By Kristen Panthagani, PhD
Since the beginning of the pandemic, there has been confusion over the numbers: are cases being undercounted or overcounted? Are deaths being correctly attributed to COVID, or is the COVID death count grossly overestimating the true death toll? People hear stories of men dying from heart attacks being listed as COVID deaths, fueling suspicions that the official COVID death counts are inaccurate, including people who died “with” COVID rather than “from” COVID. Are these suspicions true?
First, let’s acknowledge the obvious: when you are trying to tally things up in real time across an entire country, the precise number is bound to be somewhat inaccurate. This is not a sign of negligence or deception; it’s a reflection of the difficulty of counting things in real time and coordinating across thousands of different health care systems simultaneously. If you want to argue with me that as of today, there are not precisely 224,292 people who have died from COVID in the US, I would say you’re probably correct. It is likely at least a little bit off from that number. We rarely have an exact number when it comes to death tolls from disease — even the seasonal flu is based on estimates, not precise counting.
I think most people realize this, and what they really want to know is this: is the official death count in the right ballpark of the true total? They want to know if it’s way off. If the true death total is actually 50,000 or 500,000, that would be important to know. If it’s actually 223,189 not 224,292, that’s really not something to make a fuss over.
How are COVID deaths counted?
So how do we count COVID deaths? The current method used by the CDC is to look at the causes of death listed on death certificates. These are filled out by doctors who took care of the patients who died, or sometimes medical coroners or medical examiners. In order to get as full of a picture as possible as to what happened, the death certificate asks the doctor to list the “final” cause of death (i.e. myocardial rupture) as well as the diseases/events that contributed to that happening (i.e. motor vehicle accident). Death certificates also have a place to list underlying conditions that likely contributed to death, but did not directly cause the death (i.e. heart disease). This form distills a complex patient story down to three or four words to describe what happened to them. From a medical perspective, this is very much an oversimplification — it misses the vast majority of the details of what happened to the person, which are documented in that person’s medical chart. From a data analysis perspective, distilling this information down into these simple diagnoses is incredibly helpful, as it allows organizations like the CDC to analyze what is going on with patients at a broad level. If we had the level of detail provided in medical charts on death certificates, the clarity on the COVID death count would be worse, not better, as there would be millions of medical notes to go through to figure out what happened to each patient. Thus it is helpful that the doctors summarize it on the death certificates. But again, it’s a simplification.
Here is an example death certificate — you can see it asks for both the underlying cause of death and the chain of events that the underlying cause triggered, ultimately leading to one or more vital organs failing. A person who gets COVID which causes pneumonia which then causes acute respiratory distress syndrome would have all three things listed under Part I: the chain of events that directly caused death. Part II of the form allows the doctor to indicate underlying health conditions that likely predisposed the patient to being ill, but are not the primary cause of death themselves.
Here is the CDC’s explanatory video for physicians on how to fill out these death certificates for COVID, which explains the process:
Up until the COVID pandemic, this process was not called into question. A person with chronic heart disease and decades to live who got into a car crash and later died due to a weak heart that couldn’t compensate for the blood loss might be listed as cardiac arrest (heart stopped beating) secondary to hypovolemic shock (not enough blood to the body) secondary to motor vehicle accident with a significant underlying condition of chronic heart disease. This would get counted as a motor vehicle death, and nobody would be upset. Did the person have heart disease? Yes. Would they still be alive if they hadn’t been in a car crash? Yes. Would they still be alive if they didn’t have heart disease? Perhaps, as maybe someone with a healthier heart could have survived the blood loss. Regardless, it is still appropriate to list car crash as a cause of death, even though their weak heart may have also contributed.
To doctors who have studied the full course of diseases and understand how different medical conditions are interconnected, this makes a lot of sense. However outside of the hospital, when we talk about what somebody “died from,” we usually only think of one cause like “car crash”. We don’t think of “what vital organ ultimately failed, what caused that, and what were the predisposing factors.” That’s how doctors think because they are trained to do so; it’s not usually how the general public thinks.
