Coronavirus

8 Possible Reasons for the Huge International Differences in COVID-19 Deaths

For each plausible theory, there are puzzling counterexamples.

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If you're trying to figure out why some places have been hit especially hard by the COVID-19 pandemic while others so far seem to be largely unscathed, there is no shortage of hypotheses. But for each seemingly plausible explanation, there are counterexamples that complicate the story.

Reporting Differences

We know that the true number of infections in any given place is far larger than the number of confirmed cases, although exactly how much larger is a matter of much dispute. We also know that deaths are undercounted, especially if they happen at home and involve people with other serious medical conditions who are never tested for the virus. While the first gap is apt to be much bigger than the second gap, the size of both is likely to vary from one country to another, depending on testing rates and reporting practices.

Still, those differences by themselves cannot account for the striking international  differences in COVID-19 deaths. "Even in places with abysmal record-keeping and broken health systems," The New York Times notes, "mass burials or hospitals turning away sick people by the thousands would be hard to miss, and a number of places are just not seeing them—at least not yet."

Stage of the Epidemic

Fewer than 50,000 COVID-19 cases and fewer than 2,000 deaths have been reported in the entire continent of Africa, which has a population of 1.3 billion. That amounts to fewer than two deaths per million people, compared to nearly 200 per million in Europe and a bit more than that in the United States—a huge difference, even allowing for underreporting.

Judging from the first confirmed cases, COVID-19 spread to Europe about three weeks before it hit Africa.* Although the death rate in Africa is bound to rise as the epidemic progresses there, the difference in timing cannot fully account for the enormous difference in fatalities per capita. And Japan, where the first COVID-19 case was reported on January 16, a week before the first confirmed cases in Europe, has a far lower COVID-19 death rate, although not as low as Africa's. South Korea, which reported its first COVID-19 case on January 20, likewise has a remarkably low death rate.

Age Demographics

Since COVID-19 fatality rates are dramatically higher among the elderly, one obvious explanation is age demographics. The population of Africa, where the median age is about 20, is much younger than the population of Europe, where the median age is about 43.

As the Times notes, however, some countries with young populations, such as Iran (median age: 32) and Ecuador (median age: 28) are seeing relatively high numbers of COVID-19 deaths, although not as many per capita as Europe. And Japan, which has an even higher median age (48) than Europe, again provides a puzzling counterexample.

Social Customs

"In Thailand and India, where virus numbers are relatively low, people greet each other at a distance, with palms joined together as in prayer," the Times notes. "In Japan and South Korea, people bow, and long before the coronavirus arrived, they tended to wear face masks when feeling unwell."

Then again, the Times says, "there are notable exceptions to the cultural distancing theory. In many parts of the Middle East, such as Iraq and the Persian Gulf countries, men often embrace or shake hands on meeting, yet most are not getting sick." Iraq, which has a population half as big as neighboring Iran's but a substantially lower median age (21 vs. 32), has reported less than 2 percent as many COVID-19 deaths.

Climate

Since the COVID-19 virus does not seem to like heat and light, the Times notes, it makes sense that it has made relatively little progress in tropical countries such as Chad and Guyana but is more pervasive in places with more temperate climates, such as Italy and the United States. Yet "some of the worst outbreaks in the developing world have been in places like the Amazonas region of Brazil, as tropical a place as any."

Population Density

It's no surprise that New York City, which has the highest population density by far of any city in the United States, has had many more COVID-19 deaths per capita than places where people live farther apart. Antibody tests conducted by the state health department in April suggested that more than a fifth of the city's population had been infected. Yet densely populated cities such as Hong Kong, Seoul, Tokyo, Bangkok, New Delhi, and Lagos have not seen anything like the cases and deaths reported in New York.

Government Policies

"Lockdowns, with bans on religious conclaves and spectator sporting events, clearly work," the Times declares, citing the World Health Organization. "More than a month after closing national borders, schools and most businesses, countries from Thailand to Jordan have seen new infections drop." Yet "counter-intuitively, some countries where authorities reacted late and with spotty enforcement of lockdowns appear to have been spared. Cambodia and Laos both had brief spates of infections when few social distancing measures were in place but neither has recorded a new case in about three weeks."

