“The U.S. coronavirus response has reignited debate about American exceptionalism and its role as a leader on the global stage.”
- Judy Woodruff, anchor and managing editor, PBS Newshour
“The pandemic has been both a bad and an embarrassing time to be an American.”
- Benjamin Wallace-Wells, American author and journalist
As a share of the Gross Domestic Product, the U.S. leads the world in healthcare spending. Why then is the mortality of SARS-CoV-2 infection so high in America? Shouldn’t the U.S. be the country with the lowest mortality? These have been some of the most perplexing (and consistently disturbing) questions on my mind throughout most of the COVID-19 pandemic. In this week’s Germ Gems post, I provide the data on how the U.S. fared in its response to the COVID-19 pandemic in comparison to other countries.
How does America’s track record on the toll of COVID-19 stack up? On May 17, 2022, the U.S. recorded its one millionth COVID-19 death. In Medscape’s Coronavirus Resource Center, journalist Marcia Frellick summed up this milestone in her article, “US Tops 1M COVID Deaths: History Should Judge Us Harshly.” How does this figure compare with COVID-19 deaths in other countries?
Epidemiologists track data on the outcomes of the COVID-19 pandemic, such as, the number of cases, mortality, hospitalizations, and vaccination rates. A huge concern for epidemiologists is the quality of the data they are tracking as it varies considerably around the world. Therefore, tracking services are only as good as the data they receive (“garbage in, garbage out”).
Nonetheless, several excellent on-line tracking sources are now available, for example, “WHO Coronavirus (COVID-19) Dashboard,” “CDC COVID Data Tracker,” “Johns Hopkins Coronavirus Resource Center,” and the University of Washington’s Institute of Health Metrics and Evaluation (IHME) “COVID-19 Projections.” If you access any of these four Internet-based resources you will find daily updated values for confirmed cases, deaths, case-fatality rates, and deaths per 100,000 people for all countries and territories in the world.
According to the John Hopkins Coronavirus Resource Center’s report issued on June 29, 2022, Peru had the highest number of deaths, 647.47/100,000 and was ranked number 1. And North Korea, which only recently admitted to havingany cases of COVID-19, was ranked last of the 195 countries listed as it had the lowest deaths, 0.02/100,000. The U.S. was ranked number 17 with 308.61 deaths/100,000 falling between Latvia with 310.57 deaths/100,000 and Poland with 307.61 deaths/100,000.
Epidemiologists also track excess mortality. Excess mortality is determined by the number of deaths that are above a country’s average number of expected deaths; countries with a decrease in mortality have a negative excess mortality number. In the landmark article “Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020-21” published in the March 10, 2022 issue of The Lancet, the IHME provided data on COVID-19-related “excess mortality” in 191 countries and territories.
Among the 11 developed countries included in their analysis, the IHME reported that the COVID-19 excess mortality was highest in the U.S (179.3). The Netherlands was closest to the U.S. (140.0). The developed countries with the lowest excess mortality were Norway (7.2), New Zealand (-9.3), and Australia (-37.6). In the ranking of excess mortality of six Nordic countries, Sweden had the highest COVID-19 excess mortality (91.2) and Iceland the lowest (-47.8). Some Germ Gems readers may recall that in previous posts I discussed that Sweden adopted a less restrictive approach than its neighbors to the COVID-19 pandemic with the goal of achieving “herd immunity”; that approach has not borne out.
Admittedly, much more goes into the determination of how countries have fared during the COVID-19 pandemic than mortality. Case numbers and COVID-19 disease severity (hospitalizations) need to be taken into account, as well as measures of social disruption (impacts on business/the economy and on education). But, the data on excess mortality is clearly disturbing: it shows “that the U.S. is below average in the world and among the worst in developed and high-income nations.” Certainly, we can do better.
Why has America performed so poorly in its response to the COVID-19 pandemic? Many experts have weighed in on this question. Not surprisingly, there is no consensus as the issue is complicated.
Some experts attribute America’s failure to respond more effectively to the pandemic, at least in part, to its ongoing culture war between libertarian conservatives and scientists. In addition, they contend that the especially robust anti-vax movement in America may contribute to our dismal performance whereas the greater uptake of vaccines by other countries played a major role in prevention of COVID-19-related mortality in those nations.
