“I can remember the New York Times headline, that it was ‘an incalculable loss’ at 100,000. Now we’re at 10 times that,” says Dimitri Drekonja, an infectious disease expert at the University of Minnesota. “If this had been the prediction at the outset, people would have been horrified, but it’s been a bit of the frog getting boiled. You get adjusted to these slow, incremental changes.”
It happens in every war. The first few deaths are shocking, but the last few thousand sometimes barely register. That seems to be happening with COVID-19, which has now killed more than 300 times as many people as the Sept. 11, 2001, terrorist attacks.
It's no longer news that hundreds of people are dying each day. More people seem to have heard about the latest subvariants being supposedly mild than that 200,000 Americans have died from COVID-19 over the past five months.
“It’s an unfathomable toll,” says Joshua Sharfstein, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health. “A million people died, but each person had a circle of people who cared about them. It’s an enormous amount of grief and sadness.”
The pandemic is not done. The number of new infections — surely an undercount due to unreported home tests — again tops 75,000 per day. The number of hospitalizations has climbed 20 percent over the past two weeks. The Biden administration has warned there could be 100 million more Americans infected by early next year. Yet Congress seems unwilling to provide more money for basic responses such as tests and vaccines, even as it becomes increasingly clear that even mild cases can lead to dangerous long-term damage.
Yet there are positive developments to consider as well. Vaccinations and certainly boosters are not where they should be, but three out of four Americans have received at least a single dose and two-thirds are fully vaccinated. The Commonwealth Fund has estimated that, absent vaccines, an additional 2.3 million Americans would have died, and 17 million more would have been hospitalized. Public health measures such as masking have largely fallen out of favor, but they helped prevent a death toll that could have been even more terrible.
“A million is way too many people, but as a result of the work that has been done, through public health and vaccination, it’s a number that’s a lot lower than it might have been,” says David Fleming, a distinguished visiting fellow at the Trust for America’s Health. “If we did not do those things, we would not be looking at the 1 million death threshold, we’d be looking at the 3 million death threshold.”
The Price of Vigilance
Aside from the direct health effects, Americans have paid an enormous cost. The pandemic led to a staggering number of small business closures and trillions of dollars in additional government spending. School closures have curtailed enrollment and led to severe learning loss, with millions of students slipping below grade level. Many downtowns remain ghost towns, more than two years on.
All kinds of social indicators are pointing the wrong way. Drug overdoses, suicides and traffic fatalities are all up. Many criminologists blame the pandemic and its societal and economic disruptions for the spike in homicides over the past couple of years. “It’s not that the whole society fell apart,” says Jeffrey Butts, director of the Research and Evaluation Center at John Jay College of Criminal Justice. “It’s just that there are enough people who were already living on the edge, and this pushed them off of it.”
These are often reckoned as the cost of the response to the pandemic, not the disease itself. But it was the coronavirus that was at the root of these disruptions. “It’s easy to blame the shutdowns or masking or whatever culprit you like, but most of the blame goes to a virus that entered our world and was extraordinarily devastating,” says Robert Wachter, who chairs the Department of Medicine at the University of California, San Francisco.
In many ways, the country got lucky. Vaccines were developed in record time, and the U.S., along with other rich nations, was able to buy and provide ample supplies. If vaccines had not been introduced prior to the spread of the delta and omicron variants, far more people would have died. Masking and social distancing have been sacrifices that have helped to save lives. Prior to vaccines, they were practically the only weapons.
“We don’t in any way, on a regular basis, recognize how much worse this could have been,” says Georges Benjamin, executive director of the American Public Health Association. “The scenario we could have had would have been even more devastating in terms of mortality and morbidity.”
Wachter points out that San Francisco has had among thenation'sstrictest safety protocols, along with public buy-in and a high rate of vaccination. As a result, the city has seen 865 COVID-19 deaths, out of a population of 815,000, or a little more than one in 100,000. The national per capita mortality rate is three times as high. “If others had done the same, half a million more people would have been alive,” Wachter says.
The Pandemic’s True Toll
The death toll of one million is based on counts maintained by organizations such as The New York Times and Johns Hopkins University. They’re almost certainly undercounts.
