How Many COVID-19 Deaths Could Have Been Avoided? More Than 150,000

Ruth Etzioni, PhD, Full Member, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center

For a numbers person like myself, the SARS-CoV-2 pandemic is supremely frustrating. Even after 8 months, there are so many numbers that we still do not know.  Even though there are thousands of researchers trying to fill in the gaps in our knowledge, the gaps persist.

As the officially recorded US death toll from SARS-CoV2 approached 200,000 last month (it’s now over 224,000), one missing number in particular began to disturb me. While I agreed with the many voices blaming the abysmal national response for the grim death count, I knew that even if we had responded optimally, the number of COVID-related deaths would not have been zero.

But how many deaths might we have expected had we responded quickly with sufficient testing, effective contact tracing and compliance with masking and social distancing?

I couldn’t find any published guesses. So I did it myself (with some help, acknowledged below).

I took as my model the country of Germany. It is frequently cited as having “crushed the curve” in March and April, because of a combination of rigorous contact tracing, quarantining, and near universal compliance with local and national lockdowns. In fact, Germany managed to keep cases and deaths ultralow through the summer.

But COVID-19 is a virus that tends to resist tidy narratives and easy explanations. Like much of Europe, despite its early accomplishments, Germany, too, is coping with a new spike in COVID-19 cases. On Sept. 22, when the official US death toll surpassed 200,000, Germany was still in good shape, recording new cases at levels only slightly higher than its summer nadir.

I asked the following question: If the US had been as successful as Germany in managing the virus, how many deaths would we have expected by September 22? By “as successful as Germany.” I meant, “if the likelihood of COVID-19 death in the US were the same as in Germany.”

It is not enough to simply translate the COVID-19 death rate per capita in Germany into a number of US deaths, because the age and demographic structures of the two countries are quite different. The vast majority of Germans are of European ethnicity. In the US, 18 percent of the population is Hispanic or Latino and 13 percent are African American. And the German population skews slightly older.

To accommodate the demographic differences between the two countries I used age-specific cumulative death rates in Germany from the Robert Koch Institute as my baseline for non-Hispanic whites. But African American and Hispanic/Latino populations in the US have had markedly higher COVID-19 mortality rates than non-Hispanic whites. Even if the US had responded properly to the pandemic, I do not expect that it would also have solved its persistent problem of racial disparities in underlying health, which makes minority populations especially vulnerable to a pandemic.

So, for these minority populations I inflated the Germany-based death rate using race-specific death rate ratios (relative to non-Hispanic whites) from the CDC. Putting this all together, I (and my co-authors) concluded that, had we been as successful as Germany at managing the virus, the US would have had 43,187 deaths rather than the recorded cumulative total of 200,000 on Sept. 22. You can read the abstract and full manuscript here at MedRxiv.

I stared for a while at this shocking result. It was much worse than anticipated. These findings suggested that almost 80% of the 200,000 lives lost – 160,000 people! – could perhaps have been saved by a response that met the gravity of the threat, a response that went all out to break the chain of community spread in order to protect American lives. Even though my result was just an approximation, I felt like it was an important data point. I wanted to publish it right away. But I knew better.

I have seen over and over again how science has been politicized during the pandemic. I wrote in these pages about inappropriate, politically motivated interpretations of the changing IHME COVID-19 model projections, and the appropriation of the Mayo Clinic convalescent plasma study for political expediency. I knew that my result could be used to support a variety of political stories.  Mostly I was concerned that it would be dismissed by Administration supporters because of its limitations, chief among them being that the US is not Germany.

So I tried to make it politicization proof. I went through all of the relevant differences that I could think of between the two countries and explained why my result was still defensible. Yes, there are cultural differences, and greater trust in the government in Germany. Yes, Americans are more likely to be obese. And yes, it is possible and even likely that what counts as a COVID death in Germany is not the same as in the US. I re-classified my work as a “thought experiment designed to provide a first quantification of a best-case scenario in this country.” I still thought it deserved to be published.

Unfortunately, the journals that I submitted it to did not agree.  I quickly received two flat-out rejections from journals that are known for publishing commentaries on the state of public health in this country.

Was the work simply too hot to handle? Were my methods at fault? Were the limitations deal breakers?  Did the editors disagree with my message?

I’ll never know. But at least my science has been validated. This weekend CNN published an article titled: “Faulty US COVID-19 response meant 130,000 to 210,000 avoidable deaths, report finds.”

Finally! I breathlessly followed the link and arrived at a report from a very reputable group of researchers at Columbia University. They had exactly the same idea as I had, but they looked not only at Germany but also at South Korea, Japan, Australia, Canada, and France.

By the time they posted their report, the US death toll stood at 217,000. The report concluded that “had the U.S. government implemented an “averaged” approach that mirrored these countries, the U.S. might have limited fatalities to between 38,000 to 85,000 lives – suggesting that a minimum of 130,000 COVID-19 deaths might have been avoidable given alternate policies, implementation, and leadership.”

In academia, there is a term for when someone publishes your idea before you have a chance to do so. It’s called getting “scooped.” Normally, it’s painful. But this time I am not at all perturbed. I’m delighted that others agree that this information is urgently needed and that they are equally determined to unearth and disseminate it.

We have a number for the human cost of our disastrous national response to COVID-19.

Now we just need to make sure everyone knows it.

Thanks to my co-authors on the article, Ivor S Douglas MD and Elan Markowiz, future PhD.

You may also like

It Ain’t Over Til It’s Over
SARS-CoV-2: Where Did It Come From and Where Does It Go Next?
Making Clinical Trials More Diverse: Michele Andrasik on The Long Run
When Does COVID Normalcy Begin?