This article discusses the current difficulties of disaster death attribution and describes the strengths and limitations of relying on death counts from death certificates, estimations of indirect deaths, and estimations of excess mortality. Improving the tabulation of direct and indirect deaths on death certificates will require concerted efforts and consensus across medical institutions and public health agencies. Besides, actionable estimates of excess mortality will require timely access to standardized and structured vital registry data, which should be shared directly at the state level to ensure rapid response for local governments. Correct attribution of direct and indirect deaths and estimation of excess mortality are complementary goals that are critical to our understanding of the pandemic and its effect on human life.

Accurate mortality estimates have real-world consequences . Although official counts have historically relied on disaster attribution in death certificates, during this pandemic the CDC, state agencies, and researchers have also been estimating all-cause excess mortality . To prevent reidentification from mortality data published by the National Center for Health Statistics, for example, all subnational death data are already suppressed when cell sizes are smaller than 10. 

Estimates of direct, indirect, and excess deaths are critical to our understanding of the pandemic and its effect on human life. They also illuminate the weaknesses in our health system and societal structures and it is imperative to get them right.