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More than 120,000 Americans have now perished from Covid-19, surpassing the total number of U.S. dead during World War I. Had American leaders taken the decisive, early measures that several other nations took when they had exactly the same information the U.S. did, at exactly the same time in their experience of the novel coronavirus, how many of these Covid-19 deaths could have been prevented?

That isn’t a hypothetical question. And the answer that emerges from a direct comparison of the fatalities in and policies of the U.S. and other countries — South Korea, Australia, Germany, and Singapore — indicates that between 70% and 99% of the Americans who died from this pandemic might have been saved by measures demonstrated by others to have been feasible.

At least three factors enable meaningful comparisons of these nations with the United States. First, we scaled up their population sizes and Covid-19 deaths to match those of the U.S. Second, in each of these countries, roughly 80% or more of the population lives in urbanized, transmission-prone areas, similar to the U.S. Third, the pandemic took root earlier in these other countries than here, as measured by the date of the 15th confirmed case in each, meaning that foreign leaders had to act with less information to guide their decisions than did U.S. leaders.

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To compare each country’s responses to the pandemic on a consistent basis, we turned to the work of an Oxford University team that has constructed a stringency index based on 13 policy responses (lockdowns, border closings, tests, etc.) to measure how strongly each country responded over time. The Oxford index shows that 14 days from the date of the 15th confirmed case in each country — a vital early window for action — the U.S. response to the outbreak lagged behind the others by miles. The U.S. stringency score of 5.7 at that point was 25% of Australia’s (23), 23% of Germany’s (25), 18% of Singapore’s (32), and only 15% of South Korea’s (38).

Due to exponential viral spread, our delay in action was devastating. In the wake of the U.S. response, 117,858 Americans died in the four months following the first 15 confirmed cases. After an equivalent period, Germany suffered only 8,863 casualties. Scaling up the German population of 83.7 million to America’s 331 million, a U.S.-sized Germany would have suffered 35,049 Covid-19 deaths. So if the U.S. had acted as effectively as Germany, 70% of U.S. coronavirus deaths might have been prevented.

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Seventy percent, though, is the most conservative estimate. Scaled-up versions of South Korea, Australia, and Singapore would have experienced 1,758, 1,324, and 1,358 deaths, respectively, in the four months after 15 cases were confirmed in each country. Had we handled the coronavirus as effectively as any of these three countries, roughly 99% of the 117,858 U.S. Covid-19 deaths might have been averted.

 

Country Population (millions) Date of 15th confirmed case Stringency Index two weeks after 15th case Number of deaths, four months after 15th case Deaths scaled up to U.S. population equivalent
Singapore 5.85 2/1 32 24 1,358
Australia 25.5 2/6 23 102 1,324
South Korea 51.2 2/2 38 272 1,758
Germany 83.7 2/12 25 8,863 35,049
United States 331 2/14 5.7 117,858 117,858

Sources: Worldometers, Statista, Oxford Covid-19 Government Response Tracker (accessed 5/20/20).

Our conclusions are strengthened by their consistency with the results from different methodologies. Two notable epidemiological projections, based on theoretical models of transmission and “idealized hypothetical assumptions,” have estimated that between 80% and 90% of American deaths could have been averted had lockdowns and social distancing begun two weeks earlier.

For a more granular perspective, we compared the American response to the actions taken by South Korea. By the time South Korea experienced its 15th confirmed case on Feb. 2, it had spearheaded a massive public information campaign, mobilized private sector players to produce testing kits, and expedited regulatory approval for these newly developed tests. Within a week, tests were widely available. Within three weeks, schools and public spaces were closed, large gatherings had been banned, and 26,000 people had been tested.

In contrast, President Trump consistently ignored confidential and public early warnings from experts and intelligence agencies prior to the 15th confirmed U.S. case on Feb. 14, then acted far more slowly and inconsistently than South Korea. The White House banned flights from China on Feb. 2 but later permitted more than 40,000 travelers from China to enter the U.S. From February through April, President Trump made dismissive and contradictory statements to which government agencies and the public paid close attention.

Often taking cues from the president’s words, state by state measures were rolled out piecemeal. Florida and Georgia, for example, waited until April 3 to issue stay-at-home orders while South Carolina held off until April 7.

Another crucial failure involved testing. Three weeks after the 15th Covid-19 case had been confirmed in the U.S., only about 10,000 tests had been administered. By an equivalent point in its epidemic, South Korea had administered approximately 17 times more tests per capita than the U.S. had done. This testing fiasco crippled vital early contact tracing efforts when hot spots could have been contained.

South Korea’s decisive actions during this critical early window produced a dramatic disparity. By mid-March, each of the two countries had suffered about 90 Covid-19 deaths. But throughout April, while a total of 85 South Koreans died from the disease, an average of more than 85 Americans died per hour. This divergence only widened as time passed.

