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Corona — the catastrophe that did not happen

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Today I want to talk about an otherwise often forgotten part of the world — the developing countries. What was not prophesied to them! There was talk of a catastrophe of biblical proportions. The German virologist Prof. Christian Drosten spoke of “scenes that we cannot imagine today”. Meanwhile, however, African intellectuals are saying: “The Europeans are worried about us. But we worry about them.” What happened?

There are still a few unsolved mysteries surrounding the Corona pandemic. For example, the question of why the mortality rate from COVID-19 has fallen so sharply in recent months. In Great Britain, for example, hospital mortality has fallen from 6 to 1.5 % from April 2020 to the present day. Some hospitals in Italy even report a 12-fold decrease in mortality. Is the virus running out of breath? (The answer is no, but the development is interesting).

Another topic that is now being pulled out of the puzzle box is “herd immunity”: Could the principle not perhaps work after all? (The answer is: It depends on the geographical location, but yes, the question is interesting). In short, the Corona debates are not running out of material (I go into these questions in detail in my (German) eBook on the Corona pandemic).

Africa in trouble

“The best advice to Africa is to prepare for the worst and start today.”

As WHO Secretary-General Adhanom Ghebreyesus said a few months ago. The Bill Gates Foundation reckoned with more than 10 million deaths.

However, if we look at developing countries today, the mortality rate from COVID-19 is very manageable there — apart from a few urban hotspots in South Africa.

Of course, there are also COVID death to mourn in Africa, but there can be no talk of a mass mortality . In fact, the official death data for Africa currently assume a population-related mortality rate that is about 40 times lower than in Europe. Now one must certainly read these data with some skepticism. Nevertheless, one thing can be said with certainty: In practically all African countries, the predicted health emergency has so far failed to materialize. If Africa were indeed shaken by mass mortality, the world would have heard about it by now.

The situation is even more remarkable when one considers the different starting positions of developing countries. They face the pandemic with virtually no significant intensive care capacity. If the countries of Africa had the same medical capabilities as the western world, the comparison would certainly be even more blatant.

Not yet arrived?

Now it can be argued that the COVID wave has perhaps not yet really arrived in Africa. The available data on this is indeed patchy. However, there is much to suggest that the wave has already reached its maximum in many urban areas at least, and will do so in rural areas within a few months. In the state of Niger, Nigeria, one quarter of the population is antibody-positive, i.e. has already been infected with SARS-CoV-2 (for methodological reasons, seroprevalence data tend to underestimate the actual immunity). Meanwhile, the WHO reports about 5 COVID-19 deaths per million inhabitants in Nigeria. Even if this number were 10 times higher, Nigeria would still have a mortality rate 10 times lower than in Great Britain (where at most 6 to 9% of the population have already experienced the virus).

Less effective mitigation efforts

What can be said with great certainty, however, is that the good situation in Africa has little to do with the anti-pandemic measures taken there. In fact, lockdowns were ordered at an early stage in many African countries, usually with the authoritarian harshness typical of the country. However, the effectiveness of the measures was rather modest, because only a small part of the population had the opportunity to go without income and social activity for several days. In addition, there is hardly any place where people live more densely packed than in Africa, and nowhere do the generations have closer contact than on this continent. For understandable reasons, social distancing measures in developing countries therefore hardly ever achieve the health policy goals set — the more reliably the measures trigger social crises that endanger the existence of large parts of the population. It is therefore foreseeable that more people in poor countries will be harmed by the fight against the pandemic than by the pandemic itself.

The comparison becomes even more stark when we look at the other health problems plaguing poor countries. Tuberculosis alone kills 1.5 million people in developing countries every year. Measles also kills 140,000 people there every year (this figure must now be revised sharply upwards — because the SARS-CoV-2 epidemic has meant that vaccination programs could and can no longer be carried out effectively).

A look at other poor countries

The Indian subcontinent also seems to get off surprisingly lightly. And this despite the “record numbers” of infections reported daily.

