The Failure of the US to Limit the Spread of Covid-19: A Comparison to What Other Countries Have Been Able to Achieve

A.  Introduction

The virus that causes Covid-19 has struck countries around the world, and it is the same virus everywhere.  But countries have responded differently.  Many countries have responded effectively, and some highly effectively.  The US is not among them.  The experience in other countries shows what would have been possible, had the US responded as they did.  Unfortunately, the US, with Trump leading as president, did not.

B.  The US Compared to Italy, Spain, Germany, and the UK

The chart above shows the daily number of new confirmed cases (on a 7-day moving average basis) since the start of the pandemic through to July 6, for the US plus several of the larger countries of Western Europe:  Italy, Spain, Germany, and the UK.  These countries were chosen in part as they were all hit with the virus that causes Covid-19 earlier than most (including earlier than in the US).  They thus faced a crisis when much was still not known about the virus, including how quickly it could spread and under what conditions, and uncertainty on what should be done to bring it under control.  The underlying data on Covid-19 case totals, from which the figures for the chart were derived, comes from the widely-used data set maintained by Johns Hopkins University.  Population numbers from the UN were used to put the number of cases on comparable terms:  of daily new cases per million residents.

Italy was the first major country in Europe to have been hit by the virus, for reasons still not fully known.  Cases rose quickly, reaching a peak at the end of March.  Spain came next, roughly a week later than Italy at first, but then rose especially quickly to a peak in early April of almost double the peak in Italy.  Germany also had a high number of cases early, but was then more successful through aggressive testing and quarantining to keep the peak from rising as high.  Finally, the UK saw a similar peak to that of Germany, but with that peak then lasting for close to a month.

Each of these European countries was then able to bring their daily new case numbers down sharply, to less than 10 new cases a day per million residents by early July (and indeed by early June for all other than the UK).  Each country had its own policies, and I will not go into the nuances of the country-specific differences here, but they succeeded through a combination of social distancing (including lockdowns), wide use of masks, extensive testing, contact tracing, and then isolation or quarantining of those infected or exposed to someone infected.  And with their success in bringing down the number of Covid-19 cases, these countries are now opening up for business, schools, and travel, and are doing so safely.

The US followed a different path.  Cases rose similarly at first as in these European countries, although with a lag (or about two weeks compared to Italy).  One should be cautious with these early numbers as testing, particularly in the US, was not as complete as was being done later, but the early trends appear to be broadly similar.

But what is important is what happened next.  In contrast to the European countries, who were all able to bring down their case numbers by 90% or more, new daily cases in the US fell much more modestly.  Despite official policies (in much, although not all, of the country) to lock down the economy to limit person-to-person spread of the virus, plus guidelines encouraging (and in some cases mandating, but with lax to no enforcement) the wearing of masks and social distancing, the daily case numbers in the US were reduced only from about 95 per million in early/mid April to a trough in early June that never fell below 60.

US cases then started to shoot up.  This followed the easing of social distancing and other measures to limit the spread of the virus during the month of May.  While there were important differences by state and indeed often by locality, most states started to lift the measures cautiously in early May and much more comprehensively by the end of May (and sometimes completely so by that point).  And as was examined in an earlier post on this blog, the increases in daily cases have been particularly sharp in the states won by Trump in 2016 – states often with governments and a population that have been particularly aggressive in lifting (or increasingly ignoring) those measures.

As a further example of the impact of this politicization of what should be seen as basic public health measures, the number of Covid-19 cases in Tulsa, Oklahoma, have now spiked two weeks after Trump held a large campaign rally in an indoor arena there.  Local health officials have said it is “more than likely” that the two are linked.  Few at the Trump rally wore masks, they were grouped closely together for the cameras, and loud cheering was of course encouraged.  The two week lag from the rally to the spike in Covid-19 cases is about what health experts say one should expect, between when there is exposure to the virus at an event such as this to when confirmed case numbers will rise as results are obtained for people seeking tests following an onset of symptoms.

C.  The US Compared to Europe, Canada, and Sweden

The chart at the top of this post highlights only a few countries.  But the same results hold for Western Europe as a whole as well as for Canada:

Cases in Western Europe as a whole rose early, reached a peak, and then fell.  Since early June cases have remained below 10 per day per million.  As of July 6, they were at 8.3, or less than 6% of the US rate of 149 per day.  The path for the countries of Eastern Europe (the countries from Estonia on the north to Bulgaria on the south, who are now mostly members of the EU) is interesting as they were able to contain the virus throughout, with a peak of less than 14 in early to mid-April.  But a modest increase in recent weeks (to almost 15 currently) warrants watching.

Canada is also interesting as the economy and the population are broadly similar to that of the US, but with very different politics.  Cases rose in Canada to a peak of about 50 in mid-April.  But they were then brought down, to levels now very similar to that of Western Europe.  Again, this is in sharp contrast to the US.

Sweden is an exception to others in Europe.  It is also the one country of the rich Western democracies that explicitly followed a different policy path.  Instead of mandating a lockdown of the economy, the wearing of masks, social distancing, and other such measures, it only issued general guidance.  And even this guidance was eased later.  Daily cases per million then reached about 60 in late April, fell only modestly to about 50 in late May, before increasing significantly to as much as 120 at points in June (although with erratic numbers that probably reflect reporting practices).  Sweden is now taken as a good example of what not to do.  Furthermore, while “protecting the economy” was presented as a rationale for Sweden’s decision to issue only general guidelines, with no requirement for businesses such as restaurants to close, early evidence indicates that the Swedish economy has suffered similarly to those of its neighbors.  There was no economic gain, but a profound human loss in sickness as well as lives.  As I write this (July 9), the accumulated number of deaths per million of population has come to 545 in Sweden, or roughly ten times the totals of 46 in neighboring Norway and 59 in Finland.

