Australia recorded its first COVID-19 death just over two years ago.
Today, thousands of Australians infected have died. As we learn to live with the virus, there's a big question we all have to face: how much death are we willing to accept?
It all started on a two-week cruise around the Pacific Ocean.
On January 20, an invisible pathogen, then virtually unknown to science, began circulating through the now notorious Diamond Princess cruise ship.
It found its way into 78-year-old James Kwan, and began replicating in his lungs and other organs.
Fewer than 10 days later — on March 1, 2020 — he died in a Perth hospital, becoming Australia's first victim of the novel coronavirus.
Two years on, the world knows so much more about the SARS-CoV-2 virus that killed Mr Kwan.
And in that time, almost 5,500 other Australians have succumbed to it.
About 80 per cent of those people have died in just the past seven months, following the rapid spread of the Delta and Omicron variants.
We've been told lockdowns and state border closures are a thing of the past, and as we learn to "live with the virus" we are, inevitably, seeing more people die with it too.
But how many deaths are too many?
And is there a number that would trigger us to change course?
The big killers
To answer that, it might help if we zoom out a bit.
Let's look beyond COVID, and see what kills the most people each year in Australia.
The year 2019 is a good one to look at, since it wasn't affected by the pandemic or our response to it.
Coronary heart disease was the biggest killer that year, responsible for almost 11 per cent of all deaths.
Dementia was the second biggest killer, responsible for about 9 per cent of deaths.
Scrolling down the list, we get to diabetes at number seven, which killed nearly 5,000 people.
So, how big a killer is COVID?
Well, it depends how you measure it.
Australia managed to keep deaths very low for nearly two years.
In fact, with lockdowns and other public health measures, Australia actually had fewer deaths from all causes over that time compared to what we would have had without a pandemic.
You can see that by looking at the Australian Bureau of Statistics' analysis of excess deaths.
It's a measure that calculates how many people are expected to die each week, and then compares that to how many people really did die. Any deaths above what was expected for at least two consecutive weeks, is called "excess mortality".
The blue line is the expected number of deaths from all causes. It oscillates with each season, peaking in late winter.
The reason it does this isn't fully understood by scientists, but it's partly because respiratory illnesses are worse in the colder months.
Let's take a look at the impact of the bad flu season in 2017.
That big spike in the pink line above the blue "expected deaths" line was caused by the flu killing a lot of people.
According to the ABS, there were 1,566 excess lives lost between July and September that year, probably all accounted for by the flu.
But look what happened shortly after COVID was first detected here.
With lockdowns and other measures in place, the total death rate fell significantly below the expected range for the first time since at least 2015.
But the experts say that may turn around this year.
With about 4,500 COVID deaths in the past 12 months, we are likely to see the total death rate increase above the expected rate for the first time since the horror 2017 flu season, but it will be a while before that can be confirmed with full official figures past the middle of 2020.
New ABS data obtained exclusively by the ABC shows there have already been some very small peaks above the expected number of deaths in three weeks in late 2021.
However, since the data isn't consecutive, according to the ABS, it doesn't meet the threshold for "excess deaths".
According to Professor James Trauer, head of Modelling and Health Economics at Monash University, Australia's Omicron wave was well past its peak, and any further Omicron waves would likely be less severe.
But, according to the Burnet Institute's Professor Brendan Crabb, the number of deaths this year is likely to be high, regardless.
"I do think it's possible for us to have between 10,000 and 20,000 deaths."
In assessing the impact of COVID, Professor Trauer said the excess death rate was the key factor to consider.
He said that figure accounted for deaths that would have happened anyway — perhaps caused by flu or something else — as well as people who died "with COVID" but possibly not "from COVID".
"We now need to particularly look at all-cause mortality to give us a sense of how big a problem this is," he said.
The mortality equation
Looking overseas to the UK's recent excess death figures might give Australians a clue about what the future of Omicron holds.
During the pandemic, the all-cause mortality in the UK has swung between positive and negative excess mortality.
Despite the reported deaths from COVID still being high in the UK – with more than 100 people dying with COVID each day – right now there are actually fewer people dying from all causes than would normally be expected.
In other words, total deaths are lower than expected, not higher.
Professor Catherine Bennett, head of epidemiology at Deakin University, said the negative excess mortality figures in the UK were partly a result of COVID bringing forward the deaths of the very elderly, frail or sick.
Experts say it is also likely due to behavioural changes — fewer people driving in cars and riding bikes and getting into accidents, for example.
Yet, they point out the key number is that the UK has had 160,000 or so excess deaths above what it normally would have over the last two years.
And certainly, the vast majority of countries saw significant excess deaths according to research published by Professor Bennett and an international team.
But it's the very successful protection of Australians' health — along with constant, daily reporting of the number of people dying — that Professor Christine Jenkins thinks has created a "phobia of death".
Proffesor Jenkins, the head of respiratory group at the George Institute for Global Health, argued we needed to accept people would die of COVID.
"We've had low death rates from a range of different conditions over the last two years as a result of protecting ourselves very effectively against COVID transmission," she said.
