The Mystery of ‘Excess Fatality’

An aerial view of Vila Formosa cemetery during a burial amid the coronavirus pandemic in São Paulo, Brazil. Photo: Miguel Schincariol/Getty Images

Less than two weeks ago, Italian newspaper Corriere Della Sera published the results of an informal study that appeared to show that, in some regions of the country, non-coronavirus deaths were rising at an alarming rate alongside confirmed COVID-19 deaths — that the total death count was up as much as sixfold from previous years. Those deaths officially attributed to the coronavirus accounted for barely a quarter of the increase.

And Italy isn’t alone. In Spain, El País obtained a study that showed mortality rates in some regions had almost doubled, with only a fraction of the increase officially attributed to COVID-19. So what accounts for all those other deaths? Is the ultimate death toll from this pandemic going to be that much higher everywhere than is understood at the time? If we were able to allocate medical resources more effectively, could we reduce that number?

The answer to those questions is a matter of the balance of two factors: How many “excess deaths” are patients who have COVID-19 but haven’t been diagnosed with it, and how many are patients with other illnesses who can’t get proper treatment in overwhelmed hospital systems?

The first number is likely bigger than you think. Italy has tested about 200,000 people and confirmed 111,000 coronavirus cases. But experts say the true number of cases could be as high as 6 million. People who die at home or in nursing homes are not tested for the coronavirus, and their deaths may be classified as resulting from an underlying condition like chronic pulmonary disease or dementia. But the impact of the resource allocation is significant as well. Beds, physicians, and ventilators are finite resources, meaning that hospital systems around the world are scaling up COVID-19 capacity at the cost of ballooning excess deaths. “If you go to the ICU under normal circumstances, there’s ample capacity available,” says Carri Chan, an associate professor at Columbia Business School who studies the consequences of congestion in intensive-care units. “But if there’s congestion, you might get sent to a step-down unit or even a general medical surgical ward.” In Bergamo, a city northeast of Milan, about 20 percent of all family physicians have been infected, according to the The Wall Street Journal, crippling everyday health care for tens of thousands of people.

Ultimately, both factors will significantly increase the pandemic’s death toll; the only question is by what factor. Since the initial report out of Italy, follow-up studies have estimated the death toll in the country’s most affected regions could be anywhere from three to ten times higher than what’s been officially reported. However, those numbers cannot be easily grafted onto other countries: The United States has had more time to prepare than Italy, and, proportionally, Italy has about twice as many people who are 80 and over than the U.S. Italy’s hospitals have about 12 critical-care beds per 100,000 people, while the United States has about 35 per 100,000.

“Italy faced a bit of a perfect storm in the regions where there were a lot of undiagnosed cases very quickly: a lot of people affected, unfavorable demographics, a health system that didn’t have the flexibility to deal with the excess cases,” said Dr. Sandro Galea, dean of Boston University School of Public Health. “They are now beginning to see a rise in incidents and morbidity and mortality associated with non-coronavirus-related illness. By the way, it would not be shocking if we had that as well, if coronavirus completely transfixes our own health system.”

“It is a classic problem when resources are so overwhelmed and not prepared that you don’t know how to rationally allocate resources. You end up making a lot of mistakes,” said Francesco Checchi, an epidemiologist at the London School of Hygiene & Tropical Medicine who studies mortality in crisis-affected populations. “Initially, the health system is just unprepared to make adequate triage decisions, to actually decide whom to admit and whom not to admit, and therefore what you get is a lot of people dying basically because they can’t get the proper care that they need.”

Reliable data establishing which deaths were directly caused by COVID-19, which were indirectly caused by COVID-19 because of failed health-care systems, and how many people would have died anyway may not be available for months or years. In the meantime, the best guide for how to think about these trade-offs may be earlier epidemics, like Ebola. With that outbreak, cases of malaria in West Africa shot up when hospitals were overwhelmed by patients seeking treatment for Ebola between 2014 and 2016. Several studies have tried to quantify the indirect effects of the Ebola epidemic on mortality, factoring in interruptions in malarial control programs like distribution of bed nets, and found that more people died of the indirect effects than the virus itself.

“The number of deaths that are being predicted from the pandemic are huge and will actually end up becoming the second or third leading cause of death this year,” said Dr. Steven Woolf, director emeritus of the Center on Society and Health at Virginia Commonwealth University. “But for the back of the envelope, all you need to do is think out a scenario where mortality rates from the leading causes of death, like heart disease, cancer, and so forth, increase by 10 percent and you’re suddenly dealing with very big numbers.”

A 2016 study in The Lancet connected at least 250,000 cancer deaths to the 2009 recession, and the stress of the pandemic and the economic crisis it has ignited will likely precipitate increased smoking, alcohol consumption, and drug use, as well. “The opioid epidemic was in the headlines until this came along, and it really hasn’t gone away,” said Woolf. “Now my colleagues in addiction medicine are reporting an increase in opioid overdoses during this pandemic.”

The Mystery of ‘Excess Fatality’