Although federal, state, and local governments share responsibility for American health policy and implementation, ultimate accountability during a national crisis heavily rests on the occupant of the White House. At a minimum, the president, perhaps through a tough “testing czar,” should have empowered private companies, labs, and hospitals to augment public testing efforts — as South Korean policymakers did — and imported readily available tests from elsewhere if necessary. If there were shortages of testing components, the president should have immediately invoked the Defense Production Act rather than waiting for months to do so for this purpose. And when the CDC and the FDA fumbled early testing efforts, President Trump responded: “I don’t take responsibility at all.”

The administration has advanced innumerable excuses and scapegoats for the vast U.S. death toll: China, the World Health Organization, the Centers for Disease Control and Prevention, former President Barack Obama, the media, and more. Yet other countries with the same information — or alleged misinformation — as the U.S. had at the time took earlier, decisive steps to quell the spread of SARS-CoV-2, the virus that causes Covid-19. Relative to the United States, their actions dramatically cut their death tolls and, on average, South Korea, Australia, Germany, and Singapore are opening up their economies sooner and more safely than the U.S.

Two recent studies published in Nature confirm the “astonishing effectiveness” of the type of government interventions we have discussed, especially when adopted early. Our analysis shows that with the same actions actually taken by other nations large and small, from East and West, the U.S. could have prevented 70% to 99% of its Covid-19 deaths. This has been a needless tragedy.

Isaac Sebenius graduated from Harvard College in May 2020 with a degree in molecular and cellular biology. James K. Sebenius is a professor of business administration at Harvard Business School and director of the Harvard Negotiation Project based at Harvard Law School.

  • We already know that it took whistleblowers in China to get the word out. Prior to that, one Dr. was forced by Police to retract his warnings to the chain of command at hospital. There is also a system for reporting any unusual frequency of symptoms directly to Beijing. The locals in Wuhan were afraid to use it for fear of upsetting the Powers That Be.

    See: https://www.nytimes.com/2020/02/06/world/asia/chinese-doctor-Li-Wenliang-coronavirus.html and
    https://www.nytimes.com/2020/03/29/world/asia/coronavirus-china.html

  • Plenty of data showing lock downs don’t work. The major issue was sending sick patients back to nursing homes. Why isn’t that in your article. No evidence closing schools doesn’t anything either. No asymptomatic transmission. You scaled up the numbers but operationally managing testing and quarantines gets a bit different with larger populations and land size.

  • Steve White, I am asking you on behalf of likely many readers of STAT news to stop dominating responses with your lengthy rants. On certain points I agree with you, others with Dr. Daniel Wirt. Keep it short, get to the point – don’t annoy others. Thank you so much.

  • Steve White, a simple Google search will confirm my identity. While you are on Google you will see the gross, voluminous hostility of Western media directed against China. The bizarre thing is that you want to “punish” China for being an “uncivilized” aggressor (“I feel the need to try to at least civilize this giant which will eventually squash us if we don’t.”) This is the grossest ignorance and hypocrisy. Consider the DOZENS of U.S. regime change coups and wars since the end of WW2. Who has China invaded since the end of WW2? How many military bases does China have outside China (the U.S. has about 800). The U.S. is the aggressive imperialist, not China. The Chinese didn’t invade Iraq (nor has China done something like invading Poland). China wants to trade, hence its “Belt and Road” initiative. Whereas the U.S. wants to impede that in order to maintain its economic hegemony. This has nothing to do with “freedom and democracy”. I have little patience for fools like you. You are not a Chinese citizen. The affairs of China, including its regional interests, are up to Chinese citizens. Yankee stay home and mind your fake democracy of corporate oligarchy (reflected in the “choice” between Trump and Biden). China’s “misconduct”? Tell that to 1.5 million plus dead Iraqis…

    Should China be considering “punishing” the U.S. for its gross imperialism?

  • I agree with your comment about SNFs not being prepared or having enough PPE however the inference about nursing homes taking covid patients doesn’t stand clinically as A significant factor. The CMS reports more about quality of the nursing home (star ratings) and most geriatricians report community spread as an underlying factor. It’s still early on so I’m open to ideas but maybe if you describe more about the patients that resulted in the spread. I say this because many Hospitalized “covid” patients pass their contagious period early on in the hospital course.

  • Did your study take into account the differences in land mass between the USA and the sample of countries you researched? For example, the USA is 13,629 times larger than Singapore (square mileage), and the USA is 28.16 times larger than Germany. If you take these size differences into account, the projected number of Covid-19 deaths in the 4 months following the 15th case changes:

    USA vs. Singapore: (13,629 larger x 24 cases = 327,096 cases est.)

    USA vs. Germany: (28.16 times larger x 8,863 cases = 249,582 cases est.)

