By admin 
The return of a controversial linguistic relic from the peak of the COVID-19 pandemic has recently resurfaced in the public discourse, this time surrounding a resurgence of measles. During the height of the global health crisis, the phrase “they died with Covid, not from it” became a frequent refrain among skeptics and those questioning the severity of the virus. Today, that same rhetorical framework is being applied to recent measles fatalities in Pennsylvania, sparking a renewed debate over how the United States counts deaths, the mechanics of medical certification, and the transparency of federal health agencies.
The current controversy began on August 25, when the Pennsylvania Department of Health confirmed two measles-associated deaths in Lancaster County. Shortly after the announcement, a local county commissioner relayed a statement from the coroner’s office, asserting that one individual—an infant—had died "WITH measles, but not FROM measles." The coroner attributed the infant’s death to a ruptured spleen. While the public is limited to the information shared by officials without access to private medical records or full autopsy reports, the distinction immediately reignited a firestorm regarding the "underlying cause" of death versus "incidental" findings.
The situation grew more complex as the Centers for Disease Control and Prevention (CDC) initially omitted these deaths from its national measles update, placing an asterisk in the mortality column instead of a numerical value. Since that initial report, Pennsylvania has identified two additional deaths, bringing the state’s total to four. While the CDC eventually added one of these deaths to its official data in late September, three remain unlisted, leading to questions about the agency’s verification process. In her first interview as the head of the CDC, Erica Schwartz addressed this discrepancy by referencing the pandemic-era "bus" analogy. She noted that during the COVID-19 crisis, if someone tested positive for the virus and was subsequently struck by a bus, the death was "often" called a COVID-related death. Schwartz emphasized that "definitions matter," suggesting that the agency is now prioritizing a more rigorous standard for attributing cause of death to infectious diseases.
To understand why this debate is so persistent, one must look at the legal and medical architecture of the U.S. Standard Certificate of Death. For most people, a death certificate is a document seen only during times of grief, yet for physicians and coroners, it is a complex tool for public health surveillance. The document is designed to capture a "cascade" of events rather than a single, isolated moment. If medical certifiers were to be strictly literal, nearly every death certificate would list "cardiac arrest" as the cause of death, because eventually, everyone’s heart stops. However, the CDC’s handbook for physicians and Pennsylvania’s own death certificate manual explicitly forbid listing terminal events like cardiac or respiratory arrest as the primary cause of death. Instead, certifiers are required to identify the specific condition that initiated the chain of events leading to the heart stopping.
The U.S. death certificate is divided into two primary sections. Part I is reserved for the "chain of events" leading directly to death. It is filled out in reverse chronological order: the top line lists the "immediate cause" (the final complication, such as respiratory failure), while the subsequent lines list the "intermediate causes" that led to that failure. The final line in Part I is the "underlying cause of death" (UCOD)—the disease or injury that started the entire sequence. Part II is for "other significant conditions" that contributed to the death but were not part of the direct causal chain.
Consider the example provided in training for Pennsylvania certifiers: a patient dies from bleeding esophageal varices caused by portal hypertension, which was a result of liver cirrhosis, which was ultimately caused by a chronic hepatitis B infection. In this scenario, while the immediate cause of death was internal bleeding, the "underlying cause" is hepatitis B. This logic is identical to how we treat trauma; if a gunshot victim survives for six months but eventually dies from a systemic infection caused by the initial wound, the death is legally and medically classified as a homicide caused by a gunshot. The infection was merely a link in the chain started by the bullet.
The "bus story" mentioned by Schwartz has a traceable origin but has been widely misinterpreted. Early in the 2020 pandemic, some health departments utilized "case surveillance" data for rapid reporting. These were preliminary counts where any death of a person with a positive COVID-19 test was flagged to provide real-time situational awareness. In one documented case from late 2020, a Florida motorcyclist who died in a crash was initially included in a county’s preliminary COVID-19 death tally. However, once the medical examiner reviewed the case and filed the formal death certificate, the COVID-19 designation was removed because the virus played no role in the trauma. The CDC’s National Center for Health Statistics (NCHS) has maintained that its official mortality statistics—which rely on finalized death certificates rather than preliminary case reports—are corrected to ensure that incidental infections are not counted as underlying causes.
However, the "with vs. from" concern was not entirely without merit, particularly during the Omicron wave when incidental hospitalizations surged. Data from the CDC shows that between 2020 and mid-2022, COVID-19 was the underlying cause of death on approximately 88% of death certificates that mentioned the virus. By late 2022, that number dropped to 76%, as more people died of other primary causes while having a contributing (but not initiating) COVID-19 infection.
To resolve the dispute over whether deaths were overcounted or undercounted, epidemiologists look to "excess mortality." This metric compares the total number of deaths from all causes in a given period to the number of deaths expected based on historical trends. Between January and October 2020, the U.S. saw roughly 299,000 more deaths than usual. Only about two-thirds of those were officially attributed to COVID-19 at the time. This suggests that, far from being overcounted, the true toll of the pandemic was likely higher than official tallies indicated, as many deaths from unrecognized COVID-19 or the indirect effects of a strained healthcare system went unrecorded as virus-related.
Applying this logic to measles is critical for public health accuracy. Measles is a devastating viral infection that rarely kills directly through the initial rash or fever. Instead, it kills by compromising the immune system and leading to severe complications. The most common cause of measles-related death is pneumonia, followed by encephalitis (inflammation of the brain). In some rare cases, a patient may develop subacute sclerosing panencephalitis (SSPE), a fatal brain disease that manifests years after the initial infection.
If a child contracts measles, which then leads to severe pneumonia, which then leads to respiratory failure and death, measles is the underlying cause. It is the "but for" cause—but for the measles infection, the chain of events leading to the fatal pneumonia would never have begun. The American Academy of Pediatrics has stressed that even if measles is not the "immediate" cause listed on the top line of a certificate, it remains the primary driver of the mortality event.
The current friction between the CDC and Pennsylvania health officials highlights a shift in how the federal government manages outbreak data. Historically, the CDC has reported deaths based on state health department notifications during an active outbreak. For instance, in 2023, the CDC included a measles death from New Mexico in its national count while the investigation was still ongoing. By withholding the current Pennsylvania deaths from the national tally until the NCHS confirms the "underlying cause" on the final death certificates—a process that can take months—the CDC is moving away from real-time surveillance toward a much slower, finalized statistical model.
Schwartz has stated that her goal is to rebuild public trust through accuracy, but this change in reporting methodology can inadvertently fuel skepticism. To the public, an "asterisk" in a death column looks like a lack of transparency or a suppression of data. In an era of declining vaccine confidence, the stakes for clear communication are high. Measles was declared eliminated in the United States in 2000, but declining vaccination rates for the Measles, Mumps, and Rubella (MMR) vaccine have allowed the virus to find a foothold in under-vaccinated communities.
The "with, not from" debate is more than a semantic disagreement; it is a fundamental question of how we value medical causality. Whether the cause of death is a fall, a gunshot, a pandemic virus, or a preventable childhood illness, the medical community relies on the "underlying cause" to understand what is killing the population. By clearly explaining the "cascade" of death and being transparent about which cases are under review, health agencies can honor the complexity of the data without alienating a public that is increasingly wary of how "the numbers" are generated. Accuracy in these definitions is not just a matter of clinical record-keeping; it is the cornerstone of the public’s ability to assess risk and protect the most vulnerable members of society.
