For the past three years, the COVID-19 pandemic has demonstrated, and will continue to demonstrate in the future, that America is one of the unhealthiest countries in the industrialized world. Critics on the right and left harp on how the pandemic was handled, but in fact the dismal outcomes in the U.S. do not reflect management of the crisis so much as our underlying health as a country.
With the caveat that the actual figures from China are unknown, in the past three years, the U.S. is the only country in the world that has suffered more than 1 million deaths from COVID-19. The U.S. death total exceeds that of every other country, except Brazil, by more than half a million. Even when normalized for population, the U.S. per capita death rate is just outside the top 10 in the world and rising steadily.
This is not the result of the policies of President Donald Trump or President Joe Biden. Nor does the explanation for the high number of U.S. deaths lie in an abnormally high case total compared with other countries. In terms of confirmed cases per capita, nearly one-third of the countries in the world have more than the U.S., and this just represents diagnosed and reported cases. Most countries, including the U.S., acknowledge that since the extremely contagious omicron variant emerged, between 80% and 90% of their populations have been infected.
This means there is little difference among countries in the fraction of the population that has had COVID-19. At this stage, national policies to control COVID-19 do not yield much distinction in the fraction of the population infected. (This does not mean there were not meaningful differences in national policies, some of which may have caused increases in total excess deaths independent of COVID-19.) Public health researcher Michael Osterholm was prescient early in the pandemic with his description that stopping COVID-19 was like trying to stop the wind.
Could the high U.S. death rate be the result of lax vaccination? A comparably low vaccination rate does account for some of the high U.S. death total, but that is not the primary reason. Vaccination clearly saves lives, and this country lags on current booster acceptance, but the U.S. vaccination rate is still in the top third of world. Moreover, the comparatively high U.S. death rate began in the first year of the pandemic before vaccines were available.
The key reason for the lethal impact of COVID-19 here is the health of the American people. Age is certainly a factor, but Canada has an older population and a per capita death rate less than half that of the U.S.
A much more important set of factors is the twin American demons of obesity and diabetes, which often coexist. This “twindemic” has been the scourge of elderly Americans and accounts for a significant fraction of U.S. COVID-19 deaths.
Now a study from The Journal of the American Medical Association reports that diabetes and obesity are rising among U.S. adults between ages 20 and 44. Because a serious excess of heart disease and strokes is now emerging in COVID-19 patients long after recovery, this means another generation of Americans will be at greater risk of premature death.
One of the study authors, Rishi Wadhera, told The Washington Post in an email, “We’re witnessing a smoldering public health crisis. ... The rising burden of risk factors that we observed among young adults — particularly if these trends continue — could result in a tsunami of cardiovascular disease over the long term, and ultimately, increases in cardiovascular mortality as the U.S. population ages.”
The ramifications of this go beyond the obvious. Another speculative reason the U.S. may be having such bad COVID-19 outcomes is because our immunity to COVID-19 might be less than that of people in other countries. If so, poor immunity in the population could be genetic or a function of less exposure to related viruses. Whether this is true is unknown because our current understanding of immunity is rudimentary and we cannot measure it easily. However, it is now known that obesity impairs the body’s immune response. In addition to the well-known short-term advantages of better cardiovascular health, losing weight may benefit an individual’s immune system years into the future.
This leads to another lesson of the pandemic: We must reexamine our traditional concept of health. In addition to weight, fitness, underlying diseases, smoking, alcohol and drug use, we should add to our health model a history of past COVID-19 infection — because of the potentially devastating long-term effects in a sizable portion of the population — and some measurement of our immunity. Developing a reliable measure for immunity should be a top priority for future immunologists. Imagine the value of quantifying an individual’s immune strength, much as we estimate cardiovascular risk or cancer risk.
Failure to prepare is preparing to fail. Unless we address the elephant in the room — the underlying poor health of the American public — all efforts at planning for the next pandemic, whenever and wherever that occurs, are destined to fall short.
COVID-19 revealed that in times of mass contagion we must do more than simply rely on bureaucratic government emergency management teams and health agencies. Becoming thinner and healthier and laying the groundwork for better immune health will be essential to successful pandemic preparation next time around.