D.  The US Compared to East Asia, Australia, and New Zealand

Europe (with the exception of Sweden), as well as Canada, have therefore been far more successful than the US in limiting the spread of the virus that causes Covid-19.  But the countries that have been by far the most successful in containing the virus have been those of East Asia, as well as Australia and New Zealand:

Drawn on the same scale as the other charts, one can barely distinguish their case levels, other than during a few, and still always low, periods (in early March in South Korea and in late March and early April for most of the others).  And the daily case rates in Taiwan were never over 1 per million of population, so one cannot distinguish its curve from the horizontal axis of the chart.  Yet Taiwan has probably closer contact with China, from business relationships as well as personal travel, than any other country in the world other than Hong Kong.

All of these countries reacted quickly as soon as it became clear that an infectious disease had spread in China.  While travel limits were imposed, these limits were complemented by extensive testing and contact tracing, quarantining of all travelers (whether citizens or not), and wide use of masks and other social distancing measures.  None of this was secret.  Nor did it require special expertise.  Others could have responded similarly, but did not.

E.  Countries with a Similar Result as the US

Which, then, are the country cases that are broadly comparable to that of the US?  The closest are Brazil and South Africa, with similarities also in the cases of Russia and Mexico:

These are not countries that the US would normally compare itself to.  One should certainly be cautious and note that the quality of the case number data may not be all that good in some of these countries (and indeed, it is not all that good in the US itself).  But the patterns are probably broadly accurate.

Brazil is the one major country in the world with more confirmed cases (per million of population) than the US.  Its right-wing president, Jair Bolsonaro, has responded to the virus in many ways similar to Trump.  He has consistently downplayed the virus (like Trump), has refused to wear a mask (like Trump), has encouraged rallies to oppose rules on social distancing that some Brazilian states and localities had issued (also like Trump), and has insisted that the disease is not serious but rather “It’s just a little flu or the sniffles”.  And like Trump, he accuses the media of stoking hysteria.

The result is that the number of cases in Brazil per million of population is now the highest of any large country in the world, and indeed second only to the US in absolute total number.  And on July 7, Bolsonaro himself tested positive for the virus.  Again like Trump (who took the drug when he was possibly exposed to the virus), Bolsonaro is now taking doses of hydroxychloroquine as a treatment, even though there is clear evidence that this drug does not help with Covid-19 and may in fact do harm.

Other countries with rising numbers of new cases include South Africa and Mexico.  The daily cases for South Africa now match the US number, with a path since mid-June broadly similar to the US path.  Russia saw an increase in April to mid-May, after which there has been some decrease.  But the daily numbers in Russia remain high.

F.  Conclusion

There is not much here for the US to be proud of.  While countries in Western Europe, as well as Canada, saw sharp increases in cases in much of March and early April, they were then all (with the notable exception of Sweden) able to bring the rates for new cases down to modest levels.  With that success, they are now reopening their economies, are permitting travel (other than, notably, to and from the US), and will be reopening schools.  They are all still cautious, and maintain aggressive efforts at testing, contact tracing, and then quarantining when warranted, but their success in bringing down the daily case numbers means they can, albeit carefully, resume a degree of normalcy.  It is possible that things will take a turn for the worse in the weeks and months ahead.  Until there is an effective vaccine that is broadly available, there will remain conditions in which the virus could pop up and cause major disruptions again.  But the situation in these countries has remained stable there for more than a month now.

Countries in East Asia, as well as Australia and New Zealand, have done far better.  They kept rates low from the start and have thus been able to reopen safely and more quickly.  Indeed, schools in Taiwan never even closed (other than for a two-week extension of the traditional Chinese New Year holiday in February).  But Taiwan then opened schools safely, with students required to wear masks, temperature checks carried out daily of all students, and with plastic shields installed to separate desks from each other.  [Not everyone liked this.  I know from direct personal information that at least a few elementary school age children thought it horribly unfair that they have had to go to school while children around the world were able to stay home.]

So who resembles the US in effectiveness in limiting the spread of the virus that causes Covid-19?:  Among the larger countries of the world, only Brazil and South Africa, and to some extent Mexico and Russia.  In the past, they were not the countries the US would see as comparables.  But they are now.

The Increase in Covid-19 Cases is Real: Hospitalization Has Gone Up in Trump States

Cases of Covid-19 infection are going up in the US.  Indeed, the daily number of new confirmed cases have been hitting record levels, with almost all of the recent increase recorded in states that Trump won in 2016.  But Trump has continued to insist the record highs are only because his administration has done such a great job in making tests finally available.  Health professionals who actually have expertise in such issues dispute this.  And many more people are seeking tests, even waiting in lines in their cars that are miles (and many hours) long.  You don’t do this if it does not look serious.

But while it is true that there would be fewer cases confirmed if we did not know about them due to fewer tests, one statistic this would not affect would be the number of those being sent to a hospital having contracted a severe case of the infection.  Numbers on those hospitalized due to the virus are available for most US states (with Florida an important exception – this will be discussed below).  One then gets the chart above when the hospitalization numbers for those states won by Trump in 2016 are compared to those won by Clinton (as a proxy for the more conservative, mostly Republican, states compared to the more liberal, mostly Democratic, ones).

