The official American death toll from the coronavirus pandemic now stands at 170,000, and while there are some encouraging indications that the growth of the disease is slowing and the fatality rate declining, the U.S. death toll is likely to grow to 227,000 by just November 1, according to Youyang Gu — to date the most accurate modeler of COVID-19 in the country. The global death toll is already 750,000, and while there are some intriguing hints that the disease may be dramatically less deadly in parts of the global south than it has proven in the global north, that total will nevertheless grow significantly in the months ahead, as well. Unfortunately, those figures may also be significantly underestimating the ultimate public-health trauma delivered by the pandemic, perhaps by several orders of magnitude. That is because the conventional death toll misses some major additional impacts of the pandemic, each larger and more distressing than the last. Taken together, they suggest that the full human cost of this pandemic will be many times larger than even horrifying death counts imply.
The first important revision of scale is perhaps somewhat familiar: the matter of “excess deaths.” This is the measure of how many more people are dying, during the pandemic, than would have been expected to in more “normal” times. The gap between officially recorded deaths and excess deaths varies from place to place, reflecting differences in both treatment and diagnostic capacity for COVID-19 and in the prevalence of other diseases and conditions on the community. In the U.S., a new estimate finds, excess deaths have already surpassed 200,000 — meaning that here in America, the death toll of the pandemic has been almost 20 percent higher than the official numbers. In England, the excess death toll is about 15 percent higher than the COVID-19 death count; in Peru, it is almost 200 percent higher. The mix of causes of this excess mortality varies from country to country, too: While those figures from Peru most likely reflect many undiagnosed cases of COVID-19, in other parts of the world the “excess” derives more from the secondary effects of the pandemic and lockdown: sick people avoiding the hospital, those in need of “elective” surgery forgoing it, limited hospital and medical resources directed exclusively to the pandemic at the expense of other ongoing risks. In still other parts, the impact might be felt through missed preventative efforts: According to one estimate recently showcased in Nature, the global excess death toll just from TB, AIDS, and malaria, which typically kill 2.4 million annually, could almost double over the next year in a worst-case scenario in which the coronavirus pandemic interferes with the distribution of preventative tools like bed nets, the diagnosis of new cases, and the treatment of those who do fall sick. Even if nothing like those worst-case scenarios comes to pass, the spillover lethality from COVID-19 would still be significant — and would only appear sub-catastrophic because we have long normalized those already catastrophic millions of annual deaths.
The second, more mind-bending revision comes from our emerging understanding of the long-term effects of COVID-19. In the spring, our picture of the disease was dominated by hospitalizations, deaths, and recoveries; most Americans following things closely probably understood the full course of illness to last about a month, start to finish. Over the last few months, however, we’ve heard more and more stories about coronavirus “long-haulers,” those still sick well after that one-month cycle should have come to a close, many of them still quite incapacitated by the illness. I don’t think our collective understanding of the disease has properly incorporated those stories, in part because most of our accounts have been, to this point, anecdotal — with the result that the experiences of those suffering in these extended and often confusing ways appear to the rest of us like eerie outliers, tragic but unusual.
But we are beginning to get more systematic research into the aftereffects of COVID-19, and though that research is early and limited, it suggests the possibility that these post-recovery complications may prove to be a more significant health trauma to the country, and the world, than the pandemic death toll. The numbers from that emerging research are genuinely hair-raising: 87 percent of Italian patients who had “recovered” from the disease after hospitalization reported at least one ongoing symptom of the disease. 78 percent of recovered German patients were found, two months later, to have suffered structural changes to their hearts; the study focused largely on those with asymptomatic or mild cases, and in follow-ups 76 percent exhibited a biomarker associated with cardiac injury following a heart attack. Another study, of 1,200 patients hospitalized across 69 countries, found that 55 percent had long-term damage to their hearts; subtracting those whose hearts may have had preexisting damage, the study found 46 percent of previously healthy patients showed some amount of long-term scarring and dysfunction. Another study of COVID-19 patients found that roughly 90 percent of those with “severe” cases, 75 percent of those with “moderate” cases, and 60 percent of those with “mild” cases were still experiencing at least one symptom after three months, the most common symptom being breathlessness and fatigue. (Though the findings were less alarming than a few of the other studies, with only about 30 percent of severely sick patients showing abnormal chest X-rays, and other acute issues at even lesser prevalence.) Experts now believe that as many as one in three patients could suffer neurological or psychological aftereffects, according to STAT News. “It’s not only an acute problem,” one critical-care physician told STAT. “This is going to be a chronic illness.”
