October 30, 2020

Different countries in the world do not calculate things the same way and their technical capabilities are not the same either, which makes intepretation complicated. How do you know for sure that the death is from Covid-19 if the health system is too overwhelmed to do systematic testing? How can you interpret the contamination and positivity rates when the testing efforts and strategies are so different between countries?

Despite these uncertainties and after an 8 month pandemic situation, some traits are starting to emerge in a consistent manner in all the various counts that are published. And their convergence does not put the American continent in a good light.

A DECIMATED CONTINENT

One of the strongest indicators of the gravity of the pandemic is the link between the number of deaths and the size of the population. Yet, looking at the number of deaths per 100 000 inhabitants worldwide, the American continent is faring badly. Taking John Hopkins University's October 27 numbers, of the 20 highest scoring countries, 10 are on the American continent. Peru has gone over the 100 cases per 100 000, which means that one thousandth of its population has already died...Bolivia, Brazil, Chile, Mexico are between 70 to 80 deaths per 100 000, and that rate is increasing regularly, so much so that they will probably get to the symbolic threshold of 1/1000e losses in the next few weeks. Interestingly, the other half of the 20 most impacted countries according to this indicator are all in Europe.

Looking at the absolute number of deaths is also revealing, though we must keep in mind the size of the country for this ranking. The 20 most impacted countries represent in and of themselves almost one million deaths, so 86.1% of all those recorded worldwide. The United States and Brazil are at the top of the list, in front of India (though having a much larger population). 9 countries on the American continent are in the "top 20", with over 602 000 deaths, so over 51.8% of total recorded deaths until now (for a population that represents 13% of the world's population)! Europe is not as visible in this ranking, with 6 countries and almost 164 000 deaths (14.1% of deaths for 9.7% of the world's population). When adding the two continents, we can see that less than 23% of the world's population registers close to 65% of deaths.

Finally, we can look at the death rate of people with Covid-19, in other words the lethality of the disease. This value is more skewed that the previous ones because it depends on each country's capacity to detect infections. In countries where the testing capabilities are weak, only the worst cases are identified, and seeing as these usually lead to more complications, the lethality rate will appear higher, while it will be smaller in countries that have a widespread testing policy and are detecting a lot more asymptomatic cases. That being said, the ranking is informative. This time, you can only find 5 countries from the Americas, in particular Mexico (10%), Equador (7.8%) and Bolivia (6.1%). Surprisingly, Canada surpasses Peru.

John Hopkins' statistics, that are compiled from the health authorities' daily reports, show some flaws and are dependent on each country's capacity to identify the causes of death and their willingness to disclose transparent reports. The tendencies that are seen however have been confirmed by evaluating the high mortality rate of the past several months from birth and death registers and from compiling death certificates whose data is more solid, but where the pace of publication and updates is slower.

So, an American CDC study revealed that close to 300 000 additional deaths were recorded in the country between January and September 2020 compared to what was expected from previous years' averages observed. Brazil had similar results. For the two most impacted countries in the world in terms of deaths currently, the health systems' daily and weekly data, though imperfect, are therefore not mistaken on the scope of the crisis that they are confronting.

WHY ARE THE AMERICAS FIRST ON THE LIST?

The American continent's place in these macabre statistics requires answers. As was regularly repeated in this blog, the various countries that comprise it have dealt with the pandemic in very different ways. Some rather took refuge in denial and refused to put national measures in place, such as Brazil, Mexico and the United States. So the breadth of their contaminations and deaths is not surprising. But other countries put much earlier and stricter measures in place, such as Argentina (that has the world record in the longest lockdown) and Colombia, and yet they have an extremely high mortality rate per 100 000 (65.8% and 61.1% respectively).

Though each country's situation should be observed in its own context, and though we must not forget that the situation in the Americas can seem worse that in other regions because they do not, willingly or from lack of technical capabilities, reveal the real scope of mortality in their country, we can still ask ourselves what reasons could explain the situation portrayed by the numbers at the continental level, where there is both a widespread circulation of Covid-19 and a high mortality rate.

The pandemic emerged in China and then arrived in Europe before widely spreading to North and South America in April, quasi regardless of the lockdown measures that were put in place. We can link this progression to the fact that the Americas are a continent connected by the globalization of business transactions, and also the flow of people. The strong ties with Asia, but most likely Europe, probably played into the dissemination of the virus, spread by middle and upper class people used to traveling in Europe and in North America for work and pleasure, but also by the economic migrants in Latin America, forced to return home because of the slowing economy and the lockdown measures on the old continent. The relatively early closing of the border to Chinese travelers, put in place by the Trump administration, did not have the predicted results since the spread of the virus in the United States did not really slow down. We can observe one of the effects of globalization: there is no point in closing one door, circulation coming from all directions.

