Covid Epi Weekly: Could Covid Kill 1 Million Americans?

Dr. Tom Frieden
7 min readJan 20, 2021


The rapid emergence of new coronavirus strains are a shot across the bow. It’s a message from the virus: We outnumber you. We’re more persistent than you. We change and adapt.

How we react to this shot across the bow is up to us. We must fight smarter, collaborate, and protect ourselves and each other better.


First, let’s take a look at the numbers. Cases, hospitalizations, and deaths continue to increase, and, sadly, we can expect further increases. The scale of cases is mind-boggling. More than 1.6 MILLION cases were diagnosed last week, and that may represent, considering underdiagnosis, as many as a million new infections a day.

We may be seeing the beginning of a plateau of hospitalizations, but it’s too soon to be sure. If we could scale up infusion of monoclonal antibodies for people who are at risk for hospitalization but not yet very ill, we could reduce this number and decrease the stress on our health workers and health systems.

Health care workers continue to be avoidably and unacceptably at risk in the US and around the world. Resolve to Save Lives and partners released a report last week calling for global action to protect them. Banging pots is great, but providing the policies, support, and supplies health care workers need is a lot better.

Next week, I’ll delve into differences in Covid incidence among the states and explain why most comparisons you read are wrong. To start, look at the differences in testing rates by state. Incidence numbers are of little use without knowing testing intensity (which ranges from <100 to 10,000 per 100K) and the percent of PCR tests that are positive.

Epidemics are guided missiles attacking disenfranchised people. We need to do much better at addressing the deep inequities in society. Disproportionate impact of Covid means the need for disproportionate resources and support. Focusing on the hardest-hit communities isn’t just about fairness, it’s also about effectiveness.

A horrifying new projection shows that COVID-19 will reduce US life expectancy by 1.1 years, with reductions for Black and Latinx populations 3 to 4 times that, reversing more than 10 years of progress closing the Black-White gap in life expectancy.

New Viral Strains

Scientists continue to research and learn more every day about new strains of Covid. Data from the UK are clear: B.1.1.7 is more infectious, maybe 30%+ more. Strains from South Africa and the U.S. are likely also more dangerous. These strains demonstrate the evolution of a microbe that changes quickly.

More infectious strains require better defenses. That means not more of the same, but better of the same. I shared in Fox News the five things we must do to prevent a surge in Covid deaths.

  1. Minimize time indoors with others not in your household.
  2. Consider better masks. Surgical or N95, as available.
  3. Accelerate vaccination.
  4. Treat infections early.
  5. Test, isolate, quarantine.

Bottom line: It’s not impossible that Covid could kill 1 million Americans. But it’s not inevitable either. This can happen, but only if we let it happen.

As I mentioned above, new variants are a shot across the bow. This scary study describes how the virus can become much more dangerous. “SARS-CoV-2 has the potential to escape an effective immune response and that vaccines and antibodies able to control emerging variants should be developed.”

Important point: More uncontrolled spread anywhere means more dangerous strains and higher thresholds for herd immunity. As we increase our immunity through infection and vaccination, the selective pressure on the virus will increase. This could result in a virus that can reinfect people more readily, or could escape vaccine-induced immunity.


In terms of vaccination, we’re making progress, but the rollout has been chaotic and the patchwork of policies has created avoidable confusion — a continuation of the marginalization of public health and the federal government’s lack of organization. The outgoing administration’s plan seems to be pointing fingers at states.

The only route to success is a whole-of-government, whole-of-society approach. If we’re divided, the virus will continue to conquer us. Vaccination won’t be quick or easy — this is the most complicated vaccination program in the history of the United States.

Fortunately, CDC’s website on vaccines has gotten better, and it’s encouraging to see that some states are doing well and making steady progress in long-term care facilities.

Vaccination prioritization should be straightforward:

  1. All nursing home residents and staff
  2. All healthcare workers with potential exposures
  3. All people over age 65
  4. All frontline essential workers.

That’s ~100 million people, ~200 million doses, but uptake will be less than 100%.

We will have too little vaccine until we have too much. We still don’t have enough transparency about how much vaccine is in the pipeline, from which companies, and when delivery is expected. There’s too little accountability or ability to plan. By March/April, we can hope to have additional authorized vaccines and supply.

Vaccination in nursing homes is crucial. By ensuring residents and staff get vaccinated, we can reduce death rates before we reduce case rates. By mid-February, the proportion of deaths from long-term care facilities should start to fall as a result of vaccination and in March, death rates should decline nationally. Currently, we have way too little data on how vaccination is progressing in these facilities.

Kudos to West Virginia (and credit to Dr. Clay Marsh and colleagues) for vaccinating more than 6% of the state population so far. The state has started vaccinations at all long-term care facilities. It also created a good vaccine dashboard (though it would be better if it compared vaccinations with the percentage of state population). If the US had given the same proportion of distributed doses as West Virginia, another 8 MILLION vaccines would have been given by the end of the week last week!

Primary care is also important for vaccination. Now, many primary care clinicians can’t even get vaccinated themselves! Data from Massachusetts shows the gap. The deeper issue is that we must fix the U.S. primary care system, in addition to fixing the U.S. public health system. More to come on this.

We should expect to see better information on who’s getting vaccinated. There needs to be more transparency on this and on the reasons for delaying the release of information. It’s understandable there’s missing data, but zip code data can help since, sadly, geography is usually a close proxy for socioeconomic status.

Some keys to successful vaccination programs:

  • Empower trusted community members and develop tailored messages
  • Provide reminders and ensure convenience (hours, locations, time)
  • Avoid hidden costs (for example, reimburse travel to vaccination sites)
  • Make vaccination the social norm
  • Anticipate and counter misinformation
  • Focus on personal, family, and collective benefits of vaccination.


Remember the wisdom of William Farr: The death rate is a fact, all else is an inference. This graph shows very concerning death rate increases in the UK, Ireland (note shape of curve!), and South Africa. A more infectious virus means more infections, which means more deaths.

Thanks to the Wall Street Journal for analyzing excess deaths. This is important. Many excess deaths — most in some countries — are from Covid directly (likely Russia, Turkey, Mexico), and others are from disruptions (e.g. treatment of heart disease) caused by Covid (such as South Korea).

A Better Future

There’s good news. Vaccines are coming. We understand the virus and how to protect ourselves better. The US response is getting more organized, competent, and transparent. There’s more recognition that we’re all connected. The virus can catalyze community and global collaboration.

Don’t let your mask down. Don’t let your guard down. Let’s learn, connect, and empower.

2021 can usher in a more connected, empathetic world.

“Only that day dawns to which we are awake. There is more day to dawn. The sun is but a morning star.” Henry David Thoreau



Dr. Tom Frieden

President and CEO, Resolve to Save Lives | Former CDC Director and NYC Health Commissioner | Focused on saving lives.