As the COVID-19 pandemic persists around the world—even while some epidemiologists hold out the hope that it may be yielding to milder variants that human beings can live with as we do with the common ‘flu—there’s a grim distinction that doctors, linguists and statisticians are all debating. It has to do with prepositions.
What’s the difference between dying “of” COVID-19 and dying “with” COVID-19?
I have no desire to fuel “Covimania”, which I define as an abnormal obsession with information about COVID-19 and its variants. But the question is serious.
Dying 'Of' COVID-19, Dying 'With' COVID-19
The world is full of cases in the last two years where people suffering from serious ailments like advanced cancer or heart disease (or even simply what are often called “old-age ailments”) also contracted COVID-19, struggled to breathe, and passed away.
Some medical systems record their passing as caused by COVID-19, on the grounds that while they may have been weakened by their underlying disease, death was undoubtedly accelerated and precipitated by COVID-19. Other places go the other way, recording that the patient succumbed to the cancer or to a heart complication, rather than to COVID-19. The first implies dying “of” COVID-19 and the second dying “with” COVID-19.
This is not a trivial distinction. It affects local, national and global health statistics, which in turn influence the allocation of resources; lockdown policies and similar restraints that affect people’s lives and paralyse economies; public health measures to battle the disease; the willingness of people to travel to such areas; and, in countries like India, compensation to the families of people who have died from COVID-19.
Official government figures are based on such prepositions. But the fundamental question is of course a medical, not a linguistic one: What defines a COVID-19 death?
How the US White House Coronavirus Task Force Changed Its Parameters
The answer is complicated. The US White House Coronavirus Task Force said that even when people who have COVID-19 die from pre-existing conditions, they are counted. “If someone dies with COVID-19, we are counting that as a COVID-19 death.” This, in turn, led some critics to allege that COVID-19 totals were inflated by deaths from other diseases (and even auto accidents, if the victims happened to have COVID-19 when they crashed).
That last element changed: US Federal and state governments now require that in order for a death to be counted as a COVID-19 death, the disease had to have played a role in the demise.
But it’s also true that COVID-19 kills in various ways, and an infection can worsen existing afflictions. COVID-19, doctors tell us, can cause pneumonia and respiratory failure, but also cause blood clots, strokes and heart attacks, as well as render patients vulnerable to other fatal illnesses, such as septic shock or the notorious “black fungus” that took many lives last year in India.
Which do you count?
What is Written on Death Certificate Matters
Many COVID-19 patients have died from multiple causes, rather than just one thing. COVID-19 can often complicate a patient’s recovery from other diseases and conditions—even unrelated injuries—and indirectly contribute to their death. The virus’s impact on people with existing medical conditions—such as diabetes, hypertension, and heart ailments—can make COVID-19 one of several contributors to a death.
Some have even died because of, during or after botched medical procedures to deal with some aspect of their condition. When elderly people in advanced physical and mental decline due to Alzheimer’s disease and atrial fibrillation contract COVID-19, they die sooner than they might otherwise have. Did they die of COVID-19, if the illness merely accelerated their death from other causes?
The death certificate might go one way or the other as the doctor filling it out examines the roles of multiple medical conditions, the person’s medical history and most recent medical data and symptoms. They consider the “immediate cause” of death, followed by any “conditions that led to the immediate cause.” Sometimes COVID-19 is not the root cause but works as an accomplice to a killing—enabling or accelerating a death rather than directly perpetrating the fatality.
Confusion Over Recovered & Misdiagnosed COVID-19 Patients
The American state of Oregon considers all cases in which a patient dies within 14 days of a positive COVID-19 test result to be a COVID-19 death. The state of Alaska expressed it well on the website of its Department of Health and Social Services: “Whether COVID-19 shortened a life by 15 years or 15 minutes; whether COVID-19 is an underlying or contributing condition, the virus was in circulation, infected an Alaskan, and hastened their death.”
But what do you do if someone had COVID-19, but had recovered from the coronavirus when they died of something else? Or if COVID-19 wasn’t diagnosed, or if the person had no symptoms when he died of something else? Unless a post-mortem establishes COVID-19, you might never know – and you won’t officially declare – whether the person died of or with the disease.
Then there are those who died from other causes as a result of avoiding medical care because of the pandemic. Should we say they died from the disease but not of or with it?
Language is No Small Matter
The truth is that in every country the official numbers don’t capture all COVID-19 deaths, for several reasons. Inadequate testing, especially in the early stages of the pandemic; misattribution of symptoms to other illnesses; deaths at home rather than in hospitals.
But in many places, counting people who died of COVID-19 and with COVID-19 as the same thing, led to a public outcry of exaggeration—which prompted some in the US to change how they reported coronavirus deaths. After all, high numbers can generate what I call “Coviphobia”, which I define as an exaggerated fear of catching the coronavirus.
Many countries have measured “excess deaths”—the number of people who have died from all causes, in excess of the normal pattern for the annual number of deaths in that period in past years—to figure out if their statistics are broadly right. That’s how independent analysts have concluded that India’s corresponding numbers are not.
All this proves that language is no small matter. It’s vital to differentiate between people who died of or from COVID-19 and people who died with COVID-19. If the difference between “of” and “with” is so vital in determining the death rate from the virus, we should all mind our prepositions!
(Dr Shashi Tharoor is a third-term MP for Thiruvananthapuram and award-winning author of 22 books, most recently ‘The Battle of Belonging’(Aleph). He tweets @ShashiTharoor. This is an opinion piece, and the views expressed are the author’s own. The Quint neither endorses nor is responsible for them.)
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