The mortality values are dispersed in an incredibly wide range of from 6030 people per million for Peru (the 1st in the list) to merely 3 people per million for China (the last in the list). Following is an attempt to find factors causing the differences among the countries.
Generally,
it is estimated that more than 50% but less than 75% Covid deaths have been
missed globally (here). However, developing countries usually report
much less deaths than developed countries, and much less of positive cases as
well, which mostly results from the lower number of performed tests.
Furthermore,
the countries differ in the procedures for completing the death certificate –
whether an external examination is needed or who completes the certificate. For
example, in Austria and Germany, any death must be subjected to an external
examination by a physician, but not in England during the Covid pandemic, when
a death can be confirmed in the absence of an external examination. In Italy,
the death certificate must include Covid-19 as a cause of death when the
SARS-CoV-2 is suspected (here). That would place Germany and Austria behind
Great Britain and Italy in the deaths counts, and indeed, the four mentioned
countries are ranked 67th, 56th, 30th, and 25th,
respectively (see the Table), so that Germany and Austria would be relatively
underreported.
Underreported
deaths and confirmed cases due to less tests
The number
of tests performed per 100 people in the country (also shown on Worldometers)
may affect the number of identified deaths and positive cases. For example,
United Kingdom performed 630 tests per 100 people and Germany performed only 106
tests per 100 people, which might have affected the identified deaths and
positive cases: about 2200 deaths and 220,000 cases per million in the UK and about
1400 deaths and 95,000 cases per million in Germany, respectively.
Developing
countries are mostly in the second half of the list of 222 countries (or regions)
arranged according to the decreasing number of deaths, testing less than 50 people from 100, or even less than 4 per 100. Indonesia with a
population of 278 million is 119th in the world list of mortalities,
India with 1.4 billion population is 130th, Egypt with 103 million
is 143rd, Nigeria with 213 million is 197th, and China
with 1.4 billion is 208th. Similar results are obtained when
arranging the countries according to decreasing number of positively tested
people (confirmed cases). The developing countries have younger population,
which can partly explain lower mortality, but low testing and underreporting the
dead and the ill surely contribute to the low values of reported deaths and confirmed
cases.
Overreported
deaths
Some
countries may have reported more deaths for various reasons. For example, Peru
which is ranked as the 1st in the world in the number of deaths per
million, may report a higher number of deaths due to a one-off correction which
has tripled the previous official Covid-19 deaths value in order to align it closer
with the excess mortality values (here, here). The real Covid mortality in Peru thus might be
closer to Bulgaria, ranked the 2nd, or possibly even to Romania,
ranked 11th; anyway, the lower healthcare standard, including access
to health coverage and the number of intensive care beds, have surely had to contribute
to the Peru’s high mortality too (here).
The Czech
Republic, ranked 8th, motivates hospitals to report patients as
Covid-infected, because the health insurance companies pay to the hospitals ten
times more for Covid patients than for other patients (here), which substantially helped the hospitals in
their payment balance (here). The U.S., ranked 20th, also
motivate the hospitals to report Covid cases (here).
High
deaths in the former communist countries
Of the
first 19 highest-deaths countries, 15 are the former members of the Soviet
bloc. Most of these countries have since progressed toward the Western democracies;
however, it can be hypothesized that the originally lower standard of the
health system may still have some effects, and interestingly also that the
Covid most vulnerable people, namely aged 65+, lived an important part of their
lives under said very unhealthy regimens exhibiting not only the low standards
of the healthcare, but also very bad environmental and nutrition situation.
Although it
seems that the former East German regions do not exhibit higher mortality than
the former West German regions, mortality from preventable and treatable causes
in EP is the highest in Hungary, Romania, Latvia, Lithuania, Estonia, Slovakia,
Croatia, Bulgaria, Poland, Czechia, and Slovenia (here).
Excess
deaths due to low-quality healthcare
Excess mortality in 2020-2021 has been higher than reported Covid-19 deaths in some countries in Eastern Europe, Africa, Mexico, and India. Even before the pandemic, an estimated five million deaths annually worldwide were allegedly due to low-quality healthcare. Excess deaths, however, may also have substantial natural annual fluctuation; e.g., Australia and Thailand saw 7% increases in deaths in 2019 versus 2018. Moreover, excess deaths in 2020-2021 reflect both Covid-19 and several death causes that possibly increased or decreased during the pandemic; death certificates have always been inaccurate, and financial incentives promoted some values (here).