The chart shows that there has been a marked increase in hospitalizations in the Trump states since about June 15.  Excluding Florida, hospitalizations in the Trump states have grown to almost 20,000 as of June 29 from only about 12,000 in early June, an increase of two-thirds.  In contrast, hospitalizations in the states won by Clinton rose fast early, but then fell.  Little was known early on about the virus and how fast it was spreading in the US, particularly in dense urban locations, in part because of the early blunders of the Trump administration that severely limited testing in February and into most of March.  But from a peak in hospitalizations in mid-April in the states won by Clinton, the numbers have come down steadily, although with some leveling off since mid-June.  They are now well below the number hospitalized in the Trump states.

The data comes from figures assembled by the CovidTracking project, a private initiative launched by The Atlantic Monthly.  The project has assembled, on a daily basis, figures officially reported by US states and territories on Covid-19 tests being conducted (and the positive or negative results), the number of deaths, the numbers hospitalized, those in an ICU and those on ventilators, and more.  The data available, and its quality, are only as good, however, as what the states and territories report.  While the figures on confirmed positive tests and on deaths appear to be of fairly good quality and completeness, what the states report on the other variables is uneven and often incomplete.  One then has to be careful in interpreting the numbers, as figures not reported by certain states (or on certain dates) are left blank and then treated as a zero when the national numbers are aggregated.  The figures on numbers in ICU beds or on ventilators are notably incomplete.  And one should be especially careful with the earlier numbers, as they are often quite partial.  The later numbers are more complete and generally more reliable.

The figures on those hospitalized due to Covid-19 are complete (as I write this) except for four states:  Kansas, Idaho, Hawaii, and notably Florida.  The number of cases in Kansas, Idaho, and especially Hawaii are all relatively small, in part as all three are relatively small states.  Based on a 7-day moving average to smooth out day to day fluctuations, the daily number of new confirmed cases in the three states totaled only 482 as of June 29 (with only 12 in the case of Hawaii, which has done a superb job of containing the virus that causes Covid-19).  In contrast, Florida alone averaged 6,589 cases daily in the 7-day period ending on June 29, or almost 14 times the other three states combined.  Florida matters – the other three states not so much.

But data reporting on the spread of Covid-19 by Florida has been especially poor, and politicized.  Rebekah Jones, the state employee who developed the Florida “dashboard” that presented the Covid-19 results by county was fired in May when she refused to manipulate the data in a way to make it appear that much of the state was meeting the criteria for reopening when in fact they were not.  She has since developed and made available over the internet a dashboard similar to the one she had developed for the State of Florida, but with data that has not been so manipulated.

The underlying problem was that Florida Governor Ron DeSantis (a close ally of Trump) had been declaring victory over the virus that causes Covid-19 already in early May, as he proceeded to reopen the state early and aggressively.  He held news conferences, including at the White House, claiming he had succeeded where others had failed, and that Florida should serve as a model for the country.  Trump lavished praise on the governor, saying he was doing a “spectacular job”.

It is therefore more than a bit embarrassing for DeSantis that cases in Florida have been rising so fast since his May 1 reopening.  For the US as a whole, the average number of daily new cases for the 7-day period ending June 29 was 37% higher than what it was for the period ending on May 1.  But in Florida, the number of daily new cases for the 7-day period ending June 29 was 11.0 times higher than what it was for the 7-day period ending May 1.

With the high number of cases in Florida, it is worthwhile to try to estimate, even if only roughly, what the hospitalization figures would look like if Florida reported its results.  They do have such data – they have reported on the number of new hospitalizations each day.  But this is incompatible with what most other states report.  And knowing the number of those infected with the virus who are currently hospitalized is closely monitored everywhere as it is important to know how close one is to current hospital limits on the ability to handle more cases.  But Florida has not made these figures available.

One can, however, make a rough estimate of what the impact would be if figures for Florida were available.  Other states with a similarly sharp rise in new cases since mid-June include Texas, Arizona, and Georgia.  Hospitalization figures are available for each.  In those states, the ratio of the number currently hospitalized (where one should keep in mind that those hospitalized for Covid-19 are always there for at least several days, and sometimes several weeks), to the 7-day average daily number of new cases, averages across the three states and on two dates to 1.015 (with not much variation around this average).  Using that ratio, one can estimate what the hospitalization figures in Florida might be, given the number of new cases found in Florida.

The result is shown in the curve in orange in the chart above.  The number of patients hospitalized due to the coronavirus in the Trump states would, with this estimate for Florida, have risen to over 26,000 as of June 29.  This is a third higher than the 19,600 hospitalized in the Trump states as of that date excluding Florida.  Or in another comparison, the increase in hospitalizations in the Trump states between June 15 and June 29 was 51% excluding Florida.  But with these estimates for Florida included, the increase over that period was an even higher 78%.

Trump’s reaction to this sharp increase in cases, concentrated in states that supported him in 2016?  It appears that he simply does not know what to do.  So while it has become clear that the increase in cases is real, with the increase in hospitalizations now also confirming this, Trump appears to have retreated into a fantasy world where the virus that causes Covid-19 simply disappears.  In an interview on June 29 on the Trump-friendly Fox Business Network, Trump said:

“I think we’re going to be very good with the coronavirus. I think that at some point that’s going to sort of just disappear”

He then added, “I hope”.  During the worst health crisis the nation has been through since the Spanish Flu pandemic of 1918/19, the US has a president who is lost, does not know what to do, and is reduced to hoping it will just go away.

The Spread of Covid-19: Trump States vs. Clinton States

Update:  A more recent post, with data for these charts through July 16, is now available.

