# Why is the COVID CFR in the GCC states so far below that of New York? **URL:** \ **Category:** The Quarantine Zone\ **Tags:** covid-quarantine\ **Created:** [May 1, 2020, 12:34pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968 "2020-05-01T12:34:53Z")\ **Posts on this page:** 17\ **Page:** 3
**Author:** ![Francis\_Vaughan](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/francis_vaughan/32/3093_2.png) [@Francis\_Vaughan](https://boards.straightdope.com/u/Francis_Vaughan)\ **Post date:** [May 2, 2020, 3:31pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/41 "2020-05-02T15:31:34Z")
> [@Chief\_Pedant](#): > > Which GCC states do you think are still experiencing “rapid exponential growth”? > Which do you think might not be testing or reporting only hospital admissions as positive? > > I don’t find it helpful to get replies that suggest possibilities not supported by the data. I was talking about the entire world. Note my first sentence. “It is not just the gulf states.” Many of the Gulf states are still sitting on 1.1 daily increases. My example based on about 1.25 was illustrating how you could get huge disparities. Easily 100:1 when growth is massive. I was illustrating a general point about the numbers, one that applies everywhere. I guess I assumed people could work out that a 10:1 disparity would occur with a lower growth number. 1.1 for three weeks will easily get you a 10:1 disparity. 1.1 is still rapid exponential growth for our purposes. If you have n ill people today, you will have over ten times that in three weeks, and 100 times that in six. It isn’t hard to look at the numbers and work out the precise values for each country one is interested in. I leave that as an exercise for the reader. Japan only tests on admission. There are likely others. The point is that it is very hard to compare countries. Japan is the sleeper in this mess. ---
**Author:** ![Chief\_Pedant](https://avatars.discourse-cdn.com/v4/letter/c/a6a055/32.png) [@Chief\_Pedant](https://boards.straightdope.com/u/Chief_Pedant)\ **Post date:** [May 2, 2020, 4:02pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/42 "2020-05-02T16:02:58Z")
> [@slash2k](#): > > Case fatality rate is not the same thing as infection fatality rate; CFR only measures the percentage of people who were tested and confirmed to have the disease, while IFR includes people who had COVID-19 but who were never tested. Per Worldometer, in New York roughly a third of the people tested were positive (927,438 tests versus 315,222 positive cases, as I write this); that ratio isn’t exact because some people may have had more than one test, but it’s probably pretty close. Meanwhile in Kuwait, out of 179,000 tests they found 4377 positives, or roughly 2.5% versus New York’s 34%. Similarly, in the UAE it’s 13,000 positives in 1.2 million tests, barely one percent; in Bahrain it’s 3170 positives in 134,000 tests, about 2.4%. That at least implies that those countries are testing a lot of people who are asymptomatic, probably as part of general surveillance, whereas New York has had well-publicized problems with test availability, to the point that even people with fairly serious illnesses have had trouble getting tested, and they’ve certainly not been able to do widespread testing of apparently healthy individuals. > > If you do widespread surveillance testing, then you are probably going to diagnose a lot more mild cases, people who never do develop serious symptoms, and include them in the denominator of your CFR, whereas if testing is more narrowly confined then you miss most of the mild cases. Comparing 7.5% of mostly-serious cases to 0.5% of cases of wildly varying seriousness is comparing apples and kumquats; it’s definitely not comparing like to like. A more valid comparison would be something like “what percentage of the people in each country who are sick enough to be hospitalized end up dying?”, or perhaps compare “percentage of those with blood oxygen levels below X%” or some other clinical symptom. I have not seen good data for those yet. I think your point about positivity rates is excellent,although I don’t think it accounts for the full difference. The WHO suggests a good benchmark is ten negatives per positive. Under that, (as New York is) and prevalence numbers for active cases are probably off. Worse, they may be skewed toward sicker patients, thus skewing your CFR. Saudi Arabia, for example, tests about 10K per million and has 5 deaths/M with a CFR of about 0.6. For Kuwait, 42K tests/M; 8 deaths/M; CFR about 0.7. New York: 47K tests/M; 1,200 deaths/M; CFR about 7.5%. New York has tested about 5% of its population; Saudi Arabia about 7.5%. Although NY is certainly missing more active cases than is SA, 5% of a population is still a pretty good sampling. The higher your total sampling rate is, the less likely you need to approach the 10:1 target to get a reasonable (though still crude) idea for the prevalence of active cases. But I want to thank you for making such a good point. I’ll go chew on it some more. ---
