The uptick in the number of deaths in Horry County rose exponentially higher in 2020 than previous year's increases, but they weren't all COVID-19 deaths.
“It has gone up every year in the last almost 20 years that I’ve been involved, but only by maybe 75 to 100,” said Horry County Deputy Coroner Tamara Willard. “But nothing like this 30% increase.”
The year 2020 was an unprecedented 365 days of death in the county and across South Carolina.
Compared to 2019, the number of mortalities in 2020 that were not ruled as COVID-19 deaths rose by 7.5% in both Horry County and the state of South Carolina, according to preliminary DHEC data. In Horry County, non-COVID deaths jump from 3,914 to 4,209.
Before last year, the death toll had been rising only several percent per year. In 2019, the state saw a .6% increase in the number of deaths; in Horry County it was a 2.5% increase.
The Horry County Coroner’s Office, which responds to deaths that occur outside of hospice or hospitals, except in a few circumstances, saw a 5% increase in calls in 2019, the vast majority of them for natural deaths. But in 2020, the number of calls spiked from 2,512 to 3,282: a 30% increase. A rise in the number of calls each year is normal, but 2020 wasn’t normal.
That means that while the number of deaths in South Carolina and Horry County was well above the incremental increases that occurred in previous years, the proportion of those deaths that occurred outside the hospital jumped up even higher. And Willard said most COVID-19 deaths occurred in hospitals.
“The coroner’s office responds to any death that is unattended, meaning that if it’s at a home or on the side of the road; anything that is not in the hospital or under hospice,” Willard said. “We do respond to the hospital if it’s a trauma event or it’s something that occurred after they were admitted but less than 24 hours of admission, or within a 48-hour time frame after a surgical procedure. And of course, we go to anything in the ER.”
There’s no definitive answer as to why non-COVID deaths and out-of-hospital deaths went up last year, but there are some compelling theories, and all link back to the effects of the pandemic.
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“It’s occurred across the country,” said Dr. John Pangia, Grand Strand Health’s director of emergency medicine. “The ‘why’ is speculation, because the ‘why’ has not been scientifically validated, but I can share with you our best guess. It’s very difficult to study, too, because you can’t go back and interview the dead.”
Pangia was a co-author of a study published in the Journal of Emergency Medicine using data from hospitals owned by HCA Healthcare. The study found that as patient visits to emergency rooms decreased, overall mortality increased. The decline in hospital ER visits occurred at Grand Strand also.
“Our volume went down at its worst about 50%; that was around June, July. It was lowest then, and it was half of what we would normally have seen,” Pangia said. “We see a direct inverse correlation. As the volume went down, we saw out-of-hospital cardiac arrests going up, and as near as we can tell, that was not due to COVID. Without adding too many details to violate privacy, we saw several people who were suffering from conditions that were essentially benign and easy to treat in the early stage but who waited much, much longer than they would have in any other time frame, and then suffered pretty drastic complications, disability and even death; some things that, really, no one should die from.”
The study theorized that folks avoided hospitals based on an unfounded fear that they would contract COVID-19 there.
While some hospital workers did get the virus, most of them caught it outside the hospital while not following safety protocols, Pangia said. “However, the in-hospital transmission of COVID was very, very small, and so in many ways, the hospital was one of the safest places in Horry County. And one of the most dangerous places was out in the general public.”
Tidelands Health saw a similar decrease in ER visits. Spokeswoman Dawn Bryant said emergency department visits declined by 25% in 2020 when compared to 2019, with some months down 40$, year over year.
Tourism to the area was also down last year, and Bryant said visits from people living outside Horry, Georgetown and Williamsburg counties declined 35% in 2020. But nationally, emergency departments saw a 42% drop in visits, Bryant said, citing the Centers for Disease Control and Prevention.