South Korea's response to COVID-19—focused on early and wide testing, coupled with aggressive contact tracing and targeted quarantines—has been notably different from the American response, which was crippled by a government-engineered test shortage and has featured broad business closures and stay-at-home orders. Government-mandated social distancing in South Korea has been significantly less strict and less sweeping.

Likewise in Japan, where schools were closed but there were no American-style lockdowns, although the government recommended precautions such as avoiding unnecessary outings. In Sweden, another country that has eschewed a broad lockdown, the COVID-19 death rate is higher than in other Scandinavian countries but lower than in such countries as Italy, Spain, France, Belgium, the Netherlands, and the U.K.

Luck

Some places may be seeing worse epidemics because they happened to have more "super-spreaders": carriers who infected an unusually large number of people at particular gatherings. The Times cites several examples, including the Diamond Princess cruise ship, a funeral in Albany, Georgia, and a church service in Daegu, South Korea.

New York City's epidemic seems to have been seeded by many international travelers, mainly from Europe. Other things being equal, places with fewer visitors can be expected to have fewer chains of transmission. That might be part of the explanation for the striking differences between New York and California, where the virus seems to have been spreading by mid-January (judging from a COVID-19 death, apparently via local transmission, on February 6 in Santa Clara County).

"Far-flung nations, such as some in the South Pacific and parts of sub-Saharan Africa, have not been as inundated with visitors bringing the virus with them," the Times notes. "Health experts in Africa cite limited travel from abroad as perhaps the main reason for the continent's relatively low infection rate."

*Update: A French doctor recently reported that a sample drawn from a hospital patient with respiratory symptoms on December 27 had tested positive for the COVID-19 virus. The former patient said he could not imagine how he was exposed, which suggests the virus was spreading in Europe earlier than public health officials originally thought.

NEXT: Who Should Pay the Rent During a Pandemic?

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  1. dafuck ? Not one mention of China and their lying asses in the entire article.

    1. Didn’t mention #metoo either. What a piece of unwoke shit!

      1. God damn you’re retarded SQELSY

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    2. Even the CIA is not sure if it came from China. Trump the chump has his propaganda machine going full blast to lay the blame on China. China makes everything for the US including all medicines. The US doesn’t even make its own penicillin and they can’t even get simple face masks or protective clothing for hospitals. If he Chinese leaders were vindictive pr*cks like that orange pompadour headed draft dodger in the white house, they would tell him to stick it were the sun don’t shine and deliver nothing to the US. Instead, being more mature than the silver spoon fed, narcissistic immature brat, they have ramped up production, delivering more medical supplies to the US to save lives.
      Being unaware of anything around you, I am sure you are not aware there is an entire wing in the Pentagon with a budget of milloins whose sole mission is to spread disinformation, a polite word for lies. They plant false stories in foreign TV, books and newspapers and do it in the US as well which is illegal. If we are the epitome of truth and justice, why are we spending millions spreading lies?

      1. Yall don’t realize how stupid these hysterically bitter screeds make you look.
        Please do keep up the good work

      2. Yikes this is kookaburra.
        I was only trying to say that I figured an article breaking down the differences in covid death numbers/ reporting etc would mention China, a pretty big player in this whole ordeal, and their numbers which they’ve even admitted to lying about. That’s literally it.

      3. “…Trump the chump..”
        Why do lefty ‘tards spend half their lives inventing ‘clever’ nicknames which would embarrass 1st-grade kids?
        Maybe it’s because they are fucking lefty ignoramuses. Well, no, not maybe.
        Fuck off and die, you pathetic piece of lefty shit

        1. When is the last time you heard them come up with a clever plan to actually fix something and not break it further? Take all the time you’d like.

        2. Crooked Hillary, Lyin James Comey, Low Energy Jeb!…. Pretty sure it was Donny Crunk who started the name calling….

          1. Yeah, but the nicknames Candidate Trump came up with actually fit…

    3. Nor any consideration of different testing and reporting practices, not to mention the possibility of outright dishonesty by many governments besides China. If a country is not testing all the dead, they are undercounting deaths from COVID-19. E.g., in many non-westernized countries it is common for people to die at home and be buried by the family – the death might not even be reported to a distant government agency, let alone have samples collected for testing. Or if government troops shoot dead everyone with the sniffles and don’t test to see if the victims had COVID-19, counted COVID-19 cases will approach zero…

      If they are testing _all_ the dead, they are probably overcounting, including not only people with a pre-existing fatal condition who also contracted COVID-19 and maybe died a few days earlier than they would have, but also murder victims who tested positive.

