PANDEMIC | 3. German, Italian Death Rates

This is the third of a series of posts on comparative coronavirus death rates. See also posts of March 19 (#1, on Germany's low death rate), March 20 (#2, on infection rates). Virus Deaths Tracker (FT).

	Cases	Deaths	Rate, %
World	307,278	13,049	4.25
USA	26,747	340	1.27
Germany	22,364	84	0.38
Italy	53,578	4,825	9.01

March 22, 2020–As of Sunday morning in the Eastern United States, the novel coronavirus (SARS-CoV2) had 307,278 confirmed infection cases in 171 countries in the world, according to the Johns Hopkins interactive COVID-19 map. Of these cases, 13,049 patients died, for a global death rate or case-fatality rate of 4.25 percent, as shown in the top line of the data in the table above.

The United States had a lower death rate than the world total, as one might expect because we are at the tail end of the westward spread of the disease, so our peak will come later. Surprisingly, Germany's death rate is less than one-third of that of the United States, and Italy's is about seven times that of the United States. Italy's death rate is nearly 24 times that of Germany's–why? I speculated on Friday in Post #2 that countries that test early flatten the curve.

What Explains Germany's Low Death Rate?

Why is Germany's death rate so low? I asked this question three days ago in Post #1, and I suggested that rapid early testing was an explanation. Here is a more comprehensive answer from a German retired corporate executive to whom I sent an email asking for his views:

I am not an expert on the virus, but I have some explanations for the low death rate: Germany has benefitted from:  1. A well-distributed nationwide lab system.  2. A "best practice" testing approach. 3. Most important, an immediate start to testing. 4. Germany has health care that is well established nationwide, health insurance for all citizens, cost coverage by insurance companies starting from the test to hospital treatment and hospitals with ICUs even in smaller communities.  5. Currently, Germany's legislative leadership, an alliance between Christian Democrats (CDU) and Social Democrats (SPD), was able to make quick decisions about expanding the number of ICUs and taking emergency measures. 6. Strong leadership from Angela Merkel and Jens Spahn (Federal Minister of Heath), both from the CDU. Plus Olaf Scholz (Federal Minister of Finance) from the SPD. They agree that money is less important than human lives, and they have the strong support of the European Commission and even their political opposition in the German Bundestag. However: 1. Germans expect a rapid increase of confirmed infections and higher death rates in the next two to four weeks. The biggest problem is to stop social interaction among citizens beyond core families, to break the chain of infections and "flatten the curve." 2. Rules about curfews and isolation have been left to decision-makers at the state level. Angela Merkel and her Government will decide on Sunday whether additional 

A CNN analysis puts its money on nurses per 1,000 population as an indicator of the quality of health care, and reports that Germany's 13.2 per thousand nursing staff is an indicator of high-quality medical care. https://www.cnn.com/2020/03/24/opinions/germany-low-death-rate-for-coronavirus-sepkowitz/index.html.

Another role model for responding to the COVID-19 disease is South Korea. That story is told here: https://thebulletin.org/2020/03/south-korea-learned-its-successful-covid-19-strategy-from-a-previous-coronavirus-outbreak-mers/. Rep. Caroline Maloney (NY-12) asked at a hearing how South Korea was able to test 15,000 people per day. http://english.hani.co.kr/arti/english_edition/e_national/933773.html.

What Explains Italy's High Death Rate?

Looking at the other end of the spectrum, what explains Italy's high death rate? That might provide some guidance for what NOT to do. I looked for answers and one came in via email from the Baltimore Fishbowl, a lively newsletter. Cara Ober interviewed Irene Woodbury, an American living in Italy. I have excerpted, and lightly edited to save space, portions of the long mid-March interview that bear on the question.

Italy was slow to respond to warnings. Italy is a few weeks ahead of the United States in spread of the virus. Italy's peak is expected in the first week of April. The Italian government closed schools and universities on March 4. But life in Italian cities and towns continued much as usual, with people eating, drinking and socializing in public. Not till cases kept surging did the government lock down the country. By the time they locked down Italy, we were at 300 deaths. The lockdown was incremental, because people resisted a complete quarantine. The 20-year-olds were thinking, “I’ll just be fine, it’s just a flu.” Statistically, they will probably will be, but they pass the virus to other people that it kills.  Now 20-year-olds are on ventilators in the hospital, and they can no longer assume they will be fine. Italians are very social and have had a hard time isolating. When the government issued a new lockdown in places like Milan, everyone ran to the train station and went home to towns in the south they’re from. The idea of two weeks isolated in their apartments was unthinkable. What made a difference was seeing people dying every day. Now people are taking it seriously. It’s weird, because you have this invisible enemy. Everyone is wearing masks and you feel you’re in a war zone. Socially, it’s so strange – no shaking hands, keeping a distance, trying to be nice to people without interacting with them. 
Supplies and equipment were lacking. People are wearing masks, but the stores all ran out of them, especially the good ones with the filters. At the beginning, they tested everyone, and healthcare workers often. When they started running out of tests, they rationed them. Now you get the test only if you have symptoms or have travelled to certain places. It has been taking up to three days to get results, because of the overload. But Italy's availability of tests has been better than in the United States. So 10 to 15 percent end up in the hospital in need of ventilators and the hospitals are running out of beds. It’s like a war zone. They’re opening up 30 new beds a day, using shipping containers to make beds and ICU units. The lack of ventilators is a national crisis. One company in Italy makes them, a small, family-run company, and they have accepted a government request to make five times the number a month; they have stopped making everything else and sell directly and only to Italy. They have brought in soldiers to help. If some people don’t get a ventilator, their lungs collapse and they die. With a normal flu, people might need a ventilator for seven days, but with this coronavirus it can require 20 days. Hospitals in the south are not as well equipped and prepared. Health professionals are scared. Nurses on TV are saying it really is a war for them, with thirty new ICU patients a day and hardly anyone leaving. Regular operations at the hospital have been shut down. If you have tonsillitis and need surgery, you have to  wait a month. "Sorry—we have to dedicate all of our resources to this virus." Italy has an enormous elderly population.  New cases include so many older people. One reason is that the elderly are used to grocery shopping every day. In public spaces,  the only thing you can do is go to the grocery store. Everyone is there. This is probably why the death rate is higher in Italy than other places.

Postscript, April 9— Here's an article that attempts to summarize the factors that affect reports of COVID cases n different countries.