I would like to say a few words about these figures here: For me, one of the most annoying facts about this pandemic is how sloppily a large part of the serious press still treats the reported figures on the course of the pandemic. “India reports a worldwide record in daily new infections” is what it says. Or: “The USA is the country most affected by the corona pandemic worldwide” . And then, in all seriousness, graphs and tables are presented comparing the death or infection figures reported from the different countries. There are figures from countries like Sweden (10 million inhabitants), the USA (330 million inhabitants) and India (1.3 billion inhabitants, 130 times more than Sweden). You might call these comparisons statistical pornography, but not serious reporting.

What happens in India?

Let’s take a look at the “leading” country in statistical pornography, India. On the subcontinent with its 1300 million inhabitants the lockdown was strict but understandably hardly more efficient than the lockdowns in Africa. Nevertheless, mortality in India is still at a much lower level than originally assumed: After 5 months of pandemic, about 60 people per million inhabitants have died of COVID-19 (as of mid-September 2020). Of course, the official figures in India should also be treated with caution. But even if there were twice as many deaths — that would still be a number many times lower than in Belgium or Great Britain (there are about 700 deaths per million inhabitants so far). At the same time, current data show that in some Indian hotspots a quarter of the population has already been infected, and in some urban slums almost 55% have already formed antibodies against SARS-CoV-2. The same is true for some rural regions of India.

This does not mean that India is now “through” the pandemic. In fact, the prevalence of the pandemic is much lower in the richer urban areas, i.e. where the elderly and pre-existing conditions are more prevalent in India (a study from Mumbai quotes a seroprevalence of 16% for the richer residential districts). In India, too, mortality will continue to rise. It is foreseeable, however, that it will fall far short of the standards of the industrialized world (the rough average for the industrialized world as a whole is currently far below 5%).

What was said for India is likely to apply similarly to Pakistan — there, too, the death rates associated with COVID-19 are undramatic — and the fact that the pandemic has already affected a large part of the population in Pakistan is shown by antibody studies of blood donors in Karachi — 40% of whom are currently antibody-positive. The same applies to Bangladesh.

And in the refugee camps, for example in Greece? The same misery prevails there as before. However, COVID-19 has not yet contributed to this.

A look at the emerging countries

What has been said suggests that the pandemic is proceeding quite differently in the poorer countries than in the richer ones. The objections to this could be made in Brazil, Mexico, Peru and Chile. Or to Iran.

However, the list of countries mentioned first points to a misunderstanding: these countries are not developing countries, but emerging economies. In fact, the SARS-CoV-2 pandemic took a different course there than in the developing countries — but also different from the industrialized countries.

Take Brazil, currently one of the countries severely affected by the pandemic. In African countries, only 2% of the population is over 65 years of age, the median age is 19. For comparison: the median age in Brazil is 31 years, 9.3% of the population is over 65 years old (in Germany the median age is 46.5 years, 21% of the population is over 65 years old). The percentage of children under 15 years of age in Brazil is 25%, i.e. in the middle range (for comparison: in Africa the median age is 41% of the population, in Germany it is about 13%). In short: the emerging countries are also in demographic transition, their population is, if you like, “medium old”.

And the mortality from COVID-19? In Brazil, it is indeed in a medium range, at least if one relates the figures to the state of the epidemic (which one should do if one wants to compare the course of the pandemic in different countries). As of today (10.9.2020), Brazil has 600 COVID-19 deaths per million inhabitants. This may seem comparable to the countries of the “First World” (for comparison: Belgium: 800/million, GB 650/million, USA 580/million). However, Brazil is likely to have a much higher overall level of contamination than the comparable countries mentioned above. In the heavily affected Brazilian state of Maranhão, for example, according to recent data, around 40% of the total population has already been infected.

In some coastal areas of Ecuador (some of which were affected early and severely by COVID-19), the prevalence is now so high that the death rate from SARS-CoV-2 is declining again even without restrictions. Also from other Latin American countries high infestation rates are reported — e.g. over 25% for Peruvian Lima. By way of comparison, the rate of infections passed through in Italy is perhaps 2 or 3 percent nationwide, in Germany it is probably even less.

The same applies to Iran. The COVID mortality rate there is currently around 275 per million inhabitants, which is in a medium range in a global comparison. Now the statistics are certainly not reliable, the death rates might be higher. Nevertheless, it can be estimated that the mortality in relation to the contamination will probably not come close to the figures from Europe, for Iran, at least for the more affected areas, a contamination rate of about 22% can be assumed.