This is a shift in conceptual perspective that isn’t just about kind — acute versus chronic — but scale. Assuming the early research holds, even somewhat, it would mean a long-term impact staggeringly larger than the acute crisis we have all been living through in terror. And it would mean these long-term effects aren’t medical curiosities to be considered on the margins of the disease — but in fact the most common outcome, by far. Today in the United States, the infection fatality rate is about 0.25 percent; at its peak it was about one percent. If even the lowest estimates of the recent studies are confirmed, it would mean many times more people would be made chronic patients than died from the disease. The German finding, in particular, is so striking it would be foolish to assume it was representative without other work confirming ratios that high, and already some of its methodology has been called into question; but even if it is off by a factor of five, it would still suggest at least 15 times as many people might emerge from COVID-19 with lasting heart damage than would die from it. And that is merely one of the emerging long-term conditions.
Mercifully, there are some reasons to think this early research may not hold up, at least precisely. The studies have been small, and they have been few. While two-thirds of those surveyed in the eye-opening German study had not been hospitalized, some of that research does focus on those patients who got most sick, at first, and their experiences may not prove representative. Indeed, because most people who get tested are exhibiting some symptoms while roughly half of cases are asymptomatic, any population-level study built around positive diagnoses may be skewed towards a severe experience of the disease, thereby making them not truly representative. There may also be some epidemiological dynamics making more severe cases show up earlier, on average, which could also mean these early results won’t predict the experience of those who haven’t yet gotten the disease. And since it is still only nine months since the disease announced itself, and only about six months since it arrived in full force in Europe and the United States, we don’t know for sure whether these conditions will taper, or linger indefinitely. It is certainly possible, and perhaps even likely, that most of these complications will resolve themselves relatively quickly — if on a timeframe of months rather than weeks. Indeed, many viruses do produce impacts like this, which then dissipate.
But a suggestive comparison is to the aftereffects of SARS-CoV-2’s close cousin, SARS-CoV-1: About 20 percent of those infected with the first SARS suffered lasting lung damage, and those left with lung lesions by that disease still had them 15 years later. When I spoke to Scripps Research founder Eric Topol last month, he told me this was where his anxiety was focused. “I’m actually a very optimistic person,” he said, “but lately I’ve become a worry wart. And the main reason I’m worried is these long-term effects.” He added, “More than half of asymptomatic people who had CT scans are registering internal damage to their lungs, and we only know about the lungs because those are the organs we’ve looked at. We haven’t even looked at other organs.”
In the U.S., in particular, the declining infection fatality rate has lately been a note of real optimism (to those who could hear it through the pandemic din). But as with everything else having to do with this disease, it is not just rates that matter, but levels. If 20 percent of those who fall sick get enduring health problems, that means one thing for a pandemic like SARS-CoV-1, which infected less than 10,000 people worldwide. It means a very different thing if the pandemic has spread as widely as this one — with more than 5 million confirmed cases just within the U.S. If anything like 75 percent of patients face even some limited long-term difficulties, the scale of impairment implied by tens of millions of sick Americans, and hundreds of millions sick around the world, is quite overwhelming. And even if the lingering disease proliferates at only a few multiples of the volume of deaths, the whole picture of the pandemic and its ultimate impact begin to look very different — and the failure to suppress the disease spread, as every one of our peer countries has done, even more catastrophic. Perhaps 45 million Americans have now been infected by SARS-CoV-2, counting those without a confirmed positive test. That is an alarmingly high number of potential chronic cases. Much of the world is waiting with bated breath for the arrival of a vaccine, which we hope may allow us to turn the page on this long, panicked phase of the pandemic. But millions of us may be carrying damage farther forward, even as the rest of the world moves on.