Meanwhile, I see from Matt's retweets that the CDC has clearly not learned its lesson on needing to stay in its lane, and continues to try to galaxy brain public relations:
“Operation Warp Speed” was terrible branding—the biggest reason I saw for vaccine hesitancy (among people who were not instinctively anti-vax) was “it was developed too quickly, I don’t know if it’s safe.” Trump had a hell of a time persuading people (other than his wealthy and elderly donors who didn’t need to be told) to take the vaccine.
Good article, Matthew. It promotes thought about the various issues. I would be in favor of a clawback and then consider the various issues and needs for the money. First I completely agree with you that giving the money in grants to states was inappropriate. To me it was Lazy bill writing. When the Dems found that with 50+1 votes they might get all the desires from every Activist passed into law, they wrote a bunch of Progressive Bills too quickly. Neither Pelosi nor Schumer appear strong enough to reign in the Bernie contingent.
BARDA has done excellent work, but now we have current Covid issues that need funding. We need to stockpile the things we will need for the next Pandemic. We need to fund more monoclonal antibodies and more vaccines. We probably have other distribution issues.
Now with the funding BARDA supplied Moderna & other firms are hard at work producing vaccines for future iterations.
"The great under-appreciated irony of 2020 is that progressives simultaneously took a sharp move to be much more skeptical of heavy-handed enforcement of rules while also wanting a bunch of new rules."
I was just saying the other day that that's been one of the more crazy-making things over the past few years.
I would endorse this strategy 100 percent. It would not hurt to try. On the other hand, I have a fine appreciation of Evolution and its ability to transcend barriers. You're asking for a high hanging fruit when you are looking for a general vaccine for a coronavirus. It may not be possible and it certainly won't be a complete barrier to evolution. Science teaches us this. Every single antibiotic ever produced for any pathogen resulted in resistant strains within a decade of introduction. Every single one.
The coronavirus behaves like flue in some respects. The most transmissible strain always becomes the dominant strain. But the other strains are still there. They still swap genes. Just like influenza. And that results in new variants all the time. Guessing which will be dominant in each flue cycle and developing appropriate vaccines is still more art than science. No one has yet to come close to developing a general vaccine that works with the flu I note.
I wish the scientists good luck in all their endeavors nevertheless.
The kinds of policies Matt describes in this post are excellent and welcomed, and if they can be pursued in a kind of Secret Congress or Secret Executive Branch way, that would be great.
But to be honest, reading the comment threads here almost gives me a feeling of nostalgia for the Great COVID Arguments of the Past. My feeling is that COVID as an issue for the general public is done done done.* No one cares anymore (https://news.gallup.com/poll/1675/most-important-problem.aspx). It's conceivable that we may get another surge so great as to push the issue back into the public consciousness, with all the sturm und drang that will entail, but my guess is that it will have to be a big honking surge with overcrowded hospitals and many many deaths.
* This is not to say that we don't have to do damage repair for the after effects of COVID, such as educational loss and mental health issues among the young. I'm referring to COVID itself as a concern for the future.
Basically, use Advance Market Commitments and prize authority for vaccine development for next generation COVID-19 vaccines and/or neglected diseases in general.
Combining this with measures to reduce R&D costs, like human challenge trials, would be a nice addition as well.
Great post. I went to med school and did residency with Jay Varma -- smart guy. I've been frustrated that the Covid vaccines weren't allotted to individual medical offices. We tried to get the them in our office, but the red tape was a nightmare. There were a good number of skeptical people that I convinced to get vaccinated but then didn't b/c we didn't actually have the vaccine in office. And what I don't get is that Medicare, in general, is getting stingier about paying for vaccines in the doctor's office. For example Medicare won't pay for Shingrix (shingles vaccine) in office, sometimes won't pay for pneumococcal vaccine. The patient has to get at the pharmacy. Then it's a nightmare trying to keep track of vaccine records. Why are they being stingy about vaccines -- one of the best preventative medicine strategies we have in our arsenal?
Anyway, from my perspective, the pandemic is getting way better. Yes -- cases are again surging, but I haven't had to hospitalize anyone for 6 months. And Paxlovid works really well and (at least in LA) is widely available. I'm generally loathe to make predictions after having been burned in the past re: Covid, but I do think this we will get to an endemic state -- just another cold virus in a few years as we are vaccinated and exposed/recover several times.
