Since the World Health Organization declared a pandemic one year ago, COVID-19 has killed around three million people, including more than 500,000 in the United States, 250,000 in Brazil, and 150,000 in India. These tallies may substantially underestimate COVID-19's true death toll. 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.
Worldwide since the beginning of 2020, COVID-19 was the fourth-leading cause of death, accounting for nearly 1 in 20 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.
COVID-19 was the leading cause of death in France, Spain, England, and several U.S. states. 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 further contributed to higher rates of COVID-19 mortality.
But 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. Countries in East Asia were well prepared for COVID-19 thanks to strong infectious disease surveillance systems they 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 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 such as 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. Currently, Brazil is experiencing its worst pandemic wave yet amid a slow vaccination rollout and low mask use. In contrast to other locations that took quick action to control COVID-19, Brazil's actions have been slow and inadequate, and conflicting messaging from politicians and public officials have sometimes undermined the epidemic response
In contrast, COVID-19 was not a leading cause of death in much of the African, South-East Asian, or Western Pacific Regions. Countries there tend to have a higher overall burden of infectious diseases compared to countries in Europe or North America. Many experts expected the pandemic would have a terrible toll there, but it hasn't materialized. Aside from notable exceptions such as South Africa, COVID-19 is not among the leading causes of death in sub-Saharan Africa or in South-East Asia.
Why are COVID-19 deaths so much lower in these regions? 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. 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. Underreporting of COVID-19 deaths, an issue seen in countries around world, could also be a factor.
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: in the last year, more than 1 in 10 deaths in the United States were caused by COVID-19, the second-leading cause of death after ischemic heart disease. More people in the United States died of COVID-19 than died of seasonal influenza in the last 10 years (2010-2020).
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. But it is more urgent than ever to expand vaccination in all settings. In the meantime, continued promotion of mask use, even among vaccinated individuals, 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 being a leading cause of death again in 2021.
This article will be updated periodically.
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.