The second element to be pointed out has to do with two concurrent vulnerabilities when comparing the Americas to Europe or Asia. Concerning the first, most of the countries on the American continent have health systems and coverage that are either insuffisant, or unequal. Access to care can be complicated and/or extremely expensive, often dependent on work contracts, and social aid of all types, including partial unemployment measures, are quite inferior to those in Western Europe. On top of this, a large portion of the population in the Americas has job insecurity, and they depend on informal and temporary jobs. Subsequently, it is hard for many people to accept being confined and not working since it means a total loss of revenue and health insurance. As we will see further on, how social and economic inequalities are involved is one of the major characteristics of the Covid-19 pandemic.

In comparison to Asian countries, some of which don't have better healthcare systems or insurance than those in the Americas, we can probably highlight several social factors that would explain the differences in the pandemic's impact. Having learned the lessons from the SARS episode and favoring taking responsability for the community versus individual freedom, these countries were able to incorporate a certain number of precautions, the most visible one being the wearing of a mask in public, already established long before 2020. These social structures and the support of the population to strong measures by the governments, sometimes significantly encroaching on people's private lives, seems to guarantee for now a better resistance to the epidemic's push.

With neither a protective social system nor those societal structures capable of slowing the spread of the pandemic, the Americas therefore seem doubly vulnerable. A third factor comes into play, inequalities. Using the Gini coefficient, which displays the revenu distribution inequalities, the Americas are yet again in a disadvantageous situation. Indeed, in the list of 20 countries with the highest coefficient (source World Bank), we find 9 countries from the Americas (10 others are African and one, the Philippines, is in Asia). Though it sorely needs updating since it leans on a country's capacity (or willingness) to provide this type of statistics (I only included the 105 countries whose data was from 2015 or more recent), this list is revealing in the position of Brazil (coefficient is 53.9, 5th place worldwide, the highest of all developed countries), of Colombia (50.4, 9th), Mexico (45.4, 15th), Chile (44.4, 18th) and the United States (41.1, 33rd). In comparison, the most unequal country in Western Europe is Italy (35.9, 55th), while Germany is at 77th place (31.9).

Yet, the American CDC study already mentioned, and others, point to the fact that Covid-19 is hitting vulnerable populations disproportionately. The high mortality rate recorded in the US is thus at 11.9% for White populations, but 28.9% for Black populations and 53.6% for Hispanic populations. As it was noted in France, it is certainly a reflection of the social and economic conditions of these groups. Job insecurity is mostly found among Blacks and Hispanics, people doing housecleaning and maintenance in hospital infrastructures, large families sharing cramped housing, but also people who have significant comorbidity factors (diabetes, obesity, etc.)...Canada, which is the most egalitarian society of the Americas (Gini at 33.3) and one of the least impacted on the continent, seems to confirm this analysis.

A CONTINENT INCAPABLE OF SOCIAL DISTANCING? 

The different factors that I've mentioned repeat themselves often enough that we can give them a certain credence. That being said, everybody can find a counter example. For example, how can you explain the huge mortality rate in the United States and Brazil when the first coutnry has a high-performance health system technology-wise, and the second a national healthcare system that is much more advanced than its neighbors? Both should have had limited damage, but the statistics show that it is not so. How can you explain the active circulation of the virus on the whole continent when a number of countries have closed their borders (there again the US is puzzling)?

According to the statistics, Europe and the Americas are the main clusters of the pandemic right now. The SARS-CoV-2 is actively circulating there which shows that social interactions are still strong and that, despite lockdown measures, they were not greatly restrained and have started back up again in an intense fashion, as can be seen in Europe where the generalized re-mingling of people over the summer and during school opening led to a particularly robust second wave. Should we see in these similar situations between the two continents a reflexion of the social and cultural proximity linking the "old continent" with the "young countries of the Americas", differentiating them from Asia and Africa? Should we see in the difference in mortality between European countries and countries in the Americas as the result of one side of the Atlantic's social and health systems that offer much better protection and are more efficient, and much more egalitarian and much less weak than the other?

François-Michel Le Tourneau is a senior research fellow at the French National Center for Scientific Research (CNRS), Deputy Director of the UMI iGLOBES and a member of the Institut des Amériques Scientific Committee.  His work focuses on settlement and use of sparsely populated areas, especially the Brazilian Amazon. He is particularly interested in indigenous people and traditional populations and their relationships with their territory. He has authored a number of papers in national and international scientific journals (list here on HAL-SHS, here on Researchgate or here on Academia.edu).

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