It has been much noted in the news in recent days that confirmed cases of Covid-19 have been soaring in a number of states in the US, primarily in the south and southwest.  But it is of interest to examine how widespread this is, and how it correlates with the politics of the different states.  With the politicization by Trump of what should be a matter of public health, states (and their residents) are responding differently in their management of this public health crisis.

One way to look at this is to group the states according to who won there in 2016:  Trump or Clinton.  This divides the country roughly in half, between more liberal and more conservative areas.  The chart above shows what then results for daily new confirmed cases (on a 7-day moving average).

The division is stark.  The states won by Clinton (which included New York, New Jersey, the Northeast, Illinois, California, and Washington) were exposed early to Covid-19.  These states are generally more highly urbanized and there is more international travel by both residents and visitors.  This left them especially vulnerable as the virus that causes Covid-19 started to spread (first with little knowledge of how fast it was spreading, due to blunders in rolling out the necessary testing program in February and into much of March).  But after peaking in April, these states brought down the daily number of new cases by over 60%, although with a partial and still limited reversal in the past week.

The pattern in the Trump states is quite different.  Confirmed cases rose in the period leading up to April (in part as testing only became broadly available then), but then leveled off in these states through essentially all of April and May.  Furthermore, the numbers leveled off at roughly 10,000 cases a day, or less than half the 21,000 cases per day seen in the Clinton states at their peak.  The Trump states are often more rural, and there is less international travel (by both residents and visitors), so the lower numbers there were taken by some as indicating they were less vulnerable to this infectious disease.

But this then changed markedly at the end of May.  As the states that voted for Trump relaxed their lockdown and social distancing measures, often rapidly, the case numbers began to rise.  And over the last ten days they have accelerated markedly.  The number of confirmed new cases is now significantly higher in the Trump states than they ever were in the Clinton states.  And there is no sign yet of this leveling off.  Quite the contrary – it is accelerating rapidly.

The similar figure for the number of deaths per day from Covid-19:

The number of daily deaths (again using 7-day moving averages) peaked in the Clinton states in mid-April at about 1,670, and has since come down to about 300 (or by 82%).  In the Trump states the peak was only around 600, but it stayed there longer and then came down more slowly, to also around 300 now (so by half).

That the death rates have come down in each is encouraging, but it is still too early to know precisely why.  It may be a combination of factors, including that doctors and hospitals know better now how to treat the most severe cases (with some therapeutics, such as dexamethasone and remdesivir, showing promise, while the doctors also now know that the therapeutic promoted strongly by Trump, hydroxychloroquine, may in fact increase death rates – the FDA has warned against its use).  Also, hospitals have become less crowded at centers of the outbreak, at least until recently, which has allowed them to provide better care.  Finally (and I would guess likely the most important reason, although I have seen no data on this), lower death rates would result if the age distribution of those infected has shifted to those who are younger.  Death rates for the elderly are an order of magnitude higher than for the middle-aged (and two orders of magnitude higher than for the young), so even a relatively modest shift in the age distribution of those infected could lead to a marked change in mortality rates.

Finally, deaths from Covid-19 come only with an average lag that may be a month or more from the day of initial exposure (with this also differing by age).  The number of daily confirmed cases began to rise less than a month ago in the Trump states (around May 30), and more sharply about ten days ago.  We will see in the days and weeks ahead whether this will now lead to a rise in the death figures.  So far, it appears that the daily death numbers have leveled off (since June 17 in the Trump states, and June 21 in the Clinton states), while they had been declining before.

But the sharp increase in the number of new cases over the last month, in particular in the Trump states as social distancing measures were lifted, suggests a number of lessons.  One is that social distancing measures worked.  When they were in place they brought down the number of new cases and deaths from the disease, while lifting them (or increasingly, ignoring them even while formally still in place) has led to a sharp rebound in the number of cases.  Trump has now made this into a political issue, with his flagrant refusal to wear a mask or to keep a distance from others.  In other times this would be considered bizarre behavior in a public health crisis, but is seen here by his supporters as a signal of freedom and independence rather than as a behavior that will lead many of them, as well as others, to become sick (and some to die).

The problem starts at the top.  Rather than model responsible behavior, Trump has insisted he will never wear a mask in public – he believes it hurts his image.  Trump also orchestrated his daily press briefings on the crisis so that through most of March the other officials present were crowded around him, shoulder to shoulder, with no masks.  This only changed (and changed only partially) later.  And now Trump has restarted his political rallies in large indoor arenas, with people crowded tightly together but with few wearing masks, while loud cheering is strongly encouraged.

Most importantly, the Trump administration has failed to address the real and important challenges of this pandemic.  Rather, he has said recently (such as on an interview on June 17 on Fox News) that the coronavirus is “fading away, it’s going to fade away” even if no vaccine is ever developed.  Similarly, at a rally at a megachurch in Phoenix, Arizona, on June 23, to an estimated 3,000 (mostly young) cheering supporters (with few, if any, wearing protective masks), Trump asserted that “It’s going away” while claiming his administration had done a wonderful job.  And over the last week he has repeatedly said that he has asked for less testing to be done, since with less testing there will be fewer cases confirmed.  See, for example, this June 23 tweet, where he says “With smaller [sic] testing we would show fewer cases!”.  Certainly true, but why he would think this wise is worrisome.

Over 124,000 Americans are now dead from the virus (as of today).  This is well more than in any other country in the world (Brazil is second at 55,000).  The US has had 377 deaths per million of population.  In contrast, Japan has had 8 deaths per million, South Korea 6, Australia 4, New Zealand 4, Singapore 4, Hong Kong 0.9, and Taiwan 0.3.  As noted in an earlier post on this blog, the US could learn a lot by simply examining why those countries, all with far closer interactions with China through travel and trade than is the case for the US, have been able to contain the virus while the US has not.

