During the pandemic, Covid-19 catapulted to the No. 3 killer of Americans in 2020 and 2021. What a difference a few years make.

Researchers at the National Center for Health Statistics Branch, Division of Vital Statistics, revisited mortality rates nationwide (Ahmad, Farida and co-authors, "Leading Causes of Death in the US, 2019-2023, Journal of the American Medical Association, Sept. 24, 2024). Covid-19 deaths have declined from 416,893 in 2021 to a still disconcerting 49,928 in 2023. In the wake of vaccinations and general population immunity, we saw one-eighth as many deaths last year, compared to what we experienced at the pandemic peak.

The 2021 death rate was 104.1 deaths per 100,000 people annually, versus 11.9 deaths per 100,000 people annually in 2023. Looking at a community Fairfield, with about 200,000 people, we would have seen about 208 deaths at the peak of the pandemic, versus about 22 deaths last year, if national rates applied locally. Clearly, factors related to individual cities and populations require health officers to track local data for specific figures.

What about the overall mortality figures, nationwide? As of 2023, the total all-cause deaths in our country were 3,090,582. That would translate into 750.4 deaths per 100,000 people annually, or about 1,500 deaths in a town of 200,000, like our own Fairfield. It is reasonable for us to maintain estate plans, and to address advance medical directive preferences. As a university physician pointed out to me years ago, "no one gets out of this life alive."

Heart disease is America's No. 1 killer, claiming 680,909 lives in 2023. Cancer, causing 613,331 deaths, was a close runner-up. Next on the 2023 list of conditions causing death are unintentional injuries (222,518 deaths), stroke (162,639 deaths), chronic lower respiratory diseases (145,350 deaths), Alzheimer's disease (114,034 deaths), diabetes (95,181 deaths), kidney disease (55,250 deaths), and chronic liver disease and cirrhosis (52,220). Next, after Covid-19 in eighth place, we see suicide (49,303 deaths), and influenza and pneumonia (45,182 deaths).

Looking critically at these figures, I can imagine both over-reporting and under-reporting of life-ending conditions on death certificates. For example, diabetes may be a major risk factor for development of vascular disease, causing heart attacks and strokes. How often is diabetes left off death certificates, however? Similarly, mental illness may contribute to liver disease if alcohol or drugs are involved. Elders perishing from dementia may eventually succumb to pneumonia as a proximate cause of death. Are kidney disease deaths masking underlying poorly controlled hypertension? To be sure, death certificates list immediate and contributing causes of death, but completion of these forms requires thoughtful analysis on the part of physicians and other officials.

Suicides, along with unintentional injuries, render mortality analyses even more complicated and confusing to assess. For example, some unintentional injuries reflect underlying suicidal ideation. Suicide itself, strictly speaking, is a "manner of death," rather than a "cause of death."

For example, if a person commits suicide by gunshot wound, the cause of death is the bullet damaging the brain or heart, causing brain death or cardiac arrest. Medical examiners must then sort out whether the death is accidental, homicidal or suicidal. So, death statistics are inherently imprecise.

In a comparable way, Covid-19 was reported on death certificates for people dying with a positive test, even if the deaths were sometimes caused by other underlying processes. Nonetheless, mortality rate studies offer useful guidance.

In terms of practical implications, you should consult your health care providers regarding staying healthy. Wearing safety belts, not drinking-and-driving, avoiding smoking, avoiding drug abuse and seeking age-appropriate screening for cancer or heart problems would all seem to be appropriate pathways to longer life. Pursue health, mentally and physically.

Scott Anderson, M.D. ([email protected]), is a clinical professor at UC Davis Medical School. This column is informational and does not constitute medical advice.