Regarding footnote #2, it exposed two things in my book. One is that there's a delusion among a sector of lefties that if they just make something a law, that alone will naturally induce people to follow it. That pretty clearly falls apart when you really need 100% compliance. The other is just how important highly visible forms of compliance are to these sectors, even if they're not the most effective.
In response to the footnotes: I will die on the hill of "Operation Warp Speed" being a stupid name. It was impossible to say it in a sentence without cracking up or feeling dumb, which is why all the news stories consistently shortened it to "OWS."
This is a minor point, but something like $9-10b out of the $40b that we tried to send to Ukraine would have gone to paying Ukrainian (non-soldier) salaries and pensions.
If we can afford that, we can definitely fund BARDA.
What amazes me is humanity’s awesome and awful ability to adapt to a new normal. Objectively, things have *somewhat* improved in the pandemic compared to its start: vaccinations and previous infection mitigate outcomes to an extent, and hospitals are better at treatment. HOWEVER, they’re not nearly as radically better as public attitude and official policy have shifted. I still remember the NYT front page “100,000 COVID deaths, an unimaginable loss” and it *was* horrifying and unimaginable *at the time*. And yet Eric Topple’s post (linked by MY) informs us of 175,000 more Americans dying from COVID just from the start of 2022! And none of us bat an eyelid! I’m not pointing this out to say that we were wrong to lockdown in 2020 or wrong to go back to normal now , but rather to suggest that we are on the verge of potentially normalizing hundreds of thousands, perhaps a million, excess deaths annually (!) , and who knows how many long term debilitating conditions. That’s kind of chilling.
One million Americans dead from covid is not the same as one million excess American deaths. Both are bad, but they are different. Old people (and covid deaths are overwhelmingly old people) eventually die of something.
I believe the excess deaths caused from COVID is actually higher than the 1 million figure. Most, but not all, are old. Everyone dies eventually, and I'd even agree that a plague killing mostly the elderly is not as bad as one killing other cohorts, BUT it is NOT the same as if it wasn't there! many of these people would have lived on for years longer!
I would think that a 15% increase in the death rate absolutely *is* earth-shattering! It’s as if we went from a world without cancer to a world with cancer.
Yeah, I think that's the right response - treat covid like cancer, take basic precautions and look into ways that we as a society can do better at reducing the burden of disease people bear. It's really bad, and reduces lifespan by a noticeable amount, but only reasonable precautions are appropriate.
1. you don't seem to have read my comment carefully, or perhaps I didn't put it carefully, if you think I was advocating for a particular policy, or if you even think I suggested that our ability to adapt is, in and of itself, a bad thing. In fact, it is a good thing, and a necessary trait for human survival. It is the fact that we *need* to adapt to this that is very sad, however.
2. The mists haven't clear about this yet, nor are we anywhere near far enough in time and research to truly know the answer to that. I would point out however, that simply to assume that being pretty sick with "flu-like symptoms" to fight off infection, on average say 3 or 4 times a year, which may well be the experience of many people moving forward (natural COVID immunity now seems to wane with 2 months), is not something we know the long-term effects of and the cumulative toll on you body, over years.
3. That's somewhat besides the point. Sure, we got better but COVID got better too. At the end of the day people are dying in very high numbers. Numbers that two years ago seemed unimaginable, and now we don't bat an eyelid, and apparently present as a success? THAT is my entire point. The Change in our perception. I'm not saying this change is a bad thing, certainly not that it could be otherwise. I'm merely reflecting it's a sad state of affairs that this is the new normal.
Put another way - often we read about historical periods, the things people had to put up with on a daily basis, and asks our selves : how could they live like this? This is your answer, this is how it works. We adapt to the new normal for better or worse, we take the baseline conditions for granted, and in the past two years humanity's baseline health conditions have significantly deteriorated. Not to pre-modern medicine levels, thank god, but nevertheless quite significantly, with no sign of returning to the 2019 peak in the medium-term, at least.
It's worth pointing out that BioNTech is just as much a small startup as Moderna and - similar to Moderna - received a large amount of money from an external source to develop their vaccine that they too could not afford to bring to mass production alone.
BioNTech's external funder was Pfizer, and it would make more sense here to compare Pfizer to BARDA rather than to Moderna.