While there are a number of elements to a successful program, one simple but key component is the wearing of masks.  This is common in East Asia, and no one there treats the wearing or not of a mask as a political statement (nor did anyone in the US, until this crisis).  It is simply something easy to do that will protect the health of you, the ones you love, and others.

Yet even now, a full half-year since the start of this crisis, it remains difficult to find in the US the N-95 masks that are the most protective against a viral infection.  Supplies are short, and the masks that are available are provided (as they should be under the circumstances) only to health professionals (although even here there are shortages).  The regular population cannot find such masks other than on a black market (with those available of uncertain pedigree and reliability).  Yet N-95 masks are not hard to make.  3M is the major manufacturer, it is based here in the US, and it would be straightforward to open up additional production lines.  Why hasn’t the Trump administration done something to ensure an adequate supply?

Consider, for example, what a more capable administration might have done.  After ensuring an adequate supply, a box of say a dozen masks per person could be mailed to every household in the US.  With 120 million households (an average of 2.6 people per household), and assuming a production and mailing cost of $20 per household, the total cost would be $2.4 billion.  This is less than one / one-thousandth of the $2.8 trillion that Congress has already approved to be spent to provide partial relief to the effects of the economic crisis brought on by the pandemic.  If everyone then wore such a mask every time they left their home, within a few weeks there would likely be a major knock-back of the infection chain to where focused efforts on the hotspots that might then still remain, or hotspots that later spring up, could be very effective.

This might well be unrealistic.  But even if feasible it would not go far in the current political environment.  Even if an adequate supply of such masks were made available, the politicization by Trump of this public health crisis means that many of his supporters would refuse to wear a mask.  They now see it as a statement of their political, and indeed cultural, beliefs to openly and flagrantly refuse.

As others have noted, it would be hard to find a time when the US was more poorly served by its president than now.

Covid-19: The US Lags Others in the Recovery Thus Far

In those countries where the spread of Covid-19 was not addressed early, all that policy-makers could then do to break its exponential growth was to lockdown the economy.  Schools were closed; non-essential businesses such as theaters, retail establishments, barbershops and hair salons, and similar were also all closed; workers were told to work from home whenever possible; and travel by other than private means was sharply curtailed.

This did succeed in reversing what had been an exponential rise in the spread of the disease, although at a tremendous cost to the economy.  While figures are not yet available on the extent of the downturn, it is clear that this will be the sharpest fall in the US economy since at least the Great Depression.  And the suddenness of the fall is unprecedented.

But as noted, the lockdowns did stabilize the number each day of new cases and of deaths, and started to bring those numbers down.  The disease was still spreading, but not at the pace of before.  There is now pressure from some quarters to lift or even fully end those lockdowns, and that process has indeed already started in much of the US as well as in other countries.  It is still too early, however, to say whether such easing will lead to a resurgence of the disease.  As was seen in January through March, several weeks will go by before one observes whether the number of daily cases will have been affected, and a further two or three weeks before one will see an impact on the daily number of deaths.

One can, however, at this point examine what the impact was of the lockdowns on the spread of the disease.  For the US, those lockdown measures were introduced starting in mid-March and lasted through end-April before they started to be partially lifted in certain jurisdictions.  And one can compare the US record to that of a number of Western European nations who also failed to stop the spread of the virus early, who then had to impose lockdown measures to break the exponential growth and start to bring it down.

The chart at the top of this post shows how the US record compares to that of a number of Western European countries in terms of the number of daily deaths from Covid-19.  It is not good.  The US is an outlier, with significantly less of a decline in the daily number of deaths than what all of these comparator countries have been able to achieve.

The chart tracks, by days from the peak day in the country, the daily deaths from the disease (using 7-day moving averages to even out the day to day fluctuations in the statistics), with the figures for each country indexed to 100 for the number of deaths on its peak day.  The data cover the period through May 17, and were calculated from the cross-country data assembled by Johns Hopkins.

Thus, for the US there were 29 days (as of May 17) since the peak day in the US of April 18, and by that point the number of daily deaths (using 7-day moving averages) was about 65% of what it was on the peak day.  In terms of absolute numbers, the US had 2,202 deaths (in terms of the 7-day average ending on that day) on April 18, and by May 17 (29 days later) the number of deaths had fallen to 1,434 (or 65% of 2,202).

European countries all did better.  By 29 days after their respective peaks, the number of deaths had fallen to 47% of what it had been in the UK, and to just 13% of what it had been in Austria (with Ireland tracking even lower, but only on its day 22).  The other European countries are all in between.  More could have been added.  I had originally included five other Western European countries in the chart, but it was then hopelessly cluttered.  So I removed those five as they were generally smaller countries (Belgium, the Netherlands, Denmark, Finland, and Portugal), plus their curves all fell in between those of Ireland on the low side and the UK on the high side.

Would the record be different if one drew a similar chart for the number of confirmed cases rather than the number of deaths?  Not really:

Here the UK curve tracks more closely to the US curve until day 28 from the respective peaks, but then fell below.  While this is speculation, one wonders if those in the UK started to take the social distancing measures more seriously once their prime minister, Boris Johnson, ended up in the intensive care unit of a hospital due to the disease (where one should keep in mind that the number of cases will then be affected only several weeks later).

