International Policy Digest

World News /26 Apr 2020

COVID-19: Global Mortality Rates and Policy

Government policies combined with characteristics of a state’s population are critical in comparing mortality rates among nations with COVID-19 outbreaks.

As for contexts or conditions, it seems reasonable in our present state of knowledge to examine the mortality rates in relation to national income estimates, population size and other demographic characteristics, in addition to air pollution, urbanity, medical resources available prior to the virus, and an acceptable estimate of social health and welfare.

Measures relating to crude size of population, cases per capita, and so on tend to introduce too much in the way of luck and irrelevance. Features such as climate, proximity relative to existing or developing sites of hyper-infection are of importance but are closely related to the incidence of infection as opposed to mortality rates. Using these conditions as precursors to mortality is problematic. The early belief that COVID-19 loses its potency in hot temperatures or humid conditions has not yet to be scientifically proven as relevant.

This approach initially omits government or broader official management responses to the virus. This is done deliberately in order to isolate these responses as possible alternative explanations of the variations in mortality rates. It is reasonable to conclude that the invasion of the virus came as a shock to all forms of governance, and that we would expect to find confusion, doubt, uncertainty in action and conflict in planning during the early stages. These, in turn, may have created unnecessary expenses, phases of paralysis, or lateness in acting, alongside growing disaffection between civil society and government. All nations that allow public dissent would suffer the consequences of this disaffection. Regardless, we are investigating cases of measurable deviation from the average of mortality rates that cannot be explained without examination of factors discussed below.

For this method, we need comparable cases. Some nations are poles apart in levels of economic development, while some nations have a high number of cases, others having surprisingly low. In order to make sound conclusions, the case characteristics of nations in question must be similar. As we shall explore, the most useful strategies for combating mortality are not necessarily the most expensive, and this could be of value to the immensely large and vulnerable poor portions of our world. However, it should also be emphasised that this is an interim report in the middle of the virus attack.

In order to minimise interference from cases of variation based on very low numbers, we combined nations into three distinct groups. It is important to note that the three groups represent 33% of the world’s population but 68% of the world’s known virus cases as late April 2020. The East Asia six – China, Japan, South Korea, Taiwan, Singapore, and Hong Kong – were the earliest nations under the virus’ attack. The six nations of the Western Core – the United States, Italy, Spain, France. Germany and the UK – were close followers. The six African nations – South Africa, Egypt, Morocco, Algeria, Cameroon, and Tunisia – are chosen as is the case with all 18 nations, as the countries with the largest numbers of COVID-19 infection registered in their respective regions, and appear to be on the brink of a virus attack congruent with what we have seen in the West and East Asia.

A member of the U.S. military operates a drive-thru screening for COVID-19.

As of April 19, the aforementioned 18 nations have experienced a combined mortality rate of 7.8%. The global average on April 19 was 6.9% which emphasizes the severity of the virus outbreak amongst countries in this study.

The weight of group one, the Western core, in the total number of virus-infected cases is large. The Western core represents 92% of confirmed cases out of the selected 18 nations. The U.S. dominates this number with the greatest number of COVID-19 cases in the world, totaling nearly 800,000. Most significantly, the mortality rates or deaths of this group as a percentage of their total cases, indicates a much higher rate at 8.0%, than those for groups two and three. Germany is performing well within this group considering its low rate of mortality of 3.1%. However, the U.S. registers a low rate (5.3%) by virtue of its enormous base of cases. The highest mortality in this group, that of 13.5% in the UK, is only surpassed by that of Algeria in group three. Apart from sheer size, do any of our suggested socio-economic factors explain the unusual contrasts between the U.S. and the UK?

The human development index or HDI, which is commonly used as a composite index measuring social health and welfare through life expectancy, education, and per capita income indicators, is almost identical in the U.S. and the UK. Estimates by the World Bank on effective per capita income levels measured through international purchasing power certainly do show differences in incomes, though not extreme. The significant difference between the UK and U.S. relates to population density, or population per square kilometre, where the much greater population density of Britain – some eight times that of the U.S. – could well come into play.