"So now we have to get used to the idea that people do die, [we] have to accept that inevitability."
That's not something Professor Nancy Baxter, head of the school of Population and Global Health at the University of Melbourne, will countenance.
"It's almost like we've decided we're not going to care anymore. And as a physician, I find that confronting."
Professor Crabb agreed.
So far, over the past 12 months, COVID has killed about 80 per cent as many people as diabetes has, or about four times the national road toll.
If COVID kills more than 10,000 people this year, as Professor Crabb suggests it could, is that too many?
How much life has COVID stolen?
Throughout the pandemic, when health officials have reported how many people have died from COVID, they've also often mentioned their age and whether they had other health conditions.
But should it matter how old or how sick people are when they die from COVID?
"By saying 'everybody's over 70, so don't worry about it, it's just old people', that's dehumanising and diminishes the death of those people," Professor Baxter said.
But Professor Jenkins said the context of the person's age and underlying health was crucial.
"There are many risk factors associated with a bad outcome from COVID-19, and one of them is being older," she said.
For some very old or sick people, if it weren't COVID that killed them, it would likely have been something else, she said.
In fact, discriminating between the old and the young, as well as the sick and the healthy, is exactly how decisions are often made about where to direct health resources.
Saving 'life years'
When governments decide whether to fund a new cancer treatment, or weigh up the cost of a public health campaign, the analysis to support that decision doesn't just look at how many lives it will save — it also looks at how many "potential life years" are saved.
In very simplistic terms, if an intervention saves the life of a 40-year-old, it will save a lot more "life years" than if it saves the life of an 80-year-old.
These measures put more value on the lives of the young and those likely to live for longer, and for that reason, some have argued they are discriminatory.
But without a measure like this, interventions that extend the life of a terminally ill patient for a few weeks could be considered just as worthwhile as one that allows a child to live a full and healthy life.
"This is often spun as devaluing the lives of people who have ill health," said Dr Leah Rand, a bioethicist at Harvard Medical School.
"It's not a judgement of the value of the person or whether or not their life is worth it. But we're trying to in some way measure what is an impact of a treatment upon someone's health."
So maybe the question should be:
How many life years lost is too many?
Using this approach, Professor Bennett and a team from around the world assessed how many life years were lost to COVID in different countries in the first eight months of 2020. They published their results in January this year.
They found each COVID death in Australia over that period, on average, resulted in a loss of 2.7 life years.
In some other countries many younger people died. In Ukraine, each death resulted in an average of 19.3 life years lost. In Peru, the number was 15.2 years.
Professor Bennett said the low number in Australia was largely because we put in place strong measures to protect the whole population.
"So if you have a low chance of serious illness in your 20s or 30s, and we reduce that by 90 per cent, then it becomes minuscule," she said.
"But as you get older, they're the groups that you can't protect."
She said failures in aged care — particularly in Melbourne — also drove that number down, since it skewed the deaths towards the elderly.
For comparison, cancer killed about 49,000 people in Australia in 2018, taking a total of 811,700 life years.
Each death took an average of about 17 potential years of life.
Injuries killed about 11,000 people, taking 344,655 life years, with each death taking an average of 30 years of life.
Professor Jenkins argued none of these deaths or years of living with illness were "OK".
But she believed the constant reporting around COVID had skewed the public's perspective.
"We should be saying that the majority of these COVID deaths are occurring in people aged over 80," she said.
"Most people aren't aware of that simple fact. The median age for people who die from COVID-19 up until August last year was 84."
She also worried what unnecessary fear about COVID was doing to people's quality of life, and their health.
Professor Bennett agreed we needed to start thinking of it more like all the other things that could hurt us.
"The aim was to have zero deaths and [for extended periods] we achieved that," she said.
"It's hard coming out of that mindset into one where we acknowledge that it is potentially going to be contributing to serious illness going ahead."
So, what’s the number?
In the end, Professor Jenkins didn't think there was an answer.
"The issue in my mind is not saying, 'Oh, this number of deaths is acceptable'," she said.
"It's really saying: 'Was the treatment this person was given the standard of care? Was it humane?'."
Professor Bennett agreed.
"It's an odd conversation around COVID," she said.
"What we normally ask [is] how far can we push down the number of deaths we get? And what are the reasonable measures we can put in place that will achieve that?" she said.
With COVID sticking around in the long term, Professor Baxter said we needed to plan better for the future: build better ventilation into spaces, and develop plans for how the health system would cope with waves of infection.
She said another way to improve the outcomes with COVID was to improve the underlying health of the population.
That meant more money spent on health care, obesity prevention, alcoholism, diabetes — all the things that cause the chronic conditions that worsen COVID outcomes.
Really, measures that target all preventable diseases.
"A healthier population is the best way to improve your resilience against any infection and extend life," Professor Bennett said.
And … prevent death.
Credits
Reporting: Michael Slezak
Digital production and editing: Nick Sas
Editing: Jessica Longbottom
Charts: Thomas Brettell and Mark Doman
Opening image: Emma Machan and Brendan Esposito
Photography: Brendan Esposito
