top of page

Much Ado About Nothing: The 2020 Pandemic in Retrospect

COVID-19 in Context: A Global US Perspective


Photo by Alexas Fotos

The World We Knew / The World We Never Knew / The COVID-19 Pandemic / Into the Future


THE WORLD WE KNEW


Once upon a time, when we would talk about the cold-and-flu season coming up, we didn’t waste much time discussing the differences between the two bugs; they both hit us around the same time of year, and they were both unpleasant illnesses that caused a slew of familiar symptoms that lasted a week or two. Many of us would go get our yearly flu vaccines, but none of us were truly concerned about winding up dead.


Influenza


In fact, so few people pass away during flu season that almost nobody in a developed country has lost a loved one to the illness. Every year, as new flu-causing viruses come around, the scientific community quickly and methodically isolates the most dangerous strains, whips up a new cocktail of dead virus, and tries to get it out to as many people as possible. Usually, they get it right. Most of us think nothing of it, and this is what we’ve grown accustomed to seeing, year after year.


We don’t think of the flu as a deadly virus. And while it is sometimes fatal, the truth is that on average, influenza claims up to 646,000 lives around the world each year, which is well under 0.01% of today’s world population, or less than 10 in every 100,000 people. (The percentage is even lower in the US).


>>> Based on deaths by population, the seasonal flu death rate for the US and the world is less than 0.01%.


Deaths are typically highest among the very young, very old, the immunocompromised, and those with limited access to healthcare, meaning that the average healthy child or adult with access to soap, water, and vaccines has an incredibly low risk of dying from the flu. The case fatality rate (CFR) of influenza, the whole family of viruses that causes the seasonal flu, is < 0.1% in the US, which is fairly characteristic of developed countries where we have the technology and resources to minimize the death toll. This is, quite simply, the number reported by our very own Center for Disease Control (CDC); The “real-world-outcome” CFR (my words) for a country or region can be much higher (even as high as > 0.1%) due to complicating factors like sanitation and access to healthcare, according to a comprehensive 2014 study aimed at reexamining and clarifying the case fatality risk of the seasonal flu, and recognizing its variability around the world.


>>> Among those with confirmed cases, the “known” seasonal flu death rate is also < 0.01%.


It’s just a coincidence that the CFR and deaths by population can both be described with the same statistic. The fact is that, year after year, this is the very safe reality in which we lived. The flu didn't scare us. We washed our hands. We counted our blessings. We knew nothing, firsthand, of the terrors that a flu virus had once visited on the world.


Human Coronaviruses


Corona is a family of viruses with a characteristic corona-like or crown-like set of spikes that attacks both animals and humans. Some of these viruses have proven to be harmless; others, quite deadly. Actually, "common" coronaviruses cause 15%-30% of all common colds each year, and of course, we know that catching one of these is almost never deadly.


>>> Four out of the seven known human coronaviruses do nothing more than cause the common cold.


The remaining three viruses you might know by name; each one has made the headlines at some point in the past 20 years, and each one is essentially unrelated to the other six; they're all very distant relatives. Just like most pandemic-causing pathogens, each of these has occurred as the result of the habit of all viruses to transmute into new and unique strains as they replicate.


In 2003, Severe Acute Respiratory Syndrome (SARS) was discovered, an illness caused by SARS-associated coronavirus (SARS-CoV). This pathogen originally appeared and caused an outbreak in Asia; it caused over 8,000 cases and 755 deaths worldwide. SARS-CoV was contained successfully through basic healthcare measures like quarantining of the sick, and essentially disappeared; however, many healthcare experts became vigilant knowing the likelihood of a similar, worse event. Fourteen years later, scientists were able to isolate the bat population where the disease originated.


>>> The SARS outbreak from 2002-2004 in Asia was caused by a deadly coronavirus that was contained fairly quickly; it wasn't extremely contagious.


In 2012, Middle East Respiratory Syndrome (MERS) was discovered, an illness caused by MERS-CoV. It has caused two outbreaks so far, in Saudi Arabia and South Korea, and it has only reached the point of about 2,600 cases and 900 deaths over all this time, worldwide. The two prominent theories as to its origins are bats and camels.


>>> The MERS outbreaks of 2014-2015 in the Middle East were caused by another deadly coronavirus that we've been able to contain very well.


Until now, none of these coronaviruses had ever successfully “crossed the line” and caused an ongoing public health crisis. If either of these COVID-19 predecessors had gotten out of hand, they might have caused the same international panic, but the fact of the matter is that they didn’t. There was the common cold, and there was a couple of briefly dangerous mutated animal viruses, and that was the whole story. Until now.


