By Ezio Di Nucci.

You are probably tired of discussing COVID-19; but please bear with me because the question I want to address here is a bit unusual: not whether too many people have died because of the pandemic, but whether too few people might have actually died. No, that’s not a typo – but I could have lost my mind.

New data from Denmark shows not only that there have been no excess deaths (that much we already knew) but also that in 2020 fewer people have died than in any of the last six years – despite the pandemic; or, indeed, because of the pandemic (or more likely because of the lockdowns imposed in order to control it)?

Some clarifications: people have in fact died of COVID-19 in Denmark (680 as of the time of writing); and while that’s not as many as in some other countries, once you adjust for population size you get around the same number as Germany, which has just short of 10,000 COVID-19 fatalities as of the time of writing. So that’s not nothing; we can debate whether that’s too many (it positively compares to a lot of other European countries, for example, not to speak of the US), but can anybody in their right mind wonder whether that’s too few?

Surely there is no such thing as too few fatalities in a crisis? Or is this particular crisis so radically different as to make logical space for this crazy question as to whether more people ought to have died this year? To try to answer the above (crazy) question, let’s take the Danish case, where 2020 appears to have been a good year in terms of mortality, because fewer people have died than in previous years. Isn’t a low-mortality year good news?

Well, it really depends on what happens in later years, because if a low-mortality year is, as we must suppose (people do die in the end, after all), followed by years with excess deaths, that might make those future years very uncomfortable both for those who die in those years and for those who survive those years (and this allows me to make one more clarification: our crazy question is neither specific to the well-being of those who die in the high-mortality years nor is it specific to the well-being of those who survive high-mortality years but rather refers to the well-being of both those groups).

It is for example plausible that dying in a high-mortality year is worse than dying in a low-mortality year, because you are likely to get less attention, both medically and personally. In a slogan: your funeral might have lower attendance in a high-mortality year than in a low-mortality year; hospitals might be busier, drugs harder to come by, etc. In fact we needn’t labour this argument too much because, for most of the world, 2020 is a high-mortality year and it certainly ain’t a pretty one.

Societies are organized around certain assumptions, including estimates about how many people will die each year (roughly: a bit less than 1% of the population for aging rich countries in Western Europe and North America); and while we might be able to accommodate gradual changes to such trends, dramatic shifts – in whichever direction – might be painful.

There are different scenarios for the effects that radical shifts in mortality could have:

• We could indeed adapt relatively quickly to radical shifts in mortality rates; in that case, a low-mortality year is good news even if it is followed by high-mortality years, as long as the overall sum of life-years or QALYs is greater; this option is optimistic but cannot be dismissed out of hand, at least non-empirically;
• Adapting to radical shifts in mortality rates is painful or expensive but, overall, still outweighed by increases in life-years or QALY totals; this option is probably the empirical reality for rich aging populations (at least before the COVID-19 pandemic);
• Radical shifts in mortality rates show that risk-taking in open liberal societies was too great, let us all learn to live a quieter but longer life (GDP per capita probably goes down but overall GDP is held up by increases in life-years if not QALYs – what happens to QALYs under scenario #3 is a good question, actually, thanks Mike);
• Increases in life-years due to an exceptionally low-mortality year (like 2020 in Denmark) are outweighed by QALY drops, in either the population that didn’t die in the exceptionally low-mortality year in question but will die in later high-mortality years or in the overall population (the human and economic cost of the lockdown, basically).

There might be more… it’s not up to me to decide between those different scenarios, I just wanted to point out the probably obvious fact that dying is bad but not-dying isn’t always better.

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Author: Ezio Di Nucci

Affiliations: Centre for Medical Science and Technology Studies, University of Copenhagen

Competing interests: none

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