Just How Do Deaths Due to COVID-19 Stack Up?
Governance

Just How Do Deaths Due to COVID-19 Stack Up?

Despite a likely undercount in many places, COVID-19 is the leading killer in most of Latin America and Western Europe

A woman mourns at the grave of her husband who passed away due to COVID-19, at a burial area provided by the government for COVID-19 victims as the country reports a record daily number of COVID-19 deaths, in Bekasi, Indonesia, on July 27, 2021
A woman mourns at the grave of her husband who passed away due to COVID-19, at a burial area provided by the government for COVID-19 victims as the country reports a record daily number of COVID-19 de REUTERS/Willy Kurniawan

Since the start of 2020, based on official counts, COVID-19 has killed more than 4.5 million people, including more than 630,000 in the United States, 570,000 in Brazil, and 430,000 in India. These tallies may substantially underestimate COVID-19's true death toll. In fact, some estimates suggest the total number of deaths could be more than twice as large as reported globally and up to ten times greater than reported in some countries. The scale of loss is staggering, but the huge numbers are difficult to understand without context. It can be helpful to consider how COVID-19 ranks as a cause of death around the world, and some of the factors driving those trends.

Looking at official statistics alone, COVID-19 was the fourth leading cause of death globally, accounting for just under one in twenty deaths worldwide since the beginning of 2020. After accounting for unreported deaths, the total toll could be as high as the third leading cause of death, responsible for an estimated 10 million deaths, or one out of every ten deaths. About half of people globally live to 70 before they die, so causes of death that tend to kill older adults such as ischemic heart disease and stroke predominate among the most common causes of death. COVID-19 mortality is similar in that it kills very few young children or adolescents but becomes sharply more dangerous with age and disproportionately kills people over 70 years old.  

Top Five Causes of Death Globally

According to official statistics, COVID-19 was the leading cause of death in France, Spain, the United Kingdom, and several U.S. states. But after accounting for undercounting of COVID-19 deaths, it was the leading cause of death in the United States, Iran, and Poland (all were second-leading before adjusting to account for total deaths due to COVID-19). COVID-19 was the leading cause of death in the Region of the Americas and the third leading cause of death in the European Region. People over 70, who are at higher risk of COVID-19 mortality, make up a higher share of the population in higher-income countries. Those countries also tend to have a higher prevalence of chronic health conditions that increase with age such as obesity, high blood pressure, diabetes, chronic kidney disease, and respiratory illness, which likely contributed to higher rates of COVID-19 mortality.

COVID-19 Deaths by WHO Region

In contrast, a handful of high-income countries, including South Korea, Japan, New Zealand, and Australia, acted quickly to control the spread of COVID-19 and kept their death counts low, even after accounting for deaths that may be missing from official statistics. These countries reported nearly all deaths due to COVID-19.

Countries in East Asia may have been well-prepared for COVID-19 thanks to strong infectious disease surveillance systems developed in response to recent respiratory disease outbreaks such as influenza H1N1 and Severe Acute Respiratory Syndrome (SARS). When COVID-19 arrived, South Korea and Japan were quick to test and trace infections and embraced mask-wearing, due in part to a culture of mask use during annual influenza season. Australia and New Zealand acted quickly, enacting strict international and domestic travel restrictions and social distancing mandates, which likely helped them sustain low levels of transmission.

COVID-19 was also the leading cause of death in many Latin American countries such as Argentina, Brazil, Colombia, Mexico, and Peru. The Americas and Europe accounted for 80 percent of COVID-19 deaths globally, even though they represent only about a quarter of the world's population. The five countries where COVID-19 represents the largest fraction of all deaths are from Latin America (Peru, Colombia, Paraguay, Brazil, Panama). The way that people die has been dramatically changed in many places, but by this measure, the distribution of deaths has shifted by the largest amount in Latin America. Two of the top five countries in terms of number of deaths caused by COVID-19 are in Latin America (Brazil and Mexico).