Infographic by Visual Capitalist

The World We Knew / The World We Never Knew / The COVID-19 Pandemic / Into the Future


THE WORLD WE NEVER KNEW


Two things stand out very clearly when we look at the US: first of all, we had a relatively tame experience of the Spanish Flu; secondly, we have had an even more muted experience of pandemics and endemic diseases over the 100 years since then. We didn't live through the 1918 pandemic, and we didn't live through the vast majority of premature death happening all over the world in the last century.


The Spanish Flu


Different strains of influenza have caused several pandemics since the 1500’s, including the “Spanish” H1N1 Flu of 1918, which got its name due to the efforts of Spanish reporters at the time, who came through with unbiased, groundbreaking news on an international crisis that was suppressed by other war-driven countries. It was one of the most infectious and deadly pandemics in human history, and came on the heels of one of the deadliest wars in world history. At the tail end of World War I (WWI), the World Health Organization (WHO) did not exist, and neither did the science, resources, nor collaboration between countries necessary to collect data on a worldwide pandemic. That’s why there is such a range in possible deaths attributed to the “mother of all pandemics.”


That famous virus claimed 50-100 million lives between 1918 and 1919, or more than 2.5 - 5% of the world population at that time, which would be 2,500 - 5,000 out of every 100,000 people. In the US alone, the virus killed 675,000 people, which was 0.66% of the US population at the time, or 660 in every 100,000 people. Though it was still a time of shocking loss and mass hysteria, this places the US death rate at 3.8 to 7.6 times lower than the worldwide death rate, which may explain why the US participated in suppressing reports of the virus’ impact at the time.


>>> Based on deaths by population, the Spanish Flu was 4-7 times less deadly in the US than worldwide.


The Spanish Flu had an estimated case fatality rate (CFR) of > 2.5% in the US, based on a comprehensive 2006 study which nods to advances in forensic science. This number makes that original strain of H1N1 (a type of Influenza A) at least 250 times more deadly than the seasonal flu — which is due, in no small part, to vaccines and hygiene practices which we use to minimize the death toll each year and to prevent another influenza virus from ravaging our nations. The numbers would not be quite so far apart, otherwise.


>>> Among those with confirmed cases, the Spanish Flu death rate was estimated to be over 250 times more deadly than the seasonal flu in the US and worldwide.


The Spanish Flu killed children and adults of all ages within days, sometimes hours, and was exceptionally contagious. Although the pandemic may have lasted for at least a year, the death toll essentially occurred over a single flu season, from September of 1918 to April of 1919; an official crisis period of 8 months. None of us were alive for that terrifying experience, and so our expectations of the flu in modern life are very mellow. Of course, that’s partly because we do everything we can to prevent another 1918, from promoting sanitation practices to creating new vaccines each year to combat the latest strains - we've just lost touch with the gravity of these practices, 100 years later.


Pandemics of the Last Century


From mid-1919 to mid-2019, the US simply didn’t lose more than about 0.07% of its population, or 70 in every 100,000 people, to any one pandemic (specifically, the Asian Flu of 1957), a mere 10% of the impact of the 1918 pandemic for us, and in the past 50 years nothing has come close to repeating that statistic.


Note that infectious diseases in general, some of which still wreak havoc to the tune of hundreds of thousands of deaths every year elsewhere in the world, are relatively insignificant in the collective memory of people living in North America, Western Europe, Australia, and Japan, not to mention our lack of familiarity with death due to indoor air pollution (think factories), poor sanitation, the environment, and noncommunicable diseases like heart disease, cancer, and diabetes.


Perhaps this disparity between the world and developed countries like the US offers the simplest explanation for our inexperience, alarmism, and devastation in dealing with this pandemic overall. We just haven't had to see so much premature death.


And then, there was COVID-19.


Infographic by the WHO

The World We Knew / The World We Never Knew / The COVID-19 Pandemic / Into the Future


THE COVID-19 PANDEMIC


COVID-19, the disease caused by the SARS-CoV-2 virus, is the first major worldwide pandemic since the internet was born. The result? A wildly emotional and unscientific commentary, drowning out the information that matters most as soon as it hits the worldwide web.


This is not to mention the reality of toxic national and international politics, as well as private interests, which are merely living up to their expectations as they muddy the waters surrounding the pandemic. There is a goldmine of web-catalyzed opportunities here.


