Why the COVID-19 Pandemic is Not the Worst Public Health Crisis in a Century

We have now had nearly 5 months to try to make sense of the COVID-19 pandemic. And while there is still much to learn about the virus, and our efforts to mitigate its harms, I think one think is certainly clear - the COVID-19 pandemic is not the “worst public health crisis in a century". Many pundits in the media and politics, and even public health officials, have claimed that it is. And I think it is important to accurately label such claims for what they actually are- hyperbole.

Just to be clear, I am not saying that the SARS-CoV-2 virus (which causes COVID-19) isn’t a serious global health problem- it is a very serious problem. But there have been, and are, much more serious public health problems than this new virus. And it is important to recognize this reality. Perhaps some hyperbole is needed to get people to take this new virus seriously. I will grant that point. But COVID-19 is clearly not one of the most significant health threats of the past hundred years. And I will explain why I think this is the case, and why it is important to acknowledge this reality.

In the twentieth century two major infectious disease pandemics stand out as the most significant health challenges of that century. The first was the 1918 (Spanish) flu pandemic which killed an estimated 50 million people. The 50 000 000 deaths (among a global population of less than 2 billion people) in 1918 are significantly higher than the 340, 000 deaths estimated to be attributed to COVID-19 to date in a world with over 7 billion humans. But the death count alone is not what made the 1918 pandemic so lethal, it was the toll it had on the young.

Nearly half of the influenza-related deaths in 1918-1919 occurred among young adults (20-40 years of age). This stands in sharp contrast to our COVID-19 pandemic. A disease that kills 30 year olds is much more devastating than a disease that kills 80 year olds in a nursing home whose health is already at high risk from multi-morbidities like cancer and heart disease. Had the 1918 flu pandemic been COVID-19 instead of the Spanish flu it probably wouldn’t have even been noticeable at the time given the global population was much younger at the time and few people survived to the ages where they would be most vulnerable to COVID-19 mortality. Again, I am not suggesting that the death toll from COVID-19 today is trivial. Each death is a tragedy for the family members impacted by the virus. And the same is true for the nearly 800 000 people who die from suicide every year, and the 1.3 million who die in traffic accidents each year, causes of death that are much less age discriminate than COVID-19.

COVID-19 is not a lethal disease for the young. This is important for citizens to understand so they can make sense of why the government will be re-opening schools for their children but keeping the kids’ grandparents isolated in nursing homes. Compare, for example, cancer deaths to COVID-19 deaths. Here is the CDC projected number of cancer deaths from 2010-2020.

(source)

This year alone it is expected that 630,000 people will die from just cancer. This number will be significantly higher than COVID-19 deaths (in the US this number is approaching 100 000 deaths). But what is even more significant than the larger number of deaths is the distribution of those deaths over the lifespan. Cancer is much more lethal for the young than COVID-19.
1,190 children under the age of 15 are expected to die from cancer in 2020 (source).

It is hard to find any data on how many children have died of COVID-19, but this report from the CDC in early April put the death toll at just 3 children. There are also worries about a (rare) complication from COVID-19, called Multisystem Inflammatory Syndrome in Children (see this). But even if we assumed a ten-fold increase in child mortality from what the data currently indicates, we are talking about numbers in the tens, not even hundreds (let alone thousands) of cases. So COVID-19 child mortality in the United States would not come close to making the top ten causes of death among the young:


(source)

More children die from firearm-related injuries every year in the United States than will from COVID-19. And yet little is done to reduce the former. One simply cannot call something "the worse public health threat in a century" when it doesn’t appear as even a blip on the leading causes of death among children. Period.

And when we look globally, not just within the United States, that message is amplified even more. According to the World Health Organization, approximately 6 million children and adolescents under the age of 15 years die each year. COVID-19 will not appear on the list of the main causes of childhood mortality. To call something the “worst public health threat” in a century when it does contribute to the mortality risks of the young in the world is myopic and distorted.

The other major infectious pandemic of the 20th century was smallpox, which killed more humans that century than any war or other infectious disease. Some estimates put the death toll from smallpox in the 20th century at 500 million people. No treatment was every developed for smallpox. But the development of a vaccine lead to the disease being eradicated in 1980. Smallpox is the only disease to have ever been eradicated worldwide.

The more common form of small pox, variola major, had an infection fatality rate of 30%. This means for every 100 people who contracted this form of smallpox, 30 people died. The COVID-19 infection fatality rate is an issue of fierce debate among scientists. Initially the World Health Organization estimated the mortality rate of COVID-19 at 3.4% which was higher than the fatality rate of the 1918 Spanish flu (>2.5). However this initial estimate for COVID-19 was based solely on the number of people who died in Wuhan, China compared to the number of people who tested positive for the virus after presenting with obvious symptoms requiring hospitalizations. We now know that most people with the virus have very mild symptoms. Most people who had the virus may not have even known they had it. An accurate infection fatality rate for COVID-19 cannot be determined if we only know the number of people who died from the virus but not the number of people actually infected.

More recent estimates of the infection fatality rate for COVID-19, such as this one from the CDC, puts it around 0.4% among symptomatic cases. Given that the CDC estimates about 35% of COVID-19 cases are asymptomatic, this means the actual infection fatality rate might end up somewhere in the 0.2-0.3%. That would be about 2-3 times the fatality of the flu, but only because it is much more lethal to the elderly and we currently have no effective treatments. However we must bear in mind that COVID-19 is much less lethal to children than the flu. The flu kills many more children each year than COVID-19 has killed. In 2018, for example, the CDC estimates that as many as 600 children may have died from influenza. Compare that number to the handful of deaths among children from COVID-19 and it is self-evident that this pandemic is not among the most significant public health threats of the past century.

Compared to the 1918 flu pandemic and small pox, COVID-19 is not a major threat to the health of human populations. But there is an even more important comparison to make to keep things in perspective. And that is the pandemic of chronic diseases that are ravaging the world’s aging populations. Cancer kills 10 million people every year, the vast majority of which are people over age 60. And cardiovascular disease kills a staggering 17 million people each year.

While the public and media have been quick to condemn those who violate the norms of social distancing and stay-at-home orders, we are much more tolerant of violations of public health measures like smoking cessation and a healthy lifestyle and diet. And yet non-compliance with the latter will cause many more premature deaths than COVID-19 ever could.

A sense of history and proportionality has never been more important than it is now. We need to get through the current global pandemic, that is true. But we must remember that once we have developed a vaccine or treatment for COVID-19 an even bigger challenge awaits us. And that is the pandemic of chronic disease. Unfortunately a remedy for COVID-19 will not aid us in combating the most prevalent diseases in the world today. It is imperative we place COVID-19 within its proper place in public health priorities so that public health funding priorities and public policies are informed by an accurate empirical understanding of the health challenges facing their populations vs sensational media headlines or opportunistic politics.

Cheers,
Colin