Since the start of 2020, based on official counts, COVID-19 has killed more than 3.4 million people, including more than 580,000 in the United States; 440,000 in Brazil; and 300,000 in India. These tallies may substantially underestimate COVID-19's true death toll. In fact, new 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 1 in 20 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 [chronic obstructive pulmonary disease], and responsible for an estimated 7.5 million deaths, or 1 out of every 10 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 as 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.
According to official statistics, COVID-19 was the leading cause of death in France, Spain, England, 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 Italy (all were all the second-leading cause before adjusting to account for total deaths due to COVID-19). 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—all of which likely contributed to higher rates of COVID-19 mortality.
In contrast, a number 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 of the deaths that occurred due to COVID-19. Countries in East Asia may have been well prepared for COVID-19 thanks to strong infectious disease surveillance systems that had been developed in response to other 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 an existing culture of mask use during influenza season. Australia and New Zealand acted quickly, enacting strict international and domestic travel restrictions and social distancing mandates, likely helping them sustain low levels of transmission.
COVID-19 was also the leading cause of death in many Latin American countries, including Mexico, Peru, Colombia, and Brazil. 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, Panama, Brazil, Mexico). The way that people die has 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).
In contrast, COVID-19 has not been a leading cause of death in much of the African, Southeast Asian, or Western Pacific regions. Even when considering underreporting and correcting for total COVID-19 deaths, aside from notable exceptions such as South Africa, COVID-19 is not among the leading causes of death in sub-Saharan Africa or in Southeast 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 Uganda, Benin, Vietnam, and Thailand.
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, 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 new 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 COVID-19. Despite having a robust vital registration system, we think that the country missed a considerable number of deaths and estimate that total COVID-19 deaths were about 1.6 times greater than reported in the United States. Additionally, more people in the United States died of COVID-19 than died of seasonal influenza in the last 10 years (2010-2020).
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. They have also 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-19 causes in 2020 than otherwise expected as people avoided injuries and respiratory diseases by staying home.
Another consideration could be that in locations with complete or near complete vital registration systems, such as the United States, deaths orginially 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 by the disruption to their communities and livelihoods. Safe and effective vaccines being distributed by many—but not all—countries have the potential to help avert future deaths. It is more urgent than ever to expand vaccination in all settings to ensure that all people have the opportunity to be vaccinated, no matter where they live. In the meantime, continued promotion of mask use indoors or 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.
ACKNOWLEDGEMENTS: The author would like to thank Katherine Leach-Kemon for her feedback and support on the article and to thank Catherine Bisignano and Emmanuela Gakidou, Katie Welgan, and Emma Castro for their feedback and fact-checking.
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.