First, coronavirus infections increased. Then, hospitalizations. Now, deaths are on the rise.

All signs indicate that this isn’t a blip but rather a reflection of a massive surge in infections that, without a dramatic effort to reverse the trend, will drive up the death toll for weeks to come. At least 229,000 people in the United States have died of covid-19, the disease caused by the virus.

But the mortality numbers have become political fodder on the campaign trail. Depending on whom you listen to, the coronavirus just isn’t that deadly anymore. Or it’s killing people in droves.

The truth is that mortality rates have improved, but the accelerating spread of the virus is driving up the absolute numbers of deaths.

Doctors have reported better outcomes thanks to improved techniques for treating patients and the use of the steroid dexamethasone and the antiviral remdesivir. In a widely reported study, researchers at NYU Langone Health found that the death rate among more than 5,000 patients in the system’s three hospitals dropped from 25.6 percent in March to 7.6 percent in August.

Still, this remains a potentially deadly disease, and a large proportion of the population is still vulnerable to infection. With the number of infections hitting daily records, there is reason to expect that deaths will keeping rising until the spread of the virus is contained.

Deaths lag infections by many weeks. In hard-hit North Dakota, daily infections have doubled since the end of September, while the average number of deaths from covid-19 is up 50 percent. In Indiana, cases are up 150 percent in that time, and deaths are up 93 percent.

In Wisconsin, cases began spiking in early September, and deaths began to rise sharply at the end of the month. Of the 2,029 deaths there from the pandemic, more than half have occurred since Sept. 25.

President Trump and his son Donald Trump Jr. have in recent days said there has been an excessive focus on infections rather than deaths, which have not risen as quickly and remain lower than in the early days of the pandemic.

“Do you ever notice, they don’t use the word ‘death’? They use the word ‘cases,’ ” the president said Tuesday in Omaha. He brought up his 14-year-old son. “Like, Barron Trump is a case. He has sniffles, he was sniffling. One Kleenex, that’s all he needed, and he was better. But he’s a case.”

The younger Trump posted a graph on his Instagram account, based on incomplete Centers for Disease Control and Prevention data, that he claimed showed deaths dropping.

“Why isn’t the ACTUAL data from the CDC being discussed? . . . [W]hile there have been increases in new cases per week, there has actually been a steady decrease in deaths per week,” Trump Jr. wrote. He echoed that argument in a television interview Thursday on Fox News, saying he asked himself why people weren’t talking about deaths, and deciding, “Oh, because the number is almost nothing. Because we’ve gotten control of this thing, we understand how it works.”

His description of the CDC death data is misleading. CDC official Robert Anderson, head of the agency’s mortality data branch, did not comment for this article but pointed to the CDC document — which Trump Jr. himself linked to from his Instagram account — that explains that the most recent death data is incomplete: “It is important to note that it can take several weeks for death records to be submitted to National Center for Health Statistics (NCHS), processed, coded, and tabulated. Therefore, the data shown on this page may be incomplete, and will likely not include all deaths that occurred during a given time period, especially for the more recent time periods.”

Former vice president Joe Biden, by contrast, emphasizes the death toll in his speeches. In a short address Wednesday in Wilmington, Del., he said Trump’s minimizing of the death rate is “an insult” to everyone who has lost a loved one to covid-19.

He spoke of “the refusal of the Trump administration to recognize the reality we’re living through at a time when almost 1,000 Americans a day are dying,” and said that refusal “is an insult to every single person suffering from covid-19 and every family who’s lost a loved one.”

That cohort includes Kathryn Hering Rikess, whose son Cole Hering died in Knoxville, Tenn., at the age of 36 after a lengthy battle with covid-19. She said she is frustrated by the politicization of the virus and the refusal of some people to follow simple health guidelines such as mask-wearing. She keeps thinking her son is going to call on Sundays to talk football, to sign off with an “I love you, Mom.”

“No one should feel the pain that I’m feeling,” she said. “No one. Just follow the rules. Let’s get over this so I can have a funeral for my child and get on with it.”

White House spokesman Judd Deere said any suggestion that Trump hasn’t taken the threat of the virus seriously “is completely false,” and cited a number of actions by the president, including the travel ban affecting China and the spring shutdown of parts of the economy, “which saved millions of lives,” as well as support for therapeutics and a vaccine. “Thanks to the bold actions of President Trump, the risks today are dramatically lower than they were only a few months ago with mortality rates falling over 80%.”

Nationally, the daily death toll from the virus remains well below the numbers seen during the initial spring wave of the pandemic, when more than 2,200 people were dying each day on average. That declined until early July. But then a surge of infections in May and June, particularly in the Sun Belt and reflecting the end of many shutdowns and restrictions, began once again driving up the death toll.

The number dipped again in September but has risen steadily this month along with the arrival of colder weather and the accelerating spread of the virus. Since Oct. 22, 13 states have reached their all-time high for average daily deaths: Alaska, Idaho, Iowa, Kansas, Kentucky, Montana, Nebraska, North Carolina, Oklahoma, South Dakota, Tennessee, Wisconsin and Wyoming.