For
example, the excess deaths per million people during the first 18 months of the
Covid-19 pandemic were 2474 in the U.S. (corresponding roughly to the present Covid
deaths), 4456 in Mexico (more than the present Covid deaths), and even minus
277 (curiously decreased mortality) in Norway, which reports 246 Covid deaths (here).
Low deaths in the island countries
The island
countries have relatively lower deaths values, including Ireland, Malta,
Cyprus, Japan, Iceland, Australia, Taiwan, and New Zealand. Some geographically
relatively isolated areas, mostly peninsulas, also exhibit low deaths, such as
Denmark, Singapore, and South Korea. These regions have probably been also more
motivated than others, and have had better means, to introduce stricter
protective and isolating measures.
The
effect of the population age
With an
increasing age, mortality increases three times for every ten years (here). Therefore, most deaths afflict people 65
years or older. This fact can explain, for example, the difference between the
mortality values of Sweden and Israel, namely 1504 and 887 per million,
respectively. Sweden has 20% people being at least 65 years old, whereas Israel
has only 10% people of this age. So that (1504/2 =) 752 deaths could be
expected for Israel; the real value of 887 is not far from that.
The
effect of the government measures
Strict
measures in the mentioned island or peninsula countries may have restricted the
epidemic spread. Several other countries, including Norway, have managed to
keep the number of cases and deaths lower, probably due to the strict bans on
travel and contacts. However, most countries do not show a clear correlation
between strict measures and lower deaths. The above example of Sweden and
Israel can be cited also here: Israel has introduced severe lockdowns, travel
bans, and compulsory masks, but still it has had more deaths than would be
expected for its younger population when compared with Sweden, which has
managed the epidemic in a most liberal way.
Sweden,
which has never introduced strict measures or even compulsory masks, is ranked
57th in the deaths per million and 46th in the number of confirmed cases per million people, situated in the list behind most other developed
countries, which have introduced much stricter measures.
It turned
out that hermetic closure against the virus was impossible, as seen for example
in Taiwan (here), but several countries may have managed to well
survive their lockdowns and strict measures till the appearance of the vaccine, and may
have lowered their number of deaths in comparison with the remaining world.
The
numbers of confirmed cases
The world
countries arranged according to the decreasing number of confirmed positive
cases per million (Worldometers) provide a ranking, which is also shown in the
Table. A great discrepancy between the death ranking and the case ranking
indicates either different lethality (due to different healthcare or different
virus strain) or inaccuracies in the reported values, or both. For example, the
U.S. have the same ranking in the deaths and in the cases (20th and
20th, see the Table). However, Peru (1st and 100th,
respectively) should probably show less of the deaths or more of the positive
cases or both; the same pays for Bosna (3rd, 82nd). On
the other hand, Denmark (114th, 29th) should probably
show more of deaths or less of positive cases or both; or alternatively, they
had a more benign Covid strain (less probable), or they managed the epidemic more
successfully with less victims.
The numbers
of positively tested people cover roughly between 10% and 25% population in
most developed countries. For example, Switzerland, Germany, and Netherland
have positively tested 19%, 9%, and 21% population, respectively. In case of Germany,
which exhibits similar mortality as the other two countries, the lower number
of confirmed cases may result from underreporting, already mentioned above; this is also
reflected by the CFR, which is double in Germany in comparison with Switzerland
and Netherland (the ratio of deaths/cases is higher when the number of cases is
lower, see the Table).
The
unknown population infection rates
The numbers
of positively tested people (confirmed cases) represent, for example, 4% of the
total population for the world, and 32% for Montenegro. Several countries show
an extremely low fraction of positively tested population, including Japan
(2%), South Korea (1%), and Taiwan (0.1%), but most developed countries range
between about 10% and 25%. However, the real number of people who have been
infected must be higher than the number of positively tested, since many people
have no symptoms, many do not report symptoms, and many do not test. The real
numbers of infected people seemed to be 10 times higher in the starting phase
of the pandemic (here), but now they may be rather thrice or twice the
reported cases.
Strangely,
the total number of infected people – highly important epidemic parameter – has
never been assessed in any country, even though it would be measurable by
taking random population samples (checking both PCR and the anti-Covid immunity
of the unvaccinated people).
Rough
estimation may provide that between 25% and 75% populations having been
infected by Covid-19 in most countries. The countries with lower infection rates
can be expected to increase the morbidity and mortality values in the future more
than the countries with higher infection rates.
