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This is the third in a series of reflections aimed at putting what we know about the COVID-19 pandemic in perspective. The first, "Ode to Joy," posted April 9, looked at examples of the human spirit rising to the challenges of the pandemic. The second, "About Those Numbers," posted May 19, looked at projections, reporting of milestones, and historical comparisons.

The U.S. just passed another milestone in COVID-19 deaths: 200,000.

Media reports, always looking to establish a frame of reference (sometimes to the detriment or credit of particular viewpoints), are suggesting that this now surpasses the number of U.S. military deaths in all wars following World War II.. Actually, it not only surpasses, but nearly doubles the number of U.S. military deaths in Korea, Vietnam, the Gulf War, Afghanistan, and Iraq.

The World War II toll was closer to 400,000 for U.S. forces, itself an interesting number since it has now been suggested as the next major milestone (though not yet connected to World War II), rather than moving to the logical increment of 250,00 or 300,000.

Did you know that during the Spanish Flu epidemic a century ago, which spanned two years, the highest number of deaths in one month was 200,000 in October 2018? It has been called the deadliest month in U.S. history. That pandemic claimed approximately 50-million lives worldwide (at least 72-million and perhaps as many as 100-million including World War I deaths). 675,000 of the deaths were in the United States. The situation became so bad in the United States that "undertakers, gravediggers and casket makers couldn't keep up" according to a February 2020 retrospective on history.com.

Where We Are Now

In the previous article, I talked about the early worst case scenarios, which suggested that using the 1918 pandemic as a template, with no serious mitigation, there could be 82-mllion Americans infected, nearly 2 billion worldwide, with global deaths approaching 100-million (approximately 2-million in the U.S. alone). .

The emphasis back in March and April was on "flattening the curve" to spread out pressure on the health care system over a longer time and models were developed that took mitigation into account. The CDC (Centers for Disease Control) began releasing its own forecasts based on current numbers, mitigation and treatment efforts, and expected trends for coming weeks.

Many media reports began to set milestones of their own—how were we doing against Italy, which seemed out of control in the early days; or comparisons with iconic benchmarks like the number of U.S. military deaths in the Vietnam War.

To provide another perspective in that article, I thought it would be helpful to look at COVID deaths alongside the top ten causes of death in the U.S. in a year. Following is an update of that data since I introduced it in early May. .

According to the CDC, the 10 leading causes of death in 2017 (the latest year available) were as follows. COVID death milestones are shown in red. Even if the final toll by the end of 2020 is well below worst-case projections, it is striking how rapid the rise in deaths has been since early March.

When I wrote in May, there were hopeful signs that the daily numbers of cases and deaths were trending down, but then as states began to open (especially those without strict mitigation requirements) and as a new school year approached, areas of resurgence began to appear. Indeed, university campuses, with all their careful planning to stem an outbreak, were ambushed by the death-defying quest to party.

COVID-19 death "milestones" (2020) against the 10 leading causes of death in America (2017)

1. Heart disease: 647,457
2. Cancer: 599,108
   • COVID-19 deaths as of September 24, 2020: 200,705
     latest number from WHO as of this writing
     The CDC's National Ensemble Forecast for September 17, the latest as of this writing, forecasts a total of 207,000 to 218,000 deaths by October 10. (The link will take you to the latest report.)
3. Accidents (unintentional injuries): 169,936
   • COVID-19 deaths as of August 23, 2020: 167,201
4. Chronic lower respiratory diseases: 160,201
   • COVID-19 deaths as of August 10, 2020: 160,989
5. Stroke (cerebrovascular diseases): 146,383
   • COVID-19 deaths as of July 27, 2020: 146,331
6. Alzheimer's disease: 121,404
   • COVID-19 deaths as of June 26, 2020: 121,645
   • COVID-19 deaths as of May 18, 2020: 91,985
     latest number as of my May 19 report
     The CDC's National Ensemble Forecast at the time suggested that "the number of cumulative deaths are likely to exceed 100,000 by June 1st." As I stated then: "We will certainly surpass that number. The forecast is extended only four weeks at a time. If a downturn in deaths becomes reality, as expected, how will the final number at year's end compare to the 200,000 upper end of the window that gained currency in April? If deaths were to continue at the present rate—about 10,000 per week, the total by year's end would be around 372,000."
7. Diabetes: 83,564
   • COVID-19 deaths as of April 28, 2020: 58,365
     not only surpassed Vietnam (58,318), but flu and pneumonia in 2017
8. Influenza and pneumonia; 55,672
9. Nephritis, nephritic syndrome, and nephrosis: 50,633
10. Intentional self-harm (suicide): 47,173
    • COVID-19 deaths as of April 11, 2020: 18,516
      date US surpassed Italy in deaths
    • COVID-19 deaths as of March 28, 2020: 1,296
      date US surpassed Italy in reported cases (85,840)

There are those who question the veracity of assigning COVID-19 to many deaths among people with underlying conditions, such as heart and respiratory disease.Still others have suggested a rise in deaths from other health issues because of deferred health care (i.e., disease, mental health issues, suicide). It will be years before all of that is sorted out. For my purposes here, I can only go by the most reliable sources available.

