The official coronavirus death toll in the United States passed 200,000 this week.

That makes it the fourth most deadly thing to happen in the United States, only surpassed by the 1918-19 pandemic, World War II, and the Civil War. That number is equal to nearly all the deaths in World War 1 times two. It is the equivalent of nearly four Vietnam wars, five-and-a-half Korean wars, 28 Iraq/Afghanistan wars, 45 Revolutionary Wars, and 67 9/11 terrorist attacks. People always say a high casualty count is “staggering,” but this one counts as “flabbergasting.”

The number is also an undercount.

While 200,000 deaths is flabbergasting on its own, it also under-represents the number of people who have died as a result of the pandemic. That’s because this pandemic has a bunch of secondary effects on society that also result in death: disruption to hospitals and nursing homes, sick people seeking less help and so on. It also has a few effects that actually save lives, but unfortunately less of those.

Let’s break down these secondary effects and what might be coming down the road.

Where extra deaths have come from

When we compare the numbers of deaths that we’ve seen in 2020 since February 1st to what we’d see in a normal year, there is a huge discrepancy. We see those 200,000 or so COVID-19 deaths, but we also see an estimated 89,699 additional deaths that didn’t have COVID listed anywhere on their death certificate.

So why did those other people die? Here’s what actually was on those death certificates.

Christopher Cherrington | The Salt Lake Tribune
Christopher Cherrington | The Salt Lake Tribune

The largest group of deaths came from those who died of Alzheimer’s and dementia: we saw 28,797 more of those deaths since February than we otherwise would have in a normal year. Why? There’s a thought that some of these deaths had undiagnosed COVID-19. Truthfully, a disruption in care or even family visits could have been the final straw in these people’s declines.

Hypertensive diseases are the next largest group, followed by heart disease. The heart disease deaths are interesting because they were so clustered early in the pandemic — a sign of the potential impact of hospital disruptions. Then come diabetes, cerebrovascular diseases (when the brain’s steady source of blood is impacted), heart failure, malignant neoplasms (a fancy term for cancer), and then flu and pneumonia. That last one is likely the result of an above-average flu season, before and during the initial part of the pandemic.

If you add up the totals above, you actually get 90,853 extra deaths — really close and just slightly over the estimate of overall excess deaths. These categories above are more than enough to account for the increase in deaths we’ve seen — which probably means there’s not a big expanded source of death due to the pandemic that we’re missing.

A quick discussion on suicide

This is one indication that, so far, we haven’t seen a huge increase in suicides as a result of the pandemic as many have feared. Those fears are reasonable — after all, 10.7% of Americans reported seriously considered suicide in a Centers for Disease Control and Prevention survey released last month, and mental health overall has clearly been on the decline.

We should also note that suicide stats are notoriously slow to collect — the latest national data is from 2018. We won’t really know how the pandemic affected total suicides in the U.S. this year until probably 2022.

Worldwide, we have some evidence of increases in New York, Thailand, and Nepal. But we also have evidence of decreases in Japan and numbers are flat in Australia. When we’ve examined natural disasters in the past, we’ve found either no change or even decreases in suicide.

That might be because people tend to come together to overcome a common tragedy. For example, after Hurricane Katrina, an increased number of people reported that they “became closer to loved ones” or “discovered inner strength.” On the other hand, maybe pandemics are different, because they lead to isolation: there is some evidence for an increase in suicides due to the 1918 pandemic.

We really just don’t know what’s going to happen here, and truthfully, a lot of it probably depends on the trajectory of the pandemic and the economic recovery from this point forward. But so far, it’s hard to find data that points to a surge in actual suicide in the U.S. In fact, non-natural deaths, a category that includes suicides, have declined in the U.S. during the pandemic.

While we are on this topic, If you or someone you know is at risk of self-harm, the National Suicide Prevention Lifeline provides 24-hour support at 1-800-273-8255.

A decline in doctor’s visits

What we have documented is a definite decrease in the number of people who get in-person care for their health problems. We’ll just run through the list here:

• 41% of Americans report having avoided medical care due to COVID-19.,32% said they had avoided routine care, and 12% said they had avoided emergency or urgent care. Avoidance of health care was more common among people with underlying medical conditions or disabilities, Black and Hispanic adults, and young people.

