The Washington PostDemocracy Dies in Darkness

The Health 202: Here's how the U.S. compares to other countries on the coronavirus pandemic

with Paige Winfield Cunningham

An October 2019 report by the Johns Hopkins Center for Global Health Security and the Nuclear Threat Initiative concluded the United States was the country best prepared to handle a pandemic.

A year and a half later, the reality looks far different.

The United States has suffered nearly one-fifth of the world’s covid-19 deaths, according to Hopkins’s own data, even as it accounts for just over 4 percent of the world’s population. Twenty-three percent of the world’s recorded coronavirus cases have occurred among Americans.

“In my book, I think of the U.S. as having the worst outcomes,” said Jennifer Nuzzo, a Johns Hopkins epidemiologist who co-led the pandemic preparedness index, which she said was meant to measure capacity, and not as a predictive tool. “It’s just the size of our epidemic and the fact that it didn’t have to be this way.”

Yet the United States is hardly the only country to struggle to tamp down the virus.

Many of its peers in Western Europe and its neighbors in the Americas have also failed to control the virus. Every country in the European Union save Cyprus and Finland, and the majority of countries in the Americas, are above the global rate of recorded deaths.

Many countries today have much higher daily new cases per capita than the United States, where around 21 new cases are being diagnosed every day for every 100,000 people.

And, the United States is surpassing most countries in the speed at which it’s vaccinating people. Four months after the first coronavirus vaccine was given emergency use authorization by the Food and Drug Administration, more than a third of Americans have received their first shot and 22 percent have been fully immunized.

The pandemic isn’t over, but it’s not too soon to reflect on how the United States has fared.

More than a year into the pandemic, here’s a look at how the country handled it compared with other nations:

The U.S. ranks 13th in the world in coronavirus deaths per capita.

Only the Czech Republic, Hungary, Belgium, Bulgaria, the United Kingdom, Slovakia and Italy — along with a handful of tiny countries — had higher death rates.

Out of every 100,000 Americans, 172 have died of the coronavirus. In the European Union, that rate is 143 per 100,000, and in South America, it is 139. The global average among the 177 countries that Hopkins publishes data on is 38.

If the United States had the same average rate as the European Union, then 91,031 deaths would have been prevented; if it had the same rate as South America, that number would be 107,126. And if it were able to match the mortality rate of its northern neighbor, Canada, 358,583 deaths would have been prevented, according to calculations based on data from Johns Hopkins and the World Bank.

On the number of recorded coronavirus cases, the United States ranks near the top.

It has recorded more than 31 million coronavirus cases — a rate of more than 9,000 cases per 100,000 people. That’s higher than Italy or the United Kingdom, which both have more than 6,000 cases per 100,000 people. In Japan, the rate is 400. 

Only a handful of smaller countries have a higher rate of recorded cases per capita compared with the United States.

Yet that's partly because the U.S. did so much testing.

Some countries may have missed many cases because of a lack of testing. But the U.S. has one of the higher per capita testing rates in the world, conducting more than 410 million tests — a rate of 1.26 tests for every person who lives in the country, according to the data aggregator Worldometer

That is behind the rate of testing in the United Kingdom, Singapore and Denmark but ahead of most countries, including Canada, Germany and Australia. 

Still, the testing rate per capita is an imperfect measurement because countries that were able to control their pandemics early on have less need for widespread testing. Some rapid, antigen tests that take place outside of labs may also go unrecorded.

The U.S. doesn't look so great on its testing positivity rate.

The percentage of tests that turn out to be positive is a key metric, because it indicates how a country's testing numbers compare to the size of its epidemic.

For example, a low percentage indicates a country is casting a wide testing net and likely picking up many of the cases. A high percentage indicates many cases are likely being missed.

From that perspective, the U.S. looks less successful, with about 10 percent of its recent reported tests coming back positive. That’s better than neighboring Mexico, which sees more than a quarter of its cases come back positive, but worse than dozens of other countries and significantly above the World Health Organization’s recommendation of a positivity rate below 5 percent. 

The U.S. has a middling case fatality rate.

In the U.S., 1.8 percent of documented coronavirus infections result in death — giving it the 78th highest case fatality rate in the world. That puts the nation around the middle of the pack globally and better than some comparable countries, such as the United Kingdom and Germany, which both have higher rates.

The high quality of U.S. hospitals may play a role in driving down fatalities. But again, these comparisons can also be hard to make because they depend on how widespread testing for the virus is. A country that tests more mild cases will appear to a have a lower case fatality rate than a country that only tests severe cases.

The United States is ranked seventh in the world on vaccine doses per 100 people.

Some of the countries with the fastest vaccination rates are relatively small and have fewer people to vaccinate. Among the countries that beat out the United States in the pace of vaccine administration, only the United Kingdom, the United Arab Emirates, Israel and Chile have populations of more than 1 million.

The United States' success stems in large part from its decision to preorder hundreds of millions of vaccine doses — a move that has made it harder for some poorer and middle-income countries to purchase scarce vaccines.

The vaccine deals have helped the United States ramp up vaccinations to a record of more than 4 million doses administered in a single day earlier this month. President Biden has called for all Americans to be eligible to receive a shot by April 19.

Scientists are still struggling to understand why so many Western countries did so poorly.

For all the factors stacked in favor of the United States in terms of resources, expertise and preparation for a pandemic, the country also had some risk factors from the start: an adult population with high levels of obesity and chronic disease; high rates of international travel that contributed to cases being seeded widely in the early days of the pandemic; and a health-care system fragmented along state lines — not to mention the Trump administration’s disjointed response.