That comparison makes BARDA look even better - Big Pharma like Pfizer have developed very little in the way of vaccines or treatments for any viral disease, which has almost always been either public sector or startup, and Big Pharma funding startups is really unusual - the Pfizer/BioNTech pair up is a really unusual example (far more often the Big Pharma buys the startup rather than partnering with it).
"The great under-appreciated irony of 2020 is that progressives simultaneously took a sharp move to be much more skeptical of heavy-handed enforcement of rules while also wanting a bunch of new rules."
Under-appreciated in some quarters, maybe, but not here in Slowboringland!
The article linked for Covid being leading cause of death in under 55 actually says “leading medical cause of death”, which is different. I was trying to reconcile it with the big NYT feature, which said amongst other things that more under 25s died of car accidents than Covid.
Car fatalities are probably about equal for people under 25 and people 25 to 55 (maybe slightly higher for the younger people, who both walk more and drive more recklessly when they drive). COVID fatalities are probably ten times as high for people 25 to 55 than people under 25, so it makes sense that it could be the leading cause of death for the entire age range, but not for the young end.
The article isn't loading for me, but I'm not sure what "leading medical cause of death" means. I believe that somewhere between 30,000-50,000 Americans of all ages have died of car crashes each year for most of the last few decades.
It looks like 66,000 Americans age 45-54 died of covid over the past two years, so that age range alone probably contributes about as many covid deaths as *all* traffic fatalities during the past two years. There's another 27,000 covid deaths age 35-44 over the past two years, and another 11,000 age 25-34, and 2,600 age 15-24, and 474 age 0-14.
It looks like in 2020, there were 1300 deaths age 0-14, 6,900 age 15-24, 14,000 age 25-44, and 12,000 age 45-64. It does look like traffic fatalities dominate over covid deaths for ages under 35 (though for 25-34 the two seem pretty close), but covid fatalities dominate over traffic deaths for age 45-54 by a huge amount, and probably age 35-44 as well.
Leading medical cause of death excludes accidents, homicides, suicides, overdoses. The article is focused on 2021 (post vaccine) and cites ~30,000 deaths in the 45-54 age group from Covid against ~26,000 from accidents, with the lower ages having more deaths from accidents than Covid.
Thanks for that clarification! (I'm not sure why the link isn't working for me.)
I suspect this classification of "accidents" includes things like falls from roofs and ladders, accidental discharge of firearms, and many other things, while I'm used to seeing "traffic fatalities" as a separate category, which I guess makes me realize that it's really not clear how to count something like this as a "leading cause of death", since splitting and lumping can make such a big difference. (For 2019, it looks like "unintentional injuries" are the leading cause of death for each age range below 45, is third for age 45-64, and sixth for higher age ranges. But since traffic fatalities are less than a fifth of all unintentional injuries, they might barely make the top 5 for people below 25, top 10 for age 25-44, and not even be top 10 for older groups: https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-09-508.pdf )
I was also bothered by this and would love to see an edit to clarify the weasel word. They also play around with percentage increases between tiny numbers and huge numbers; if usually 30 people die and this year 40 died, that was a massive 33.3% increase, but if 300,000 people typically die and this year 378,000 died, that is ONLY a 26% increase.
I'm not sure that's an important clarification - see my comment below with some numbers. I'm thinking that "medical cause of death" means "cause of death as registered on a medical record".
Meanwhile, I see from Matt's retweets that the CDC has clearly not learned its lesson on needing to stay in its lane, and continues to try to galaxy brain public relations:
https://twitter.com/zeynep/status/1526988125695778817
“Operation Warp Speed” was terrible branding—the biggest reason I saw for vaccine hesitancy (among people who were not instinctively anti-vax) was “it was developed too quickly, I don’t know if it’s safe.” Trump had a hell of a time persuading people (other than his wealthy and elderly donors who didn’t need to be told) to take the vaccine.
Good article, Matthew. It promotes thought about the various issues. I would be in favor of a clawback and then consider the various issues and needs for the money. First I completely agree with you that giving the money in grants to states was inappropriate. To me it was Lazy bill writing. When the Dems found that with 50+1 votes they might get all the desires from every Activist passed into law, they wrote a bunch of Progressive Bills too quickly. Neither Pelosi nor Schumer appear strong enough to reign in the Bernie contingent.