• The number of people diagnosed with cancer dropped 46% in the United States. This isn’t due to reduced cancers, of course, just fewer people are getting checked for it.

• According to the CDC, emergency room visits for heart attacks declined 23%, visits for stroke declined 20%, and visits for hyperglycemic crisis declined 10% in the 10 weeks after the pandemic began.

• We saw a huge increase in the rates of people suffering from heart attacks without going to the hospital in varied places like New York City, Denver, France and Brazil.

• Stillbirths have jumped during the pandemic worldwide, including in the U.S. Figuring out whether these are due to undiagnosed COVID-19 or fewer pre-natal doctor visits is difficult, but most doctors seem to be pointing toward the latter.

• Routine vaccinations are down. In a CDC study from Michigan, among kids who were supposed to get vaccinated during the pandemic, fewer than 50% of kids were up to date.

Let me be extremely clear about this: To the extent possible, do not avoid health care because of the pandemic. Avoiding treatment for a heart attack or literal cancer because you’re worried about COVID-19 is a classic example of being penny wise but pound foolish. If you are queasy about going to the hospital or seeing a doctor, we have a solution for you: Use telehealth services to speak to a doctor. But... just... do something, even for the small stuff.

It’s hard to know how much increased death we have seen and will continue to see due to this decline in people seeking health care, but it will be significant. I’m already anticipating people blaming these deaths on the media’s pandemic scare tactics. But look, I’m part of the media! And here I am telling you to seek health care.

Good news about the flu

After all that extra death, I wanted to end on this positive note.

As you probably know, there are a bunch of different types of flu. Here are the types we saw on a weekly basis in this year’s flu season.

https://emergency.cdc.gov/coca/ppt/2020/COCA-Call-Slides_091720_Final.pdf

Every year, a consortium of flu doctors nationwide have to figure out two things: what kind of flu vaccine is going to be most effective, and how much of it to distribute. They do this by looking at what’s happening in the Southern Hemisphere’s flu season — our summer, their winter — knowing that the types of flu that are spreading down there are likely to be the ones that spread in the U.S. when our winter rolls around. They also know that a bad Southern Hemisphere flu season likely means a bad one for us as well.

But when they’ve looked at the Southern Hemisphere this year, they’ve had a problem in finding out which types of flu are most prevalent. There just are hardly any cases of flu in those countries, period. Take this graph of Australia’s flu season: the various dotted lines are flu positivity rates in previous years. The solid line you can barely see at the bottom of the graph is this year’s flu positivity rate. They’re still testing people, but there’s hardly any flu out there.

https://www.cdc.gov/mmwr/volumes/69/wr/mm6937a6.htm?s_cid=mm6937a6_w
https://www.cdc.gov/mmwr/volumes/69/wr/mm6937a6.htm?s_cid=mm6937a6_w

The same is true in other southern countries like Chile and South Africa, and this makes sense. While our coronavirus restrictions and precautions haven’t eliminated the coronavirus, just mitigated it, the coronavirus is more contagious than the flu. That means steps that are just harmful to coronavirus transmission look devastating to flu transmission. Here, the secondary effects of the pandemic are actually helpful.

Now, because everyone is worried about the potential hospital-destroying effects of a busy flu season combined with a busy coronavirus season, American doctors erred on the side of caution and ordered more flu vaccine doses than usual. That makes a lot of sense, as does getting the flu vaccine this year. But if the flu season in the Northern Hemisphere is anything like the one in the Southern Hemisphere, we’ll see huge decreases in flu sickness and death.

Is that just a silver lining to a flabbergastingly dark cloud of the pandemic’s excess deaths? Yeah. But with a potentially tough winter ahead, it’s a silver lining we all could use.

Andy Larsen is a data columnist who is focusing on the coronavirus. He is also one of The Salt Lake Tribune’s Utah Jazz beat writers. You can reach him at alarsen@sltrib.com.