COVID-19 Around the World: Why Do Different Countries have Different Outcomes?
We’ve watched the horror story unfold around the world. Dead and dying in Italy. Infected and suffering people in Spain. We’ve seen images of COVID-19 patients lining the hallways in New York City hospitals at the peak of the pandemic.
However, despite those images, the truth is that COVID-19’s impact varies dramatically from nation to nation. What is the mechanism responsible for such drastically different outcomes? Is it all related to early and effective lockdowns, or is there more at play?
The Situation Around the World
The SARS-CoV2 virus has circled the world, mutating as it went. In response, hundreds of nations, each with its own healthcare system, political system, and stance toward mitigating the spread of the virus have experienced dramatically different results in terms of infections and deaths.
For instance, in early May, the United States had 1.291 million cases, while Sweden only had 25,921 cases. The US had seen almost 78,000 deaths, but Sweden had seen 3,220 deaths, giving the US a case-fatality rate of 6.0% and Sweden a case-fatality rate of 12.4%. With differences between population size adjusted, why did Sweden have double the CFR? Meanwhile, Japan had seen over 15,500 infections, but only 590 deaths, with a CFR of just 3.8%. What was it that Japan was doing that made their efforts so much more effective in saving the lives of patients?
While it would be, the truth is much, much more complicated. There is no single factor that we can point to as the primary driver. Multiple factors each play a role in infection rate, death rate, and other outcomes.
Delving into the Underlying Reasons
While there, we can glean insights from different factors in play. These range from the degree and speed of lockdown to the particular strain of the virus circulating in each country. For greater understanding, we need to look deeper.
The Extent of Testing
One factor with a significant impact on reported numbers is the availability of testing. However, the results of wide–spread testing do not seem to skew the data higher. Asian nations with greater access to testing have experienced both lower infection rates and lower death rates. The US and some European nations (such as Spain) had less accessible testing, at least during part of the pandemic, but have trended higher in both infections and deaths when compared to most Asian nations.
What constitutes a COVID-19 death? That’s a seemingly simple question with multiple, complicated answers. For instance, during the initial days of the outbreak, China required that a deceased individual’s case meet a minimum of six criteria related to the virus for it to be counted as COVID-19-related. This skewed China’s numbers down, resulting in what could be a five-fold underestimation of deaths at that time.
It is also important to understand that, like the virus itself, our understanding of how COVID-19 works continues to evolve. That means each nation’s definition of a COVID-19-related death has evolved, too. As an example, in mid-April, the CDC in the US had begun counting both confirmed and suspected COVID-19 deaths.
Complicating the picture is that COVID-19 is rarely the direct cause of death, considering that the majority of patients who have died from it suffered from underlying conditions. Because the disease exacerbates symptoms of those conditions, a percentage of deaths may go unnoticed and unreported. Even when they are reported, it can lead to controversy and cries of “conspiracy” such as has been seen in many areas of the United States.
One suspected cause of death with COVID-19 has nothing to do with the virus itself, and everything to do with a viral infection opening a pathway for dangerous bacteria. Italy in particular has seen a significant number of COVID-19 patients die due to antimicrobial resistance. One-third of all such deaths in the EU come from Italy. In these patients, it is possible that the virus opened the way for a condition like drug-resistant bacterial pneumonia. Because it was resistant to antibiotics, it could not be treated, resulting in death from pneumonia, not the virus.
A significant number of COVID-19 deaths occurs among older populations. This is another contributing factor to the strange skewing of statistics around the world. Ultimately, it relates to the average age of a nation’s population. The older the overall population, the higher the incidence of death. The younger the population, the lower the overall death rate, although younger populations did not necessarily see lower rates of infection.
Most Western nations have significantly larger aged populations than do Asian and African nations. For example, 16% of Italy’s population is 70 or older, while Asian nations come in around 3%. For example, the population of over-70-year-olds in Thailand is under 4.4%. However, that does not apply in all cases. Brazil is an example of a nation with a large younger population that has still seen high death rates from COVID-19. Japan is the reverse – a larger aged population but remarkably low death rates.
Healthcare System Capabilities
The quality of care a patient receives, the availability of skilled medical practitioners, and other healthcare system-related factors are critical for preventing COVID-19 deaths. Nations such as Japan, with universal healthcare and access to high-quality medical facilities, have seen lower cases of patient deaths. Conversely, nations like the United States, without universal healthcare, have not fared as well.
It is also important to understand the impact of a spike or “hotspot” on the local healthcare infrastructure. Italy and New York’s healthcare systems were overloaded by the significant, sudden rise in cases, leaving fewer resources available to treat all patients.
Many of the nations that experienced low death rates were the most prepared for a viral outbreak. Hong Kong and Singapore are both excellent examples of nations with robust preparedness solutions in place. Canada also ranked very well, thanks to its experience during the 2003 SARS pandemic. Other nations that did not fare as well lacked such planning and preparedness, while the United States had recently deconstructed its pandemic task force and dismantled many of the protections originally put in place in 2003.
SARS-CoV2 is spread by direct contact, as well as in aerosols. Good personal hygiene is a vital step in stemming transmission, which means that nations with better than average habits in this area will see lower rates of transmission, infection, and death. This, at least in part, is what has helped Japan stave off the worst. The population regularly washes their hands and avoids hugging and handshakes. Many people in Western nations do not practice regular handwashing, which increases the chance of viral spread through contact with the individuals, but also contact with contaminated surfaces.
Despite many Westerner’s aversion to wearing facemasks, evidence that shows masks are effective. However, even Americans and Europeans who now embrace masks were at first put off by WHO recommendations (and CDC recommendations) to avoid wearing masks. Many Asian nations have populations that have worn masks for years due to pollution and fears of communicating viruses. Because of this, they may have had an advantage in limiting the virus’ spread.
Obesity is a critical factor that contributes to COVID-19 mortality. Studying obesity levels around the world, it becomes clear that nations with more obese people saw higher levels of severe side effects and death. For instance, almost 20% of Italy’s population is counted as obese, and over 36% of the US population is obese. Contrast that with just 3.9% of India’s population and 4.3% of Japan’s, both nations with a low number of COVID-19-related deaths.
The Evolution of the Virus
Viruses evolve rapidly, and SARS-CoV2 is no exception. New evidence shows that the virus mutated significantly as it moved from Asian nations into Europe, becoming more resilient to environmental conditions and more deadly at the same time. Couple that mutation with the cooler, more virus-friendly climates of Europe and parts of America, and increased transmission rates are seen. However, this is not applicable in all situations, as some South American nations with warmer climates also saw higher transmission rates than Asian nations.
A Complex Picture
SARS-CoV2 is a novel virus. As such, our understanding of it and its effects continues to evolve. Likewise, the virus continues to mutate and change, giving us yet more to learn. Add to this the myriad of factors discussed previously and we can see just how complex the picture of infection and COVID-19-related deaths truly is.
It also serves to highlight how deeply connected our globalized society has become and how seemingly unrelated factors, such as body fat percentage or personal hygiene habits, can affect an individual’s likelihood of contracting the virus. Because of the complexity, it will be many years before we fully understand the varying impacts COVID-19 has had on different nations around the world. In the meantime, we all have a responsibility to follow what science has taught us in the past months: socially distance when possible, wear a mask, and take seriously the potential consequences of outbreaks in our communities.