1
A Tale of Two Cities –
Lagos, Nigeria’s Apparent Success in the War Against COVID-19
(Crossover Prophylaxis Against Coronavirus by Antimalarial Agents)
Abstract
A person’s chances of dying from the coronavirus in this 2020 COVID-19 pandemic
are more than six hundred times greater in New York City than in Lagos, Nigeria. This fact,
at least this specific comparison, does not seem to be previously reported in the medical literature.
It certainly is not emphasized. This dramatic disparity contradicts or at least diminishes the
conventional wisdom that coronavirus mortality is exacerbated by city life, specifically poverty,
overcrowding, racial differences, and diminished access to health care. The dramatic disparity in
fatality rates between these two cities flies in the face of our traditional understanding of the social
determinants of health. There is clearly a different factor at play here. These facts demand an
explanation. This apparent protective effect conferred on those living in Lagos compared to New
York City should be further analyzed for its etiology, significance, and potential benefit to others.
Keywords: coronavirus, COVID-19, mortality, fatality, disparity, New York City, NYC,
Lagos, Nigeria, antimalarial, racial, poverty, overcrowding, protective, pharmacology,
prophylaxis, crossover, epidemiology, quinoline, atovaquone, mefloquine, chloroquine
The available and reported official data persistently demonstrates that a person’s chances
of dying from the coronavirus in this 2020 pandemic are more than six hundred times greater in
New York City (“NYC”) than in Lagos, Nigeria. This is counter intuitive and contrary to most of
what experts and pundits tell us. Conventional wisdom tells us that COVID-19, like any serious
disease, should disproportionality attack the poor and those without access to medical resources.
Conventional wisdom tells us that there should be a racial disparity in the impact of COVID-19.
U.S. data reveals that COVID-19 does disproportionality impact racial minorities. But, while this
does seem to be true within the United States, these general rules simply don’t hold up on a
worldwide basis. Any differences due to racial disparity are overshadowed by the dramatic
protective effect seen in Lagos, Nigeria.
It is widely noted that NYC has among the highest coronavirus fatality rates in the world.
This has by no means gone unnoticed. The U.S. has about 28% of the world’s coronavirus deaths.
NYC alone has about 16% of those U.S. deaths. In NYC, any success in fighting coronavirus is
usually attributed to lockdown measures. Hindsight analysis has argued that lives could have been
saved had more stringent lockdown measures been instituted earlier.
1
Throughout the pandemic,
in NYC there has been little discussion of any early treatment intervention against coronavirus.
It is puzzling that NYC should have such a high coronavirus fatality rate. New York State
ranks second in the United States for its number of doctors practicing in the state. The State has
345 doctors for every 100,000 people.
2
Many of these doctors and hospitals are located in NYC.
NYC’s high coronavirus fatality rate has been attributed to poverty,
3
race,
4
and poverty
and race.
5
It has been noted that other large U.S. cities have lower coronavirus fatality rates than
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
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NYC. This discrepancy has led some experts to claim that the high number of deaths in NYC are
due to “exposure density”. Wendell Cox argues, “Compared to Angelenos, Cox suggests, New
Yorkers tend to work in large, crowded workplaces and are far more mass transit-dependent.”
6
Thus, despite its large numbers of doctors, hospitals and medical schools, experts typically
attribute the high coronavirus fatality rates seen in NYC to poverty, overcrowding, and a large
population of racial minorities, particularly African Americans. This is what makes the
comparison between NYC and Lagos, Nigeria so intriguing.
Lagos Nigeria is a crowded urban center with about twenty-two million residents.
7
Nigeria
suffers from extreme poverty. It was widely anticipated that Africa would be devastated by the
2020 COVID-19 pandemic. Science Magazine called Africa a “ticking time bomb.”
8
The BBC,
citing the World Bank, the UN, the Nigerian government and USAid asserts that “50% of
Nigerians live in extreme poverty, 70% do not have safe drinking water and sanitation, 69% of
urban residents [Lagos] live in slum conditions, 49% of children under five are stunted, too thin
or overweight, and 23% of the labor force is unemployed.”
9
The BBC further asserts that social
distancing is impossible in urban areas of Nigeria where “30 families often cram into a building,
sharing the same bathroom and toilet.” Id. Obviously, Nigeria has far more Africans than NYC
so race, per se, has nowhere near the importance attributed to it in the U.S.
