Since the start of the COVID-19 pandemic in Texas, the state’s death toll from all causes has soared by thousands above historical averages — a sobering spike that experts say reveals the true toll of the disease.
Between the beginning of the local pandemic and the end of July, 95,000 deaths were reported in Texas, according to U.S. Centers for Disease Control data. Based on historical mortality records and predictive modeling, government epidemiologists would have expected to see about 82,500 deaths during that time.
The CDC attributed more than 7,100 deaths to COVID-19, but that leaves roughly 5,500 more than expected and with no identified tie to the pandemic. The CDC’s chief of mortality, Dr. Bob Anderson, said these “excess deaths” are likely from a range of pandemic-related problems, including misclassifications because doctors did not initially understand the many ways that COVID-19 affects the circulatory system and results in a stroke or a heart attack.
“It can cause all sorts of havoc in the body,” he said.
The CDC data offers an opaque but important estimate of how deadly the virus has been in Texas, which suffered from testing shortages for weeks as COVID-19 case counts climbed.
“It has shocked me to see people think that there’s overcounts of the COVID deaths, because I can’t even imagine that that’d be the case,” said Mark Hayward, a professor at the University of Texas who studies mortality trends. “The undercount is so dramatic.”
And there is a clear racial disparity in the undercounts. Between March and the end of July, Texas recorded more than 21,000 deaths of Latinos — more than 5,000 higher than epidemiologists predicted. Of those, about 2,100 were attributed to COVID-19. That leaves more than 3,000 deaths in excess of the expected number, many of them in border counties that lack resources for testing.
Latinos are especially vulnerable to COVID-19 because they are more likely than their white counterparts to be exposed to the virus at jobs where working from home is impossible. They also have a higher prevalence of conditions including obesity and diabetes, which heighten the risk of serious illness for COVID-19 patients.
In Starr County, Chuy Alvarez said he and his fellow justices of the peace — who are charged with investigating potential COVID-19 deaths — do not test bodies because of cost issues. The Rio Grande Valley county has yet to record a single at-home coronavirus fatality, he said, though its confirmed virus deaths of 8.8 per 10,000 residents is more than 2.5 times higher than Harris County’s, according to state health department figures.
Among the dead in Houston is Raul Lopez, a 46-year-old nursing home maintenance director who died of a heart attack July 25 in Houston while hospitalized for the virus. His wife, Maribel Gutierrez, said she is concerned his death certificate will not list COVID-19 as the underlying cause of death.
“I still hear a lot of people don’t believe this,” Gutierrez said. “I still hear of people not wanting to wear masks, and I don’t want more of this — more deaths.”
Photo: Godofredo A. Vásquez/Staff Photographer
A telling gap
As the coronavirus started spreading rapidly in the spring and case counts grew day after day, so, too, did the gap between two critical and telling figures: the number of people expected to die within a year in Texas and the number who actually did.
Scientific modeling can usually predict, with a high degree of certainty, the number of deaths to expect in a geographic area for natural causes such as the flu, pneumonia, heart disease and cancer by using decades of death certificate data. What Texas has experienced since this spring, experts say, is a wave of excess deaths with no modern parallel that confirmed COVID-19 fatalities only partially explain.
Texas’ decentralized death certification system, in which only a handful of the state’s 254 counties have medical examiners, shifts some of the burden to determine cause of death to justices of the peace.
These elected officials, who often are not medical professionals and whose typical duties are dominated by dockets of traffic tickets, may lack the resources and expertise to track what can be a mysterious killer, Hayward said.
Then there are the deaths that public officials and medical professionals say must be acknowledged as caused by the pandemic, even if a patient was never infected with COVID-19. Houston Fire Chief Sam Peña said his department has seen “heightened number of people that are expiring at home,” which he and others attribute to people waiting too long to call 911 for fear of exposing themselves to the virus at a hospital.
The patients who died before first responders could transport them to the hospital increased by a third between February and April in the Houston area.
The Texas State Department of Health Services has not done a comprehensive analysis of excess deaths, spokesman Chris Van Deusen said in an email.
“We have done a quick comparison of deaths this year with previous years and didn’t find a large excess number of deaths that weren’t explained by COVID,” he said.
A somber summer
The responsibility for certifying a death in Texas depends on where it occurs. In hospitals, most death certificates are filled out by an attending physician. Anderson from the CDC said he was concerned some doctors may fail to list COVID-19 as the underlying cause of death when someone also suffers a heart attack or has pneumonia because of a lack of training or experience certifying deaths.
In Harris County deaths, when someone dies at home or outside a doctor’s care, or unexpectedly, such as in a vehicle crash or by homicide, the medical examiner determines the cause of death.
Dr. Dwayne Wolf, deputy chief medical examiner for Harris County, said investigators look for possible evidence of COVID-19 infections and conduct autopsies if necessary.
“Do I think there are COVID deaths missed at home? No, absolutely not,” Wolf said.
Wolf cautioned, however, that other counties may lack the same trained staff, large public health departments, testing capability and willingness to do autopsies as Harris. Most do not have their own morgue and rely on justices of the peace to certify deaths that would fall to a medical examiner.
Hayward, the UT researcher, said that while justices of the peace are trained in death certification, the education is not extensive. Limited testing across the state — some estimates peg the actual number of cases 10 times higher than health officials’ tally — may leave JPs with few clues a death was caused by the virus.