Unfortunately, the origin of COVID-19 is its most controversial aspect. The theories of the US National Intelligence Council and this troubling interview of a former Chinese military virologist both offer compelling food for thought, but ultimately, “Beijing’s lack of cooperation on origins [is] not diagnostic of [any] hypothesis,” according to the NIC. Only Beijing can clear the water surrounding what happened in Wuhan; the rest of us are just raking a pool skimmer through the ocean.


At any rate, let’s address the more pressing matter at hand, and find out just how deadly the virus really is. The numbers are crying out for someone to tell their story, and to leave Joe and Donald out of it. So, let’s take a look, shall we?


Comparing Death Rates


Now, it is incredibly difficult to nail down a case fatality rate (CFR) for an extremely contagious novel virus at all, given all its variants everywhere in the world, so the scientific community has not yet been able to produce a CFR that can be used for comparison purposes. And it’s not their fault. It’s just that age is such a strong determining factor of death for this disease, and the age structures of different countries are so diverse, that it was expressly recommended against by the National Institute of Health (NIH) in October of 2020 to use any of the CFR's that were available for comparison between countries, except "at the very least" age-adjusted CFR's — which isn't exactly a ringing endorsement to use those, either.


>>> According to the NIH, using the highly variable CFR as a tool for comparison during this pandemic is premature and misleading.


Despite this, for some inexplicable reason, the scientific community set forth a CFR of 1.8%, beginning in December of 2020 and declining slightly over the past year, as a key metric for the virus. At first glance, this simply lines up with reported cases and fatalities to date, which do yield a CFR of about 1.6% for the US and 2% worldwide, and it paints a very clear picture of our situation: from these numbers, it looks like COVID-19 isn't too far off from our baseline catastrophe (the Spanish Flu), both in the US and worldwide, and is devastating compared to the seasonal flu; however, when we continue to explore the numbers, it will become clear why the NIH warned against using the CFR in this way, and why their warning still rings true a full year later.


>>> Among those with confirmed cases, COVID-19 death rates appear to be 160 and 200 times worse than the seasonal flu, and 64% and 80% as deadly as the Spanish Flu, in the US and worldwide respectively.


Even if we were to use the "real-world-outcome" CFR of > 0.1% for the seasonal flu (see above), it still looks like COVID-19 is at least 20 times more deadly among confirmed cases than the seasonal flu worldwide, which may be a bit more relevant to the worldwide experience of the pandemic, but ultimately these numbers don’t describe anything of substance about the experience of actual deaths in the US and worldwide.


So, let’s try something different. Let’s turn to the metric used to compare pandemic and endemic diseases historically, when all we had to go on was the crude number of deaths and (sometimes) the size of the population. Let’s paint a better picture.


Officially 20 months into the crisis, two years into the outbreak, and going into our third covid-and-flu season, this novel coronavirus has claimed almost 5 million lives worldwide and counting, which is about 0.06% of today’s world population or 60 out of every 100,000 people. Remember that flu deaths every year are < 0.01% of the world population and that COVID-19 has lasted two years, which is not factored into any of my hand-made statistics for the sake of simplicity.


>>> Worldwide, based on deaths by population, COVID-19 is at least 6 times more deadly than the seasonal flu.


For context, the Spanish Flu (which took 2.5% - 5%) was between 40 and 100 times more deadly than COVID-19 (at 0.66%), making a continued comparison of the two pandemics on a worldwide scale essentially baseless — especially when you consider that fact that today’s pandemic has lasted twice as long, both in total outbreak durations of one year versus two and in periods of extreme death of 8 months versus 16 months (excluding summers of 2020 and 2021).


>>> Worldwide, based on deaths by population, the Spanish Flu was 40 to 100 times more deadly than COVID-19.


In the US, the disparity between the two pandemics does not seem so ridiculous, on the surface: the COVID-19 pandemic is credited with the deaths of 740,000, which is about 0.22% of today’s US population, or 220 in every 100,000 people, over two years and overlapping three cold-and-flu seasons (so far); remember that flu deaths every year are < 0.01% of the US population and that COVID-19 has taken 0.22% over twice as many months.


>>> In the US, based on deaths by population, COVID-19 is over 22 times more deadly than the seasonal flu.


For context, that surpasses the crude death toll (675,000) and is about 33% of the death rate per capita (0.66%) of the Spanish Flu pandemic — not forgetting that the 1918 pandemic was also half as long.


>>> In the US, based on deaths by population, the Spanish Flu was only 3 times more deadly than COVID-19.