Complicating and seemingly counteracting this is that the only other great difference between the two nations lies in per capita emissions of carbon dioxide, where the much higher emissions per capita in the U.S. (eight times the UK figure) might be expected to work strongly against that nation’s lower mortality rate. Furthermore, in that group both the U.S. and Germany, the two nations of lowest COVID-19 mortality, are also those of higher carbon emissions.

Other measures such as the proportion of aged citizens, the degree of urbanism, and the general welfare of populations represented by their HDI generally, show no great differences, not only between the UK and the U.S. but within the total group. Within group one, no element or clutch of elements seems to explain significant differences in mortality rates.

The East Asia six, group two, share significantly low mortality rates, down to 2.2% for large population nations such as Japan and South Korea, and the singularity of 0.2% for Singapore. These nations share high levels of income, high measures of social welfare, but also high levels of air pollution. Urbanism varies significantly within the group as does the figure for hospital beds per thousand of the population, but such variations do not correlate with the variations in mortality rates.

Outstanding features of the group include that they were the earliest to suffer COVID-19, are proximate to the original epicentre, and have low mortality rates but high levels of air pollution. Smaller populations have lower mortality rates, but it should be noted that Japan with a population of over 127 million – far larger than the European nations – has a mortality rate far lower than its Western counterparts, standing at 2.2%. This number is around only one-sixth of that of France, Spain, Italy, and Britain. Tentatively, we might conclude that groups one and two in combination represent the COVID-19 global core. On their mortality rates, the characteristics of their state suggest that air pollution, income levels, and even general social welfare may be discounted as effective explanations of rates of COVID-19 mortality. Interestingly, initial hospital resources, measured here as hospital beds per 1,000 persons, might be of importance. Thus, Korea, Japan, and Germany have impressively low mortality (2.2%, 2.2%, and 3.1% respectively) and the strongest hospital capacity of the 18 nations. Korea and Japan are the only large nations with mortality rates around 2%.

A woman in Cairo, Egypt wears a surgical mask. (Xinhua)

Group three, the six African nations with the highest numbers of COVID-19 infection cases, share low levels of income and low estimates of social welfare measured in monetary terms by the HDI. These nations also significantly vary in mortality rates, ranging from the high 14.5% of Algeria to the low 1.7% of South Africa. This range is a plausible function of the comparatively later date of COVID-19 attack in each respective country. Great variations in the date of infection impede our ability to make legitimate comparisons between data because there are varying times in which the virus may pass from infection to mortality. The first African nation to register a COVID-19 case was the United Arab Emirates (29 January), the first in our group of six nations was Egypt (14 February), the last in our group was Cameroon (5 March).

Timing is a major determinant for Africa’s mortality rate at this stage of global infection. However, there are interesting features that we may use in our forecast. Given what we have argued about groups one and two, it is noteworthy that the African group has relatively low levels of air pollution, a much smaller proportion of the population that is over 65-years, and a lower density of living. We may even claim that it might not be paramount that Africa is significantly poorer or that its measured social welfare is lower than in groups one and two, for it has some real advantages that might begin to hold down mortality rates as weeks go by.

Measuring air pollution per capita using the Emissions Database for Global Atmospheric Research, South Africa is the only nation (with emissions at 8.3) that approaches the East Asian average of 9.8 or the Western core at 7.9 metric tons. The other five African nations have a per capita average of only 2.3. The proportion of over 65-year olds in their populations averages 6.1%, compared to 17.5% for the East Asia group, and 20.5% for the Western core. Finally, the average population density per square kilometre for the African six is 61, that for East Asia is 2,721, and that for the Western core is 157.

