What follows is an OpEd that I co-authored with Andrew Foy, MD, from Penn State University. Andrew is an academic cardiologist who studies the quality of scientific evidence.
Two outlets have declined to publish our piece. This is not surprising given that we critique a research letter written by prominent academic leaders. As you read our take, please keep in mind that we oppose only the ideas expressed in the interpretation of data.
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The Journal of the American Medical Association recently published a research letter that reported an excess of nearly 12,000 deaths among younger adults this year. Of these deaths, slightly more than one in three were due to COVID19.
Three of the authors then explained their findings in an OpEd in the New York Times that ran with the title “People Thought Covid-19 Was Relatively Harmless for Younger Adults. They Were Wrong.†The subtitle doubled down on the fearsome messaging: “New research shows that July may have been the deadliest month for young adults in modern American history.â€
We do not deny the seriousness of COVID19, but we are concerned that prominent medical leaders have potentially misinterpreted their findings. This is remarkable because one of the co-authors is Rochelle P. Walensky, MD the newly appointed head of the CDC.
We offer four reasons why this study and OpEd do not support the claim that young adults should live in fear from the virus. The point of our critique is not to tell young people to avoid basic measures such as mask wearing and social distancing, but instead to counter the exaggeration of scientific findings—even if the intent is well-meaning.
The first problem relates to the authors’ choice to assess excess mortality rather than death due directly to COVID19. They state that this was a better way to assess the full burden of the pandemic, as “mortality in young adults may go uncaptured due to uncoded COVID19 and other pandemic-related mortality.â€
As doctors who care for patients in the hospital and ICU, we disagree with the premise that undercounting of COVID19 deaths in young adults is common. In an older person with numerous advanced organ diseases, it is sometimes difficult to sort out the true cause of death—especially when death occurs at home. But in a young person, without these chronic diseases, death due to COVID19 pneumonia is much more straightforward to diagnose.
If under-reporting of COVID19 death is not a major problem in young adults, then one could assess the burden of viral infection by simply counting the number of deaths from the virus. That has been done. A systematic review of more than a hundred studies has shown that the infection fatality rate for young adults is quite low. The authors even cite a study documenting the low case-fatality rate in this age group.
The second issue relates to the choice to compare excess deaths this year to accidental opioid overdoses from 2018. When we looked at the data presented in the paper and its supplement, we found that with exception of a few scattered months, in a couple of regions, COVID19 deaths were lower than opioid overdose deaths in 2018. An alternative conclusion therefore could be that COVID19 deaths in this age group are much less common than opioid overdose deaths. The authors acknowledge this point in their discussion of the study’s limitations.
The third issue is the tiny absolute increase in risk. An excess of 12,000 deaths sounds bad, but Professor Don Boudreaux, from George Mason University, has noted that there are nearly 88 million people in this age group. Thus, the individual risk for a person this age is found by dividing 4,560 (the number dead from COVID19 in this study) by 88 million. This equates to a 0.0052% risk of dying from COVID19.
While people have different risk thresholds, we struggle squaring a 1 in 20,000 chance of death from the virus with the following statement in the NYT OpED: “Young adults are dying at historic rates.â€
The fourth issue relates to the ratio of virus-related and non-virus-related death. The authors report that 38% were related to COVID19. We ask: what were the causes of the other 62% of excess deaths?
All practicing doctors understand that harm can come from both a disease and its therapies. In this case, the disease is the viral infection; the main therapy is societal interventions. Based on the finding that a higher proportion of deaths occurred from non-viral causes, why wouldn’t an impartial scientist consider the possibility that pandemic interventions have dealt more harm to young adults than the infection itself?
To prove this thesis would require a deeper look into the data, but we propose that it is reasonable to speculate that economic damage brought by the pandemic could have increased “diseases of despair,†such as depression, suicide and drug overdoses. Another plausible reason for an increase non-COVID19 deaths is avoidance of routine medical care and the postponement of non-emergent procedures.
In sum, the data in this research letter is inconclusive for drawing conclusions about the risk of dying from COVID19 infection in young adults. The authors noted some of these limitations in the manuscript, but then amplified a fearsome message in the New York Times.
We understand that the authors’ intention to nudge young adults to adhere to social distancing is benevolent. Our aim in submitting this critical appraisal is not to minimize COVID19 nor to attack the authors, but to uphold the impartial judging of science. Because without impartiality, public trust is lost. And trust will prove crucial for maximizing the benefits of the newly developed vaccines.
The young have many reasons—ethical and moral–to adhere to social distancing during the pandemic. Fear of death is not one of them. In our view, promoting flawed evidence is counterproductive.