On a recent Tuesday evening in southeastern Missouri, John Freeze stood in front of yet another angry group of constituents.
Some here believe the number of COVID-19 deaths are being purposefully inflated for financial gain. Among the culprits, in their mistaken view: Hospitals seeking Medicare reimbursements; the federal government, led by Dr. Anthony Fauci and President Joe Biden; and families of those who died seeking funeral expense reimbursements from FEMA.
Freeze is a retired dentist who also serves as the elected, unpaid chairman of the Cape Girardeau County Public Health Board of Trustees. He has an admittedly delicate job in one of the most conservative, and COVID-skeptical, parts of Missouri.
He oversees the county health department, which handles things such as immunizations and inspections. But he has little connection or oversight with the county coroner, who records the deaths of most residents — roughly two-thirds of all deaths — who die outside of hospital settings each year.
The coroner — Wavis Jordan, a Republican who took office in January 2021 — has worked as a school security guard, hearse driver and funeral florist but has no prior training or experience handling the dead. He has a long-running policy of requiring that families provide proof of a recent, positive PCR test of COVID-19 to his office before labeling a death COVID, a policy that goes against CDC guidance.
As a result, many likely COVID-19 deaths don’t get counted as such. Put another way, the coroner “doesn’t do Covid deaths,” he told the Documenting COVID-19 project and the USA TODAY network for its series on death certificate inaccuracies called “Uncounted.”
So Freeze started that Tuesday meeting with a prepared statement, designed to reassure the crowd and allay fears that COVID-19 deaths were being improperly recorded.
But in the process, he unknowingly spread COVID-19 misinformation that only served to make things worse.
Is the CDC ‘padding the numbers’? No.
Freeze told the crowd that if the coroner doesn’t catch and properly record deaths, death certificates are then sent from the state Missouri Department of Health and Senior Services to the CDC, and, if they are actually COVID-19-related deaths, they are almost assuredly changed to reflect that by the federal government.
“As far as how COVID deaths are handled, even if the coroner doesn’t put it [COVID-19] on the death certificate after someone in the county dies, a representative of the state health department forwards those to the CDC,” he said. “The CDC then makes the determination that that person died of COVID.”
Freeze’s comments about the CDC left some Cape Girardeau residents confused and alarmed, according to state Rep. Barry Hovis, a Republican who represents the region.
Is the CDC “padding the numbers” to increase the overall COVID-19 death toll, some of them wondered?
The answer is no. Freeze’s false claim is rooted in a mistaken understanding of how death investigations work and the role of the CDC in reviewing death certificates.
“[The CDC] doesn’t change death certificates,” said Dr. Bob Anderson, the agency’s chief of its mortality statistics branch, who was provided Freeze’s comments. “If COVID is not reported on the death certificate, we can’t count it as a COVID death in the death certificate data and it won’t be included in the official death counts for the nation.”
After the Documenting COVID-19 project alerted them, the CDC, the Missouri state health department and the Cape Girardeau County health department took the unusual step to publicly correct Freeze’s statement — and Freeze himself acknowledged his error.
Freeze, serving his second four-year term, said in an interview that he didn’t fully understand Missouri’s death reporting process and simply wanted to provide a level of calm at a public meeting all too quick to devolve into bitterness.
“My statements just reflect a lack of understanding of it,” Freeze said. “I understand it better. My comments were incorrect.”
Still, Freeze doesn’t think there’s an undercount of COVID-19 deaths in the Cape because, as he sees it, attending physicians, and not the coroner’s office, complete the death certificates for most COVID-19 fatalities.
That’s also not true.
Roughly two-thirds of deaths in Cape take place outside a hospital, and death certificates are filled out by the coroner or staff at nursing homes. Even then, physicians say they are not trained on how to fill out death certificates themselves, leading to errors.
The episode in Cape Girardeau underscores an unfortunate truism about the pandemic, now entering its third year:
The deadly impact of COVID-19 virus is still being litigated, in places with deeply entrenched partisanship and low trust in government. On both sides, there’s a knowledge gap about how many COVID-19 deaths are occurring and what’s being recorded, or not, in official numbers.