It is also not surprising that Nigeria also has fewer doctors and hospitals than NYC. “[L]ike
the other 57 HRH crisis countries, [Nigeria] has densities of nurses, midwives and doctors that are
still too low to effectively deliver essential health services (1.95 per 1,000).”
10
This is one more
reason why the COVID-19 death rate should be worse in Lagos. It is not.
This paper examines these various factors purported to cause such an incidence of
coronavirus infection and death in NYC. With regard to these factors, NYC will be compared to
Lagos, Nigeria. Since the 2020 COVID-19 pandemic originated in Wuhan, China, both NYC and
Lagos acquired their coronavirus infections by seeding from infected travelers, ultimately and
initially from China and later from Europe. Both cities date the onset of their respective infections
to within a few days of March 1, 2020. Prior to that date, neither city had any intrinsic coronavirus
infection. This seeding of a city, the introduction of the infection, is a crucial factor as the reader
will see in the discussion that follows.
Looking to the high fatality rates in NYC, nothing in this paper should be construed to
impugn the dedication and hard work of the countless healthcare providers in NYC. The point of
this paper is that another factor is working against those NYC physicians and healthcare workers
or at least working in favor of other populations such as the residents of Lagos, Nigeria. It is thus
instructive to compare the remarkable disparity in coronavirus fatality rates between these two
large urban centers. How is it possible that Lagos, Nigeria has better coronavirus outcomes so
much better than NYC? How can it be that NYC has fatality rates more than six hundred times
greater than Lagos? The postulated explanation follows in the discussion below.
Methods & Results
This paper considers a significant subset of the available data, a total group of thirty million
people living in NYC (NYC - 8 million) and to those living in Lagos, Nigeria (21 million). Data
was obtained primarily from the Coronavirus COVID-19 Global Cases Dashboard from The
Center for Systems Science and Engineering (CSSE) at Johns Hopkins University Whiting School
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
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of Engineering.
11
The available data was examined to determine the relative population-based
coronavirus fatality rates of these two, large, crowded urban areas. NYC and Lagos were both
infected within a couple of days of each other, Feb. 24 for Lagos, March 1 for NYC. Both were
infected by arriving travelers, mostly from Europe. Both have had the same fourteen weeks for
the infection to spread. The latest data available in this rapidly changing 2020 pandemic indicates
that NYC has had 16,877 coronavirus deaths.
12
In the fourteen weeks of the Coronavirus
pandemic in New York and Africa since March first, Lagos, Nigeria has experienced 67
coronavirus deaths. This low number of coronavirus deaths in Lagos was verified through Lagos
government sources through its webpage.
13
The population-adjusted death rate from coronavirus in NYC is 0.210963% or 2,110
deaths per million. The population death rate from coronavirus in Lagos, Nigeria is 0.000319%
or 3 deaths per million. The relative population-adjusted fatality rate in NYC is 652 times that of
Lagos, Nigeria (95% CI 642.2 – 661.9). This difference in the population-adjusted fatality rates
is highly significant statistically with a p value < 2.2e-16.
FN1
This, of course, is a p value so
infinitesimally small as to mean it is virtually impossible for these disparate death rates to have
occurred by chance. Thus, a person’s chances of dying from the coronavirus in this 2020
pandemic are more than six hundred times greater in NYC than in Lagos, Nigeria. This
disparity must be evaluated and analyzed so that the protective effect against coronavirus death
seen in the Nigerian population may be shared with the rest with the potential to save thousands
of lives.
Discussion
The catastrophic launch of the space shuttle Challenger was one of the greatest failures of
science and technology in U.S. history. We know in hindsight that the weather was too cold,
causing stiffening and leakage of the O-rings on the rocket boosters. Physicist Richard Feynman
was brought in to perform a root cause analysis on behalf of the President, Congress, and the
American people. Testifying before Congress as to why the engineers who balked at launching
Challenger in the cold weather were correct in their reservations, Feynman testified, “when you
don't have any data, you have to use reason.”
14
Similarly, today, we can all agree that randomized
clinical trials (“RCT”) are the preferred method to evaluate a proposed new medical therapy. In
the midst of today's worldwide COVID-19 pandemic, many argue that we don’t have time for the
luxury of protracted RCTs. What we do have here are facts. Some of the facts of the 2020
COVID-19 pandemic are set forth in this paper. The population-adjusted coronavirus fatality in
NYC is more than six hundred times that of Lagos, Nigeria. The author submits that the scientific
community should heed Dr. Feynman’s advice and apply reason to these facts.
