The sight of Donald Trump fumbling with charts during his interview on HBO this Monday has provided much ammunition for his enemies. The words ‘train wreck’ and ‘toe-curling’ have been used multiple times to describe how the President insisted that the US has one of the lowest death rates from Covid-19, while interviewer Jonathan Swan quoted figures suggesting the US has one of the worst rates.
True, Trump looked ill-prepared, but was he fibbing, as many of his critics have implied?
The truth lies somewhere between what Trump and Swan were each trying to assert. America cannot claim to have a death rate that is lower than other comparable western countries – but neither, on a reasoned analysis, does it come out especially badly.
First, the particular set of figures with which the President was fumbling. They were for a metric known as Case Fatality Ratio (CFR) which is, simply, the number of deaths attributed to Covid-19 divided by the number of recorded cases. On this metric, the US does indeed come out, as Trump suggested, better than Europe; better than the rest of the world. The US currently has a CFR of 0.033 compared with 0.037 for the world as a whole, 0.043 in Germany, 0.14 in Italy and 0.15 in Britain. On the face of it, this would suggest that the US healthcare system has been especially effective at saving the lives of people who have caught Covid-19 – while offering no insight into how effective the US has been in preventing people catching the virus in the first place.
But there is a problem with CFR, which renders it pretty well meaningless. Most cases of Covid-19 – and this applies throughout the world – are going undiagnosed for the simple reason that in most people the infection causes mild, or indeed zero, symptoms. The CFR is very sensitive to the proportion of actual infections which are being recorded. The more successful a country is in detecting cases of Covid-19, the higher its number of recorded cases will be and the lower its CFR will be. Given that the US has one of the highest rates of Covid-19 testing in the world, it is almost certainly detecting a higher proportion of cases than are other countries.
The flipside of the high rate of testing in the US, however, is that it comes out badly in another commonly used metric: the infection rate, defined as the number of recorded cases per million inhabitants. On this measure, the US has had 14,682 cases per million – nearly three times as many, for example, as have been recorded in Britain. It is the overall infection rate which has led to the US being singled out in recent weeks for its supposed failure to contain the epidemic. While recorded cases in Europe are running at a much lower rate now than they were in April, in the US they are running much higher. This has led many commentators to claim that the US is suffering a ‘second wave’. As Trump has frequently suggested, those same commentators rarely stop to ask: is the US simply detecting more cases because it is doing more testing?
If there is any fair way to compare the success of various countries in containing the virus and treating the disease, it is in the number of deaths per million residents. It is not fool-proof because countries have different methodologies in counting deaths – some, for example, count anyone who died after being diagnosed with Covid-19, regardless of what other conditions might have caused their death. But it is a lot more meaningful than simply counting recorded cases. On this measure the US, with 480 deaths per million, is in a mid-table position compared with other western democracies. It is worse than Canada (237) and Germany (110), level with France (464), but better than Italy (582), Spain (609) and the UK (680).
All in all, Donald Trump has nothing to boast about when it comes to the US and Covid-19. But neither can his critics fairly claim that America has done badly.
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