‘OK, so what really caused it?’
Death certificates have long been prone to error. There is a lack of training, certification, job requirements and accreditation in many states. There is a lack of funding for rural, elected coroners for salaries and personnel, equipment and autopsies. And there is an increasing number of cases many coroners and medical examiners see each year.
Case in point: In 2018, Cape Girardeau County’s elected coroner “accepted,” or at least partially reviewed, 748 deaths and conducted 32 autopsies. The office has a $270,000 budget and more than half that amount, roughly $152,600, is spent on salaries and benefits. That leaves just $70,000 for “inquest” bills, or autopsies, in a county with more than 80,000 residents and now more than 900 deaths a year.
Each autopsy can range in cost from $1,000 to $2,500 or more, according to county budget documents, and at the end of the 2020, Cape Girardeau had to give the coroner’s office an additional $23,000 to cover outstanding autopsy bills.
There is also a measure of clinical judgment — the idea of assigning one specific cause of death as the ultimate single reason for someone’s demise — that allows for a level of nuance and subjectivity on the part of the coroner. Up to 20 contributing causes of death can be listed on the document but there can be just one final cause.
That can lead to an all-too-common incorrect cause of “cardiac arrest” listed on death certificates, which Cape Girardeau has assigned to 35 deaths in 2020 and 2021.
“It’s not easy. The running joke is, when you see an obituary that says a patient died of cardiac arrest, physicians ask, ‘OK, so what really caused it?’ Because everyone dies of cardiac arrest,” said Dr. Alex Garza, who now serves as the chief community health officer for SSM Health, which includes 11,000 health providers across four Midwestern states.
In Missouri’s metro areas, including Columbia, Kansas City and St. Louis, most COVID deaths occur in hospital settings. But in other areas of the state, a majority of deaths occur at private homes or nursing homes.
That urban-rural divide explains at least some of the large discrepancy between death rates across Missouri.
“There’s a lot of imprecision. Even for many physicians, it’s not a common occurrence to fill out a death certificate,” said Dr. Clay Dunagan, the chief clinical officer of BJC HealthCare, a 15-facility hospital system in Missouri and Illinois with more than 4,700 physicians.
And there’s little in the way of checking or auditing death certificates after they are filed and sent to the state — whether they’re incorrect or not.
The reality is that the vast majority of U.S. death certificates — some 80%, by recent estimates — are analyzed by the CDC within minutes, with a computer program automatically matching text phrases used for causes of death with numerical codes. For example, the word “COVID” would be translated into its corresponding code — U07.1.
Beyond the statistical matching, there’s not much the CDC does to check the numbers. The CDC doesn’t have access to a patient’s medical file or COVID-19 test results. As a result, it has no way of knowing if COVID should or shouldn’t be included because of an omission or error.
On top of that, a small percentage of Missouri’s 146,862 deaths over the past two years have been amended or corrected by local and state officials after being initially certified.
According to the state health department, just 4,826, or 3.3%, of those death certificates have been subsequently corrected. It is unclear how many were for the most common issues cited by physicians: spelling errors in names or updating a death certificate previously marked “pending” after autopsy results come back.
That number is down from pre-pandemic levels, when roughly 4.1% of deaths, or about 5,200, were corrected in 2018 and 2019.
The result of Missouri’s messy, chaotic death investigation system is an undercount of specific causes of death.
Discrepancies between Missouri’s official, or “confirmed,” COVID-19 death figures and the number of excess deaths compared to pre-pandemic figures dates back to March 2020, according to Christopher Prener, an assistant professor and medical sociologist at Saint Louis University who has been tracking Missouri COVID-19 data.
The state’s then-director of health, Dr. Randall Williams, decided to separate confirmed COVID deaths, which have a positive PCR test, and probable or suspected COVID deaths, which might have an antigen test or reported symptoms of the virus.
Until November 2021, the state did not report publicly any data on probable COVID deaths.
