Coronavirus: How the US death toll came to hit 100,000

United States has lost nearly as many people to Covid-19 as Americans killed in the Vietnam, Korean, Afghanistan and Iraq wars combined, writes Alex Woodward

Gavin Roberts, 10, son of police officer Charles Rob Roberts, looks on during the funeral service of his father, who died of coronavirus weeks after contracting the disease while on duty, in Glen Ridge, New Jersey on May 14, 2020 (TIMOTHY A. CLARY/AFP via Getty Images)

On 29 February, a man in his 50s being treated at a long-term care centre in Washington state was the first person in the US to be confirmed to have died from the coronavirus outbreak that, officials believed at the time, had infected 22 people.

Two months later, health officials in California determined that two other people who died on 6 February — weeks before the Washington patient's death — were also infected with Covid-19, confirming health officials' suspicions that the virus was in the US for weeks earlier than initially believed.

By then, at least 45,000 people in the US had died from coronavirus-related illness, a figure that would more than double in the weeks to follow.

The nation's death toll has reached a horrific milestone with the loss of more than 100,000 lives, an imprecise reflection of the individual loss and devastation that a once invisible threat has wrought in a nation ill prepared for the public health crisis that experts believe will linger for an uncertain future.

Self-described "wartime" president Donald Trump has within three months seen his nation's death toll approach more lives lost than in wars in Korea, Vietnam, Iraq and Afghanistan combined.

Covid-19 deaths in the US have reached nearly as many American lives lost in World War I.

Dr Anthony Fauci, the man leading the White House response, has said he believes the number is "almost certainly" higher.

Critics have condemned the president's delayed, fractured response for its callousness, claiming it is worsened by the political vendettas wrapped within it, while states have developed patchwork plans limited by the strengths of their health systems.

But the delayed federal response to the emergency, which initially focussed on preventing travel from China and Europe, likely allowed for the virus to spread through communities within the US for more than two months before the White House issued its guidelines to prevent the spread of the outbreak.

Though hospitalisations have decreased in some areas, doctors and health workers, once seeing their wards overwhelmed with death, now are beginning to feel the toll of their work as the pace begins to slow while bracing for more work to come.

Covid-19 has upended US life, changing how Americans communicate, shop, worship, work and mourn. Now nearly every state has begun easing restrictions, hoping to return life to a new "normal" after unprecedented unemployment, isolation and frustration, though experts fear the country is still in the beginning stages of the crisis.

A deadly April

April 2020 was one of the deadliest months in US history.

The president has yet to perform any memorials or pay any hospital or family visits, while the logistics and constraints of the disease have made funerals and services impossible.

The World Health Organisation (WHO) declared a pandemic on 11 March, and within three weeks, the number of deaths in the US eclipsed the reported death toll in China, once the epicentre of the outbreak. though questions have been raised about the veracity of numbers announced by Beijing.

By the end of the month, there were more than 1,000 deaths in New York alone.

But the devastating month to follow would see that grim figure multiply more than a dozen times, with the nation's death toll surpassing the number of Americans killed over two decades in conflict in Vietnam.

In that month alone, more than 58,000 Americans died from Covid-19-related illness.

Horrific images of mass death were viewed from afar with a cold frequency — numbers, charts, temporary graves, refrigerated trucks outside hospitals to assist with overflowing morgues, government agencies preparing shipments of thousands of body bags.

More people died in April of coronavirus than any other cause of death in a typical April in other years, overtaking heart disease and cancer.

Healthcare workers wait for patients to be tested at a walk-in Covid-19 testing site on 12 May, 2020, in Arlington, Virginia (OLIVIER DOULIERY/AFP via Getty Images)

Reports began to show that hundreds of young people, initially thought to be safe from more severe illness from Covid-19, were dying. Ventilators, critically needed medical equipment to help patients breathe through their damaged lungs and in short supply in many under-resourced hospitals, weren't saving as many lives as initially believed.

By the end of April, as many as 2,000 people were dying each day. Within a month, another 40,000 people would die from coronavirus-related illness.

The deadliest day in the pandemic was on 1 May, when 2,909 people died of Covid-19 within 24 hours.

The White House response

On 16 March, the president said: "I've always viewed it as very serious."

His statement followed weeks of downplaying Covid-19's impact in the US, revealing a timeline that shows a shifting, inconsistent narrative among White House leadership and the health experts assigned to manage the crisis.

The president was routinely attacked for a shallow emotional response to the virus while deflecting criticism that he had ignored or downplayed the outbreak for weeks by raising conspiracies and touting what he claimed was a successful testing system — and then urging Americans to get back to work.

His administration's death projections ranged from none, to 50,000, to 60,000, to "hopefully" less than 100,000.

