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Editorial
April 2, 2021

Learning From Excess Pandemic Deaths

Author Affiliations
  • 1Harvard University, Cambridge, Massachusetts
JAMA. Published online April 2, 2021. doi:10.1001/jama.2021.5120

A comprehensive ability to anticipate and plan for future events distinguishes Homo sapiens from lower animals. But humans are flawed planners. Focusing on the near term has undoubtedly served humans well throughout evolutionary history, yet often leads to unintended consequences. Individuals eat the extra slice of pie with pleasure, but regret the indulgence when they stand on the scale. As small indiscretions accumulate over the years, they threaten health and well-being. Individual present-centeredness is mirrored in the larger society, which struggles with preparations for future needs and long-delayed risks. The maintenance of public infrastructure is a societal responsibility that is often deferred until it can no longer be ignored, as when a bridge collapses. Many are loath to bear the immediate costs of limiting carbon release into the atmosphere despite the growing awareness that eventually the failure to act will lead to environmental catastrophe. There are few rewards to legislators and government leaders who ask constituents to make sacrifices now to avert a future problem that seems as abstract and distant as it is potentially devastating.

Preparations for infectious disease outbreaks, like public health measures more generally, are stymied by the disincentives to commit time, effort, and money to plans for distant and uncertain risks. Public health experts have long warned that the US is not adequately prepared for massive influenza pandemics, even though such outbreaks have occurred regularly in the past.1 National and international agencies had flawed responses to the 2009 H1N1 influenza pandemic, including slow vaccine rollouts.2 The confused and disorganized response to COVID-19 in much of the US and other nations around the world is especially disappointing because the pandemic emerged about 100 years after the great influenza pandemic of 1918, just when another massive influenza outbreak was expected. Less than 2 years before COVID-19 became known, Bill Gates had presciently warned that the next pandemic might not be caused by an influenza virus but rather by “an unknown pathogen that we see for the first time during an outbreak, as was the case with SARS (severe acute respiratory syndrome) [and] MERS (Middle East respiratory syndrome)”3—both caused by coronaviruses similar to SARS-CoV-2.

The missteps in responding to an outbreak that not only could be, but largely was, predicted should not give governments confidence that they are prepared for threats that are more speculative and possibly further in the future. Failure to anticipate the scale of the potential damage from such future catastrophes will only exacerbate the tendency to downplay their importance, making it less likely that governments will prepare adequately. That is why understanding the toll of a pandemic is an important step in the right direction.

There is no more visible or alarming manifestation of the toll of the COVID-19 pandemic than the deaths it has caused. In this issue of JAMA, Woolf and colleagues provide updated analyses that demonstrate that the excess mortality in the US between March 1, 2020, and January 2, 2021, has been massive, amounting to a 23% increase over prepandemic levels, representing more than 500 000 excess deaths in 2020.4

Many COVID deaths have been misclassified, due to gaps in testing for SARS-CoV-2 as well as inconsistencies and delays in reporting.5 Furthermore, a pandemic can increase the risk of death indirectly, even among people who are not infected. Much of the toll of war takes the form of indirect deaths as well; until World War II, US armed forces in wartime were more likely to die of disease than from combat.6 The civilian population bears much of the harm. More civilians than soldiers died in the Second World War, for example.7 The economic and social disruption of a pandemic can lead to deaths due to privation, suicide, violence, and trauma. Recognizing the possible undercount that results from measuring only deaths directly attributed to COVID-19 on death certificates and similar sources, Woolf et al projected the number of deaths expected in the 10-month period beginning in the last week of February 2020 by extrapolating from prior-year mortality rates and trends. The difference between actual deaths that occurred in that period and the number expected is their more comprehensive measure of mortality attributable to COVID-19.

Methods for estimating excess mortality vary, making it difficult to compare results across studies. Nevertheless, it seems likely that COVID-19 will have contributed to nearly as many deaths in the US as the great influenza pandemic of 1918, and more than in any influenza outbreak in the US since then (Table).8-10 In earlier work, Woolf and colleagues showed that age-specific mortality from COVID-19 is more than half the mortality from heart disease or cancer.4 Stunning advances in science, medicine, and public health have greatly improved the current ability to detect viral disease and to treat many aspects of infection, but this progress has not been enough to overcome the toll of a highly contagious and potentially lethal pathogen.

Table.  Excess Mortality During Pandemics
Excess Mortality During Pandemics

Mortality from COVID-19 rises steeply with advancing age, in a pattern that largely parallels overall mortality.11 Age-specific mortality rates increased more for groups that already experienced greater mortality, such as non-Hispanic Black people, as reflected in projections of life expectancy at birth. Thus, as has been widely noted, the decline in survival greatly exacerbated racial and ethnic disparities.12

The burden of a pandemic, of course, extends well beyond mortality. Morbidity alone may be responsible for as much as 40% of the health costs of COVID-19.13 The loss of employment and decline in productivity in multiple sectors, disrupted schooling, and the shutdown of entire industries like in-person live entertainment and much of travel have upended life for nearly all of society. The corresponding economic loss—estimated as high as $16 trillion in the US, or about 90% of the gross domestic product14—is staggering. Yet for many people the significance of mortality is incontrovertible, and notwithstanding the challenges in attributing a cause of death, it is relatively straightforward to measure.

