COVID-19 related deaths are indeed caused by COVID-19 and not by contributing health conditions
Underlying cause of death is defined as a medical condition that triggers a chain of clinical events that leads to the death of a patient. Contributing medical conditions can either be a consequence of that underlying cause of death or a pre-existing condition that weakens a patient’s resistance to injuries or diseases and indirectly contributes to their death. COVID-19 is the underlying cause of death in the large majority of recorded COVID-19 related deaths.
Flawed reasoning: Because 94% of COVID-19 death certificates listed contributing health conditions, the author of the claim incorrectly reasoned that only 6% of the deaths attributed to COVID-19 were actually caused by the disease. However, the contributing conditions listed on the death certificate can also be caused by COVID-19 itself, While others, like obesity, wouldn’t have been fatal in themselves.
Misleading: The underlying cause of death is the trigger for the events leading to death. These events are concluded by the immediate cause of death. The claim misleadingly overlooked the fact that a death from cardiac arrest (immediate cause) can be the consequence of COVID-19 (underlying cause).
The COVID-19 pandemic has affected the U.S. since early 2020 and caused nearly 31 million identified cases and 560,000 deaths in the country, and 2.9 million deaths worldwide, as of April 2021. Intensive care units being critically overwhelmed in several U.S. counties and the excess mortality in 2020 compared to previous years illustrate the toll of this respiratory disease on the population.
However, recurring misinformation has attempted to minimize the extent of the health threat by casting doubt on the COVID-19 death toll. This is the case of this claim relayed by One America News Network (OANN) that “the coronavirus itself is responsible for just 6% of all deaths listed as coronavirus related”, the others being “due to pre-existing comorbidities”.
To support its claim, OANN quoted numbers from Table 3 in this webpage (Table 3) by the U.S. Centers for Disease Control and Prevention the CDC. This aforementioned document from the CDC lists the additional “conditions contributing to deaths” on death certificates where COVID-19 is mentioned. Based on this report, OANN concluded that all the patients listed as having a contributing condition should have been listed as having died from that condition, and not from COVID-19. For instance: “28,000 died from cardiac arrest, yet all of these […] were marked down as died from the coronavirus”.#.
This reasoning is flawed as it conflates the immediate cause of death, the underlying cause of death, and comorbidities and misrepresents how cause of death is determined. A similar claim made by Donald Trump in August 2020 was previously debunked by Health Feedback.
In its guidelines, the CDC explains that the underlying cause of death is “the disease or injury which initiated the train of morbid events leading directly to death”. Part I of the U.S. standard death certificate clearly separates this underlying cause of death from the immediate cause of death. The immediate cause of death is the last event that directly caused the patient’s demise, whereas the underlying cause of death is the starting point of the chain of events leading to death. Robert Anderson, Chief of Mortality Statistics at the CDC illustrated this distinction with a practical example:
“We might see a chain of events such as acute respiratory distress due to chronic obstructive pulmonary disease. So acute respiratory distress would be the immediate cause of death and then the COPD – the chronic obstructive pulmonary disease – would be the underlying cause of death.”
Therefore, it is possible to have a death certificate listing both COVID-19 and cardiac arrest as cause of death. In that case, cardiac arrest, which is a directly fatal condition, is the immediate cause of death, whereas COVID-19 is the underlying cause of death.
In order to assess the death toll of a disease, the underlying cause of death is the primary factor to consider because without it there would be no death. As Anderson explained:
“Suppose a person is shot by another person but survives with serious complications from the bullet wound. If those complications result in death, even if it occurs years later, then the underlying cause would be homicide. And actually these sorts of cases would be investigated as a homicide as well.”
But by following OANN’s reasoning, if this person were to die from health complications resulting from their wound, it shouldn’t be investigated as a homicide and the murderer would walk free.
Jeff Lancashire, the acting associate director for communications at the U.S. National Center for Health Statistics (NCHS), explained in a fact-check by PolitiFact that, “In 92% of all deaths that mention COVID-19, COVID-19 is listed as the underlying cause of death”. In other words, COVID-19 was the initial cause that triggered the chain of medical events leading to the patient’s demise in the very large majority of cases. Therefore, those people died from COVID-19 and not just with COVID-19.
Importantly, the CDC didn’t say that all the listed contributing health conditions were pre-existing, contrary to what OANN claimed. While some conditions are pre-existing, such as diabetes, others may be a consequence of COVID-19, although not directly involved in the sequence of clinical events leading to death.
As Justin Lessler, an infectious disease specialist at Johns Hopkins University’s Bloomberg School of Public Health, explained in an article published by the university’s Office of Communications, some conditions are actually downstream of COVID-19, such as respiratory failure. In this example, the patient’s death would still be solely due to COVID-19, even though respiratory failure is listed on the death certificate as a contributing health condition. In other words, the claim ignores the fact that some of the listed contributing conditions like respiratory failure are a consequence of COVID-19 and not a separate cause.
Other listed conditions are aggravating factors that decrease the overall health of the patient and weaken their ability to survive COVID-19, such as chronic lower respiratory diseases, diabetes, Alzheimer’s disease or hypertensive diseases. These are called comorbidities. The death certificate explicitly defines comorbidities in Part II as the “other significant conditions contributing to death but not resulting in the underlying cause of death”.
Hence, the major difference between a cause of death and a comorbidity is that comorbidities are not part of the series of events leading to the patient’s death described in Part I of the death certificate. A person dies from an underlying cause of death, but dies with comorbidities. In many cases, if the disease or injury had been avoided, those patients with comorbidities, including pre-existing conditions like diabetes, wouldn’t have died at that time.
Furthermore, the claim incorrectly assumed that if a contributing condition was listed on the death certificate, then the patient must have always died from the contributing condition and never from COVID-19. For instance, there were 106,488 COVID-19 deaths where the patient also suffered from hypertensive diseases, as of 4 April 2021 (in the OANN news segment, the number was 44,000). There is no reason to assume that a patient suffering from hypertensive disease and COVID-19 would always die from the former and never from the latter. Likewise, not all deceased patients who were both obese and suffering from COVID-19 died from obesity and not from COVID-19.
Finally, the claim made by OANN doesn’t account for the magnitude of excess deaths recorded in the U.S. during the pandemic. The CDC compared the mortality from February 2020 to March 2021 with the mortality from the previous years and found an excess of more than 600,000 deaths. There is plausible explanation for why people with diabetes, hypertension or Alzheimer’s disease would suddenly die at a higher rate during 2020 compared to previous years. It is more likely that the emergence of a new disease, COVID-19, caused most of this additional mortality.
In summary, COVID-19 caused the death of more than 500,000 people in the U.S. as of April 2021. In many cases, the death certificates listed contributing conditions. Some may have been pre-existing conditions that weakened the patient, such as diabetes, while others may have been caused by COVID-19 itself, such as respiratory failure. In the vast large majority of cases, COVID-19 was the underlying cause of death that triggered the chain of events leading to the patient’s demise.
# The broadcast date of the OANN segment is unclear but appears to be from 2020 as it mentions 220,000 COVID-19 deaths in the U.S. whereas the death toll reached more than 560,000 as of April 2021. Data available from the CDC are thus logically higher than those mentioned in the segment.