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--:-- Host (Sean Rameswaram): Bob Duffy was a retired firefighter who lived in Nassau County on Long Island. And he had a lot of pre-existing conditions. He had had multiple cancers. He had had a stroke at one point in the past 20 years. And he got very sick very quickly. He became extremely fatigued. He ran a fever of 103 degrees. At first it was he couldn't walk down the block. Then it was he couldn't walk out of his house. And then his wife, Fran, was having to kind of move him around inside the house because every time he tried to walk, he would fall. He never went to a hospital. Partly that was because he didn't want to be separated from his wife and he knew that if he had gone into a hospital, she would have had to stay outside. And partly it was because the idea of loading him into the car with his supplemental oxygen and driving him out there seemed like a harder thing than just not knowing what he had.
--:-- Host (Sean Rameswaram): The symptoms that he had pointed to things that lined up with what we know are symptoms of COVID-19. He was also in contact with multiple people who were later diagnosed with COVID-19, including one woman who died. But his death was not recorded as a COVID death. Maggie Kurth, senior science reporter at FiveThirtyEight.
--:-- Maggie Kurth: This is the week that the U.S. surpassed 100,000 deaths. But there are a lot of people out there like Bob who haven't been officially counted as COVID-19 deaths. So how confident should we feel about the current death counts that we have in this country? Well, what the experts told me is that we should think of it as an at least. We should feel fairly confident that at least 100,000 people have died. It's probably higher than that. But by how much, nobody's entirely clear.
--:-- Maggie Kurth: You know, some of the experts were sort of tossing around numbers like, well, maybe it's like 25%, maybe it's like 15%, maybe it's like 40%. But a lot of people think that a lot of the undercounting happened early on when, you know, we didn't know all the things that could be symptoms of COVID and when we weren't necessarily even like watching for it everywhere.
--:-- Maggie Kurth: Generally, there's this whole bureaucracy that's set up to work best if you die after a test has been administered and you've been formally diagnosed in a hospital. And anything that sort of happens outside of that very tidy setup could end up with you not being counted. So if you have a heart attack and you had no symptoms of COVID and you hadn't been in contact with anyone who had COVID and there's no reason to suspect you had it and that it contributed to your heart attack, that would not get marked as a probable COVID death.
--:-- Maggie Kurth: If you had a heart attack and you had had symptoms of the disease and you had been in contact with people who had been diagnosed but you had not been yourself diagnosed, that would get counted as a probable COVID death. At least it should be, according to the CDC. So with Bob Duffy, who you talked about at the top, should he have been counted as a COVID death? He certainly seems like a probable COVID death.
--:-- Maggie Kurth: So what I think is particularly interesting about his case is that two weeks after he died the CDC had a webinar for doctors that was kind of meant to sort of walk them through how you should be filling out these death certificates how to decide whether a case is a probable COVID case or not. And one of the hypothetical examples that they used in that webinar matched a lot of what was going on in Bob's case.
--:-- Maggie Kurth: You know, they used this hypothetical example of an older person with pre-existing conditions and contact with people who were later diagnosed and with symptoms, and then they die. And from that CDC webinar, you know, if Bob had died two weeks later, he would have been counted. So I guess the way of counting COVID deaths has kind of been in flux for a while.
--:-- Maggie Kurth: Did where Bob died impact how he was counted too? So there's not one single process for how deaths are counted in the U.S. There's many. How they are currently determined varies a lot depending on where you are. One example that I heard about that really stood out to me was that in Milwaukee County, if you die and it's a probable COVID death, somebody's going to come and investigate that and check and make sure it should be counted and kind of run through like a bunch of different, you know, medical and epidemiological research.
--:-- Maggie Kurth: Whereas if you look at someplace like Nassau County in New York, that's not what's going on there. The medical examiners did call Bob Duffy's family. You know, they kind of called Fran up and they asked her a few questions about his health. And when she was kind of listing off to them all the different things that he had had go wrong with his body over the last 20 years, they were like, oh, okay, you're fine. And that was it.
