“Indirect” Mortality During the COVID-19 Pandemic

As of July 9, 2021, a little over 600,000 Americans1 and four million people worldwide2 had died from COVID-19. Yet, according to experts, these data, as grim as they may seem, belie the true toll the coronavirus pandemic has exacted on public health. These official COVID-19 death tolls only include people who died as a direct result of contracting SARS-CoV-2 and developing an infection. But many indirect deaths not accounted for in reported mortality rates have occurred during the COVID-19 pandemic, possibly due to the disruption of medical services and people’s hesitancy in seeking medical care for fear of catching the virus.

An important study that estimated the prevalence of indirect COVID-19 deaths during 2020 was conducted by Islam et al.3 and published in April 2021. The researchers gathered data on the number of deaths from all causes in 29 high income countries and compared these figures against the expected number of deaths obtained from a model that accounted for historical baselines and seasonal variability in mortality. As expected, nearly all countries in the study had “excess deaths” for 2020: in total, about one million excess deaths occurred. But many countries also had more excess deaths than reported COVID-19 deaths even after adjusting for estimated underreporting of COVID-19 deaths, indicating a higher than usual level of mortality not directly attributable to COVID-19, though likely related to the pandemic. For example, both the US and UK had 30% more excess deaths, and some European countries had up to 50% more excess deaths than official COVID-19 deaths. The authors acknowledged that their analysis does not offer insights into the sources and mechanisms of indirect COVID-19 deaths, but their study provides strong evidence suggesting that indirect COVID-19 deaths occurred on a large scale in 2020.

Determining the causes of these indirect COVID-19 deaths is difficult, as the complex set of social and economic changes induced by the pandemic may have changed people’s decision-making and overall wellbeing, leading to higher mortality. One theory is that people died from medical conditions for which they would have sought lifesaving medical treatment had they not been afraid of catching COVID-19. Dr. Donald Lloyd-Jones of Northwestern University subscribes to this theory and noted that the number of patients presenting to the emergency room with heart attacks in 2020 decreased drastically as the hospitalization rates for COVID-19 increased.4 CDC data show that in 2020, over 690,000 Americans died from heart disease, compared to an average of about 646,000 over the previous five years.5 Dr. Jones has also suggested that the stress of the pandemic caused people to allow their health to worsen by gaining weight or cutting back on medication.4 The increase in American overdose deaths in 2020 could be a sign of this increase in stress.6

Stokes et al. estimated that 17% of excess deaths attributable to the pandemic were not assigned to COVID-19 on death certificates.7 These deaths could include mortality caused directly by COVID-19 that were misclassified and indirect mortality related to COVID-19. They also found that these excess deaths occurred at higher rates in counties with lower socioeconomic status and among people with comorbidities, which may indicate that indirect COVID-19 deaths account for a large percentage of the excess deaths. Regardless of the exact causes and statistics surrounding COVID-19’s indirect impact on mortality, it is clear that the virus caused more deaths than the official death counts would suggest.


“CDC COVID Data Tracker.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, covid.cdc.gov/covid-data-tracker.  

2 “WHO Coronavirus (COVID-19) Dashboard.” World Health Organization, World Health Organization, covid19.who.int.  

3 Islam, N., et al. “Excess Deaths Associated with Covid-19 Pandemic in 2020: Age and Sex Disaggregated Time Series Analysis in 29 High Income Countries.” BMJ, 2021, doi:10.1136/bmj.n1137.  

4 “U.S. Deaths from Heart Disease and Diabetes Climbed amid Covid.” CNBC, CNBC, 9 June 2021, www.cnbc.com/2021/06/09/us-deaths-from-heart-disease-and-diabetes-climbed-amid-covid.html.  

5 Ahmad, F. B., and R. N. Anderson. “The Leading Causes of Death in the US for 2020.” JAMA, vol. 325, no. 18, 2021, p. 1829., doi:10.1001/jama.2021.5469.  

6 Van Beusekom, M. “COVID-19 May Have Killed 20% More than Reported in US.” CIDRAP, 21 May 2021, www.cidrap.umn.edu/news-perspective/2021/05/covid-19-may-have-killed-20-more-reported-us.  

7 Stokes, A. C., et al. “COVID-19 and Excess Mortality in the United States: A County-Level Analysis.” PLOS Medicine, vol. 18, no. 5, 2021, doi:10.1371/journal.pmed.1003571.  

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