“A Covid Mystery” proclaimed a New York Times newsletter. “Why has the death toll been relatively low across much of Africa and Asia?” Like a know-it-all kid in 7th grade, I thought, “Call on me! I know this!” and clicked on the item. But, to my surprise, the account that followed completely failed to mention what I thought was the obvious answer.
David Leonhardt’s piece notes the fact that, against all expectations dating from the early stages of this pandemic, poorer countries of Africa and Asia have suffered only a small fraction of the death rates from the coronavirus that wealthier nations have experienced. “This isn’t how public health emergencies usually work,” Leonhardt writes. “They tend to inflict their worst damage in poorer places, which is indeed what’s happening within the U.S., where the toll has been higher in many minority and low-income communities.”
But when you look at international comparisons, poorer countries in Africa and Asia have had many fewer fatalities than richer nations. In the United States, we’ve had 1,580 deaths per million inhabitants and Italy has had 1,651, whereas Egypt has had 109 and Nigeria 10.
Leonhardt lists some potential causes for this unexpected result. Could it be that poorer countries have younger populations? They do. But that doesn’t quite account for the disparity. Even controlling for age, poorer countries have fewer deaths than richer ones. Maybe it’s because people in poorer countries spend more time outdoors? Could be, and Leonhardt suggests that this contains lessons for us about ventilation.
Another potential cause of the disparity: It’s possible that people in Africa and Asia have had exposure to similar pathogens in the past and that their immune systems were primed for COVID-19. Leonhardt quotes Salim Abdool Karim, a South African epidemiologist: “There is a lot of circumstantial evidence, but there is no smoking gun.”
Some countries’ leaders responded better than others to the pandemic. But that doesn’t solve the puzzle either, writes Leonhardt, since many of the nations with low death tolls have had government responses that have been as weak and scattershot as countries with higher mortality.
Leonhardt closes by concluding that multiple factors must be a work. That is almost certainly right, and yet, there is one factor he failed to take into account.
Pulitzer Prize-winning writer and cancer specialist Siddhartha Mukherjee addresses the same subject in the New Yorker. (If you haven’t read his book The Emperor of All Maladies, you should. It’s fascinating and moving.) Mukherjee notes the scope of the disparities in deaths:
Pakistan, with a population of two hundred and twenty million, was predicted to have as many as six hundred and fifty thousand deaths; it has so far reported twelve thousand. Côte d’Ivoire was predicted to have as many as fifty-two thousand deaths; by mid-February, a year after the pandemic reached the continent, it had reported under two hundred.
While speculating that poor countries may be underreporting their deaths, Mukherjee nonetheless concludes that “For many statisticians, virologists, and public-health experts, the regional disparities in COVID-19 mortality represent the greatest conundrum of the pandemic.”
This seems odd because just last week, the World Obesity Federation issued a report showing that there is a clear link between excess body weight, especially obesity, and COVID-19 mortality. Reviewing research from around the globe, the federation found that being overweight was a “highly significant predictor of developing complications from COVID19, including the need for hospitalization, for intensive care, and for ventilation. Overweight is also a predictor of death from COVID19.” Overweight was more predictive of severe COVID-19 illness than any factor with the exception of age. They found that in countries where less than half the adult population was classified as overweight, the risk of death from the coronavirus was about one-tenth the level found in nations where more than half are overweight or obese.
People who are overweight or obese are more likely to get severely ill and to die of COVID-19 even after controlling for factors such as sex, ethnicity, and income.
In his New Yorker piece puzzling about international disparities, Murkerjee raises the examples of Mexico and India, noting that they are quite close in age distribution, yet India’s death rate is only about one-tenth of Mexico’s. He continues: “So perhaps other populational features are significant. Take, for instance, the structure of an individual family and its living arrangements: who cohabitates with whom?”
But wait, do we need to ask that? The World Obesity Federation provides country-by-country breakdowns of overweight and obesity. According to their data, the percentage of India’s adult population categorized as obese is 3.9. In Mexico, it’s 28.9.
This brings us back to David Leonhardt’s point about the poor and minorities in America being hardest hit by the pandemic. This is true, and many factors may be at work, including people’s living situations, the necessity of reporting to in-person jobs instead of working from home, and limited access to medical care. But overweight is also a factor that almost never gets mentioned.
In the United States, coronavirus mortality rates by ethnicity map onto obesity rates pretty closely. According to the Centers for Disease Control, the obesity rate among African-American adults is 49.6 percent, followed by Hispanics (44.8), whites (42.2), and Asians (17.4). The death rate from COVID-19 so far, according to APM Research Lab, has indigenous Americans with the highest rate (they were not included in the CDC data), but African-Americans were second highest, followed by whites and Hispanics (with nearly identical rates), with Asians significantly behind.
I am no epidemiologist, but I do detect some tip-toeing around a delicate subject. No one wants to suggest that people are to blame for their illness. And certainly grandma’s death from COVID-19 is no less of tragedy because she needed to lose a few pounds.
But the rush to condemn the American medical system as severely racist, which characterized a lot of the early analysis of these data about racial disparities, may have been overwrought. It doesn’t mean there is no racism in the medical system. There are troubling studies, for example, about African Americans being prescribed less pain medication than other patients. And God knows, a nation that conducted the Tuskegee experiment cannot expect African Americans to be trusting for a few more generations. But the idea that rampant racism among doctors and nurses, many of whom are non-white, could account for the disparity in deaths from the coronavirus seemed dubious.
There is solid evidence suggesting that this virus is like a guided missile aimed at out-of-shape and overweight Americans and denizens of other wealthy countries. Nor is it the only this coronavirus that discriminates this way. The World Obesity Federation warns that other viruses such as the H3N2 and H1N1 flus also result in higher morbidity and mortality for the overweight and obese.
So before the next pandemic strikes, we need to take steps to prepare. We should have learned by now to stockpile PPE, syringes, and so forth. And we need better coordination at all levels of government. But Americans can also take responsibility for their own health by shedding those extra pounds.