The World Health Organization released a study last week suggesting that 15 million people have died due to COVID-19 globally. That’s 9 million more than official country-by-country estimates. The WHO suggests that about 110,000 more Americans died last year than were officially counted.
A study published last month that looked at excess deaths — the number of deaths that actually happened vs. the number that would normally have been expected, absent a pandemic — found nearly 200,000 excess deaths that were not attributed to COVID-19. Last year, after vaccines became widely available, the number of “non-COVID” excess deaths was 21 times higher in counties that had voted for Donald Trump in 2020 than voted for Joe Biden. Nearly a quarter-million deaths since last June could have been prevented by vaccination, according to the Kaiser Family Foundation.
Death is not the only bad outcome. One new study suggests that COVID-19 patients can end up with cognitive impairment that is the equivalent of 20 years of brain aging, or the loss of 10 IQ points. An increasing number of Americans are suffering from long COVID-19 — any of a long list of symptoms that persist for more than six months, including fatigue, brain fog and heart palpitations. Between eight and 23 million Americans have developed long COVID-19, according to a U.S. Government Accountability Officereport from March.
Official counts put the nation’s total number of coronavirus cases at about 90 million, or just over a quarter of the population. Last month, the Centers for Disease Control and Prevention estimated that the share of Americans who have been infected is actually much higher, around 60 percent.
We know the coronavirus can damage the brain, heart, lungs, liver and other organs, including in children. What we have no way of knowing is what the long-term damage will be, say, 20 years after infection. Other viruses can lay dormant and cause disease decades after initial infection.
Public Health Lessons
As happened following outbreaks of Zika and Ebola, people in public health are lamenting that policymakers are unwilling to provide sustained funding for their efforts. One of the common cliches in the field is that you wouldn’t wait for a fire to break out to build a fire department, yet that’s exactly what happens with public health. “One of the historically perennial problems that public health faces is that when we are effective in prevention, by definition nothing happens,” says Fleming, a former health director for Seattle and King County.
Certainly, public health experts and policymakers have made lots of mistakes. Over the course of the pandemic, guidance on masking has been confusing and at times contradictory. The decision early on in the pandemic to close parks was misguided at the time and seems idiotic in retrospect. There’s now a combination of exhaustion and a desire to get back to normal — along with distrust of government and science among many Americans — that has made mandates almost entirely a thing of the past.
But too many people have concluded that public health measures as a whole were not just intrusive but ineffective, says Sharfstein, the Johns Hopkins physician. “Some people are trying to teach the lesson that there’s nothing you can do — you just go about your life and there shouldn’t be any public health response,” he says. “That is a terrible idea.”
It’s human nature to want to forget and move on. We are now better equipped to deal with infections and keep case fatality rates down, with effective anti-viral medications available. Yet cases are rising once again and the nation seems to have let down its guard. “I’m pretty frustrated that even relatively simple mitigation strategies seem to be beyond what most Americans are willing to put up with, at least in a coordinated effort,” Drekonja says.
People are returning to work and classrooms while still infected. Congress has proven unwilling thus far to honor the Biden administration’s requests for additional funding for tests, vaccines and other COVID-19 responses. On Monday, Biden called on Congress to split funding packages for COVID-19 and Ukraine, not wanting to hold up funding for that country in its fight against Russia. The House passed a $40 billion aid package for Ukraine the next day.
Misinformation continues to run rampant, including from the mouths and social media accounts of elected officials. In a number of states, health authority has been weakened, including the ability to impose mask mandates. Last Friday, Arizona Gov. Doug Ducey signed legislation that will prevent future governors from wielding the same emergency powers he used during the pandemic. “I haven’t seen anything that comes out of this that makes me feel hopeful that we’re going to be better at this next time,” Wachter says.
As unimaginable as the pandemic’s toll has been, it still could have been worse. People who work in public health are optimists by nature, believing they can help prevent diseases from spreading. Sharfstein says it’s important to keep in mind the successes — the vaccines and non-pharmaceutical safety measures that have saved millions of lives — and not fall into despair about how the pandemic has been politicized and polarized.
“We have to recognize what we’ve gone through and honor the people whose lives we’ve lost,” he says. “We have to learn the lessons of the pandemic. You don’t want to lose a million people and put them in the rearview mirror and keep going.”
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