On 27 March 2020 I wrote a piece entitled “The USA and China...why we are watching both.” (Click here to read that piece.)
Both then, and in subsequent updates to the piece, reference was repeatedly made to the fact that the US was lifting its lockdowns early against the advice of its own medical advisors who were warning the pandemic had not yet peaked in the country. Despite the fact no other country had eased lockdown at the same stage of their outbreaks, intense pressure to do so came from both the politicians and the public. (1)
Three months later the USA has recorded nearly 3 million confirmed cases and just under 131,000 deaths from COVID-19 across the country. The US accounts for 4% of the world’s population but has recorded 25% of both the world’s cases and deaths from COVID-19.
(2) (3)
As the third largest country in the world by population (with China first and India second) one would expect the USA to have more cases than much smaller countries. However, compared to China and India, it is still faring badly with four times as many cases as India and 32 times as many as China.
It may be unfair to draw comparisons with these two countries as India does not yet have the same level of testing capacity as the USA and scientists across the world are sceptical about China’s figures and suspect the official numbers released by Beijing do not reflect the true numbers of either cases or deaths. (4)
A more accurate way to compare countries is by looking at their cases and deaths per 1 million of the population. Even this can be fraught with difficulties, as I discussed here, because different countries report COVID-19 deaths in different ways. However case numbers are reported on the basis of a positive COVID-19 swab test so this allows for more consistent reporting across nations.
Adjusting for population size the USA has more cases per 1 million people than Italy, Spain, the UK, France, Russia or any South American country except Chile.
Comparing the USA specifically with the UK (my own country) and Italy (the first country to be affected in Europe) reveals the following rankings out of 215 countries and territories affected by the pandemic:
Cases per one million of the population:
USA - 8,250 cases per 1m population 12th position
UK - 4,606 cases per 1m population 28th position
Italy - 3,979 cases per 1m population 33rd position
Deaths per one million of the population:
USA - 393 per 1 million population 9th position
UK - 644 per 1m population 4th position
Italy - 575 per 1m population 6th position
(It should be noted that the top four places in this ranking system include the Vatican City, San Marino and Andorra whose tiny populations disproportionately skew their figures when extrapolated up to 1 million people.) (5) (6)
Adjusting for population sizes it can be seen that the USA has double the number of total cases compared to either the UK or Italy but fewer deaths. However, both Italy and the UK are past the peak of their pandemics and both their case and death numbers are falling. In the USA they are rising. (7)
The Initial Predictions
On 1 April 2020, health experts in the USA predicted the peak of their pandemic would be around 15 April 2020 with an estimated 2,214 deaths on that date. They advised that if lockdown was imposed there would be between 100,000 - 240,000 total deaths from COVID-19. Without lockdown restrictions they estimated between 1.5 and 2.2 million deaths. (8)
On 9 April 2020 Dr Fauci, the director of the National Institute of Allergy and Infectious Diseases (NIAID) and one of the lead members of the Trump Administration's White House Coronavirus Task Force, revised that estimate announcing that the final death toll "looks more like 60,000 than the 100,000 to 200,000 that U.S. officials previously estimated” (9)
On 5 May 2020 this was revised again to 134,475 predicted deaths by researchers at the Institute for Health Metrics and Evaluation (IHME). (7)
The Reality
On 15 April 2020 there were 2,690 deaths from COVID-19, only a little over the projected 2,214. However, this date has proved to not be the peak of the pandemic in the USA.
Total deaths from COVID-19 on 2 July 2020 are 130,813.
The average number of new cases per day is over 45,000 and rising. (10)
Dr Fauci now fears the daily case rate will soon reach 100,000 and has said he can no longer predict a death tally but gave the stark warning, “It is going to be very disturbing, I guarantee you that.” (11)
What is the current situation in the USA?
Given the size of the USA trying to present one set of figures that represent the entire country is impossible. It would be similar to combining the data of every country in Europe into a set of single figures and claiming that one set reflects each individual country.
Although the overall number of daily cases in the USA is increasing rapidly the biggest increases are seen mostly in the southern and western states. Cases in New York and many eastern and central states are declining and these states are not seeing an upsurge in new cases. (12)
The highly devolved administrative system in the USA means individual states, and even counties and cities within them, have been able to set their own lockdown requirements.
The states that implemented lockdown late and lifted it early are seeing their case numbers soar. In particular Texas, Arizona, California and Florida are now recording more new cases each day than they had in total before they locked down. (13)
In Texas, lockdown began on 1 April 2020 and was eased from 30 April 2020. Even businesses where social distancing is not possible, such as beauticians and tattoo artists, were allowed to reopen despite the fact daily case numbers were rising with a daily average of around 1000 new cases per day. The state is now seeing between 7,000 and 8,000 new cases per day. As a result the state governor has re-closed bars and restaurants but at the time of writing all other businesses remain open. (14)
Arizona went into lockdown on 31 March 2020 when it was recording around 100 new cases per day. It began to ease lockdown on 16 May 2020 when the average daily number of new cases had risen to 500. This has climbed to just under 5,000 per day and the state governor has re-imposed many restrictions including closing bars, restaurants, gyms and cinemas. (15)
California went into lockdown on 19 March 2020 when it was recording under 200 new cases per day. It began reopening on 8 May 2020 despite averaging 2,000 new cases daily. As of 1 July 2020 it is recording just under 8,000 new cases daily. Other than bar and restaurant closures in some counties, the state remains open although Los Angeles has announced that its beaches will be closed over the Independence Day weekend of 4th July. (16)
Florida remained officially restriction free until April 3rd by which time there had been over 7000 cases although some individual counties within Florida were closing public places sooner. The state now has 158,997 cases as of 2 July 2020 and is averaging 8,000 new cases each day, more per day than the total of 7,000 when they instigated lockdown. Despite this Florida is in the process of reopening its theme parks with its governor announcing he will not stop this or re-impose lockdown in Florida other than restricting alcohol sales in bars and restaurants. (17) (18) (19)
Ten other states have paused their re-openings but many more remain fully open despite climbing case numbers. New York which along with the eastern seaboard states of Massachusetts and New Jersey bore the brunt of the outbreak when it first began in the US are yet to relax many of their lockdown measures and many public facilities such as cinemas, restaurants and gyms remain closed. Case numbers in these states continue to fall in a pattern similar to that seen in Europe. (20) (21) (22)
Why is the USA being so badly hit?
