Undercoverage of Covid-19 deaths highest in pro-Trump areas

TThousands of Covid-19 deaths go unreported in the United States, according to a new study, and many more are missed in counties that have strongly supported former President Trump.

The numbers suggest that political trends have helped suppress the true scale of deaths. In cases where the deceased has not undergone a Covid-19 test, a coroner or medical examiner is free to interpret the symptoms.

“There is potentially leeway to pass judgment conditional on a set of beliefs about Covid and whether it represents a serious problem or a hoax,” said Andrew Stokes, professor of global health at the Boston University School of Public Health who performed the analysis for STAT.

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More than 413,000 people have died in the United States with Covid-19 assigned somewhere on their death certificate. The actual number of deaths, as evidenced by the number of excess deaths in 2020 compared to annual deaths from 2013 to 2018, is even higher. A separate study, led by Stokes, of 787 counties with more than 20 deaths linked to Covid-19 between February 1 and October 17, 2020, found that while there had been 199,124 official deaths from Covid-19 during This period, an additional 88,142 deaths have not been attributed to the virus.

Some of these excessive deaths are likely due to factors that have been exacerbated by the pandemic, such as overdoses and suicide in response to isolation and economic hardship, or poor health care in an overburdened system. But researchers believe that many deaths linked to Covid-19 are innumerable. Overall, the true death toll from Covid-19 is 31% higher than official figures, according to the study, which was submitted to PLOS Medicine.

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The researchers found that deaths not attributed to Covid-19 were significantly higher in rural areas than in urban areas; in the South compared to other regions; and in areas with low education levels. All of these factors tend to correlate with support for Trump.

“We see a lot of variation in excessive deaths, and it’s a little hard to explain,” said Katherine Hempstead, another study researcher and senior policy adviser at the Robert Wood Johnson Foundation. There appears to be a correlation between areas that were less inclined to take Covid-19 seriously and adopt preventive measures, such as mask wearing and social distancing, and those with higher levels of unrecognized deaths of Covid-19, she said.

Not all variations in excess deaths indicate a Trump effect: low-income counties, which tend to vote Democratic, also have much higher rates of excess deaths. But preliminary research by Stokes, which is not part of the larger study, explicitly looked at political correlations and found that excess deaths not attributed to Covid-19 are much more common in counties most favorable to Trump, based on the 2020 and 2016 presidential elections. Election results, only to the lesser.

In total across the country, there have been 44 excess deaths that have not been officially recognized as Covid-19 for every 100 official deaths from Covid-19. But the countless deaths are much higher in the 25% of counties with the most Trump voters in 2020, with 163 excess deaths per 100 deaths from Covid-19. By comparison, there were only 18 more deaths per 100 Covid-19 deaths in the lower quarter of those counties.

Throughout the pandemic, the response to Covid-19 has been intensely partisan, and politicized reactions to the virus could easily shape how death itself is recorded. Former President Trump has spoken out against testing, mistakenly saying it creates more cases. Since patients are less likely to be recorded as Covid-19 deaths if they haven’t been tested, this would contribute to missing cases.

Adoption of the tests will likely be lower in more conservative areas, Stokes said. “Undiagnosed people are less likely to be assigned Covid-19 on their death certificate than those diagnosed.”

IIn areas where the pandemic is downplayed or viewed as a myth, the death reporting process leaves room for those who do not take Covid-19 seriously to leave the virus out of death certificates. Covid-19 is usually the underlying cause of death, leading to conditions such as pneumonia or a heart attack which is the most direct cause. In cases where someone has not been tested, coroners are free to attribute a death to the most direct condition and leave Covid-19 entirely.