Other experts suggest our poor performance is due to the U.S. obsession with individualism, that is, making achievement of a personal rather than a collective goal paramount. They blame our attachment to technology and our giving priority to medical care, i.e., treatment after the fact, over robust public health policies which focus on prevention.
Our healthcare system may be at the heart of the problem. As pointed out above, the U.S. has the highest COVID-19 excess mortality rate of 11 developed countries. And the ranking of excess mortality is closely correlated with the overall rating of the healthcare systems of different countries.
In his article “How Does the US Response to COVID-19 Compare with the Rest of the World,” published on March 22, 2022 in Infection Control Today, Kevin Kavanaugh, M.D. wrote: “[O]f 11 high-income nations, the United States is dead last in access to care, equity, health care outcomes and overall ranking. Unfortunately, in all of the categories but care processes, the United States vastly underperforms the next closest high-income country.”
America’s scientific and technological accomplishments. As was emphasized in the June 22, 2022 Germ Gems post, “mRNA Vaccines Usher in a New Era of Vaccinology,” the many scientific discoveries and technological achievements that went into making vaccines against SARS-CoV-2 available in less than a year’s time were truly amazing.
American science cannot, however, take singular credit for this accomplishment. This was a global scientific triumph, starting with the discovery and characterization of SARS-CoV-2 in Wuhan, China in early January 2020. Without the involvement of hundreds of scientists from America and other countries beforehand, the development of effective vaccines, and more recently of antiviral drugs, would never have happened.
Universal vaccine. In this third year of the COVID-19 pandemic, one thing that seems certain is that the citizens of many, if not all, countries are exhausted. Sadly, the SARS-CoV-2 virus is not tired of us. According to the World Health Organization, the number of cases of COVID-19 rose by 18% the last week of June, with more than 4.1 million cases, globally. COVID-19-related deaths increased in three regions: the Middle East, Southeast Asia, and the Americas.
SARS-CoV-2 is an exceptionally adept pathogen. The one feature of SARS-CoV-2 that makes it so successful is the rapid mutation of its spike protein, which is the target of most vaccines. The rise in cases seen in 110 countries, including in the U.S., is mostly driven by the BA.4 and BA.5 Omicron subvariants. Unfortunately, the effectiveness of the current vaccines against Omicron subvariants is diminished. Also, these subvariants more effectively evade monoclonal antibodies, one of our most effective therapies.
In response to these developments, on June 30 U.S. Food and Drug Administration advisers recommended updated boosters that target Omicron subvariants. An overwhelming majority of committee advisors voted in favor of adding an Omicron BA.4/5 spike protein component to the current vaccine composition to create a trivalent booster vaccine with the aim that the modified vaccines can be used starting in early to mid-fall 2022. (Pfizer/BioNTech and Moderna, manufacturers of mRNA vaccines, are working on boosters that include BA.4 and BA.5 that should be available this fall.)
The subvariant that is of greatest concern is BA.5. An excellent review of what makes BA.5 so “fit” (highly contagious) and worrisome is provided by Dr. Eric Topol, director of the Scripps Translational Research Institute, in a June 27 article in Ground Truths, “The BA.5 Story.” He asks, “Should we wait for a BA.5 booster?” His view is that “variant chasing” is a flawed approach. “All of this gets back to the vital need for new generation vaccines that are universal, that is variant-proof.” Topol opines, “It’s frankly sickening to watch this virus continue to outrun us, knowing we are so damn capable of getting ahead of it.”
On an optimistic note, Pfizer/BioNTech announced on June 29 that they would start tests on humans of next-generation shots that protect against a wide variety of coronaviruses. If one considers that the development of a successful universal mRNA vaccine against SARS-CoV-2 could be a prelude to development of a universal vaccine targeting another very nasty RNA virus, namely, influenza virus, this would be a colossally exceptional achievement.
If Dr. Topol’s assessment about our scientific capability is correct, it begs the question what about massive investment by the public and private sectors in an international “Manhattan Project”-like approach, similar to the one that resulted in the development of the atomic bomb? One of the key players in such a hypothetical strategy—the National Institutes of Health (NIH)—announced on July1 that they are initiating a clinical trial of a universal flu vaccine in humans. Personally, I believe the NIH is the premier medical research institution in the world, and if provided with exceptional support from the public and private sectors in the U.S. and abroad, they could lead a successful “Universal COVID-19 Vaccine Project.”