It has become commonplace to compare covid-19 outcomes in one country to another.
By now you’re all familiar with the arguments…
“Country A did better. Country B did worse. Country A and their leaders should be praised; Country B and their leaders should be condemned.”
Lost in these simplistic conclusions are the many important factors that could have lead to different outcomes.
Without examining these factors, comparing covid-19 outcomes in any one country to another is problematic to say the least.
The world is not homogenous. What you’ll find in a cursory look at various countries are vast differences in:
- Testing rates.
- Measurement, reporting and classification of deaths.
- Demographics (health/age of populations) and density.
- Cultures.
- Privacy laws.
- Forms of government.
- Timing and luck.
These differences, in turn, can lead to sizable differences in observed or reported outcomes. Let’s delve into each of these to illustrate just how important each factor can be.
1) Testing Rates
At nearly 1.4 billion people, India’s population is over 4 times as large as the United States.
Thus far, India has reported 7.6 million cases and 115,000 deaths versus 8.4 million cases and 225,000 deaths in the US (source).
Based on these facts alone, one might conclude that India has done a much better job in controlling covid-19 than the US.
While that may in fact be true, it is impossible to say with any level of certainty.
Why?
The US has tested the equivalent of 38% of its population (127 million tests) while India has tested 6.8% (95 million tests). This wide disparity in testing rates is most certainly leading to fewer identified cases in India and likely leading to fewer identified deaths as well.
“The deaths are certainly being undercounted because a lot of people who die without getting a Covid test aren’t counted as Covid deaths,” said Ramanan Laxminarayan, a senior research scholar at Princeton University.
2) Measurement, Reporting, and Classification of Deaths
The first case of covid-19 has been traced back to at least November 17 in the Hubei province of China, and China did not start its lockdown until more than two months later (January 23).
We now know how quickly the virus spreads and the approximate fatality rates. Given that knowledge and the fact that China has over 1.4 billion people, what are the odds that the number of covid-19 deaths in China (4,634) is less than half that of Belgium (10,443), a country with only 10 million people?
0.
Confirming these odds is the fact that China hasn’t reported a single covid-19 death since mid-April, over six months ago.
Over that same time period, South Korea (a country that has one of lowest number of infections and widely viewed as one of the best in terms of its handling of the virus) has reported 220 deaths.
We’ll never know the true number of covid-19 deaths in China, but without question it is higher than what has been reported.
This is not only true in China, but many other countries as well. There are obviously huge incentives for leaders to underreport covid-19 deaths and portray an image to the public that is rosier than reality. Those in power want to remain in power.
3) Demographics & Density
All covid-19 cases are not equivalent, not by a long shot. Who gets the virus is everything in terms of fatality rates. Using fatality data from the CDC based on age groups, I’ve estimated the risk of death for those in 85+ group is 13,800x higher than children 5-14 years old.
All else equal, if a county has a younger population, you should expect fewer fatalities from covid-19 when compared to a country with an older population.
Iraq has a median age of 19.7 with 50% of its population under 20 while Italy has a median age of 44 with 18% of its population under 20 (source). Given this disparity, it is not at all surprising to see Italy’s deaths as a percent of its population (0.061%) considerably higher than Iraq’s (0.026%).
In addition to age, underlying health conditions are an important factor in covid-19 fatality rates. Countries with higher obesity rates (and as a result, higher rates of diabetes, etc.) would be expected to have higher fatality rates (all else equal).
The US is in this category with among the highest obesity rates in the world.
Given the highly contagious nature of the virus, population density can also play a role in covid outcomes, as social distancing becomes increasingly difficult in higher density areas.
The Netherlands has a population density that is 34 times higher than Norway. It is not surprising to learn that the Netherlands has a significantly higher case count (14,253 cases per million) and death rate (397 deaths per million) as compared to Norway (3,069 cases & 51 deaths per million).
4) Cultures
No two cultures are the same and when it comes to covid, even small differences in culture can have a large impact on outcomes.