BARDA has done excellent work, but now we have current Covid issues that need funding. We need to stockpile the things we will need for the next Pandemic. We need to fund more monoclonal antibodies and more vaccines. We probably have other distribution issues.
Now with the funding BARDA supplied Moderna & other firms are hard at work producing vaccines for future iterations.
"The great under-appreciated irony of 2020 is that progressives simultaneously took a sharp move to be much more skeptical of heavy-handed enforcement of rules while also wanting a bunch of new rules."
I was just saying the other day that that's been one of the more crazy-making things over the past few years.
I would endorse this strategy 100 percent. It would not hurt to try. On the other hand, I have a fine appreciation of Evolution and its ability to transcend barriers. You're asking for a high hanging fruit when you are looking for a general vaccine for a coronavirus. It may not be possible and it certainly won't be a complete barrier to evolution. Science teaches us this. Every single antibiotic ever produced for any pathogen resulted in resistant strains within a decade of introduction. Every single one.
The coronavirus behaves like flue in some respects. The most transmissible strain always becomes the dominant strain. But the other strains are still there. They still swap genes. Just like influenza. And that results in new variants all the time. Guessing which will be dominant in each flue cycle and developing appropriate vaccines is still more art than science. No one has yet to come close to developing a general vaccine that works with the flu I note.
I wish the scientists good luck in all their endeavors nevertheless.
The kinds of policies Matt describes in this post are excellent and welcomed, and if they can be pursued in a kind of Secret Congress or Secret Executive Branch way, that would be great.
But to be honest, reading the comment threads here almost gives me a feeling of nostalgia for the Great COVID Arguments of the Past. My feeling is that COVID as an issue for the general public is done done done.* No one cares anymore (https://news.gallup.com/poll/1675/most-important-problem.aspx). It's conceivable that we may get another surge so great as to push the issue back into the public consciousness, with all the sturm und drang that will entail, but my guess is that it will have to be a big honking surge with overcrowded hospitals and many many deaths.
* This is not to say that we don't have to do damage repair for the after effects of COVID, such as educational loss and mental health issues among the young. I'm referring to COVID itself as a concern for the future.
Are OTAs specifically good for driving innovation, or are they just not the actively counterproductive cost-plus model?
Great article. I argued something similar in a policy memo for the Institute for Progress a few months ago.
https://progress.institute/creating-advanced-market-commitments-and-prizes-for-pandemic-preparedness/
Basically, use Advance Market Commitments and prize authority for vaccine development for next generation COVID-19 vaccines and/or neglected diseases in general.
Combining this with measures to reduce R&D costs, like human challenge trials, would be a nice addition as well.
Great post. I went to med school and did residency with Jay Varma -- smart guy. I've been frustrated that the Covid vaccines weren't allotted to individual medical offices. We tried to get the them in our office, but the red tape was a nightmare. There were a good number of skeptical people that I convinced to get vaccinated but then didn't b/c we didn't actually have the vaccine in office. And what I don't get is that Medicare, in general, is getting stingier about paying for vaccines in the doctor's office. For example Medicare won't pay for Shingrix (shingles vaccine) in office, sometimes won't pay for pneumococcal vaccine. The patient has to get at the pharmacy. Then it's a nightmare trying to keep track of vaccine records. Why are they being stingy about vaccines -- one of the best preventative medicine strategies we have in our arsenal?
Anyway, from my perspective, the pandemic is getting way better. Yes -- cases are again surging, but I haven't had to hospitalize anyone for 6 months. And Paxlovid works really well and (at least in LA) is widely available. I'm generally loathe to make predictions after having been burned in the past re: Covid, but I do think this we will get to an endemic state -- just another cold virus in a few years as we are vaccinated and exposed/recover several times.
Regarding footnote #2, it exposed two things in my book. One is that there's a delusion among a sector of lefties that if they just make something a law, that alone will naturally induce people to follow it. That pretty clearly falls apart when you really need 100% compliance. The other is just how important highly visible forms of compliance are to these sectors, even if they're not the most effective.
This article (https://slate.com/news-and-politics/2022/05/abortion-activism-pro-choice-messaging-language-ireland-argentina.html) has nothing to do with this topic, but its last paragraph was just such a dead-on example of that type of mindset.
