A joint Virginia Commonwealth University and Yale University study published Wednesday in the Journal of the American Medical Association suggests that the COVID-19 death counts reported to the U.S. public underestimate the true death toll of the pandemic in the country. 

“There are several potential reasons for this under-count,” lead author Dr. Steven Woolf, director emeritus of VCU’s Center on Society and Health, said in a statement. “Some of it may reflect under-reporting; it takes a while for some of these data to come in. Some cases might involve patients with COVID-19 who died from related complications, such as heart disease, and those complications may have been listed as the cause of death rather than COVID-19.”

And although the spread of COVID-19 in the U.S. has increased death rates in recent months, deaths attributed to COVID-19 account for only about two-thirds of the death rate increase in March and April, according to the study. 

From March 1 to April 25, there were 87,001 excess deaths (deaths above the expected number, based on averages from the past five years), but only 65% of those deaths were attributed to COVID-19, according to “Excess Deaths from COVID-19 and Other Causes, March-April 2020.” And in 14 states, including California and Texas, more than 50% of excess deaths were tied to underlying causes not related to coronavirus.

“[A] possibility, the one we’re quite concerned about, is indirect mortality — deaths caused by the response to the pandemic,” Woolf said in a statement. “People who never had the virus may have died from other causes because of the spillover effects of the pandemic, such as delayed medical care, economic hardship or emotional distress.”

The study also shows that deaths from causes unrelated to COVID-19 rose more sharply in states that saw the most coronavirus deaths in March and April, including Massachusetts, Michigan, New Jersey, New York and Pennsylvania. Diabetes deaths in those states rose 96% above the expected number when compared to weekly averages in January and February this year. Heart disease deaths rose 89%, Alzheimer’s deaths rose 64% and stroke deaths rose 35%.

But the most staggering of all was a 398% heart disease death rate increase in New York City and a 356% diabetes death rate increase.

The study suggests that some of these deaths occurred during acute emergencies (such as heart attack or stroke) in people who were too afraid to go to the hospital during the pandemic.

“We can’t forget about mental health,” Woolf said in a statement. “A number of people struggling with depression, addiction and very difficult economic conditions caused by lockdowns may have become increasingly desperate, and some may have died by suicide. People addicted to opioids and other drugs may have overdosed.

“All told, what we’re seeing is a death count well beyond what we would normally expect for this time of year, and it’s only partially explained by COVID-19.”

Further studies are needed to determine the number of COVID-19 deaths versus indirect deaths “caused by disruptions in society that diminished or delayed access to health care and the social determinants of health (e.g., jobs, income, food security),” Woolf and co-authors Derek Chapman, Roy Sabo and Latoya Hill of VCU and Daniel M. Weinberger of Yale wrote in the study.

“The findings from our VCU researchers’ study confirm an alarming trend across the U.S., where community members experiencing a health emergency are staying home — a decision that can have long-term, and sometimes fatal, consequences,” Dr. Peter Buckley, interim CEO of VCU Health System and interim senior vice president of VCU Health Sciences, said in a statement. “Health systems nationwide need to let patients know it is safe and important to seek care in a health emergency, whether it’s through telehealth or in person.”

The VCU/Yale joint research was funded by the National Center for Advancing Translational Sciences and the National Institute of Allergy and Infectious Diseases.

“Public officials need to be thinking about behavioral health care and ramping up their services for those patients in need,” Woolf said in a statement. “The absence of systems to deal with these kinds of other health issues will only increase this number of excess deaths.”

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