Issue of the Week: Disease

THE MAGNITUDE OF THE country’s loss is nearly impossible to grasp.

More Americans have died of Covid-19 than in two decades of car crashes or on battlefields in all of the country’s wars combined.

Experts say deaths were all but inevitable from a new virus of such severity and transmissibility. Yet, one million dead is a stunning toll, even for a country the size of the United States, and the true number is almost certainly higher because of undercounting.

It is the result of many factors, including elected officials who played down the threat posed by the coronavirus and resisted safety measures; a decentralized, overburdened health care system that struggled with testing, tracing and treatment; and lower vaccination and booster rates than other rich countries, partly the result of widespread mistrust and resistance fanned by right-wing media and politicians.

The virus did not claim lives evenly, or randomly. The New York Times analyzed 25 months of data on deaths during the pandemic and found that some demographic groups, occupations and communities were far more vulnerable than others. A significant proportion of the nation’s oldest residents died, making up about three-quarters of the total deaths. And among younger adults across the nation, Black and Hispanic people died at much higher rates than white people.

Understanding the toll — who makes up the one million and how the country failed them — is essential as the pandemic continues. More than 300 people are still dying of Covid every day.

“We are a country with the best doctors in the world, we got a vaccine in an astoundingly short period of time, and yet we’ve had so many deaths,” said Mary T. Bassett, the health commissioner for New York State.

“It really should be a moment for us all to reflect on what sort of society we want to have,” she added.

THE FIRST WAVE OF DEATHS was concentrated in the Northeast, especially New York City and its suburbs. No one knew much in those early months. Doctors were not sure how best to treat the disease. Hospitals were overwhelmed. Deaths climbed sharply.

New York City was hit harder in March and April 2020 than any other city in the country has been during the pandemic. At the height of this outbreak, a New Yorker was dying of Covid almost every two minutes — nearly 800 people per day, a rate five times as high as the city’s normal pace of death.

Among them was Dr. Jay Galst, 69, an otherwise healthy ophthalmologist in Manhattan, who most likely contracted Covid from a patient. His widow, Joann Galst, blamed President Donald J. Trump, who sought to quell concern about the virus in early March, asserting that it would go away with rising temperatures. She also blamed federal health officials, who declined to recommend masks for the public in those earliest days.

“Does it give me consolation that he was doing the work that he loved?” Dr. Galst asked of her husband’s death. “That he was following preventive measures that we both thought was the best he could have done at the time? Not really, since I now know, had we been honestly informed of the immense danger we were all facing in New York City, we could have and would have done more.”

Epidemiologists have pointed to New York’s density and its role as an international hub of commerce and tourism to explain the early spike in cases and deaths. Still, the earliest surge also took an acute toll in cities including Detroit, New Orleans and Albany, Ga.

A spike in emergency room visits to New York City hospitals by people who had “flu-like symptoms” in early March suggested that thousands of city residents were infected.

Health workers at the Brooklyn Hospital Center in New York City in late March 2020. Victor J. Blue for The New York Times

On March 15, Mayor Bill de Blasio shuttered bars and restaurants and announced that public schools would closethe next day. Gov. Andrew M. Cuomo imposed broad restrictions on nonessential businesses on March 22. Those near-lockdown measures were most likely responsible for a more than 50 percent reduction in transmission of the virus, a Columbia University study found.

By summer, New York was garnering praise as a model of infection control. Death rates in New York City would never rise as high as they did in the early wave.

But Dr. Thomas R. Frieden, a former head of the Centers for Disease Control and Prevention and a former commissioner of New York City’s Health Department, said he believed that restrictions came too late. More than half of the New Yorkers who died in the earliest days might have lived, he estimated, had officials put the lockdown measures in place even a week or two earlier. “Cases were doubling every two days, and every two days you were doubling the impact,” he said.

New York’s political leaders cited lack of direction from the federal government, inconsistent messages from public health experts and the daunting task of getting the public on board with a massive disruption of everyday life for the timing of restrictions.

“I don’t think any of us understood the scale of it,” Dr. Mitch Katz, who runs New York City’s public hospitals and participated in the de Blasio administration’s meetings, told The Times in March.

Rich Azzopardi, a spokesman for Mr. Cuomo, said a lack of tests and the Trump administration’s failure to shut down international travel “seeded Covid in New York for two months before our first confirmed case.’’

In an interview, Mr. de Blasio said, “It is hard to say to people when no one had died and the cases are limited, ‘We’re closing down your livelihood, we don’t know when it’s going to come back. We don’t know what’s going to happen to your life, we don’t know what’s going to happen to your family.’” He added, “It’s not something you do lightly.”

