The novel coronavirus has infected more than 10 million people in the United States — nearly the entire population of Sweden.

As of Sunday afternoon, more than 237,000 Americans have died — 659 in Utah.

As striking as those numbers are, experts have long worried that a second wave of COVID-19 cases in the fall and winter would be even worse than the first, said Dr. Steven Woolf, a social epidemiologist and director emeritus and senior adviser at the VCU Center on Society and Health at Virginia Commonwealth University.

Utah governor orders statewide mask mandate to slow COVID-19 surge

As states loosened restrictions, the spring surge was never fully controlled and instead of an epidemiological curve we got a staircase. That means the impending second wave is more like a ”very dangerous” third surge, Woolf said. Growing case counts are being fueled by pandemic fatigue, decreasing vigilance and colder weather pushing gatherings indoors.

Utah’s figures are especially concerning:

The state’s current seven-day average for new confirmed cases is 2,290, which in a state of 3.21 million translates to 71 cases per 100,000 per day.

In New York, at the peak of its crisis in April, the Empire State was averaging nearly 10,000 confirmed cases a day. In a state of 19.45 million that translates to 51 cases per 100,000 per day.

“In terms of cumulative cases, there are more in New York,” said David Dowdy, an associate professor of epidemiology at Johns Hopkins Bloomberg School of Public Health, “but in terms of when we would have said New York was on fire — that’s where Utah is right now.”

As the country marches toward Thanksgiving, per capita cases is just one of two figures that epidemiologists and statisticians say offer a more nuanced and well-rounded view of the pandemic and its impacts. The second is excess deaths, a number that captures just how far-reaching those impacts are.

Most years, there are zero excess deaths in the U.S. — deaths above and beyond the number officials were expecting — but this year, there’s been nearly 300,000 so far, with two-thirds attributed to COVID-19.

This story explores the true human cost of COVID-19 and the forecast for winter. Because if changes aren’t made, even more people will die.

Dr. Erik Christensen, Utah’s chief medical examiner, poses for a photograph in his office at the Utah Office of the Medical Examiner in Taylorsville on Thursday, Oct. 29, 2020. | Spenser Heaps, Deseret News

Per capita comparisons

“The spread is happening in our homes and it is killing people and overwhelming our hospitals,” Spencer Cox, Utah’s governor-elect said Thursday. “This is crunch time. ... The next two months are absolutely critical. We are in a dire situation and we cannot emphasize that enough.”

Despite pleas from the governor and from Cox since summer that Utahns wear masks and socially distance, not all are willing to wear face coverings (some remain adamantly opposed) and many continue to gather, closely. Case numbers continue to climb.

And it’s not just in Utah.

The New York Times tracker shows a positive cumulative case rate for North Dakota of 7,127 per 100,000 residents — one of the highest rates in the country right now.

Thanks to advances in treating the disease, the number of people dying of COVID-19 isn’t increasing at the same speed as the number of cases, said Dowdy, but “at some point, the number of cases goes up so dramatically that deaths can’t help but follow.”

The mostly rural North Dakota is currently at 8 deaths per million — the only state besides Montana glowing red on the daily COVID-19 death rate projections from the University of Washington’s Institute for Health Metrics and Evaluation. Utah is at 1 to 1.9 per million.

The fact that the virus has seemingly moved from politically left-leaning blue states to more right-leaning red states, and states like North Dakota and Utah are now topping charts for all the wrong reasons isn’t entirely surprising, said Dr. Ali Mokdad, a professor of Health Metrics Sciences at the Institute for Health Metrics and Evaluation and chief strategy officer for Population Health at the University of Washington. Rather, it reflects the reality of how diseases spread.

The novel coronavirus first hit large urban hubs with international airports, wreaking havoc in big cities while giving folks in smaller cities a “false sense of security (that) this is not us,” he said. He’s seen the same thing happen with tobacco and HIV, where big cities were hit first, then rural communities — which are still struggling.

