Why COVID death counts in America may be higher than officials say

December 9, 2021
People line up to take a COVID-19 test in the Sunset Park neighborhood, which was experiencing a spike in coronavirus cases, on August 13, 2020 in New York City. City officials sent teams to the neighborhood, which has a large number of Latino and Asian residents, for both testing and to provide outreach to the community.
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Brown Institute for Media Innovation and MuckRock’s Documenting COVID-19 project

Death rates among Native, Hispanic and Black Americans still outpace pre-pandemic figures, showing the hidden toll of COVID-19 on communities of color even as vaccines have become widely available, according to data released this week by the Centers for Disease Control and Prevention.

Consider the impact to Hispanic residents: In the first 10 months of 2021, before the typically deadly winter months, the death rate for Hispanic Americans was 17% higher than it was in all of 2019. That follows 2020, when the death rate was 40% higher than 2019.

It’s particularly bad in places like Albuquerque, New Mexico; Miami-Dade County, Florida; Jersey City, New Jersey; and New York City. All have had higher death rates for Hispanics during the pandemic than the national rate.

The new data, which provide cause of death information down to the county level for 2020 and January through October of this year, have more detail, more recently, on deaths during the pandemic than ever before. 

Information included – such as where someone died, what other causes of death were on the death certificate or whether a body was autopsied – can point to communities where COVID-19 deaths have been undercounted. 

Public health experts say the true death toll of the pandemic in the U.S. is upwards of 20% higher than the official tally. That’s based on research showing that deaths attributed to COVID-19 do not account for all of the increased deaths in 2020 and 2021 when compared to prior years. Researchers call the number of deaths above a typical year “excess deaths.”

That means the number of Americans who have died from the virus could be closer to 1 million, not the roughly 793,000 deaths officially recorded as of Wednesday.

But it’s been hard for researchers to figure out exactly how many COVID-19 deaths are going uncounted and why. 

“We’ve almost certainly undercounted,” Dr. Bob Anderson, chief of mortality statistics for the CDC, said. “But if we want to really improve the data, we need to know a little more. We need to know where we’re missing cases.” 

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On Monday, the CDC released new data and a public tool that will bring researchers closer to understanding that.

The data could answer questions about what types of non-COVID deaths increased during the pandemic and which COVID-19 deaths have been misclassified as something else, such as a death from heart disease, stroke or a respiratory illness, said Andrew Stokes, an assistant professor of demography and sociology at Boston University’s Department of Global Health.

“In a public health emergency, real-time surveillance is critical,” Stokes said. “This data will be routinely updated with a two-to-four-week lag, and it also allows us to drill down to the county level and see how things are evolving locally. That is unprecedented compared to where we were at just a year ago.” 

COVID’s unequal impact on people of color

Hispanics had the highest increase in death rates from 2019 to 2020 of any single demographic group tracked by the CDC. Native Americans, Alaska Natives and Black Americans weren’t far behind. The death rate for Native Americans and Alaska Natives rose by 37% from 2019 to 2020. For Black Americans, it rose by 29%.

The new CDC data shows the 2021 death rates for those groups are on track to exceed pre-pandemic levels.

For Native Americans and Alaska Natives, the death rate so far in 2021 is 11% higher than it was in all of 2019. The 2021 death rate among Black Americans is on track to remain above 2019.

In 2020, the death rate among white Americans was 14% higher than in 2019. For the first 10 months of 2021, it’s 9% lower than 2019, suggesting that deaths for the full year will be closer to pre-pandemic levels. 

Daniel Dawes, executive director of the Satcher Health Leadership Institute at the Morehouse School of Medicine in Atlanta, said the 2021 figures for communities of color are “really troubling,” though the disparities are not surprising.

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The figures reflect the unequal impact of the coronavirus on communities of color. Hispanics, African Americans and other people of color have long struggled with access to health care and insurance to deal with health conditions such as asthma and diabetes.

