The United States is about to record its one millionth confirmed COVID-19 death-a once-unfathomable number, but one that a new study suggests might be a big undercount of the true death toll. Researchers at Boston University School of Public Health, the University of Pennsylvania, and the Robert Wood Johnson Foundation have found official COVID-19 death trackers may have missed more than 170,000 deaths. One of the experts behind the study, Andrew C. Stokes, an SPH assistant professor of global health, has suggested the current COVID-19 death total may even be above 1.2 million.
The study examined excess deaths-a metric that captures the number of deaths in a crisis beyond what would be expected in normal times-in 3,127 US counties between March 2020 and December 2021. Among 936,911 excess deaths, 171,188 of them, or 18 percent, were so-called hidden deaths-uncounted COVID-19 deaths that were assigned to another cause and indirect deaths that occurred due to other pandemic-related factors, such as limited healthcare access, increased substance use, and other social and economic hardships. Stokes says the hidden deaths mean the United States is likely long past the grim one-million mark.
The research, which was made available as a preprint on medRxiv ahead of peer-reviewed publication, is the first comprehensive assessment of excess COVID-19 mortality in the United States in 2021; prior studies have focused on excess mortality in 2020.
COVID-19 Mortality Burden Falling on Rural America
The findings paint a clear picture of the changing geographic patterns of mortality across counties, regions, and urban-rural areas throughout the pandemic. While COVID-19 deaths in 2020 were more pronounced in large, urban areas in the Northeast, far West, Southeast, and Southwest, the mortality burden shifted sharply to rural areas, especially in the Southeast and Southwest, during 2021.
Examining excess deaths by county reveals patterns in mortality not discernable at the state level and captures the mortality impact specific to local communities. It can also identify places where the mortality impact of the pandemic has been hidden.
"These new estimates are our best guess at the true impact of COVID-19 across US communities," says Stokes, the corresponding author on the paper. He's studied excess deaths closely throughout the pandemic. "While the total number of hidden deaths decreased from 2020 to 2021, the mortality impact of the pandemic is still effectively hidden in many parts of the country, especially in rural areas and in the South."
The researchers captured a geographical snapshot of excess mortality by COVID-19:
- Among the top 20 counties with the highest death undercounts in 2021: Shelby County, Tenn., Calloway County, Ky., and Lafayette County, La.
- In 2020 and 2021, Mississippi and Arizona were among the top five states with the most uncounted COVID-19 deaths.
- In 2020 and 2021, Massachusetts was among a small number of states with no uncounted COVID-19 deaths.
Flawed Death Investigations
The team's previous research, along with an investigative reporting collaboration with USA Today, suggests that the underestimated official COVID-19 death counts are, in part, a product of the country's flawed death investigation system. Pandemic-related deaths are only recorded as such if COVID-19 is listed on a death certificate as the official cause of death. Death investigation processes vary widely from county to county-particularly in rural areas, where the investigations are often led by inexperienced, politically appointed coroners or justices of the peace, who may intentionally and unintentionally bungle the examinations and fail to label COVID-19 as the official cause of death.
Families who have lost loved ones to COVID-19 are eligible for up to $35,000 of Federal Emergency Management Agency assistance if COVID-19 is listed on the death certificate, Stokes says. "But there are a lot of applications being denied because the certificate lists other causes of death. It's a real issue," he says.
Another reason behind the underreporting of COVID-19 deaths is a lack of testing, says Stokes, noting that in certain areas, testing has been limited throughout the entire pandemic. "We've seen a decline in PCR testing, and testing capacity and infrastructure," he says. "The rapid tests that individuals take themselves are not necessarily being relayed to a medical professional or certifier, and the positive cases that unfortunately turn into deaths may not contribute to the official death tallies."
"This research makes clear that the pandemic is far from over," says Dielle Lundberg (SPH'19), a research fellow in SPH's global health department and a study coauthor. "And state and federal governments' focus on individual behaviors instead of population-level measures-like paid family and medical leave, universal healthcare, and targeted vaccine delivery campaigns for the communities most impacted-has had severe consequences."
Financial support for this work came from the Robert Wood Johnson Foundation, the National Institute on Aging, and the W.K. Kellogg Foundation. The study was also coauthored by Jacob Bor, an SPH assistant professor of global health and epidemiology, Ahyoung Cho (GRS'25), and Rafeya Raquib (SPH'23). Other authors include Eugenio Paglino, Irma T. Elo, and Samuel H. Preston, all of the University of Pennsylvania, and Joe A. Wasserman and Katherine Hempstead of the Robert Wood Johnson Foundation.
