Some acquaintances recently paddled surfboards and kayaks into the Pacific to disperse a relative’s ashes where he loved to surf. During the memorial service, one brother of the deceased expressed concern about the risk from sharks.
The image of an aggressive shark in the deep ocean is graphic and terrifying, but the risk of mundane threats far outweighs the risk from shark attack. The dead man’s brother should worry much more about heart disease, which felled his brother, and devote his attention to lowering that and similar risks. There is only so much time and energy; each unit of energy spent on lowering the risk from sharks is one less unit that can be spent on hearts.
What should we fear? What threats are most likely to kill us? Setting aside cataclysmic events such as nuclear wars and planet-altering meteorites, there are some risks that generate a lot of fear but few deaths, such as shark attacks, terrorism, and killings by police. On the other end of the spectrum are everyday risks that kill a large number, such as heart disease and cancer. In between are risks from motor vehicle collisions and the seasonal flu. And this year is a new risk: COVID-19.
This is from David R. Henderson and Charles L. Hooper, “What Should We Fear Most and What Should We Do About It?, Regulation, Winter 2020-21.
Another excerpt:
Larger risks / The typical American faces much greater risk of death from comparatively mundane causes. Heart disease kills about 1 in 502 Americans each year, while cancer kills 1 in 542.
The number of deaths from seasonal flu varies significantly from year to year, but it has averaged about 40,000 in the United States in recent years, which works out to 1 death in 8,125 Americans. The good news is that rate has fallen significantly over the decades; if the death rate from flu in the 1950s and 1960s were applied to today’s population, we would see over 160,000 deaths per year.
If the death rates from these diseases seem high, it is because they are. Heart disease alone kills as many Americans each year as the combined U.S. combat casualties from all American wars.
Read the whole thing and check out our table.
READER COMMENTS
Andre
Dec 7 2020 at 9:06am
Yeah, this is the drum I beat. Heart disease and cancer will each out-kill Covid this decade by a factor of 15. Combined, they’ll kill 5 people in 2020 for every person dying from Covid. And most of those deaths are entirely preventable. They just happen not to be contagious.
What’s more, most of the people dying of Covid have a co-morbidity such as advanced atherosclerosis. Many if not most would not have died of Covid had they had a healthy diet in the first place (see Esselstyn, Ornish), though for the very old (>80), that may not have saved them, either.
Alan Goldhammer
Dec 7 2020 at 9:20am
Yes, I did read the whole thing! The comments about deaths from influenza are misleading at best. Much of the past mortality resulted from secondary infections. The advent of multi-valent pneumonia vaccines along with antibiotics have reduced this risk. Most new strains of influenza have mild mutations and those with past exposure may possess immunity and of course there is the annual flu shot that is created from the circulating strains that are suspected to be risky.
SARS-CoV-2 is a novel virus with practically no human exposure (one cannot say zero as there may have been exceedingly low levels that were never detected). Despite being into the ninth month of the US pandemic we still don’t know what the herd immunity number is or the actual case fatality rate. The one thing we do know is there are a heck of a lot of hospitalization in all age groups. Most of these patients will recover though some will have lingering symptoms.
We have a case fatality rate of 0.3% from the UK for the Asian Flu epidemic of 1957-58. If you extrapolate that to present day US, the death number is far larger than what you note.
Finally, your comparison to deaths from cancer and heart disease to that from an infectious virus is not valid. Some cancers have a genetic cause and others are a result of stuff happening when you get old. Much of heart disease is a result of lifestyle choices though pharmaceutical interventions have made a marked contribution in this area.
I have commented in the past on your proposal to reform the FDA which seems to be recycled at four month intervals. I’ll not waste any time rebutting that as it continues to cherry pick selected references as well as a lack of understanding about current drug development and regulation.
JFA
Dec 7 2020 at 10:59am
“Some cancers have a genetic cause and others are a result of stuff happening when you get old. Much of heart disease is a result of lifestyle choices though pharmaceutical interventions have made a marked contribution in this area.”
Presumably this is also the case with Covid. Some people will be less susceptible to it due to various genetic factors, and the life style choices that lead to diabetes, heart disease, and obesity contribute mightily to people’s outcomes from Covid.
robc
Dec 7 2020 at 11:21am
COVID is also stuff that happens when you get old.