The medical literature was reviewed. In the Pub Med database, there exists not one article
comparing coronavirus population fatality rates between NYC and Lagos, Nigeria.
FN2
Because
this topic has not been studied by the scientific community, the reader may notice a preponderance
of citations to less formal publications. The high rate of coronavirus death in NYC has been
appreciated, but this remarkable disparity between the fatality rate of NYC and other large cities
such as Lagos has rarely attracted any attention. When it has, it has usually been just a passing
FN1
0.000000000000022%
FN2
There was found not one publication on this subject using the search terms of “New York City” and Lagos and
(coronavirus or COVID) AND (fatality or death).
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
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note that coronavirus fatality rates in Africa are low. The remarkable disparity has generally been
viewed as curiosity, a mere unexplained aberrancy. So, even if this phenomenon has received
some notice, it is not nearly enough.
What could explain this great disparity in the fatality rates between these two cities? It is
widely recognized that NYC has a relatively high coronavirus infection and fatality rate compared
to other U.S. cities. This is usually attributed to “exposure density” or overcrowding. It is also
attributed to poverty or race. It is true that Blacks in NYC are about twice as likely (100% more
likely) to die of coronavirus infection as whites.
15
While some of these factors may explain why
NYC has a higher coronavirus fatality rate that other U.S. cities, these factors in no way explain
the disparity seen here between NYC and Lagos. Obviously, Lagos has more residents of African
descent than NYC. The available data indicates that on a population-adjusted or per capita basis,
an African American in NYC is 65,000% more likely to die of coronavirus infection than a Black
African in Lagos. This disparity is not explained on the basis of race.
Lagos also has more poverty and more overcrowding than NYC. The coronavirus fatality
rate should be expected to be higher or worse in Lagos. It is not. Finally, Lagos has far less access
to health care than residents of NYC. This is one more reason why fatality rates should be worse
in Lagos than in NYC. They are not.
One other explanation which is sometimes put forth in an attempt to explain the high death rate in
NYC is that fact that NYC is thought to have a higher percentage of elderly residents than most
areas. For example, Quaresima et. al. argue: “A second strong advantage is Africa's very young
population as age is among the top risk factors for developing a severe acute respiratory syndrome
necessitating intensive care.” Those authors note that people aged 65 years or older constitute
18% of the population of Europe and North America where “SSA [sub-Saharan Africa] has a very
young population in comparison, with a median age of 19.7 years and only 31.9 million people or
3% of the population aged 65 years or older.”
17
There is a bit of truth in this, but it comes nowhere near explaining the disparate fatality
rates between NYC and Lagos. About 17% of New York residents are over sixty-five years of
age. This figure is only 2.7% for Lagos. At first blush this might look like an answer. However,
Florida has an even higher percentage of elderly residents (20%) but Florida has only 2460
coronavirus deaths with a population-adjusted coronavirus fatality rate of only 0.011442% or 114
per million, less than 1% of NYC’s rate.
FN3
FN3
Looking at this elderly resident problem from another angle and assuming that there were zero elderly patients in
Lagos (they actually comprise 2.7%), at one point NYC data indicated deaths in those over 65 to have been 12,665.
Deaths in those less than 65 year of age equaled 4,538.
11
The population of those under 65 is about 6.7 million. Thus,
the population-adjusted coronavirus fatality rate in NYC residents under 65 is 0.067530% or 675 per million. The
fatality rate for NYC in this hypothetical scenario is still more than 300 times the fatality rate for residents of Lagos.
If instead, half of the deaths in Lagos were in the elderly age group as might be expected, this apparent impact is even
less. In that case, the NYC rate would be about 450-500 times the hypothetical Lagos rate. Thus, the larger elderly
population in NYC could make a slight difference but it does not change the conclusions of this paper.
One more reason that the number of elderly patients in NYC is not significant is that the absolute number of elderly
(>65 years old) living in NYC was not significantly greater than Lagos. It is only twice as many. Not 650 times as
many. The elderly constitute 3% of Lagos. 3% x 20,000,000 = 600,000. The elderly constitute 16% of NYC. 16%
x 8,000,000 = 1.2 million. Thus, there are about twice as many elderly residents in NYC as Lagos. Not 650 times
more. If it had the same proportional fatality rate as NYC, Lagos alone would have 5,000 deaths. It has had 67.
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
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Another proposed reason for a falsely low coronavirus fatality rate in Lagos and other areas
of Africa is a relative lack of testing. Many believe that the low number of COVID-19 confirmed
cases in Africa is due to poor documenting and low testing rates. However, this hypothesis has yet
to be adequately investigated and documented. Coronavirus testing is mired in controversy around
the world. Africa is no exception. Thus, it is quite likely that the number of coronavirus tests
performed are too low and the reported incidence of coronavirus infection is too low. This is why
this paper looks to population-adjusted fatality rates as opposed to infection rates. Death is more
concretely definable and is presumed to be more accurate due to the possibility of clinical diagnosis
even in the presence of suboptimal virus testing. The population-adjusted fatality rate is thought
to be a more accurate, but by no means perfect measure.
Another explanation for the wide disparity might be that the Lagos fatality numbers are too
low; deaths due to coronavirus are simply not reported. The numbers do seem to be statistically
challenging, but they are what we are given. They are asserted to be factual. Do skeptics really
assert that the data produced by the Nigerian government is grossly inaccurate, that Nigeria is lying
about its coronavirus deaths? Do skeptics assert that Nigeria is concealing the bodies of tens of
thousands of coronavirus victims? These questions must be asked if anyone argues that this
enormous disparity between the population-adjusted coronavirus fatality rates of these two, large,
crowded cities is not relevant.
There are virtually no articles in the medical literature specifically describing the accuracy
of the diagnosis or the counting of coronavirus as a cause of death in Africa. Worldwide it has
been suggested that there are errors of overcounting and undercounting.
18
Both the New York
Times and the Wall Street Journal assert that coronavirus deaths are underreported worldwide.
19,20
There is evidence that there was at least one case of underreporting of some significance
in Nigeria. There was a mini epidemic in Nano State. This was thought to consist of about one
thousand unreported deaths due to Covid-19.
21
This seems to be the most significant allegation of
underreporting in Nigeria. Three facts should be understood with regard to this paper. One, this
underreporting error in Nano State does not affect Lagos per se. Two, if true, the Nano State
underreporting error would increase the death toll in Nigeria by 250% which seems very
significant. Three, even if the correct death rate of Nigeria were 250% higher and it was proven
that there was no underreporting of COVID-19 fatalities in NYC, this would in no way change the
conclusion of this paper. The population-adjusted coronavirus fatality rate of NYC would still be
more than 300 times and more than two orders of magnitude greater than that of Nigeria.
Similarly, the Financial Times argues that the Global coronavirus death toll could be 60% higher
than reported.
22
Again, even if the correct death rate of Lagos were 60% higher, and it was proven
that the reported fatality rate of NYC was perfect, this would in no way change the conclusion of
this paper.
The accuracy of the Lagos figures is further corroborated by the fact, as previously
reported, that other malaria-endemic countries in sub-Saharan Africa have similarly low
coronavirus fatality rates.
23
The fatality rates in South Asia are similarly decreased but not quite
as low. The three countries, India, Pakistan, and Bangladesh, have a combined population of 1.7
billion. If these countries had NYC’s 0.211% fatality rate, they would have 3.5 million deaths.
They claim to have about 11,000 coronavirus deaths between them. No one really believes these
countries could be hiding 3.5 million corpses. If its fatality rate matched that of NYC, Lagos
would have to be hiding 44,000 bodies. Does anyone believe this to be the case? There is no good
reason to believe that the statistics presented by the city of Lagos are fundamentally inaccurate.
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
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There is one more reason to believe that the COVID-19 fatality rates reported by Lagos are
generally accurate. If Lagos experienced fatality rates similar to NYC, its medical system would
have been completely overwhelmed, as was NYC’s. There is little doubt that Lagos’s health care
system is not nearly as robust as NYC’s. Lagos’s health care system would be expected to be
overwhelmed far more easily, by far fewer coronavirus infections than NYC. There were no
reports of this occurring. There is no evidence to suggest that Lagos suffered coronavirus
infections and fatalities anywhere near the scale of NYC.