BECKY BENNETT SAID SHE and her father, Barrie, were like “peas in a pod,” hiking, biking and shooting together in the Blackfoot, Idaho, area. But vaccines were something they could not agree on.

“Please, kitten, don’t get the shot,” she recalled him telling her. “You don’t know what’s in it.”

He told her that the vaccines were a government scheme to “test her compliance,” citing YouTube videos.

Even after Mr. Bennett, 72, contracted Covid in December last year and was struggling to breathe, his daughter said he was unwilling to promise her that he would get a shot if he recovered.

Becky Bennett, left, and her sister Celestia Hadley tried to persuade their father to get vaccinated. Lindsay D’Addato for The New York Times

Mr. Bennett, who was athletic and in good health, was eventually put on a ventilator in an intensive care unit. He died in January.

Among wealthy countries, the United States has been notably unsuccessful at persuading residents to get fully vaccinated and boosted. Today, about a third of people across the United States have not been fully vaccinated, and some 70 percent of the population has not received a booster. (By contrast, 17 percent of people in Canada have not been fully vaccinated, and 46 percent have not had boosters.)

Nearly half of the deaths from Covid in the United States occurred after vaccines were made widely available. The failure to vaccinate, epidemiologists say, contributed to hundreds of thousands of deaths. During the Omicron wave in December 2021 and January 2022, for instance, the Covid death rate in the United States was higher than in Germany, France, Britain or Canada, which had each fully vaccinated and boosted larger shares of their populations.

“It’s just sobering that in a country with remarkable resources like ours that we are seeing deaths like this,” said Dr. Lisa Cooper, director of the Johns Hopkins Center for Health Equity. “And we’re seeing a lack of benefit from therapy that we know is accessible.”

Public health experts say the government failed to do enough to help the public understand how effective the vaccines are, or to combat misinformation and conspiracy theories by some right-wing media and politicians.

The vaccines have been shown to be largely effective at preventing severe disease and death. But Debra Furr-Holden, an epidemiologist at Michigan State University and the incoming dean of New York University’s school of global public health, said that deaths among vaccinated people had not been explained well and had exacerbated fears surrounding the vaccine and distrust of the government.

The C.D.C. has received data on deaths by vaccination status from only about half of the states, so it is impossible to know exactly how many vaccinated people are among the million who have died. But at least 50,000 vaccinated people, many of them older or without booster shots, were among the deaths reported since late April 2021, when vaccines became widely available.

Still, vaccinated people have had a much lower death rate — unvaccinated people have been at least nine times as likely to die since April 2021.

In recent months, states have scaled back on vaccination campaigns and incentives, and also dropped masking requirements and other mitigation measures that help protect the unvaccinated and other vulnerable people.

Dr. Furr-Holden said the rush to get close to a prepandemic normal — to put people back in restaurants, stadiums and offices — had overshadowed more time-consuming efforts to persuade people who were still unsure about shots. And she worried that government-ordered employer vaccine mandates drove some people away from the vaccines.

“Instead of blaming, shaming and trying to ostracize those people, it would be better to do the work to try to remedy their concerns,” she said.

Older people tend to have weaker organ function and immune systems, leaving them more vulnerable to disease and less likely to respond to vaccines. Indeed, age has sometimes been a bigger risk factor than vaccine status during the pandemic. People 80 and older who had gotten shots were almost twice as likely to die at the height of the Omicron wave as those in their 50s or early 60s who had not, according to C.D.C. data.

But public health experts said the reluctance of others to adapt their behavior was a contributing factor to the large number of deaths among older people over the course of the pandemic.

“A lot of what has effectively been a slaughter has been the product of policies and public health failings, and just not caring,” said Dr. Louise Aronson, a geriatrician at the University of California, San Francisco.

A common refrain, Dr. Aronson said, is that older Americans might have died of something else — cancer, heart disease or old age — had Covid not hit them. But that does not mean, she said, that their final years were not cut short. In the two years before the pandemic, an average of 877,000 people over 85 died each year. In 2020 and 2021, the same age group saw 100,000 more deaths than that each year.

Comparisons to the impact of the flu, which overwhelmingly kills older people, do not hold up either. Covid has killed at least eight times as many people as the flu and pneumonia do in a comparable timespan, according to Andrew Noymer, an associate professor of public health at the University of California, Irvine.