Another gauge, which you will find in the previous article in a section called "If you had been born in 1900," traces major events (war, disease) and their death tolls through the 20th and into the 21st century. It also shows the growth in world and U.S. population, which is needed to give raw numbers perspective.

The U.S. compared to the World

This section was updated after the original posting to add mortality rates. In so doing, the data in the section was also updated to statistics available September 28, 2020.

Is the U.S. the worst in the world in terms of COVID-19 statistics? Overall, we are being hit harder by COVID than many other countries, sometimes with well-deserved criticism for the free-wheeling, anti-establishment, "cowboy" stereotype through which much of the world views the United States.

Personally, being in DuPage County, Illinois, an area in the Chicago suburbs that is highly compliant with common mitigation protocols (masks, social distancing, and increased testing in particular), it is astounding how cavalier are other regions of the country, parts of our own state, and population cohorts (with the young in general and university students in particular as schools reopened for the fall term). There is a complex mix of factors, so some further analysis may prove helpful, but there is no doubt the U.S. cannot twist the numbers to make things look less than troubling.

To help frame the analysis that follows, consider a quick profile of a range of different countries that appear near the top of the measures included.

Here is the latest (September 28) from worldmeter.info, whose numbers vary slightly from those in the section above because of differing sources and timing. The numbers reveal a complicated mix of cases versus population, mortality rates among those who do become infected, testing levels and other factors.

It does show how one can cherry pick statistics to some extent to support a point of view. As stated in my previous article, raw numbers can be powerful but somewhat misleading, so it is necessary to compare them with rates and shares, which the worldmeter data provides:

Remember, this is a snapshot of a particular day (Sept 28), so running the reports again in the future will change both the numbers and the rankings.

• TOTAL CASES: 33.5-million worldwide
  • The total comes from 215 countries and represents 0.4% of world population of 7.8-billion
  • USA (1), 7.3-million cases—2.2% of its population;
    with 4% of world population, the U.S. accounts for 21.8% of world cases
  • India (2), 6.1M—0.4% of its population, but late to join the ranks of infected countries
    with 17.7% of world population, India accounts for 18.2% of world cases
  • Brazil (3), 4.7M cases—2.3% of its population
    with 2.6% of world population, Brazil accounts for 14.0% of world cases
  • Russia (4), 1.2M cases—0.8% of its population
    with 1.9% of wotld population, Russian accounts for 3.6% of world cases
  • All of Europe combined has 4.9-million cases—0.7% of its population
    with 9% of world population, Europe accounts for 14.6% of world cases
  • Peru (6), 805,302—2.4% of its population
    with 0.4% of world population, Peru accounts for 2.4% of world cases
  • Spain (7), 748,266—1.6% of its population
    with 0.6% of world population, Spain accounts for 2.2% of world cases
  • Mexico (8), 730,317 cases—0.5% of its population
    with 1.6% of world population, Mexico accounts for 2.2% of world cases
  • France (11), 542,639—0.8% of its popuation
    with 0.8% of world population, France accounts for 1.6% of world cases
  • Chile (12), 459,671 cases—2.4% of its population
    with 0.2% of world population Chile accounts for 1.4% of world cases
  • Iran (13), 449,960 cases—0.5% of its population
    with 1.1% of the world population, Iran accounts for 1.4% of world cases
  • UK (14), 439,013 cases—0.7% of its population
    with with 0.7% of world population the UK accounts for 1.3% of world cases
  • Italy (19), 311,364 cases—0.5% of its population;
    with 0.7% of world population, Italy accounts for 0.9% of world cases
  • Germany (22), 288,617 cases—0.3% of its population;
    with 1.7% of the world population, Germany accounts for 0.9% of world cases
  • Canada (26), 154,628 cases—0.4% of its population:
    with 0.5% of world population, Canada accounts for 0.5% of world cases
  • Ecuador (27), 134.965 cases—0.8% of its population
    with 0.2% of world population, Ecuador accounts for 0.4% of world cases
  • Bolivia (28), 133,901 cases—1.1% of its population
    with 0.2% of world population, Bolivia accounts for 0.4% of world cases
  • Belgium (33), 114,179 cases—1.0% of its population
    with 0.1% of world population, Belguim accounts for 0.3% of world cases
  • The 1918-19 Spanish Flu pandemic is estimated to have infected 500 million, 26.3% of the world population of 1.9-billion at that time. If COVID-19 hit at the same rate, about 2-billion would be infected worldwide. At the present rate of infection after seven months, the number could be closer to 110-million after two full years. That is admittedly too simplistic, but it shows the vast difference in scale between the Spanish Flu pandemic a century ago and COVID-19 now (even without adjusting the numbers for the four-fold growth in population since 1918).
    
