TRAVERSE CITY – Briana Leal woke up on December 3, expecting to pick up her stepfather, Rogelio, from the hospital.
That was not what happened.
When Leals arrived at Munson Medical Center, a nurse showed up to tell them that Rogelio died that morning at 6 p.m. 7:17. Rogelio, who was walking past Roger, had coded the night before, the nurses told Roger’s brother.
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The family waited for hours to receive an explanation from Roger’s doctor. Roger was 62 and living with diabetes. He had checked in a month before to have a gangrenous part of his toe removed. After three consecutive surgeries, Briana said his nurses were confused as to why he had died suddenly.
“I do not know what happened,” she said, as one of the nurses told her. “We literally made his printing papers.”
The doctor never showed up to explain Leal’s death to his family. Instead, Leals left with a death certificate stating that Roger died of gangrene, complicated by COVID-19, which Briana said he got during his month in a Munson hospital bed.
So what killed Roger Leal? The impossibility of an answer sheds light on the difficulty of classifying deaths during the pandemic. Was it COVID? Was it his poor management of his illness after almost two years of avoiding hospitals? Roger’s hospitalization occurred while delta variant cases peaked in northwestern Michigan. Did the strain on the hospital system affect his care?
His death is among thousands in Michigan, as experts credit the pandemic, though they were not marked as attributable solely to COVID-19. They are deaths marked as heart attacks, liver failure and strokes. Sometimes they are credited as being caused by dementia or Alzheimer’s. Other deaths were marked as respiratory failure.
Deaths in all of these categories have risen since the pandemic began, renewing attention to what the Centers for Disease Control and Prevention calls “excess deaths.” These are deaths that, after taking COVID-19 into account, remain inexplicably numerous compared to expected death rates.
For example, if a region had 181 more deaths than expected – of which 71 deaths were attributed to COVID-19 – then the remaining 110 would be excess deaths. These figures tell the story of Benzie, Mason and Manistee counties in 2020, where 61 percent of excess deaths are unexplained by statistical models, CDC data show.
Across all 50 states, Michigan ranks sixth in the number of excess deaths excluding COVID-19, per capita. February 1st. The excess death toll is just over 9,000.
Other figures provided by the state illustrate how these deaths could have been disguised as other diseases. From 2019 to 2020, Michigan had 1,500 more deaths due to heart disease, 700 more deaths due to stroke, 500 more deaths due to diabetes and 400 more deaths due to Alzheimer’s.
Nationwide, they are just a drop in a death toll estimated at more than 200,000. And a study published Thursday in the medical journal The Lancet outlined a worldwide estimate of excess deaths far in excess of those recorded in the official COVID-19 death track.
“It’s just a huge increase in the number of deaths in general,” said Bob Anderson, head of mortality statistics for the CDC. “You have to explain them somehow, and that can only really be explained by the pandemic.”
Researchers are investigating deaths that may not seem obvious at first. They include suicide, which may have been triggered by isolation, job loss, and stress. They could also include deaths due to months of delayed care – such as with cancer deaths that could have been prevented if hospitals had not been flooded with pandemic patients.
Roger Leal’s death could also fit that bill, Anderson speculated.
“We know there were a lot of diabetes patients who didn’t get diabetes treatment,” Anderson said. “It sounds like he got the acute treatment, but there may have just been too much damage. They may have done everything possible and he may have received very good emergency treatment, but the problem may have been in the past that he did not get adequate regular care and the result was that diabetes got out of control. ”
Munson Medical Center has not provided Roger Leal’s physician with comments. The hospital also did not comment on whether COVID caseload standards affected his care.
Excess deaths rose, just as the death rate in Michigan exceeded births for the first time. The two phenomena are impossible not to connect, said Jeff Duncan, MDHHS director of vital statistics.
“There is a clear link between the pandemic and life expectancy, which is declining for the first time in years and years of rising,” Duncan said.
Experts identified urban areas, racially diverse areas as excess dead spots. Northern Michigan is predominantly white, with most rural areas stretching from Grand Rapids up through the Upper Peninsula.
These regions sparked concerns for Joshua Meyerson, health director for the Northwest Michigan Health Department.
Residents of counties like Presque Isle can be 45 minutes or more from a health care provider. Even in Mancelona Township, Antrim County, Meyerson observed more deaths that were difficult to explain than in previous years.
This access factor may show up in the unusual increase in deaths at home. Rural areas like Grand Traverse saw home deaths increase by 42 percent between 2019 and 2021, according to data from the CDC’s WONDER system for disseminating public health data and information. Deaths at home also rose in Antrim, Emmet and Leelanau counties.
“We see that here when we get into some of our more rural areas. “Even when you adjust for age, we have areas in our region where you see disproportionate effects from all of these factors,” Meyerson said. “It all builds on itself.”
The result, Meyerson said, is that excess deaths in his jurisdiction have been “the highest we’ve seen in more than a generation.”
Still, the majority are COVID-19, but they just are not identified by forensic pathologists and doctors.
Lois Goslinoski is a physician for the Benzie and Manistee Health Departments. She said she tests bodies of people who die of natural causes, but sometimes even positive test results do not do a COVID death.
For example, it is her job to deduce whether a pulmonary embolism played a more immediate role than the disease itself. If she thinks it did, pulmonary embolism would come in first line in her death certificate, with COVID-19 as a contributing factor. These contributing factors may be lost in the CDC’s reporting system, which skews mortality statistics downwards.
It should be noted – for surveillance purposes, public death trackers sometimes include these deaths. Machine algorithms in the CDC’s Mortality Statics department capture certificates in which COVID played a role and then add them to the tracker, according to Anderson, the CDC statistician. Death certificates include only one “leading cause,” a decision that prevents death certificates from becoming a messy, incomprehensible mess.
“Ultimately, it’s my decision. You have to decide what makes the most sense?” said Goslinoski. “You make the decision, ‘How important is COVID-19 in their cause of death?'”
These are sentencing calls – made by forensic pathologists, doctors and physicians who may be working in hospitals with short staff. One result, Goslinoski said, is that they do not always identify the disease.
“Some doctors are not even aware that there is this line – with very, very, very small print,” Goslinoski said. “If someone has a heart attack and they are also COVID-positive, if I do a full autopsy, I can sometimes associate the risk of that heart attack with coagulopathy, which is part of the syndrome that comes with COVID-19.”
At least for the Lealers, clarity would be welcome. The morning Roger died, they sat and waited for an explanation that never came.
Afterwards, Rogers’ son, Rolando, spent days on the phone searching for an explanation – the same explanation that thousands of families in Michigan might well be looking for, and one that their doctors, statisticians, forensic scientists, and officials can only guess at.
“That’s shit,” Briana said. “Because it’s not their family that has to go through this.”