On 22 January, the president said "we do have a plan" while in Davos, Switzerland. "We have it under control."

Two days later he praised China for its "efforts and transparency", among several similarly reassuring statements, before he later unleashed a streak of conspiracies alleging the WHO's cover-up of a virus "leak" from a Wuhan lab, echoed by right-wing media and the president's allies on social media and in Washington.

His claims followed a growing number of reports revealing how top brass had dismissed early intelligence reports and other warnings about the virus's impact in the US, later corroborated in an explosive whistleblower report from the former head of an agency tasked with overseeing the development of a vaccine.

But weeks earlier, after celebrating his acquittal in his impeachment in the US Senate, Mr Trump suggested that the virus will get "weaker with warmer weather, then gone".

On 26 February, he announced that within days the number of cases — then at 15 — "is going to be down close to zero". The following day he said it would "disappear" like "a miracle".

February, like January, was largely a "lost month" from the administration, according to Jeremy Konyndyk, an expert in disease outbreak preparedness at the Centre for Global Development.

On 10 March, with a pandemic declaration imminent, Mr Trump told Americans to "stay calm" and said the virus "will go away".

The following day, when 32 deaths were confirmed, he said: "Thirty-two is a lot. Thirty-two is too many. But when you look at the kind of numbers that you're seeing coming out of other countries, it's pretty amazing when you think of it."

It wasn't until the end of March that he warned Americans what was to follow, saying that the US was in for a "hell of a bad two weeks".

He falsely compared the virus to the flu for more than two months before saying, on 31 March, that "it's not the flu. It's vicious."

By then, the Centres for Disease Control and Prevention was no longer the point of contact for updates, instead controlled by the president's coronavirus task force, headed by his vice president Mike Pence, who does not have a public health background.

The US made some relative progress in March, from testing only a few dozens people a day to more than 100,000.

But by April, that dramatic scaling appeared to stall, with an average of 220,000 tests a day.

On 16 April, the president announced guidelines for "Opening Up America Again" — a three-phase set of non-binding rules for states to meet certain criteria before businesses can reopen — states and local governments must have a "downward trajectory" of flu-like illnesses and Covid-19 symptoms or documented coronavirus cases within a two-week period before they can move from the first phase and into the next.

The following day, the president sided with protesters at rallies staged by right-wing groups across the US and called on his supporters to "liberate" three states with Democratic governors with stay-at-home orders in place.

A New York Times analysis found that delays in lockdown measures may have cost the lives of 36,000 people.

On Memorial Day weekend, for the first time since March, he spent two days at his Virginia golf course.

The toll among states

At the start of May, officials in most states were preparing to begin lifting stay-at-home orders and restrictions on businesses and large gatherings by the middle of the month.

By Memorial Day weekend – 23 to 25 May – stay-at-home orders in states throughout the south, Midwest and the Great Plains had expired, nonessential businesses were allowed to reopen, and social distancing measures — what health officials predict will be part of a "new normal" for many months or years to follow — were beginning to loosen.

But it could be weeks before officials determine whether those experiments had accelerated the spread of the virus, effectively erasing any improvements made over weeks of quarantines.

Several states, mostly along the East and West coasts, have kept some of those measures in place, or have slowly eased from their more-stringent lockdowns, after suffering significantly higher death rates than other states.

New York remains the deadliest state in the US, with its nearly 30,000 deaths accounting for roughly 33 per cent of all fatalities in the US as it emerged as a global epicentre for the virus.

Governor Andrew Cuomo imposed its stay-at-home order on 22 March. Its single deadliest day followed two weeks later on 6 April with the deaths of 805 New Yorkers.

Reported deaths in the northeastern US made up two-thirds of the total in the US, with more than 11,000 reported in neighbouring New Jersey and more than 6,000 in Massachusetts.

In Illinois, nearly 4,800 people have died from Covid-19, half in the Chicago area.

But the per capita death rates across the US underscore health disparities among lower-income communities in cash-strapped states without significant health safety nets to respond to the pandemic.

Several parishes in Louisiana were among the deadliest in the US, falling behind New York City with only a fraction of the population.

Nursing homes also were early epicentres of community outbreaks, with nearly 20 per cent of reported deaths among patients living in care facilities.

And though the impact has been felt in nursing care facilities across the US, the racial disparities that emerged from the pandemic are no less apparent in the country's nursing homes, regardless of their location or government rating.

Nursing homes with relatively larger populations of African American and Latino residents were twice as likely to be impacted by the virus than facilities with more white people.

The virus has laid bare the consequences of a historic lack of public health support and institutional deficiencies from decades of under-resourced programmes for the nation's poorest residents.

Coronavirus has killed black Americans at rates far higher than white Americans, according to early demographic results released by several states.