Let us summarize

So far this is known of SARS-CoV-2: This virus can run havoc, especially in places where there are many old people, few young people, many chronically ill people, many overweight people and many socially excluded people — and in this league, the “highly developed” countries are in the lead (and if political idiots are in charge, they are the league´s leaders). The other countries, on the other hand, seem to suffer less from the pandemic, the poorer the less — in contrast to influenza, which often affects children in developing countries. What influences could explain this dynamic?

Why the pandemic is milder in poor countries

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Age distribution of selected geographic regions

Age structure as influencing factor

A look at the age structure is striking — this has already been mentioned. The median age of the total population of Africa is about 19 years (only in places where the virus also rages more severely in Africa, such as in the urban areas of the emerging country South Africa, is the median age significantly higher). In India, the median age is 27 years, in Brazil 31 years, in the USA 36 years, in Italy and Germany 48 years. And the more old people there are in a population, as the mortality statistics clearly show, the more often very severe and fatal COVID-19 courses occur.

Did I say “more frequently”? If we look at the numbers, even that is an understatement: The risk of a person over 80 years of age to die of COVID-19 is about 650 times higher than that of 20 to 40-year-olds. This simple factor alone could explain why the predictions for poor countries were so wrong (although this very part of the COVID-19 story was quite well described from the beginning).

But also the high percentage of children under 15 years is striking. Therefore here again the data for the shares of the population under 15 years:

What do children have to do with the course of the pandemic? On the one hand, they are, of course, depressing the mortality statistics. The more children there are in a population, the more mild or even asymptomatic the course of the pandemic.

Young people as “dike wardens”

However, an overall young population could also have another favorable influence on the course of the epidemic. Adolescents and young adults (unlike younger children) are among the most socially mobile and sociable citizens — they are therefore more likely to fall ill earlier and more frequently. This, in turn, could contribute to the epidemic spreading rapidly at first, but then quickly losing momentum again because the socially mobile members of the population responsible for super spreading are immune at an early stage — possibly before the particularly vulnerable older population groups are fully affected. In fact, such a preference for the middle age groups can be clearly seen in Nigeria, for example.

Pre-existing conditions

The fact that the developing countries could also be affected by a completely different disease burden in the developing countries can be seen from the high mortality risk posed by diseases of civilization such as obesity, diabetes mellitus, high blood pressure and other cardiovascular diseases. These diseases are relatively rare in developing countries, but chronic infectious diseases dominate there. And some of them could even strengthen the immune system against viruses such as SARS-CoV-2 (worm diseases, for example, are known to cause milder courses of measles, and similar non-specific antiviral effects are attributed to certain infectious diseases, but also to live vaccines such as polio or tuberculosis). According to the “hygiene hypothesis”, a generally stronger confrontation with the “benign” microbes of everyday life could also strengthen the immune system as a whole.

A model calculation in which the expected mortality in Brazil is compared with that for Nigeria shows how decisive pre-existing conditions could be as an explanatory factor for the low COVID mortality in poor countries. By the way, this study shows in an exemplary way ehy emerging countries are not really comparable with developing countries. In fact, the factors obesity and diabetes mellitus, which strongly influence the course of COVID-19 disease, are surprisingly widespread in the more severely affected Latin American emerging countries such as Brazil and Mexico — and especially in middle age.

Another mystery — the example of Turkey

The factors age structure and previous illnesses could perhaps even explain another mystery of this pandemic. And one that affects the league of the developed world itself.

Let us take a look at Turkey. Bad times were predicted for Turkey, too — especially since the lockdown there was quite chaotic, at least that’s what the press reported (although I personally know of hardly any country where the lockdown was not chaotic). Also in Turkey, COVID-19 so far has been surprisingly mild: with 75 cases per million inhabitants, the mortality rate of COVID-19 is 10 times lower than in Italy or Belgium.

