California saw nearly 20% more deaths since 2020, and COVID alone can’t explain it

The state has seen the biggest rise in causes of death in drug overdoses, Alzheimer’s disease and alcohol-related conditions.

Three years after the first COVID cases were detected in the Bay Area, a vexing question persists that can no longer be explained by the terrifying arrival of a deadly novel coronavirus: Why are so many people still dying?

Since 2020, California has recorded 130,000 more deaths than in the three previous years, a nearly 20% increase in mortality, the largest sustained spike in more than a century, and the reversal of a decades-long trend of decreasing death rates. In essence, experts say, that’s 130,000 more burials, cremations, viewings and funerals than there should have been.

Those lost lives, referred to as “excess deaths” in the public health world, are the number of deaths over what could be expected based on historical data and demographic trends. COVID-19 — which was first confirmed in California in late January 2020 — is the obvious culprit for the bulk of them. But officially the virus is blamed for just under 100,000 of those deaths. So why did the other 30,000 Californians die?

No single cause explains the momentous change, according to the California Department of Public Health. Since early 2020, aside from COVID, the Golden State has seen the biggest rise in causes of death in drug overdoses, Alzheimer’s disease and alcohol-related conditions followed by hypertensive heart disease, ischemic heart disease, stroke, diabetes, kidney diseases, road injury and homicide.

Nationally, Robert Anderson, chief of the Mortality Statistics Branch at the National Center for Health Statistics, is seeing much the same.

“It’s those non-COVID excess deaths that are really tricky,” he said.

Why are they going up now?

“The pandemic certainly is a factor,” Anderson said, “Whether it’s the virus itself [exacerbating other health problems] or whether it’s other factors related to the pandemic, it’s hard to know for sure.”

While the reasons might be complex, you don’t need a fancy formula to see that more people than normal are dying.

In California, those excess deaths started early in 2020, and — except for a few weeks — have continued the last three years to exceed the upper limit of what was expected, based on historical trends.

California’s deadliest week in the past six years was the first week of 2021, when 11,908 people died in the Golden State. COVID was responsible for 4,858 of those deaths, according to the state health department. But that left an additional 7,050 people dying from other causes.

During that week, ending Jan. 8, 2021, the number of reported deaths was nearly double the number of expected deaths, according to estimates published by the Centers for Disease Control and Prevention. Even if you subtract the record-high official COVID deaths, more people died in California that week than even the deadliest week in the three years before 2020.

Overall, the data show that when COVID deaths have peaked in the past three years, so have other deaths. And while the number of deaths was lower in 2022 than in 2021, there are more non-COVID “excess” deaths now than early in the pandemic.

This pattern of continued excess deaths is happening around the country, not just in California.

Each faction in the grand COVID debates has its explanation: the COVID-cautious say the true toll of the virus is undercounted; others think lockdowns have played the biggest role, disrupting the psycho-social fabric with a parallel epidemic of loneliness and isolation; still others blame delayed medical care. Many are concerned the health care system has been stretched too thin by years of continued crises.

Dr. Monica Gandhi, a professor of medicine at UC San Francisco, thinks the negative impacts of early lockdowns and large-scale social distancing efforts like work-from-home are an overlooked contributor to recent increases in mortality — especially in places like the Bay Area, where lockdowns were long and strict, compared to other parts of the country.

But she also points to the pandemic causing massive disruptions in our health care system. “I had a lot of patients who were scared of coming in,” Gandhi said. Now she is seeing many patients who waited too long to seek care, and are having worse outcomes.

Dr. John Swartzberg, clinical professor emeritus of infectious diseases and vaccinology at UC-Berkeley’s School of Public Health, agrees that some people may be dying now because they avoided medical care during the pandemic. “But there’s also the piece about COVID having had a profound effect on our health care system,” he said.

“The workforce … has declined considerably,” he said, raising a quiet concern from the field that outcomes at hospitals might not be as good now. Simply put, there are fewer health workers and more patients. “They don’t have the same resources they had before COVID.”

Swartzberg thinks there is also merit to the argument that some of the long-term effects of COVID are not being counted in the virus’s official toll.

Anderson acknowledges some COVID deaths might not get labeled as such. “The reason why it gets so complicated is that COVID can result in circulatory complications, it can complicate diabetes, it can also result in neurological complications,” he said.

For example, a study published last year in Nature Medicine used data from the Department of Veterans Affairs and found an increased risk of cardiovascular disease for those who had been diagnosed with COVID, compared to those who had not.

We are also seeing more “diseases of despair,” Gandhi said, like suicide, homicide and overdoses since the pandemic began.

Then there’s the overdose problem.

Statewide the California Department of Justice said 5,502 people died of opioid overdoses in California in 2020, a marked increase as fentanyl overdoses have exploded in recent years. More young people have been dying too, and fentanyl is a major contributor, now behind 1 out of every 5 youth deaths.

San Francisco notably saw more overdoses in the past three years than COVID deaths in the same period, but the city has had unusually low COVID deaths and unusually high overdose deaths in that time period, compared to the rest of the state.

Before 2020, periods of excess deaths were relatively infrequent and typically an indicator of bad flu seasons, Anderson said. What’s happening now is unprecedented in modern times.

“It’s complex,” Anderson said. “I think that that’s the important message. There is no easy explanation.”