What actually kills people
The top of the table barely moves. Everything underneath it has been rearranging itself for fifty years.
Ask people what kills the most people worldwide and the answers skew violent and infectious: war, terrorism, murder, epidemics. The actual answer is duller and much larger. It is cardiovascular disease1, and it has been for a very long time.
The table
Cardiovascular disease (ischaemic heart disease2 and stroke, principally) accounts for nearly three in ten deaths globally, at least 19 million a year in the WHO Global Health Estimates for 2021. Ischaemic heart disease alone is the single largest cause, at roughly 9 million deaths a year. Stroke is usually next, at around 7 million. In 2021, those estimates put COVID-19 above stroke, at 8.8 million.
Cancers, taken together, come to about 10 million a year. Chronic respiratory disease3 adds about 4 million, most of it from COPD4. Lower respiratory infections5 killed 2.5 million people in those same estimates. Neonatal conditions6 still account for more than 2 million deaths a year, split across several certified causes. Alzheimer's disease and other dementias killed 1.8 million, and diabetes and kidney disease sit just behind that in the top ten. Road injuries account for about 1.2 million.
This is why the Ledger's Pathological column dwarfs its Accidental column. Cardiovascular demise, counted here from 18.6 million deaths a year, ticks at 0.589 per second. Fatal electrocution, counted here from 30,000 a year, ticks at 0.001. The first is about 600 times the second. That gap is not a presentational choice. It is the shape of the figures.
What has changed
The rearrangement underneath the top line is the real story, and it has a name: the epidemiological transition7. As countries grow wealthier, infectious disease recedes through clean water, sanitation, vaccination and antibiotics, and the deaths that used to happen in childhood happen decades later instead, from chronic disease. People do not stop dying. They start dying of different things, and they die older.
Two movements stand out.
Dementia has climbed steeply. Alzheimer's disease and other dementias have risen sharply in the rankings over recent decades and are now the leading cause of death overall in several wealthy countries, including England and Wales. Very little of this is a real increase in risk. It is mostly that dementia is a disease of advanced age, more people now reach advanced age, and, not trivially, doctors have become far more willing to record dementia on a death certificate rather than the pneumonia that finally arrived.
Infectious disease has receded, unevenly. Diarrhoeal disease8, tuberculosis, HIV and malaria have all fallen since 2000, some of them sharply. They remain leading causes in low-income countries, which is why the Ledger's country atlas shows such radically different tables for Nigeria and Germany. The transition is not finished; it is just much further along in some places than others.
The certification problem
A death certificate names one underlying cause9. Real deaths frequently do not have one.
Consider someone with type 2 diabetes and chronic kidney disease10 who dies of a heart attack. Diabetes damaged the blood vessels; kidney disease strained the heart; the heart attack was the final event. Depending on the certifying physician's judgement and the local coding convention, that death might be counted under diabetes, kidney disease or ischaemic heart disease. All three are defensible. Only one gets counted.
This is why cause-of-death comparisons across countries are shakier than they look, and why the Global Burden of Disease study reports risk factors (high blood pressure, tobacco, diet and air pollution) alongside causes. More deaths are attributed to high systolic blood pressure11, about 11 million in its 2021 estimates, than to any single named disease, because it feeds into so many of them at once. That framing is often more useful than the cause table, and much less frequently quoted.
What this does not tell you
Counting deaths tells you nothing about when they happened. A cause that kills 500,000 infants and one that kills 500,000 ninety-year-olds appear identical in a mortality table, and are not remotely the same event.
This is what measures like years of life lost12 exist to capture, and by that measure the table reshuffles. Neonatal conditions and road injuries climb sharply, because they take people young. Self-harm rises for the same reason. The Ledger's demographic bars put about half of all deaths at age 70 or over. That is a rounded picture of the global pattern, but the mortality table on its own will always flatter causes that kill older people.
None of this is health advice. Population statistics describe populations, not people. Knowing that cardiovascular disease leads the global table tells you nothing useful about your own risk, which depends on factors no statistic on this site measures. If you have concerns about your health, speak to a doctor.
Notes
- Cardiovascular disease. Disease of the heart and blood vessels. Ischaemic heart disease and stroke make up most of the deaths in this group. ↩
- Ischaemic heart disease. Disease in which the heart muscle receives too little blood, usually because the arteries that supply it have narrowed. A heart attack is the best-known form. ↩
- Chronic respiratory disease. Long-term disease of the lungs and airways. In the global figures, most of these deaths are from COPD. ↩
- COPD. Chronic obstructive pulmonary disease, a lasting lung disease in which the airways narrow and breathing becomes steadily harder. Smoking is the most common cause. The term covers chronic bronchitis, a lasting cough with mucus, and emphysema, in which the air sacs of the lungs are damaged. ↩
- Lower respiratory infections. Infections of the lungs and the lower airways. Pneumonia is the largest of them. ↩
- Neonatal conditions. Illness and injury in the first 28 days of life, including premature birth, complications during birth and serious infection. ↩
- Epidemiological transition. The shift, as a population grows wealthier and more children survive, from deaths caused by infection to deaths caused by chronic disease at older ages. ↩
- Diarrhoeal disease. Severe diarrhoea, usually from infection. It kills mainly by dehydration, and most of the deaths are in young children. ↩
- Underlying cause. The disease or injury that started the chain of events leading to death. A death certificate records one, even when several illnesses were involved. ↩
- Chronic kidney disease. Long-term damage that leaves the kidneys less able to filter the blood. It often follows diabetes or high blood pressure. ↩
- Systolic blood pressure. The higher of the two numbers in a blood pressure reading, taken while the heart is contracting. A high figure, held over years rather than on a single day, damages the blood vessels. ↩
- Years of life lost. A count of the years of life a death cuts short. A death at 20 adds far more than a death at 90, so causes that kill younger people rise in this ranking. ↩