Sweden may also be of interest.  In contrast to other countries, Sweden never issued legally binding lockdown orders, but rather just guidelines.  The result, however, was that the number of cases has not come down much from its peak (see the chart).  While still early, the number of daily new cases is close to 90% of what it was at its peak.  This is similar to what it was for the US at the same point in terms of the number of days from the respective peaks.  The UK path was also broadly similar at that point.

There is a difference, however, in terms of how far deaths had come down (the chart at the top of this post).  The path for Sweden has been below that of the US and in the range of other European countries.  From these observations alone one cannot say why Sweden has seen a greater reduction in its daily number of deaths (relative to their respective peaks) despite a similar number of cases as the US (relative to their peaks).  It might be because Sweden enjoys a much better health care system than the US (despite the US spending 60% more than Sweden as a share of GDP).  The age composition of those coming down with the disease might also be a factor, if younger people are, on average, a higher share of those being infected in Sweden than in the US.

But overall, the key question is why has the US performed more poorly than all the others in bringing down the number of deaths?  There are a number of possible reasons, and these reasons are not mutually exclusive – they could all be contributory.  They include:

a)  There was no national lockdown order given, but rather different states issued their orders at different times, mostly between mid-March and the beginning of April.  Indeed, a few, generally less populous, states never even issued formal lockdown orders, but simply guidelines.  This would spread out the impact, leading to less of a fall in the number of deaths relative to the national peak for any given day.

b)  Those lockdown orders varied greatly in terms of their degree of strictness.  Some were strong, and some notably lax.  Furthermore, enforcement was typically lax.  The lockdown orders were usually more serious (and much more seriously enforced) in Europe (but with Sweden as an exception).

c)  Cultural factors undoubtedly also entered.  Some Americans took social distancing measures seriously – others did not.  Indeed, some have been especially loud and insistent on not obeying such orders, in a childish display of contrariness.  They assert they have a constitutional right to do as they please (even if this may infect others with a deadly disease).

But perhaps the most important reason for the poor record of the US has been the failure of responsible presidential leadership.  There has been no coherent, and scientifically informed, national policy.  Trump spent two months denying that the virus was a concern, and the US failed to take the critical early actions which could have stemmed the spread (as the developed countries of East Asia and the Pacific were all able to do, and successfully so).  Then, when he was finally forced to admit the obvious (spurred more by a crashing stock market than by the disease itself), he has only reluctantly backed the measures needed to address the crisis.  And he has personally not modeled the behavior that the federal government’s own guidelines call for:

a)  He refused, and continues to refuse, to wear a mask in public.

b)  He continued to shake hands with those close by (leading to awkward, and amusing, moments when the other party had begun some other action of greeting).

c)  Rather than follow the social distancing guidelines at his highly publicized daily press briefings, for several weeks he had for the cameras a large number of officials and assistants all standing shoulder to shoulder around him.

d)  Most recently, Trump confirmed that he has started to take the controversial drug hydroxychloroquine, despite FDA warnings that to do so was dangerous.  Indeed, a recent study found that a higher share of Covid-19 patients who took the drug ended up dying than did those not given the drug.  Along with some of his other suggestions (such as to examine ingesting bleach or some other disinfectant to kill the virus – which health officials hastened to tell everyone not to do as it could kill them), Trump has conveyed to the public a disrespect for science and instead to do what he believes “in his gut”.

Coupled with Trump’s twitter outbursts (including the early encouragement of small, but well-organized, groups of gun-brandishing demonstrators in several states calling for an immediate lifting of the lockdown measures), it should not be a surprise that the US has been a laggard compared to what other nations have been able to accomplish.

Politicizing this public health crisis, as Trump has, will now also make it more difficult to emerge from it.  Guidelines that had been prepared by the CDC on how to safely reopen the economy, and which would have been issued on May 1, were instead suppressed by the White House.  Trump instead announced (following intensive lobbying by affected industries), that he did not want cautions to continue, but rather that everything should be quickly reopened back to “where it was” three months ago.

With such political pressures superseding the recommendation of health professionals, many will approach any opening even more cautiously than they otherwise would have.  With uncertainty as to whether restaurants, say, were re-opened because it was truly safe or because of political pressures, many will hold off on patronizing them for an extended time.  I certainly will.

Covid-19 by State: The Impact of Urbanization on the Spread

A.  Urban Concentration and Covid-19 Cumulative Deaths as of May 3

The virus that causes Covid-19, like other such viruses, spreads person to person.  Thus one should expect that there will be a more rapid pace of spread in urban areas, where people are in closer day-to-day contact.  This is not an indication of what the ultimate spread might be, as catching an infectious disease is a one-time event and contacts with others still add up over time.  It is just that instead of encountering a certain number of people in one day, it might instead take several days or even weeks.  But greater person-to-person contact increases the likelihood that one will catch the disease earlier.

Thus one should expect that at this point in the middle of the spread of Covid-19, those states that are more highly urbanized will have seen a greater number of deaths from the disease (per unit of population) than states that are more rural.  And that is indeed what one finds, although with some interesting exceptions.

The chart above shows the number of deaths in each US state per million of population, plotted against the percentage share of the urban population in the state.  The share of the state’s population that is defined as residing in an “urban” area comes from the US Census Bureau, which applies a very specific (and uniform) definition of what it labels as urban.  The calculations are based on what the Census Bureau defines as “urbanized areas”.  Under this definition, the urban population is the total population in the state living in an area with a dense urban core, including in the surrounding (suburban) areas meeting certain population density requirements, and with a total population within that area of 50,000 or more.  (Note that the Census Bureau also has a broader concept of what it considers “urban” that includes communities down to a population of 2,500.  Statements on urban populations in states are often based on this broader definition.)

