Julio Ayala first felt the ache in his bones during back-to-back shifts behind the wheel of a delivery truck and a janitor’s mop. By the time he returned to his East Boston apartment one evening last month, a fever had seized his large frame.

The Salvadoran immigrant called in sick the next day. When his longtime partner, Idalia, made him food, the barrel-chested 45-year-old had no appetite. Then Julio lost his sense of smell and taste.

As a cough began to rattle his broad chest, Idalia begged him to get tested for the novel coronavirus.

“Go to the hospital,” she recalled telling him repeatedly. “Don’t stay here.”

Each time, however, he refused.

Across the country, thousands of people infected with the lethal virus are staying home even as their conditions deteriorate. Some are unsure if they have covid-19 because of a lack of testing and the evolving list of symptoms linked to the disease. Others underestimate the toll the illness will take on them.

Yet many stay home not out of confusion or overconfidence, but fear.

Fear that hospitalization will bring financial ruin.

Fear that Immigration and Customs Enforcement agents will find them.

Fear that they will die alone in an unfamiliar place, rather than in their own bed, surrounded by loved ones.

Those anxieties run deepest in poor, minority and undocumented communities, which have been ravaged most by the pandemic.

For Julio, who had temporary protected status and permission to work in the United States, ICE posed a threat not to him but to his undocumented partner and her 15-year-old son. Mostly, he feared what a trip to the hospital would mean for a family already struggling to pay the rent.

“He was worried about the bills,” said Idalia, who spoke on the condition that The Washington Post use her middle name for fear of deportation.

On the evening of April 10, Julio’s cough became a painful wheeze, she said. This time, when she implored him to go the hospital, he agreed.

“Mañana,” he said. Tomorrow.

He wouldn’t make it there.

'I can handle this'

Since the start of the pandemic, the coronavirus has been quietly killing thousands of Americans in their own homes.

When Patricia Dowd fatally collapsed in her San Jose kitchen on Feb. 6, the death of the healthy 57-year-old was initially attributed to a freak heart attack.

There were only a dozen known coronavirus infections in the United States at the time, and it would be three weeks before a Seattle hospital patient would be announced as the country’s first coronavirus fatality.

But when an autopsy was completed on Dowd last month, the cause of death was revealed as covid-19.

The findings upended the pandemic’s timeline in the United States and underscored a startling fact: the virus wasn’t just killing people in emergency rooms or ICUs.

According to official data from the Centers for Disease Control and Prevention, roughly 7 percent of covid-19 deaths through April 28 occurred at home, compared with 73 percent in hospitals and 19 percent in nursing facilities or hospices.

But an investigation by The Post found that many covid-19 deaths went uncounted in March and early April: There were nearly twice as many additional deaths in the United States as were publicly attributed to coronavirus at the time. Data from local governments suggests that many of those additional deaths were people dying at home of covid-19.

In Santa Clara County, where Dowd lived, at-home deaths were up 17 percent in March compared with a year earlier, according to the San Jose Mercury News.

In the District, where deaths outside of hospitals have spiked by 74 percent, at least three people with covid-19 have died at home.

And in New York City, where the number of people dying at home has increased tenfold, at-home deaths make up 3 percent of confirmed covid-19 deaths but a quarter of those suspected to stem from the disease.

Though data remains scarce on those who die at home of covid-19, their ranks include the old and young; the frail and fit; the ill-prepared and health-care professionals.

Some, like Dowd, succumbed early in the pandemic without ever realizing they had covid-19. Others suspected they had the deadly virus but died without knowing for sure.

On Long Island, a 99-year-old died at home after being unable to get tested.

In Palm Beach, Fla., a 33-year-old nurse’s test came back inconclusive. Two weeks later, her husband found her lifeless on the couch.

And in Columbia, S.C., Tim Liszewski had been awaiting his test results for a week when the fever that had hovered around 102 degrees suddenly dropped. But when his fiancee came downstairs the next morning, she found the 60-year-old liberal political activist slumped near his computer. Both of them, she later learned, had covid-19.

“We never considered going to a hospital because we didn’t have shortness of breath or tightness in the chest,” Maris Burton told The Post, adding that Liszewski had been in touch with doctors. “It was never, ‘Oh, my God, you’re about to die. Let’s get you out of there.’ ”

Since his death, the CDC added many of his symptoms — shaking chills, headache, loss of smell and taste — to its list of covid-19 indicators.

Burton, who recovered from the disease, said she was glad the man she was due to marry later this month didn’t go to the emergency room.

“He still would have died,” she said. “But he would have died at the hospital, alone.”

When Donald Starver’s test came back positive on April 1, the former city official in Rochester, N.Y., kept the results to himself. A fit and independent 56-year-old who never married and had no children, he only reluctantly told his sister he wasn’t feeling well.

“I told him to go to the hospital, but he said the hospital was for people who were more sick than he was,” Kelly Starver said. “My brother was, ‘I’m strong, I’m a man, I’ve never been sick, I can handle this.’ ”

Kelly, a nurse in their hometown of Pittsburgh, made him call every six hours.

“The last time I spoke with him, he said, ‘My fever has finally broken. I think I’ve finally turned the corner,’ ” she recalled.

But when she didn’t hear from him for two days, she asked police to do a welfare check. His landlord found Donald dead in his bed on April 16.

When Kelly drove to his home a few days later, she found the test results and a pillow stained with mucus.

“I had hoped that he just went to sleep,” she said. “But I now know that’s not the case.”