“We saw a decline in business to our emergency room for chest pain, for stroke, for heart disease a year ago, starting in the spring of 2020,” said Dr. Gerald Harmon, Tidelands’ vice president of medical affairs. “We started to recover a little bit, then we had the summertime peak in July when we started seeing a lot of inpatients in our community. We didn’t have as many visits to our emergency rooms and to our clinics for let’s say heart disease and emergency conditions. So it could have been some downstream implications that we had an increase in deaths from cardiovascular disease.”
But Harmon pointed out that other ancillary effects of the COVID-19 pandemic, like a more sedentary lifestyle, fewer opportunities for exercise and putting off preventative care could also have driven up the mortality rate. He said some folks may have delayed screenings because they were scared to go to the hospital.
“What appears to be rather self-evident to me is deferring diagnostic care for cancer, deferring known maintenance care for cardiovascular disease, for lung disease, for diabetes, high blood pressure, all those things are certainly going to increase the rate of disease and secondarily will increase the rate of death,” he added, stressing the importance of routine screenings.
In some cases, he said, COVID-19 may have made existing diseases worse, even if COVID-19 wasn’t listed as the cause of death.
“If I have a patient that’s already on renal dialysis and they get COVID and they advance their renal diseases to the point where dialysis can’t keep up and they get secondary complications, their cause of death may still be renal failure,” Harmon said, “but if you put secondary to low blood pressure, which is secondary to coronavirus infection, I can’t speak to the official cause of death from the DHEC statistic.”
DHEC said it relies on death certificates to determine the cause of death, following CDC guidelines: if COVID-19 was listed as the cause or a contributing cause, the death is included in the state’s COVID-19 numbers.
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While a 33.5% increase in natural deaths drove the spike in the number coroner's office calls, the number of drug overdoses, suicides and homicides rose as well.
While there were 19 deaths ruled as homicides in 2019, there were 43 homicides in Horry County in 2020
The increase in murder occurred across the country last year, but it made headlines mostly in large metropolitan areas like Chicago and New York City.
“We move really slow as academics, so we don’t really have any rigorous empirical observations on it yet,” said University of South Carolina criminology and criminal justice professor Cory Schnell. “But not surprisingly, most of our research goes toward the pandemic. We, not surprisingly, are focused on the pandemic and the impact of the pandemic. That would be the obvious and most likely connection to make.”
Generally, most homicides stem from disagreements between people who know each other, Schnell said, and pandemic lockdowns could have kept people together for long periods of time. But it's still to early to definitely point to a causal factor.
“So there’s this whole mental health side and this change in social life side of the pandemic, where you’re not seeing as many people and you’re kind of confined in closer quarters with people that you might know and that might drive you crazy,” Schnell said. “While it’s specifically unproven right now… that to me seems like a reasonable hypothesis we would test when we have a little more hindsight based on what happened in 2020.”
Broadly speaking, violent crime and homicides have been trending down for decades, and it’s too early to tell if 2020 was just an outlier or the first year in a longer reversal of the established trend, Schnell added. A continued increase in homicides in future years could indicate a bigger systemic change.
“It’s a very clear uptick, but it’s not necessarily this change-of-course," he explained. "I would expect to see some sort of reversion to the mean once things start to settle down. Or at least to keep an eye on expecting that it’ll go down, and then if it continues, that adds another layer in that context of ‘OK, maybe what we’re seeing is a permanent change,’ as opposed to something that’s tied in very situationally to the pandemic."
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In 2020, the life expectancy for Americans decreased overall, from 78.8 down to 77.8 years. It was the first time that Americans’ life expectancy had decreased since World War II. Dr. Harmon noted that the restrictions and lifestyle changes that came with the pandemic certainly didn’t do anything to slow the rates of heart disease and cancer in the U.S., which are the leading causes of death.
“That’s 75 years ago. Why do we have a decline in life expectancy in 2020?” Harmon asked. “What happened to that? There’s a lot of what happened-type questions, and I can’t give you an answer.”