A few examples:
-In some cultures, it is customary for multiple generations to live together, which increases the risk of spreading the virus to an elderly family member.
-In some cultures, kissing, hugging and shaking hands when greeting is customary, which will in turn increase the risk of spreading the virus.
-In some cultures, socialization at bars, restaurants, and large gatherings (weddings, religious ceremonies, etc.) is a big part of everyday life. These have all been shown to increase the risk of spread.
-In some cultures, particularly in Asia, mask wearing was customary, even before covid-19. This was likely a huge advantage in curbing the spread of the virus.
5) Privacy Laws
South Korea has a government-mandated smartphone app that tracks your every move. When a covid-19 case has been identified, the government sends a message alert to all those who were in locations near that person in the recent past.
While this approach has been extremely helpful in contact tracing and testing, there are a number of privacy concerns (to start with, personal data from the app has already been hacked). In countries with more stringent privacy laws such as the US, it would be nearly impossible to implement such an approach.
6) Forms of Government
Authoritarian forms of government such as China make unilateral decisions with no input or pushback allowed from the general public (in fact, any such pushback is quickly reprimanded and erased from the record).
Some of the draconian methods reportedly used by China…
- Spraying detainees with acidic disinfectant.
- Physically locking residents in homes.
- Imposing strict quarantines of more than 40 days and arresting those who do not comply.
- Forcing residents to swallow medicines.
Needless to say, such methods would not fly in most countries.
In democracies like the US, everyone has a voice, and each state has acted almost like a separate country. From state to state, the differences in response to covid-19 were many, from whether or not to shutdown, to how long to shutdown, to which businesses should be allowed to open, to whether schools should be allowed to open, to whether masks should be voluntary or mandatory.
The government in Singapore mandated all nursing home employees to move to hotels to reduce their interaction with the community. This was said to significantly reduce the death rate as the elderly population was protected. How many countries could forcefully execute such a plan?
7) Timing and Luck
The role of timing and luck is rarely discussed when it comes to covid, but they may end up being the most important factors of all.
All throughout the pandemic the media has been quick to praise countries for their response (as if the story had already ended) only to see spike in cases and deaths a few months later.
I’ll give you two examples but there are countless more (see feed here)…
a) Argentina had one of the longest and strictest lockdowns and was widely praised for its efforts, “showing the world what a humane covid-19 response looks like.”
Fast forward to today and Argentina’s cases and deaths have exploded to one of the highest per capita in the world.
b) The Czech Republic was said to have “beaten” covid and even had a “farewell party for the pandemic.”
Fast forward to today and its outbreak is surging higher.
Were Argentina and the Czech Republic really models for the world to follow or just lucky in that the virus had yet to hit them hard?
Lessons Learned
The takeaway here is that simplistic comparisons of one country to another are almost always flawed as there are so many complicating factors that can obscure the truth.
Does Russia really have one of the lowest death rates in Europe or do the factors above make it impossible to compare it to the UK, Italy, France, and Spain? You are now better equipped to answer that question.
Even if two countries were exactly alike, there is no one “right answer” as to what the best course of action is.
Do you follow a more draconian approach in an attempt to save every single life (which is impossible) or strike a balance between enacting protective measures while still maintaining basic freedoms and our way of life? Initially, when there were many unknowns, much of the world took a somewhat draconian approach (of varying degrees). But upon realization that the downside of such an approach was far too costly (not just in terms of dollars, but in overall mental/physical health) to sustain for very long, it quickly morphed into a series of tradeoffs.
It’s impossible to say what the right balance to take is because the ending to the covid-19 story has yet to be written. We don’t know how long the virus is going to be with us and how vaccinations and future treatments will alter its course.
The good news is that we know so much more about the virus today than we did back in March. From testing to treatments, we have shown dramatic improvements which often gets lost in the heated debates. To be sure, there’s still more work to be done. But I’m confident that if we can work together and continue to push forward, we’ll eventually beat this scourge once and for all.
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