  2. Another problem is trying to compare giant countries like the United States with small dense states like South Korea, or even city states like Hong Kong.

    Another possible factor is the strain of disease. Most West Coast cases are hit by a strain of COVID that came directly from China. The East Coast was hit by the same strain that burned through such hot spots as France, Belgium, Spain and Italy. It is possible that the infection and fatality rates of these two strains are sufficiently different.

    1. Not to mention the cultural differences.

  3. Currently 3.55M positive cases, 249K deaths. Number of infected at a minimum is x10 # of cases, so TFR is 0.7 worldwide. But reality would say it’s probably x20 to x50, so final TFR is going to be about 0.2-0.3.

    Which is similar to 1957 and 1968, and therefore this is not worse, and also none of this lockdown bullshit was necessary because you are gonna get one day until you get a vaccine and even then you will still likely get it if it mutates.

    1. You can’t just make shit up (“minimum of 10”) and use it to come up with “facts” (“so TFR is 0.7”).

      1. No one cares what you think SQRLSY

  4. The world puts an asterisk next to China’s name.

    https://spectator.us/china-asterisk/

    From the Spectator article:

    “After months of publishing suspiciously low numbers for coronavirus infections and deaths, the Chinese Communist Party (CCP) finally acknowledged it had consciously undercounted cases, initially excluding those who were asymptomatic, and belatedly revised its official death total in Wuhan by 50 percent, to 3,869*. Even so, many believe that is still too low.”

    Interesting this doesn’t get a passing glance in Sullum’s piece.

    1. Why should it get a place in this article? It’s junk. Why compare real data with junk to come up with bogus conclusions?

      1. Because Sullum also made a largely basis assumption

      2. While I totally agree w you, you are annoying as fuck

  5. Another reason for international differences, especially when the per 1 million case count compared to the 1 million death count, such as Turkey’s death rate per 1 million is 1/8th ours, is to see how the country is treating Covid-19. Many countries are using Hydroxychloroquine/Zpack/Zinc Rx both at a prophylactic for their medical workers and as an early patient Rx at signs of symptoms. Turkey is, and they do 65% as much testing as US does per 1 million people. Google for such data. Use 91-Divoc to chart differences, focusing on adjusted per population and “add highlight” option. I’d provide links if your comments allowed it but most of the time it doesn’t. The American Association of Physicians and Surgeons has a nice page on international Covid-19 treatment approaches and efficacy. They mentioned Turkey in their examples.

  6. A. There is no vaccine and won’t be for a year.

    B. Everyone, or at least some close approximation like 90%, has to be infected before the virus stops spreading.

    C. No economy can be locked down until a vaccine is developed, tested, and applied.

    D. It doesn’t really matter which countries have what infection rates right now. See A and B.

    E. The only rationale for all these lockdowns recognized A and B andaimed only at flattening the curve so hospitals weren’t overloaded.

    F. Hospitals even in New York are not overloaded and have not been overloaded.

    Z. Stop the fucking lockdowns.

      1. Herd immunity starts the slowing of the disease at the very first person who has antibodies. The less potential hosts, the slower the virus will spread. It may be that the reproduction rate goes below 1 at 60%, but the spread will be slowed all the way from 1% to 59% as well.

        1. Correct. The herd immunity becoming effective depends on several factors including the infection rate R, the mixing in the society (are regions isolated from each other), the number frequency of person to person encounters, and the virulence. 60% is typical.

    1. “You can’t just make shit up (Everyone, or at least some close approximation like 90%, has to be infected before the virus stops spreading.) and use it to come up with “facts”

      1. I did not present my conclusion as fact.

        1. And I didn’t say you did.

          So what the fuck are you crying about.

    2. B. Everyone, or at least some close approximation like 90%

      Do you have some evidence that R0=10?

      “You can’t just make shit up”

  7. Death are undercounted due to home deaths but the over count due to lying by hospitals, coroners and government is far in excess of the undercount.