--:-- Maggie Kurth: So there's definitely a big spread in how counties are handling this. And are certain groups being undercounted more than others? Oh, absolutely. I mean, rural areas are probably being undercounted. That was one thing that experts told me. Basically, anywhere that you have people with a lot of pre-existing conditions and not a lot of access to health care, you're probably going to be having undercounting happening.
--:-- Maggie Kurth: And much like the cases of COVID, the undercounting is probably not consistent across the U.S. You know, some places probably have a lot more undercounting than others. What does it mean for the country when there's an undercounting problem like this? I mean, why is it so crucial to get this right?
--:-- Maggie Kurth: There's a couple of reasons. I mean, you know, on the one hand, you really want to know how many people are dying because it helps you make policy decisions. And you want to know how many people are dying in what places, because obviously we are having a pandemic that does not affect every place in the same way at the same time. So knowing how many people are dying and where is pretty important to knowing how we should be responding.
--:-- Maggie Kurth: The other thing I think is also a psychological issue. You know, talking to Bob's family, a lot of their suffering mentally, you know, emotionally about this is the not knowing what he died from and knowing that they have reason to suspect it was COVID-19, but that he's not being counted among those deaths. That kind of feeling of him being missed and falling through the cracks, I think is a pretty painful one for families.
--:-- Maggie Kurth: I think one of the things that this sort of hammers home to me about this entire COVID-19 experience is how much it's sort of forcing us to be intimate with uncertainty. You know, we are taught in school that science is this thing where you get these facts and you go and you do the process and the process gives you a fact. And then you memorize the fact and you're done. That's not really how it works in the real world, particularly when we're just learning about a new virus.
--:-- Host (Noam Hassenfeld): Up next, death counts are notoriously hard to get right, but the Trump administration seems to be making the problem worse. I'm Noam Hassenfeld, filling in for Sean Ramas-Furham. This is Today Explained.
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--:-- Matthew Iglesias: What is the government doing about this undercounting problem? I mean, if you look at the Trump administration, they are making it worse. You know, we've had reporting from both Axios and The Washington Post, which says that Trump and some other members of his administration have been complaining quite vocally, clinging on to various different theories that say the death count is too high, that it's being inflated.
--:-- Matthew Iglesias: At current, it's about 86,000, yes. Do you think that's accurate or do you think it's higher than that? I don't, or lower than that. I don't know. That in particular, when New York City added a bunch of presumed deaths to their count, that they were really upset. In fact, I see this morning where New York added 3,000 deaths because they died. And they're now saying rather than it was a heart attack, they're saying it was a heart attack caused by this. So they're adding just in case.
--:-- Matthew Iglesias: And the Post has said that Dr. Birx has started, you know, sort of asking around at the CDC, making sure they're tightening up the numbers on it. You also see in the forecasts that, you know, President Trump keeps picking the low end of the range of different forward-looking forecasts. We're going toward 50 or 60,000 people. That's at the lower, as you know, the low number was supposed to be 100,000 people. We could end up at 50 to 60. OK. All of the sort of statistical evidence suggests exactly the opposite, that we are undercounting deaths, which is not unusual in these circumstances.
--:-- Matthew Iglesias: And a responsible, you know, government official would be saying, look, like we're counting, but sort of hold your horses. There's more problems out there. Instead, we have a lot of conspiratorial type thinking from, you know, a White House that engages in that sort of thing constantly, attempts to delegitimize any sources of information that they think might reflect poorly on them.
--:-- Matthew Iglesias: And, you know, the concern is that state governments that are sort of bought in on the let's open things up worldview are going to be engaged in different kinds of shenanigans, putting pressure down to county coroners everywhere to sort of lowball estimates. So to be clear, the government doesn't control the death count, but the Trump administration is pushing back against some of these higher numbers?
--:-- Matthew Iglesias: Yeah, I mean, exactly. And to suggest to the media, right, particularly the ideologically friendly media, that these should be understood as high counts when the reality is that they should be understood as low counts.
--:-- Matthew Iglesias: In the first half of the show, Maggie talked about just how hard it is to get accurate death counts. So how can we tell the difference between difficulty in counting and purposeful undercounting? You know, I mean, it's hard to know on some level, what's what. But I think that, you know, you can tell from how people talk about these things, right? I mean, are they pushing to get better information?