“If I die of Covid today, my death is borrowed against future deaths,” Dr. Noymer said. “But the point is, it may be borrowed 10 years in advance.”

BY MARCH 2021, Howard Jenkins, the pastor of Bethel A.M.E. Church in Providence, R.I., already felt, he said, “bombarded by death.”

He had consoled numerous congregants whose family members had died of Covid. He had eulogized a personal friend who had died of Covid. Appalled at the toll the virus was taking on Black people, he said, he had overcome his own reluctance to get vaccinated so that he could encourage others to do so.

Howard Jenkins has witnessed how Covid has disproportionately affected his Black and Latino neighbors. Sophie Park for The New York Times

At 7 a.m. and 7 p.m. prayer sessions with his congregation, Mr. Jenkins said, he would hear from family members who had lost loved ones. “I could see the toll it was taking on the African American population, in the state and outside the state.”

Black and Hispanic people in every age group have died at higher rates than white people. The racial disparity in deaths was especially extreme at the beginning of the pandemic, but the gaps remain today.

Hispanic people ages 25 to 54 died at a rate more than four times as high as white people of the same age group before vaccines became widely available. Black people of the same age group died at more than three times the rate during that period.

In part, that is because a disproportionate share of essential workers are people of color, public health experts said.

Another reason for persistent disparities in deaths was lower vaccination rates. White people were significantly more likely to be vaccinated than Black and Hispanic people in the first months of the vaccine rollout.

The gap between Black and white people has since narrowed to about six percentage points, while Hispanic people now have a slightly higher rate of vaccination than white people, according to a recent analysis by the Kaiser Family Foundation.

David Hayes-Bautista, a professor of medicine and the director of the Center for the Study of Latino Health and Culture at the University of California, Los Angeles, said more crowded housing might also have contributed to higher transmission rates, hospitalizations and deaths in Black and Hispanic families.

In early 2021, at an east Los Angeles hospital that serves mostly Latino residents, “I could see it right there in front of my eyes,” Dr. Hayes-Bautista said.

“About the third week of January, we thought, ‘We can’t add one more patient.’”

MEAT-PACKING WORKERS HAD been dying of Covid. Transit workers had been dying of Covid. Farm workers had been dying of Covid. At the Ralphs grocery store where Carmen Portillo worked as a cashier, the bakery manager had died of Covid.

“If you don’t have to come back, don’t come back,” Ms. Portillo, 53, recalled her co-workers telling her after she took a short leave. “Because this is bad.”

But like many workers who came to be known as “essential” because their jobs required in-person work, Ms. Portillo felt she had no choice. Her husband, a restaurant worker, was making less because of closures, and they had a mortgage on their home in the Los Angeles neighborhood of Van Nuys.

Carmen Portillo has been a grocery store worker at Ralphs for the past 32 years. Mark Abramson for The New York Times

Even as she silently raged at some customers who refused to wear masks, she said she took satisfaction in the praise she received from others.

“Not a single day passed by that someone didn’t say, ‘You guys are heroes,’” she said.

Ms. Portillo survived a bout of Covid in the fall of 2020, but a close friend, Jose Sanchez, a janitor at a Los Angeles-area mall, did not. Mr. Sanchez had tested positive a few days after accepting a ride home with a co-worker who was later found to have had Covid, Ms. Portillo said.

“They worked late, till 1 a.m.,” Ms. Portillo said. “There were no buses at that time.”

Nearly 80 percent of workers ages 20 to 64 who died of Covid in 2020 worked in industries designated as essential, according to data obtained by a team of researchers led by Yea-Hung Chen, an epidemiologist at the University of California, San Francisco. Workers in 11 sectors that were exempt from stay-at-home orders — including food services, health care, construction, transportation, agriculture and manufacturing — were almost twice as likely to die from Covid as others the same age, the researchers found. About two-thirds of workers in the United States are employed in industries that fall within the classification.

“These workers were by definition more exposed, but the extent of the disparities was striking,” Dr. Chen said.

Income is also a predictor of a person’s risk of dying of Covid in this country. People without a college degree and those who live in poorer neighborhoods have been more likely to die of Covid than those with a college degree and people who live in wealthier ZIP codes.

Data from the country’s three largest cities shows that the highest-income neighborhoods have generally seen the least death over the course of the pandemic, while the poorest neighborhoods have seen the most.

