[American flags fly at half-staff to mark one million deaths from the coronavirus on the National Mall in Washington, on 12 May. Photograph: Jim Lo Scalzo/EPA]

More than one million people have died in the Covid-19 pandemic in the US, according to Johns Hopkins, far and away the most deaths of any country.

While the sheer number of deaths from the coronavirus sets the US apart, the country’s large population of 332.5 million people does not explain the staggering mortality rate, which is among the highest in the world.

For every 100,000 residents, 291 people have died from Covid-19, according to the Johns Hopkins University Coronavirus Resource Center. Among the 20 worst affected nations, only two other countries – Brazil and Poland – have higher mortality rates per 100,000 people.

Deaths directly attributable to Covid-19 are only one measure of the pandemic’s toll. Deaths from drug overdoses hit a record high in 2021, killing at least 100,000 Americans. Chronic conditions such as heart disease, hypertension and dementia have contributed to the number of “excess deaths” – a number which includes other ailments exacerbated by the pandemic, as well as those deaths caused directly by Covid-19. This number crossed the one million threshold in mid-February.

The extraordinary toll has set the US apart among wealthy, peer nations, exposing inequality, a unique and fragmented health system, and polarized politics – all of which likely made the crisis worse, researchers said.

“In terms of understanding why we had such a bad experience from the pandemic, we have to think about the systemic issues that already were in place when the pandemic arrived,” said Steven Woolf, a social epidemiologist and population health researcher at Virginia Commonwealth University. “And, on top of that, mishandling of the pandemic by the government and by the public, frankly.”

The pandemic shone a light on longstanding racial and ethnic health disparities, as Black, Latino and Native American people were infected, hospitalized and died of Covid-19 at rates that were, at times, double those of white Americans.

The drivers of those outcomes – the disproportionate likelihood for people of color to lack the same quality housing, employment and healthcare access as white Americans – are well known and documented. Such disparities are the “intended or unintended consequences of policy decisions”, a recent commentary in the Journal of the American Medical Association said.

The US has nonetheless had difficulty correcting course. Vaccines were at first slow to reach minority, low-income and rural areas. One recent study has shown how at least one advanced Covid-19 therapy, monoclonal antibodies, were the least likely to reach the highest risk patients for whom they are recommended.

“It just exacerbated the struggles we currently have and pulled back the curtain on all the issues we’ve been dealing with for so many years,” said Terrence Shirley, CEO of the Community Health Center Association of Mississippi. Community health centers help treat indigent and marginalized Americans who cannot pay for healthcare.

The all-consuming nature of the pandemic has also allowed preventable and treatable infectious diseases to flourish. Thousands of young children, particularly in low-income households, have fallen behind on routine vaccinations. Rates of sexually transmitted diseases have reached the “highest numbers in American history”, as overwhelmed and underfunded local health agencies reallocated resources to Covid-19.

Meanwhile, the mental health of adolescents in particular has suffered, as millions were cut off from the mental health services provided by schools. Pediatricians, children’s hospitals and psychiatrists declared a mental health crisis among the nation’s youth, and a recent CDC study has shown how emergency room visits for eating disorders has increased dramatically among adolescent girls.

Millions of children were also thrust into food insecurity, as the numbers of children receiving school meals plummeted. Missed academic time appears to have caused the educational achievement gap to widen.

“The US has been experiencing worse health outcomes for some years now. Life expectancy in the US is the lowest of any high income country,” said Woolf. “There’s a set of reasons for it, but all of those rolled right into the pandemic.”

However, America’s reliance on an expensive, private and exclusionary health system is not solely to blame. Although policies that exclude 28 million uninsured individuals from healthcare have likely made things worse, they are only one example of how fragmented policy has worsened Americans’ health.

Concepts fundamental to US governance also proved problematic in the pandemic. In just one example, the US Constitution makes public health the responsibility of individual states, creating a patchwork of different pandemic responses.

Culture and environment also appear played a role. Americans are more likely than citizens of other countries to engage in what public health researchers consider risky behavior, such as gun ownership, smoking, consuming more calories and exercising less. Polarized politics make it more difficult to implement guardrails on these behaviors.

Floundering responses by federal, state and local governments compounded existing issues, and eventually allowed pandemic-related public health guidance to become political and cultural footballs.

Less than two-thirds of Republicans have received at least one dose of the Covid-19 vaccine, compared with 91% of Democrats, according to the Kaiser Family Foundation’s January 2022 vaccine tracking poll. The only thing both parties appear to agree on, according to the same poll, is how the pandemic has exhausted them.

That has led to another riddle – as more and more pandemic prevention measures are dropped, Americans will be faced with how to live with a disease that can be chronic and disabling, even if it isn’t as deadly.

“Death is not the only serious outcome from Covid,” said David Putrino, the Director of Rehabilitation Innovation for Mount Sinai Health System. Putrino has seen thousands of cases of so-called “long Covid”, where many varied and at times severe symptoms persist for months. A recent analysis by the Center for American Progress found the syndrome resulted in an estimated 1.2 million more disabled people in 2021.

“We are addressing the acute illness,” said Shirley, “and not resolving the issues that could prevent the illness in the first place”.

Jessica Glenza
@JessicaGlenza