The available data shows that the rate of coronavirus infection is surprisingly low in Lagos
as it is in many areas. The rate of coronavirus infection does not fit into some preconceived
narrative that it should be worse in poor countries, it is simply “too low.” However, these lower
fatality rates are found in many countries, all of sub-Saharan Africa and even the massive
population centers of South Asia. If the fatality rates reported by all these countries are falsely
low, this must represent some vast under reporting conspiracy by multiple countries with hundreds
of millions of residents. If someone believes that the death rate reported by so many countries is
truly so erroneous, they should come forth and prove it.
FN4
Despite the data, experts continue to predict African catastrophe. Accruing data continues
to fail to support such predictions. There are logical reasons to believe that areas of Africa and
Nigeria in particular are fragile and vulnerable to more serious COVID-19 infection.
24
But, thus
far, the data as provided simply does not support these negative predictions. The dire predictions
concerning Africa have just not materialized.
Even if, in the worst case, this 2020 COVID-19 pandemic was to explode in Africa, this
would not necessarily disprove the effect of crossover prophylaxis by antimalarial agents. It might
only mean that person-to-person has become the predominant form of disease transmission. The
low rates of infection in Africa have already persisted fourteen weeks into the 2020 pandemic.
Crossover prophylaxis by antimalarial agents is almost certain to be the cause of the low rates of
infection for the first fourteen weeks of the 2020 pandemic in Africa. Even if coronavirus
infections were to skyrocket in Africa, there may still be a role for antimalarial drugs as
prophylactic agents or for treatment. Even if coronavirus infections were to skyrocket in Africa,
it is almost certain that COVID-19 was held at bay for fourteen weeks by the crossover effect of
antimalarial prophylaxis.
It is indisputable that to date, the highest rates of coronavirus infection and death have been
seen in the West. The highest is NYC. What if the data is correct as it increasingly appears? What
if there is a coronavirus protective effect in Africa, especially in SSA, even in large, poor, crowded
cities like Lagos? How is it that Nigerians are so much safer from coronavirus than New Yorkers?
Do skeptics have an alternate explanation for this six-hundred-fold discrepancy? The author
submits that some real factor is causing this 99.85% reduction in the death rate in Nigeria compared
to NYC. The author submits that this is a true disparity which cannot be explained away.
Crossover prophylaxis against coronavirus by antimalarial agents explains why the data does not
conform to certain experts’ expectations of reality.
FN4
In the fast-changing world of the COVID-19 pandemic, the broad data from 400 million people of the six malaria
endemic countries of sub-Saharan Africa (“SSA”) beyond Lagos studied in the previous paper were reevaluated and
compared to the population-adjusted fatality rate in New York City. As of June 13, 2020, the population-adjusted
fatality rate (0.000390%) for six malaria endemic-countries of SSA as a whole, like Lagos, was also far less than 1%
of that of New York City (0.216888%). This fact is highly corroborative of the hypothesis of this paper, that there
exists crossover prophylaxis against coronavirus by antimalarial agents.
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
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The traditionally understood factors, the social determinants of disease generally used to
explain the high coronavirus death rate in NYC simply don’t tell the whole story. The author
submits that some other factor is causing this disparity – the relative safety of the residents of
Lagos in the midst of the 2020 coronavirus pandemic. This factor needs to be discovered and
moved to the forefront of the discussion. When our traditional understanding does not fit the facts,
we must ask why. This is the essence of scientific inquiry. Here a general understanding of the
social determinates of disease does not explain the apparent protective effect against coronavirus
seen in Nigeria and other African countries.
The author hypothesizes that the Nigerian protective factor causing the disparate fatality
rates between NYC and Lagos is what could be called the crossover prophylaxis against
coronavirus by antimalarial agents. This hypothesis was set forth in part in a previous paper
currently under consideration and published electronically on May 1, 2020.
25
In that previous
paper, the author looked at population-adjusted coronavirus fatality rates for sub-Saharan African
countries compared to the industrialized West.
26
The difference in this paper it that it narrows the focus from a study of broad regional
differences including large regions such as the whole of the U.S. and South Asia to a city-to-city
comparison of NYC vs. Lagos, Nigeria. In particular, this paper looks at the “big city factors” said
to cause the high rate of coronavirus fatalities in large cities like NYC. These “big city factors”
purported to explain the high coronavirus death rate in NYC are more accurately characterized as
social determinants of disease. As seen in this paper, these social determinants of disease simply
do not adequately explain the way COVID-19 manifests itself in our world, particularly the
protective effect against COVID-19 seen in cities like Lagos, Nigeria.
