This work was written by Mark Joslyn and Louis Joslyn . Louis is a PhD candidate in computational medicine and bioinformatics at the University of Michigan.
In Part 1, we introduced the case fatality rate, a measure used by health experts and elected officials to determine the severity of COVID19. The proportion has become a politically charged statistic. Republicans consider the actual number of cases as much larger than Democrats. This leads to disputes over the severity of the disease and thus the appropriate public policies moving forward.
As that debate simmers, a new conflict has flared over the count of COVID19 deaths.
Are Deaths Underestimated?
We present the arguments why the death toll here and abroad may be underestimated.
- Many countries count only those COVID19 deaths that occur in hospitals. A potentially large number of deaths thus escape official documentation. When France added nursing homes deaths to its national totals, the death count rose 40 percent.
- Center for Disease Control numbers are based on reports submitted by the U.S. states. While the CDC has issued guidelines, states have their own laws and criteria for reporting. And, in some states, standards have changed during the course of the pandemic.
- At the start of the pandemic, the CDC counted deaths only when a laboratory test confirmed the presence of COVID19. On April 14, CDC directed the states to begin counting suspected as well as lab confirmed cases. Thereafter, New York released a revised death count that included suspected cases. This added 3,700 deaths.
- Researchers discovered that many more people died over the last two months than would be expected to have died. This “excess morality” could be attributed to the pandemic but official death numbers do not include it.
Are Deaths Overestimated?
We present the arguments why the death toll in the United States may be overestimated.
- The CDC’s initial guidelines – that reported deaths only after a positive laboratory test – produced counts that may have nothing to do with the virus. In an extreme example, let’s say an infected person died in an automobile accident. According to the CDC guideline, that death would be reported as COVID19.
- Later, the refined CDC guidelines that asked states to consider suspected – as well as laboratory confirmed – cases affords potentially too much latitude. In other words, despite a postmortem negative coronavirus test – or the absence of a test, deaths can now be classified as COVID19 based on symptoms. New York’s revised estimates underscore the problem – 3,700 additional people were presumed to have died of the coronavirus but never tested positive.
- In uncertain situations, where a patient tested negative but exhibited flu-like symptoms, Doctors may feel some pressure to report death by COVID19. The CARES Act adds 20% premium for COVID19 Medicare patients.
- Finally, over the past two months, COVID19 may not be the only cause of deaths or excess deaths – greater than expected. Some could be attributed to delayed treatment out of fear of contracting the virus in the hospital, concerns about straining medical personnel, or inadequate emergency care due to resources and personnel diverted to accommodate COVID patients.
The death count is broadcast daily and analyzed repeatedly. It is a grim reminder of tragedy and a powerful signal of how well elected officials are dealing with the pandemic. In fact, it has clear political implications for the President and many Governors across the United States.
Conservative and progressive news outlets apply different numbers to calculate the case fatality rate. Both sides offer evidence that the standards used to count deaths are imprecise and can misinform the public about the true risks of the disease.
Republicans push the idea that we are overestimating deaths from COVID19, and thereby unnecessarily keeping people locked down, and destroying the economy and livelihood of millions.
Democrats assert that we are underestimating the death count from COVID19, and thereby creating a false sense of security that will lead to thousands of additional deaths should we reopen the economy too early.
First, the decentralized process of defining deaths, cases, and administering testing lays bare the properties of American federalism – good and bad.
A top-down, centralized system could impose standardization across the states. It could allocate resources efficiently and compel states and counties to follow a clear set of guidelines for recording the number of cases and deaths. The result would be a comprehensive and reliable set of measurements from which public policies could be fashioned.
Alternatively, a strong federal hand may be slower to adopt to an evolving fast spreading disease. It could crush state innovation and eventually pursue national interests at the expense of local concerns. For example, the Food and Drug Administration recently ordered a pioneering testing program supported by billionaire Bill Gates and Seattle health officials to stop pending additional federal reviews.
Yes, centralization may achieve standardization and efficiency but that does not mean the resulting data are valid nor the testing technology advanced.
Our federalist structure toggles between state and federal control, balancing precariously between these the two poles of authority. Crises generally impose centralization. It may take some time – we are only a couple months into this calamity, but the pandemic will inevitably strengthen federal control of public health and expand government investment in disease containment and immunological research.
The second take-a-way concerns science. Conflicting measures and changing formulations illustrate science in motion. Scientists often disagree on measurement and debate interpretations of a specific formulation.
In this instance, researchers are tracking a fast-moving, relatively unknown virus. As time passes, more will be known, earlier benchmarks abandoned and new ones established. This is progress – in real-time. It can be messy, not always linear – and it is now under unusually intense political pressures.
Scientists do agree on one aspect, however. More testing will uncover many of the mysteries of COVID19. Federal and state government would be wise to heed these calls.