**Author:** ![Chief\_Pedant](https://avatars.discourse-cdn.com/v4/letter/c/a6a055/32.png) [@Chief\_Pedant](https://boards.straightdope.com/u/Chief_Pedant)\ **Post date:** [May 2, 2020, 4:05pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/43 "2020-05-02T16:05:42Z")
> [@Francis\_Vaughan](#): > > I was talking about the entire world. Note my first sentence. “It is not just the gulf states.” Many of the Gulf states are still sitting on 1.1 daily increases. My example based on about 1.25 was illustrating how you could get huge disparities. Easily 100:1 when growth is massive. I was illustrating a general point about the numbers, one that applies everywhere. I’m specifically calling out the GCC v NY difference, so comments about “the entire world” are not helpful for me. I can’t find any GCC state “still sitting on 1.1 daily increases.” Are you able to support that contention? ---
**Author:** ![Chief\_Pedant](https://avatars.discourse-cdn.com/v4/letter/c/a6a055/32.png) [@Chief\_Pedant](https://boards.straightdope.com/u/Chief_Pedant)\ **Post date:** [May 2, 2020, 4:09pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/44 "2020-05-02T16:09:43Z")
> [@DSeid](#): > > I got to say your responses in this thread makes one think that you have a preferred hypothesis that you are looking for someone to suggest. Knowing your past history on this board let me guess! Genetic differences! If I was right do I win a prize? I thought ad hominem attacks were frowned on here. LOL. Genetic differences never occurred to me. ---
**Author:** ![jshore](https://avatars.discourse-cdn.com/v4/letter/j/b5e925/32.png) [@jshore](https://boards.straightdope.com/u/jshore)\ **Post date:** [May 3, 2020, 2:39am UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/45 "2020-05-03T02:39:31Z")
In addition to some of the reasons cited (higher percentage of elderly in New York, on a different part of the curve, …), here is another major possibility: Antibody testing across NYS comes up with [an estimate that 12.3% of the population has antibodies for the virus](https://www.governor.ny.gov/news/amid-ongoing-covid-19-pandemic-governor-cuomo-announces-results-completed-antibody-testing). While false-positives might in principle be an issue, the fact that the rate varies so significantly between regions of the state suggests that the false positives can’t account for more than a couple percent of these at best. If you use that number to compute a death rate, you get about 1%. ---
**Author:** ![MaverocK](https://avatars.discourse-cdn.com/v4/letter/m/9de0a6/32.png) [@MaverocK](https://boards.straightdope.com/u/MaverocK)\ **Post date:** [May 3, 2020, 3:09am UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/46 "2020-05-03T03:09:16Z")
Elon Musk in the near past said that hospitals might be inflating COVID-19 numbers because they get more money for that. I don’t know how true this is. But this might be one of the reasons. ---
**Author:** ![Banksiaman](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/banksiaman/32/3334_2.png) [@Banksiaman](https://boards.straightdope.com/u/Banksiaman)\ **Post date:** [May 3, 2020, 3:39am UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/47 "2020-05-03T03:39:36Z")
> [@MaverocK](#): > > Elon Musk in the near past said that hospitals might be inflating COVID-19 numbers because they get more money for that. I don’t know how true this is. But this might be one of the reasons. If there is a concern among some contributors here that countries and organisations are making up stats out of arse-protection, self-interest or even problems with counting big numbers reliably, then i suspect all of that applies doubly to private pundits, especially those who have a track record of shooting from the mouth and equating enlightened public policy with their own self-interest. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [May 3, 2020, 1:40pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/48 "2020-05-03T13:40:24Z")
