still need to reach consensus on how we will attribute these deaths as the weeks and the months roll by.”

One solution to both problems, both Dr. Eisenman and Dr. Balsari said, is to compare the number of deaths right now to seasonal averages from prior years, once those numbers are available.

“I think it’s a little too early to see that. We’re still only a few weeks into that part of the epidemic where our outpatient clinic numbers and emergency numbers are lower,” Dr. Balsari said.

Complicating the process, he explained, is that the quarantine measures and sheltering in place may reduce certain kinds of deaths and injuries, like traffic injuries and falls.

Not just how, but who

Part of the problem isn’t just how Covid-19 is killing people. An equally disturbing question is whom it’s killing.

Social inequity will likely play a strong role in deaths related to the virus, both Dr. Balsari and Dr. Eisenman said.

For example, the disease seems to be disproportionately affecting African Americans. Dr. Eisenman explained that a number of factors may contribute: a higher rate of comorbidities; lower levels of access to insurance and health care; jobs that require face-to-face contact and thus greater risk; more densely populated neighborhoods.

In addition, Dr. Balsari said, vulnerable groups are also at higher risk of indirect death. “There are going to be intersecting, compounded effects,” he explained. “You’ve lost your job. You don’t have savings. You may not be able to continue taking care of yourselves or your underlying medical conditions…You may not be able to afford you medications. You can’t get good food.”

“You are now poorer, but likely also sicker,” he added.

“Disasters illuminate the inequities in society. They’re not equal opportunity killers,” Dr. Eisenman said.

Those deaths will most likely eventually be counted, Dr. Balsari said. But society’s most vulnerable are also at greater risk of being counted later.

Counting and learning

So why count? Satisfying curiosity aside, what’s the benefit of knowing how many people a disease is killing – directly or otherwise?

For one thing, Dr. Eisenman said, knowing just how deadly the disease is will change the way researchers and policymakers respond to it.

“It’s even more important now than it was for other disasters because it has implications for how we proceed in the future that are much more immediate and relevant to people than hurricanes, which we seem to immediately forget about,” he said.

For example, if Covid-19 does, indeed, turn out to be much deadlier than the seasonal flu, “it supports the importance of social distancing.”

It’s also important for individual families to have their losses acknowledged, according to Dr. Balsari: “As we saw with Hurricane Maria…it was almost a cathartic experience for Puerto Rico to finally have recognition or acknowledgment that their loss had been grave.”

On a broader level, tracking not just the number of fatalities, but who’s dying and why, can play an important role in addressing precisely the kind of inequities that are revealed during a disaster.

“Figuring out what kinds of populations were most affected helps unearth the weaknesses in our society,” Dr. Balsari said. “So as we go through these large global disasters, these massive humanitarian crises, we also have an opportunity to reimagine and reexamine the systems that we have built, so we can identify the weaknesses that left all these people behind.”

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