    1. Also, if the point is saving the health care system, people who die at home shouldn’t really change the equation.

    2. For the millionth time. The CDC publishes data on the number of people who die in any given week (see link below). This data takes a bit of time to get in (a lot of people have misinterpreted the 100% complete number to indicate all data is in, it actually indicates reports have come in from all areas) so this will only be accurate for weeks ending up to 4/11. However, one of two things is true:
      1. We are dramatically under-counting Covid 19 deaths
      2. Something else is killing a lot of people
      If you believe it is 2, please let me know what you suspect.

      https://gis.cdc.gov/grasp/fluview/mortality.html

      1. Econimic disaster and the accompanying stress it places on people kills people. It is likely to kill 10s of thousands this year if we continue like this. Not being treated adeequately for their existing medical conditions also kills people. There is a lot of that going on with the hospitals all closed.

  8. “We also know that deaths are undercounted,”

    Why is reason pushing this bogus assumption? Multiple doctors, a github dump, and morticians are claiming it is over counted at the moment.

    1. The individual is usually right, moral, and trustworthy, except for all those deplorable individuals keeping the COVID-addled corpses of their relatives in their basement just to keep the numbers down.

  9. Hope that the corona virus situation will be easier soon.

  10. >>We know that the true number of infections in any given place is far larger than the number of confirmed cases

    shame this ^ + “stay out of New York City” did not = “hey this is not really worth the hullaballoo”

  11. As the Times notes, however, some countries with young populations, such as Iran (median age: 32) and Ecuador (median age: 28) are seeing relatively high numbers of COVID-19 deaths, although not as many per capita as Europe. And Japan, which has an even higher median age (48) than Europe, again provides a puzzling counterexample.

    It would be interesting to provide median age of death rather than just median age of the entire population. Anyway we slice it the death rate is not even close to evenly distributed among the population. We see scary things of younger folks dying, but it really does appear to be an outlier in most cases I’ve seen.

    Not mentioned here, but I’m curious about, I’ve read that a very large portion of this is this hitting nursing homes very hard. Some random article I found:
    https://chicago.suntimes.com/coronavirus/2020/5/1/21244898/coronavirus-deaths-cases-illinois-nursing-homes-covid-19

    Apparently in IL 44% of all deaths are in nursing homes. I wonder how much this particular type of mass elderly care affects things.

    I certainly have no idea.

    1. Exactly. You can’t just look at one stat and dismiss the idea. In Africa not many people live to be old and sick.

  12. Vietnam, which has a long border with China, and according to the Lancet was one of the top 5 int’l destinations for from Wuhan Int’l airport, has 0 deaths.

  13. Why isn’t this headed “Jake Sullum reads the New York Times so you don’t have to”? Please give us a heads up if this is going to be a continuing feature, so I can cancel my subscription. Anyway, it’s a nice article. Too bad so many Reason commenters are averse to, you know, “reason”.

    1. Why would you ‘have to’ read the NYT?

  14. If you can’t separate the Third World from the First World BEFORE you try to parse reasons for international differences, then really you’re not even fucking trying to understand anything. Those are two separate universes that essentially have nothing to do with other. And virtually every generic comment or analysis or somesuch that one is gonna read in our universe (meaning First World) is only going to apply in our universe as well.

    1. Fuck off and die, asshole. With your PANIC flag jammed up your ass, stick first.
      Make your family proud and the world a better place.
      You may think I’m joking. I’m not: PLEASE FUCK OFF AND DIE

      1. Really, I will applaud the day you die. You, by your existence, cause harm to those of us who wish to live our lives. You are, at best a pimple on the ass of humanity; please fuck off and die.

      2. You may think I’m joking.

        No I don’t think you’re joking. Boring – yes. Pathetic – yes. Sinking into the little hate-filled sewer that comprises the entirety of your soul as you lose contact with reality – yes.

  15. Most of Asia has a culture of wearing masks and had protocols on responding to viral outbreaks since they had to deal with bird flus and the like in the past. We can probably credit the relative success in those regions on preparedness.

    For the rest of the world popularity density, relationship with China and contact all played a role in the spread. NY went out of their way to become the next epicenter and Americans don’t usually wear masks, so they’re a stark contrast to Seoul, which is packed and relies on subways but took early action.

    America is big enough to be its own continent and was basically virgin territory for this kind of pandemic. Looking at Covid numbers in big states, we could probably conclude that car culture and suburbs probably saved them. We don’t ride subways here in CA, and I imagine the same is true for Texas.