In response to the footnotes: I will die on the hill of "Operation Warp Speed" being a stupid name. It was impossible to say it in a sentence without cracking up or feeling dumb, which is why all the news stories consistently shortened it to "OWS."
Next time we need to go to Operation Ludicrous Speed--even if we've never gone that fast before and we're not sure that this society can take it.
I'm not sure if society can handle that much plaid.
This is a minor point, but something like $9-10b out of the $40b that we tried to send to Ukraine would have gone to paying Ukrainian (non-soldier) salaries and pensions.
If we can afford that, we can definitely fund BARDA.
The US can basically afford whatever it wants (that is within human capability). If we’re “unable” to pay for something it’s because we prefer not to.
What amazes me is humanity’s awesome and awful ability to adapt to a new normal. Objectively, things have *somewhat* improved in the pandemic compared to its start: vaccinations and previous infection mitigate outcomes to an extent, and hospitals are better at treatment. HOWEVER, they’re not nearly as radically better as public attitude and official policy have shifted. I still remember the NYT front page “100,000 COVID deaths, an unimaginable loss” and it *was* horrifying and unimaginable *at the time*. And yet Eric Topple’s post (linked by MY) informs us of 175,000 more Americans dying from COVID just from the start of 2022! And none of us bat an eyelid! I’m not pointing this out to say that we were wrong to lockdown in 2020 or wrong to go back to normal now , but rather to suggest that we are on the verge of potentially normalizing hundreds of thousands, perhaps a million, excess deaths annually (!) , and who knows how many long term debilitating conditions. That’s kind of chilling.
One million Americans dead from covid is not the same as one million excess American deaths. Both are bad, but they are different. Old people (and covid deaths are overwhelmingly old people) eventually die of something.
I believe the excess deaths caused from COVID is actually higher than the 1 million figure. Most, but not all, are old. Everyone dies eventually, and I'd even agree that a plague killing mostly the elderly is not as bad as one killing other cohorts, BUT it is NOT the same as if it wasn't there! many of these people would have lived on for years longer!
The 'baseline' yearly mortality rate in the US is approximately 3 million.
1 million people dying over the course of 2 years is only a ~16% increase of that baseline.
The sheer numbers are terrible. The % increase, assuming it isn't maintained for decades, isn't earth-shattering or society-shaking.
I would think that a 15% increase in the death rate absolutely *is* earth-shattering! It’s as if we went from a world without cancer to a world with cancer.
It's temporary, so I just kind of take reasonable precautions and shrug.
Yeah, I think that's the right response - treat covid like cancer, take basic precautions and look into ways that we as a society can do better at reducing the burden of disease people bear. It's really bad, and reduces lifespan by a noticeable amount, but only reasonable precautions are appropriate.
1. you don't seem to have read my comment carefully, or perhaps I didn't put it carefully, if you think I was advocating for a particular policy, or if you even think I suggested that our ability to adapt is, in and of itself, a bad thing. In fact, it is a good thing, and a necessary trait for human survival. It is the fact that we *need* to adapt to this that is very sad, however.
2. The mists haven't clear about this yet, nor are we anywhere near far enough in time and research to truly know the answer to that. I would point out however, that simply to assume that being pretty sick with "flu-like symptoms" to fight off infection, on average say 3 or 4 times a year, which may well be the experience of many people moving forward (natural COVID immunity now seems to wane with 2 months), is not something we know the long-term effects of and the cumulative toll on you body, over years.
3. That's somewhat besides the point. Sure, we got better but COVID got better too. At the end of the day people are dying in very high numbers. Numbers that two years ago seemed unimaginable, and now we don't bat an eyelid, and apparently present as a success? THAT is my entire point. The Change in our perception. I'm not saying this change is a bad thing, certainly not that it could be otherwise. I'm merely reflecting it's a sad state of affairs that this is the new normal.
Put another way - often we read about historical periods, the things people had to put up with on a daily basis, and asks our selves : how could they live like this? This is your answer, this is how it works. We adapt to the new normal for better or worse, we take the baseline conditions for granted, and in the past two years humanity's baseline health conditions have significantly deteriorated. Not to pre-modern medicine levels, thank god, but nevertheless quite significantly, with no sign of returning to the 2019 peak in the medium-term, at least.