'Dance with me'

When the alarm on Julio Ayala’s cellphone rang each morning at 5 a.m., the big man would try to roll out of bed without waking Idalia and head to the kitchen for coffee and his daily insulin injection. Then it was off to his back-to-back jobs.

They had met on Idalia’s first day in the United States, in 2008, when her head was still full of dreams of getting her G.E.D., learning English and buying a house.

She was in her mid-20s, with raven hair, no papers and an abusive ex-husband in El Salvador.

He was six years older, with the bald head and bulky physique of a Hollywood heavy.

“He looked like a bad guy,” she recalled with a laugh.

But when she saw him again at a party a few days later, his first words to her betrayed a gentle soul.

“Dance with me,” he said, taking her hand and teaching her bachata. They went out the next day, then again a few days later. Soon she had moved into his apartment in East Boston, a working-class Hispanic neighborhood near Logan International Airport. Though they never officially married, they began calling each other husband and wife.

The easier life she had imagined in America never quite arrived, however. She worked at a series of restaurants, where she said bosses sometimes used her undocumented status to stiff her out of meager wages.

Julio was able to work legally but sent much of his earnings to his mother and a daughter in El Salvador. Idalia also supported two children back home. And even after she brought her son to the United States about five years ago, the couple continued to rent a spare bedroom to a friend of Julio’s.

In early April, Idalia overheard the friend worry he had caught the coronavirus from a co-worker at a chicken plant, she said. But when Julio asked if he was sick, the friend denied it.

A few days later, Julio came home feeling sore and feverish.

The virus tore through him with incredible speed, Idalia said. In little over a day, he lost his appetite and ability to smell or taste. His stomach became upset, and he began to cough.

Idalia soon developed the same symptoms. She urged Julio, who had health insurance, to get tested. But he worried a trip to the hospital would leave the family strapped with debt.

On April 10, three days after getting sick, he drove them to a convenience store to pick up bottles of Ensure. But he felt faint, she said, and they had to rush home.

That night, Julio finally agreed to go to the hospital.

But the virus would not wait. Julio woke up at 1:30 a.m. complaining that he felt like he was “suffocating.”

Idalia put Vicks VapoRub on his chest to help him breathe. But when she put her arms around him, he shrugged her off. She turned away from him and fell asleep.

She woke up three hours later to the sound of his alarm, ringing and ringing.

'It's your fault'

On a breezy Saturday afternoon in late April, Idalia covered her face and stepped outside for the second time since Julio’s death.

The first had been a trip to the hospital with her son to get tested.

Now she was walking to collect Julio’s ashes.

The sky, normally screaming with planes over Logan, was quiet. The streets were clear — emptied by a pandemic that had hit East Boston harder than any other part of the city.

After nearly two miles, she arrived at the Ruggiero Family Memorial Home, where an employee handed her a cardboard box and apologized for her loss.

On the way home, Idalia sat on a bench, staring at the ships in the harbor and wondering how the center of her life now fit in the palms of her hands.

It had been two weeks since she had heard his alarm and called 911, compressing his large chest as the operator instructed. Two weeks since the paramedics had tried to revive him on the bedroom floor.

Two weeks since the funeral home employees had arrived in hazmat suits and taken him away.

Julio was one of 70 people the funeral home had buried or cremated in April, more than three times as many as normal, according to director Joe Ruggiero. About 90 percent were suspected covid-19 cases.

“We are definitely seeing that a lot of people dying at home are from poorer backgrounds,” he said, adding that many were immigrants whose families would normally send their bodies overseas but now could not if covid-19 was involved.

Julio’s death had come early in the pandemic, before the funeral home had been able to acquire new protective equipment.

“It was scary, man,” Ruggiero recalled of stepping into the apartment in a hazmat suit he’d been saving in case of a tuberculosis outbreak. “It’s not the way you want to treat someone’s loved one.”

The death also stood out among the dozens he’d handled recently because of what came afterward.

“The whole house got infected,” Ruggiero said.

Idalia tested positive. So did her son. So did a cousin of Julio’s who had stopped by the day he died.

So did their landlord, who had helped Julio and Idalia install a new kitchen faucet a few days earlier.

So did the landlord’s wife, who is recovering at home while her husband remains in the hospital in critical condition. Their son-in-law wound up on a ventilator for 20 days.

The cascade of infections left Idalia feeling both angry and guilty: angry at Julio’s friend, who she blamed for allegedly bringing the virus into their home, and guilty for unwittingly infecting others.

Above all, she felt alone.

She rarely saw her son, who stayed in his room playing video games his stepfather had bought for him. She hadn’t hugged the tall, quiet 15-year-old since they had gone into isolation.

She was even cut off from Julio.

Because they had never married, she had no access to his bank accounts or life insurance benefits, even as she was arranging his cremation.

Donations would ultimately cover the funeral home costs but not their rent. Idalia had been jobless since the pandemic shuttered the restaurant where she had worked.

Would she stay in the apartment where everything reminded her of Julio?

In the end, the decision was made for her.

When she arrived home with his ashes, she put them on the nightstand next to the bed they’d shared and started making dinner.

But while she was cooking, she was distracted by thoughts of Julio. Suddenly, there was smoke in the kitchen and sirens in the distance and the landlord’s daughter angrily standing at the door.

“It’s your fault that my family is in the hospital,” the woman said, according to Idalia. “You are the ones that brought illness into this house.”

The landlord’s daughter declined to comment.

Idalia began giving away Julio’s belongings and packing her own. She found a relative willing to let her and her son move in for a short time.

Then she lifted Julio’s ashes from the nightstand beside the bed where he died and left.

Julie Tate and Emma Brown contributed to this report.

Read more: