Even allowing for different testing policies and counting methods, and questions over full disclosure of cases, stark differences in mortality across the world have caught the attention of researchers trying to crack the coronavirus code.

Parts of Asia reacted quickly to the threat and largely started social distancing earlier on. But researchers are also examining other factors, including differences in genetics and immune system responses, separate virus strains and regional contrasts in obesity levels and general health.

– What are the numbers? China, where the virus emerged late last year in Wuhan, has recorded fewer than 5,000 deaths, which translates to three deaths per million inhabitants. Japan has around seven per million, Pakistan six, South Korea and Indonesia five, India three and Thailand fewer than one per million. Vietnam, Cambodia and Mongolia say they have recorded zero covid-19-related deaths.

Compare that with about 100 deaths per million in Germany, about 180 in Canada, nearly 300 in the United States and more than 500 in Britain, Italy and Spain.

Scientists at Japan’s Chiba University plotted the trajectory of the virus across the world and said they noticed stark regional disparities.

“That means we need to take into consideration regional differences first, before analyzing what policies and other factors are affecting the spread of infection in any given country,” said Akihiro Hisaka of the university’s Graduate School of Pharmaceutical Sciences.

– The conventional wisdom: The baseline assumption, at the moment, is that the virus – officially SARS-CoV-2 – mutates the way all viruses do and is just as innately contagious and lethal in one part of the world as in another.

“We are all facing the same bug with the same general arsenal of immune responses,” said Jeffrey Shaman, an epidemiologist at Columbia University. “There are differences in testing, reporting, control from country to country. And there are differences in rates of hypertension, chronic lung disease, et cetera, on a country-by-country basis.”

Part of the reason for the high number of deaths in the United States and Western Europe may lie in an initial reluctance to react to an epidemic that seemed distant and unthreatening. In Asia, meanwhile, previous experience with the SARS and MERS epidemics enabled much faster responses to the new threat.

Taiwan, for example, has been widely praised for its speedy response to the epidemic, including early screening of air passengers from Wuhan. South Korea built a massive program of testing, tracing and isolating patients.

But in Japan and India, two very different countries, the relatively low death toll has baffled many scientists. Similar mysteries have emerged from Pakistan to the Philippines.

– Weather and culture a reason? Hot and humid weather could be a factor in places such as Cambodia, Vietnam and Singapore. Several studies have suggested that heat and humidity can slow, although not stop, the spread of the virus, just as is seen with influenza and with coronaviruses that cause common colds. But some equatorial countries, including Ecuador and Brazil, have seen many cases and deaths linked to covid-19.

Demographics also play a role in regional disparities. Africa’s generally younger population may have been more resistant than northern Italy’s older communities, for example.

In Japan, which has the world’s oldest population, different reasons are being explored.

There is a widespread belief in Japan that good hygiene and habits, like wearing masks and avoiding handshakes, helped slow the spread of the virus, while universal health care and the country’s emphasis on protecting the elderly may have lowered the death toll.

– What about different strains? Research by a team at Cambridge University showed how the virus mutated as it left East Asia and traveled to Europe, noting the possibility that the initial strain may have been “immunologically or environmentally adapted to a large section of the East Asian population” and needed to mutate to overcome resistance outside that region.

Peter Forster, the geneticist who led that study, said there is “very limited clinical data” on how the various virus strains interacted with different populations. He noted, however, that the question “should be followed up” on whether different strains explained contrasting mortality rates.

A team of scientists at Los Alamos National Laboratory also argued that a more highly contagious strain of the virus has taken hold in Europe and spread in the United States – but other experts have said the significance of emergent strains remains unclear.

“It could just be an accident that whoever had that mutant went to the most rock festivals and nightclubs and transmitted to the most people,” said Jeremy Luban, a virologist at the University of Massachusetts Medical School. “But the other possibility is that that strain is more transmissible.”

– Genes and immune systems: Nobel laureate Tasuku Honjo, a Japanese physician-scientist and immunologist, said people with Asian and European ancestry have enormous differences in the human leukocyte antigen (HLA) haplotype, genes that control the immune system’s response to a virus.

That might help explain lower Asian death rates, he said, but is unlikely to be the only reason.

Scientists at Chiba University said a whole range of possible genetic factors might condition the body’s response to the virus and deserved further study – even while stressing that there is no evidence yet to back up the idea.

Different immune responses could also play a role.

Tatsuhiko Kodama of the University of Tokyo said preliminary studies show that Japanese people’s immune systems tend to react to the novel coronavirus as though they had previous exposure, and notes that there are centuries of history of coronaviruses emerging from East Asia.

“The enigma of lower death rates in East Asia can be explained by the presence of immunity,” he said.

Other studies have suggested that rates of Bacille Calmette-Guerin (BCG) vaccination might have played a role, because the anti-tuberculosis shot can potentially cause immune-boosting response at the cell level.

“Our hypothesis is that BCG, plus infection or exposure to TB, would be protective,” said Tsuyoshi Miyakawa of Fujita Health University.

But Japan has a record of BCG vaccination similar to that of France – albeit with a different strain of the vaccine – and yet a very different covid-19 mortality rate.

Experts are divided, but clinical trials are underway.

Megan Murray, an epidemiologist at Harvard Medical School, said another factor worth exploring is differences in microbiomes – the trillions of bacteria that reside in a person’s gut and play a huge role in immune response.

“Microbiomes are very different in different places. People eat very different food,” she said.

– Obesity under study. But don’t discount random chance. There’s something else that many Asian countries have in common – much lower rates of obesity than in the West.

Obesity is a leading risk factor for serious covid-19 illness. Just over 4% of Japanese people are classified as obese, and less than 5% of South Koreans. That compares with 20% or more in Western Europe, and 36% of people in the United States, according to the World Health Organization.

But random chance is also at play. Russia, for example, looked remarkably unscathed by the virus for a couple of months, and now it’s a hot spot. Cases are now rising in India after a relatively flat curve.

All the epidemiological research on the virus suffers from incomplete data, and any conclusions drawn from the initial numbers may melt away as new data emerges. It is still early in the pandemic, experts say, and the hard-science questions take time.

In any case, it doesn’t change the need for every country to remain on high alert.

“All of the strains that are circulating on the planet,” said UMass professor Luban, “seem to be capable of killing people.”

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The administration has brokered an agreement between insulin manufacturers and some Medicare prescription drug plans that would lower costs for some seniors beginning in 2010 by capping co-pays at $35 for a monthly supply – a figure that administration officials said would lead to about a two-thirds drop in out-of-pocket costs and would encourage seniors to be able to continue taking insulin.

“We have reached a breakthrough agreement to dramatically slash the out-of-pocket costs of insulin,” Trump said from the Rose Garden during the late-afternoon event. “You know what’s happened to insulin over the years, right? Through the roof.”

The president, who is not known to be diabetic, added: “I don’t use insulin. Should I be? I never thought about it.”

Surgeon General Jerome Adams later explained to Trump that he did not need to take insulin because the president’s body produces it on its own.

Trump’s relative strength with seniors, particularly in key swing states, helped seal his win against Democratic candidate Hillary Clinton in 2016. In Florida, more than 20% of those who voted in the 2016 election were older than 65, and Trump won the Florida senior vote by 17 points, according to exit polling.

But Trump has struggled with those older voters as he competes with Biden, according to state and national polls.

A Quinnipiac University poll of registered voters released last week shows Biden leading by 10 points nationally among voters over 65. A Quinnipiac poll of Florida voters in late April found that 52% of Florida seniors support Biden, compared with 42% for Trump.

The president took a swipe at Biden during the official White House event, saying: “Sleepy Joe can’t do this. That I can tell you.”

Kellyanne Conway, adviser to the president, said the timing of the announcement was geared more toward open enrollment and dismissed the notion that it was aimed to shore up Trump’s political struggles with the senior demographic.

“We just continue to fight for seniors,” Conway said on a call with reporters. “This is a president who promised as a candidate that he would, quote, ‘not touch Medicare or Social Security.’ He’s touched it in the right way.”

Trump has lost support with older voters as many have perceived the president to have mishandled the coronavirus pandemic, which disproportionately affects older Americans. More than one-third of the country’s nearly 100,000 covid-19 deaths have been in nursing homes. Covid-19 is the disease caused by the novel coronavirus.

Before the pandemic, Trump and his administration were focused on lowering drug prices, which consistently polled as a top concern – especially among older voters. The price of insulin has become a frequent focus for politicians who complain about high drug prices because of its ubiquity.

Trump embraced and regularly touted traditionally Democratic ideas to lower prices, including allowing Medicare to negotiate drug prices with pharmaceutical manufacturers and proposing an international pricing index that would base the price of some Medicare drugs on the lower prices paid in other countries – both proposals that are anathema to congressional Republicans.

Little came of those efforts, however, as Trump’s advisers and Health and Human Services Secretary Alex Azar regularly feuded over the best policies to lower prices.

The Trump administration had begun moving forward on a proposal late last year to allow states, drug wholesalers and pharmacies to import some cheaper drugs from Canada, though officials did not say when the plan might go into effect.

Trump also embraced a legislative proposal from Chuck Grassley, R-Iowa, chairman of the Senate Finance Committee, and Ron Wyden, D-Ore., the committee’s top Democrat, that would limit price increases in Medicare’s prescription drug benefit to the rate of inflation or otherwise force companies to pay a penalty in the form of a rebate. It would also limit seniors’ out-of-pocket drug costs to $3,100 a year.

Trump last week told Grassley at a Senate Republican lunch that he still wanted to move forward on the legislation, but it faces opposition from most Senate Republicans, including Senate Majority Leader Mitch McConnell, R-Ky.

Seema Verma, the administrator for the Centers for Medicare and Medicaid Services singled out two swing states critical to the president’s reelection – Florida and Michigan – where more than 95% of Medicare Part D beneficiaries had access to a lower premium plan under the Trump presidency.

Verma said that nearly 90 insurers that offer about 1,750 health care plans have applied to the effort to lower insulin costs and that, if effective, this plan could be replicated to reduce costs of other expensive drugs.

“We fully anticipate that many plans will go further in lowering or even eliminating co-pays for insulin,” Verma said, later adding: “For those whose health and even lives depend on insulin, these savings are nothing short of a godsend.”

Accompanying Trump at the Rose Garden event were executives from various pharmaceutical companies, health insurers, patient advocacy organizations and the head of the American Diabetes Association.

Isabela Rivera was the first in her home to test positive for the novel coronavirus. Unable to fully isolate in the three-bedroom apartment she and her husband, Danilo, share with two other northern Virginia families, the Riveras sent their 7-year-old son to live with a family friend. Danilo sleeps on the couch, unsure whether he is infected. The other families have taken cover in their rooms, hoping a closed door will protect them from the deadly and highly contagious virus.

But their apartment complex in Herndon has become a coronavirus magnet. Soon, others were coughing and wheezing.

Latinos, who make up about 10% of the population in the District of Columbia, Maryland and Virginia, make up about a third of the coronavirus cases in the region, according to a Washington Post analysis of jurisdictions that track the race and ethnicity of patients with covid-19, the disease the virus causes.

The disparity is not unique to the capital area. Latinos young and old are contracting the virus at alarmingly high rates in places such as New York, Chicago and Los Angeles, although the fatality rate for their community is significantly lower than that of African Americans. In an ABC News-Ipsos poll released Friday, 26% of Latino adults in the country said they know someone who has died of the virus or of complications related to it.

Experts cite many explanations: Latinos are a dominant presence in service industry jobs, leaving them unable to ride out the pandemic from home. Many have struggled to get protective equipment, while others ignored shutdown orders to take risky jobs in exchange for much-needed cash.

Outside of work, avoiding the virus can be nearly impossible, either because Latino families are more likely to live in multigenerational homes or because many take on multiple roommates to manage the Washington region’s high housing costs.

Efforts to slow the virus’s spread are tangled with complications, public health experts say, including language barriers, economic stressors, limited resources and, in some cases, a slow response from local governments.

“There is a lot of fear,” said Yukmila Soriano, a primary care doctor at Virginia Hospital Center in Arlington County, Virginia, where a majority of the 100 patients tested per day tend to be Latino. “We are asking everybody to stay home, but the idea of staying home is very different depending on who you are and what your role in society is.”

In northern Virginia, Latinos make up 16.8% of Fairfax County’s population but nearly 64% of its coronavirus cases in which ethnicity is known, records show. In Prince William County, Latinos represent 24% of the population and nearly 77% of infections in which ethnicity is known. In the Maryland suburbs and D.C., predominantly Latino neighborhoods also have some of the highest rates of contracting the coronavirus.

As it spreads, the virus has gnawed through the region’s economic backbone, sidelining thousands of cooks, custodians, landscapers and other front-line workers.

Fredys Medina, a diabetic construction worker from Arlington County, waved off his wife’s suggestion that he had the virus after he developed a cough and fever in late April, and he continued to work.

Two weeks later, he collapsed on the living room floor. By the time paramedics arrived, Medina, 56, was gone. His wife, Leonor Medina, an unemployed hotel housekeeper, was left with an $8,000 funeral bill she could not pay until neighbors and members of their church chipped in.

At the funeral, the couple’s middle child, Alberto, 14, flung himself onto his father’s body, holding tightly as he wept. He has since tested positive for the virus. So did his mother and 11-year-old brother, Freddy. Leonor Medina seeks comfort in her Pentecostal Christian faith, grateful that her symptoms – and those of her children – have been mild.

“This is a demon that wants to kill everyone,” she said. “I was spared, and so were my sons.”

Jeff McKay, chairman of the Fairfax County Board of Supervisors, said the number of Latinos who work in hotels, restaurants and stores was one reason he asked Gov. Ralph Northam, a Democrat, to delay relaxing restrictions on nonessential businesses in northern Virginia until at least Thursday.

“Some of them are eager to work again because they’re not getting income, but there is a whole lot of them also scared to go back to work,” said McKay, a Democrat. “That’s a really bad position for anyone to be in.”

– – –

In D.C.’s historically Latino Columbia Heights neighborhood, the virus ripped through Flor Morales’ home like a tornado. The neighborhood still does not know how it got in.

Morales, 23, lost her job as an office custodian when the pandemic began. But her husband continued to work in construction, and her twin sister, Rosa Morales, kept her job at McDonald’s, despite her growing unease over maskless customers and the cramped restaurant kitchen.

In early April, their mother, Maria Elena Velasquez, got sick and died of covid-19. Soon, Rosa was coughing. She quarantined in the only vacant room: the one her mother had used. Within days, her father’s temperature spiked. Both tested positive for the coronavirus.

The family heard about sick friends and neighbors – a pastor and his wife, the owner of a pupuseria down the block, co-workers, street vendors, supermarket employees.

One of the boarders who rented a room from the Morales family also fell ill.

Flor Morales spends her days taking care of everyone else – delivering food to her father, leaving hot soup and tea outside the basement door for her sister, caring for her three children and four nieces and nephews, the youngest one 6 months old.

When Morales’ 8-year-old niece developed a fever, she carried the girl to her car and took off toward the hospital, passing groups gathered on corners, neighbors talking without masks. One night, she shut herself in the bathroom she shares with her husband and their kids, threw herself onto the tile floor and screamed.

“God!” she shouted. “Why did you take her away from me?”

Downstairs, her sister Rosa leaned against the closed basement door and cried.

Ivan Torres, a language access coordinator for D.C., said quarantining Latino patients who live in crowded multigenerational homes is rarely effective. Instead, Torres said, local governments must provide lodging and support to allow individuals to quarantine safely away from their families.

“We know not everyone can say, ‘OK, I’ll just stay in my room’ or ‘I have my own bathroom,’ ” Torres said. “We understand what the reality is.”

D.C. and parts of Maryland and Virginia have worked to provide individuals with a place to isolate. But advocates say most rooms go to homeless people, and many Latino residents do not know about the option.

In the predominantly Central American immigrant neighborhood of Langley Park, Maryland, an entire family of six came down with the virus, said Prince George’s County Council member Deni Taveras, a Democrat. When the parents were hospitalized, the four children were taken in by relatives – adding another layer of potential exposure.

“It is a desperate, desperate state of affairs,” said Taveras, who lost four family members to covid-19 in New York.

Prince George’s recently opened a quarantine site seven miles from Langley Park that can hold 100 people, but officials declined to say how many rooms are in use. In Virginia, Fairfax County has rented 221 hotel rooms, and Prince William County has rented 40. D.C. has designated 864 hotel isolation rooms, which officials said primarily are used by people who otherwise would be in shelters or on the street. D.C. data shows that 38 people have used the hotel rooms because they were unable to quarantine at home.

Public health advocates and doctors said government agencies need to do more. James Lamberti, a pulmonary care doctor whose practice in heavily Latino Annandale treats as many as 30 patients per day, called the lack of quarantine sites in Fairfax County “an embarrassment.”

“There’s a history for this with public health with tuberculosis,” he said. “If people were not able to go back to a home, they got put up in a hotel. A lot of this ongoing community spread over the last month could have been prevented by better public health, by figuring out where the problem was at a local level.”

Fairfax County, which has 1.1 million people, had reported 9,482 infections and 331 deaths as of Monday. Officials say they plan to rent an additional 160 hotel rooms for quarantining, on top of the 221 that are mostly occupied.

Local governments also have struggled to get Spanish-speaking residents information about the coronavirus and to track its spread in the community.

Spanish-language text alerts recently launched by Fairfax reach fewer than 200 residents, despite a population of about 53,000 who speak mostly Spanish. About 39,000 residents of Prince William County primarily speak Spanish; 53 have signed up for their alerts.

Steven Woolf, a researcher with the Northern Virginia Health Foundation, said increased testing and the ability to track people potentially exposed to an infected person are crucial to control community spread of the disease. But, Woolf said, many contact-tracing efforts do not include interpreters.

Another obstacle local governments and health-care providers must contend with is fear.

Jair Carrasco, an organizer with D.C. street-vendor advocacy group Vendadores Unidos, has heard from immigrant families afraid to take sick relatives to a hospital that they are concerned immigration agents could be lurking there.

“On top of the virus and people not wanting to go outside due to safety concerns, you’re also dealing with immigrant communities with a long history of police abuse and discrimination,” said Carrasco, 29, who began to feel ill in early May after his girlfriend came home from her supermarket job feeling feverish and dizzy. She later tested positive for the coronavirus.

While he waited to be seen by a doctor, he decided to try out D.C.’s Spanish-language coronavirus hotline. He was transferred three times, he said, and given a new number to call. He never found the food-delivery service he was seeking.

“What if I was only a Spanish speaker and they’re giving me this go-around?” he said. “That can make the difference between someone getting help and people suffering.”

D.C. officials said they consulted with a wide range of organizations that work in the Latino community before launching robocalls in Spanish and attempting to streamline the city’s complex web of bureaucracy for non-English speakers.

“Something we saw at the [outset] that was really devastating is, we had residents dying in their homes because they had not sought care,” said Tomás Talamante, the deputy chief of staff for D.C. Mayor Muriel Bowser, a Democrat. “That’s the message we’ve been trying to get out: Regardless of immigration status, regardless of socioeconomic situation, we want our residents to seek care.”

– – –

On a recent morning, a line of patients stretched down the block outside the Upper Cardozo Health Center in Columbia Heights.

The clinic – which tests more than 80 people daily, about half of them Latino – opens its doors at 8 a.m. Patients have been known to arrive as early as 6.

Medical director Blanca Toso worries that they are just the tip of a much larger iceberg. She spends her weekends making calls to patients, reminding those who have tested positive to treat the symptoms, isolate and call for help if conditions get worse.

Though the respiratory effects of the coronavirus are well known, she said, many of her patients are unaware of the disease’s other manifestations. Often, if a patient is ill but does not have a hacking cough, Toso said, they do not think it’s possible that they could have the virus. Some try home remedies as a cure: herbal teas or roots mailed from relatives outside the United States.

“A lot of these people still have to go to work every day, so they’re not able to keep up with the news or every new symptom that we’re discovering about this virus,” Toso said. “They may not think they have the virus, but many of them do.”

Others have tried to get tested and, amid an initial shortage of test kits and supplies, were turned away.

Edith Morejon rarely ventures outside her apartment in Hyattsville, Maryland, anymore. Still, she said, it feels as if the virus is closing in.

Her husband, who works during the week in Pennsylvania and shares an apartment with four other men, recently came home with a fever and a cough.

Within days, he was diagnosed with covid-19. Morejon, 40, was not able to get tested, despite having a fever. Her doctor advised her to try again if her symptoms got worse, she said.

To protect their three children – ages 12, 10 and 6 – Morejon kept her husband isolated inside the bedroom. When the children ran to hug her, she waved them off, unsure whether it was safe.

Morejon has done everything officials have asked. She keeps up to date on covid-19 news and signed up for text alerts from Prince George’s County. Even though Maryland recently expanded its testing options, as of Thursday, she had not been able to secure a test.

“I’m just waiting here in my house, passing my quarantine so as not to infect anyone else,” Morejon said. “I don’t know what else to do.”

– – –

The virus can dissolve what little economic stability some families have.

Before the pandemic struck, Danilo and Isabela Rivera relied mostly on her income as a hotel housekeeper near Dulles International Airport in Virginia. He lost his job as a house painter last year.

Now, with Isabela bedridden, Danilo puts on a cloth mask every morning to stand outside a 7-Eleven with other day laborers.

He leaves food donated by a neighborhood church by his wife’s bedroom door and checks in by phone with their son, Alan, who does not understand why he can’t just come home.

“He cried a lot the first three days,” Danilo said. “We’ve wanted to give him a hug and kiss him but haven’t been able.”

In Washington, Jose Mardoqueo Reyes was hospitalized with covid-19 in late April, the day his wife, Blanca Bonilla, was discharged from a hospital after her symptoms subsided. He died three weeks later.

The family isn’t sure how the virus entered their household of six, though it had several possible avenues.

Bonilla worked at a McDonald’s before the pandemic took hold in March. Mardoqueo Reyes, a well-known Spanish-language sportscaster in the region, also worked in construction. His eldest son, Mardo Reyes, 28, drove a delivery truck.

Mardo’s wife, Emmy, who has been on leave from her job as a nurse, was the first to experience symptoms and was briefly hospitalized last month.

Ingrid Reyes, 26, Mardo’s sister, lives elsewhere in the neighborhood and has stayed healthy. After her father spent three weeks on a ventilator, she asked for two weeks off from her job as a construction site traffic controller to help care for her family.

Instead, she said, her boss fired her.

Mardoqueo Reyes died on May 12. The family is now seeking help with the $14,000 burial costs.

“Everything just hit us at once,” his daughter said.