    When both Singapore’s and Germany’s number of cases 4 months after the 15th person contracted the virus are projected using each country’s square miles of land mass, both of the above countries show a far greater number of cases. One single death from this fearsome virus is a tragedy, and yet USA data are smaller than the counterparts from 2 other countries in your study when land mass differential is a factor.

    • Greater land masses for the same number of people = fewer people per square mile = LESS spread. The more important number is population density / people per square mile. Adjust your math this way, and the US looks really, really, really bad.

    • I’m trying to better understand Richard T.’s comments below on my argument. Here is my reply, comparing two countries of the study: USA and Germany

      Germany is 134,836 sq. miles and 2019 pop. = 83,020,000
      USA is 3,797,000 sq. miles and 2019 pop. = 328,200, 000

      Germany’s pop. per sq. mile = 615.7
      USA’s pop. per sq. mile = 86.44

      Germany is more population dense than the USA.

      As for the actual Covid cases noted by the authors as of their writing, Germany had 8,863 cases and USA had 117,858 cases.

      Germany’s Covid cases per sq. mile = .066 (8,863 / 134,836)
      USA’s Covid cases per sq. mile = .031 (117,858 / 3,797,000)

      From these numbers, if my observations are correct, Germany is both more population dense than the USA, and had more Covid cases per sq. mile than the USA. These results contradict Richard T.’s comments that the USA looks much worse. How so?

  • The 16th case of Covid-19 in Lombardy was confirmed on Feb. 20. From the link provided, by Feb. 23 the stringency index of Italy was 69. Why are the authors cherrypicking?

  • MichaelDavid Winery was the first business to close its doors in Lodi, well before the CA governor ordered shutdown the following week. Our daughter, a virologist and professor of micro engineering, was influential in this decision. Perhaps a thousand people visit our tasting room on a normal weekend but we’re unable to visit because of the closure. While the loss of sales was not good for our winery or our cafe, we hope that our pro active stance in slowing community transmission had an effect on viral spread. In addition, our new wine, Going Viral (trademarked & made over a year prior) was due to be released. Because we did not want to exploit the tragedy of a worldwide pandemic, every penny of sales from this wine go to COVID19 research in our daughter’s lab. Maybe it would be good for people to know some of the things being done right instead of those that were done wrong. The learning curve of this disease has been exponential, with new research results being released daily in an atmosphere of collaboration and purpose.

    • I have long enjoyed Michael David wines. But lockdowns (quarantining the healthy and shutting down economies) have made no difference in the mortality curves anywhere. But the secondary effects of lockdowns have already cost the lives of tens of thousands — millions of deaths worldwide in the relatively near future.

  • It is so easy to make facts fit whatever story you want to sell – AFTER THE EVENT. So I award Oxford University as well as the Author(s) – ‘non’ points.
    Where were all these so called academics when the Virus was developing? They should have been screaming from the rooftops – BUT I HEARD NOTHING.

    • They were! Columbia, UPenn, Wash U all were since the end of January. Us clinical literally screamed for a national lockdown the last week of February after the models started coming out in community spread.

    • Matthew Dawson, the models have been shown to be complete bulldust — wildly off the mark by at least an order of magnitude. Lockdowns (quarantining the healthy and shutting down economies) have made NO difference anywhere in the mortality curves, but have already cost tens of thousands of lives and are reasonably expected to cost millions of lives worldwide in the near future.

  • Dr. Wirt – I am not sure if you are saying everyone who blames the government of China for bad actions is sociopathically scapegoating them – I hope not.

    I feel sincere and not motivate by politics – and certainly not motivated by a desire to excuse incompetent actions here in the US.

    But you seem very determined to absolve China of it’s very serious failings, I believe worse, in how they dealt with the epidemic.

    It seems pretty much certain doctors in Wuhan knew there was a virus, easily airborne, highly pathogenic, easily spread from human to human, and probably novel, by some time in November 2019.

    At that point in time, the responsible action was clearly to admit there was a danger, broadcast that danger as far and wide as they could – which would absolutely beyond any doubt include sending patient samples around the world, if they had not been able to get the actual virus in vitro by that time – and include warning their own people. And consider a very strict internal quarantine of the effected regions, but at least keep travel down to a minimum.

    Those are the actions of responsible people. One need not know what is going with the new disease to take them – in fact, I believe one can argue that, had the virus made the zoonotic jump in a part of the world with no functioning governement at all – just a doctor working from a tent or grass hut with a radio to call out – the response, vis a vis world health, could have been better than what the Chinese government did – because without a government to STOP them, doctors would have been able to fly in, get samples, and take them back to the CDC, WHO, School of Tropical Diseases, etcetera, and start the research

    I mean that last part in no way to be disrespectful of China which has a lot going on and I assume many great scientists- I am just saying, when the government actually STOPS research, all that great people and facilities do not help so much.

    Anyway, that is speculation but we do know there were plentiful samples available in late November, which should have been shared with virologists around the world. Or do you disagree with that?

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