Vivian Darkbloom
Dec 7 2020 at 11:07am
“The comments about deaths from influenza are misleading at best. Much of the past mortality resulted from secondary infections.”
Alan, I don’t view this any more “misleading” than someone whose death is attributed to Covid merely because he or she had tested positive for the virus. Or, had never been tested for Covid, but whose death is attributed to Covid under the rather lax standards prevailing today in the US. Is this also “misleading at best”? Why apply a different standard to a death resulting from secondary infections if that person also had influenza?
“The one thing we do know is there are a heck of a lot of hospitalization in all age groups”. “Heck of a lot of” is a rather vague standard. What we do know is that a very percentage of those who die or are hospitalized due to Covid are under 65 and those who are almost always have serious co-morbidities. Here is one summary of the CDC data:
https://www.forbes.com/sites/theapothecary/2020/10/06/what-is-your-risk-of-dying-from-covid-19/?sh=5ec84ab86159
“Much of heart disease is a result of lifestyle choices…”
Ditto Covid and co-morbidities. Much of those co-morbidities creating greater risks to Covid are also due to lifestyle choices–obesity being a prime example. Again, why the double standard?
The real issue is what is the balance between the risk faced and the cost of and effectiveness of avoidance measures. I’m ok with the tradeoff of wearing a mask in indoor public spaces (although I’m skeptical that normal mask usage changes the odds much); but, wearing a mask outdoors doesn’t strike me as a good or sensible tradeoff. Neither does closing schools.
Michael
Dec 7 2020 at 11:56am
The best way to get around this issue is to look at excess all-cause deaths. Last I looked, that number was higher than “deaths attributed to Covid-19”, which is a pretty good indication that Covid-19 related deaths are not wildly overestimated.
Vivian Darkbloom
Dec 7 2020 at 12:31pm
“The best way to get around this issue is to look at excess all-cause deaths.”
That is not responsive to my point. The point is that it appears to me Alan is using a different standard for attributing deaths to influenza than he is to Covid. If we used the same standard for influenza, how many influenza deaths would there be or have been?
As for “excess all-cause deaths”, they are just that—deaths due to *all causes*. I can’t recall any period in recent history where influenza deaths or any other causes of death were calculated by using a rather artificial baseline and attributing all deaths in excess of that baseline to influenza or some other specific cause. Can you cite an example?
Michael
Dec 8 2020 at 6:19am
So, I agree that using different attribution standards is problematic.
Tracking all-cause deaths is a standard method in medicine/public health designed to get around any bias introduced by attribution. The number of deaths is fairly stable year to year, so if a lot more deaths occur in 2020 than the expected range, it can be detected. CDC shows it here:
https://www.cdc.gov/mmwr/volumes/69/wr/mm6942e2.htm
Vivian Darkbloom
Dec 8 2020 at 8:38am
Thanks for that link; however, it doesn’t address the central question. If we assume the CDC baseline is a valid one, then there indeed have been more deaths than anticipated so far in 2020 *for all causes*. This does not solve the question as to which specific cause (e.g., the corona virus) those excess deaths should be attributed.
You are undoubtedly aware of the study done by Genevieve Briand published in a Johns Hopkins journal and later deleted. Briand showed that per the CDC’s specific cause of death baseline for things such as heart disease, those causes are well under the pre-established baseline for the same period. If you believe in CDC baselines, then you need to acknowlege this is problematic and something that needs to be addressed. Most likely, in my view, this demonstrates the laxity with which deaths have been attributed to Covid rather than other possible causes; it stretches the notion of “causality” to limits not heretofore applied and supports the theory that the bias toward Covid causality has been significant. The data as a whole actually supports my initial point, to which you now agree, that the recordkeepers and the media have been using a different standard of causality for Covid than for other specific causes of death.
The bottom line is that yes, per the CDC baseline, there have been “excess deaths” due to *all causes* as I noted in my initial response to you. The unresolved issue is what standard of causality should be applied and, consistently using that standard to all possible causes, to which diseases those excess deaths should be attributed.
