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Morbid Matters: Estimating COVID-19 Mortality

It has dominated news cycles, debates, and policies since 2020, but COVID-19 continues to exercise the interest of number crunchers and talliers. While the ghoulish daily press announcements about infections and deaths across many a country have diminished and, in some cases, disappeared altogether, publications abound about how many were taken during the pandemic.

The World Health Organization, ever that herald of dark news, has offered a revised assessment of the SARS-CoV-2 death toll associated either directly or indirectly with the pandemic. Between January 1, 2020, and December 31, 2021, the global health body suggests that the mortality figure is closer to 14.9 million, with a range of 13.3 million to 16.6 million.

The number considers excess mortality, the figure reached after accounting for the difference between the number of deaths that have occurred, and the number expected in the absence of the pandemic. It also accounts for deaths occasioned directly by COVID-19, or indirectly (for instance, the pandemic’s disruption of society and health systems).

Burial of COVID victim in Saint Petersburg, Russia
Burial of COVID victim in Saint Petersburg, Russia.

The impact, as expected, has been disproportionate in terms of which countries have suffered more. Of the excess deaths, 68% were concentrated in 10 countries – Brazil, Egypt, India, Indonesia, Peru, Russia, South Africa, Turkey, and the United States. Middle-income countries accounted for 81% of excess deaths; high-income countries, for 15%, and low-income countries, 4%.

The United States, if only for being ascendant in terms of power, wealth, and incompetence in dealing with the virus, finds itself in the undistinguished position of having lost a million people. “Today,” remarked President Joe Biden, “we mark a tragic milestone here in the United States, one million COVID deaths, one million empty chairs around the family dinner table, each irreplaceable, irreplaceable losses, each leaving behind a family, a community forever changed because of this pandemic.”

Anthony Fauci, Chief Medical Adviser to the President, rued the fact that “at least a quarter of those deaths, namely about 250,000” might have been saved by vaccinations. He also warned about the ugly prospect of a resurgence in numbers, and not bringing “down our guard.”

In light of such figures, WHO Director-General Tedros Adhanom reiterates the line he and his colleagues have done so for months. Pandemics demand more “resilient health systems that can sustain essential health services during crises, including stronger health information systems.” His organisation “was committed to working with all countries to strengthen their health information systems to generate better data for better decisions and better outcomes.” Much of this will be wishful thinking.

Figures, certainly when they concern matters of mortality, can become the subject of bitter dispute. COVID-19 has proved no exception. In Africa, 41 of 54 countries reported insufficient data. Some countries have released incomplete data sets; others, none to speak of. This meant, inevitably, that the WHO’s Technical Advisory Group for COVID-19 Mortality Assessment could only model the missing figures to fill gaps.

Mass cremation of COVID victims in New Delhi, India
Mass cremation of COVID victims in New Delhi, India.

As a result, scrapping and arguments over methodology duly emerged. India, for one, has very publicly objected to the way the WHO has approached the compilation, communicating its concerns in no less than six letters between November 2021 and March 2022 and in a number of virtual meetings. Concerns have also been registered by WHO Member States, including China, Iran, Bangladesh, Syria, Ethiopia, and Egypt.

The case with India is particularly telling, given WHO modeling showing 4,740,894 excess deaths, almost triple that of New Delhi’s own figures. Such figures imply, as epidemiologist Prabhat Jha of the University of Toronto claimed back in January, that the authorities were “trying to suppress the numbers in the way that they coded the COVID deaths.”

In an indignant statement from the Union Health Ministry released early this month, much is made of “how the statistical model projects estimates for a country of geographical size & population of India and also fits in with other countries which have smaller population.” This constituted an unacceptable “one-size-fits-all approach and models which are true for smaller countries like Tunisia may not be applicable to India with a population of 1.3 billion.”

The WHO model also returned two highly varied sets of excess mortality estimates when using data from Tier 1 countries and when using data from 18 Indian states that had not been verified. “India has asserted that if the model [is] accurate and reliable, it should be authenticated by running it for all Tier 1 countries” and the “result of such exercise may be shared with all Member States.”

WHO assistant director-general for emergency response, Ibrahima Soće Fall, concedes that any accurate picture is only as complete as the data provided. “We know where the data gaps are, and we must collectively intensify our support to countries, so that every country has the capability to track outbreaks in real-time, ensure delivery of essential health services, and safeguard population health.”

The degree of fractiousness that persists in public health shows that sharp fault lines remain in each country’s approach to the pandemic problem. Disunity and factionalism, petty nationalism, and self-interest, remain imperishable, even at the direst of times. And all governments, given the chance, will err on the side of inaccuracy rather than risk acute embarrassment.