COVID-19 vaccination rates for people of color have lagged white Americans. Recent data suggests the gap is narrowing, but it hasn’t been eliminated. 

Data sheds light on deaths at home

Of the 3.4 million Americans who died in 2020, roughly a third died in their home, mirroring national trends prior to the pandemic. However, deaths at home increased from 2019 to 2020 more than in-patient deaths, especially in the early months of the pandemic. 

While COVID-19 was the leading cause of death for those who died in a medical facility, the virus ranks considerably lower for those who died at home. The leading cause of death at home, lung cancer, was 13% higher than in previous years, and the second, coronary heart disease, was 20% higher. 

Deaths at home increased in states with larger rural populations, including Maine, New Hampshire, Vermont and Iowa.

“Almost all of the excess home deaths are occurring for other causes,” Stokes said. 

“Whatever the story explaining the difference between excess and COVID deaths is, it’s in these home deaths, and we need to get to the bottom of them,” he said. “These were people who were afraid to go to the hospital, who were afraid to lose contact with loved ones, who heard the shelter-in-place policies and thought they wouldn’t be able to get care, or who, if ICU beds were full, didn’t have access.”

Tool allows researchers to investigate deaths in communities

By looking at groupings of underlying causes of death – such as deaths from heart attacks in Hinds and Rankin counties, two counties in the Jackson, Mississippi, area – we can see how the pandemic changed why and how Americans die. 

In Hinds County, deaths from acute myocardial infarction, or heart attacks, increased 54% from 2019 to 2020. In neighboring Rankin County they doubled. In both places, the majority of those deaths happened at home.

The increase in heart attack deaths at home suggests that those people avoided treatment for other conditions or were in fact sick with COVID-19. 

While deaths from heart attacks are common outside a hospital, the stark increase during the pandemic points to existing problems worsened by the pandemic. Mississippi ranks lowest in the country on a number of health indicators, and it has one of the country’s highest rates of diabetes and heart disease. 

“The combination of fear and misinformation around COVID meant people who may have contracted the disease were afraid to go in, or they didn’t have access to health care, so they couldn’t afford it,” said Dr. Paul Burns, a social epidemiologist and assistant professor of population health at the University of Mississippi Medical Center.

There are sizable gaps in the data as local and state medical examiners and coroners wrap up their death reporting for the year. 

Due to a lag in death certificate reporting, more than 110,000 deaths in 2021 haven’t been assigned a cause of death yet. Another 74,000 deaths in 2021 are attributed to an “ill-defined” cause – nearly double the annual average before the pandemic. That’s likely due to overwhelmed medical examiners and coroners who have’t finished investigating those deaths.

The impact of undercounted COVID-19 deaths is twofold, experts say. It can lead to complacency and undermine preventative measures like masking. And a low count of COVID-19 deaths might result in fewer state and federal resources into a given county or region.

“That’s why accurate reporting of COVID deaths is important,” said Enbal Shacham, a professor of public health at Saint Louis University and a leading expert on community health and health behavior. “It should define the public health infrastructure in your community.”

Help Documenting COVID-19 investigate

The Documenting COVID-19 project wants to help reporters, researchers and the public access and interpret this data. So they’re cleaning and posting county- and state-level data from the CDC, a Department of Justice survey released earlier this month covering some 2,000 medical examiner and coroner’s offices, and “excess death” modeling from Boston University and other academic teams. 

We will publish our findings as part of yearslong investigation into the undercounting of certain causes of death, to be published jointly with the USA TODAY Network. We’re also inviting those who have dealt with death certificates to reach out to us, and share information and stories about what they’ve seen across the country.

Contributing: Nada Hassanein, USA TODAY

The Documenting COVID-19 project, supported by Columbia University’s Brown Institute for Media Innovation and MuckRock, collects and shares government documents related to the COVID-19 pandemic and works on investigative journalism projects with partner newsrooms.

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