The counterintuitive anomaly of Covid-19 deaths concentrated in high- and middle-income countries needs to be researched
The ignominy of the highest death per million, however, goes to the UK (1830) and not the US (1618). (Representative image)
The Covid-19 pandemic has now been around for one full year. The outbreak began in China. On March 6, 2020 there were 3,384 Covid-19 deaths globally, of which 3,098 were in China. The epidemic was, however, stopped in its tracks in the place of origin over the next six weeks, even as it spread rapidly to Europe and the Americas. China, meanwhile, has reported just four Covid-19 deaths since April 20, 2020, and current mortality is 3 per million. The accompanying table traces the course of the Covid-19 pandemic in 33 major countries over the past year through six weekly snapshots beginning March 6, 2020. These countries account for 71.2% of the global population and 85% of Covid-19 deaths. Aggregate continental mortality is shown separately. Comparisons are made through mortality per million to control for differences in population across countries.
The countries are divided into three regions, namely the East Atlantic and Mediterranean (15 countries), the West Atlantic comprising North and South America (10 countries), and Asia excluding West and Central Asia (8 countries). As of March 6, there were 2.6 million (336 per million people) Covid-19 related deaths globally, 80% were in Europe and the Americas, which account for just 23% of the global population. The average Covid death rate is now about 1,200 per million in these regions.
Asia, Africa and Oceania, with 77% of the global population, account for just 20% of Covid-19 deaths. The average death rate in these areas is significantly below 100 per million. The share of Africa drops to 0.9% (with 13.9% of the population) if Egypt, Algeria, Morocco and Tunisia, all bordering the Mediterranean, and South Africa, are excluded. Likewise, the share of Asia and Oceania falls sharply once West and Central Asia, bordering Europe and included in the East Transatlantic-Mediterranean region, are excluded.
Mortality in five countries has crossed the 100,000-mark. Expectedly, four are located in the transatlantic region—the US (535,563), UK (124,261), Brazil (262,948) and Mexico (189,578). India (157,693) is the only country outside the transatlantic to cross the six-digit mark. Although its mortality has fallen sharply over the last few months, it remains twice that of its neighbours, Pakistan (59) and Bangladesh (51), on account of high legacy deaths.
Although Covid-19 mortality is nowhere near the Spanish-flu levels of 1918-19, the US stands out as a notable exception. Not only is its mortality by far the highest globally, accounting for about a fifth of all Covid deaths, but its aggregate mortality is approaching the toll during the Spanish Flu, estimated at 675,000. The ignominy of the highest death per million, however, goes to the UK (1830) and not the US (1618).
The data shows that the second wave began around October 2020 and peaked in the six-week period between December 6 and January 21, except in the West Atlantic, where mortality during the last six weeks is the highest on record and is now receding slowly. This process is likely to be helped on its way by the mass vaccinations currently underway. The second wave is notable by its absence in Africa and Asia, barring the mystifying rise in Indonesia and Japan, albeit on a relatively low base. The pandemic started receding in these continents even as it entered the deadly second wave in other parts of the world from October 2020.
In view of such skewed mortality, the question is whether Covid-19 is really a pandemic, or a Transatlantic phenomenon, extending up to the Mediterranean regions of Central and Western Asia and North Africa. The average Covid-19 mortality in this region exceeds 1,000 per million. The highest mortality outside these regions is much lower barring South Africa (845), Indonesia (134), India (114) and Philippines (113)—all located along major shipping lanes. The very high death rate in South Africa is puzzling and needs to be explained.
The counterintuitive anomaly of Covid-19 deaths in high- and middle-income countries also needs to be researched. Currently, racial, epidemiological and immunological differences seem to be the villains. But there are probably other variables lurking in the shadows waiting to be uncovered.
Covid-19 mortality of 2.6 million (335 per million) is nearer to the 1957-59 and 1968 influenza epidemics, where the death toll is estimated in the 1-4 million range (330 to 1300 per million). Nevertheless, parallels are sometimes drawn with the Spanish Flu of a century ago, where the toll was much higher, estimated contemporaneously at a little above 20 million, and since revised upwards to at least 50 million, or 26300 per million when controlled for the population. This is perhaps because both were characterised by a second wave that was deadlier than the first. The Spanish flu petered out after a milder third wave. Covid-19, too seems headed in that direction, with vaccinations on a mass scale making it likely that a third wave may be avoided altogether. Mutations, however, remain the joker in the pack.
Medicare and hygiene levels were much poorer in 1918, and the rampant World War-I made social distancing difficult. Autopsies reveal most of the spanish flu deaths were on account of bacterial coinfections with common species of the upper respiratory tract, such as Streptococcus pneumoniae. Antibacterial interventions and pneumococcal immunisation have since reduced influenza mortality over the years. It is unlikely that the Spanish flu would have had such high mortality if it had occurred today.
The relatively high Covid mortality despite the availability of good medicare in countries with the highest mortality is because, first, unlike ordinary influenza, severe and fatal SARS-CoV-2 infections do not result from the combined occurrence of viral and bacterial pneumonia. They arise out of secondary vascular and inflammatory disease in which immune responses dysregulation and host factors have a role. These are still little understood. The earlier coronavirus epidemics, although as deadly as Covid-19, were not as contagious, and so mortality could be contained. This is not the case with Covid-19, which is both deadly and highly contagious.
RBI chair professor in macroeconomics, Icrier. Views are personal