We are now well into the second month of the COVID-19 crisis which has been entirely framed by both Gov. Andrew Cuomo’s and Gov. Phil Murphy’s daily briefings and their daily data dumps which include hospitalizations, the number of intensive care unit patients, intubations, patient discharges and COVID confirmed cases.

Based on the arc of those data points, both Gov. Cuomo and Gov. Murphy have sounded guardedly optimistic that the public’s compliance with social distancing and stay at home orders are producing the desired effect of reducing the crush of demand on the health care system.

George Kelder is the CEO and executive director of the New Jersey State Funeral Directors Association whose members are responsible for dealing with bodies at the hospital, congregant care facilities and private residences.

Kelder warns that if we rely solely on official numbers carried on the TV, we will miss the big picture and not fully appreciate the lethality of the virus while over-estimating our success in combating it.

FIXING THE NUMBERS

In a phone interview, Kelder confirmed that back on April 15 New Jersey’s Office of Vital Statistics and Registry, in accordance with the CDC’s National Vital Statistics System, had ordered that deaths of confirmed COVID-19 or suspected COVID-19 no longer be reported as the immediate cause of death.

“The guidance, available on the New Jersey’s Electronic Death Registration System website, states that COVID-19 is not considered an immediate cause of death and should NOT be reported by the medical certifier on the first line of section 36a (CAUSE OF DEATH, PART I) of the death certificate,”  advised New Jersey State Funeral Directors Association to its members. “Instead, the immediate cause of death, such as “Acute Respiratory Distress Syndrome,” should be listed on the first line. COVID-19 should be listed LAST in Section 36a after the immediate cause(s) has been listed.”

“During the five weeks of these fatalities New Jersey physicians had been instructed to used COVID-19, Coronavirus 19 or pending COVID-19 as the primary cause of death,” Kelder said. “Last week, because of changes on the national level, the primary cause of death can no longer be COVID-19. It can be a secondary or a consequence of the primary cause of death. But the primary cause of death must be something other than the virus itself.”

Kelder observed that the pervasive lack of testing, along with the rejiggering of the how COVID-19 deaths are to be classified would mean the numbers being used officially “would not be equal to what is happening on the street.

“My concern is that we will be getting a false sense of the fatalities based on an administrative and statistical change in reporting,” he said.

Lost in the abstraction of the daily graphs tracking the state’s ‘progress’ is the actual scale of the number of deaths and how the volume is overwhelming the funeral industry itself.

UNPRECEDENTED CHALLENGE

Bob Prout is a third generational funeral director who runs his environmentally minded funeral home in Verona with his daughter Julia. They have been dealing with the full gamut of COVID-19 confirmed and suspected cases in hospitals, congregant living and residential settings.

“Most people are having a hard time with the sheer volume of deaths and realizing that when a burial happens it is out of the funeral parlor’s hands,” he said during a phone interview. “Even if a family has set aside a burial plot, cemeteries have such a huge volume and a backlog.”

He continued. “Even our state’s crematoriums are backed up as much as three weeks because the New York funeral directors are sending their bodies over here. I wish the Governor would sign an executive order that for 60 or 90 days our state’s crematoriums would have to handle just the bodies of Jersey residents who lived and paid taxes here.”

Kelder warned that such a restriction could up end reciprocity between both New York State and Pennsylvania for New Jersey families looking to bury their loved one out of state.

The Prouts consider that any corpse they encounter, no matter where they pick it up, is a possible COVID positive case and take universal precautions based on the latest guidelines from their national trade association that tracks the CDC guidelines.

Personal Protective Equipment has also been a problem for the funeral industry. “We are at a critical stage on this and are looking to the NJ State Police to unlock the supply chain,” said Kelder. “When we look back at this it will be clear we have not factored in mortuary care as part of the health care system.”

As it turns out, according to Kelder, the greatest threat to the health of his members and their employees comes from the surviving family members of a COVID-19 virus fatality who were exposed to that loved one when he or she was still alive.

“We have surviving family members who think it is ok to break their quarantine to deal with the final arrangements for their loved ones,” he said.

MISSING THE FOREST FOR THE TREES

On April 14, even before the changes to how COVID-19 deaths were to be recorded, Newark Patch reported that Essex County officials had conceded their official COVID-19 death toll, the actual number of the deaths due to the pandemic, were actually “much greater than indicated.”

Throughout the crisis it’s been the deaths in hospitals and senior citizens facilities that have been widely reported on, whereas deaths at home received scant attention.

In an April 18 phone interview, long time Orange residents Rev. Tony Johnson and Jody Leight described how they saw local EMTs respond to a neighbor’s home donned in bio-hazard protective gear with a police patrol car staying parked outside until their neighbor’s body was retrieved from the residence five hours later.

“In communities like ours there are many undocumented people that are out there working jobs where they have no protective equipment and are working jobs off the books and there are living four or five families to one house,” said Leight. “How is social distancing even possible in Orange.”

She continued. “We don’t have a hospital in Orange, and I am concerned we have hundreds of people here who are at risk and will most likely die in their homes.”

In New York City at one point earlier in the month, the FDNY confirmed that over several days the city was averaging well over 200 residential fatal heart attacks a day, a ten-fold increase over the number recorded this time last year. Even as late as this past weekend the number of cardiac arrests were running exponentially higher than would normally be recorded this time of year.

In subsequent debriefs with the EMS unions, I learned that their members were encountering people who had actually been released from the hospital, only to die at home and others who prolonged seeking medical attention for fear of being forced to go to the hospital and being exposed to COVID-19.

THE BIGGER PICTURE

Dr. Joseph Fennelly, an internist, who served for decades as the chairman or co-chairman of the Medical Society of New Jersey’s bioethics committee, thinks that the fight to contain COVID-19 can’t be just limited to the hospitals and congregant care facilities that have been generating the headlines because the virus is not just inside these facilities but in the community.

“You have to look at this in terms of a cell, a living system and what is the energy that feeds it and you can’t get a handle on that without looking at the residential facet of this,” he said.

One way to do that in real time, posits Fennelly, would be to track the deaths at home in real time even if they can’t be linked to COVID-19 as a way of getting a bead on what we don’t know.

Certainly, we should know how many of those deaths at home were people that were discharged first by the hospital. It would certainly put those patient COVID-19 discharge numbers both Murphy and Cuomo are so fond of citing in their proper context.