The Hidden Death Toll
A new study published this week estimates that approximately 155,000 COVID-19 deaths that occurred outside of hospitals went uncounted during the first two years of the pandemic, meaning the official U.S. death toll for 2020 and 2021 may have been understated by roughly 16 percent. The research, which used machine learning methods to analyze patterns in excess mortality data, adds to a growing body of evidence suggesting that the pandemic's human cost was even larger than the staggering official figures suggested.
About 840,000 COVID-19 deaths were recorded on death certificates in 2020 and 2021, making it the third leading cause of death in the United States during that period. But a team of researchers found that when they examined all-cause mortality data — the total number of deaths from any cause, compared against historical trends — there was a substantial gap between expected and observed deaths that was not explained by the recorded COVID toll or by other known factors.
Why Deaths Go Uncounted
Death certificate reporting is imperfect under any circumstances, and the early months of the pandemic created conditions that amplified those imperfections. Hospitals and medical examiners were overwhelmed. Testing was severely limited, meaning many patients who died of COVID-like illnesses never received a confirmed diagnosis. In the absence of a positive test, clinicians had to make judgment calls about whether COVID-19 was the underlying cause of death — and those calls were inconsistently applied across jurisdictions.
Outside of hospitals, the attribution problem was more severe. People who died at home, in nursing facilities, or in rural settings with limited healthcare access were less likely to receive post-mortem testing or detailed medical review. If a 75-year-old with underlying conditions died at home in April 2020 without receiving medical care, their death might be recorded as natural causes or attributed to heart disease — particularly early in the pandemic, when COVID's symptom profile was not yet well-understood by clinicians.
