1 Million People Have Died of COVID-19. It’s a Reminder That We Still Have So Much to Do

With an ever-climbing tally of COVID-19 infections, deaths, and calculations about how quickly the virus is spreading, the numbers can start to lose meaning. But one million is a resonant milestone.

According to the Johns Hopkins Coronavirus Resource Center, the world has now lost one million lives to the new coronavirus. It’s easy to draw analogies—one million people dying of COVID-19 would be the equivalent of just over the entire population of a country like Djibouti, or just under the populace of Cyprus. Perhaps more sobering would be to think of that number less as an entity and more in terms of the precious individual lives it represents. It’s a chance to remind ourselves that each of those deaths is a mother, a father, a grandmother, a grandfather, a friend, a loved one.

It’s also a warning to learn from these deaths so they haven’t occurred in vain. When the novel coronavirus burst into the world last winter, the best virus and public health experts were initially helpless to combat infections in a world where almost nobody had any immunity to fight it. As a result, the mortality rate, which hovered just under 3% around the world starting in late January, slowly began to creep upward, doubling in two months and hitting a peak of more than 7% at the end of April before inching downward again.

While every death from COVID-19 is one too many, public health experts see some hope in the fact that while new cases continue to pile up around the world, deaths are starting to slow. That declining case fatality curve was and continues to be fueled by everything we have learned about SARS-CoV-2 (the COVID-19 virus) and everything that we have put into practice to fight it. That includes using experimental therapies like the antiviral drug remdesivir, as well as existing anti-inflammatory medicines that reduce the inflammation that can compromise and damage the lungs and respiratory tissues in the most severely ill patients.

That falling case fatality is also due in part to wider adoption of prevention strategies such as frequent hand washing, mask wearing and social distancing. And to the fact that globally, we began testing more people so those who are infected can then self-isolate quickly.

Read more: The Lives Lost to Coronavirus

Still, another thing we have learned from the pandemic is that deaths often lag behind cases, sometimes by months. And the number of cases globally continues to increase, especially in new hot spots in South America and India, so the declining curve of the fatality rate hasn’t necessarily led to fewer overall deaths.

Understanding how the geography and nature of COVID-19 deaths have shifted in recent months will be critical to maintaining any progress we’ve made, as nations and as a species, in suppressing COVID-19. In the U.S., for example, deaths early in the pandemic were centered in densely populated metropolitan areas, where infections spread quickly and hospitals became overwhelmed with severely ill people needing intensive care and ventilators to breathe. The virus had the advantage, and exploited the fact that there wasn’t much that science or medicine could do to fight it.

Read more: COVID-19 Has Killed More Than 200,000 Americans. How Many More Lives Will Be Lost Before the U.S. Gets It Right?

The only strategy was to take ourselves out of the virus’s way. Lockdowns that prohibited gatherings, mandates for social distancing and requirements that people wear masks in public helped to slow transmission and gradually reduce mortality, as the most vulnerable were protected from infection. But nine months into the pandemic, deaths are beginning to rise in less populated parts of the country. Medium- and small-sized cities and rural areas accounted for around 30% of U.S. deaths at their peak in late April, but in September they have been responsible for about half of COVID-19 deaths in the country.

The reason for that, public health experts suspect, has to do with the false sense of security that less populated communities felt and the assumption that the virus wouldn’t find them. Less stringent requirements and enforcement of social distancing and basic hygiene practices like hand washing and mask-wearing could have provided SARS-CoV-2 the entrée it needed to find new chances to infect people as those opportunities in more populated regions began to dwindle. Furthermore, health resources in rural areas aren’t as well distributed as they are in metropolitan regions, which makes preparing for an infectious disease more challenging.

Globally, COVID-19 mortality also reflects the unequal distribution of health care around the world. While developed countries are able to rely on existing resources—including hospital systems equipped with the latest medical tools and well-trained nurses and doctors—those resources aren’t as robust in lower income countries where health care isn’t always a high national priority. That puts these countries at greater risk of higher fatality from COVID-19 as new infections climb. Without medical equipment and personnel to ramp up testing and isolate infected people, or to care for the sickest patients, deaths quickly follow new infections.

That tragic reality is being borne out in recent case fatality trends. While the U.S. continues to lead the world in overall COVID-19 cases and deaths, the burden of deaths is shifting to countries such as Brazil and Mexico; Brazil has just over half the number of deaths of the U.S. Deaths in India are also likely to continue inching upward before they start to decline, as survival there under lockdown conditions is nearly impossible for families that have no income to buy food and pay rent. The pressure to reopen and re-emerge into densely populated cities will provide more fertile ground for COVID-19 to spread—and to claim more lives—before better treatments and vaccines can start to suppress the virus’ relentless blaze of despair.