JFA
Dec 8 2020 at 10:00am
I couldn’t let the reference to Briand’s work go unchallenged. Please just go to the CDC website (https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm), click on “Weekly Number of Deaths by Cause Subgroup”, click “Update Dashboard”, and then choose “Circulatory diseases” under “Select a cause of death group”. You will see that deaths from ischemic heart disease are above the baseline (with a huge spike in April). The same goes for hypertensive diseases (with a shallower uptick in April). Deaths from diabetes are also above baseline. The other causes of death are right around the average of the past few years.
From the Technical Notes: “For the majority of deaths where COVID-19 is reported on the death certificate (approximately 95%), COVID-19 is selected as the underlying cause of death.” “Deaths with an underlying cause of death of COVID-19 are not included in these estimates of deaths due to other causes”. This means that all the deaths with an underlying cause from ischemic heart disease and hypertensive disease and diabetes are above baseline and are not just being tossed into the CDC’s estimate of Covid deaths.
There is no conspiracy in which Briand is being silenced. She did a shoddy analysis and thankfully her worked was pulled (though apparently not soon enough).
Michael
Dec 8 2020 at 8:47pm
Agreed. It is a complementary approach to the tracking of deaths attributed to Covid-19, since attribution will never be perfect and is a potential source of bias.
Robert Vodnoy
Dec 7 2020 at 10:23am
Hello David, I ran across your posting about my father, Dr. Bernard Vodnoy, the other day. I was delighted to read it–you captured the essence of the man. By way of correction, he contracted polio in 1950, which was 5-6 years before the vaccine, not months. It seems to me that the case of Scott Atlas is the reverse of the Vodnoy Paradox, that is to say that an ‘expert’ in one field was promoted to a government position in which he has no expertise, for political end. When you compound the problem we now face with ‘experts’ in every field self-promoting in social media, the problem is much worse than my father would have imagined (he died in 2006). The level of risk to the population posed by covid-19 has escalated dramatically, even compared to the high points last spring. Healthcare systems now face classic supply chain problems, the most critical being labor shortage. I wonder what you have to say about ‘experts’ who are muddying the waters with both the risks of covid, the benefits of simple remedies such as masking and social-distancing, and the risks/benefit of vaccination? As the son of a polio survivor (who also contracted a ‘mild’ case of polio in 1954, before the vaccine), I find the entire situation terrifying. Compare the public reaction to real experts now with how the public reacted to Jonas Salk.
David Henderson
Dec 7 2020 at 11:52am
Robert,
Thank you, and thanks for getting in touch.
I can’t take credit for my characterization of your father, who sounds like an amazing man. I was quoting from Art Diamond’s book, I believe.
You write:
I understand why you would think that way by looking at Scott’s title. But as a Hoover colleague of Scott, I’ve gotten to know him and his work over the years, and I do think he brought a lot of wisdom, including basic ability to parse aggregate statistics (something that Fauci seemed short on) to his White House position.
By the way, kind of tangential, but I’m both the son and the brother of two polio survivors, my father (1943) and my sister (1952).
Robert Vodnoy
Dec 7 2020 at 3:19pm
Nice to hear from, and sorry I confused who knew my father. I certainly don’t want to get into a back-and-forth about Scott Atlas, but 78 of former Stanford colleagues criticized his “falsehoods and misrepresentations of science” that “run counter to established science” and “undermine public health authorities and the credible science that guides effective public health policy” and 85% of the faculty senate voted to concur. His ideas about herd immunity were, as far as I can tell as a musician and not an epidemiologist, wildly off base. As far as his rejection of masks, there were anti-masking societies during the 1918 flu epidemic, too. Some Americans never seem from history.
I was sorry to read of your family’s experience with polio. Within my family, both my mother and father contracted polio, although only he had any paralysis. In addition to me, my mother’s cousin also contracted polio in the 1950s, and she was more profoundly effected.
David Henderson
Dec 7 2020 at 4:01pm
Thanks, Robert. Your father sounds like someone I would have liked to know.
I know you said that you don’t want to get into a back and forth about Scott Atlas, but I’m unwilling to those charges against him stand without being answered.
I read the letter from his Stanford medical colleagues twice, once quickly and once methodically. The reason for my second reading: as I told my MD who mentioned it to me, they didn’t give a single argument. They simply made accusations.