It's worth pointing out that BioNTech is just as much a small startup as Moderna and - similar to Moderna - received a large amount of money from an external source to develop their vaccine that they too could not afford to bring to mass production alone.
BioNTech's external funder was Pfizer, and it would make more sense here to compare Pfizer to BARDA rather than to Moderna.
That comparison makes BARDA look even better - Big Pharma like Pfizer have developed very little in the way of vaccines or treatments for any viral disease, which has almost always been either public sector or startup, and Big Pharma funding startups is really unusual - the Pfizer/BioNTech pair up is a really unusual example (far more often the Big Pharma buys the startup rather than partnering with it).
"The great under-appreciated irony of 2020 is that progressives simultaneously took a sharp move to be much more skeptical of heavy-handed enforcement of rules while also wanting a bunch of new rules."
Under-appreciated in some quarters, maybe, but not here in Slowboringland!
The article linked for Covid being leading cause of death in under 55 actually says “leading medical cause of death”, which is different. I was trying to reconcile it with the big NYT feature, which said amongst other things that more under 25s died of car accidents than Covid.
Car fatalities are probably about equal for people under 25 and people 25 to 55 (maybe slightly higher for the younger people, who both walk more and drive more recklessly when they drive). COVID fatalities are probably ten times as high for people 25 to 55 than people under 25, so it makes sense that it could be the leading cause of death for the entire age range, but not for the young end.
I agree and so read the linked article and it doesn’t say leading cause of death for under 55, it says leading medical cause of death.
The article isn't loading for me, but I'm not sure what "leading medical cause of death" means. I believe that somewhere between 30,000-50,000 Americans of all ages have died of car crashes each year for most of the last few decades.
I found covid deaths stratified by age here: https://data.cdc.gov/widgets/9bhg-hcku?mobile_redirect=true
It looks like 66,000 Americans age 45-54 died of covid over the past two years, so that age range alone probably contributes about as many covid deaths as *all* traffic fatalities during the past two years. There's another 27,000 covid deaths age 35-44 over the past two years, and another 11,000 age 25-34, and 2,600 age 15-24, and 474 age 0-14.
I found a site that claims to have traffic fatalities by year stratified by age: https://injuryfacts.nsc.org/motor-vehicle/historical-fatality-trends/deaths-by-age-group/
It looks like in 2020, there were 1300 deaths age 0-14, 6,900 age 15-24, 14,000 age 25-44, and 12,000 age 45-64. It does look like traffic fatalities dominate over covid deaths for ages under 35 (though for 25-34 the two seem pretty close), but covid fatalities dominate over traffic deaths for age 45-54 by a huge amount, and probably age 35-44 as well.
Leading medical cause of death excludes accidents, homicides, suicides, overdoses. The article is focused on 2021 (post vaccine) and cites ~30,000 deaths in the 45-54 age group from Covid against ~26,000 from accidents, with the lower ages having more deaths from accidents than Covid.
Thanks for that clarification! (I'm not sure why the link isn't working for me.)
I suspect this classification of "accidents" includes things like falls from roofs and ladders, accidental discharge of firearms, and many other things, while I'm used to seeing "traffic fatalities" as a separate category, which I guess makes me realize that it's really not clear how to count something like this as a "leading cause of death", since splitting and lumping can make such a big difference. (For 2019, it looks like "unintentional injuries" are the leading cause of death for each age range below 45, is third for age 45-64, and sixth for higher age ranges. But since traffic fatalities are less than a fifth of all unintentional injuries, they might barely make the top 5 for people below 25, top 10 for age 25-44, and not even be top 10 for older groups: https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-09-508.pdf )
Yup absolutely there’s a huge discretization problem.
I was also bothered by this and would love to see an edit to clarify the weasel word. They also play around with percentage increases between tiny numbers and huge numbers; if usually 30 people die and this year 40 died, that was a massive 33.3% increase, but if 300,000 people typically die and this year 378,000 died, that is ONLY a 26% increase.
Wow, an important clarification, thanks!
I'm not sure that's an important clarification - see my comment below with some numbers. I'm thinking that "medical cause of death" means "cause of death as registered on a medical record".
If so then you'd be right!
NYT link please?
https://www.nytimes.com/interactive/2022/05/13/us/covid-deaths-us-one-million.html