> [@Chief\_Pedant](#): > > I thought ad hominem attacks were frowned on here. LOL. > Genetic differences never occurred to me. Not sure what ad hominem attack you read. And I have no grounds to question your veracity. Meanwhile [this NYT article](https://www.nytimes.com/2020/05/03/world/asia/coronavirus-spread-where-why.html) asks the question of “Why Does the Virus Wallop Some Places and Spare Others?” inclusive of S.A. and may be of interest here. FWIW genetic differences among sub-populations is, as it should be, one possibility to investigate as a contributing factor. > [@](#): > > … The question of why the virus has overwhelmed some places and left others relatively untouched is a puzzle that has spawned numerous theories and speculations but no definitive answers. That knowledge could have profound implications for how countries respond to the virus, for determining who is at risk and for knowing when it’s safe to go out again. > > There are already hundreds of studies underway around the world looking into how demographics, pre-existing conditions and genetics might affect the wide variation in impact. > > Doctors in Saudi Arabia are studying whether genetic differences may help explain varying levels of severity in Covid-19 cases among Saudi Arabs, while scientists in Brazil are looking into the relationship between genetics and Covid-19 complications. Teams in multiple countries are studying if common hypertension medications might worsen the disease’s severity and whether a particular tuberculosis vaccine might do the opposite. … > > … One theory that is unproven but impossible to refute: maybe the virus just hasn’t gotten to those countries yet. Russia and Turkey appeared to be fine until, suddenly, they were not. … > > … Interviews with more than two dozen infectious disease experts, health officials, epidemiologists and academics around the globe suggest four main factors that could help explain where the virus thrives and where it doesn’t: demographics, culture, environment and the speed of government responses. > > Each possible explanation comes with considerable caveats and confounding counter-evidence. … The article is worth a read. ---
**Author:** ![Chief\_Pedant](https://avatars.discourse-cdn.com/v4/letter/c/a6a055/32.png) [@Chief\_Pedant](https://boards.straightdope.com/u/Chief_Pedant)\ **Post date:** [May 4, 2020, 7:57pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/49 "2020-05-04T19:57:41Z")
> [@DSeid](#): > > Not sure what ad hominem attack you read. And I have no grounds to question your veracity. > Meanwhile [this NYT article](https://www.nytimes.com/2020/05/03/world/asia/coronavirus-spread-where-why.html) asks the question of “Why Does the Virus Wallop Some Places and Spare Others?” inclusive of S.A. and may be of interest here. FWIW genetic differences among sub-populations is, as it should be, one possibility to investigate as a contributing factor. > > The article is worth a read. Thanks. I read it, and have read almost everything I can find on SARS CoV 2. Like BCG, the “genetics” idea is pure speculation. Sure; maybe. But speculation. I was curious with that article that they did not mention hydroxychloroquine wrt India’s approach. It is 180 degrees opposite of New York for early use of HCQ. India and Bangladesh are using HCQ like crazy. The Indian Council for Medical Research recommends it for prophylaxis (not tx, interestingly enough) and the broad Indian medical community uses it very generously for positive cases, official recommendation notwithstanding. By way of comparison, India’s reported CFR is something under 4%; Bangladesh under 2%; both nations so far have been doing pretty good keeping positives low per million. It will be kind of interesting to see how much that changes. Can they keep it up, and if so will it turn out HCQ is good for either prophylaxis or early treatment? Iceland is another interesting cohort. They test like mad and are probably not missing any cases. Their CFR is 0.5%. BTW, to the point of your quote from the article that “Turkey was fine…until it was not”…how is Turkey not fine? Turkey has 1500 cases/M; NY 16K. Turkey has 41 deaths/M; NY 1250. Turkey’s CFR is 1/3 that of New York (Turkey attributes this to their early use of HCQ). I haven’t looked at Russia. On the ad hominem issue, I was wondering why you thought any other positions–highly unpopular here, LOL–that I take are relevant. But maybe you think genes really are relevant for COVID. I remain unconvinced. ---
**Author:** ![Chief\_Pedant](https://avatars.discourse-cdn.com/v4/letter/c/a6a055/32.png) [@Chief\_Pedant](https://boards.straightdope.com/u/Chief_Pedant)\ **Post date:** [May 4, 2020, 7:58pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/50 "2020-05-04T19:58:42Z")
> [@MaverocK](#): > > Elon Musk in the near past said that hospitals might be inflating COVID-19 numbers because they get more money for that. I don’t know how true this is. But this might be one of the reasons. Just New York? ---