Some of the countries that were able to mitigate the coronavirus were in East Asia and the Pacific. Experts say many of these countries acted quickly to contain the virus through strict lockdowns, aggressive testing and contact tracing or travel limitations. 

Wuhan Maya Beach Water Park held an outdoor electronic music festival on Aug. 15, as coronavirus fears in Wuhan, China, subsided following a 76-day lockdown. (Video: The Washington Post)

After a 76-day lockdown in Wuhan, China, coronavirus fears subsided and people attended an outdoor water park festival.

By the time the United States and many European countries reacted, in contrast, the virus was already widespread.

“It’s much easier to maintain a low level of transmission than it is to bring transmission down again once it’s high,” said Patrick Walker, a researcher at the Imperial College London who specializes in using mathematical models to track the spread of disease.

Ahh, oof and ouch

AHH: Texas still has one of the lowest coronavirus case rates in the United States even after lifting restrictions.

Gov. Greg Abbott (R) garnered widespread criticism from Democrats when he lifted the state's mask mandate and many other social distancing restrictions at the beginning of March. Yet the state has only 12 daily reported cases per 100,000 residents — a rate much lower than other states that have been slower to ease restrictions, including Michigan and New York.

Abbott attributed the state's apparent success to “simple math,” in an interview yesterday with Fox News's Chris Wallace.

“When you add the number of vaccinations that have taken place as well as the acquired immunity, it means it’s a whole lot more difficult for the virus to spread to people in the state of Texas,” Abbott said, adding that “we did an excellent job of vaccinating our senior population.”

OOF: States have been slow to order new vaccine doses.

“The question that defined the early weeks of the vaccine rollout was why states were taking so long to administer the doses they got from the federal government. Four months into the effort, what’s most mystifying is the number of states waiting to order all the doses they’ve been allotted, based on their adult populations and the supplies available that week,” The Post’s Isaac Stanley-Becker reports.

The delays may be “a sign the nation is moving past its supply pinch and now faces more acute challenges related to demand, staffing and inoculation of hard-to-reach populations,” Isaac writes.

Some federal officials believe that states are slow to order additional doses because of softening demand and concern that they can’t get them into arms fast enough. If states receive doses that they can’t administer, it can push them down in rankings of vaccine efficacy. 

OUCH: China’s vaccine needs improvement, according to a top official.

The head of the Chinese Center for Disease Control and Prevention conceded that the efficacy of the Chinese coronavirus vaccines is “not high” and that the country is considering options to change its vaccines, The Post’s Gerry Shih reports.

The comments from George Gao come after the country has already distributed hundreds of millions of doses to other countries. Chinese vaccines have been approved in at least 60 countries and are crucial to many nations’ vaccine plans. Chinese pharmaceutical firms have not released clinical trial data about the vaccines’ efficacy.

Head of Chinese Centers for Disease Control and Prevention Gao Fu said on April 10 that available vaccines in China “don’t have very high rates of protection.” (Video: Reuters)

“Gao’s remarks, which appeared inadvertent and quickly spread through Chinese social media on Saturday before being mostly censored, marked a departure from the rosy assessments of Chinese-made vaccines by the government. By Sunday, Internet users were intentionally misspelling words in their posts while discussing Gao’s comments to keep them from being removed,” Gerry writes.

Chinese pharmaceutical companies are racing to catch up with the mRNA technology used by Pfizer and Moderna, and there could be a Chinese mRNA vaccine as early as this year.

More in coronavirus news

There are vaccine shortages in India amid rising cases.

On Friday, dozens of hospitals in Mumbai halted vaccinations because their supplies ran out, Joanna Slater and Niha Masih report.

If no additional supplies are received, the city’s vaccinations will completely stop on Saturday, said Kishori Pednekar, Mumbai’s mayor. “We are anxious,” she said. “To stop the second wave, we need this.”

Several Indian states have reported dwindling vaccine inventories in recent days. In the eastern state of Odisha, authorities temporarily shuttered 700 vaccination centers — half the total — due to a lack of supplies, according to the the state’s health secretary.

The surge of cases has also led India to ban the export of Remdesivir, a drug used to treat covid-19, Reuters’s Devjyot Ghoshal and Krishna N. Das report.

  • The federal government has said that everyone has a right to a coronavirus vaccine, regardless of immigration status, but some immigrants are running into barriers when asked to provide driver’s licenses, Social Security numbers or health insurance cards, The Post’s Akilah Johnson reports.
  • The messenger-RNA technology used in the Pfizer and Moderna coronavirus vaccines could pave the way for flu shots that could be developed in record time, The Post’s Lindsey Bever reports.
  • In rare cases, people who have been fully vaccinated can still get sick with covid-19. Experts say that such “breakthrough cases” are to be expected. The Centers for Disease Control and Prevention is ramping up monitoring to better understand the cases, The Post’s Lena H. Sun and Joel Achenbach report.

Elsewhere in health care

Democrats are divided on whether to focus on expanding Obamacare or Medicare.

House Speaker Nancy Pelosi’s office is pushing the White House to make permanent a temporary expansion of Affordable Care Act subsidies that were included in the $1.9 trillion stimulus legislation last month, Jeff Stein reports.

But Sen. Bernie Sanders (I-Vt.) told Jeff he's arguing for lowering the age of Medicare eligibility to 55 or 60 and expanding the program for seniors so it covers dental, vision and hearing care.

“The contrasting visions for the next phase of President Biden’s legislative agenda reflect divisions within the Democratic Party about how Biden should further overhaul health insurance in the United States,” Jeff writes.

Sugar rush