What happened to all the deaths that AREN’T from COVID-19?

I’ve seen this meme and the sentiments expressed therein posted around the internet, and from spending some time in ultimately futile arguments with the people sharing them, I am slowly coming to the realization that the “I wonder why” might actually be rhetorical. When I’ve tried to explain “why” so they don’t have to wonder anymore, it seems like maybe they thought they already knew the answer. In fact, shockingly, it seems that rather than a sincere question about medical statistics, they are actually implying that the COVID-19 death rate is being inflated for political or other purposes. So rather than continuing to offer my explanations to people who have sort of already decided they don’t want them, maybe I will offer them to you, who at least might find it a little interesting.

One word to begin with; one possible implication here (which has been stated explicitly elsewhere) is that Physicians are falsely attributing deaths to COVID-19 that are really caused by other diseases, in order to inflate these numbers. You will have to ask the conspiracy theorists for more details. For instance, what agenda are the doctors trying to forward here? If this is an anti-Trump thing, how did the libs manage to convert all of the 60 year old docs I work with that get mad when I turn off Fox News in the doctor’s lounge? If this is to give the current government more emergency powers or something like that, how did they convert the physicians I know who went into medicine to further social justice? We are a pretty diverse group here in doctor land, and if somebody has managed to recruit us all into a nation-wide conspiracy, I’d like to attend that person’s TED Talk. The medical community could use more people like you! The insurance companies, healthcare administrators, and pharmaceutical companies have been callously taking advantage of our compassion, energy, and time for years, and we, our families, and especially our patients are the ones who end up paying for it. So once you are done with your COVID-19 conspiracy please stick around and help us get organized!

To be clear, I have never heard of a doctor lying on a death certificate. It happens all the time on TV shows so it must happen in real life, right? And it probably does, at least sometimes. But if it does, it’s because that individual clinician has failed the integrity test, or more often the cognitive dissonance test, and described the events of the patient’s death in a way that diminishes or obscures their culpability. If that’s the case it really is shameful, and there are failsafes and powerful analytical tools in place (although I honestly believe, not used often enough) to ensure that the events of a patient’s death, especially an unexpected death, are really and thoroughly understood. I will say, most of the Physicians I know are more likely to swing the other way; to take on too much personal responsibility, to assign too much blame to themselves when a patient passes. We carry our dead around with us for years, and very, very often there wasn’t anything that anyone could have done differently. When there was, hopefully we have learned from it; but the pain may last nearly as long as the lesson. But all that to say, the idea of doctors across the nation suddenly embellishing death certificates and medical records to make a virus we HATE seem even more dangerous than it already is seems pretty ridiculous, aside from being just blatantly not true.

Of course, there are people who will be quick, especially when speaking to a Physician personally, to remove this culpability by one degree of separation; maybe it isn’t the doctors themselves but hospital administrators or bureaucrats, or the ‘deep state’ officials at the CDC and WHO, who are falsifying the data. Weary unto death, all I can answer is “fine, maybe.” There’s only so many layers of conspiracy theory I can personally unpack for someone. Listen, you won’t find many people who spend more of their time fighting medical bureaucracy than I do (I’ve written Hamilton rap parodies about it), but please consider the sheer number of people who would have to be in on it; governments across the globe and all across the political spectrum, Trump allies and critics alike, the army of scientists and researchers and analysts at these big organizations, most of whom stand to gain absolutely nothing by falsifying data and who have deep seated personal convictions about the integrity of their work, just like you and I do, and who probably have to be very careful talking about politics around the office because they have diverse and sometimes volatile political leanings, just like your office does. Not to mention the hundreds of thousands of Physicians, Nurse Practitioners, Physician Assistants, Nurses, CNA’s, Respiratory Therapists, and other healthcare workers around the globe who are sharing their personal stories from the hospitals they actually work at every day. I mean, thank you for extending the courtesy to not believe I am personally a dishonest, corrupt conspirator; but pretending that each physician you personally know just happens to be “one of the good ones,” but are ultimately naive and have the wool pulled over our eyes, really isn’t much better.

