How many people have died in the US so far from the COVID-19 pandemic? It depends on how you count the numbers. The official count of US COVID-19 deaths is 214,000. This number is often reported as “at least” this amount, because this is a compilation of all deaths where COVID-19 was officially listed as a cause of death. Experts recognize that this is likely to be a gross underestimation, because people may die from the disease at home without ever being diagnosed.

In any such system, regardless of how careful you are, there are going to be false positives and false negatives. When it comes to the cause of death there are very specific coding guidelines. COVID-19 must have directly lead to the death of the individual. Laboratory confirmation is strongly encouraged, but doctors may code COVID-19 as a probable cause of, in their clinical judgement, the patient had COVID-19 and it fits the epidemiology, even if they did not get a test. When COVID-19 is severe enough to kill, it is a fairly recognizable clinical condition. This does open the door to other fatal viral respiratory infections to be coded as COVID, but these instances are likely to be rare.

States report their data differently. Some only report confirmed cases. Some report confirmed and probable. Some states get their numbers from death certificates, while others count deaths among diagnosed cases of COVID-19. Taking all of this into consideration, COVID-19 deaths are likely to be underestimated in the aggregate rather than overestimated. Some critics argue that allowing “probable” cases overestimates the total deaths from COVID, but if you look at the data state-by-state you will see that probable cases are small in number compared to confirmed. In Arizona, for example, probable cases are only about 5% of the total deaths reports, the vast majority of which are confirmed. So even in the very unlikely scenario that all probable cases are false positives, that only gives a 5% variance (and keep in mind, many states don’t report probable cases at all).

There is another way to get at the impact of the pandemic other than counting death certificates. Several researchers have looked at excess deaths during the pandemic, either regionally or nationally. The largest such study was just published in JAMA. The total number of deaths in the US is remarkably consistent year-to-year, so a dramatic change in this baseline must have a specific cause. The study found:

Between March 1 and August 1, 2020, 1,336,561 deaths occurred in the US, a 20% increase over expected deaths (1 ,111, 031 [95% CI, 1 110 364 to 1 111 697]).

That’s 225,530 excess deaths. However, only 67% of these excess deaths can be explained as official COVID-19 deaths. If we apply these ratios to the total pandemic, that means that there have been a total of 319,402 excess deaths total during the pandemic (214,000 is 67% of 319,402). This should put an end to any notion that the pandemic is a hoax or overblown or that the total deaths are somehow grossly overestimated. If anything, total COVID-19 deaths are likely underestimated.

Some of these uncounted excess deaths are likely to be missed cases of COVID-19, again most likely from people who died at home. Some are likely due to probable cases that are not reported in those states that only report confirmed cases. But this does not account for all the excess deaths. That data also shows that some of those deaths can be accounted for by increases in the baseline death rate from things like Alzheimer’s disease and heart disease. Such causes can be considered part of the disruption of normal health care. Some people have been delaying care or avoiding emergency departments for fear of catching COVID.

The authors warn that this disruption may cause excess deaths for years, from diabetics not taking care of themselves, disruptions in chemotherapy for cancer patients, and delays in testing such as mammograms. Another category of excess deaths is due to the emotional and economic stress caused by the pandemic, which has lead to an increase in suicides and overdoses.

The study also takes a more granular view of the data, looking state-by-state and showing that the excess deaths coincides with surges of reported cases of COVID-19, as we would expect if COVID was the primary cause.

What, then, is the death toll of the pandemic? Should we count deaths caused by the disruption in health care but not directly related to infection? There is no right or wrong answer here. We can say, neutrally, that the COVID-19 pandemic has directly caused at least 214,000 deaths, although this number is likely an underestimate. Further, it has caused another 100,000 deaths, some of which are likely to be uncounted direct deaths, but the rest are indirect deaths due to the disruptions caused by the pandemic.

Some may wish to focus on the excess deaths due to suicides and overdoses, arguing that these result from our reaction to the pandemic rather than the pandemic itself. This is reasonable, but we need to keep it in perspective. These deaths are a tiny percentage of total deaths. Further, the data also shows that the strongest predictor of deaths is the number of COVID cases. As one of the authors notes:

“We can’t prove causally that the early reopening of those states led to the summer surges. But it seems quite likely,” said Woolf. “And most models predict our country will have more excess deaths if states don’t take more assertive approaches in dealing with community spread. The enforcement of mask mandates and social distancing is really important if we are to avoid these surges and major loss of life.”

Of course we should fight the pandemic smartly and minimize unintended consequences. Mask mandates, for example, not only reduce spread of COVID they allow people to work and get out of the house. Shut downs should be a last resort, but they do work when necessary, and the alternative of letting the pandemic spread has proven the most deadly option.