Williams, who resigned suddenly and without explanation a year ago, made that decision over the objection of state health staffers. There was confusion over why a death with a positive antigen test and COVID listed as a contributing cause or immediate cause wouldn’t be counted in official numbers, according to state employees with knowledge of the situation who did not want to be identified for fear of reprisal.
Rural communities largely switched from using PCR tests to antigen tests after vaccines became ubiquitous. Of 81 counties with fewer than 35,000 people, antigen test positives account for more than 40 percent of COVID cases, and in six, all with fewer than 15,000, the majority of positive results are from antigen testing.
Missouri counts COVID-19 deaths as confirmed only if they are documented with a recent PCR test.
As a result, rural death rates have long lagged official statistics, sometimes by months. Even then, the numbers don’t reflect reality, with the number of “excess deaths” — the number of deaths in the pandemic era above what would be expected in a given year — far outpacing COVID death rates, even when factoring in upticks from drug overdose and car crash deaths.
“Nothing ever quite lines up,” Prener said.
In Missouri, death certificates have to be filed within 5 days, by state law
Nowhere in the state is that more on display than in Cape, newly-released CDC data shows.
In Cape Girardeau County, at least according to official statistics, deaths from all causes fell 15% in 2021 from the year before, from 1,079 to just 919. That’s more than double the drop in Missouri statewide.
If that was true, the Cape would be the epicenter of a remarkable, almost miraculous, public health recovery in 2021.
But these numbers — reported by Cape Girardeau County to the Missouri Department of Health and Senior Service and, ultimately, to the CDC, for national statistics that underpin this country’s public health system — are likely wrong.
CDC data shows that deaths at home attributed to heart attacks, Alzheimer’s and chronic obstructive pulmonary disease have all increased over the past two years, by rates two and three times higher than before the pandemic. There’s no evidence that Cape Girardeau — with 48% of its adult population fully vaccinated, far below both the statewide and U.S. average; with fairly average health and death rates; with no notable population or economic shifts — has rebounded and recovered in any way beyond neighboring counties or the U.S. as a whole.
The number of confirmed COVID-19 deaths in Cape Girardeau fell significantly — plummeting from 113 in 2020 to 70 in 2021, according to the CDC. While those numbers are slightly different than those reported by the state, they were vastly different than Missouri and national death trends from the virus, by considerable margins.
Deaths from motor vehicle crashes and suicides fell to the single digits, and now stands at rates lower than pre-pandemic 2018 or 2019. That’s in stark contrast to Missouri and national trends, where car crash and suicides markedly increased in 2021.
Even drug overdoses — a scourge of rural America and especially in Missouri, where such deaths rose by 20% in 2020, mostly due to opioids, and will likely do so again in 2021 — fell last year in Cape Girardeau, to below pre-COVID rates.
And there ares just 18 death certificates in the Cape awaiting final sign-off by a certifier, according to CDC statistics. Those deaths, when finally logged, probably won’t change these larger trends.
The most likely explanation, experts say, is that death certificates are still awaiting a final signature and, as a result, haven’t been officially counted, weeks and months after the fact. And that breaks Missouri law, which requires death certificates be signed and sent to the state within five days of someone dying.
Particularly difficult death certificate questions can be addressed within six months of the death. But the death certificates themselves — and the cause of death or “pending” notation — has to be sent to the Missouri Department of Health and Senior Services within five days.
The problem with delayed death certificates is not unique to Cape Girardeau. Many Missouri coroners lack training of any kind, and a statewide commission meant to create new requirements for coroners is stalled due to a lack of members appointed by the governor.
“The biggest challenge is getting coroners properly trained,” said Erik Hall, the director of forensic science at Saint Louis University and who previously worked for St. Louis’ police crime lab for 12 years. “Gathering the facts, getting the medical information, getting in touch with the hospital or physician, all while being independent and impartial as possible.”
When presented with findings from the “Uncounted” series, Hovis, the region’s state legislature and a former state highway patrolman, said he is seeking answers from the coroner’s office before proceeding further.
This article is published from The Missouri Independent through a Creative Commons license.