The number of people killed by coronavirus in Massachusetts in the early days of the pandemic is likely much higher than reflected by the official death toll, according to a Globe analysis of preliminary state death records from March.
Total deaths in Massachusetts soared by 11 percent last month over the March average for the last 20 years, a statistically significant increase that far exceeded the expected swings from year to year.
The March spike in deaths eclipsed the number of fatalities attributed to the coronavirus in official counts, and also suggests that fatalities began to climb before the full extent of the outbreak was clear. While the number of total deaths increased, the state saw a steep drop in fatal accidents and suicides.
The phenomenon points to a likely undercount of deaths linked to the disease, according to public health experts.
“We are absolutely undercounting COVID-19 deaths, there is not a doubt in my mind about that,” said Dr. Michael Mina, an assistant professor of epidemiology at Harvard T. H. Chan School of Public Health. “And if we undercount deaths, we deflate fatality rates.”
An accurate accounting of the dead is critical because it helps public health experts understand the disease and can shape public policy and the allocation of resources.
Increasing evidence from across the globe suggests that the pandemic may be claiming far more lives than the fatality figures published each day by states and countries the world over show. Here in Massachusetts, the overall data from the Department of Public Health was particularly stark, although officials warned that the figures were subject to change and should be viewed with caution.
Since 1999, an average of 5,049 people have died each March in Massachusetts. But this year, March deaths swelled to 5,578. It was the largest number of March deaths in at least 20 years, topping the previous high of 5,405 in the brutal winter of 2015.
The surge of 529 deaths above average far surpassed the 89 fatalities officially attributed to the virus through the end of March.
Governor Charlie Baker’s administration said in a statement that it was actively reviewing death certificate data back to March 1 or earlier to ensure that the full impact of COVID-19 is measured.
“The department will continue to update numbers and investigate COVID cases as far back as the data suggests,” the statement said. The results of that review were not included in the March death totals, and the administration did not say when its analysis would be completed.
The data analyzed by the Globe also found a sharp uptick in the number of people who died at home, a total that jumped 32 percent in March 2020 compared to the 20-year March average.
The jump in home deaths was particularly noticeable in Plymouth County, which has a population that is older on average than much of the state. The number of home deaths there jumped by a third with 32 additional fatalities. Home deaths also jumped substantially in Suffolk, Worcester, and Middlesex counties, according to the data.
Deaths in people’s homes that occur outside of hospitals and nursing facilities are important because they may indicate officials are missing the full toll exacted by the coronavirus, health specialists say.
The increased number of deaths may in part stem from people’s fears of seeking treatment in hospitals and doctor’s offices for heart, kidney, and other health problems and instead they are dying from those diseases at home, according to Mina, the Harvard epidemiology professor. That notion raises an equally vexing problem.
“This should be a wakeup call for anybody who lives by the mantra that the US is number one in health care. We are not,” Mina said. "This is extraordinarily unacceptable that we don’t have the resources to diagnose people who are dying.”
The Globe’s findings were “highly suggestive that deaths connected to COVID-19 have been undercounted in Massachusetts,” according to Ronald D. Fricker Jr., a dean and professor of statistics at Virginia Tech.
The trend mirrors that of other places such as New York City, which has experienced an increase of deaths at home that have suggested an undercount of COVID-19 fatalities, Fricker noted.
While the rise in deaths could be explained in part by Massachusetts’ recent population growth or another phenomenon, the “strong evidence of an undercount" may require an adjustment in the death toll, Fricker said
Last week the state medical examiner’s office sent an e-mail on behalf of the governor’s office asking whether funeral directors had noticed a spike in home deaths, according to C.R. Lyons, president of the Massachusetts Funeral Directors Association. The April 14 e-mail indicated that the governor wanted an answer that afternoon.
Sixteen funeral directors — a sliver of the association’s 500 members — responded and said they hadn’t noticed a jump in home deaths.
The state’s official death count Wednesday rose to 2,182, jumping by 221, the largest single-day increase of the pandemic.
Massachusetts had one of the nation’s earliest known instances of coronavirus, with its first confirmed case Feb. 1. Another seven weeks would pass before the state had its first confirmed fatality on March 20. The death toll rose gradually until surging more recently.
Officials across the country are scrambling to assess the earliest cases tied to the pandemic. Just this week, health officials in Santa Clara County, Calif., announced autopsy results had determined coronavirus contributed to the deaths of two people on Feb. 6 and Feb. 17 in their homes. Those deaths occurred weeks before what had been the first known COVID-19 fatality in the United States, in Washington state.
In Massachusetts, the state medical examiner’s office began on March 3 to administer nasal swab tests on people who died at home — or outside of hospitals and nursing homes — and were suspected of having COVID-19. A spokesman said they’ve tested about 60 people, and of those, six tested positive for COVID-19. Those positive cases were all in April.
Concern about undercounted deaths is not unique to Massachusetts. In Detroit as well as in New York City, for instance, authorities have responded to a surge of calls for in-home deaths and those who died outside of hospitals compared to earlier years, according to recent findings by ProPublica, which also highlighted a surge of home deaths here in Middlesex County.
The New York Times has tracked a similar phenomenon in 11 countries around the world, finding at least 25,000 more people died over the last month than the official COVID-19 death toll. The totals include deaths from COVID-19 and other causes, likely including people who could not be treated as hospitals became overwhelmed.
Undercounting coronavirus-related deaths is not surprising, said Dr. Howard Forman, a professor of public health and management at Yale University and an emergency department physician at Yale New Haven Hospital. Forman suspects missed COVID-19 fatalities will likely be concentrated in poor and immigrant neighborhoods and communities of color, where there has been a historic mistrust of the health care industry.
“Eventually the uncounted deaths will be sorted out and it will highlight this in a way like no one has ever imagined,” Forman said. “This is going to be a band-aid that will come off and expose just how horrible health disparities are.”
Forman said he believes that much earlier in the outbreak, in February and early March, his hospital and many others inadvertently missed some COVID-19 deaths among patients with pneumonia because few thought to check for coronavirus among such elderly, sick patients. Now, he said, it’s routine testing.
But he worries that some states that may not be aggressively testing in nursing homes may still be missing COVID-19 deaths.
“If it’s not in their best interest to be looking for COVID deaths then they’re not finding it,” Forman said. “When you are dealing with an older population or an under-resourced population, it’s easier to say they died from pneumonia.”