How the U.S. Messed Up Covid-19 So Badly
Harvard social epidemiologist Nancy Krieger breaks down excess deaths and workplace safety findings
To call the state of coronavirus affairs in the United States grim feels like the understatement of the year. As the nation rounds the bend on Thanksgiving amid skyrocketing infection rates, we again find ourselves in a protracted moment of anxious chaos, which reliably erupts like clockwork in lieu of a coordinated response to an incredibly severe public health emergency.
The virus has America in its grip in part because we’re an easy target. We have not responded to its ferocity in an organized, national, mandatory, resourced way, as we would in wartime — and make no mistake, this is a kind of war.
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Instead, we have reacted, often belatedly, in a variety of directions. U.S. border control measures designed to contain the coronavirus at the start were inconsistent at best. As the virus vacillates between erupting and quieting, we observe some states and cities enacting strict measures, others less so. We know that certain lifestyles—typically those of privilege—align more easily with social isolation, while others revolve around the daily grind of essential work outside the home. In plenty of domains, the slow, proven (admittedly boring but also caring, necessary, and potentially creative) prevention efforts rule the day. In others, slow and boring are discarded as inconvenient affronts to freedom. And all the while, the virus persists — bobbing and weaving its way through loopholes, discrepancies, and contradictions.
People are dying en masse — and more deaths are slated. That’s the ugly, dangerous truth. And yet there is reason for hope. New leadership will invite science back to the White House, emerging vaccine developments show real promise, and other countries are coming down off their peaks of infectious horror, reminding us that life in tandem with Covid-19 can, in fact, be responsibly lived.
There has been much debate over what got us here to begin with — how the United States in particular has failed so miserably at containing and managing the virus. To flesh out more of the specifics, Elemental sat down with Nancy Krieger, professor of social epidemiology at the Harvard T.H. Chan School of Public Health. In a recently published paper, “Covid-19: U.S. Federal Accountability for Entry, Spread, and Inequities—Lessons for the Future,” Krieger and co-authors explore in data-based detail just where the United States went so horribly wrong, the nuance of challenges we continue to face, and where we might course correct as the virus rages on.
Elemental: You report that the United States, which is responsible for 4% of the global population, has seen 22% of the Covid-19 deaths—and of course that only accounts for numbers through September 2020. Apart from being incredibly sobering, what do these numbers tell us?
Nancy Krieger: I think a very important thing to point out is that with a lot of the Covid-19 data, people have resorted to counting cases and then looking at what percentage of the population they are. So, when you come up with statistics like 4% of the population and 22% of the deaths, it tells you something — but it doesn’t tell you enough. The better data, to really compare countries accurately, that isn’t compromised by variables like how many people have access to testing, how accurate the testing is, how Covid-19 deaths are being defined, etc., is the data around excess deaths.
We calculated something on the order of 260,000 excess deaths for the United States for the period of January 1 through September 12, 2020. Soon after we published our findings, the Morbidity and Mortality Weekly Report (the main journal of the CDC) came out with its analysis showing upwards of 300,000 excess deaths in the United States.
So, the disproportion—4% of the population responsible for 22% of the deaths—is one part of understanding what we’re seeing in the United States during this pandemic. Another part is just how many excess deaths we’re seeing.
“If you look at the excess death numbers by race/ethnicity, the percent increase has been 54% for Hispanics, 37% for Asian Americans, 33% for Black Americans, 29% for American Indians, and only 12% for white Americans.”
For those unfamiliar with this measure, how do you define excess deaths?
You consider the number of deaths that occurred within the last two weeks of March 2020, for example, regardless of cause. Once you know how big the population is, you compute how many deaths per 100,000 people there were in that two-week interval. Then you compute the same thing for the same two weeks over the past five years and take the average. The final step is to determine if the number of deaths for the two-week period in 2020 is larger, the same as, or smaller than the number of deaths for the corresponding two-week period for the average of 2015–2019, and if it is larger, that’s the excess number of deaths.
The value of this approach is that it immediately takes into account seasonality of deaths—deaths from the flu in winter, for instance. We measure excess deaths to understand not just the impact of epidemics, but of natural disasters as well.