    1. BART, Muni, and the LACMTA Red and Purple Lines are all functionally subways.

  16. The numbers are provided by an omnipotent god, but by people with various methods and agendas. The number of cases is proportional to the number tests, if one country tests more they will have more cases. Deaths depend on how it’s reported. Many deaths are people who had other serious conditions. If someone dies who had kidney failure and Covid-19, one country might report the cause as kidney failure, another Covid-19. There is also perverse incentive to over report the number of deaths, as it would justify the extreme lockdowns some policiticans have placed.

  17. Well we do know one thing for, the experts don’t knew either. Beyond the scope of modern bio science

    1. They are sure not about to let that ignorance keep them from knee-capping the world’s economy, with that shitbag lefty JFree leading the way!
      If not, that cowardly piece of lefty shit might catch a cold!

      1. Do you morons have to make everything D vs. R? Even a global catastrophe? What’s the point? To get Trump reelected? But he’s sucking at his job!

  18. This is something which we can not ignore. Its time to live with it now with no other option..

  19. Are people so conditioned to not even consider this was a manipulated event designed for other reasons? When they stop counting pneumonia deaths all of a sudden, but then call them Corona, or someone comes in with a gun shot but are positive for Corona get counted as Corona and not the gun shot, etc. I think we will learn more once it settles down and the investigations are conducted. I think there were players who coordinated and saw this through. Oh, and party politics makes people look so stupid. It’s not D or R, it’s the people vs anyone taking our freedoms. When you ignore the bad and stand for one side, you are part of the problem. We need to clean out the corrupt, and fine tune our original system. It’s been raped, beaten and murdered as is.

    1. If you find yourself thinking everything is a conspiracy, you might need to take extra care in examining your thoughts. It’s a simple tic of the mind. You have trouble believing that things just happen without nefarious human agents behind them. Lots of people have this condition. I recommend steadfast self-reflection.

  20. I’ve been following this closely since mid-March. Population density is the biggest factor in death rates by far. However, most of Asia’s high population cities are nearly untouched. The only factor that seems to jump out is how long a country has had a BCG vaccine program going on (for tuberculosis). I detail this phenomenon on my blog post here : https://notyourdemographic.com/article/2020-05-02-WuhanDailyUpdates/

  21. Gosh, it might just be a complex problem with multiple causes!

    1. No, it’s all due to CO2. If you get the bug you can’t get rid of your CO2 fast enough and die from that.

      CO2 is the root of all Earths problems!

  22. A coworker on a conference call referred to the “Wuhan virus nonsense.”

    I wonder, is it nonsense, or is it a plot by China? Did China create a nonexistent threat? How can something be both an evil plot and overblown nonsense at the same time?

    Why is racism the one place Trump goes every single goddamn time he’s trying to blame someone else for his idiocy?

    1. I mean, hundreds of thousands of people aren’t dying all over the globe because Trump messed up somehow. The virus came from China, the Chinese and WHO covered up crucial detail, and most everyone thought this was just another flu for most February and parts of March. Solve the equation.

      If this outbreak originated in AL and its GOP governor suppressed relevant information, the left would screaming murder and urging boycott of the entire state. Trump didn’t kill anyone. China did. China has been killing and sending Muslims to concentration camps for years now. Get the facts straight.

      1. Both China and Trump can be evil.

        He wants to dust off any responsibility of his own by blaming China. That much is clear. But his response as the head of state in the country with by far the worst outcomes is on him, and he continues to spin fairy tales in place of doing anything about it. We have models for how successful countries beat back the illness, and we’re ignoring that in favor of “It’s not so bad” and recently “What’s a few hundred thousand dead when there’s a GDP to consider?”

  23. The obvious answer is that they are measuring different corona viruses. The common flu/cold (corona virus) comes in many variants that exist at the same time and they also mutate rapidly; that’s why they can’t come up with a catch-all vaccine. Anyway, this really is no big deal – idiot politicians are following the advice of incompetent medical technocrats in a virtuous (for them) cycle of nonsense. Unfortunately the politicians get to act like heroes and become more popular as these issues seem to be beyond the grasp of the average person.

  24. Here’s a pretty good epidemiological report (I think) on Youtube.

    Get the latest information from the CDC about COVID-19.

  25. New York City is a definite outlier, in terms of statistics.

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