The city of Wuhan in China experienced the first major outburst of the COVID-19 pandemic, leading Chinese authorities to impose a tight lockout on the city and the adjoining Hubei province between the last week of January and the beginning of April 2020. During more than half of this period the US was still virtually virus free. Till the beginning of March, the number of new cases in the US was zero or negligible. But, as can be seen from Figure 1, by the beginning of April, the number of new cases had already exceeded 30,000 per day in the US while in China they dropped to negligible quantities, creating a huge positive difference between new cases in the US and China. Moreover, Figure 1 suggests that this large difference in favour of China’s struggle with the pandemic persisted during the six months from April to the present.1
International statistics reveal that there is a positive correlation between the number of tests and reported new cases. Since the number of tests varies across countries, a more reliable yardstick for cross-country comparisons on the incidence of the virus is the number of coronavirus-related deaths. Figure 2 shows official statistics for the daily evolution of deaths in the US and China. The main conclusion from this comparison is similar to that from Figure 1: since April 2020 the number of daily confirmed deaths in the US is numerous times higher than that of China.
Taking the official statistics at face value, the first section of this blog explores the view that (at least part of) the much better Chinese performance is due to more efficient mobilisation of collective action in authoritarian China than in the democratic US. In view of anecdotal evidence supporting the existence of under-reporting of COVID-19 Chinese deaths between the end of January and the end of March, a subsequent section attempts to assess whether the entire difference in performance between China and the US may be due to Chinese under-reporting.
Figure 1 The US vs China (seven-day averages)
Figure 2 The US vs China (seven-day averages)
Differences in the effectiveness of collective action between the US and China
Due to the high contagiousness of COVID-19 and the absence of a vaccine, moderating the spread of the disease relies mainly on social distancing, the wearing of masks and isolation of known and suspected active cases from the rest of society. This is clearly an externality that requires each individual in society to adhere to the medical guidelines not only for his own sake, but mainly to maintain and hopefully reduce the spread of the disease. Tight adherence to medical guidelines creates a positive externality for society at large, while partial disregard for them imposes a negative externality on society. This is clearly a case in which the ability to effectively mobilise individuals to adhere to medical guidelines for the common good is key. In a democratic society such as the US, there is room for expressing different points of view about the necessity and the enforcement of any given set of medical guidelines. This is amplified by the fact that no single set of medical guidelines has been given at the federal level. In addition, the norm of civil liberties and doubts about the optimality of medical guidelines prevent full voluntary adherence even at the state level. By contrast, in authoritarian China the preannounced country-wide set of medical guidelines relies not only on the voluntary cooperation of its citizens but also on strict enforcement procedures backed by harsh measures against infringements.
In a recent column on reopening of schools in China, the New York Times correspondent to China notes:
“China’s top-down, state-led political system allows the party to drive its vast bureaucracy in pursuit of a single target — an approach that would be nearly impossible anywhere else in the world. In the US, where the pandemic is still raging, discussions about how and when to resume in-person classes have been fraught. An absence of a national strategy has left school districts to craft their own approach. Coronavirus tests can be hard to come by. Parents have expressed misgivings about sending their children back to classrooms. Teachers’ unions have threatened to strike, while college students have flouted rules against gatherings. In China, where the virus has largely been under control for months, there is no such debate. The party controls the courts and the news media and quashes any perceived threats to its agenda. Local bureaucracies have little choice but to obey the orders of the all-powerful central government. Independent labour unions are banned and activism is discouraged, making it difficult for the country’s more than 12 million teachers to organize. Administrators have corralled college students inside campuses, forbidding them to leave school grounds to eat or meet friends.” (Hernandez 2020b).
The impact of Chinese cover-ups on reported performance in the struggle against the virus
During the initial phases of Wuhan’s major outbreak of the virus, the Chinese Communist Party (CCP) actively suppressed information about the emerging pandemic, delayed the publication of information about the fact that it is transmitted from human to human, and swiftly suspended millions of informative messages on WeChat and similar outlets that were relaying information from medical stuff about the dire medical situation in Wuhan to colleagues in the rest of China (Yuan 2020). Dr Li Wenliang at Wuhan City Central Hospital had been silenced by the police after warning about the new coronavirus that has killed hundreds in China and sickened thousands. Shortly after, he died from the virus. His death ignited responses from people with different backgrounds, including government officials, prominent business figures and ordinary online users. They have posted numerous messages expressing their grief for the doctor and their anger over his silencing by the police. Most of the accounts of the message senders were closed after a while by the CCP (Li 2020).
