Making America Not So Great

“Short days, sharp days, long nights come on apace,
Ah, who shall hide us from the winter's face?
Cold doth increase, the sickness will not cease,
And here we lie, God knows, with little ease.
From winter, plague, and pestilence, good Lord deliver us!”

– from Autumn, Thomas Nashe [1567–1601]

As we look upon winter’s face, we see colder temperatures, short days, several upcoming holidays, and a tendency to gather together indoors. Yuletide gatherings and indoor environments enhance transmission of respiratory viruses in general, and this comes at a time of widespread seeding of SARS-CoV-2. One side glance at the daily case count data from the Johns Hopkins COVID-19 Dashboard¹ is sufficient to convince all but the most hardened skeptic that we, as the winter solstice approaches, are experiencing the third—and worst—wave so far of the SARS-CoV-2 pandemic.

The first case of COVID-19 was detected in the United States on January 19, 2020.² Looking back, what do we, as a nation, have to show for our collective response over the first 8 months (January 19–September 19) of this pandemic? Compared against 18 other upper-income countries with populations of 5 million or more people, the answer is “not much.” Authors of a thought-provoking study³ evaluated national levels of COVID-19–related and all-cause mortality over three time periods, each ending on September 19th:

• From the start of the pandemic (35 weeks)
• From May 10th (19 weeks)
• From June 7th (15 weeks)

The three time intervals were used to allow for learning about the virus, and adaptation through policy interventions and public response. Although the United States did not have the highest overall 35-week mortality rate (that award goes to Belgium), it was in the highest tier of COVID-19 mortality with 60.3 deaths per 100,000, and this rate was 86 times that of South Korea (the nation with the lowest mortality). With the later start point of May 10th, knowledge gained over the initial 16 weeks, implementation of public health measures, and enhanced therapeutics, the overall mortality in the United States dropped to 36.9/100,000; this level, however, placed the United States at the highest level of mortality and at 184 times that of South Korea. Over this interval, the only other country that came close was Sweden—a nation that gambled on the failed strategy of herd immunity. After an additional 4 weeks of experience, the United States mortality rate for the final interval dropped even more to 27.2/100,000; every other nation, however, declined even more, again leaving the United States with the highest mortality rate and at 136 times that of South Korea.

In a separate analysis, the United States registered higher excess mortality than every other county in the second and third (shorter) time periods. Only over the entire assessment interval did Belgium, Spain, and the United Kingdom outpace us.

One could conclude from this assessment that America was first, but first in high mortality is not where we could or should be. So, what does this tell us? First, we can see that there is a learning component to dealing with SARS-CoV-2—that lessons learned can be applied and can have dramatic effects on mortality. Second, an inconsistent and checkerboard response to the pandemic, wrapped in politicization, resulted in unparalleled excessive mortality in the United States. Finally, our response underscores 40 years of public health defunding. We can do better than this.