But of course, we’ve established that the US experience of the Spanish Flu was very tame, being that we were a developed country in a time with very few developed countries; therefore, reproducing the crude deaths of the 1918 pandemic in a country that barely experienced said pandemic (see above) and has more than tripled in size isn’t exactly apocalyptic; and yet, given that the US hasn’t lost more than 0.07% of its population to a pandemic in the 100 years since the Spanish Flu (see above), it may very well feel like it.


>>> In the US, based on deaths by population, COVID-19 is about 3 times more deadly than any pandemic in 100 years.


Compared directly, with crude death rates per capita of 0.22% and 0.06%, respectively, COVID-19 is 3.7 times more deadly in the US than in the world overall; in fact, the US is (currently) the 7th-most-impacted nation in the world.


>>> Based on deaths by population, the US is the 7th-most impacted nation in the world during this pandemic.


Still looking for the silver lining? Unlike the 1918 influenza virus, which struck at random, COVID-19's deaths are targeting a much more specific, at-risk population. This makes it easier to identify and protect that segment of the populace, rather than, well, whatever it is that we’ve been doing.


Of all COVID-19 deaths in the US, 94% were among those aged 50 and over, and 75% were among those aged 65 and over. In addition, at least 89% of all those hospitalized with COVID-19 in the US had a pre-existing condition, while 96.5% of all those who died had at least two; "anxiety and fear-related disorders" proved to be the second biggest risk factor among them. There is, of course, significant overlap between these two groups; about 94% of deaths occurred among persons who fell into both categories.


>>> According to the CDC, 94% of COVID-19 deaths in the US happened to people 50 and older, while 75% happened to people 65 and older.


>>> According to a year-long study by the CDC, 96.5% of COVID-19 deaths in the US happened to people with multiple underlying health conditions.


Taking into account that the US population has one of the larger proportions of aging people in the world, as well as the likelihood that that many more immunocompromised people are living in the US than elsewhere (an educated speculation, given that many such people would probably not survive to old age with these health conditions in many parts of the world), may help us to account for some of the difference in death rates.


Infographic by GEOstata
This map compares age structure between countries.


There is only one last metric of the virus’ impact that I’d like to look at, which others have pointed out: comparing death projections for 2020 to actual deaths, based on population. Since no COVID-19 deaths would have been anticipated for the year 2020, all of them should belong to the count of excess deaths, along with all other unanticipated deaths. That number should be about 3 million, based on WHO estimates for 2020.


So, there should be about 3 million excess deaths, worldwide, from COVID-19, which is 0.04% of the world population, or 0.4 in 1,000 people. In other words, the death rate for 2020 should be at least 0.04% higher than it was projected to be. Well, what do the numbers say? The global projection was about 59.23 million, or 0.76%, and the actual death rate was also 0.76%. This means that there was no excess death, statistically speaking. This death rate was incredibly difficult to find, given the rampant misuse of the projection as a statistic and the interesting lack of real data for 2020 provided by relevant sources, such as the UN. I can understand their hesitancy. Please follow the trail of links in any articles you see to find out whether they lead back to a projection or actual data.


>>> The global death rate for 2020 was 0% in excess of its projection.


Another consideration is that a map of excess deaths based on population should include the relative death toll of COVID-19 between countries, and that countries with aging populations should have relative excess deaths that are at least somewhat reflective of their age structures. We should, therefore, expect to find similar excess death among aging countries; the map below should show some correlation with the map above. Especially because all of these aging nations have many things in common as developed countries, with regards to public health policy, resources, and death reporting.


Infographic by Our World in Data
This map compares excess deaths between countries.


Between the two maps, do you find a significant pattern? For a devastating new pandemic that targets the aged population so relentlessly, there should be some level of clear correlation between countries with aging populations and excess death rates. This map shows us that, specifically:


>>> In 2020, the age structure of a country was not a major factor in excess deaths, even though age is the clearest factor in COVID-19 deaths.


Let's set aside the fact that, for this map and the 0% global excess to co-exist, there need to be below-projection death rates somewhere, matching the number of COVID-19 deaths. Australia and Japan weren't significantly below-projection, and negative excess deaths certainly didn't happen in China or India during 2020, so most likely somewhere in Africa there need to be 3 million fewer deaths than projected. This is not entirely infeasible, but it doesn't appear likely, given that Africa has historically been the deadliest continent in recent history (see above).


Excess death is not based directly on death in previous years, but based on projections that look at trends over the years; in other words, if an increase in world death was expected for 2020, which it was, then this is already accounted for in the projection. Excess death is over and above all expected increase or decrease in world death.