The “one million deaths” milestone fails to capture the pandemic’s true toll

This week, many headlines declared that the U.S. has reached one million COVID-19 deaths. While a major milestone, this number is actually far below the full impact of the pandemic; looking at excess deaths and demographic breakdowns allows us to get closer.

NBC News was the first outlet to make this declaration, announcing that its internal COVID-19 tracker had hit the one million mark. Other trackers, including the CDC itself, have yet to formally reach this number, but major publications still jumped on the news cycle in anticipation of this milestone. (Various trackers tend to have close-but-differing COVID-19 counts due to differences in their methodologies; Sara Simon wrote about this on the COVID Tracking Project blog back when the official death toll was 200,000.)

But the recent articles about “one million deaths” fail to mention that the U.S. actually reached this milestone a long time ago. This is because the official count only includes the deaths formally logged as COVID-19, in which the disease was listed on a death certificate or diagnosed before a patient passed. Such a count fails to include deaths that were tied to COVID-19, but never proven with a positive test result, or deaths that were indirectly linked to the pandemic for a myriad of reasons.

To get closer to the pandemic’s true toll, demographers use a metric called excess deaths: the number of deaths that occurred in a given region and time period above what would be expected for that region and time period. Experts calculate that “expected death” number with statistical models based on patterns from previous years.

In total, the U.S. has reported 1,118,540 excess deaths between early 2020 and last month. 221,026 of those deaths have not been formally tied to COVID-19. According to a new World Health Organization report, the U.S. was already close to one million COVID-related deaths by December 2021.

To give a more specific example: in the U.S., in the week ending January 22, 2022, CDC analysts estimated that 61,303 deaths would have occurred if there were no COVID-19 pandemic. But actually, a total of 85,179 deaths occurred in the country that week. The difference between the observed and expected values, 23,876, is the excess deaths for this week.

I selected the week ending January 22 as an example here because it has one of the highest excess death tolls of any week in the last two years. This week marked the peak of the Omicron surge, a variant that many U.S. leaders called “mild” and dismissed without instituting further safety measures.

During this week, the CDC reports 21,130 official COVID-19 deaths. That suggests most of the excess deaths in this week, the deaths which occurred over pre-pandemic expectations, were directly caused by the virus.

But what about the 2,746 deaths that weren’t? How many of these deaths were also caused by COVID-19, but in patients who were never able to access a PCR test? How many occurred in counties like Cape Girardeu, Missouri, where coroner Wavis Jordan claimed his office “doesn’t do COVID deaths” and refuses to put the disease on a death certificate without specific proof?

And how many deaths resulted from people being unable to access the healthcare they needed because hospitals were full of COVID-19 patients, or people dying in car accidents during an era of less road safety, or people dying of opioid overdoses brought on by increased stress and financial instability?

Answering these questions takes a lot of in-depth reporting, which I know well because the Documenting COVID-19 team has been doing our best to answer them through our (award-winning!) Uncounted investigation.

As we’ve found, every state—and in some cases, every county—has a unique system for investigating and reporting deaths, especially those linked to the pandemic. In some places, coroners or medical examiners are elected officials who face political pressure to report COVID-19 deaths in a particular way. In others, they face chronic underfunding and a lack of training, leaving them to work long hours in an attempt to produce accurate numbers.

You can see the resource difference when comparing officially-reported COVID-19 deaths to excess deaths by state or county. Some states, like those in New England, have COVID-19 death numbers that closely match or even exceed their excess death numbers; medical examiners in these states have centralized death reporting systems and a lot of resources for this process, reporting by my colleague Dillon Bergin showed.

Other states, like Alaska, Oregon, and West Virginia, have officially logged fewer than three in four excess deaths as COVID-19 deaths. Such a number may signal that a state is failing to properly identify all of its COVID-19 fatalities.

For more granular data on this topic, I recommend reading the work of Andrew Stokes and his team at Boston University. Andrew is the Documenting COVID-19 project’s main academic collaborator on Uncounted; his team just shared their latest county-level excess death estimates in a preprint. (County-level data are also available in the Uncounted project’s GitHub repository.)

Excess deaths can also show how the pandemic continues to hit disadvantaged Americans harder. In 2020, COVID-19 death rates (i.e. deaths per 100,000 people) for Black, Indigenous, and Hispanic Americans were higher than the rates for White Americans; in 2021, some of these disparities actually got worse despite the broad availability of vaccines and other mitigation measures. Non-white groups also saw all-cause mortality (not just COVID-19 deaths) increase more from 2019 in both 2020 and 2021, compared to white Americans.

Please note, the chart below shows crude death rates, which don’t account for differences in age breakdowns between race and ethnicity groups. For example, crude death rates for white Americans tend to be higher because white people generally live longer than people of color in the U.S., and more seniors have died of COVID-19. You can see the difference that ade-adjustment makes in the CDC charts here.

Why is it important to acknowledge and investigate these excess deaths, going beyond the reported COVID-19 numbers? At an individual level, family members who lost loved ones to COVID-19 find that diagnosis important; they can access FEMA aid for funerals, and can receive acknowledgment of how this one death fits into the broader pandemic.

And at the county, state, and national levels, looking at excess deaths allows us to see a full picture of how COVID-19 has affected us. Experts say that inaccurate COVID-19 death numbers can create a negative feedback loop: if your community has a too-low toll, you may not realize the disease’s impact, and so you may be less likely to wear a mask or practice other safety precautions—contributing to more deaths going forward.

As a data journalist, sharing these statistics and charts is my way of acknowledging the one million deaths milestone, and all of the uncounted deaths that are not included in it. But this pales in comparison to actual stories shared by family members and friends of those who have died in the last two years.

To read these stories, I often turn to memorial projects like Missing Them (from THE CITY), which captures names and stories of over 2,000 New Yorkers who died from COVID-19. Social media accounts like FacesOfCOVID also share these stories. And if any COVID-19 Data dispatch readers would like to share a story of someone they lost to this disease, please email me at betsy@coviddatadispatch.com; I would be honored to share your words in next week’s issue.

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