I also followed the Stanford Daily‘s story about the faculty attack on Scott. I wrote the reporter a follow-up about something I thought missing: the fact that Condi Rice, my boss at Hoover, had defended Scott’s academic freedom. The reporter affirmed that Condi had but that that part of her story had been cut because the news story was becoming too long. Possibly for the same reason, the story didn’t mention anything behind the faculty charges. But more likely, I suspect, is that the faculty had nothing.
Re my family’s polio, it worked out alright. My mother visited him in the hospital (although her family was very low income and his was high income, they were in the same church) and she played the ukelele for him. Shortly after, he proposed and in 1944 they were married. It turned out not to be a happy marriage, but, hey, I was one of the products.
Re my sister. She died suddenly two years ago and a few months before that we were reminiscing on the phone and the main she remembered from her time in the hospital at age 6 was being able to eat ice cream. 🙂 That was a luxury in our household. So polio wasn’t tragic for her.
Polio did affect how my father walked: his legs were like toothpicks or Manute Bol’s–take your pick. But he was physically active until about 5 months before he died at age 87.
JFA
Dec 7 2020 at 10:54am
I’m curious about this statement: “Put another way, COVID-19 subjects us to a risk equivalent to that of driving about 73,000 miles.” Earlier you put that there was 1 death per 80 million miles driven. Is there something I’m missing in the comparison between driving and Covid? Shouldn’t the 73,000 miles be about 600 million miles?
Also, (and this is a little nit-picky (a term whose true meaning I didn’t grok until my kids got lice at daycare)) you say the death toll from Covid will “be substantially below the tolls for both heart disease and cancer”. “Substantially” is certainly subjective, but I’m not sure “substantially” is appropriate here. Yes, the death toll from Covid will be about half that of cancer or heart disease, but Covid deaths will about 7.4 times as many as average seasonal flu (1 in 8125 Americans for the flu vs. 1 in 1100 Americans for Covid). Looking at the 2018 causes of death (https://www.cdc.gov/nchs/fastats/deaths.htm), the 3rd leading cause of death was accidents (unintentional injury) with 167,000 deaths. Covid will probably be this year’s 3rd leading cause of death with just about twice as many deaths as 2018 accidents. Probably “somewhat” instead of “substantially” is more appropriate, or just take the subjective part out altogether.
This is not a dig at you, but I wonder if you would comment about your earlier bet with someone (was it also Hooper?) about whether deaths would go over 100,000. What have you learned about your prior beliefs; what would your self from February or March say about the actual death toll being 3 times larger than that over/under threshold; how much more uncertainty do you place on your beliefs about the value of various interventions being correct?
David Henderson
Dec 7 2020 at 3:01pm
I don’t think I understand your first question in the first paragraph. Could you clarify?
I’ll respond to the other part later.
JFA
Dec 7 2020 at 4:35pm
I didn’t say it very well, so I don’t blame you for being confused. I guess I just don’t know how you came up with the “COVID-19 subjects us to a risk equivalent to that of driving about 73,000 miles.” But now thinking about it is it just solving the equation 1/1100 = (some # of miles)/ 80,000,000… there you go… not your fault… just took me a second thought to set up the problem properly.
David Henderson
Dec 7 2020 at 7:59pm
Ok, thanks.
Now to the other points.
You wrote:
I think of half as substantial, but others may differ. Given that we actually gave the numbers, though, the reader is free to differ but at least can differ on the basis of information.
You wrote:
Yes it was Charley Hooper. My belief was actually that it would go over 200,000 and I actually thought well over. So I’ve been right. I didn’t expect 400,000 but 300,000 doesn’t surprise me. My self from March would say that I was roughly right. When I was offering the bet, I wasn’t sure what the interventions would be. I didn’t anticipate Andrew Cuomo and Phil Murphy killing people in nursing homes, but I also didn’t anticipate the lockdowns lasting over 6 months. It’s not clear that the lockdowns have even worked, though.
JFA
Dec 7 2020 at 8:17pm
I knew you had won the bet. You had expressed that you thought you might lose and that you had been largely convinced by Hooper’s reasoning (though you still took the bet), so it surprises me that you say that you expected well over 200,000 deaths. I was also definitely surprised with Cuomo’s nursing home policy (and the media’s lack of interest in it).