These officials, whose duties include hearing landlord-tenant disputes and other civil cases, take their death certification role seriously, said Justices of the Peace and Constable Association President Rick Hill. He said he is confident in justices’ ability to catch COVID deaths, though he conceded some may be missed.
“It may have happened, but you can pretty much determine what’s been going on in someone’s life,” said Hill, a JP in Brazos County. “You see the medicines on the nightstand. You can talk to caregivers. Were they complaining about certain symptoms of things?”
Hill said in cases where the cause of death is inconclusive, justices can send bodies to a county with a medical examiner for an autopsy. These procedures can be expensive, however, totaling more than $5,000 when transportation costs are factored in.
Dr. Stephen Pustilnik, the Fort Bend County medical examiner, said he is concerned about misclassified COVID-19 deaths at home because nasal swab tests have been hard for his office to come by.
Pustilnik said the most reliable measure of the pandemic’s toll is the number of excess deaths. Since Texas remains one of the fastest-growing states, Pustilnik said he’d expect a commensurate increase in deaths — a factor the CDC estimates take into account. Yet the state’s rise in death still exceeds the agency’s projections, even while accounting for known COVID-19 deaths.
“The population is growing at a steady rate,” he said. “All the sudden you see a spike in death. It has to do with this overwhelming health crisis that we’re in.”
And the data available now does not capture what some experts fear will also lead to higher-than-normal mortality rates: a reluctance to go to the doctor. According to research by the IQVIA Institute for Human Data Science, cancer screenings decreased by 90 percent in April compared to February’s numbers, likely leading to tens of thousands of missed diagnosis.
National Cancer Institute Director Dr. Ned Sharpless warned in June that ignoring life-threatening non-COVID-19 conditions such as cancer for too long “may turn one public health crisis into many others.”
A predictable outcome
The state’s increase in overall deaths began in the spring as the Northeast and West Coast struggled to contain the spread of the virus. The week of April 11 was the first in more than two years that Texas crossed the “excess death” threshold set by the CDC. That means that more deaths were reported that week than epidemiologists had modeled based on historical data, counting for population growth and other factors. The state has exceeded the expected death count every week since then.
From the start, deaths among Latino residents made up a disproportionate share of the increase, though not an overwhelming one. That held constant through early in May, with Latino deaths up 25 percent compared to 23 percent for Black residents and 7 percent for whites.
By mid-July, Latino deaths had exploded to 134 percent above average, compared to 45 percent for Black residents and 38 percent for whites.
The whiteboard at Compean Funeral Home in southeast Houston is filled with Hispanic surnames. Eleven of 15 are marked with a small C, denoting a COVID death. They include Francisco Javier, 55, a mechanic. Mery Josefina Morales, 59, a teacher. Trancito Rangel Diaz, 46, a construction worker.
Lopez, whose wife worried he would not be counted as a COVID-19 death, was memorialized in a service there on Monday evening.
The funeral home normally handles 35 clients a month, said general manager Rosa Soto. Since June, it has averaged double that. About 80 percent are COVID deaths.
The funeral home upended its operation to accommodate the increase. Morticians store some embalmed bodies on stretchers, which are normally used only for transport, as a way to save space. A refrigerated trailer under construction behind the building will provide more capacity.
“We buried two people today, but four more families called,” Soto said. “I don’t know when this is going to end.”
The facility has two chapels and is limiting services to 50 people, with every other pew vacant. Staff take the temperature of everyone at the door. Owner Greg Campeon recalled a woman who was angry she was refused entry for a high fever. He urged her to get tested for the virus.
“I said, ma’am, I’d rather have you leave here upset at me than to be back here as a client,” Campeon said.
Mortician Jeff Sonka and his assistant Manuel Santos spent the morning Wednesday embalming a 74-year-old pastor who succumbed to the virus.
Sonka speaks little Spanish and Santos, a former Mexican police officer, speaks a comparable amount of English. Yet after a decade together they have developed an efficient cadence to their work, anticipating each other’s movements. An embalming can take several hours, depending on the size and condition of the artery through which the preservative fluids are pumped.
They began the day at 8 a.m. and planned to process four bodies, double the usual workload, to clear a backlog driven by COVID deaths. It proved a Sisyphean task.
Around noon, the phone rang. Baylor St. Luke’s in Pearland had another COVID body but no morgue in which to store it.
Sonka and Santos slipped off their latex gloves, removed their long green aprons and headed for the door.
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Godofredo Vasquez and Currie Engel contributed to this report.
Zach Despart covers Harris County for the Chronicle, including Commissioners Court and flood control. He came to Houston from the Burlington Free Press in Vermont and was also the managing editor of the Houston Press. In 2017 he won the Best Feature award from the Association of Alternative Newsmedia for his feature on Venezuelan corruption in Houston and Miami. He is a New York native and graduate of the University of Vermont. Follow him on Twitter or email him at firstname.lastname@example.org.
Stephanie Lamm is a data journalist for the Houston Chronicle. She looks for stories in datasets and public records. She also creates interactive graphics for online stories. Stephanie previously worked for the Dallas Morning News and attended The University of North Carolina at Chapel Hill. Follow her on Twitter or email her at email@example.com.
Godofredo A. Vásquez is a staff photographer for the Houston Chronicle, primarily covering breaking news. Vásquez was born in El Salvador but grew up in the Bay Area, where he attended San Francisco State University and graduated with a B.A. in Photojournalism. Follow him on Twitter or email him at Godofredo.Vasquez@chron.com.
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