Lockdown
Lockdown was one of the few tools the world could implement quickly as COVID-19 quickly spread. With no known cure or vaccine available, stopping the spread of the virus was the first priority and that could only be achieved by reducing the opportunities the virus had in which to spread. Countries that imposed strict, nationwide lockdowns appear to have blunted the spread of the virus.
Lockdown across the USA has been incredibly variable not just state to state but with wide variations between counties and cities within each state.
Those states that instituted lockdowns similar to those in Europe, and are only easing them cautiously, are not seeing the surge in new cases other states are.
The states that are now seeing their numbers spiralling higher and higher have in common that they all began to come out of lockdown when their case numbers were still increasing.
Although there have been anti-lockdown demonstrations in many countries around the world those in the US appeared to have the support of the president when he encouraged people to “liberate their states” in mid-April. This perhaps added to the pressure on state officials to reopen their states sooner rather than later. (23) (24)
Does testing more mean there are more cases?
President Trump has claimed that the main reason the US has more cases is because it is leading the world in testing capacity. In theory a country that can test more people might be expected to record more cases but if the number of positive tests is increasing the simple fact is the virus is spreading. If it wasn’t then increased testing would return a great many negative results. (25)
The claim that the US is testing more than anywhere else is not borne out by the data. If the number of tests carried out per million people is studied, the US is in 27th position behind 26 other countries. The UK is 15th and Italy 31st. (26)
The UK has carried out around 10m swab tests, the US 35m tests, over three times more. If both countries had the same underlying level of infection then the US should identify around three times as many cases as the UK. The US has nearly nine times more cases than the UK (2,751,119 versus 313,483). (27)
Age
As the pandemic has advanced across the globe more young people are being infected and this has particularly been the case in a handful of countries including the US, Israel and Portugal. This trend has been most marked in the US as noted by the WHO (World Health Organisation) and within the US this has been most apparent in Florida, Texas and Arizona. (28)
Seen more as a disease of older people experts fear that younger people view themselves as relatively immune to it and have been quicker to flout lockdown rules and take any advantage of any minor relaxation of restrictions.
Cases in the US rose quickly when bars, shops and restaurants reopened. In Florida, 31% of new cases are in the 15 to 34 year age group and the average age of a COVID-19 patient is now under 35.
Likewise in Arizona more than half of all cases are now in those under the age of 45.
Although younger people have a better outlook from COVID-19 infection it is important to remember two things. Some young people do still become critically ill and can die from COVID-19. They may also transmit the infection to their more vulnerable relatives and friends who are far more likely to die. (29)
Florian Krammer, a professor of microbiology at Icahn School of Medicine in New York, examined data from Iran and saw that a second peak in the country began amongst younger people. Three to four weeks later there was an increase in infections and deaths amongst the older population. (30)
Politics
This is a scientific blog centred round COVID-19 and not a political space. However, the overlap between politics and the pandemic in the US cannot be ignored.
Heading towards a bid for re-election in the Autumn President Trump is keen to be seen as giving the people what they want. His seeming reluctance to wear a face mask has become an area of political debate as the Senate committee chair, the Republican Lamar Alexander, summarised when he said, “This small, life-saving practice has become part of the political debate that says, if you are for Trump you don’t wear a mask and if you are against Trump you do.” (31)
Mask wearing has been discussed here on the blog and it is fair to say scientists do not fully agree with each other on their role in preventing infection spread. However it is a debate that needs to be decided by science and not politics.
The virus does not discriminate between one country and another, one political party and another but this simple fact is in danger of being forgotten as leaders and politicians the world over jostle with each other over how and where the virus started and who has dealt with it the most effectively.
In Conclusion
The recent developments in the US are alarming.
Even when adjusting for population sizes it is currently the worst affected country in the world and the data suggests it has not yet seen the peak of its pandemic although there is huge variation between states.
The best measure to try and put a brake on the spiralling numbers would be to re-impose a strict lockdown akin to those seen in Europe. With no political will or public appetite to do so it is likely the US will retain its unenviable position at the top of the global COVID-19 data board.
(4) https://www.news-medical.net/news/20200608/Cremation-numbers-reveal-possible-suppression-of-true-COVID-19-data-in-China.aspx
(11) https://www.theguardian.com/world/2020/jun/30/coronavirus-fauci-senate-states-reverse-reopening
(23) https://www.vox.com/2020/5/20/21263919/anti-lockdown-protests-coronavirus-germany-brazil-uk-chile