    
    
• CASES PER MILLION (to express as percentage, move the decimal point five places to the left: the US rate of 21,542 case per million equals 2.15% of its population, while Germany's 3,357 cases represents 0.33% of its population).
  • The top ten, led by Qatar, Bahrain and Aruba, are all small countries (most with less than 10-million population)
  • Peru (8), 24,343 cases per million
  • Chili (10), 23,996 cases per million
  • Brazil (11), 22,246 cases per million.
  • USA (12), 22,166 cases per million
  • Spain (19), 16,003 cases per million
  • Bolivia (28), 11,434 cases per million
  • Belgium (36), 9,841 cases per million
  • France (44), 8,309 case per million
  • Russia (48), 7,945 cases per million
  • Ecuador (51), 7,622 cases per million
  • UK (58), 6,459 cases per million
  • Mexico (63), 5,650 cases per million
  • Iran (69), 5,341 cases per million
  • Italy (70), 5,152 cases per million
  • India (80), 4.441 cases per million
  • Canada (85), 4,088 cases per million
  • Germany (95), 3,442 cases per million
  • China (201), 59 cases per million
  • The rate for the Spanish Flu in its entirety would be approximately 265,000 cases per million worldwide, with the U.S. number close to that—roughly ten times the current U.S. rate, but we're only 7 months into COVID-19 and the Spanish Flu went on for two years. As cases continue to rise, so will cases per million, though unless something drastically alters current patterns, the final rate will remain well below the Spanish Flu, both in real numbers and the 2.7-million it would represent today with population growth.
    
    
    
• TOTAL DEATHS - 1,005,057 worldwide
  • All of Europe combined has 220,822, or 21.8% of all deaths
  • USA (1) among countries, with 209,682 deaths, 20.8% of all deaths
  • Brazil (2), 141,887 deaths, 14.1% of all deaths
  • India (3), 96,351 deaths, 9.6% of all deaths
  • Mexico (4), 76,430 deaths, 7.6% of all deaths
  • UK (5), 42,001 deaths, 4.2% of all deaths
  • Italy (6), 35,851 deaths, 3.6% of all deaths
  • Peru (7), 32,262 deaths, 3.2% of all deaths
  • France (8), 31,808 deaths, 3.2%% of all deaths
  • Spain (9), 31,411 deaths, 3.1% of all deaths
  • Iran (10), 25,779 deaths, 2.6% of all deaths
  • Russia (12), 20.385 deaths, 2.3% of all deaths
  • Chile (15), 12,698 deaths, 1.3% of all deaths
  • Ecuador (16), 11,290 deaths, 1.1% of all deahts
  • Belgium (18), 9,980 deaths, 1,0% of all deaths
  • Germany (19), 9,554 deaths, 0.9% of all deaths
  • Canada (20), 9,271 deaths, 0.9% of all deaths
  • Bolivia (23), 7,858 deaths, 0.8% of all deaths
  • China (32), 4,634 deaths, 0.5% of all deaths
  • Deaths from the Spanish Flu have been widely estimated at between 50- and 100-million worldwide, with 675,000 estimated in the U.S. (information gathering then was not nearly as good as now, though current efforts are not without problems). At the rate experienced over the past seven months, the total for the pandemic could exceed 3-milliion worldwide.
    
    
    
• DEATHS PER MILLION
  • The top ten in deaths per million include some larger countries than seen with cases per million:
  • Peru (2), with 33.0M people, had 975 deaths per million, 4.0% of cases
  • Belgium (3), with 11.6M people, had 860 deaths per million, 8.7% of cases
  • Spain (5), with 46.8M people, had 672 deaths per million, 4.2% of cases
  • Bolivia (6), with 11.7M people, had 671 deaths per million, 5.9% of cases
  • Brazil (7), with 212.9M people, had 666 deaths per million, 3.0% of cases
  • Chile (8), with 19.2M people, had 663 deaths per million, 2.8% of cases
  • Ecuador (9), with 17.7M people, had 637 deaths per million, 8.4% of cases
  • USA (10), with 331.5M people, had 633 deaths per million, 2.8% of cases
  • UK (11), with 67.9M people, had 618 death per million, 9.6% of cases
  • Italy (12), with 60.4M people, had 593 deaths per million, 11.5% of cases
  • Mexico (14,) with 129.3M people, had 591 deaths per million, 10.5% of cases
  • France (18), with 65.3M people, had 487 deaths per million, 5.9% of cases
  • Iran (25), with 84.3M people, had 306 deaths per million, 5.7% of cases
  • Canada (32), with 37.8M people, had 245 deaths per million, 6.0% of cases
  • Russia (54), 145.9M people, had 140 deaths per million, 1.8% of cases
  • Germany (60), with 83.9M people, had 114 deaths per million, 3.3% of cases
  • India (78), with 1,383M people, had 70 deaths per million, 1.6% if cases
  • China (175), with 1,439M people, had 59 death million, 5.3% of cases
     