Lower incomes also correlate with a lower likelihood of vaccination, which is in turn associated with Covid deaths. For example, while Republicans have been far more likely to go unvaccinated than Democrats, a divide also exists between high-earning Republicans and poorer ones: According to one survey of self-identified Republican voters in June 2021 conducted by Abram Wagner, a University of Michigan epidemiologist, Republicans with monthly incomes of under $2,000 were twice as likely to be unvaccinated as those with monthly incomes of $5,000 or above.

The United States is far from the only country that has suffered a staggering death toll. The World Health Organization estimates that 4.7 million more people died in India during the pandemic than would have in normal times, and that one million more died in both Russia and Indonesia. Several smaller countries also have experienced higher death rates than the United States.

But there is little doubt that America fared worse than almost all wealthy nations, with one of the highest rates of infection, according to an analysis in The Lancet. Among working-age people, Dr. Chen said, essential workers “bore the brunt of these exposures.”

WHEN MARY-ANN CAREY OF Granville, N.Y., fell and broke her hip in May 2020, she moved into a nursing home for an eight-week stay. Her daughter, Frances Brunner, was terrified.

The nursing home, like others around the country, did not allow family members to come inside, and Ms. Brunner worried that the home was understaffed and would be hit by the virus, as so many others were during the pandemic.

“People’s family members were dying and they couldn’t see them,” said Ms. Brunner, who said she eventually pulled her mother out of the home against the staff’s recommendations. “I got the best-case scenario because I got my mother back. I’m one of the lucky ones.”

In a Pennsylvania nursing home, a patient was transported back to her room after a visit with her daughter in March 2021. Kristian Thacker for The New York Times

Her mother, who is in her 80s, has suffered a cognitive decline and last year became ill with a stomach flu that left Ms. Brunner wondering whether she could continue taking care of her.

In the end, though, Ms. Brunner said the pandemic turned her against the idea of her mother living in a facility long term.

“This is my mother,” Ms. Brunner said. “If I put her in a nursing home, she’d never come home again.”

The virus swept through places like prisons, colleges and group homes, where people live together, but the toll was especially high in long-term care facilities, like nursing homes.

Residents of long-term care facilities continued to die long after the early months of the pandemic, and long after lockdowns that were criticized later for isolating seniors in dangerous, damaging ways.

As Delta and then Omicron swept the country months later, deaths in nursing homes rose again, though never to the levels seen before vaccinations.

Some experts blamed relatively low vaccination rates among nursing home workers before shots were mandated by the federal government. But experts also pointed to problems that existed before the pandemic, like crowding, underfunding and staffing shortages.

Industry leaders have called on the federal government to make a major investment to protect nursing homes by improving staffing and care.

But Dr. David Gifford, the chief medical officer for the American Health Care Association, which represents thousands of long-term care facilities, is not optimistic.

“It’s baffling,” he said, “that public health and government officials point out that there was a large proportion of the deaths from nursing homes, and then when asked to provide resources, they’re combative.”

Dr. Jim Wright, who was the medical director at a Richmond, Va., nursing home where 51 people died, said that Covid had exposed failings in the country’s system of long-term care centers that had yet to be widely addressed.

“What have we done to prevent 200,000 nursing home deaths from the next virus?” Dr. Wright, who now works at two different care facilities, asked. “We didn’t do much.”

The South has also experienced the highest death rates from Covid of any region. In part, that is because it is home to some of the lowest vaccination rates in the country. Since vaccines became available, the average death rate fell everywhere but the South, where it rose by about 4 percent.

Epidemiologists also pointed to less stringent responses — lockdowns that ended sooner and masking restrictions that were not enforced as strictly, even when they were in place.

The South has also suffered because the share of adults with three or more chronic health conditions is higher on average than in any other region. Many chronic health problems are risk factors for the coronavirus, and several studies have suggested that 30 percent to 40 percent of all Covid deaths in the United States involved people with diabetes.

Mississippi has the highest Covid death rate of any state, and one of the lowest vaccination rates. Dr. Thomas Dobbs, the state’s health officer, said that even given the catastrophic problems with underlying illnesses in Mississippi, persuading more people to get vaccinated would have helped prevent many deaths.

It has been an uphill battle, Dr. Dobbs said, to compete with misinformation, especially on social media, and with people who tried to downplay the seriousness of the pandemic. Polarization around the virus and vaccines, he said, was devastating.

“Either you were fully on board or you did absolutely nothing and ran headlong into the buzz saw that was Covid,” he said.

For Mr. Seals, the coroner, the scale of loss has been hard to wrap his mind around.

“When I ran for county coroner, my biggest fear was a plane falling in my county, or a school bus crash,” he said. “Only the grace of God and my faith kept me grounded.”