“By definition of epidemic, it’s going to hit everybody,” Mokdad said. “COVID-19 doesn’t know age, it doesn’t know geography, doesn’t know race. (It’s a) stubborn virus, opportunistic virus. Make a mistake, let down your guard, this virus is going to get you.”

Dr. Erik Christensen, Utah’s chief medical examiner, calls up an X-ray that shows changes in the lungs typical of a person who died with COVID-19 as he gives a tour of the Utah Office of the Medical Examiner in Taylorsville on Thursday, Oct. 29, 2020. | Spenser Heaps, Deseret News

Projections vs. realities

Utah, which staved off a major spike in the spring, is now dealing with the virus running rampant.

Masks are now required in 22 (of 29) counties where transmission levels are high and hospital officials are teetering on the edge of entering crisis levels of care, which means care rationing and even more exhausted providers — the very things flattening the curve was supposed to prevent.

But Utah’s numbers no longer portent a curve — just a line headed north.

In the latest Institute of Health Metrics and Evaluation projection, 2,121 Utahns will die from COVID-19 by Feb. 1, 2021.

In the United States, deaths are projected to total 399,163 by Feb. 1, with nearly 2,250 COVID-19 deaths a day by mid-January — three times higher than current daily deaths. (The institute usually issues new projections weekly.)

Institute for Health Metrics and Evaluation, University of Washington

Those numbers are based on states locking back down when they hit 8 deaths per million people — what 90% of states did in the spring when they reached those same levels.

Under that timeline, Utah would be locking down again sometime in December — along with Kansas, Oklahoma, Minnesota, Louisiana, Alabama, Pennsylvania, New Jersey, Connecticut and Massachusetts.

If states choose not to, or even loosen restrictions, numbers just climb higher: Utah potentially loses 2,932 people to COVID-19, the nation nearly 513,657.

IHME predictions about hospital beds considered facilities under “extreme stress” if more than 20% of regular beds or 60% of intensive care units are filled by COVID-19 patients. Utah is projected to hit “extreme stress” for both bed types by the end of December.

However, the projections also calculated that if 95% of people wear masks — the rate seen in Singapore — closures could be delayed and nearly 62,000 lives could be saved nationwide by Feb. 1.

“The best strategy to delay reimposition of mandates and the associated economic hardship is to expand mask use,” the IHME Oct. 22 finding brief explained.

In Utah, masking at 95% would mean a total of 1,381 deaths by Feb. 1 — about 740 fewer COVID-19 deaths than the current prediction.

Institute for Health Metrics and Evaluation, University of Washington

For Mokdad, who’s been in public health for more than 30 years, these upward trends are painful and discouraging. He would love to see people wear masks, limit mobility and stay distanced, and have his team’s numbers prove to be drastic overestimates.

“We hope that people will change their behaviors,” he said. “I pray that I am wrong, that people will make me wrong.”

And it’s possible.

Understanding modeling

Projections and models are good at predicting what will happen under certain circumstances, said Fred Brauer, a professor emeritus of the University of Wisconsin and currently an honorary professor of mathematics at the University of British Columbia who studies epidemiological modeling. However, they have a harder time capturing human behavior, which can change rapidly when faced with a serious disease.

Brauer notes that during the 2014 Ebola outbreak in Africa, the models predicted millions of deaths, but by the end of the crisis, the death figure was around 11,300 — still tragic, but significantly less than feared.

“The best explanation I’ve heard so far is people really changed their behavior and avoided the very dangerous funeral practices,” said Brauer, “even before there was any government move to encourage this behavior.”

People’s behavior changed because they took Ebola seriously, he said, which he hopes will finally happen with COVID-19.

“You don’t know what influences them,” he said, “whether it’s the number of cases, or the number of new cases or the number of deaths, we just don’t know.”

