No measure of COVID-19 has come under more skepticism than the accuracy of the death toll — a pandemic statistic key in shaping public opinion and policymaking that's been widely scrutinized and even the subject of conspiracy theories.
The scrutiny centers on how the COVID-19 death tally should account for people who have COVID-19 but who also have other underlying health issues, such as cancer or kidney disease.
In New York, Gov. Andrew Cuomo on Sunday touched on the matter when he announced his state's lowest daily death toll — 23 on Saturday — since the early days of the pandemic.
"When the number gets this low, it's basically a question of how people are reporting the cause of death across the nation," Cuomo said. "You have situations where a person dies from multiple causes. You could put down COVID, you could put down cancer, you could put down heart disease. So, at one point, it becomes fairly random, and we're basically at that point."
So far, more than 116,000 COVID-19 deaths have been recorded in the U.S, according to an NBC News counter that tracks state data, and experts are quick to point to the increased likelihood that the total is an undercount.
Meanwhile, the CDC's collection of death data from individual states is hampered by differing state policies while additionally, a hodgepodge of local health officials, including medical examiners, coroners, health care providers, funeral homes and health departments are tasked with filling out death certificates — and often must make judgment calls in doing so.
The federal government relies on two parallel systems to keep track of COVID-19 deaths. One, run through the National Notifiable Disease Surveillance System, uses reports of cases from the states and is able to be more quickly updated. The second, managed via the National Vital Statistics System, relies on death certificate reporting and what is cited by health officials on that document.
The first count is subject to differing state policies on reporting, such as whether a state includes probable deaths in its count, whereas the latter count is part of the decadeslong standardized death certificate reporting system throughout the U.S. In that count, there is no distinction between a probable or confirmed case for the purposes of tallying the death total.
The CDC and the Council of State and Territorial Epidemiologists, a group that works with the CDC to offer guidelines on tracking diseases, recommend that states report probable COVID-19 deaths — which include deaths where the virus may not have been tested for — as part of their total that is plugged into the surveillance system.
But that's not mandatory and, as a result, some states are not reporting probable deaths, as The Washington Post found last week.
"You have this issue with the probables and the confirmed cases," Robert Anderson, who oversees the death certificate reporting system as chief of mortality statistics at the National Center for Health Statistics, told NBC News.
"We're asking a medical professional, physician, medical examiner, coroner to provide the cause of death information and using the term probable is acceptable," he continued. "If the certifying physician feels that COVID-19 was the probable cause of death, we count it as the cause of death. We trust their medical judgment that they know sufficient about the case to say, 'Yes, in fact this was due to COVID-19.'"
CDC guidance for death certificate reporting says COVID-19 can be listed as the immediate cause of death, the underlying cause of death or a contributing factor, stating that "if COVID–19 played a role in the death, this condition should be specified on the death certificate."
Whether COVID-19 played a role in a death can be a subjective determination and comes under the discretion of whoever signs a death certificate. Take Bill Harris, the coroner for Lee County, Alabama, for example. He told NBC News that he's of the belief that "if you have the virus, it is, in some sort or fashion, a contributing factor possibly to your death."
"I mean, my opinion is if they're positive for the virus, it should be on the death certificate," he added.
The presence of the virus itself raises the risk of death from other underlying conditions, and experts said any death involving someone who tested positive for the disease should be included in the COVID-19 death total.
"You have an acute infection (with COVID-19) and you have other co-morbidities and what changed? It's your acute infection that changed," said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists, adding that for many, COVID-19 is "the tipping point" in a death.
Nate Wardle, press secretary for the Pennsylvania Department of Health, said "there would be very few, if any, cases in the state where COVID-19 would be the cause of death," but rather an underlying cause of death.
Yet it is those determinations that have seen some push back. As The New York Times reported last month, President Donald Trump was questioning whether the death toll had been inflated amid his push to reopen the country, with the publication pointing to conversations about just which deaths were being included.
And in Colorado last month, Gov. Jared Polis, a Democrat, told "Fox News Sunday" that "the CDC criteria include anybody who has died with COVID-19, but what the people of Colorado and the people of the country want to know is how many people died of COVID-19."
Polis' state recalibrated its death count reporting in May, splitting its total into deaths where the virus is a contributing factor and a slightly longer list of total deaths of those who've had the virus.
Kirk Bol, manager of the Colorado Department of Public Health and Environment's vital statistics program, told NBC News it will be some time before experts know the true number of any over or under counts of COVID-19 deaths. But with time, the numbers are going to continue to be better perfected.
"I do have faith that these numbers are accurate and useful in their form, in terms of driving policy and decision making and people's thoughts and concerns of COVID-19," he said, pointing to the federal vital record system. "There's a lot of rigor and a lot of highly trained and skilled individuals participating in that system."
State health departments across the country noted the difficulty of providing numbers to the public on the fly but said they have confidence in their reporting structures and that the public should have faith in what they're seeing.
"It is difficult trying to report deaths in real time," said Melaney Arnold, public information officer for the Illinois Department of Public Health, adding, "Normally, public health officials investigate and gather additional information before reporting a death. With COVID-19, as IDPH learns more information, the total number of deaths are adjusted."
As Anderson said, the numbers are "not perfect by any stretch, but I think (Americans) should understand there's a good faith effort to produce good numbers."
"Those of us who are part of that federal statistical system, those who do disease surveillance, we don't have a dog in the race with regard to politics," he added.
While the death counts have drifted downward in recent weeks as northeastern states see a reduction of the virus, cases, hospitalizations and positive test rates are on the rise in several states, including Alabama.
When discussing the death count, it's important to remember the human aspect, said Karen Landers, assistant state health officer for the Alabama Department of Public Health, told NBC News.
In Landers' state earlier this month, legendary former Auburn University football coach Pat Dye, 80, was one of those who died with multiple complications in the mix — liver and kidney failure weeks after testing positive for COVID-19, according to Harris, who performed Dye's autopsy.
Dye was recently set to rest under a special tree he helped grow 15 feet over the course of six years. The Hall of Fame coach who brought the Auburn program to national prominence had requested a simple burial.
"Every one of these deaths is a person, it's a family, it's a loss to society," Landers said. "So we have to remember when we're looking at numbers, we're also looking at people."
