In the first five days of April, 1,125 people were pronounced dead in their homes or on the street in New York City, more than eight times the deaths recorded during the same period in 2019, according to the Fire Department.
Many of these deaths were probably caused by COVID-19, but were not accounted for in the coronavirus tallies given by Gov. Andrew Cuomo during his widely watched daily news conferences — statistics that are viewed as key measures of the impact of the outbreak.
On Thursday, Cuomo said 799 people in New York had died from coronavirus in a single 24-hour period — more than 33 an hour — bringing the state's total to 7,067.
But epidemiologists, city officials and medical personnel say those numbers are likely to be far below the city's actual death toll.
The data on deaths of people in their homes or on the street shows that the state's statistics don't tell the whole story. Here's what we know:
Who is being included in the death count?
Cuomo said Wednesday that the official death count numbers presented each day by the state are based on hospital data. Our most conservative understanding right now is that patients who have tested positive for the virus and die in hospitals are reflected in the state's official death count.
The city has a different measure: Any patient who has had a positive coronavirus test and then later dies — whether at home or in a hospital — is being counted as a coronavirus death, said Dr. Oxiris Barbot, the commissioner of the city's Department of Health.
"To date, we have only been recording on people who have had the test," she said Thursday morning.
So who isn't being counted?
A staggering number of people are dying at home with presumed cases of coronavirus, and it does not appear that the state has a clear mechanism for factoring those victims into official death tallies.
In the past three days, 766 people were found dead in their homes, bringing the total for the first eight days of April to 1,891, according to the city's medical examiner's office. It's likely that many have not been counted in the current tally.
Paramedics are not performing coronavirus tests on those they pronounce dead. Recent Fire Department policy says that death determinations on emergency calls should be made on scene rather than having paramedics take patients to nearby hospitals, where, in theory, health care workers could conduct post-mortem testing.
It is almost impossible to say how many of those 1,125 patients who died at home or in street in the first five days of April had coronavirus — some may have been previously tested before their death and either were never admitted to a hospital or had been sent home.
But the discrepancy between the Fire Department numbers from this year, at the height of the epidemic, compared with those of last year suggests that many of those who died probably were infected.
"The driver of this huge uptick in deaths at home is COVID-19. And some people are dying directly of it, and some people are dying indirectly of it, but it is the tragic 'X' factor here," said Mayor Bill de Blasio on Thursday.
Some of the deaths of people at home or in the street were unrelated to the virus.
We also don't really know how each of the city's dozens of hospitals and medical facilities are counting their dead. For example, if a patient who is presumed to have coronavirus is admitted to the hospital, but dies there before they can be tested, it is unclear how they might factor into the formal death tally.
Why don't we have an accurate number?
There aren't really any mechanisms in place for having an immediate, efficient method to calculate the death toll during a pandemic. Normal procedures are usually abandoned quickly in such a crisis.
For example, when someone died at home six months ago, a fairly straightforward process began: Paramedics, if they were called, would pronounce the person dead on scene or transport them to the hospital, where doctors would pronounce them dead, certify the death and issue a cause.
The body would be taken to a funeral home or to a morgue — if an autopsy was merited. The death would be certified by an attending doctor or by the city medical examiner's office.
Or, if someone died at a hospital, a doctor would certify the death and the body would be taken by a mortuary service or to the morgue. Family doctors, too, could certify the death.
During the coronavirus pandemic, these procedures are inconsistent at best. Doctors are struggling to certify deaths quickly enough. The medical examiner's office, which would normally only be involved if a death was suspicious or required further study, is now in charge of picking up and storing bodies until the pandemic abates.
Paramedics are not transporting unresponsive patients to hospitals unless they immediately find a pulse. Bodies are piling up in hospital morgues and freezer trucks lined with makeshift shelves because the institutions are overloaded with the dead and dying. Few, if any, of these facilities are doing post-mortem testing.
"We are doing everything we can to expand the city's morgue capacity, and help people collect the bodies of their loved ones in a timely manner," said Aja Worthy-Davis, a spokeswoman for the city's medical examiner's office.
Both that office and the Department of Health, she said, "are working together to better understand how to appropriately include non-healthcare facility, natural-cause deaths into the citywide fatality count."
About 120 morgue workers and soldiers from the U.S. Army, the National Guard and the Air National Guard are working in shifts around the clock, driving rented vans around the city to pick up the bodies of as many as 280 people a day who have died at home and have probably not been part of the official death count.
Fifteen four-person teams overseen by Office of the Chief Medical Examiner perform the grim work during each 12-hour shift, a task normally handled by 14 workers, according to Worthy-Davis.
Will we ever really know how many people died?
Counting the dead after most disasters — a plane crash, a hurricane, a gas explosion, a terror attack or a mass shooting, for example — is not complex.
A virus raises a whole host of more complicated issues, according to Michael A.L. Balboni, who about a decade ago served as the head of the state's public safety office, and now heads an association of for-profit nursing homes in the New York City area and a crisis management consulting company.
"A virus presents a unique set of circumstances for a cause of death, especially if the target is the elderly, because of the presence of comorbidities," he said — multiple conditions. For example, a person with COVID-19 may end up dying of a heart attack.
"As the number of decedents increase," Balboni said, "so does the inaccuracy of determining a cause of death."
Barbot said the city is intent on doing everything possible to get an accurate death count.
"I think that as a city, it is part of the healing process to be able to grieve and mourn for all of those that have passed because of COVID-19," she said.
But it's unclear how the city medical examiner's office will meet that goal.
It is almost impossible to grasp the full scale of a highly contagious pandemic like COVID-19 in real time, said Dr. Howard Markel, a professor of medical history at the University of Michigan who has researched past epidemiological events in New York City.
"You have an idea of what numbers are, but you don't have an exact source," he said. It takes extensive, retroactive research, testing and academic study to even estimate the toll of a biological crisis like COVID-19, he said.
But, Markel said, debates over official death counts are arguably unimportant in the midst of the city's crisis.
"Even if we're underestimating deaths and cases, particularly in the New York situation, there are enough of both to tell us this is very serious," he said. "It's already all hands on deck, and I think that's appropriate."
Written by: Ali Watkins and William K. Rashbaum
© 2020 THE NEW YORK TIMES