For most Southeastern Pennsylvanians, just a few clicks on their county’s website gets them current local information on COVID-19 cases and deaths.

Unless they live in Bucks County.

That county’s Health Department stopped providing new data on the pandemic’s spread in each of its 54 municipalities about a month ago, saying it was too overwhelmed by the surging number of cases to adequately contact-trace new positives. Other area counties also struggle with tracing yet still provide daily updates.

It’s the latest example of how the county’s Health Department and its controversial director, David Damsker, have stood apart from, and sometimes at odds with, most health experts throughout the pandemic.

When others recommended six feet of social distancing within schools, Damsker said three feet would do. He pushed for schools to keep in-person instruction going as some experts urged virtual lessons. And until recently his department kept its own count of COVID-19 deaths that tallied 100 fewer deaths than the state, in part because Damsker left out cases where his department deemed COVID-19 infection was not the “substantial” cause of death.

“I’m not sure how you can absolutely sort that out without an autopsy being done,” said Charles Kiessling, Lycoming County coroner and president of the Pennsylvania Coroners Association.

Damsker has run the Health Department for 12 years, retaining the post through a realignment last year that gave Democrats control of Bucks County’s Board of Commissioners. The three county commissioners and Damsker, a graduate of Drexel University’s medical school, declined to be interviewed directly, responding instead to questions through spokesperson Larry King. Damsker’s approach, King said, sought a more nuanced perspective on the pandemic by prioritizing data investigation, not just data reporting.

Critics say Damsker’s recommendations and approach can be confusing, at best, and risky at worst. This fall, 20 doctors in the region, including Bucks County, signed a statement condemning Damsker’s endorsement of a less-restrictive quarantine for some people exposed to the virus, saying his approach “endangers students, staff members and the community.”

Matt Groden, a former teacher in Bucks County who now runs a tutoring business and who gathered the signatures, said doctors he contacted at first thought he wasn’t explaining Damsker’s approach accurately.

“They said, ‘Are you sure?’”

A different vision for schools

Damsker’s recommendations on school safety have been his most divisive, though some hail them as a refreshing alternative that prioritizes children’s education.

“Clearly David has a perspective on health and COVID that’s different than other health professionals,” said William Harner, superintendent of Bucks County’s Quakertown Community School District. “It helps me, helps the other superintendents have a different point of view.”

As state officials and Children’s Hospital of Philadelphia PolicyLab called on schools around the Philadelphia region last month to shift to virtual learning, Damsker was unequivocal in his opposition.

» READ MORE: Why CHOP lab recommends Philly-area schools close amid coronavirus surge

“The Bucks County Department of Health unconditionally recommends not to change the model of instruction for your school districts to virtual at this time,” Damsker told superintendents. “There is no existing evidence, anywhere, indicating that in-person schooling contributes to spread in the community.”

That’s a hard claim to assess, since Pennsylvania is not publicly reporting data on outbreaks in schools, though researchers say there are indicators schools are not playing a significant role in transmission. King said the county had identified “no clear-cut cases” of transmission in Bucks schools, “but there have been a few instances where we could not rule it out as a possibility.”

In June, Damsker urged school leaders to “begin treating” the coronavirus no differently than they would cases of flu, whooping cough, measles, strep throat — all of which either have proven vaccines or can be treated with antibiotics.

“It is our strong intention to keep all classrooms, schools, and districts open, in the event of confirmed cases of COVID-19,” Damsker said in the letter. He also advised schools against requiring students to wear masks — saying children would be uncomfortable and more likely to touch their faces.

The state’s face-covering mandate later overruled that guidance.

Damsker’s recommendation of three feet of social distancing relied on the minimum guidance from the World Health Organization, though it has also said “maintain an even greater distance between yourself and others when indoors.”

Some Bucks County districts have been able to get students back to classrooms five days a week — unlike schools that are staggering schedules to maintain a six-foot distance. But it has also alarmed some parents and teachers.

Damsker has endorsed a “modified quarantine,” in which the county advises some people who have been exposed to the virus but are asymptomatic that they don’t have to quarantine at home, but can return to work and school if they follow certain requirements, such as wearing a mask. At least some school districts in the county have followed the practice.

» READ MORE: Schools with coronavirus cases could be forced to close on short notice under new Pa. rules

Defining COVID-19 deaths

When Bucks County stopped providing case data by municipality in November, it also stopped its own tally of COVID-19-related deaths. Damsker has said the state’s count inflates the death toll because, King said, “it is an overestimate to say that everyone who died with COVID also died from COVID.”

As an example, King pointed to a situation such as a person in hospice with cancer who also tests positive for the coronavirus. If that person dies within a few days, the Bucks County Health Department may not decide COVID-19 contributed to the death. Bucks County also filters out duplicated reports and people who died in Bucks County hospitals but lived outside the county.

“It makes no difference whether it’s 500-plus deaths or 600-plus deaths,” King said of the discrepancy between county and state figures. “Either number is tragic and convincing evidence that COVID-19 is a deadly virus that must be taken seriously by all.”

Precisely determining COVID-19 was present but not the cause of death is virtually impossible in most cases, said Meredith Buck, the county coroner.

“There’s not enough information yet, enough research yet, to say they’re testing positive for COVID but that didn’t have anything to do with their death,” Buck said. “Nobody knows that right now.”

People with serious preexisting conditions are at higher risk of COVID-19, health experts said, and the virus can do damage to every organ system in the body. But even a terminally ill person might have lived longer without the virus.

“If COVID is anywhere listed on the death certificate, most jurisdictions would certainly list it as a COVID death or a COVID-related death,” said Greg McDonald, chair of the forensic medicine and pathology department at Philadelphia College of Osteopathic Medicine.

» READ MORE: As COVID-19 cases surge, should schools stay open? Around the Philly region, approaches vary wildly.

Any death certificate that lists COVID-19 as a contributing factor is included in the state’s count of virus-related deaths, health officials said, and Pennsylvania counts 727 coronavirus-related deaths in Bucks County this year as of Tuesday.

Because the coroner and the state keep track of COVID-19 deaths independently of the Health Department, Buck said, there’s little chance of any deaths going uncounted, but having an accurate count, and agreement on what constitutes a COVID-19-related death, makes communication easier, and provides consistency.

“It’s changing the numbers,” said Buck, who supported legislation vetoed this year by the governor that would require coroners be notified of every death in their counties where COVID-19 was a factor. “It skews the numbers and there are so many ways the numbers are being skewed right now.”

How many cases are there?

In the early days of the pandemic, Bucks County did an exceptional job of contact tracing, boasting it reached 95% of its positive cases for months. The county is now tracing only people over age 60 or under 19, King said. While no other counties link contact tracing to providing case counts to its residents, Bucks County says an investigation into each case provides important context.

“The home municipality, or zip code, for that matter, often has little connection to where a person became infected,” King said.

Damsker, meanwhile, has said national experts are moving in his direction. As the Centers for Disease Control and Prevention last week announced its support for shorter quarantines in certain circumstances, Damsker advised Quakertown school board members that Bucks County had reached its own conclusions about balancing risk with hardship.

The CDC’s recommendations are “based on data,” he said. “The same data that we have here.”