Sweden? Japan? UK? Debates over who had a ‘good’ Covid won’t end | Francois Balloux

National Covid death rates are, inevitably, political. How could they not be when they are viewed as evidence for good or bad government on matters of life or death? How did the UK fare compared with, say, Germany? Should both countries have been more like Sweden? However, when new data arrives, far from settling arguments over which pandemic mitigation strategies worked best, it tends to further inflame disagreements or harden pre-existing positions.

So it is with the much-anticipated report by the World Health Organization (WHO) on Covid-associated deaths, released last week. The WHO estimates that around 15 million additional people died because of the pandemic in 2020-2021, about 2.7 times higher than officially recorded deaths.

While staggering, the estimated excess deaths didn’t really come as a surprise to those who have been closely following the situation. If anything, this estimate is lower than many may have anticipated. Indeed, two previous modelling efforts, by the Economist and the University of Washington, suggested around 18 million excess deaths.

That more people died in the pandemic than have been officially registered as Covid deaths should be largely uncontroversial. Many countries simply did not have the diagnostic infrastructure in place to identify every Covid death. The pandemic – and, to an extent, our response to it – has also been devastating to social and healthcare around the world.

Now the WHO report seems to provide ammunition for essentially any narrative and it is unlikely to check the politicisation of the Covid debate – in the UK or elsewhere.

For example, India’s own official excess death estimate is about 10 times lower than the 4.7 million people reported by the WHO. Indian authorities have vehemently rejected the methodology used by the WHO and its estimate for their country. They even opposed publication of the report and released their own 2020 death figures two to three months ahead of schedule to offer a counter-narrative.

Here, many comparisons have been made with other countries to highlight the UK as either the epitome of failure or a roaring success. In fact, according to the WHO report, the UK has fared fairly unremarkably. An estimated 109 excess deaths per 100,000 people places it at 56th in the global ranking of “best performing” countries, and middle of the table relative to the European Union, coming 15th out of the 27 EU member states. The UK’s estimated excess death toll is below Germany’s and Italy’s, but above France’s. According to the WHO estimates, Germany significantly underestimated Covid deaths, France overestimated them and the UK got it about right, suggesting that the much-criticised “death within 28 days of a positive test” approach was a reasonable proxy for Covid death before the Omicron wave.

Some countries became synonymous in the public imagination with particular pandemic mitigation strategies. Sweden has been criticised by some for the lack of stringency of its measures and hailed by others as a shining example of how to protect the rights of its citizens while navigating a health crisis.

To the possible disappointment of both its supporters and detractors, Sweden’s estimated excess death of 56/100,000 is about half the UK’s and, while it is above those of other Nordic nations, it still looks flattering relative to the majority of EU countries.

An additional reason why the WHO report won’t settle many arguments stems from Covid excess death figures being extremely difficult to measure precisely. Even in the absence of ideological disagreements, they do not offer simple, incontrovertible “follow the science” answers. Pandemic excess deaths represent the difference between the number of people who died, relative to a hypothetical number of people who may have died, had the pandemic not happened.

The number of actual deaths is accurately registered in high-income countries but this is not necessarily the case in many parts of the world, where estimates can be crude. Getting an accurate number for the hypothetical number of deaths that may have occurred had the pandemic not happened is even more challenging. (The WHO relied on a fairly complex model and the extent to which some of its estimates may have been coloured by modelling assumptions will be scrutinised and criticised.)

The report paints a complex picture supporting no single straightforward narrative. Which shouldn’t be too surprising. A single number for each country is unlikely to capture the full complexity of vastly different socioeconomic situations and two years of often inconsistent policies. Lower-middle income countries in eastern Europe and South America have been particularly badly affected, probably because of a relatively unfavourable age pyramid, low vaccination coverage and disruption to their economy and healthcare systems. Richer countries tended to do better overall, with the exception of the US, which fared quite poorly with 144/100,000 excess deaths.

A few countries kept excess deaths close to, or even below zero, including Australia, Iceland, Japan, Luxembourg, Mongolia and New Zealand. Being rich and geographically isolated helps.

The stringency of mitigation measures does not seem to be a particularly strong predictor of excess deaths. While countries that achieved low excess deaths tended to have fairly tight measures in place, the worst performer by some margin is Peru, despite enforcing the harshest, longest lockdown. This proved ineffective at reducing viral transmission and probably contributed negatively to the excess death toll.

The results from the WHO report will undoubtedly be analysed extensively by pandemic planners, though they are unlikely to be of much help to inform actionable “one-fits-all-follow-the-science” strategies. The major message is that richer, more insular countries kept excess deaths low by limiting the spread of Sars-CoV-2 until the arrival of vaccines and then achieved high vaccination coverage in elderly people. Those relative success stories largely built on pre-existing geographic and socioeconomic advantages rather than unique, well-thought-out mitigation plans.

Read that way, the main thrust of the WHO report boils down to reducing inequality, improving health and providing a robust social and healthcare system offering the best pandemic preparedness. That would be money well spent, even if the next one takes a while to hit.

Francois Balloux is the director of the Genetics Institute at University College London

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