Vastly unequal US has world’s highest Covid death toll – it’s no coincidence

The US is nearing 900,000 confirmed deaths from Covid-19, the highest figure of any nation. The death toll would be equivalent to the 15th most populous city in the country, more than San Francisco, Washington DC or Boston – a city of ghosts with its population swelling each day.

It’s not just the total numbers. America also has the highest death rate of any wealthy country, with half of the deaths occurring after vaccines became available.

The US has never responded to the Covid pandemic in a sustained, proactive way as a unified nation. Instead, much of the responsibility – and blame – has fallen on individuals. In a country with vast income inequality, poor health and sharp political divides, the results have been grim.

“All of those factors put people at higher risk of Covid death,” said Megan Ranney, emergency physician and academic dean of public health at Brown University.

Vaccinations, in particular, have lagged, especially compared with other wealthy countries. The health system was already precarious when it began to be battered by wave after wave of Covid.

Other countries with similarly high death tolls earlier in the pandemic have seen fewer fatalities from the Omicron variant – yet in the US, the Omicron death toll is surpassing the Delta wave of autumn 2021. Last month was one of the deadliest of the entire pandemic.

Meanwhile, American leaders are attempting to mimic other countries’ return to normal, despite a markedly different situation with hospitalizations and deaths – which, every day, nearly reach the losses from the September 11 terrorist attacks.

“The first and most obvious [issue] is our vaccination and booster rate,” said Ranney. “Our rate of vaccination, period, is lower than in most other high-income countries, and our booster rate is lower as well. And as ample CDC data proves, vaccines and boosters are tremendously effective at protecting against death, even with Omicron.”

Less than two-thirds – about 64% – of Americans are vaccinated, and only 48% of those are boosted, despite ample vaccine supply.

“For a country which has a vaccines-only strategy, we’re not very good at vaccination,” said William Hanage, associate professor of epidemiology at the Harvard TH Chan School of Public Health and co-director of the Center on Communicable Disease Dynamics. “There are large parts of the country which are not vaccinated to higher levels … and that’s made worse by the fact that with Omicron, to get really good protection, you also need to be boosted.”

Problems with access to vaccines linger, too. Better-off people have had plenty of opportunities to be vaccinated, but those in poorer households still struggle to get vaccines – and time off to recover from any side effects. Some 15% to 20% of unvaccinated Americans say they are still interested in getting their shots, Hanage said – they simply haven’t been able to yet.

Meanwhile, poorer unvaccinated people also face a “double whammy” because they are also more likely to contract Covid, he said.

“You have people who are more likely to be exposed to the virus, who are less likely to receive vaccines, who are less likely to be able to take steps to protect themselves even with vaccination, because they’re scared of missing a paycheck, they’re scared of taking a day off, their employer won’t let them.”

The US is the most economically unequal of G7 countries, and it offers no guaranteed sick leave.

“The absence of paid sick leave is an absolute scandal,” Hanage said. “If you care about working people, give them sick leave. That sick leave will enable them to avoid infecting others, it will enable them to help protect workplaces – it’s just a no-brainer.”

Another reason for the disparate outcomes in the US is the fractured healthcare system. People who lack health insurance tend to wait longer to be seen by physicians, making worse outcomes more likely. They are also more likely to have pre-existing health conditions that put them at greater risk for Covid.

“There are lots and lots of ways in which societal inequities are mirrored and magnified in our death rates,” Ranney said. “With Covid, there is now no longer any way to cover up all of these underlying problems, and the impact of those problems got magnified because many of the social supports which allowed us to muddle through were no longer present.”

The US also has higher rates of death from opioids and gun violence, and lower rates of life expectancy, than similar countries. Hospital overcrowding is also higher in the US than other countries, Ranney said.

“Overcrowding correlates with poor outcomes for multiple types of diseases and injuries,” she said. “And there’s been preliminary data that people are more likely to die of Covid when there’s a higher number of Covid patients in the hospital or when ICUs [intensive care units] are overwhelmed.”

One predictor of Covid deaths by country is trust in government, according to a recent report in the Lancet: countries with lower levels of trust in government had higher rates of cases and deaths.

“If you don’t trust the government, you’re less likely to follow suggestions or mandates around lockdowns, early on, or masks. And then the lack of trust also impairs governments’ ability to do important things like masking or testing or good data acquisition,” Ranney said.

Only 25 US states share reliable data on cases by age, which makes it difficult to know how many children are sick, for instance. “And then that hurts our ability to put data-driven public health measures in place, and then people don’t follow the public health measures, because they don’t trust them. And it becomes this circular problem,” Ranney said.

National leaders in the US are unable to mandate precautions, like masks or vaccines, for the entire country, with responsibilities largely falling instead to state and local leaders.

Yet leaders have seen their ability to act during health emergencies limited even more during the pandemic, with more than half of US states introducing new limits on public health powers.

“There is a constituency within the US that is beginning to look at this and see this opportunity,” Hanage said. “A lot of that comes down to: how much illness and death will people accept?”

Those who are interested in limiting public health regulations “are looking at this and thinking, whoa, a significant fraction of the population is fine with 900,000 deaths”.

There is still time to change course and prevent future losses, Ranney said.

“I do think that there’s a chance to create a better future,” she said, noting that leaders can “use this moment to build up the infrastructure that is needed, so if and when there is another variant or some other acute epidemic, we have the system in place to address it”.

But the US reaction to the pandemic is also compounded by an American sense of exceptionalism.

“It’s a very American idea to suggest that reality is what you want it to be. You can be whoever you want to be. Reality is a real thing, though. The virus doesn’t care who you are,” Hanage said. “It only cares that it can infect you..”