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21 September 20
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FOCUS: Dhruv Khullar | Two Hundred Thousand Americans Are Dead
Dhruv Khullar, The New Yorker
Excerpt: "What have we learned during the coronavirus pandemic - and what have we refused to learn?"
t some point in 1993, the two-hundred-thousandth American died of AIDS. By that time, a decade had passed since the Centers for Disease Control and Prevention first described the emergence of a mysterious new syndrome. Freddie Mercury and Arthur Ashe had died of the virus, and Magic Johnson had announced his retirement from the N.B.A. Tom Hanks was soon to win an Oscar for his role as an H.I.V.-positive gay man, in “Philadelphia.” Still, the tragic milestone passed without much notice. H.I.V. had become the leading cause of death among young American men, but researchers and activists were still fighting to raise awareness about the virus, and acceptance for the people who were suffering from it. Two years earlier, the hundred-thousandth American had died of AIDS. That death was announced in a short article on page eighteen of the Times, which dispassionately reviewed statistics and projections.
The novel coronavirus is about to claim its two-hundred-thousandth American life. (It may already have done so; statistics lag.) Less than eight months have passed since the start of the pandemic. There hasn’t been time to make a movie about it, and there’s been no need to raise awareness; the toll of the virus is tracked daily, even hourly, across the country and across the world. But that doesn’t make the extraordinary loss of life any easier to fathom. In less than a year, COVID-19 has killed four times as many Americans as died from the opioid crisis during its deadliest year. It has killed more Americans than those who perished in every armed conflict combined since the Second World War. Globally, it has killed nearly a million people.
Reckoning with such a number, we might try to imagine the dead as individuals. Though the virus is worse for those who are older, people of all ages have died, and of all races, backgrounds, trades, and political persuasions. Each life lost was embedded in a web of relations. According to one estimate, each person who dies of COVID-19 leaves behind an average of nine surviving family members. If this is right, then there are now at least 1.8 million Americans mourning the loss of kin—parents, husbands, wives, children, siblings, grandparents—and millions more who are mourning with them. Meanwhile, as a doctor, when I think of two hundred thousand lost lives, I think of the ones I wasn’t able to save while caring for patients in the early days of the outbreak in New York. I think of the couples transferred hand in hand to the hospice unit; of a parent comforting young children through FaceTime; of an elderly man worrying about using a ventilator that might be needed by someone younger.
Moments of national tragedy are usually met with elevating Presidential rhetoric. The country looks to its leaders to offer hope and give meaning to its collective suffering. Three days after the September 11th attacks, in a speech at Ground Zero, George W. Bush told the nation, “I can hear you. The rest of the world hears you. And the people who knocked these buildings down will hear all of us soon.” Later, at a prayer service, Bush said that “grief and tragedy and hatred are only for a time. But goodness, remembrance, and love have no end.” After President John F. Kennedy’s assassination, Lyndon B. Johnson called on the country to “put an end to the teaching and the preaching of hate and evil and violence”; he urged Americans to turn away from “the apostles of bitterness and bigotry.”
No such messages will be coming from this President. Donald Trump has abdicated both managerial and moral leadership. (“I don’t take responsibility at all,” he has said, and, “It is what it is.”) Instead of helping the nation heal, he uses his bully pulpit to sow confusion, division, and distrust. He freely admits to misleading the public about the lethality of the virus; he disrupts the efforts of public-health agencies, tarring them with his own brand of partisanship and misinformation; he argues that talk of the virus is designed to damage his reëlection prospects. Meanwhile, his surrogates describe the pandemic, which sickens or kills thousands more Americans each day, in the past tense.
There are those, including the President, who question the veracity of the U.S. coronavirus death estimates. That skepticism doesn’t cohere with reality. Across the United States, excess mortality—the difference in the total number of deaths, from any cause, compared with a historical average—far exceeds official tallies of COVID-19 fatalities. In all likelihood, there are more, not fewer, COVID-19 deaths than we have confirmed. And the pandemic, in addition to devastating the economy, has caused enormous collateral health damage. Thousands of Americans have had their medical care postponed or cancelled, or have chosen to avoid health care altogether for fear of contracting the virus. Many have died.