Tallying the cost of the pandemic can help in understanding how much society stands to gain by preparing for the next one. Preparations have substantial costs that are incurred long before they are likely to pay off. Just as military leaders prepare their armies for fighting the last war, society will always be better prepared to fight the pandemics of the past than the unknown pandemics yet to come. Catastrophic events are not simple replays of previous crises. Even if planning is both difficult and imperfect, it has an important role to play. The obvious failures—among them the neglect of the Strategic National Stockpile, widespread shortages of personal protective equipment, missteps in rolling out tests for the presence of the virus, overwhelmed intensive care units, mixed and often misleading messages from public officials, and lack of coordination within and between branches of government—suggest that basic planning measures could go a long way toward mitigating the consequences of the next pandemic.

Some progress has been made. During months of physical separation, developments in online capabilities allowed life to go on in ways that were barely imaginable a generation ago. The tools to manage pandemics have improved, including stunning progress in vaccine platforms that built on many years of research. The rapid development of multiple, extraordinarily effective vaccines is without precedent. Alone, though, these advances are not enough. The ability to take advantage of them depends on vigilance, improvisation, adaptation, and decisive action, all of which require specific planning. The US and other countries are most likely to learn from the pandemic if they understand the consequences of failure. The work of Woolf and colleagues illustrates what is at stake: despite the scientific, medical, and public health progress of recent decades, the loss of life attributable to the COVID-19 pandemic exceeds the mortality of major wars. No nation should squander this opportunity to do what it takes to prepare for the next one.

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Article Information

Corresponding Author: Alan M. Garber, MD, PhD, Harvard University, Office of President and Provost, Massachusetts Hall, Cambridge, MA 02138 (alan_garber@harvard.edu).

Published Online: April 2, 2021. doi:10.1001/jama.2021.5120

Conflict of Interest Disclosures: Dr Garber reported receiving personal fees from Exelixis Inc and from Vertex Pharmaceuticals Inc outside the submitted work. He also serves as director and chair of the board for the Center for Advanced Biological Innovation and Manufacturing (uncompensated).

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Woolf  SH, Chapman  DA, Sabo  RT, Zimmerman  EB.  Excess deaths from COVID-19 and other causes in the US, March 1, 2020, to January 2, 2021.   JAMA. Published online April 2, 2021. doi:10.1001/jama.2021.5199Google Scholar
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Kamp  J. States are finding more unreported Covid-19 deaths. Wall Street Journal. March 14, 2021. https://www.wsj.com/articles/states-are-finding-more-unreported-covid-19-deaths-11615730402
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Cirillo  VJ.  Two faces of death: fatalities from disease and combat in America’s principal wars, 1775 to present.   Perspect Biol Med. 2008;51(1):121-133. doi:10.1353/pbm.2008.0005PubMedGoogle ScholarCrossref
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Centers for Disease Control and Prevention. 2009 H1N1 pandemic (H1N1pdm09 virus). June 11, 2019. Accessed March 21, 2021. https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html?web=1&wdLOR=c0AE06F82-078D-453B-B65E-DDC625C07676
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Goldstein  JR, Lee  RD.  Demographic perspectives on the mortality of COVID-19 and other epidemics.   Proc Natl Acad Sci U S A. 2020;117(36):22035-22041. doi:10.1073/pnas.2006392117PubMedGoogle ScholarCrossref
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    2 Comments for this article
    EXPAND ALL
    Preparation & Politics
    Hardee Hodges, Physics | U of A
    Planning and preparation for remote possibilities are valid governmental responsibilities and the US has created multiple institutions to deal with the potentials. Leaders of these institutions must insist to Congress their needs. That the stockpile was allowed to not maintain supplies nor necessary periodic respirator maintenance is a leadership failure. Oversight organizations did not suitably act with urgency.

    In this pandemic the politics became enmeshed with the election producing even more dysfunction. The public has paid that price for the inability of leaders to cooperate. The press has not performed well in nonpartisan information
    amplifying the political instability. The Congress needs to lead in efforts that include restoring public faith in accountability.
    CONFLICT OF INTEREST: None Reported
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    Pandemic Deaths
    Peter Bogaty, M.A. M.D. | Laval University
    '...it seems likely that COVID-19 will have contributed to nearly as many deaths in the US as the great influenza pandemic of 1918...'

    This needs qualifying. First, the population of the US in 1918 was less than a third of today's. That would make the mortality of the 1918 pandemic four times that of Covid-19. Second, the 1918 pandemic was unique in the severity of the death toll in the 20-40 year-old healthy population contrasting with the mortality of Covid-19 preponderantly concentrated among the elderly, especially the very old. In terms of years of life lost, there is absolutely
    no comparison.
    CONFLICT OF INTEREST: None Reported
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