A year later, Amanda has more questions than answers: Denny's original death certificate, which she received months after his passing, listed the cause of death as "pending further study." Later, his diagnosis was updated to "acute intoxication" without her knowledge, and even though many deaths have multiple causes listed on the certificate, COVID-19 was not mentioned on Denny's.

In Augusta, Georgia, Bruce Davis' family was also left without answers when his death certificate listed sepsis and renal failure, not COVID-19.

Across the country, tens of thousands of families whose loved ones died during the pandemic without a COVID-19 diagnosis may be asking similar questions.

Excess deaths far outweigh official COVID-19 toll.

Since early in the pandemic, epidemiologists, concerned with the potential undercounting of virus cases in situations like Gilliam's and Davis' (especially in the wake of an early bungled rollout of COVID-19 testing), have tracked "excess death" as a rough approximation of the pandemic's impact on the country.

Centers for Disease Control and Prevention tracked up to 713,873 excess deaths, of which nearly a quarter—up to 169,687—are not currently attributed to COVID-19.

While not all of the excess deaths during the pandemic are likely to have been caused directly by COVID-19, experts say the discrepancy points to the likely undercounting of COVID-19 cases because it is far higher than can be explained by historical patterns or official COVID-19 numbers.

The World Health Organization (WHO) recently estimated that, globally, the true death burden from the pandemic is up to three times that of official statistics.

But if the models are accurate, it means that thousands of deaths resembling Davis' and Gilliam's—with official causes other than COVID-19, but reasons to suspect otherwise—could be going uncounted.

And like many consequences of the pandemic, the death burden isn't distributed evenly across the country.

Instead, the excess death toll brings the impact of socioeconomic and racial inequities into even sharper relief, with the estimated additional pandemic deaths higher than official numbers in communities that are rural, poorer, less educated, Southern, non-white (especially Black), or where more people face medical risk factors (such as diabetes, obesity and smoking).

"Our analysis suggests that the substantial racial inequities observed in directly assigned COVID-19 death rates for the non-Hispanic Black population are even larger in excess death rates not assigned to COVID-19," the Boston University-led research team concluded, noting "a pattern related to structural racism.".

If, as experts suspect, at least some of those 169,687 deaths are COVID-19 cases that have gone uncounted, the consequences could be significant.

View our Excess Death map below.

These excess death numbers suggest the pandemic's impact on the country is likely even greater than the official statistics have shown.

For example, Politico reported that thousands of Americans have faced delays or denials in reimbursement from federal funeral assistance programs due to absence of a COVID-19 diagnosis on their loved one's death certificate.

Hundreds of thousands of American families like the Gilliams have turned to death certificates to help them understand their loved ones' deaths during the pandemic.

Understanding why excess deaths during the pandemic might be so different from the official COVID-19 death counts, said Robert Anderson, chief of mortality statistics within the CDC's National Center for Health Statistics, requires some background on how the systems that track vital statistics came into being.

Relying on counties for death investigation has led to fundamental differences in how COVID-19 deaths have been certified during the pandemic.

For example, in East Baton Rouge Parish, Louisiana, a county of 440,000 where the excess death rate is far higher than the COVID-19 rate, decedents have the virus on their death certificates only if they had both a positive test and known symptoms.

Certifiers "too often just chalk a death up to bronchopneumonia or dementia or cardiopulmonary arrest," he said, "none of which are causes of death, but any of which may co-occur with COVID-19.".

For example, clinicians may be pressured to leave a diagnosis off the certificate.

Additional forthcoming research by the Boston University excess death team—shared with Capital & Main in advance of publication—corroborates these claims, finding that Trump-voting counties, and those that are coroner-based, were more likely to have high rates of excess deaths that were never attributed to COVID-19.

In May 2021, the Institute for Health Metrics and Evaluation (IHME), a nonpartisan population health research center associated with the University of Washington, released a model suggesting that nearly 14,000 deaths due to COVID-19 went uncounted in Florida since the beginning of the pandemic.

(As of June 3, Florida Department of Health statistics counted 37,717 deaths compared to 51,496 in the IHME model. On June 4, Florida stopped releasing daily death counts and discontinued its online dashboard.).

There's no doubt that some excess deaths during the pandemic had nothing to do with COVID-19.

While the official CDC numbers have not yet been released, preliminary estimates of the rates of drug overdoses, homicides and accidental deaths, such as traffic accidents, are all up since March of 2020; the emotional and economic trauma caused by the COVID-19 have driven the so-called deaths of despair, along with homicides and accidents.

Still, those causes can't account for all the excess deaths over the past year, experts say.

While collecting the 2020 data is expected to take 18 months or more, it's unlikely that injury deaths could have increased 54% to account for all the excess deaths not attributed to COVID-19 in 2020.

deaths from COVID-19 were in Black communities, according to the CDC.

In Louisiana, a state whose population is 33 percent Black, 38 percent of the state's COVID-19 death toll was borne by Black individuals, according to the Louisiana Department of Health?

Hundreds more may have gone uncounted based on the many excess deaths not currently attributed to COVID-19.

"And if you miss [cases], you will have deaths that otherwise wouldn't occur.".

Living without answers: The legacy of pandemic deaths.

Deaths commonly result from multiple causes: Amanda said that the context of his work—providing hands-on care in a hospital overwhelmed by patients with the virus—along with the presence of respiratory symptoms before his death have convinced her the virus is involved

Without a COVID-19 diagnosis, Amanda can't file for workers' compensation from his agency