The lexicon of the COVID-19 pandemic—a period defined by unprecedented global upheaval—has proven remarkably resilient, particularly in its ability to distort public perception of mortality. During the height of the crisis, the phrase “they died with COVID, not from it” became a staple of social media discourse and political debate. It was a rhetorical device used to cast doubt on official death tolls, suggesting that a positive test result was being used to inflate mortality statistics regardless of the actual cause of death.
Today, that same phrase has been resurrected, this time in the context of a resurgence of measles. As Pennsylvania navigates a concerning cluster of measles-associated deaths in Lancaster, the debate over how we classify mortality has once again spilled into the public square. This linguistic battle is more than a semantic disagreement; it represents a fundamental misunderstanding of how medical science documents the end of life and how public health agencies track the lethality of infectious disease.
A Chronology of Conflict: The Pennsylvania Measles Cases
The current controversy erupted on August 25, when the Pennsylvania Department of Health confirmed two measles-associated deaths in Lancaster. On that same day, a local county commissioner relayed the coroner’s office position regarding one of the decedents—an infant—asserting that the child had died “with measles, but not from measles.” The coroner attributed the infant’s death to a ruptured spleen.
Without full public access to medical records or the completed autopsy report, the public and the medical community were left to rely solely on the brief, potentially incomplete summary provided by the local coroner. Following the lead of the local report, the Centers for Disease Control and Prevention (CDC) initially excluded both deaths from its national measles update, placing an asterisk in the mortality column as a placeholder for further investigation.
As the situation evolved, Pennsylvania reported two additional deaths, bringing the state’s total to four. In late September, the CDC updated its national data to include one of these deaths, yet the other three remained conspicuously absent from the agency’s official tally. This lack of uniformity—between state reporting and federal surveillance—has fueled skepticism and highlighted the friction between local death investigations and national epidemiological standards.
The CDC’s Stance: Navigating the “Bus Story”
On September 16, in her first formal interview as the newly appointed head of the CDC, Erica Schwartz addressed the agency’s exclusion of the Pennsylvania deaths. When questioned about the discrepancy, Schwartz invoked the ghost of the pandemic, drawing a comparison to the “hit by a bus” hypothetical that became shorthand for COVID-19 skepticism. She argued that if a patient with COVID-19 were hit by a bus, the death would historically have been classified as COVID-related in some jurisdictions, emphasizing that “definitions matter.”
Schwartz’s point—that a positive test and a death are distinct events—is technically accurate. However, it sidesteps the rigorous clinical process of death certification. By suggesting that the inclusion of such deaths was a systemic flaw rather than a rare outlier, the CDC director’s comments have inadvertently validated a narrative that many medical professionals find deeply frustrating.
The Anatomy of a Death Certificate: Decoding the Cascade
To understand why the “with vs. from” argument is often a fallacy, one must look at the legal and clinical document that records the end of life: the death certificate. Most laypeople rarely encounter this form, which leads to significant misconceptions about how doctors record mortality.
Death is rarely a singular event; it is a physiological cascade. If physicians were to be entirely literal, the vast majority of human deaths would be recorded simply as “cardiac arrest.” However, the CDC’s Handbook for Physicians and the death certificate manuals utilized by states like Pennsylvania explicitly forbid this. They mandate that clinicians “DO NOT enter terminal events such as cardiac arrest” without identifying the underlying disease or injury that initiated the heart’s cessation.
The U.S. standard death certificate is designed to track this chain of causality in reverse. The top line records the “immediate cause,” the final disease or complication that claimed the patient. Each subsequent line documents the condition that led to the one above it. The bottom-most entry is the “underlying cause”—the disease or trauma that initiated the entire chain of events.
For instance, if a patient dies of bleeding esophageal varices caused by portal hypertension, which resulted from liver cirrhosis, which was ultimately caused by hepatitis B, the death certificate lists the bleeding at the top and the hepatitis B at the bottom. The hepatitis B is the underlying cause because, without that infection, the chain of events would never have begun. This is the same logic used in homicide investigations: if a gunshot victim dies months later from complications related to their wounds, the death is still legally a homicide. Applying this standard to measles or COVID-19 is not an act of statistical inflation; it is standard clinical practice.
The Myth of the “Bus Death”
The “hit by a bus” argument, while emotionally potent, is largely a distortion of how data was handled during the pandemic. Early in the crisis, some local health departments did use rapid, preliminary case surveillance data—which merely flagged deaths among individuals who had tested positive—to issue quick reports.
When investigative journalists and medical experts scrutinized these tallies, they did find isolated instances where trauma deaths (such as motorcycle accidents) were inadvertently included in preliminary counts. However, medical examiners almost universally corrected these records before they were finalized as official mortality statistics. As the CDC’s own mortality statistics chief noted at the time, this was the system working exactly as it was designed to.
According to the CDC’s own certification guidance, COVID-19 should only appear on a death certificate if it played a significant role in the physiological decline leading to death. An incidental positive test result does not qualify as a cause of death under these established guidelines.
Analyzing Excess Mortality: The Independent Check
For those who remain skeptical of death certificates, “excess mortality” provides an independent, objective check. This method does not rely on individual physician judgment; it simply compares the total number of deaths from all causes during a specific period against the historical average for that same period.
During the first several months of the pandemic in 2020, the U.S. recorded approximately 299,000 excess deaths. Of those, roughly 198,000 were explicitly attributed to COVID-19. While the remaining 100,000 deaths were not labeled as COVID-19, they represent a massive surge in mortality that cannot be explained by anything other than the direct and indirect impacts of the pandemic. This data confirms that even if there were minor reporting discrepancies, the scale of mortality was not overcounted; if anything, it was likely undercounted in the early stages of the crisis.
The Implications for Measles Surveillance
The ongoing debate over the Pennsylvania measles deaths highlights a critical tension in public health. Measles is a devastating disease that causes immune amnesia, pneumonia, and subacute sclerosing panencephalitis—a fatal brain disease. When a child dies from pneumonia following a measles infection, the pneumonia is the immediate cause, but measles is the underlying cause.
By holding these deaths out of the national count until the National Center for Health Statistics confirms the cause of death, the CDC is essentially reversing the traditional order of surveillance. During an outbreak, public health officials typically rely on rapid reporting to identify trends and protect the public. By delaying the inclusion of these deaths, the CDC may be creating a false sense of security and fueling public distrust.
As Erica Schwartz has stated, her goal is to rebuild trust through accuracy and transparency. However, true transparency requires acknowledging that mortality data is a complex, hierarchical system, not a binary choice between “with” and “from.”
When health officials allow the “with vs. from” narrative to persist, they undermine the very science they are tasked with upholding. The public deserves to know that when a measles death is reported, it is because that virus initiated a cascade that the patient could not survive. By clarifying these standards and showing exactly how state-reported deaths are being reviewed, the CDC can move away from the defensive posture of the pandemic era and toward a more robust, science-based model of public health communication.
The death of a child is a tragedy that demands clarity. It is time to retire the misleading rhetoric of the pandemic and return to the clinical rigors of the death certificate—a document designed to honor the truth of how and why we die.
