The million US Covid dead are younger than you think.

Nearly a quarter million dead are under age 65 and Covid-19 was the leading medical cause of death among all US residents under age 55 during 2021.

One million people have now died of Covid-19 in the United States. As awful as this milestone is on its own terms, it is more painful because so many deaths were preventable. And more of these deaths occurred in younger people than is commonly realized.

In the early days of the pandemic, little could be done to stop the spread of Covid-19. It was not until a few months into the pandemic that we had good data to show that non-geriatric adults were dying at historic rates.

But we’ve known since 2020 that Covid-19 outbreaks cause a larger relative increase in deaths among young and middle-aged adults than in among seniors.

Yes, you read that correctly.

Covid-19 has caused a greater deviation from normal death rates among non-seniors than seniors.

Since the start of the pandemic there has been a 30% increase in all-cause mortality among US adults ages 18-49, and a 26% increase among adults ages 50-64. The increase has been “just” 17% for adults ages 65 and up. However, because the usual mortality rate for seniors is so much higher to begin with, the raw numerical increases in mortality among seniors has been greater, accounting for around two-thirds of all excess deaths since the pandemic erupted on US soil.

Covid-19 has caused a greater deviation from normal death rates among non-seniors than seniors.

It's hard to believe, but we’ve now actually spent more time with adequate testing capacity, effective vaccines, and knowledge about good masking and ventilation than we ever spent without those tools. These interventions have saved hundreds of thousands of lives. But had they been leveraged correctly, and by more people, they could have also saved hundreds of thousands more.

While it would take a dissertation to get to the bottom of why this happened, I believe one of the reasons that Covid-19 has killed so many comes out of a misperception of the risks. Many believe that Covid-19 is merely a cold for all young people and a death sentence for a handful of older folks who probably would have died around the same time anyway.

That is wrong.

We know there has been extraordinary “excess mortality”—that is more deaths than usual during the pandemic. It’s not just that people dying of cancer happened to have caught Covid in the last weeks of their lives. Rather, people are dying way early—sometimes months, but more often years and decades earlier than they otherwise would have. Overall, 3.4 million people died in the US in 2021, an all-time record. That’s around 525,000 more deaths than projected based on pre-pandemic trends (around 2.9 million deaths were “expected” last year). Around 88% of the excess mortality appears to have been directly attributable to Covid-19, though it’s unclear how much of the remaining 12% resulted of complications that were blamed on other causes.

What surprises many is just how many young and middle-aged adults have died. Nearly 250,000 people under the age of 65 have died of Covid-19 in the United States so far. Around 61,000 of these deaths were in people under the age of 50.

Covid-19 (red) was the leading medical cause of death for most of 2021 among US residents ages 0-64. It even eclipsed "external" causes (like homicide, overdoses, and suicide) at times, which is the leading cause of death among young people, generally. (Source: CDC, provisional data).

In the first 10 months of 2021, Covid-19 was the single leading cause of deaths among US adults ages 45 to 54, killing 30,361 people over that period. (We don’t know if Covid was the leading cause for the entire year because deaths from non-medical “external” causes like homicide, suicide, and drug overdoses are not yet available for November and December.) That’s more than heart disease (28,656), cancer (27,944), accidents (26,025), liver disease (8,695), and all other causes.

In the first 10 months of 2021, Covid-19 was the single leading cause of deaths among US adults ages 45 to 54.

When we look to younger groups, we find equally surprising and alarming figures. During 2021, Covid-19 was the leading medical cause of death in every single 5-year ages bracket starting at age 20-24, up through ages 50-54. In fact, in 2021, Covid-19 was the leading medical cause of death for all US residents under the age of 54 combined. Meanwhile, Covid was the 3rd leading cause of death (either medical or external) for all US residents ages 55 and older.

In 2021, Covid-19 (blue, far left) was the leading medical cause of death among US residents under age 55. (Source: CDC, provisional data).

So while many tend to think of Covid-19 as a disease that only threatens the lives of the elderly, the data don’t bear that out, even though the per-infection death rate is far lower, the younger the patient. In fact, the older we look, the less relative impact we see. Covid-19 was the 4th leading cause of death (either medical or external) among US seniors ages 90 and older in 2021.

During 2021, Covid-19 was the leading medical cause of death in every single 5-year age bracket starting at ages 20-24, up through ages 50-54.

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Looking through the data, what strikes me is that older people clearly have taken this pandemic seriously. Over 90% of US adults ages 65 and older have received two doses of a Covid-19 vaccine, 70% among adults ages 18-64, but just 30% in persons under age 18. So effective were vaccines during the pre-Delta era (and the vaccinations among the elderly were recent at that time), that there were actually periods in 2021 in which adults ages 50-64 had higher excess mortality rates per capita than those ages 65 and up. That’s an astounding achievement of vaccines, and a clear sign that the 20% vaccination rate gap between younger and geriatric adults had a massively harmful impact on those younger adults.

At the beginning of the pandemic, before we had vaccines and therapeutics, I once estimated that if Covid-19 were to infect most people in the United States, around 2 million people would die (I assumed that 85% of the population would need to be infected to achieve some kind of “herd immunity” state and that the fatality rate was around 0.7%, which is not far off the real average).

We are now halfway there.

The first half million deaths occurred in 2020 before we had vaccines. The only way we could have prevented most of those deaths would have been through the clunky but reliable hard work of better physical distancing, better air ventilation, and masks. To me, the saddest part is that we’ve recorded another half million deaths during the vaccine and therapeutics era. These are deaths that science gave us the opportunity to prevent. How far from 2 million deaths we remain will depend on how well our vaccines hold up and the emergence of improved therapeutics. But none of that will work if the public won’t accept what science and medicine have to offer.

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Sources: CDC Wonder provisional data, and my research collaborators at Yale's Center for Outcomes Research and Evaluation.