COVID Pandemic-Related Deaths Are Much Higher Than Reported — And Soon We’ll Know How Much Mark Rabkin Follow Apr 4 · 14 min read

(Updated Apr 8, 9am.)

Latest updates:

UK : Very thorough Apr 7 data release has big jump in total mortality through Mar 27. FT points out that NHS (hospital) data a 78% higher death toll than the government reports (this is not using total mortality). Direct look at mortality figures suggest a 61% undercounting on a very naive reading . We’ll know much more when the ONS releases the next week’s data set on Tue Apr 14 (that week has ~5x more deaths).

: Very thorough Apr 7 data release has big jump in total mortality through Mar 27. FT points out that NHS (hospital) data a than the government reports (this is not using total mortality). Direct look at mortality figures suggest a . We’ll know much more when the ONS releases the next week’s data set on Tue Apr 14 (that week has ~5x more deaths). Spain: Experiencing huge reporting delays after Mar 24. They’re doing daily updates, but with incomplete data — showing huge drop in deaths after mar 24 whereas official counts almost doubled from that date. We’ll have to wait to see when the data catches up.

Experiencing huge reporting delays after Mar 24. They’re doing daily updates, but with incomplete data — showing huge drop in deaths after mar 24 whereas official counts almost doubled from that date. We’ll have to wait to see when the data catches up. France: Next national data release is Fri Apr 10.

Next national data release is Fri Apr 10. US: NYC death tolls don’t count people who died at home, leading to undercounting from 35% to 49% according to FDNY data (from NPR, Gothamist, NYT). City authorities vow to fix this.

Are death tolls accurate?

For a variety of good reasons, much of the public discourse has shifted to deaths rather than cases, given how fickle case counts are. Cases reflect the testing regime just as much as they reflect the reality of disease spread. As the epidemic grows, even countries that were doing sometimes won’t be able to keep up with testing. So now we face a grim reality: at this stage, deaths are a more reliable way to see how a given state or country is affected by the epidemic.

This makes sense. Deaths are much harder to miss or under-count than an infection. And since there’s 10–100x fewer deaths than cases, counting deaths is also more tractable.



But emerging evidence from the last few days suggests that our death tolls still have some of the same undercounting problems as confirmed cases. In democracies, the undercounting seems to stem mostly from missing deaths outside hospitals (at home, in nursing homes) or simply from insufficient testing or overly stringent diagnosis requirements.



Until just now, it was hard to tell how big this undercounting was — but initial data is showing that in hard-hit areas in Italy/Spain, real deaths are 2–4x higher than official tallies. Meanwhile, broad national data is starting to show 61–78% under-counting in the UK and ~40% under-counting in France (see section below). Similarly, we’re seeing ~35% under-counting in NYC due to not counting deaths at home.

This data right now is really early, since mortality figures take at least a week to collect in most countries. To make the data better, some countries are pushing ahead: France now has online updates with 4 days delay; Spain has a daily bulletin full of information, but alas big data delays. Unfortunately, the United States is a sitting duck with credible data available only after about 3 weeks.

(To be clear, this new data doesn’t mean the disease is more fatal to the average person — it mostly just confirms the pandemic has spread further than we know, and caused a lot of cases and deaths that weren’t properly attributed.)



This is important — for decision-making by governments, for people to take it seriously, and most importantly so we don’t miss the second-order effects of the devastation of this epidemic.

Excess Mortality

For the clearest view of this, we can look at total excess mortality. This just means: compare how many people died in, say, the 2nd week of March 2020 to that same week the last 5–10 years. In big populations deaths typically vary only 10–15% a year, mostly due to changes in climate and diseases like the flu.

The good thing about this method is that it captures every death that got a death certificate. You don’t need to argue about why fatality rates per case differ. You don’t need to dispel Elon’s conspiracy theories on whether cause of death in Italy is overstated by 8x (hint: nope, army trucks for body hauling don’t come in for no reason). You just need to know: how many total people died total — and is it unusual?

The bad thing is it doesn’t explain the mechanism and thus it doesn’t explain the solution. Many of the extra deaths might be from the non-COVID conditions that don’t get treatment with a lockdown with an overrun health system. Or it maybe the economic disruption from the lockdowns is leading to lack of food or medicine for many people. We don’t know and this data doesn’t say.

There’s also surprising inverse effects from the lockdowns: in some places, mortalities from other causes are way down. Car crashes and fatalities are down by half in California in March. Flu cases are down 2–3x in Japan from from social distancing. Great air quality due to lack of traffic might save lives.

So again — this method shows us the net total, with all the pluses and minuses (without explaining them).

Roughly this same method produces the large yearly flu deaths estimates — the ones that led to all the terrible “this is just like a flu, it’s even smaller than the flu” narratives that crippled response for weeks or months in many countries. The CDC estimates ~24k-63k deaths in the US from flu in 2019, using a model that (as far as I understand) projects out from a small # of actual flu tests, and correlates with excess mortality to calibrate. So those flu deaths were a shitty comparison: after-the-fact fully modeled flu mortality vs. solely directly confirmed COVID deaths, way early in an exponential epidemic.

This excess mortality method hasn’t been used much yet for COVID because it only works once you have a cause of death that’s big enough to spike up the total numbers at least 20% or so. Unfortunately, the COVID pandemic in many places is now so big that we’re finally able to see total mortality numbers — and they’re concerning.

We will know a lot more in the next few weeks as these numbers get more accurate.

What We Know So Far

Over the last few days, we’re now seeing spikes in total mortality in most countries that are heavily affected. That puts us a lot closer to understanding the true impact of COVID on fatalities.

I’ve been really curious about this and have been looking around at what most countries are sharing. As mentioned above, it’s a pretty mixed bag for what countries share, but it’s good that we have what we have. The main pain point in this data is the delays. Worldwide, the number of deaths has grown 2x in the last 5 days and 4x in 10 days. So numbers that are 5–10 days slow are extremely out of date.

However, even in hindsight this data is starting to reveal flaws in how deaths are counted that I think will lead to big improvements in the tallies. Good on those countries that are making this transparently available online in as close to real time as they can do it (yay France and Spain!).

Here’s what I’ve found for each country:

United States

Update Apr 8: NYC has now had some revelations, showing undercounting of 35–49% due to deaths at home being missed.

This was first investigated and broken by the Gothamist, that revealed deaths at home (not in hospital) weren’t counted. NPR estimates that on Monday Apr 7 there were 727 deaths in NYC, with 280 deaths at home versus a normal rate of 20–25 a day in the city, an excess of 255+. This is an undercounting of ~35%.

Mark Levine, chair of NYC Council Health Committee confirmed 3days ago:

Today, the Gothamist states the city has reversed policy and will begin to count “probable deaths” from COVID that occurred at home. They share this:

Earlier in the day, Mayor Bill de Blasio acknowledged that the vast majority of deaths taking place at home were likely also due to the virus, meaning the death toll could be as much as 70 percent higher than currently reported figures. “We do want to know the truth about every death at home, but it’s safe to assume that the vast majority are coronavirus related,” he said. “That makes it even more sober, the sense of how many people we are losing.”

FDNY says over the last two weeks (Mar20 to Apr5) 2192 NYC residents died in their home versus 453 same period last year (+1739). The cumulative NYC deaths official report stood at 3544 on Apr 8, a 49% undercounting.