The real answer to this meme is a lot more straightforward, and quite frankly a lot more worrisome, at least for a Family Medicine Physician like me. You see, these “other” causes of death that this meme is talking about don’t typically cause death all at once, suddenly, all on their own. Most chronic conditions that statisticians point to as “leading causes of death”, like chronic lung disease, diabetes, and even most types of heart disease, won’t cause you to just suddenly die (again, especially certain cardiac conditions are an exception to this). If a person passes away suddenly and has Diabetes listed as a cause of death, you won’t hear their doctor tell the family, “well, you know, sometimes this happens when you have diabetes.” With most chronic diseases, death from that disease is going to be preceded by a sub-acute deterioration and/or an acute exacerbation, often triggered by other acute illnesses, lapses in care, and other factors. In fact, there will usually be multiple cycles of recovery and deterioration before the hospitalization that leads to their passing, depending on the specific medical condition and the patient’s wishes and planning for end of life care as that condition worsens.

In this way, most chronic conditions can, from a mortality standpoint, be thought of as severe medical vulnerabilities; if managed well, it is usually still going to take an event or acute illness of some kind to kill you, but those medical conditions make you that much more vulnerable to those events and illnesses. I have seen older people with congestive heart failure go into acute respiratory distress from pulmonary edema a few hours after eating salty movie theatre popcorn. I have seen poorly controlled diabetics rapidly deteriorate after just a few missed doses of (now unbelievably overpriced) insulin. I have seen cancer patients quickly pass away following a pulmonary embolism, a blood clot that formed in their lungs because the cancer makes their blood hypercoaguable. And of course, we have all seen countless men and women with COPD and CHF pass away from complications of the flu, which a younger person without similar comorbidities might have been able to weather at home. However, unlike other medical vulnerabilities (poverty, lack of transportation, living in a food dessert, marginalized status, etc.), these medical conditions are typically listed in the medical record under distinct diagnostic codes and are listed under the sequence of events in a death certificate. Because of this, it really is possible to track the degree to which these diseases are implicated in death over time. But these diagnostic codes are not mutually exclusive; if a Physician believes that a patient’s Diabetes and Congestive Heart Failure directly contributed to their death from Pneumonia, all of these would be listed both in the patient’s medical chart and in their death certificate. So depending on whether you are examining data for immediate causes of death, contributing causes of death, or underlying causes of death, you are going to get some drastically different data sets. Hypertension and kidney disease, for instance, are much more likely to be contributing factors to death than immediate causes of death.

So, with all of this background information, where are all of the deaths from stroke, heart attacks, and pneumonia? Well, I think there are four likely (and non-mutually-exclusive) answers to this.

1. You might notice that in contravention of the icanhazcheesburger act of 2014, this meme doesn’t actually cite any sources; nor have I seen any data sources that suggest the actual death rate attributable to standard leading causes of death have actually decreased. This may simply be a falsehood, pure and simple. Are you surprised? Welcome to the internet; I’ll help you build a geocities site. I’ve searched for data actually showing that over the last 2 months there has been a drop in all-cause mortality or non-covid-19 related mortality either regionally or nationally, and it just doesn’t seem to exist. If you have it, please send it along; I’d be very happy to sit down and pore over it with you (over zoom). If anything, and here’s where we really get controversial, there’s plenty of evidence that the statistics may actually BE UNDERESTIMATING mortality attributable to COVID-19. But that’s outside the scope of this entirely too long already post.

2. In some ways, we do expect death due to certain conditions to decrease during a pandemic. Social distancing means less travel and thus fewer accidents. Fewer parties and social events generally means fewer deaths from accidental drug overdoses and alcohol. Other more subtle factors are likely at play; less travel also means fewer patients who take a 5 day trip and forget to pack their blood thinner or insulin, and less eating out probably means fewer diet-related episodes of DKA or CHF exacerbations. Of course other causes of death, such as those related to suicide, domestic violence, and child abuse may go up; it’s too early to see all of the ramifications of the drastic measures we have taken to fight this terrible disease. The cost has yet to be counted.