If a person is hospitalized for breathing problems, gets tested for Covid-19, and dies from those breathing problems, then the virus is clearly an underlying cause. “These deaths are relatively straightforward to follow,” said Greg Hess, chief medical examiner for Pima County, Arizona. “On a death certificate, you would mention the fact that you diagnosed the person with Covid, and that they died of viral pneumonia due to Covid. “

But other cases are less clear, Hess said. A patient could contract Covid-19 in hospital for a hip fracture, which could worsen their underlying heart disease and diabetes. They could then recover from Covid-19, but ultimately die from their deteriorated health. “So now what happens on a death certificate?” Well, it really depends on who writes it, ”Hess said.

The death registration system in the United States is fragmented. Although most deaths are reported by a physician, when a patient dies at home and is not under the care of a physician, a medical examiner or coroner will usually be called upon to report the death.

The Stokes-led study found that counties that used coroners, who are elected and may be lay people, had higher rates of excess deaths from Covid-19 than counties with medical examiners, who are medical officials named.

“They will vote for you. I’m sure there’s pressure, that’s one of the hardships to get elected, ”said Sally Aiken, Spokane County, Wash., Medical examiner and chair of the board of directors. National Association of Forensic Pathologists. “In those smaller areas, there are fewer voters, so it doesn’t take that many to get rid of you.”

Death investigators are used to dealing with pressure from family members. “Families have certain expectations or stories they have in mind about why their loved one died that might be contrary or supported by what is available in the medical record,” Hess said. “Sometimes someone can adapt the way a death certificate is written to try to get relief from a family member who might upset or harass them.” There is no evidence that this is happening locally, he added.

Aiken said she had investigated several deaths where the family insisted Covid-19 could not have played a role. “There is an element of pressure from some people who frankly don’t believe Covid exists. So they don’t want it on the death certificate, ”she said.

Most of them gave in once the deceased was tested, but she said a family insisted, even when a test came back positive, that the other underlying conditions of their loved ones were the real cause, rather than Covid-19.

“Families don’t decide what is on the death certificate, at least in my jurisdiction, but in some jurisdictions it probably influences what is on the death certificate, especially in borderline cases where a person has a death certificate. underlying significant natural disease, so Covid, ”Aiken said.

Deaths linked to Covid-19 are more likely to be missed in areas of the country where tests are fewer. If a patient dies without a Covid-19 test, it is up to the investigator responsible for the death to choose to order a post-mortem test. Although Hess and Aiken have done this for all cases where Covid-19 is suspected, Hess said it was not possible for all coroners and medical examiners to do it routinely across the country. “There just isn’t the bandwidth in the system to do this,” he says. “There are going to be deaths that occurred during this pandemic, where Covid was a component of death, and that is not being recorded.”

The cost of ordering a test is also a deterrent, especially in areas where coroners have to pay for postmortem testing out of their budget, Aiken said. “This probably doesn’t happen in some very rural and poorly funded death investigation systems,” she said. “Even though they might have been exposed, or you know, maybe the coroner doesn’t believe it, maybe the family doesn’t believe it, they just think they had the flu. or that they got sick or died suddenly. “

Political beliefs and finances are not the only reasons Covid-19 might be omitted from a death certificate. In New Jersey, the state health department said Covid-19 should be listed as the underlying cause, not the leading cause of death; the specific cause, such as pneumonia or heart disease, must be mentioned on the death certificate.

Sherry Bensimon, New Jersey and New York funeral director on the board of the Metropolitan Funeral Directors Association, said she had received death certificates simply stating Covid-19 and, when she calls to explain they will be rejected, doctors simply change one primary cause for another, without adding Covid-19 as an underlying cause. “I’ve seen it a few times where the doctors haven’t,” she says. “They’re exhausted, they’re busy, and they have a funeral director stalking them.

Unfortunately, Aiken said, even the most rigorous system will miss some deaths from Covid-19. Most Covid-19 death certificates are signed by hospital or community doctors, who receive little training on how to sign death certificates. And there are a lot of false negatives on Covid-19 tests, which have not been studied for their post-mortem accuracy.

The true death toll from Covid-19 may never be definitively determined, but deaths from the virus are certainly underestimated, Aiken said. “It’s a real disease. People are dying. It shouldn’t be political, it should just be the truth.