There are strong indications that between January and the beginning of April 2020, the actual number of deaths in Wuhan was many times higher than the officially reported figures. To minimise contagion, virus casualties were cremated. Accounts by residents of Wuhan and relative of deceased individuals from the virus suggest that Wuhan area crematoriums operated at abnormally large capacity for many weeks and that the number of urns delivered by funeral homes to families of the deceased far exceeded the official figures.
One popular estimate is based on the cremation capacity of funeral homes in Wuhan that run a total of 84 furnaces with a capacity of 1,560 urns city-wide over 24 hours. Assuming that one cremation takes one hour and full utilisation of capacity, this calculation returns an estimate of 46,800 deaths. Other estimates by residents are lower but all imply the cumulative number of deaths are at least ten time larger than the 3,000 or so official figure. Radio Free Asia reported in April that a resident of Hubei province said ultimately most people in the area believe that more than 40,000 people died in the city before and during the lockdown.2
Given those accounts, there is little doubt that official death statistics during the Wuhan outbreak and lockdown are substantially biased downwards. This conclusion raises the following questions: First, is it likely that such a large downward bias also characterises the period between 8 April 2020 and the present?3 Second, even if we assume that a similar bias persisted throughout the second period, can it explain all or most of the difference between the corona death toll in the US and China during that period?
It is convenient to first provide a back of the envelope approximate answer to the second question. By 8 April, the official cumulative number of deaths in China was 3,337. Assuming that the true number is 46,800, as implied by the calculation above, this implies that during the first period the number of deaths was 14 times larger than the official account. I will refer to this number as the ‘cover-up ratio’ during the Hubei outbreak. Official statistics imply that between 13 October and 8 April, deaths in China totalled 1,402. Assuming that the cover-up ratios in the second and first periods are equal this implies that the actual number of deaths in the second period was 19,628 (1402*14). During the same period, actual deaths in the US amounted to 193,167 implying that only a tenth of the difference in the cumulative number of deaths between the US and China in the second period is attributable to cover-ups.4 In spring 2020, the Daily Mail reported that UK Prime Minister Boris Johnson had been warned by scientists that the cover-up ratio during the first period could be anywhere between 15 and 40. Given the evidence at hand the upper bound appears as grossly exaggerated. In any case, even at this upper bound, cover-ups can account for at most a third of the difference in the cumulative number of deaths between the US and China during the second period.
I turn next to the first question of whether it is likely that the official statistics for the second period are contaminated by a downward bias similar in magnitude to that of the first period. Although a downward bias cannot be excluded, there are reasons to believe it is lower during the second period than during the first for a number of reasons. Although there were limitations on social mobility, strict lockdowns such as the one imposed on Wuhan were not imposed during the second period, suggesting the number of deaths was indeed lower than in the first period. On 23 August, Hernandez (2020a) reported that restaurant and bars in China had reopened and that restrictions on internal flights had eased substantially. Most of the Chinese economy, including internal tourism, had returned to almost full operation.
Subject to appropriate and strictly enforced safeguards, China brought nearly 200 million students back to school (Hernandez 2020b). Such steps would not have been taken had the state of the pandemic been similar to its incidence in the first period. The IMF estimates that China will be one of the few economies, and possibly the only economy, with a positive rate of growth during 2020. It is unlikely such a performance would have been possible in the absence of adequate control over the pandemic. Most likely the severity of the Wuhan outbreak took the CCP by surprise, raising its motivation to cover up in the first period. During the second period the authorities were better prepared. Along with some hard-won successes of measures against the virus, those factors reduced the motivation of the CCP to bias deaths and new cases downward.
The main conclusion from the discussion in this section is that at least two thirds of the large discrepancy between the US and China in the incidence of deaths from the COVID-19 virus during the second period are not due to cover-ups.
The Trump–Bolsonaro factor
Presidents Trump and Bolsonaro are well known for playing down the contagiousness, health hazards and lethality of COVID-19. Trump deliberately scorns the wearing of masks and social distancing, and so does Bolsonaro in Brazil. Bolsonaro often appeared in public to shake hands with supporters and mingle with crowds, often without a face mask, and often at protests against the restrictions imposed by regional governors in Brazil. By contrast. Prime Minister Modi of India took those hazards quite seriously. On 25 March. a country-wide lockdown was imposed and, following a number of extensions, lifted only gradually starting at the beginning of June.