**Author:** ![Chief\_Pedant](https://avatars.discourse-cdn.com/v4/letter/c/a6a055/32.png) [@Chief\_Pedant](https://boards.straightdope.com/u/Chief_Pedant)\ **Post date:** [May 4, 2020, 7:59pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/51 "2020-05-04T19:59:52Z")
> [@jshore](#): > > In addition to some of the reasons cited (higher percentage of elderly in New York, on a different part of the curve, …), here is another major possibility: Antibody testing across NYS comes up with [an estimate that 12.3% of the population has antibodies for the virus](https://www.governor.ny.gov/news/amid-ongoing-covid-19-pandemic-governor-cuomo-announces-results-completed-antibody-testing). While false-positives might in principle be an issue, the fact that the rate varies so significantly between regions of the state suggests that the false positives can’t account for more than a couple percent of these at best. > > If you use that number to compute a death rate, you get about 1%. It’s unlikely that only New York has such a high ratio of recognized to unrecognized SARS CoV 2 infections. ---
**Author:** ![Chief\_Pedant](https://avatars.discourse-cdn.com/v4/letter/c/a6a055/32.png) [@Chief\_Pedant](https://boards.straightdope.com/u/Chief_Pedant)\ **Post date:** [May 4, 2020, 8:11pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/52 "2020-05-04T20:11:07Z")
> [@DSeid](#): > > **AK84** , also surprised by Dubai but would still be surprised if there was as much variety of international travel and as much of it staying there as New York City. But not interested enough to research it out, so I will admit that my impression that New York City is in a special class in that way may be just an impression. > **Chief Pedant** yeah CFR reflects selection bias of who gets tested more than anything else. You confuse it for something that means something that requires some bigger explanation than that. Deaths per million (not absolute number of) being so low there is a bit more the issue. If you find CFR rate to be something that needs more explanation than that then you may end up muttering to yourself alone. > > Not sure where you get the average age difference of only 3 years (or even why you think _that_ difference would not be a big deal in terms of death rates once infected) but the median age in [NYC](https://www1.nyc.gov/site/planning/planning-level/nyc-population/population-facts.page) is about 36 years old, in [S.A.](https://www1.nyc.gov/site/planning/planning-level/nyc-population/population-facts.page) it’s 27.5 (and atypically more males in older age groups than females and in comparison there are more women than men in NYC). > > I get that you think more than 4 times as many in the highest risk age group demographic is not meaningful to how many die. Personally I disagree. > > Climate as _a_ contributing factor is a hypothesis. Certainly it is not a factor that is the single most important item across the globe. The impact of climate, along with shorter term changes in humidity and temperature, on spread of infectious agents is a pattern that has been seen in the past for some other agents. > > Population density has to do with deaths per million. More infections faster means both farther on the growth curve and able to get higher. It also can make it harder to protect the most vulnerable populations, including but not limited to the elderly, so IFR (unlike CFR a meaningful number even if we don’t have it at this time) is higher too. > > No data to support BCG as a factor period? Wow. That’s a bold and ignorant statement. Fair to state that you are unaware of the data, or that it is not conclusive data at this time, but the reason that it has been mentioned several times is because there is in fact [some suggestive data](https://www.nytimes.com/2020/04/03/health/coronavirus-bcg-vaccine.html), even if it is just suggestive. The current evidence is suggestive enough that multiple RCTs are in progress in among front line workers. If increased testing frequency or pop density had anything to do with it, I don’t think India and Bangladesh would be doing as well. Agree that age is certainly contributing, though not sufficient to drive differences. Florida seems to be doing much better than is New York, both in terms of overall prevalence and CFR that is half that of NY. In Fl, 20% are over 65 v NY’s 16%. And b/c NY is testing at twice the rate of FL, if anything NY should have more minimally symptomatic positives. ---
**Author:** ![slash2k](https://avatars.discourse-cdn.com/v4/letter/s/439d5e/32.png) [@slash2k](https://boards.straightdope.com/u/slash2k)\ **Post date:** [May 4, 2020, 9:20pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/53 "2020-05-04T21:20:23Z")
> [@Chief\_Pedant](#): > > And b/c NY is testing at twice the rate of FL, if anything NY should have more minimally symptomatic positives. Why? That would be true only if the prevalence of COVID-19 is equal in New York and Florida, and there is no reason to believe that is the case. Suppose, for a (contrived) example, that twelve percent of New Yorkers and six percent of Floridians are infected. In that case, if New York tested at twice the rate of Florida, they’d still find only about the same percentage of minimally symptomatic cases in each state (assuming similar testing protocols, test accuracy, etc.). Now, is Florida’s infection rate half of New York’s, more than half, or less than half? The evidence suggests it is much lower: per Worldometer, New York has more than nine times as many confirmed cases as Florida per million population (16,509 versus 1791). One of every three New York cases is positive, versus about 1 in 12 in the Sunshine State. That would suggest that it is Florida that is much more likely to be detecting minimally symptomatic positives. ---