An influential model from the University of Washington’s Institute for Health Metrics and Evaluation forecasts that, under current policies, more than 2,000 people will be dying each day by the end of December, close to the horrific death toll in April when the Northeast was first pounded by the pandemic.

But that is not set in stone: Public health measures can reverse the trends if people adhere to guidelines, including wearing facial coverings and maintaining physical distancing, and if communities are aggressive about contact tracing and isolation of people who are infected, experts say.

This week, Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said he is generally skeptical of models because their forecasts depend on many assumptions fed into them. He expressed alarm at the high rate of infections daily — the “baseline” — as the country heads deeper into fall and winter.

But he also noted that improved treatments have lowered mortality among the severely ill. There is no way to predict accurately what the death toll will be, he said.

“I would expect that as more people get infected, and more people get into the hospital, we will have an increase in deaths. It is impossible to predict what the level of deaths will be related to the number of hospitalizations,” Fauci said.

He and others have warned that widespread transmission of the virus among young people will lead to dangerous cases among the more vulnerable members of society — the elderly and people with chronic health conditions. The virus incubates for up to 14 days and the spread can be subtle and slow.

“One 20-year-old infects another 20-year-old who infects another 20-year-old who infects Grandma. So you have eight to 10 weeks,” Fauci said.

The scientific reality hasn’t changed since the start of the pandemic: This is a potentially lethal but quirky virus that can infect some people without generating any symptoms at all, while making others severely ill, damaging their lungs, heart, kidneys and other organs, with symptoms sometimes lingering for weeks or months — a syndrome known informally as “long covid.”

The CDC has stated that its best estimate for the infection fatality rate is 0.65 percent, meaning that for every 10,000 people who get the virus, 65 will die. There is a sharp age gradient: Mortality rises steadily with age, and the disease is far more likely to be fatal in the elderly. Other factors increasing risk involve underlying chronic conditions, including obesity, heart disease and diabetes.

The fatality rate, though, is not an intrinsic feature of the virus but rather one that depends on many factors, including improving treatments, level of exposure to the virus and access to health care.

Some demographic groups have borne a disproportionate burden of the disease. In the United States, African Americans account for 1 in 5 deaths, far exceeding their proportion of the population, and there are other disparities in infections, hospitalizations and deaths affecting people of color. Hispanics, for example, have much higher infection rates than Whites.

When infections rise, hospitalizations tend to increase a few weeks later. Some hospitalized patients end up in intensive care units, and some are placed on ventilators. This can take weeks to unfold. At the end of it, the death toll rises in an inescapable echo of the infections weeks earlier.

“Everything follows the thing before it. So the new positive cases drive the hospitalizations. The number of hospitalizations drive the pressure on the intensive care units. And those numbers drive the number of deaths,” said Bill Melms, chief medical officer at Wisconsin’s Marshfield Clinic Health System, which has locations in rural parts of the state.

Coronavirus hospitalizations across the Marshfield Clinic Health System were up 60 percent this week compared with last week. The system had 90 patients spread across nine hospitals Thursday — a number that is concerning because of the small, rural nature of their facilities. Melms expects the number could double in the next four weeks.

“We’re not going to see a light at the end of the tunnel — whether we’re talking about deaths, intensive care unit admissions or total hospital admissions — until we see the average number of positive cases in the state start to drop, and start to drop in a sustained way,” Melms said.

Experts said they believe the virus is spreading primarily in small, indoor gatherings, including inside bars and restaurants. Colder weather and the return of students to college campuses are also likely factors. Wisconsin, like many places in the United States far from the coasts, went largely unscathed in earlier waves of the pandemic. Those interior states are now flooded with cases.

Even so, some of the hardest-hit states have the lowest rates of mask-wearing.

“The current mind-set appears to be, at least, that people have said, ‘Well, it is what it is,’ ” said Nasia Safdar, medical director of infection control at University of Wisconsin Hospital and Clinics. “But it can’t really continue like this because health systems will soon have to come to a point where they may have to make very difficult decisions about covid care versus care for patients who don’t have covid but still need it.”

Trump has been blasting the news media for focusing on infections going up, falsely claiming this is simply because of more testing. His own testing czar, Adm. Brett Giroir, said this week that testing cannot explain the spike in cases because hospitalizations are rising.

Trump also used his own bout of covid-19 as a case study.

“I had it. Here I am, right?” he said in Omaha.

“That just shows you he doesn’t take this seriously even after he himself was hospitalized and had the whole world watching and hoping for his recovery,” said Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security and a spokesman for the Infectious Diseases Society of America. “There’s no way to minimize what this virus has done in any kind of honest way. This is another example of living in an alternative reality.”

Trump had access to experimental drugs not yet available to the general public. But his case is not statistically unusual: Most 74-year-old men with covid-19 survive, with or without special treatment.

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