In the United States, peaks of panic have given way to plateaus of resignation. The country continues to record tens of thousands of new coronavirus cases each day but remains without a coherent plan to alter that trajectory. Because we never truly subdued the virus, we’re experiencing our newest waves on rising seas. In May, after strict lockdowns, the number of newly diagnosed cases levelled off at around twenty thousand per day. But September’s number is closer to forty thousand. We’re performing more tests, and that helps explain the higher number of new confirmed cases. But it’s also true that the virus is circulating in more places than before.
Early in the pandemic, it became clear that a coherent and unified national response would not be coming. States were left to procure supplies and equipment on their own. Individuals and families waded through mixed messages about how contagious and lethal the virus was—and about how they might keep themselves and their loved ones safe. At the end of February, Jerome Adams, the Surgeon General, tweeted that masks are “NOT effective in preventing general public from catching #Coronavirus,” and Robert Redfield, the director of the C.D.C., said that there was “no role” in the pandemic for masks worn by ordinary Americans. Those messages may have been intended to preserve mask supplies for health-care workers, but they seriously damaged the public’s trust in the information that was being provided by the country’s top health officials. It wasn’t until early April—after New York had logged tens of thousands of cases, and after the virus had seeded every state in the country—that the C.D.C. advised the public to begin wearing masks. (Redfield has since said that “cloth face coverings are one of the most powerful weapons we have to slow and stop the spread of the virus.”)
It’s easy to focus on national numbers. But the story of the American pandemic is really that of a virus bobbing across the country, searching for oxygen as it’s tamped down in one region or another. A pandemic that began in dense metropolitan areas has now made its way to every part of the United States. In the Northeast, states that once stored dead bodies in refrigerated trucks are now among the safest in the country. Other states, including California and Ohio, took early and decisive action but have seen cases and deaths rise over time. At the beginning of June, new COVID-19 hot spots were more likely to be rural counties than urban ones. By then, the virus had crept into small towns and ski resorts, the Navajo Nation and the rural South, and into prisons, retirement communities, and meatpacking plants, leaving a trail of destruction in its wake.
By staying home and flattening the curve, Americans succeeded in buying time for many health-care systems to adjust. The likelihood of dying of COVID-19 has declined substantially since the pandemic began, in large part because we’ve gotten better at preparing for and treating the disease. A statistic called the case-fatality rate (C.F.R.) measures the percentage of people who go on to die after being diagnosed with a disease. States where the pandemic hit early—New York, New Jersey, Massachusetts—ended up with C.F.R.s above seven per cent; the national average is now about three per cent, thanks to lower death rates in states where the virus spread later. In recent months, therefore, the apocalyptic elements of the pandemic have receded from view. There are fewer places where endless streams of patients confront dwindling I.C.U. capacity; there are fewer bidding wars for ventilators and N95s. We’ve settled, instead, into a grinding battle, in which lives are lost incrementally but no less tragically. Six thousand dead in Georgia; two thousand in Minnesota; fifteen hundred in Nevada. It’s these small yet significant numbers, adding up month after month, that have gotten us to two hundred thousand.
The coronavirus has assailed America’s image of itself. How does one reconcile the deaths of two hundred thousand people—a fifth of all the COVID-19 deaths in the world—with the idea of an exceptional America, a compassionate America, a scientifically advanced America? The most piercing question has come to be whether we live in a just America. Inequalities in income, housing, employment, and medical care have resulted in Black and brown Americans dying of COVID-19 at higher rates than whites. The pandemic has especially hurt low-income Americans, many of whom are now out of work, but Congress remains locked in a stalemate over whether and how to deliver relief. Meanwhile, in some states, more than half of all COVID-19 deaths are linked to nursing homes, where many older Americans have died without being able to say goodbye to their loved ones. We tolerate these deaths because of a communal ageism. Our inability to protect the most vulnerable Americans has become both a public-health failure and a moral stain.