David Henderson
Dec 8 2020 at 12:18am
Here’s an email I wrote to a colleague on March 9:
What made me start to think I might lose, as I explained back in, I think, late March, was the Diamond Princess case.
JFA
Dec 8 2020 at 6:49am
Cheers.
Jon Murphy
Dec 7 2020 at 10:57am
I suspect focusing on more deadly things like heart disease will also help lower deaths in unrelated areas. For example, COVID seems to really only be deadly in people with various existing health conditions. By reducing the prevalence of those conditions, COVID would become less deadly. In other words, it’s possible focusing marginal dollars on high marginal benefit areas, one can get even higher unintended benefits.
Thomas Hutcheson
Dec 7 2020 at 3:03pm
Part of the difference about what to do is whether the the actions we choose affect only our risks or risks to others. That extra slice of cheesecake raises only my risk of heart disease diabetes, etc. Going out without a mask exposes other to the risk that I will infect them and that they will go on to infect others.
David Henderson
Dec 7 2020 at 4:48pm
Good point. So going out without a mask is more like the example of driving a car.
Michael
Dec 8 2020 at 6:28am
The car example is better than the extra slice of cheesecake example, but still not quite analogous to an infectious disease.
If I go for the cheesecake, I endanger myself.
If I drive recklessly, I endanger myself and those I encounter on the road. But I don’t somehow inspire those I encounter to themselves drive recklessly and put others who I did not encounter at risk.
Not wearing a mask (in a setting where transmission of the virus is plausible) puts the people I encounter at risk, along with their families, the people they encounter and their familes, and so on.
David R Henderson
Dec 8 2020 at 12:37pm
Michael,
Good point.
JFA
Dec 8 2020 at 1:35pm
“If I drive recklessly, I endanger myself and those I encounter on the road. But I don’t somehow inspire those I encounter to themselves drive recklessly and put others who I did not encounter at risk.”
I guess that depends on how crowded the road is. You might be on a remote highway and run into one car. Or you might be on a crowded freeway, sideswipe one car, which then plows into a big rig, which then flips over blocking one side of the freeway (we’ll call that a superspreader event).
David Seltzer
Dec 7 2020 at 7:07pm
Thomas, your point: ” That extra slice of cheesecake raises only my risk of heart disease diabetes, etc.” raises an interesting question. If you risk your health, does that risk get socialized to others? Who pays the healthcare costs associated with obesity or heart disease if those extra slices are the cause? Are there higher health insurance premiums for people other than you? If that’s true, I’m at financial risk without commensurate reward.
nobody.really
Dec 9 2020 at 10:04am
Michael, on Dec 8 2020 at 6:28am, observed:
This illustrates social dynamics–a famously challenging issue for libertarians.
The larger point of Henderson’s article is to argue that the cost of testing drug efficacy exceeds its benefits. He sites a Frank Lichtenberg study saying “The estimates indicate that the increase in life expectancy at birth due to the increase in the fraction of drugs consumed that were launched after 1990 was 1.27 years—73% of the actual increase in life expectancy at birth.”
Note the word consumed. Drug production was not sufficient to produce these benefits; we also needed to persuade the public to actually take the drugs. Efficacy analysis may have some bearing on this matter.
Henderson also cites a 1973 analysis by Sam Peltzman:
What does today’s booming market for “herbal supplements” tell us about the market’s power to evaluate efficacy? It is unclear that supplements have any efficacy, yet people still buy them. On the other hand, it is not clear that supplements do much harm. And (consistent with a libertarian perspective) it seems not only socially sub-optimal, but individually intrusive, to deprive buyers and sellers from assuming their own risks related to a potential new drug.
So, returning to Michael’s initial thoughts: Perhaps we could conduct an experiment by relaxing efficacy requirements on drugs that have few social externalities. (David Seltzer sagely notes that, given our socialized medical marketplace, it seems likely that all health care decisions can have SOME social effects.) Can we identify medical conditions where a person’s choice to take treatment would have few impacts on others, akin to the choice to eat the cheesecake?
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