The often cramped living conditions in Turkey might have rather promoted than hindered the spreading of the virus (unfortunately reliable rates for the infection rates in Turkey are not available). So perhaps the age structure of the population plays a decisive role here too? While in Germany and Italy only 13% of the population is under 15 years old, there are almost twice as many in Turkey. And the number of over 65-year-olds in Italy and Germany is 21% — in Turkey, on the other hand, it is only 8.5%.

Other influences?

Now, other influences could also cause differences in mortality, such as climate, humidity, air pollution, the extent of contact between the young and the old generation, and much more. However, these factors are likely to play a minor role at best. In Brazil, for example, it is the tropical Amazon basin that is most affected.

However, observations made during the pandemic show that another factor could play a role in the unequal distribution of mortality. I am referring to the role of contact patterns, i.e. the typical way in which infections are being transmitted during the pandemic.

Could the infection patterns play a role?

So lets briefly look at why contact patterns may matter. Societies with many children could, of course, have a lower COVID-19 related mortality just because the population is not old and rather healthy. However, children could also have a braking effect on the course of the pandemic (my colleagues and I have been pursuing this question for some time in a scientific paper). In view of the data on the course of the pandemic that have been reported so far, it can indeed be assumed that children could have such a curbing influence. Indeed, the available data suggest that the course of a SARS-CoV-2 infection — i.e. how severe or mild the infection is — does not only depend on the previous illnesses, the age and the state of the immune system of the “infected” person. Rather, the amount of viral load transmitted may also play an important role.

It is known from other viral diseases that the higher the “infectious dose”, the more severe the disease. This is now also suspected for SARS-CoV-2. For example, comparisons of Swiss groups of recruits show that where masks are worn and hygiene rules are observed, the progression is significantly milder than in groups where these rules are not observed. It can also be shown that infections occurring at home in a family context are milder than those acquired in public.¹

What does this have to do with the children?

This has two things to do with the children.

In concrete terms, this means that a larger number of children in the population could well ensure that the epidemic runs a clinically milder course overall.

And this is exactly what we are seeing in developing countries and other countries with high numbers of children.

Nothing new about the pandemic, really?

Let’s summarize what has been said. Recently, it was claimed that “not a single truly new finding” has been added in the past two months regarding the corona pandemic. This is not true. The data on the course of the pandemic in developing countries is now robust. It points out that the pandemic is proceeding fundamentally differently in the “young” societies of the world than in the “old” countries. This means that the pandemic is proceeding differently than most experts initially expected. In my opinion, this is the most important recent finding on this pandemic.

It should definitely be widely discussed, because the question now is whether the mitigation strategies to combat the SARS-CoV-2 pandemic developed by the WHO are actually permissible in their blanket form. In any case, it is currently becoming apparent that a large part of the world population is now suffering more from the pandemic plans than from the pandemic itself.

Really, what a tragedy. A crisis is sweeping around the world, threatening above all the rich, old part of the world and actually taking it easy on the global South, which is otherwise plagued by all kinds of afflictions. And who suffers most from this pandemic? Again those who live from hand to mouth. Two billion people on this earth are day laborers, and the International Labor Organization (ILO) expects their income to drop by 82% because of the pandemic. Especially women and young people are affected. And the WHO estimates that 1.4 million people in developing countries will die from tuberculosis alone in the next five years due to a lack of medical supplies.

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The duty to learn, and to learn fast

If there is one thing that the relationships described above show, it is how little we were prepared for this pandemic. And how long it took the decision-makers to take into account in their recommendations and statements what could have been clear even after the first, “Chinese” weeks of the pandemic: Mortality from this virus is manageable until the age of 60. Why should countries in which 60-year-olds are considered to be very old take the same measures as those that are largely made up of old people?

And what has been said underscores something else: the importance of keeping a close eye on this pandemic and constantly analyzing the incoming data, reports and study results. And to use the knowledge gained to come to an ever better way of dealing with this pandemic. Iit is normal for mistakes to happen. This look at the “global South” shows how urgently we need to learn from them.


Dr. med. Herbert Renz-Polster

Written by

I am a physician researcher trained in pediatrics and public health, interested in child development and all things related to building a sustainable society.

Dr. med. Herbert Renz-Polster

Written by

I am a physician researcher trained in pediatrics and public health, interested in child development and all things related to building a sustainable society.

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