The U.S. holds the unhappy distinction of suffering the most coronavirus deaths in the world. Still, adjusted for population, it ranks ninth among countries with significant numbers of cases, landing between the United Kingdom and Italy—bad, but not the worst. The case-fatality rate in America as a whole—three per cent—is also substantially lower than in many other developed countries: the C.F.R. is fifteen in the U.K., and fourteen in Italy. C.F.R. is not a perfect statistic: it’s calculated using the number of confirmed cases, not total infections, and so it fluctuates depending on how much testing is done among different populations. (If you test mostly older, hospitalized patients, as the U.S. did at the start of the pandemic, then the C.F.R. will appear higher, because a relatively high proportion of them will go on to die.) One way to understand America’s lower C.F.R., therefore, is to look at its demography. Age remains the most important factor for predicting how deadly the coronavirus pandemic will be: Americans over the age of sixty-five account for nearly eighty per cent of the country’s COVID-19 deaths. Across the world, a country’s case-fatality rate is highly correlated with the age of its population. In Uganda, where the median age is sixteen, the C.F.R. is one per cent. The median age is forty-six in Italy, and is forty in the U.K. We might conclude that the U.S. is lucky to be a relatively young nation, with a median age of thirty-eight. (On the other hand, Japan—one of the world’s oldest countries, with a median age of forty-eight—has mounted an exemplary response to the pandemic and has a C.F.R. of only two per cent.)
The excess death toll is less likely to be skewed by confounding variables. It seems to be similar in the United States and Europe, once it’s been adjusted for size. There’s no question that the U.S. squandered valuable time early in the pandemic, and it’s clear that the country has since failed to develop the infrastructure necessary to effectively control the virus. But European countries, such as France and Spain, have also struggled, and are now seeing resurgent coronavirus cases and hospitalizations. The U.S. also isn’t the only country that’s been unable to protect its most vulnerable citizens. A high proportion of the COVID-19 deaths in Canada and Sweden have happened in nursing homes. In the U.K., Black people also die of COVID-19 at much higher rates than whites, even though its nationalized health system generally does a better job than ours at reducing inequities in access to medical care. As bad as Trump has been on masks, citizens of other Western democracies resist wearing them, too.
As troubling as our pandemic response has been, the largest gap may not be between our performance and that of other countries but between our pre-pandemic understanding of America and what we now see revealed. The United States spends more on scientific research than any other nation and, as recently as 2019, was ranked the world’s most prepared to handle a pandemic—and yet our response has been strictly mediocre, and unusually fractious, politicized, and confused. How much of America’s struggle is due to bungled leadership—Trump’s distraction and disinformation, governors who’ve been slow to embrace masks or restrict gatherings—and how much is the result of long-standing features of our political and public-health systems? Answering that question is more than an academic or partisan exercise, and it behooves us to answer it honestly; what we find will have implications for identifying what’s broken and figuring out how to fix it. In the meantime, a recent survey of people in thirteen high-income countries found that confidence in America has plummeted during the pandemic: it’s now as low as it’s been at any point in recent history.
It’s not all bad. Our doctors, scientists, and pharmaceutical companies have been world-class. Many American hospitals rapidly and dramatically transformed to accommodate the deluge of critically ill COVID-19 patients; many doctors found ways to provide care through telemedicine. Meanwhile, in less than a year, researchers have discovered an extraordinary amount about the biology, transmission, and treatment of a never-before-seen virus. Vaccine development is proceeding at unprecedented speed, aided by cutting-edge advances in biotechnology; enormous investments in clinical trials mean that dozens of drugs may soon be available to reduce the spread and deadliness of the virus. Much of this work builds on decades of biomedical research, a lot of which has been publicly funded. If the coronavirus had emerged just twenty or thirty years ago, we would have far less reason to be hopeful about better treatments or a cure. Now, even though our efforts to contain the virus have stumbled, researchers stand a good chance of helping ourselves and the world.
Step by step, we have developed a nuanced picture of how the virus spreads. In the beginning of the pandemic, we worried a lot about contaminated surfaces; now we know that they aren’t a major driver of transmission. (Wash your hands and avoid touching your face; but there’s probably no need to scrub your mail.) We understand that the virus travels primarily through respiratory droplets exhaled by infected people and through microscopic secretions known as aerosols. Droplets, which are relatively large, quickly fall to the floor, but aerosols can float in the air for minutes or hours, making poorly ventilated indoor spaces, such as movie theatres and campaign rallies, especially risky. It took time, and the collaborative efforts of scientists around the world, to come to grips with the aerosol threat. The World Health Organization maintained that aerosol spread was worrisome mainly during medical procedures, until July, when two hundred and thirty-nine scientists signed an open letter urging it to revise its assessment. At that point, the W.H.O. released a statement acknowledging that aerosol-based transmission in restaurants, gyms, and other crowded spaces “cannot be ruled out.” Many reopening plans were revised accordingly—favoring the outdoors over the indoors, and urging the opening of windows and the upgrading of ventilation systems when indoor activity was unavoidable.
