“Of” versus “With.” Covid deaths are getting harder to count, but they still matter.
Whether or not Covid is the main or contributing cause of a death matters less than many think. Too many people are still dying overall.
Note: I originally published this essay on Bulletin.com on November 4, 2022. A CDC analysis with the same findings was published November 16, 2022.
Did that patient die "of Covid" or "with Covid?"
Early in the pandemic, just about every Covid-19 death looked the same. Patients had pneumonia all over the lungs, had low oxygen levels, were gasping for air, and were dying either before they could be placed on a ventilator, or despite it.
The numbers were staggering, as we all know. Among doctors filling out death certificates, the “underlying” cause of death among Covid-19 patients was almost always straightforward: Covid-19. Virtually all Covid deaths were in people clearly dying "of" Covid.
But death certificates also have “contributing” causes of death. Figuring out which disease was the underlying cause and which were contributing causes can be easy or hard, depending on the case. When someone clutches their chest, collapses, and dies, a heart attack should probably appear as the underlying cause of death, while some underlying conditions like high blood pressure and diabetes might appear as contributors.
Many times, it’s more complicated. If a patient with advanced cancer gets influenza and dies, what was the underlying cause of death? Was it the influenza infection? Or would they have survived that illness if their cancer had not wiped out their immune system?
As the pandemic protracts, these types of questions are getting harder with respect to Covid. Covid patients rarely have that awful pneumonia we used to see on every x-ray and they rarely have low oxygen levels, like we saw early on. That doesn’t mean Covid did not kill many or most of them, though. Indeed, most deaths in people who died while infected with Covid-19 were not merely “incidental Covid deaths,” where Covid had no role in the death and just happened to be along for the ride (e.g., rare cases where a patient dies after going to the OR for a gunshot wound and happened to test positive for Covid). It’s just a little less clear how much of the blame Covid deserves in many cases nowadays. Imagine a patient who dies of a stroke during the peak of a Covid illness. Does Covid deserve 20% of the blame or 80%? Did the patient die "of Covid" or "with Covid"? It's impossible to know.