Monday, April 25, 2022

Causes of Death Among Young Americans


It has been nearly 2 years since I wrote this blog post arguing that the COVID-19 pandemic was not, and will not- at least in time- be viewed as, the most pressing public health threat of the past century.  

I still stand behind that initial assessment, despite what the media headlines have been saying for over 2 years.  Those headlines are designed to maximize "clicks" and reader interest vs portray an accurate and plausible picture of the public health challenges facing today's aging populations.   

One of the main reasons for my stance on this topic is that COVID-19 does not pose a serious health threat to the young (even before vaccines were developed).  Period.  

This does not mean the pandemic isn't a serious public health problem, it is a significant problem.  But it does not rank among "the highest public health problems of the past century" or even of today. 

Consider, for example, that in the pre-pandemic world of 2019 approximately 5.2 million children under the age of 5 died (source).  If you were to tell me, in the year 2019, that in the following year (in 2020) the worst public health threat of the past century would arrive what increase in the deaths among the young would I have thought would occur?  Perhaps an additional million deaths (or 20% increase)?  Or maybe, horrifically, a doubling of deaths to 10 million deaths among children under age 5 (a 200% increase) (edging us close to the 12 million deaths in the year 1990 (source)?  Had either of these developments occurred I would never have been motivated to write my blog post. 

But what actually occurred with the COVID-19 pandemic in terms of mortality among young children? Unicef estimates that the total number of COVID deaths among children under age 9 over the past 2+ years is... 5,628, or an increase of 0.1076% to the annual death toll among children under age 5 in pre-pandemic times.   After nearly 2.5 years of the COVID-19 pandemic the total number of deaths among persons under age 20 has only been 13,400.  Way more deaths occur in this age category every year in suicides (over 100,000 deaths in 2019- source), a year of suicide kills 20X the total number of COVID deaths among persons age < 20 since the COVID-19 pandemic has started.  And yet I have not heard any media headline addressing suicide among the young as a major public health crisis.  One could also mention deaths from accidents, or TB which killed an estimated 170,000 children in pre-pandemic world in 2018 (source).

Now of course there are two obvious rejoinders to my position.  The first criticism is that my position fixates too much on deaths among the young.  What about deaths among adults, especially older adults?  This response I will address below.  

A second rejoinder some may make is the argument that we avoided very high mortality rates among children because of measures like school closures, face mandates, etc.  I do not see any basis for that claim.  So I will ignore that response, but concede some people may think millions of children would have died from COVID-19 had we not closed our societies for close to 2 years.  But I am confident the evidence will show such claims to be false.

With respect to the first point above, that older deaths capture the severity of the pandemic, that takes me into much more familiar terrain as most of the my research over the past number of years looks at this issue. It is true most deaths from COVID-19 are among older persons, but it is also true that most deaths among older persons from are not from COVID-19.  We don't keep rolling annual death numbers for cancer (10 million per year = 23 million since the start of the pandemic), heart disease and stroke, etc.  If we did do this for causes of death in late life, chronic diseases would dwarf the death rate from COVID-19 (both pre and post vaccine).  This is not to trivialize the severity of COVID-19 pandemic, it is a serious public health threat.  But it is imperative to situate that threat in its appropriate context of the health risks for aging populations- COVID is a disease that is most lethal for older persons, persons that are also at high risk of multi-morbidity.  

The catalyst for my writing this blog post this morning was this Correspondence item in NEJM which details the leading causes of death among Americans age < 20 from 1999-2020 (including the first year of the pandemic).  And no COVID does not make this list as other causes kill more children and teens than COVID.  Of the deaths from 2020-2022 for ages 0-17 COVID is listed as the cause of death for only 1.3% of the deaths (or 1001 COVID deaths from the 76,892 of total deaths). 

Despite the low level of COVID deaths among young Americans there was a spike in two causes of death in the years 2019 and 2020.  Death from firearm injury is now the leading cause of death among children and teens in the US.  And death from drug overdose and poisoning also increased in this timeframe.  Over the past two years has anything been done to reduce these two causes of death among the young in America?  The problem is likely to get worse if other public health problems are bracketed and ignored because our attention and resources are fixated on mitigating the risks from COVID.

There is one last criticism that I concede deflates some of what I say above, but not the central claim concerning the pandemic's severity when compared to other (past and present) public health challenges, and that is the pandemic has had a huge adverse impact on children even if the virus has not caused significant mortality for them.  Death of caregivers has a huge impact on children, so I wanted to note that as the moral landscape is more expansive than simply pointing to mortality numbers.