While this is the best one can do in defining what it means to be living in an urban area, note that it is still highly imperfect for the purposes here.  Urban areas differ greatly.  The day-to-day contact one would experience in New York is quite different from what would normally find in a city of 50,000.  Even comparing similarly large cities, it will be quite different between New York and, say, Los Angeles.  Still, it is of interest to see whether states with a higher share of their population living in urbanized areas, as defined by the Census Bureau, have at this point in the spread of Covid-19 experienced a higher fatality rate from the disease.

The chart indicates that in general they have.  The data on the number of deaths from Covid-19 comes from the data set maintained by the New York Times, with the figures as of May 3, 2020 (and downloaded in the afternoon of May 4).  The Census Bureau figures on state total populations and on those living within urbanized areas (of 50,000 or more) are all from the 2010 census.  While these are now ten years old and will be updated once the 2020 census is completed, for the purposes of this exercise they more than suffice.  The relative populations across states will not have changed all that much.

At this point in the pandemic, states with urban population shares of up to almost 60% have uniformly relatively low (as compared to other states) death rates from Covid-19 per million of population, with all at about 100 or less (Mississippi is at 102).  Half the states (25 of the 51 including Washington, DC, as a 51st) fall into this category, with their names on the chart crowded and overlapping.  For those interested, the figures for individual states can be found in a table at the bottom of this post.

The states with urban population shares of just below 60% (Indiana) up to 80% then show more variety.  The fatality rates are very low for some (e.g. Hawaii, at 12.5 per million with an urban share of 71.5%) and substantially higher for others (e.g. Louisiana, at 434 per million and an urban share of 61%).

But the most substantial variation is seen in those states with an urban share of 80% or more.  The fatality rate at this point in the pandemic is just 18 per million in Utah despite an urban share of 81%, while it is close to 1,000 per million in the state of New York with an urban share of 83%.  Several other states in this group also have relatively low fatality rates, including California, Arizona, Nevada, and Florida.  Thus while there is a clear association seen between a higher share of a state’s population living in an urbanized area and the deaths per million from Covid-19, that relationship is not fate.  There are important exceptions.

The broad range in cumulative death rates among the states with the higher urban population shares is a consequence of several factors.  While it is not surprising that a higher urban share appears to make a location more vulnerable to a rapid spread of the virus, it is also clear that it is not inevitable.  There are a number of exceptions.  California, while vulnerable, imposed state-wide lockdown orders relatively early, for example.  The Utah public health system has also functioned particularly well.  And the state totals may be consistent with some very limited evidence (but disputed, and far from certain) that the virus that causes Covid-19 might spread less in warmer and moderately humid environments.  This might in part explain the low rates seen, despite high urbanized shares, in Arizona, California, Florida, and Nevada, as well as in Texas and Hawaii.

At the other end, the areas around New York City (in the states of New York, New Jersey, and Connecticut) saw an early and rapid spread of the virus before many were aware of it.  Based on analysis of the genome, researchers have found that the virus found there had in most cases arrived from Europe rather than directly from China.  Furthermore, they found that it was introduced to the New York area from multiple independent sources (i.e. not from just one traveler) and that it may well have arrived already in January.  There has also been a recent report that the virus had already been introduced into Europe as early as late December.  A recent analysis of a sample of bodily fluids taken from a French man living in the Paris region, who went to a local hospital on December 27 with a case of suspected pneumonia, indicated that he in fact had the virus that causes Covid-19.  He had not traveled abroad.

Thus bad luck can also play a role.  A region with a high degree of urban concentration (such as New York), with frequent travelers to and from a region where the disease had spread but where this was not known at the time (Europe), would be particularly susceptible to a highly infectious viral disease such as Covid-19.

Florida may be a surprising case.  It is a state with a relatively high share (87%) of its population residing in urbanized areas (as defined by the Census Bureau measure).  But its cumulative death rate (as of May 3) is also relatively low.  Florida has been criticized for not shutting down the spring break holidays of mid-March when numerous college students from around the country fly to Florida for parties and more.  But while the impact on cases leading to deaths in Florida itself appears to have been limited, outbreaks of the virus in other parts of the US have been traced to the spring break vacationers in Florida then returning to their homes across the US.

B.  Urban Concentration and the Recent Daily Path of Covid-19 Deaths

The picture outlined above is a static one, as it focused on the rate of fatalities from the disease at a particular point in time (May 3).  It is also of interest to review what the path has been in daily deaths from the disease, particularly over the past several weeks.  The social distancing measures that the states imposed in mid to late-March (with a good deal of variation in both when they were imposed and how strong the measures were) would be expected to have an impact on reducing the pace of the spread, with a lag of a few weeks.  They would then hopefully reduce the number of deaths from the disease a further week or so later.

In this, it is clear that the social distancing measures did succeed in flattening and then bringing down the curve, but with an important difference between the more highly urbanized states and the less urbanized ones:

The fatality rate for the US as a whole has come down since reaching a peak of about 2,000 deaths per day in mid-April (using 7-day moving averages to smooth out day-to-day fluctuations, where the dates shown are for the end of each 7-day period).  The number of deaths then fell to just below 1,800 by May 4, a reduction of 10%.  Based in part on this, the Trump administration is now encouraging states to lift their social distancing measures so that economic activity would, they hope, then recover.

But while the number of fatalities from this disease have begun to fall in the US as a whole, this has been entirely in the more urbanized states.  Between the 7-day periods ending on April 17 and on May 4, the number of fatalities in the highly urbanized states fell by 25%.  During that same period, they rose by 15% in the less urbanized states.