The door to the body cooler at the Utah Office of the Medical Examiner in Taylorsville is pictured on Thursday, Oct. 29, 2020. | Spenser Heaps, Deseret News

Excess deaths

One new alarming number is 299,028.

That’s the number of people who died in the United States from late January to Oct. 3 — above and beyond the number of deaths officials were expecting, according to a recent Centers for Disease Control and Prevention report.

Excess death is calculated by comparing all the deaths during a certain time period against the average number of deaths during that same time period in previous years, considering both population dynamics and seasonal fluctuations. Anything above the expected number for a specific time and place is considered excess.

Last year, like most years, there were zero excess deaths in the U.S., said Dowdy, but this year, there’s been nearly 300,000 so far, with two-thirds attributed to COVID-19.

“We have had a higher mortality rate on the U.S. level than in any recent year in history,” Dowdy said. “We know that this is a deadly disease.”

Excess deaths is an important metric because it adjust for flaws or gaps in record keeping that’s been disrupted by a crisis, said Nancy Krieger, a professor of social epidemiology at the Harvard T.H. Chan School of Public Health.

It also cuts out worries about politicization or manipulation of data.

Perhaps a state isn’t testing enough. Not a problem.

Faulty tests? Doesn’t matter.

What if a death is labeled a stroke instead of COVID-19 or vice versa? No impact.

None of these record-keeping problems affect the excess death figure, because it’s a measure of mortality stripped of all other factors. A death is a death.

During most Januarys in the United States, statisticians and epidemiologists project an average of 60,000 weekly deaths — both from natural causes like old age, influenza and other health conditions, plus nonnatural causes like car accidents, homicides and even skiing accidents.

They also calculate a “worst-case scenario” number, shown in the CDC excess death graphs as a red-orange line, meaning the highest number of deaths they would expect in any given week in a year.


The last time U.S. deaths broke through the orange line was late December 2017 — likely due to a particularly virulent flu season. But the peak subsided after January 2018 and deaths dropped below the orange line for the next two years.

Then COVID-19 hit.

By March 28, roughly two months after the first U.S. case, the observed number of weekly deaths was already punching through the orange line, peaking on the week ending April 11 at nearly 79,000 deaths — 36% higher than even the worst-case scenario of 58,266 deaths.

For more than six months, weekly U.S deaths remained abnormally high.

The week ending October 24, 2020 was the first time since late March that deaths fell below the “worst-case scenario” level — though deaths still remain above average.

From March to Aug. 1, Utah saw 953 excess deaths, with 311 or 33% due to COVID-19, according to Woolf’s research recently published in JAMA. His findings echoed the CDC’s: U.S. deaths have increased 20% during 2020.

In 13 of the last 17 weeks in Utah, CDC week-by-week death data show the state has surpassed the worst-case-scenario number of deaths — ranging from 13% to 26% increases this year over years past.

But if only two-thirds of the U.S.’s excess deaths — and one-third of Utah’s deaths (as of Aug. 1) — were caused by COVID-19, what else is causing so many people to die?


The other COVID-19 fatalities

Utah’s Chief Medical Examiner Erik Christensen is busier now than he’s ever been during his 12 years in this position.

Thus far in 2020, he’s seen 300 to 400 more non-COVID-19 deaths (not every death is reviewed by his office) than last year. While he doesn’t know all the reasons why numbers are so high, he has a few theories.

First, some of the “gap” deaths may be unclassified COVID-19 deaths.

Doctors are continually learning about COVID-19’s effects on the body, leading to more accurate labeling of such deaths now compared to what happened during the first months of the pandemic.

Christensen said he’s both diagnosing COVID-19 in previously undiagnosed deaths, (around a quarter of the 300 to 400 deaths) and removing any COVID-19 designation if it’s unwarranted (around a dozen times).

However, he — along with many other public health officials — believes the bulk of excess deaths are collateral COVID-19 damage: people dying as a result of “disruptions from the pandemic.”