The crossover prophylaxis hypothesis is suggested by the fact that despite receiving such
large numbers of travelers from China and Europe, Nigeria and Lagos in particular, simply do not
experience the expected large number of COVID-19 infections and deaths. This is believed to be
due to the fact that nearly all inbound travelers to Lagos, Nigeria are taking some form an
antimalarial prophylaxis, while virtually none of the inbound travelers to NYC are taking such
antimalarial agents.
Africa is thought to be at risk because coronavirus infection originated in Wuhan, China
and was introduced into countries by travelers. A country is understood to be seeded with
coronavirus by inbound travelers from other countries, first China and later Europe. Africa was
and is believed to be at risk of severe coronavirus infection because of the “2 million Chinese
nationals that live and work in Africa.”
27
In February the NYT noted that because of “steady
traffic to and from China, experts worry that the epidemic could overrun already-strained health
systems.”
28
One source notes that 2.5 billion people fly from China to Africa each year. Nigeria
ranks third on the list of African countries receiving travelers from China.
29
Despite receiving
these large numbers of travelers from China, the data persistently indicate that Africa in general,
and Nigeria and Lagos in particular, simply do not experience the large expected numbers of
COVID-19 infections and deaths. This paper hypothesizes that Chinese travelers, like travelers to
Africa from the West, especially those traveling to sub-Saharan Africa, are likely taking
antimalarial prophylaxis.
Malaria prophylaxis is generally recommended for all travelers to Nigeria. Drugs typically
recommended for use as antimalarial prophylaxis in travelers entering Nigeria are antimalarial
quinolines: atovaquone/proguanil (Malarone), mefloquine (Lariam), tafenoquine (Krintafel,
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
8
Arakoda), or possibly the fluoroquinolone ciprofloxacin or the tetracycline doxycycline.
Chloroquine and hydroxychloroquine are also antimalarial agents of the quinoline group.
This fact is thought to be the critical factor explaining the widely disparate fatality rates
between NYC and Lagos. It is hypothesized that these antimalarial agents exert a crossover
prophylaxis against coronavirus transmission by travelers from Europe and probably from China
as well. Travelers entering Lagos who would otherwise be expected to seed these African
countries with coronavirus are taking antimalarial agents which block their carriage of coronavirus
and thus prevent their seeding their African destination with the virus.
It will not escape the reader’s attention that the controversial drug hydroxychloroquine is
also a quinoline antimalarial agent. The hypothesis that antimalarial agents exert a beneficial
crossover prophylactic effect against coronavirus cannot be entirely separated from the contentions
ongoing debate over the risks and benefits of hydroxychloroquine. Because hydroxychloroquine
is one of the antimalarial agents, this apparent beneficial effect of crossover prophylaxis against
coronavirus by antimalarial agents certainly offers some support for the proposition that
hydroxychloroquine may be beneficial. However, prophylaxis and treatment are not synonymous.
A particular agent may be efficacious in one regard and not the other. The specific risks and
benefits of the use of hydroxychloroquine, particularly as treatment, are beyond the scope of this
paper.
FN5
Here, the available data suggests a crossover benefit against coronavirus by antimalarial
agents as a group and that this apparent crossover benefit is worthy of further investigation. The
author is unaware of any evidence disproving the crossover benefit of antimalarial agents or
suggesting a viable alternative hypothesis. If this factor, which at present appears to be saving so
many lives in Africa, were to be applied in the developed world, the currently available evidence
suggests that thousands of lives could be saved.
Summary
The data as provided by experts and government entities demonstrates a persistent and
marked disparity in the population-adjusted death rate between NYC and Lagos, Nigeria. A
person’s chances of dying from the coronavirus in this 2020 COVID-19 pandemic are more than
six hundred times greater in NYC than in Lagos, Nigeria.
This marked disparity has persisted for fourteen weeks in the 2020 pandemic and does not
appear to be lessening. This marked disparity has not been disproved. This author respectfully
suggests that the world (especially the developed world) needs to know what causes this disparate
death rate between these two large cities. Whatever it is the people of Nigeria are doing to fight
COVID-19 is cheaper and more effective than what is being done in NYC. If the Nigerian
FN5
Nigeria is also one the many countries which uses hydroxychloroquine to treat coronaviruses infections. The
enormous protective benefit seen in Nigeria may be partially attributed to that country’s use of hydroxychloroquine.
One plausible reason why the coronavirus is so much more dangerous in New York than it is in Lagos, Nigeria is that
New York, like many other U.S. states, has criminalized one of the world’s most popular coronavirus treatments and
a physician’s free exercise of his or her clinical judgment.
28
Shortly before the publication of this paper, the World
Health Organization announced the cessation of clinal trials based on an article by Mehra et. al. Despite the WHO
announcement, Nigeria announced it would continue to use hydroxychloroquine.
29
The Mehra paper has new been
fully retracted by its authors.
30
Hydroxychloroquine use is most closely associated with India. Although not quite as
extreme as the benefit seen in Lagos, India also has coronavirus outcomes about two orders of magnitude better that
the West. The specific issues as to the risks and benefits of hydroxychloroquine will have to be answered elsewhere.
This paper suggests that other antimalarial agents have a benefit in regard to prophylaxis against coronavirus.
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
9
advantage is the widespread use of antimalarial agents, then the most effective agent must be
identified and utilized in NYC and elsewhere. If the Nigerian advantage is something else, that
factor should be identified so that others may survive the current 2020 COVID-19 pandemic.
Experts’ dire predictions that Africa would be overwhelmed by COVID-19 have thus far
not materialized. Even if COVID-19 infections were to suddenly increase this would not disprove
the premise of this paper. Even if COVID-19 infections were to suddenly increase, this would
probably mean that the predominant mode of infection shifted to person-to-person transmission
within the country as opposed to seeding of infection from travelers.
The marked disparity in the population-adjusted death rate between NYC and Lagos is best
explained by crossover prophylaxis against coronavirus by antimalarial agents. The thing that is
unique about these travelers from China and Europe to Lagos who might otherwise be expected to
transmit COVID -19 infections is that these travelers, unlike travelers to Western countries and
NYC, are almost certain to be taking prophylactic antimalarial agents such as atovaquone,
mefloquine, or tafenoquine.
One particular reason why an understanding of this crossover effect protecting the residents
of Lagos is so important is because of the particular risk of coronavirus infection noted in U.S.
minority populations. This increased risk of death from coronavirus infection is simply not
observed in Lagos. In NYC the coronavirus death rate of African Americans is about 2,244 per
million, double that of whites and seven hundred times the rate of Black Africans in Lagos. This
is all the more reason why this apparent Nigerian protective factor, presumably the crossover
prophylaxis against coronavirus by antimalarial agents, must be accurately understood. U.S.
public health officials should learn from Lagos and apply this knowledge to aid afflicted minorities
in the U.S.
These facts, the protective effect exerted over the people of Lagos, and the reasons for the
increased risk of death from coronavirus for those living in NYC, deserve the concerted effort and
undivided attention of the scientific community to determine the precise causes. If Lagos’s
protective effect is due to a shared coronavirus susceptibility to antimalarial agents, these drugs
should be studied immediately and diligently. Alternatively, if another protective factor causing
the greatly diminished fatality rate in Nigeria is identified, this as yet unidentified factor should be
identified and thoroughly researched as quickly as possible.
Conclusion
The currently available data demonstrates that those residing in NYC are more than six
hundred times more likely to die of coronavirus infection than those residing in Lagos, Nigeria.
Regarding COVID-19, residents of Lagos are 99.85% safer than residents of NYC. The available
data suggests that there exists a crossover prophylactic effect of antimalarial agents against
coronavirus which accounts for the dramatically decreased numbers of deaths due to coronavirus
seen in Lagos. This Nigerian safety factor should be analyzed, understood, and applied to NYC
and the West. The currently available evidence suggests that if antimalarial agents, which appear
to be saving so many lives in Africa, were utilized in NYC, thousands of lives could be saved.
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
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Funding: There was no funding for this paper.
Competing interests: The author declares that he has no competing interests.
Author details: Geoff Mitchell, MD, JD
Department of Emergency Medicine
The University of Toledo
gmitch@columbus.rr.com
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
11
References
This is a preprint version of this article. All of the citations are thought to be
accurate but several will require further formatting prior to final publication.
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3628644