While the daily number of deaths remains at this point higher in the more urbanized states than in the less urbanized ones, this might soon change:

The daily number of new confirmed cases of Covid-19 is now higher in the less urbanized states.  While the measurement of confirmed cases has been suspect (it depends on how broadly one is testing), it is better now than it was in March and even early April, when testing supplies were still limited and constrained the availability of testing.  And the chart suggests that with the number of new confirmed cases now higher in the less urbanized states than in the more urbanized ones, and still heading upwards, the number of deaths from the disease in the less urbanized states may soon be higher in absolute number.

C.  What is the Plan? 

The Trump administration, and especially Trump himself, are now encouraging states to lift their social distancing measures.  The stated aim is for the economy then to recover.  However, with all the disruption that has resulted from the failure of the Trump administration to take this pandemic seriously early on, it is far from clear that this will suffice.  The economy has been severely affected, where an astounding 30 million Americans (18% of the labor force) have already applied for unemployment insurance as of the week of April 25.  Such a sharp and rapid collapse is unprecedented.  It did not happen even in the Great Depression.

The Trump administration has argued that with the daily number of deaths from Covid-19 now falling in the US, the time has come to reopen businesses.  And a number of governors, primarily Republicans in the more rural states, have started to do this, arguing that with their more rural spaces there is no longer a need for such social distancing.  But as seen in the charts above, while the accumulated number of deaths per million from Covid-19 has often (but not always) been less in the less urbanized states, the absolute number of deaths in these states has continued to grow over the last several weeks even while they have gone down significantly in the more urbanized states.  And the number of deaths each day may indeed soon be higher in the less urbanized states than in the more urbanized ones.

But what is the plan to address this?  From all I can see, there is no plan.  The Trump administration has not set out any coherent plan to safely reopen the economy.  Rather, it has simply called for the lifting of social distancing measures while hoping for the best.

Could there be a plan?  Certainly.  As public health experts have called for from the start, and as the developed market economies of East Asia and the Pacific have demonstrated is possible, management of a pandemic requires wide testing of those who appear they may have the disease, isolation if the test proves that they do, tracing the contacts of all those found to have the disease, and then testing and quarantining for about two weeks those contacts who might have been exposed to the virus.

This can be most easily done early in the course of a pandemic, when the number of cases is relatively small.  However, in January (and still through February) Trump insisted that all was fine and under control, and little was done.  Now, with over 27,000 new confirmed cases each day (as of the week ending May 4), this will be far more difficult.  The social distancing measures were implemented to stabilize the situation and then bring this number down to more manageable levels.  But while they succeeded in bringing the total number down from its peak (the daily number of new cases had been over 31,000), it is still far too high.

In addition to bringing down the daily number of new cases to more manageable levels, the social distancing measures were also put in place to give the government time to develop the capacity then to carry out the standard public health measures of testing, isolating, contact tracing, and quarantining.  But while some states appear to be building up that capacity to the extent they can, the evidence for others is scant, and for few, if any, does the capacity appear to be anywhere close to adequate.

And what is certainly missing is any leadership at the top – from Trump and his administration.  States have rather been left largely on their own, with some assistance perhaps at the working levels but without a clear nationally-led program to build the necessary capacity.

The economy of course certainly needs to be reopened, with the social distancing measures loosened and eventually lifted.  The issue is not whether this should be done but instead under what conditions.  Rather than lead a national effort to bring down the number of daily new cases through a coherent and consistent program of social distancing measures (which may well differ between urban and rural areas, but not based on political boundaries), and using the time thus gained to ramp up the public health capacity that is required, the Trump administration has floundered, with a response that has been limited, ineffective, and rudderless.

 

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The data underlying the chart at the top of this post:

Urban population %

Deaths per million

Vermont

17.4%

84.7

Wyoming

24.5%

12.4

Maine

26.2%

42.9

Montana

26.5%

16.2

Mississippi

27.6%

102.1

South Dakota

29.9%

25.8

West Virginia

33.2%

27.0

Arkansas

39.5%

26.1

North Dakota

40.0%

37.2

Kentucky

41.0%

58.8

Iowa

41.7%

60.4

Alaska

44.5%

9.9

Oklahoma

45.8%

63.4

New Hampshire

47.3%

65.3

Alabama

48.7%

60.7

Kansas

50.2%

49.8

Idaho

50.5%

40.8

New Mexico

53.8%

73.3

Nebraska

53.8%

42.7

Tennessee

54.4%

34.7

North Carolina

54.9%

45.7

South Carolina

55.8%

59.5

Wisconsin

55.8%

59.6

Missouri

56.6%

63.1

Minnesota

58.0%

79.0

Indiana

59.2%

174.6

Louisiana

61.3%

434.3

Oregon

62.5%

28.5

Ohio

65.3%

90.0

Georgia

65.4%

120.6

Michigan

66.4%

409.7

Delaware

68.7%

197.1

Virginia

69.8%

82.5

Pennsylvania

70.7%

223.8

Hawaii

71.5%

12.5

Washington

75.0%

124.9

Texas

75.4%

35.4

Colorado

76.9%

167.0

Illinois

80.0%

205.1

Arizona

80.1%

56.6

Utah

81.2%

18.1

New York

82.7%

990.2

Maryland

83.5%

204.7

Connecticut

84.8%

681.6

Nevada

86.5%

97.0

Florida

87.4%

73.3

California

89.7%

60.0

Massachusetts

90.3%

611.5

Rhode Island

90.5%

304.0

New Jersey

92.2%

895.3

District of Columbia

100.0%

417.1