Early in the pandemic, we didn’t fully grasp the challenges posed by asymptomatic transmission. We now know that people can start “shedding” the virus several days before they develop symptoms; in fact, viral loads seem to peak just when symptoms are starting to appear. A recent study, not yet peer-reviewed, found that three-quarters of coronavirus transmissions occur in the two to three days before or after people develop symptoms. Because asymptomatic carriers, who may account for as many as forty per cent of infections, can also transmit the virus, it’s clear that curtailing the spread requires everyone’s participation—even the participation of those who don’t think they are sick. (That recognition is one reason that recent C.D.C. guidance that asymptomatic people should not be tested was met with widespread criticism by scientists. The C.D.C. has since reversed its recommendation.)
Our understanding of COVID-19, the disease caused by the coronavirus, has also evolved. It’s become clear that, though it primarily affects the lungs, it can damage hearts, brains, blood vessels, and other organs. It can also linger, creating a growing cohort of “long-haulers” who continue to experience symptoms weeks, even months, after infection. One study of hospitalized patients found that nearly ninety per cent still experienced at least one symptom—most commonly fatigue or shortness of breath—two months after getting sick. Another study of non-hospitalized people who had tested positive for the coronavirus found that, weeks later, more than a third had not returned to their usual state of health. Among younger Americans without chronic medical problems, one in five continued to have symptoms.
In all of these ways, we’ve taken a more accurate measure of our foe. But there are still many unanswered questions—among them, how long immunity lasts. SARS-CoV-2 has not turned out to be a champion mutator in the vein of influenza or H.I.V. Still, we don’t know whether immunity to the virus will wane with time, allowing previously infected people to become susceptible to it again. The answer has huge implications for individual behavior, public policy, and vaccine efficacy. So far, less than a year into the pandemic, there’s no evidence of widespread repeat infections. But infections of most respiratory viruses, including other coronaviruses, do not confer lifelong immunity—and it’s too early to tell with SARS-CoV-2.
Even as we continue to learn about the virus, there’s a sense in which we already know what we need to know—and have known for some time. For months, we’ve known the essential steps to containing the virus: testing, tracing, masks, and distance. We also know that, as bad as things have been, it’s possible for them to get worse. In many parts of the country, winter will soon close off opportunities to dine and gather outdoors, forcing us inside, where the virus is more likely to spread. One widely cited model has the American COVID-19 death toll doubling to four hundred thousand by January, 2021. That outcome is far from inevitable, but escaping it will require a more thorough and united approach to the pandemic than we’ve managed to date. It will require us to act more effectively on what we know.
Moments of tragedy are also moments of possibility. We search for meaning in grief, hoping to find some purpose in our suffering, or at least some reassurance that we will emerge stronger and more prepared in the future. In the past, catastrophes, both natural and man-made, have led to new ideas, laws, and cultural and political paradigms. Social Security, food stamps, and a more robust safety net emerged from the Great Depression. In mid-century America, people hoping to report an emergency had to find and dial a local phone number or ask for an operator, leading to delays, confusion, and needless tragedy; the gruesome murder of Kitty Genovese—which, at the time, was said to have been witnessed by thirty-eight people, none of whom called the police—was partly responsible for the invention of the 911 system we use today. In the nineteen-sixties, the U.S. recorded about twice as many car-crash fatalities per person as it does now (in some years, more than fifty-two thousand people died); then came seat belts, airbags, and the enforcement of drunk-driving laws.
Viktor Frankl, the famed psychiatrist and Holocaust survivor, once said that “everybody in the midst of suffering is given a chance to bear testimony of the human potential at its best, which is to turn a personal tragedy into a human triumph.” The monumental loss of life during the coronavirus pandemic so far could push us toward a better future. It could help restore a belief in independent science and competent government. It may help us value the essential work performed by society’s most marginalized people. And it could lead us to create a public-health infrastructure that spares future generations of Americans a similar fate in the inevitable pandemics to come.
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