• MORTALITY RATE (Deaths as proportion of cases— worst to least, using countries listed throughout this analysis). While deaths per million seems to provide a fair gauge of how countries are doing, another significant measure is the mortality rate—which can be seen as relative risk of death for those who become infected.
  • Italy—11.5%
  • Mexico—10.5%
  • UK—9.6%
  • Belgium—8.7%
  • Ecuador—8.6%
  • Canada—6,0%
  • France—5.9%
  • Bolivia—5.9%
  • Iran—5.7%
  • China—5.3%
  • All of Europe—4.5%
  • Spain—4.2%
  • Peru—4.0%
  • Germany—3.3%
  • Brazil—3.0%
  • USA—2.8%
  • Chile—2.8%
  • Russia—1.8%
    
  • India—1.6%
  • The local COVID dashboard that I have been following, as well as news reports from around the world, indicate that black and hispanic populations are hit with noteably higher rates of infection than whites or the general population. What has also been apparent, at least in the Chicago area, is that while both blacks and hispanics have higher infection rates, mortality rates have been higher-than-average for blacks and lower-than-average for hispanics. In general, mortality is concentrated in people over 60 and particularly those in nursing homes and similar settings.
    
    
    
• TOTAL TESTS
  Total tests and Tests per million will grow increasingly vague as testing methods improve and testing of individuals is done with varying frequency (i.e., some colleges and places of business requiring weekly tests, which will inflate the number of tests, but not provide a true sense of coverage of the population).
  • China (1), 160.0-million tests
  • USA (2), 105.1-million tests
  • India (3), 71.9-million tests
  • Russia (4), 45.4-million tests
  • UK (5), 24.0-million tests
  • Brazil (6), 17.9-million tests
  • Germany (7), 15.6-million tests
  • Spain (8), 12.7-million tests
  • Italy (9), 11.1-million tests
  • France (10), 10.7-million tests
  • Canada (14), 7.1-million tests
  • Iran (17), 3.9-million tests
  • Peru (18), 3.9-million tests
  • Chile (26), 3.3-million tests
  • Belgium (28), 3.1-million tests
  • Mexico (43), 1.7-million tests
  • Ecuador (83), 419-thousand tests
  • Bolivia (87), 297-thousand
     
• TESTS PER MILLION
  • As with cases per million, the top 19 countries by tests per million all have populations below 10-million.
  • UK (18), 353,329 tests per million
  • USA (20), 317,038 tests per million
  • Russia (21), 311,066 tests per million
  • Spain (28), 272,117 tests per million
  • Belgium (29), 270,239 tests per million
  • Canada (39), 188,190 tests per million
  • Germany (40), 186,577 tests per million
  • Italy (41), 184,285 tests per million
  • Chile (47), 170,491 tests per million
  • France (49), 164,026 tests per million
  • Peru (68), 116,383 tests per million
  • China (70), 111,163 tests per million
  • Brazil (82), 84,067 tests per million
  • India (109), 52,027 tests per million
  • Iran (114), 47,000 tests per million
  • Bolivia (139), 25,376 tests per million
  • Ecuador (140), 23,705 tests per million
  • Mexico (156), 12,929 tests per million

What to Make of All This

I am admittedly a number cruncher and pattern seeker, so there are two broad conclusions to make at this point during the COVID-19 pandemic.

First, it does not look like COVID-19 will come anywhere near the truly apocalyptic toll of the Spanish Flu a century ago. That was exacerbated by a world war, which in many ways pushed the pandemic itself into the background. Together, the war and flu accounted for 72-million to perhaps 100-million deaths, roughly 4% of the world population at the time.

Second while the U.S. mortality rate is relatively low (2.9%), the U.S. so far is poised to come out of COVID-19 looking much worse than many other countries because the number of cases is so high. A lot of blame is heaped on the Trump administration, which may be deserved, but we also have to account for significant differences in responses by state and region. In some respects our federal republic looks like 50 different countries and the profiles above show how different they can be.

I have tried to help guide you through some of the numbers to add perspective and an understanding of how to read the numbers.

Moving ahead into the potentially dangerous winter months will require more resolve than we've demonstrated to date—and sadly I don't see reasons to be very optimistic right now. America, prove me wrong!

This article was also posted on SeniorLifestyle, which I edit