**Author:** ![drivekiller](https://avatars.discourse-cdn.com/v4/letter/d/cdc98d/32.png) [@drivekiller](https://boards.straightdope.com/u/drivekiller)\ **Post date:** [May 5, 2020, 1:22am UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/54 "2020-05-05T01:22:02Z")
If one is devoutly wearing a burka and washing for prayer 5 times a day, that may be a pretty effective pandemic response already. ---
**Author:** ![Chief\_Pedant](https://avatars.discourse-cdn.com/v4/letter/c/a6a055/32.png) [@Chief\_Pedant](https://boards.straightdope.com/u/Chief_Pedant)\ **Post date:** [May 5, 2020, 9:41pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/55 "2020-05-05T21:41:59Z")
> [@slash2k](#): > > Why? If you test more frequently, the percentage of positives that are minimally asymptomatic is higher because you are coming closer to actual prevalence for all positives. If you test less frequently, you tend to confine your testing to symptomatic patients, and if you test infrequently, you tend to confine your testing only to quite symptomatic patients. ---
**Author:** ![Chief\_Pedant](https://avatars.discourse-cdn.com/v4/letter/c/a6a055/32.png) [@Chief\_Pedant](https://boards.straightdope.com/u/Chief_Pedant)\ **Post date:** [May 5, 2020, 9:43pm UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/56 "2020-05-05T21:43:34Z")
> [@drivekiller](#): > > If one is devoutly wearing a burka and washing for prayer 5 times a day, that may be a pretty effective pandemic response already. Muslim men don’t wear burkhas. They tend to be very social, and in particular, social while praying, which they prefer to do in large groups where possible. ---
**Author:** ![slash2k](https://avatars.discourse-cdn.com/v4/letter/s/439d5e/32.png) [@slash2k](https://boards.straightdope.com/u/slash2k)\ **Post date:** [May 6, 2020, 3:25am UTC](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968/57 "2020-05-06T03:25:02Z")
> [@Chief\_Pedant](#): > > If you test more frequently, the percentage of positives that are minimally asymptomatic is higher because you are coming closer to actual prevalence for all positives. > > If you test less frequently, you tend to confine your testing to symptomatic patients, and if you test infrequently, you tend to confine your testing only to quite symptomatic patients. I think you are misunderstanding the point I am trying to make, which is that your testing results depend on BOTH the frequency of testing and the prevalence of the disease in the first place. Consider, for example, two separate populations, each with 10,000 people. Both focus their testing first on the most symptomatic, and then widen their net. Population A has 26 positive cases, of which 2 cases are serious and 24 are minimally symptomatic. They’ve done 250 tests in that population, so about 1 in 10 will be positive and 1 in 125 (less than one percent) will be a serious positive. Population B has 260 positive cases, of which 20 are serious and 240 are fairly minimal. They’ve completed 500 tests, so about 1 in 2 will be positive and 1 in 25 will be a serious positive. Although population B has been tested at twice the frequency of A, there are so many more cases in B that they would have needed to test at TEN TIMES the frequency to obtain about the same distribution of symptomatic/asymptomatic, because there are ten times as many cases to find. In A, less than one percent of tests will locate a serious case; there simply aren’t many serious cases to find. In B, even though testing is more prevalent, a much higher percentage of those tests are going to be focused on the quite symptomatic because there are so many more people with symptoms. Testing in Population A, even at lower frequency, probably comes closer to revealing actual prevalence of the disease. New York and Florida are close to equal in population (20 million versus 22 million), but one has had 330,000 cases and 25,000 deaths, while the other has found 37,000 cases and not even 2000 deaths. That suggests the disease to date has infected a much MUCH greater percentage of New York’s population. [Previous page](https://boards.straightdope.com/t/why-is-the-covid-cfr-in-the-gcc-states-so-far-below-that-of-new-york/852968.md?page=2)