Of the 300,000 deaths the CDC reported, about 100,000 don’t show up as Covid-19 deaths. These are deaths that reflect the impact of the pandemic regardless of whether you were infected with the virus — deaths from delayed surgeries or interrupted chemotherapy, for example. The data also shows that the percent increase of excess deaths is particularly high for people ages 25 to 44, which probably reflects workplace exposure. Even as a lot of elderly people have died from Covid-19, elderly people by definition die at higher rates to begin with.
If you look at the excess death numbers by race/ethnicity, the percent increase has been 54% for Hispanics, 37% for Asian Americans, 33% for Black Americans, 29% for American Indians, and only 12% for white Americans. The social patterning of this excess is incredibly stark in terms of the inequities that are revealed. Each and every death matters, period. And each one has enormous ripple effects. What is the impact on families? What is the impact of so much concentrated death on neighborhoods?
The other thing to remember here is that deaths are just one part of the picture. The work is only now underway looking at what happens if you have a serious case and survive, but then continue on with potentially debilitating symptoms as a long-hauler. If you’re 25 years old and you recover from the virus, we have no idea how you will be impacted when you’re 50 years old. If 8 million people are affected by the virus and 20% go on to be long-haulers, that’s on par with the number of new cancer cases we see every year in our country (1.76 million). If only 7% become long-haulers, that’s still on par with the number of cancer deaths per year (606,880), and cancer is the second leading cause of death in the United States.
How do we swallow what we’re seeing in America when it comes to Covid-19 alongside the idea that the United States is a supposed world leader in medicine?
The United States has phenomenal resources available to some people with regard to biomedical advances, but the U.S. also leads, among industrialized nations, in the number of people who are uninsured. We can say the U.S. leads in terms of biomedical technology and expertise, but in terms of actual access of the population to health care itself, the U.S. does not lead—it falls way, way behind.
Public health and clinical care should be complementary partners. In the United States, clinical care has gotten a lot more attention in terms of health dollars. Privatization has a lot to do with this. In the U.S., public health has long been underfunded. After the 2008 economic debacle, lots of public health was cut and then never recovered. And, of course, the functions of public health departments are very different from the functions of medical entities providing care to patients. The fact that there are some public health agencies across this country that still rely on pen and paper and fax machines is an indicator.
The other thing is that public health is a very fragmented system. The federal government has some responsibility, but the state and local governments have a lot of responsibility. And, of course, the virus couldn’t care less about the fact that we have state boundaries, different jurisdictions, and various levels of government.
That’s why we needed to have a federal response that coordinated what the national response would be — to set the tone and the rules and the protocol that would apply everywhere. Because that’s how a virus works.
“The virus couldn’t care less about the fact that we have state boundaries, different jurisdictions, and various levels of government.”
What are some specific things that we could be doing in the United States to curb the spread of the virus that we aren’t yet doing — or aren’t doing enough?
The data shows that there is lack of sufficient attention to how transmission is happening because people have to work. We should have a national standard for OSHA around Covid-19. Some states, California in particular, are setting up stricter rules around workplace complaints and conditions and safety that ought to be followed up with serious fines. A big issue is paid sick leave. People need both social protection and physical protection in the workplace. Both matter, and both ought be mandated.
When we analyzed the relationship between the frequency of workplace safety complaints and the occurrence of Covid-19 cases and Covid-19 deaths, we found a strong correlation of a lag time of 16 to 17 days between time of complaint and time of death. This proved to be true across the country. In other words, worker complaints preceded deaths. People weren’t complaining because deaths were happening around them. They were complaining and then the deaths happened. This speaks to the importance of paying attention when workers speak up about things not being safe. That is the proverbial canary in the coal mine — and you don’t wait until the canary dies.
For the virus to wreak havoc, it needs to be transmitted. To stop the spread, we can’t just give people advice—wear masks, wash your hands. We need to also give people resources. If people cannot afford masks or can’t access them at work, that’s a problem. If people are worried about being evicted, that’s a problem. Because where, then, are they going to wash their hands, protect themselves, and be safe? These are the questions that need to be addressed.