3. The data does show that COVID-19 is “now the leading cause of death in the United States” as one news source put it (google it; I won’t clutter up this post with link after link). Does that mean that deaths from heart disease and chronic lung disease are down? Is that because doctors or administrators or the CDC is “recategorizing” these deaths as COVID-19 deaths? No. A great number of those COVID-19 deaths ARE deaths from heart disease, chronic lung disease, and uncontrolled diabetes, just as a great number of deaths from the flu are ALSO deaths from heart disease, lung disease, and diabetes. These vulnerable patients that have these diseases are the very same people we are trying hardest to defend with social distancing and innovative healthcare delivery and isolating suspected and confirmed COVID-19 patients. Doctors and nurses aren’t ‘wondering why people aren’t dying’ from these diseases anymore; they are seeing them dying from these diseases making them significantly more vulnerable to complications of COVID-19, and desperately trying to protect them. Data that shows the full set of contributing factors will still show these diseases; but you might see the underlying cause of death data be more readily available, because slicing data in a way that minimizes the impact of an actually terribly deadly virus isn’t particularly helpful in the middle of a pandemic. What we want to know is how dangerous is this virus to ALL of our patients, even and especially the ones we worry about already.

4. Finally, regardless of this meme’s failure to give any sort of statistical support, I highly suspect that there are patients who might have been in the hospital right now for their heart failure, their lung disease, or their cancer who aren’t because of the Pandemic. This is due to a lot of factors, but all of them boil down to a necessary but dangerous shift in treatment thresholds and an overwhelmed or potentially overwhelmed medical infrastructure. ER doctors have a higher threshold to admit patients to the hospital because, even more so than at normal times, they are safer from infection at home; the risk-benefit ratio has shifted. Clinic doctors are handling more than ever before over telemedicine and other innovative care options, but that transition in itself is going to mean that things are missed because the routine is disrupted. Where are the hospitalizations and deaths from heart disease and lung disease, from strokes and diabetes? They are there as part of the COVID-19 hospitalizations, certainly; but we are terribly, terribly afraid that they are also at home, with the worsening of their condition going unnoticed, and that by the time this pandemic is over and normal life resumes it will be too late to intervene. All of us are afraid of a second spike in COVID-19 deaths if social distancing measures are discontinued too soon, but we are also concerned about a third spike; a spike of all-cause mortality and morbidity from the disruption this pandemic is causing to our normal modes of treating patients. That’s why we are working around the clock to figure out the best way to take care of the patients under our charge while at the same time preparing for and fighting the battle with COVID-19. Maybe you are tempted to look at this last point and say, ‘see, this means we should open things up and get back to normal life!’ That would be a costly decision in terms of human lives; what good does it do to catch someone’s worsening glycemic control a month early if in doing so you’ve exposed them to a virus that will kill them in 2 weeks? We are having meetings daily and working past midnight to try to figure out how to do both; to care for the chronic diseases and catch the lurking threats early, and yet protect the patient from the known enemy that has already claimed AT LEAST 23,604 lives in the US alone since February 29th. It’s a moving target, but we are still in the middle of this fight, and for the physicians and nurses on the ground politics has nothing to do with it; we are fighting for our patients. That is, for you.

So please, from your facebook friend who also happens to be a doctor, think twice before sharing memes or youtube videos that imply we are all part of some big conspiracy (wittingly or otherwise) to inflate the pandemic and hurt this group or undermine that politician. I promise you we are all far too busy.

Edit: Please forgive typos, I have patient calls to do before bed and won’t re-read this monstrosity.

Edit 2: For anyone who cares, I’ll try to address that youtube video sometime this week. You know the one.

Edit 3: A colleague shared the original article, which would have answered the tweeter’s “I wonder why” if she had bothered to read it. It is written by another MD experiencing the ‘calm before the storm’ of social distancing measures in areas where the peak hasn’t hit yet, just as we are here in Waco. He mainly talks about the concepts I’ve discussed in explanation 4 and 2 above, in that order, and encourages people NOT to delay emergency care for other diseases or conditions out of fear of the virus, which is good advice.

What he does NOT do is imply that someone is alternating cause of death in reports.

You can read it here: https://www.nytimes.com/2020/04/06/well/live/coronavirus-doctors-hospitals-emergency-care-heart-attack-stroke.html?fbclid=IwAR2qO2ip3oihI9-cix00xQaVCPOKjORW4uIcX5GJEJsU9GaUfbJTEI3ore8#click=https://t.co/HOX2Tc5PWt