African Americans made up nearly 60 per cent of deaths in Louisiana in April but only 32 per cent of the population.

Deaths of black Americans in Washington DC accounted for 77 per cent of the capital city's toll, but African Americans make up less than half the area's population.

Black Americans are more likely to be hospitalised from coronavirus, according to a Sutter Health study published this month. The findings suggest that black patients are less likely to seek care until their illness has worsened, with a lack of access to care proving to be a massive obstacle in the fight against the virus.

"The Covid-19 pandemic has ripped a Band-Aid off the structural inequities that exist within our society," said Stephen Lockhart, chief medical officer at Sutter Health. "We must address these disparities right away because the cost of not addressing them is measured in human life."

Disparities also significantly disrupt Americans' lives in quarantine.

Less than 30 per cent of Americans were able to work from home, according to the Economic Policy Institute. Among that group, only 16 per cent of Latino workers and less than 20 per cent of black workers are able to telework.

Experts also believe the numbers are undercounting the scale of death.

Nationwide, nearly 64,000 more people died above "normal" rates between mid-March through April than usual – but that figure is still 16,000 higher than the official death toll from that same time period.

The future

Unemployment has skyrocketed. Millions of people have lost their jobs and their employer-provided health insurance. A looming rental and housing crisis could devastate families for years.

Experts say resuming public life is not a matter of returning to life as it once was but adapting to the world as it is now. Scientists are sprinting towards the development of a vaccine, though it's not likely to wipe out the disease but combat it like the flu.

The enormity of loss is overwhelming. Obituaries across the US are beginning to stitch together a picture of the lives lost in the pandemic.

Still, the US death toll falls short of projections shared by the White House, showing nearly 135,000 deaths by August, according to the University of Washington's Institute for Health Metrics and Evaluation.

Without significant federal investments to address the overwhelming "isolation, pain and suffering" among Americans following unprecedented unemployment rates, mandated social isolation and anxiety through the crisis, as many as 75,000 others could die in the years to come, according to a report from mental health policy group Well Being Trust and the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

Without that intervention, "the collective impact of Covid-19 will be even more devastating", the report says.

But at least 370,000 people in the US have recovered from their illness, among countless others who experienced only mild symptoms.

Hospitalisation rates and emergency room visits for coronavirus- and flu-like illnesses are beginning to slow, and nearly every state is finding that less than 10 per cent of people who are tested are positive, according to Deborah Birx, the administration's coronavirus response coordinator.

But what the White House reports as good news dodges reports from several states experiencing shortages and the inability to scale testing capacity for the more than 300 million people living in the US.

Doctors and experts attribute those declines to the weeks of quarantine and stay-at-home measures, which are largely being lifted in nearly every state.

Now rural hospitals, clinging to relief from the first wave, are also bracing for a "second wave" if they're overwhelmed by a surge in new cases.

More than 450 rural hospitals — nearly 25 per cent of all rural hospitals — are vulnerable to closure, according to the Chartis Centre for Rural Health. Since 2016, 41 rural hospitals across the US have closed, mostly in the southeast and Great Plains.

More than 40 per cent of rural hospitals in Florida, Missouri, Mississippi, Tennessee and Texas are considered "vulnerable" to closure.

Cities and densely packed urban areas were among the first hotspots to experience deadly outbreaks. But new cases and deaths are now emerging in more remote parts of the country that were previously off the radar.

A CDC report this month discovered nearly 5,000 coronavirus cases among workers at meat processing plants in at least 19 states, and at least 30,000 people in the nation's prisons – many in isolated areas – have also been identified, according to the Marshall Project, largely because of aggressive testing among a handful of states.

States now are tasked with aggressively scaling up contact tracing and testing, though it's unclear whether they're prepared.

Many states are still outside the "recommended" case range of the president's three-phase reopening plans, but reopenings persist.

By the end of May, nearly two dozen states were reporting a record number of new Covid-19 cases, up from 13 in the month's second to last week, according to a Reuters analysis of data from The Covid Tracking Project.

Cases in Missouri rose 27 per cent from the previous week, and cases in North Carolina rose 26 per cent. New cases in Georgia, one of the first states to reopen, rose 21 per cent after two weeks of declines.

In Alabama, Governor Kay Ivey is lifting bans on entertainment venues, athletic activities and schools and child care — though the Alabama Department of Public Health continues to show increases in seven- and 14-day averages of new cases, with a 28 per cent increase in new cases from the previous week.

Montgomery Mayor Steven Reed has warned that the city's metropolitan area is running out of intensive care beds.

Since the beginning of May, the area has seen a 110 per cent spike in new infections.

"Any time that you can see the cliff is coming you want to warn the people that you're leading that there's a cliff up there," he said during a 21 May press conference. "You don't want to wait until you get right up to it before you tell somebody."