Table 3: Confuse America
This has led to substantial confusion over COVID death certificates: several weeks ago, the CDC released the data on the COVID death certificates, and of course, multiple things were listed (because that is the proper way to fill out a death certificate). You can see the table below. 6% of them had only one cause listed (COVID), which in reality probably meant that those death certificates were incomplete. But this data was rapidly misinterpreted: the general public saw that multiple causes were listed, and many assumed that those other diseases were the true causes of death, and COVID was only listed because they happened to test positive, but they were about to die anyways. Many seemed to assume that people who truly died from COVID should only have one thing listed on their death certificates, and attributed that 6% number to the “true” death toll. To make matters more confusing, the CDC did not separate out the two sections on the death certificate: Part I (which describes the chain of events leading to death like COVID => pneumonia => respiratory failure) and Part II (which describes the underlying health conditions that contributed to death like high blood pressure and obesity) were all mixed together into one table. This, in my opinion, is a mistake on the part of the CDC: this is a very confusing way to present the data. This confused many, and led to the widely circulated rumor that only 6% of COVID deaths were truly due to COVID, and everyone else was super sick already with all these other diseases. In reality, many of the other conditions listed in the table were directly caused by COVID (i.e. pneumonia, respiratory failure). But you couldn’t easily tell that because Part I and Part II were all are mixed together. Furthermore, one can’t determine how “sick” these people were based on this data. If someone has diabetes, they may be a well controlled diabetic with decades to live, or they may be someone who has not taken their medication or controlled their diet for years and only has 6 months to live. Knowing that they have diabetes does give you some information, but it cannot be used to argue that the person was already super sick and on death’s doorstep.
Then why are heart attacks being counted as COVID deaths?
One of the most common arguments I’ve heard with regard to the accuracy of the COVID death certificates is the confusion over heart attacks. The argument goes something like: someone has a heart attack and also happens to test positive for COVID, and then they’re counting it as a COVID death! This is doesn’t make any sense! What’s going on here? Are these rumors true?
First of all, it’s false that everyone who tests positive for COVID and dies automatically has COVID listed on their death certificate. Only conditions that caused or contributed to death are listed on the death certificates. Doctors don’t list every diagnosis a patient has, only the ones that, based on the details of that patient’s hospital course, the doctor knows to be pertinent to the disease process that ultimately killed them. This is stated directly on the CDC website:
So ultimately, doctors are using all their knowledge about how disease processes work to decide what actually killed someone. It is not the CDC who is deciding this, it’s doctors/medical examiners, all across the country. By writing “COVID-19” on the death certificate, they are not simply stating that the person who died was COVID positive; they are stating that “yes, COVID caused (or contributed) to this person’s death.” The CDC is not making this determination; the doctors are. Someone who is arguing that the COVID death count is wrong is not arguing with the CDC, they are arguing with all the doctors who actually took care of those patients, saw them die, and then filled out these forms describing what happened. Because these doctors had access to all the patients’ medical records, know the details, and are trained in medicine, they are in the best position to make this call. Looking at the limited information given by the death certificate and trying to argue that the doctor was wrong is like having access to three chapter titles of someone else’s book, not the full text, then trying to argue with the author of the book that they have the story wrong. Trying to do this from a conglomeration of thousands of these death certificates in the table above is even worse, as then you don’t even know whether each condition was listed under Part I (cause of death) or Part II (underlying condition), what other conditions each person had, nor how they were connected.
Then where are these stories coming from about COVID and heart attacks? Well, it turns out that one of the weird complications of COVID is blood clots. For reasons we don’t fully understand, in addition to attacking the lung cells, the virus can also cause blood clots to form more easily than normal. Heart attacks are often caused by blood clots clogging the vessels that bring blood to the heart, which deprives the heart of oxygen and makes it stop working. So it is actually very plausible that COVID could directly cause a heart attack, especially in someone who has high blood pressure and high cholesterol, as these predispose the blood vessels to clot as well. But it can even in occur in someone without these risk factors, as reported here. So if both COVID and heart attack are listed on a death certificate, this does not mean the patient just happened to test positive for COVID right before their heart attack and died “with COVID, not from COVID.” It means that the doctor who filled out that death certificate, based on everything he or she knew about the patient, determined that COVID contributed to that person’s death. Are doctors perfect at assigning cause of death? Probably not, but if you would like to reasonably argue with them, you need both 1. a high level of medical knowledge and 2. access to the details of that patient’s medical records. Without these things, any arguments are pure speculation of what maybe happened based on minimal information, which are frivolous.
