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Trump’s plan to limit the pandemic’s death toll: Undercount the numbers

Experts say the official numbers are too low. The White House wants to make them lower.

White House coronavirus task force coordinator Dr. Deborah Birx answers a question in the Oval Office of the White House on April 28, 2020, in Washington, DC.
Doug Mills/The New York Times/Getty Images

Experts have a range of ideas to suppress the Covid-19 pandemic, save lives, and avert new waves of economic misery. But President Donald Trump seems to be embracing another plan — massaging the numbers to make inconvenient deaths go away.

But experts believe the problem with the numbers is the opposite — official statistics understate the Covid-19 death toll.

Recent methodological changes have annoyed the president by pushing death numbers higher. These changes, according to experts, are a sound and reasonable effort to reduce the amount of undercounting. They factor in that deaths have surged by more than the official coronavirus stats say.

On Wednesday, the Daily Beast reported that Trump and members of his coronavirus task force are now pressuring the Centers for Disease Control and Prevention to get states to change how they count deaths, a campaign designed to lower the numbers.

As Trump tries to juke the stats, he’s committing the original sin of America’s pandemic response — falling way beyond the curve in terms of testing and surveillance. For Trump, that seemingly doesn’t matter because it’s more politically convenient to keep official infection numbers low.

Coronavirus death count methodologies, explained

The original way the United States counted coronavirus deaths started with the fact that if you were seriously ill, you might (or might not) be tested for Covid-19. If you were tested, the test came back positive, you were admitted to the hospital for treatment, and then you died, that was counted as a Covid-19 death.

But we’ve known all along that many more people were infected with the virus than were actually receiving tests and obtaining positive results. Tests have been in short supply, and some of the most widely used tests have fairly high false negative rates.

Consequently, people who’ve died at home or in a long-term care facility without making it to the hospital were initially not counted as Covid-19 deaths. In mid-April, however, New York City added nearly 4,000 “probable” Covid-19 deaths to its official count based on doctors’ assessment of the symptoms of the deceased.

This shift is in part an effort to obtain more accurate statistics, and in part an effort to use testing capacity in a more efficient way. There is no Covid-19 pill to give people who test positive, so it makes little sense to prioritize gravely ill people for testing when those scarce tests could be better used on sick people’s close contacts.

That makes sense as a process, but adding these suspected cases into the mix makes the situation look worse, and Trump isn’t happy about it.

Trump wants to lowball coronavirus deaths

On May 6, Jonathan Swan and Sam Baker reported for Axios that “Trump has complained to advisers about the way coronavirus deaths are being calculated, suggesting the real numbers are actually lower — and a number of his senior aides share this view, according to sources with direct knowledge.”

They specifically reported concern about the CDC moving broadly to adopt New York’s method of classifying probable Covid-19 deaths as Covid-19 deaths.

Then on May 13, Erin Banco and Asawin Suebsaeng reported that the White House, including Dr. Deborah Birx, is pressuring the CDC to exclude not only probable Covid-19 deaths but also the deaths of some people who have tested positive for the infection:

The White House has pressed the CDC, in particular, to work with states to change how they count coronavirus deaths and report them back to the federal government, according to two officials with knowledge of those conversations. And Deborah Birx, the coordinator of the administration’s coronavirus task force, has urged CDC officials to exclude from coronavirus death-count reporting some of those individuals who either do not have confirmed lab results and are presumed positive or who have the virus and may not have died as a direct result of it, according to three senior administration officials.

This stems from an idea, long simmering in virus-skeptical circles, that public health officials are improperly classifying people who died “with” coronavirus as having died “of” coronavirus instead. The basic thinking is that a large share of the dead are older, a large share of Covid-19 cases are mild, and consequently, older people with mild Covid-19 infections may be dying for unrelated reasons. It’s a fair hypothesis to offer, but empirically it seems to be false — many more people are dying than can be accounted for by the official statistics.

Experts say the US is undercounting Covid-19 deaths

Testifying before the Senate’s health committee on Tuesday, Dr. Anthony Fauci expressed the view of most public health professionals that even with the attempted adjustment for probable cases, the official numbers still underestimate the true death toll.

The basic issue is that even the “probable” standard still requires an individualized assessment of symptoms, while broad statistical aggregates show that a lot of people are dying.

You see this by doing an excess deaths calculation. First, you take the number of people who would die in a typical month in the United States, and then look at how many people actually died. When a Yale School of Public Health team did this for March 2020, they found about 15,400 excess deaths, of which only 8,128 were officially attributed to the coronavirus.

Are all 7,000 of the unexplained deaths really Covid-19 cases? Probably not. Some excess mortality is due to people not getting medical treatment for other ailments. On the other hand, it’s likely fewer people will have died in traffic accidents than you see in a typical March. A group of economists calculated that several hundred air pollution deaths were avoided in April with fewer cars on the road.

At the same time, the death reporting infrastructure in the United States is very decentralized and a little clunky, so the tendency is for all death counts to be revised upward over time as more jurisdictions report. It’s going to take a long time and a fair amount of statistical work to get a really clear picture of how many people died of Covid-19 this year.

But it’s pretty clear that the CDC’s case counts are an underestimate, a product of a gap between the health care system’s ability to make individualized determinations about cause of death, and the statistical reality that people are dying at an unusually high rate. Trump is pushing to make inaccurate numbers even less accurate, and that’s dangerous.

Bad data makes bad policy

It’s not unusual for politicians to want to spin away unflattering facts or for Trump to lie about something.

But as policymakers, business leaders, school officials, and individual citizens are making day-to-day decisions about how to cope with the pandemic, spreading bad information is risky. The more people underestimate how bad the situation is, the more likely they are to engage in excessively risky behavior and make the situation worse.

Trump is a shrewd person attuned to the political relevance of data. In early March, he infamously opined that he didn’t really want to see infected American citizens on cruise ships brought home for treatment because “I like the numbers where they are.” Bringing them on shore for treatment would create a worse statistical record, but also lead to a better outcome in the real world since they could get better treatment. In that case, Trump was persuaded to do the right thing and simply complained about it.

But the same basic tension has bedeviled American policy since at least February.

Stark warnings to the public could have saved lives but also risked spooking the stock market. Widespread testing would have made it easier to contain the outbreak but also would have meant much higher confirmed case numbers. Accurate death counts help people make smart decisions but also undermine the president’s push for a quick relaxation of restrictions on business.

Throughout his career in both business and politics, Trump has gotten far by relying on spin and bluster to paper over problems of substance. And while this seems unlikely to be the best way to cope with the pandemic, it’s something he’s good at and there’s at least an outside chance he could make it work for himself politically. But a strategy focused on juking the stats is overwhelmingly likely to end with more real-world deaths than necessary.