--:-- Matthew Iglesias: And in particular, are they looking to try to get information about what the statisticians call excess mortality? And the way that goes is you look at how many people have died in total. Over any given period of time in any given place. And then you also look historically at how many people normally die at that time of year in that given place. That gives you a much better ballpark than sort of looking at tests because, you know, a certain number of people, particularly vulnerable populations or people in nursing homes, may have passed away without ever having gone through a hospitalization and testing phase.
--:-- Matthew Iglesias: Yeah, that covers the whole idea of probable COVID deaths Maggie was talking about, but should we really be expanding the COVID death count to include excess mortality? I mean, is it fair to count those as COVID deaths? Yeah, I mean, I think we want to know, right? I mean, in most of the country right now, it seems unlikely that we have very many people in that category.
--:-- Matthew Iglesias: But we know that we have seen big spikes in cases in New York City at one point, in Italy at another point, in Paris and in Madrid. And when that happens, right, when a sort of metro area gets really, really slammed, we know that's when a high death toll is occurring. But we also know that's exactly when people are most likely to not really make it into the hospitals, right? If they hear the hospitals are overwhelmed or people aren't even getting good treatment there, they may not go.
--:-- Matthew Iglesias: If ambulances can't come quickly, they may not go. Whenever things go really bad for a place, these kinds of official death counts get a little bit hazy because it's fussy paperwork type stuff. And in a true emergency, it doesn't get done right. And if you want to understand what really happened, you need to look to excess mortality.
--:-- Matthew Iglesias: And this isn't the first time we've seen this type of undercounting from the Trump administration, right? I remember the whole controversy about the death count after Hurricane Maria, right?
--:-- Matthew Iglesias: Yeah, I mean, this is sort of classic issue in government statistics. Hurricane Maria, it devastated Puerto Rico. There were obviously huge problems there. Hurricane Maria will go down as one of the deadliest natural disasters in U.S. history because the official toll went up dramatically today from 64 to 2,975.
--:-- Matthew Iglesias: Excess mortality was looking at, look, what was the impact on the population of a prolonged period of blackouts, of a lack of safe drinking water, right, of a health care system that was crippled by all this destroyed infrastructure? Researchers at George Washington University estimate nearly 3,000 people died during the six months after the hurricane hit.
--:-- Matthew Iglesias: Now, the study looked at historical death patterns from 2010 to 2017 to predict how many people would have died had Maria not hit the Island. That figure was then compared to the actual number of deaths. And it was finding that huge numbers of people were dying in Puerto Rico, many, many more people than would normally sort of pass away.
--:-- Matthew Iglesias: And that's, you know, I think in a common sense term, the true death toll of a natural disaster. But the Trump administration really did not want to acknowledge the full severity of that. And they were going with this lowballed number.
--:-- Matthew Iglesias: And you have something similar to that happening here with coronavirus. It reflects poorly on Trump that there are so many infections in the United States, and he would rather take the rosiest possible view of the death toll.
--:-- Matthew Iglesias: So I guess it's reasonable to assume that the consequences of this pandemic are just much more far-reaching than we think? I mean, I think it's important for people in the media, people like us, to make sure that we don't don't repeat specific preliminary figures too definitively or too frequently.
--:-- Matthew Iglesias: Because once people get sort of locked in their head, oh, I know what the death toll was, then when new information starts coming out, they can be very resistant to revising it. And it's the most important thing, you know, people need to know is that to really understand the full scope of a tragedy, you need an excess mortality calculation.
--:-- Matthew Iglesias: You know, the 100,000 deaths landmark, you know, was sort of a big deal in the press. But it's important to understand, like, that was not right. The one thing we know is that the real number is higher than that, or that that threshold was crossed sooner.
--:-- Matthew Iglesias: And it's misleading to portray it as this kind of super precise counter. What we have is a floor. We have people who we know this is why they died in a very specific kind of way, but the real scope is much bigger than that.
--:-- Host (Noam Hassenfeld): Thanks for listening to today's episode of Today Explained.