But what if doctors are lying?
It has been suggested that perhaps the doctors filling out these death certificates are doing so dishonestly, and falsely writing COVID diagnoses to make money. I’m not gonna lie, this one hurts. If you could see inside hospitals right now and know what doctors are sacrificing for their patients, you would know how much of a slap in the face this is. But let’s put emotions aside and see if this argument holds merit.
First, let’s note that falsely assigning an ICD-10 code for billing purposes is considered fraud, and doctors who do this lose their license. Second, let’s look at the impact COVID has had on hospitals and doctors: has the pandemic brought them lots of business making them rich? No, just the opposite: higher COVID cases has cost hospitals revenue, not increased profits. From a business persective, hospitals are financially incentivized to keep COVID numbers low so that they don’t have to divert resources away from other revenue streams. Falsely elevating their COVID numbers does not help them do this — it is not in the doctor’s nor the hospital’s financial interest to falsely inflate COVID numbers.
But even if there were truly financial incentives to falsely list COVID on the death certificate, would doctors do it? There are bound to be a few corrupt doctors out there, so maybe a handful of doctors would do so. Would this have a significant impact on the death count? No: in order for the effect of corrupt doctors allegedly falsely filling out COVID death certificates to significantly impact the COVID death count, you would need more than a handful of doctors committing this fraud… you’d need like half of the doctors in American doing it. This is usually where conspiracy theories fall apart: a few corrupt people doing something shady is plausible; half of an entire profession doing something shady, conspiring in secret, to deceive the public is not plausible at all. 50% of American doctors are not risking their jobs and purposefully deceiving the public in the middle of a pandemic just to make a little cash. No.
Cross-checking death counts: Are more people dying than normal?
One way we can cross check the COVID death numbers is by looking at total deaths during the pandemic, from all causes. If COVID deaths were being falsely inflated and those dying truly died from underlying causes that were going to kill them anyways, then we would not expect to see a big increase in overall deaths during the pandemic. So what do we see?
The CDC went back and looked at all deaths during the pandemic, and compared it to deaths during previous years to determine if their were “excess deaths” (deaths above what’s normally expected for that time of year). They found that as of Oct 3, 2020, there were 299,028 excess deaths, while only 198,061 deaths attributed to COVID on death certificates. So there were actually 100k more excess deaths than were being captured by the COVID death count. This could be explained by several possible factors — it could be that some of the excess deaths were due to COVID but it wasn’t reflected on their death certificate for one reason or another (maybe it was an abnormal presentation and the doctors didn’t realize it was COVID, or it was before widespread testing was available). Or perhaps some of these deaths are from the longer term complications of COVID that we don’t understand yet. Some are also likely due to other impacts of the pandemic, like people delaying care for other illnesses due to shutdowns or concerns about going to the hospital. We can’t say for sure, but the fact that the excess deaths are actually way higher than the official COVID count does not support the idea that the COVID death certificates are falsely inflating the death numbers. If anything, it supports the idea that COVID deaths may be undercounted.
In conclusion: no, the COVID death counts are not dramatically overestimating the number of COVID deaths. These numbers are based on the doctor’s evaluation of what killed the patient, and not simply counting people who just happened to test positive right before they died from something else. Additionally, there is no data to indicate that these were all super sick people who were going to die anyway; how “sick” they were prior to contracting COVID cannot be accurately gleaned from death certificates. The all cause mortality during the pandemic has dramatically increased above normal levels, confirming that way more people than normal are dying right now.