The US, Brazil and India are currently near the top of national COVID-19 death statistics. Unlike authoritarian China, all three countries are democracies. It is therefore likely that any differences in deaths among those countries do not reflect the more effective mobilisation of public action by an authoritarian regime. Instead, by comparing death incidence in the US and Brazil to that of India, one gets an upper bound estimate on the impact of the COVID-19 denial by Trump and Bolsonaro on excess deaths in the US and Brazil relatively to India. Figure 3 shows the evolution of daily new confirmed deaths in the three countries per million people since confirmed deaths reached 0.1 per million people. The death count in the US and Brazil is uniformly higher than that of India. The maximum number for India is less than one, while following initial swift accelerations it is normally above two and four in the US and Brazil, respectively.5
It is likely that the Trump–Bolsonaro effect raises deaths in the US and Brazil through the following mechanisms. First, and most obvious, the authorities in the COVID-19 denial countries deploy less measures against the virus. Second, a fraction of the population in the denying countries accepts the view that the pandemic is not serious and refrains from following basic protective procedures such as wearing masks and maintaining social distancing. Finally, the attitudes of the federal leaders also influence the actions of state governments.6
The excess of deaths in Brazil in comparison to the US at least partially reflects the better sanitation and health systems of the US. Applying a similar consideration to the US versus India implies that, if India had sanitation and medical systems similar to those of the US, the excess deaths in the US in comparison to India due to the Trump–Bolsonaro effect would have been even larger.
Figure 3 The US and Brazil vs India (normalised by population)
Figures 1 and 2 show that since April 2020, COVID-19 incidence measured by new cases and deaths has been dramatically higher in the US than in China. The cover-up of information about deaths by the CCP in the initial outbreak period during the first third of 2020 raises the suspicion that at least part of the better Chinese performance since April is due to under-reporting of deaths. Some counterfactual thought experiments imply that, at most, one third of the discrepancy between the US and China since April may be due to under-reporting.
Accordingly, the main conclusion of this blog is that the remaining two thirds reflect the advantage of the Chinese authoritarian regime in mobilising public collective action against the pandemic as well as the public minimisation of the virus health hazards by president Trump and his widely publicised opposition to basic sanitary actions (like wearing masks and maintaining social distancing) against the virus. Although this conclusion does not exclude other possible factors, it is likely that those two factors go a long way towards explaining the huge difference in deaths between the US and China.
Before closing two qualification are in order. The conclusion that, other things equal, a coercive authoritarian regime is more effective in mobilising public action against a pandemic should not be construed as a recommendation for permanently paying the costs of such a regime in terms of human liberties. But, in the face of a dangerous adverse externality such as swift contagiousness, it does open the door for temporarily considering the imposition of restrictions on the public by enlightened leaders in democracies. Second, effective collective action against a pandemic can also be achieved by transparent and truthful dissemination of medical information in a way that builds up public trust. The relatively good performance of democratic Taiwan and South Korea attests to that (Tworek 2020). Such a strategy is more likely to succeed in culturally homogeneous and disciplined societies.
Author’s note: I benefited from discussions with Manyan Ng and Assaf Razin. The usual disclaimer applies.
Hernandez, X (2020a), “In China, Where the Pandemic Began, Life Is Starting to Look … Normal”, New York Times, 23 August.
Hernandez, X (2020b), “How China Brought Nearly 200 Million Students Back to School”, New York Times, 12 September.
House Foreign Affairs Committee (2020), Minority Staff Interim Report, June.
Tworek, H (2020), “Lessons learned from Taiwan and Sout Korea tech-enabled communications”, Tech Stream, Brookings, 6 October.
Li, Yuan (2020), “Widespread Outcry in China Over Death of Coronavirus Doctor”, New York Times,8 February.
Yuan, S (2020), “Inside the Early Days of China’s Coronavirus Cover-up”, Wired, 7 May.
1 This difference is even more dramatic when one takes into consideration that Chinese population is about four times larger than that of the US.
2 Further documentation appears in House Foreign Affairs Committee (2020).
3 I chose this date as the cutoff between the Wuhan-Hubei outbreak first period and the subsequent second broad period till the first half of October since the Hubei lockout was lifted on that day.
4 Or, in other words, the ratio of US/China deaths after generous allowance for possible cover-ups during the second period is at least 9.84. The source of the numbers in this paragraph is the John Hopkins University Corona Virus Resource Center for the US and the Chinese Center for Disease Control and Prevention.
5 Since it is possible that the fraction of under-reported deaths in India is larger than in the US the comparison in the text only provides an upper bound on the effect of the Trump-Bolsonaro factor in the US. Further work is needed to obtain a tighter estimate.
6 The US, Brazil and India are all federal countries.