Ranking COVID-19 Deaths Among All Causes of Death Since Start of 2020

In contrast, COVID-19 has not been a leading cause of death in much of the African, South East Asian, or Western Pacific Regions. Even when considering underreporting and correcting for total COVID-19 deaths—aside from notable exceptions such as Angola, Tunisia, and South Africa—the virus is not among the leading causes of death in sub-Saharan Africa or in South East Asia. Countries in these regions tend to have a higher overall burden of infectious diseases compared to countries in Europe or North America. Once we account for total COVID-19 deaths, some of the lowest mortality rates in the world are in Burundi, China, Laos, and Bhutan.

Why are COVID-19 deaths lower in some regions and locations? Experts have attributed this to a number of causes such as decisive and effective government responses, international coordination in response and diagnostic testing, a younger population structure, income inequality, and lower rates of chronic diseases including obesity. Seroprevalence studies have also found a lower risk of death among people with COVID-19 in some settings compared to others before accounting for estimated underreporting of deaths. Other potential explanations include cross-immunity from higher exposure to other coronaviruses, experience from other infectious disease outbreaks like Ebola and SARS that built strong epidemic preparedness, and a mismatch of environmental or climatological suitability with the virus. IHME's analysis suggests it is an issue worldwide, but the fraction of missed COVID-19 deaths might be highest in Eastern Europe and Central Asia.

More people in the United States died of COVID-19 than in any other country. Although this is in part due to the large U.S. population, the country also has a high death rate due to the virus. Despite having a robust vital registration system, we think that the United States missed a considerable number of deaths and estimate that total COVID-19 deaths were about 1.5 times greater than reported in the United States. More people in the United States died of COVID-19 than died of seasonal influenza in the last ten years (2010-2020).

Top Five Causes of Death in the United States

When the causes of death are ranked in this article, it assumes that estimates for non-COVID-19 causes would remain the same in the absence of COVID-19. This may not be true. During the pandemic, researchers have noticed decreases in injuries and road traffic deaths due to lower mobility, have observed decreases in routine health-care utilization potentially affecting mortality due to chronic but treatable diseases, decreases in other respiratory diseases such as pneumonia, and other changes in disease burden. In total, there may have been 600,000 fewer deaths globally from non-COVID causes in 2020 than otherwise expected because people avoided injuries and respiratory diseases by staying home. Another consideration could be that in locations, such as the United States, that have complete or near complete vital registration systems, deaths originally determined as a non-COVID-19 cause were actually caused by COVID-19, potentially changing the ranking of causes of death presented in this post.

People all over the world are grief-stricken at the loss of friends, family members, and neighbors, and the disruption to their communities and livelihoods.  Safe and effective vaccines being distributed by many—but importantly, not all—countries have the potential to help avert future deaths. It is more urgent than ever to expand vaccination in all settings and ensure all people have the opportunity to be vaccinated, no matter where they live. In the meantime, continued promotion of mask use indoors and when social distancing is not possible, limits on social gathering sizes, and adherence to public health guidelines can help protect our communities from COVID-19. As individuals and societies, we must all work to prevent COVID-19 from continuing as a leading cause of death.

An exhibition of white flags representing Americans who have died of coronavirus disease (COVID-19), which are placed over 20 acres of the National Mall, is seen in Washington, U.S., September 17, 2021
An exhibition of white flags representing Americans who have died of COVID-19, which are placed over 20 acres of the National Mall, is seen in Washington, DC, on September 17, 2021. REUTERS/Joshua Roberts

ACKNOWLEDGEMENTS: The author would like to thank Katherine Leach-Kemon for her support on the article; and Catherine Bisignano, Katie Welgan, Emma Castro, Erin Frame, Rebecca Sirull, and Professors Robert Reiner and Emmanuela Gakidou for their feedback and fact-checking assistance.

EDITOR'S NOTE: The author is employed by the University of Washington's Institute for Health Metrics and Evaluation (IHME), which produced the COVID-19 forecasts described in this article. IHME collaborates with the Council on Foreign Relations on Think Global Health. All statements and views expressed in this article are solely those of the individual author and are not necessarily shared by their institution.

Christopher Troeger is a doctoral student at the University of Washington and a pre-doctoral research assistant at the University of Washington's Institute for Health Metrics and Evaluation (IHME).

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