Unreliable
reported values
Some
countries report not too reliable values, particularly developing countries, and
authoritative regimens.
Evidently erroneous are the values provided by China: the deaths per million people, for example, reported by China are by three orders lower than the values for most other countries, even though SARS-Cov-2 virus undeniably escaped from Wuhan laboratories and was spreading in the whole country from summer 2019 till December 2019 before it was reported to the WHO. The reported Chinese deaths of 3 per million and positive cases of 71 per million till January 2022 can hardly be believed, particularly in view of the values 36 and 746 for the neighboring Taiwan, or 1504 and 153,000 for Sweden. The numbers of performed tests reported by China, a value of 10 per 100 people not having changed for 16 months, seem also nonsensical (here, here).
Case
fatality rates
The ratio
of the deaths and the confirmed cases, when multiplied by 100 (the percent
death of all cases), is called case fatality rate (CFR), and it is also shown
in the Table. Higher fatality rate may indicate worse healthcare, but it also
reflects a lower number of the positively tested people, which is in accordance
with the fact that CFR in the Table correlates with the number of tests
performed per 100 people in the country (also shown on Worldometers) – the more
tests, the lower CFR. For example, only 68 tests per 100 people have been
performed in Peru, 50 in Bosna, 10 in Mexico, and 41 on Taiwan (fatality rates
of 8.6, 4.6, 7.3, and 4.9, respectively), while 340 tests per 100 people have
been performed in Georgia, 260 in the U.S., 630 in the United Kingdom, and 780
on Cyprus (fatality rates of 1.5, 1.4, 1.0, and 0.3, respectively).
Switzerland
and Germany, already mentioned above, both exhibit mortality of about 1400 per
million, but the former shows CFR of 0.8% and the latter 1.5%, which results
from the fact that Switzerland positively tested 19% population (employing 176
tests per 100 people), whereas Germany confirmed only 9% (106 tests per 100
people).
Covid-19
lethality
The traditional
Western democratic countries, supposed to report the values accurately, show
the CFR values of 1.4% (U.S.) or less such as 1.1% for Sweden, 1.0% for UK, 0.8%
for Switzerland, 0.6% for Netherland, 0.5% for Israel, 0.4% for Denmark, 0.3%
for Norway, 0.2% for Australia, and 0.1% for Iceland (see the Table). The real
fatality rate, lethality (100 x dead/really infected), should be close to the CFR
values found in the countries more strictly tracking the cases; the last
four above-named countries provide an average CFR of about 0.25%.
If
supposing that the whole population has already been infected, then the U.S.
2573 deaths per million would provide 0.2573 dead per 100 infected, which would
make about 0.26% lethality. Similarly, Sweden would provide 0.15%, UK 0.22%,
Switzerland 0.14%, Netherland 0.12%, and Israel about 0.1% (see the Table). If assuming
that there are no differences among different Covid strains, the real lethality
for Covid-19 (fraction of the people dying after infection) would be between
0.1% and 0.2%, which is in accordance with the previous estimations (here).
The fraction
of the vaccinated population
The effect
of the vaccination rate on the total deaths is not too clear in the Table; low
vaccination countries are dispersed along the whole list (2nd Bulgaria,
19th Moldova, 117th Cyprus), as well as high vaccination
countries (1st Peru, 21st Argentina, 114th Denmark).
The
Worldometers website enables to well compare the number of the deaths during
the first year and the second year of the pandemics. It is seen that the number
of deaths was the same or higher in the second year, even though the
vaccination was performed in this second year.
Extrapolating
the future mortality from the last week deaths
For example,
in the U.S., the deaths have increased from 2573 to 2616 per million from
January 10 to January 17, adding 43 more deaths per million per week; for a
wave lasting 10 weeks, this would make 430 additional deaths, increasing the
mortality of 2573 by 17%. Such extrapolation provides, for example, the following
mortality increase predictions: more than 100% for Taiwan and Australia, more
than 50% for Iceland and Finland, more than 25% for South Korea, Japan, Cyprus,
Denmark, Monaco, Malta, and Poland. The predictions for other developed
countries are lower, for example 17% for the U.S. and Bulgaria, 15% for Italy, 13%
for Germany, France, and UK, 9% for Sweden, and 7% for Czechia. So that the
low-mortality countries will mostly increase their mortalities relatively to the
high-mortality countries.
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