The low proportion of over-65-year-olds in the African six could be of exceptional importance, as this virus particularly targets those of old age. Where many other viruses have been lethal for younger demographics, COVID-19 relatively spares the age group. In groups one and two, the cases of middle-age mortality have so far usually been associated with immune deficiency or repeated exposure and infection, especially amongst medical and care workers. Combined with a very low density of living and a very low level of air pollution, Africa might be standing in a reasonably good position. It is this peculiar combination that forces us to conclude with the implications of this paper for policy, both that of the recent past and the potential future.

Remaining with mortality rate as our measure, our data suggests that there is no overwhelming factor amongst standard measures that explain the great variations between the 18 nations. Income and welfare, seemingly obvious conditioners, do not do the job. Levels of air pollution are just too contradictory to be trusted- Germany, South Korea, Taiwan, and South Africa are all highly air-polluted yet have very low mortality rates. Across all nations of the world, and over the long period, variations in income may begin to provide insight, but presently they do not.

From a group of nations harbouring over two-thirds of all COVID-19 cases in the world, no obvious demographic, geographic or economic elements stand out as an active determinant of COVID-19 mortality, nor do a related clutch of factors presently emerge. Yet, mortality variations are significant. We are left with two other possibilities. Variations of mortality primarily arise from variations in government policies, and the relations between civil society and government. In the case of a global pandemic, official policies matter but their effectiveness depends upon civil society responses. Managing COVID-19 depends on politics and the cultures within which political systems are forged.

We recently learned that the U.S. state of Georgia, in opposition to large amounts of stormy criticism, will part from the national project and policy prescription of what has come to be called ‘lockdown.’ With a population of less than 11 million and a figure of confirmed cases of 19,000, greater than the number for Japan, Singapore, Hong Kong, and Taiwan combined (population 164 million), Georgia is now opening its economy outwards.

This decision is exemplary. No equivalent can be found in East Asia. Perhaps obeisance is not unexpected for China, but the five remaining countries of our East Asia group are democratic and can erupt in chaos, from the incredible overturning of governance by a group of Taiwanese students in the Sunflower movement of 2014, to the still burning civil disobedience and political radicalism of a large segment of the population of Hong Kong. The strong interpretation of transitory but global evidence is that political systems are not determinants, but management-oriented regimes are proving strong in wearing off the virus. The Western nations of high mortality rates are associated with policies that have been variable, stilted, and incomplete. The mortality rates of China and the United States are similar, but few people in those countries or elsewhere would claim much equivalence between their political systems. Disobedience and disturbance are now arising in the West as a result of the virus, little of which has been identified for East Asia.

Government policy that is early and clearly directed at identifying, testing, and then treating COVID-19 works best in a culture of acquiescence rather than one of legislated conformity – it is not by chance that a favourite term used by all of British media and governance is ‘compliance.’ This might be acceptable if it was not confused by often rigid policing and monitoring. The British official policy of ‘following the science’ as an additional ‘authority’ also ended in adding academic doubt to popular confusion. We might admit that luck could contribute to mortality rates.

An exemplary case is worth ending with. While a grad student and young academic in the 1970s, I lived and traveled around East Asia, especially Japan. It was impossible to ignore the commonality of the face mask. Face masks were worn by everyone with a cold, everyone riding or driving during the crowded and thus polluted rush-hours, anyone visiting the hospital or anyone attempting some city jogging. In the East, COVID-19 simply invited more of the same, and masks remained ubiquitous and familiar. Meanwhile, in the West, we had ‘scientific reasons’ to believe that masks were of little use and promoted carelessness in social distancing. So, now we quarrel about whether government should admit with medical science that there might be a case for masks amongst healthcare workers, but in doing so deny the behavioural science that advises not to publicise this new-found efficacy, for to do so would create a huge demand for masks amongst the general population, and this would cut supplies to hospitals. Meanwhile, East Asia manufactures masks, wears masks, sends masks to the West, and registers very low mortality rates.