Woolf further divides this group into three categories.

Cook County Medical Examiner forensic technician Pero Paunovich wheels the body of a COVID-19 victim from an emergency-management truck that just arrived at the medical examiner’s auxiliary surge storage center in Chicago on Tuesday, May 5, 2020. | Charles Rex Arbogast, Associated Press

The first is people experiencing acute emergencies — someone with chest pain who’s afraid to call 911 because of COVID-19 and dies of a heart attack. Or the reverse, someone who actually calls 911, but medical personnel are too busy with COVID-19 patients to respond.

The second group is anyone with a chronic disease — diabetes, cancer, HIV — who, because of the pandemic, can’t stay in control of their illness, develops complications and dies.

The third group includes those with behavioral health concerns like depression or substance abuse disorders who, “under stressors produced by the pandemic develop fatal complications,” said Woolf, noting that the opioid epidemic didn’t stop when the virus arrived.

Woolf said their research also found a spike in deaths from Alzheimer’s and dementia within states hit first by the pandemic. He noted nursing home residents are more likely to be dealing with those two diseases, and many nursing homes have been hit hard by the novel coronavirus.

These deaths may not carry a COVID-19 tag, but they will show up in excess death numbers — the collateral damage of a crisis and a view into how this “pandemic is shaping people’s risk of dying,” said Krieger at Harvard.

Other potential causes for the “gap” between the number of excess deaths and counted COVID-19 deaths are those who died as a result of domestic violence or homicides — results of being locked down with abusers or stuck in volatile situations during pandemic restrictions.

“While there’s some validity to the concern that our reaction to the virus and our steps to protect public health have these immediate harms, it’s a mistake to back off on trying to nip this in the bud and control community spread,” Woolf said, “because in the end, (failure to do so) will even cost even more lives.”

Salt Lake County mobile testers administer COVID-19 tests at the county’s testing site in the Maverik Center parking lot in West Valley City on Tuesday, Oct. 27, 2020. | Steve Griffin, Deseret News

Utah’s numbers

Having any mortality data at this point in the pandemic is helpful, considering mortality stats aren’t normally finalized until up to 18 months after the year in question, said Michael Staley, suicide prevention research coordinator with the Utah Department of Health. (He’s still waiting for official 2019 mortality data.)

Nearly every expert the Deseret News spoke with mentioned how time will prove a great clarifier for death data. Even the CDC notes on their graphics that “data in recent weeks are incomplete,” and that it can take up to eight weeks for mortality data to be at least 75% complete.

In the meantime, here’s a look at what Utah officials know about deaths in the state this year:

  • Suicide

There was a 30% decrease in the number of people seeking medical attention for suicide ideation during the first few months of the pandemic, but returned to normal levels around mid-June, said Staley. However, the number of suicide deaths hasn’t changed significantly in 2020 compared to 2019 or 2018.

  • Drugs

The drug overdose death rate has been going down since its peak in 2015, but did start to increase in April, said Staley. However, drug overdose counts are still within the average range.

  • Domestic violence
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In 2020, there have been 29 domestic-violence related deaths. Last year at this time, there’d been 32. However, calls to the Utah Domestic Violence LINKLine (1-800-897-LINK) have increased 25% to 50% since March, with an increased need for shelter and longer shelter stays, said Liz Sollis, spokesperson for the Utah Domestic Violence Coalition.

  • Traffic fatalities

By late October, 233 people had died on Utah roads. Last year at this time, it was 191, and in 2018 at the same time there were 234 traffic deaths, said Jason Mettmann, communications manager for the Utah Highway Safety Office.

Officials will continue to gather and sort death data for months, looking for ways to show the pandemic’s full impact on the state. Yet, even if the data aren’t perfectly clear yet, Christensen’s message is.

“Just wear a mask,” he said. “It doesn’t reduce things to zero, but every one we don’t have to deal with is somebody that’s still going home.”

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