New York City’s death toll in the first Covid wave was unusually high. By the end of June the city had suffered excess deaths of 183 per 100,000 people. For comparison, nearby Maryland suffered 60 per 100,000 in the same period.
The reason so many people died in New York that spring has been speculated on since the start. One popular theory is that it was the mania for mechanical ventilators that was chiefly to blame. For instance, Michael Senger writes:
The outsized number of excess deaths in the area around New York is better explained by the particular hysteria in that region for mechanical ventilators which decreased the survival rate for patients over age 65 by 26-fold.
While Senger elsewhere allows that “other iatrogenesis” may have played a role, he takes the main culprit to be ventilators, as the above quote indicates. He is far from alone in this view.
However, it is straightforward to show from public data that mechanical ventilation cannot be responsible for more than 20% – or a fifth – of the Covid deaths in NYC that spring.
The first salient fact is that just 12% of NYC hospitalised patients were on mechanical ventilation as of April 4th 2020, according to a study in JAMA. The same study shows that the death rate for intubated Covid patients was 88%.
According to the CDC, 32% of NYC Covid hospital patients died during the first wave. (The CDC notes this rate was similar to the U.K. rate of 33%.)
If we assume that the 88% ventilator mortality rate continued after April 4th then ventilator deaths would account for 11% of all hospital patients and thus 34% of all hospital deaths (i.e., 11% ÷ 32%).
Hospital deaths were 79% of total NYC first wave deaths, again according to the CDC (this is assuming that deaths not at home or in a nursing home were in hospital).
This means that deaths of intubated patients accounted for 27% of total NYC first wave deaths (i.e., 34% × 79%). The normal death rate for patients on mechanical ventilation suffering from viral pneumonia is 22%, according to a study from Atlanta. So if we (conservatively) assume that all Covid ventilator deaths above that level were avoidable, preventing those would cut the NYC Covid death toll by 20% (i.e., 75% of 27%, where 75% is 100%–(22% ÷ 88%)). The NYC ventilator panic cannot be blamed for more than that.
It might be suggested that NYC simply intubated too many people unnecessarily and should have intubated far fewer. However, 12% of hospital patients being on mechanical ventilation is relatively low compared to, for example, England in its various Covid waves. The proportion of hospital patients on mechanical ventilation in NYC was not unusually high.
Why was the NYC ventilator mortality rate so high? The Atlanta study compares it to the rates for other states and finds it at the top end.
In some of the earliest reports of COVID-19 from Wuhan, mortality rates among those admitted to ICUs ranged from 52-62%, and increased to 86-97% among those requiring invasive mechanical ventilation. In more recent data from the United Kingdom, 67% of those who had received mechanical ventilation died, as compared to 22% of patients intubated with viral pneumonia in the preceding three years. Early reports of smaller cohorts from Seattle, where some of the first COVID-19 outbreaks occurred in the United States, indicated that 50-67% of patients admitted to the ICU and 71-75% of those receiving invasive mechanical ventilation died. A recently published report from New York also found high mortality of 88.1% among those who required mechanical ventilation.
For Atlanta, the study found a rate of 47% (49 died, 55 discharged), which the authors attempt to explain by suggesting that a policy of early intubation helped lower the death rate: “Our internal guidelines emphasised early intubation and standard lung-protective ventilation strategies.”
If Atlanta was intubating more readily while NYC was prioritising sicker patients, that could explain the difference. However, that would be the opposite of the iatrogenic theory, which argues that early intubation is what was killing people.
In any case, with intubated patients accounting for just 12% of hospital patients and 34% of hospital deaths, and hospital deaths making up 79% of all deaths, ventilators cannot be held responsible for more than a fifth of NYC first wave deaths.
The New York nursing home policy of discharging Covid positive patients into the homes has also been blamed for killing large numbers of older people unnecessarily. However, with only 12% of NYC Covid deaths occurring in nursing homes, there is a clear limit to how much that can explain as well.
Wrongheaded policies and treatment protocols certainly contributed to excess deaths during the pandemic. However, there can be little doubt that most of the excess deaths during Covid waves were due to the virus. That’s why they invariably closely track the other epidemiological measures. Symptoms, PCR test positivity, LFT positivity, genetic sequencing of variants, hospitalisations and antibodies all rise and fall together as waves pass through. A review in the Lancet of all 1,095 autopsies of Covid-positive patients in Germany found that 86% died directly due to the virus and 14% died with the virus as a secondary cause (or incidentally present).
Lockdown scepticism doesn’t rest on proving that COVID-19 is no more severe than the flu. Flu is generally understood to have a 0.1% fatality rate. Professor John Ioannidis estimated the fatality rate of Covid in the first wave to be around 0.4% in Europe and the Americas (note that NYC’s overall excess mortality, after three years, no longer stands out). The slightly higher fatality rate is not unexpected for a virus slightly more severe than influenza. Lockdown scepticism does not depend on convincing people that that 0.4% is really 0.1%. Rather, it depends on convincing people that our freedoms, prosperity and way of life should not be sacrificed in order to try to suppress or contain a virus with a mortality rate well below 1%.
Of course, we should also try to identify policies and treatment protocols that were harmful in order not to repeat them. And pointing out that interventions aren’t actually anywhere near as effective as claimed is always worthwhile. But the most important goal is to establish the priority of freedom over cowering in fear from a not-so-deadly virus.
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