18 million excess mortality from COVID-19 – what does it mean?

A PAPER published in the Lancet last week caused a stir, asserting that ‘excess deaths’ owing to the pandemic reached 18.2 million around the world during 2020-21.  This is triple the official COVID-19 death tally of 5.9 million for the same period.

For those not steeped in the terminology: ‘Excess Deaths’ are deaths over and above those that one expects in the normal way of things, based upon the average over the preceding years. Excess deaths measure the full impact of the pandemic.  And that is what matters. By contrast, ‘COVID deaths’ are detected cases who died ‘from’ or ‘with’ COVID, and are prone to miscounting.

The authors believe that most excess deaths were directly due to COVID rather than to disruption of other healthcare.  I’m less sure. For week after week through 2020 and 2021 the UK recorded 500 extra non-COVID deaths at home, many from cardiac disease.   How many were folks who would have survived had they not been too frightened or too polite to trouble the hospital?

The 18 million estimate has received stick, not least from my friends at the Daily Sceptic.  They stress, rightly, that the authors’ numbers are based on complex modelling, not simple counts, particularly for more recent months.  This is because the registration of deaths is often delayed, with official statistics lagging the actualite. The modelling is complex and inexact owing by changing variants, changing vaccination rates and by the fact that, as time goes by, the population increasingly comprises ‘survivors’, who are unlikely to succumb to a second infection.

Critics point to wide divergences between the authors’ estimates for some countries and those of the Economist, running a similar analysis of excess deaths, and from more basic calculations by Our World in Data. The Lancet authors think there were 17,900 excess deaths in China but the Economist estimates 409,000 more.  There are peculiar internal inconsistencies: a 0.96 ratio of excess mortality to reported COVID deaths in Goa versus 27 in Bihar. Why are two Indian states so different?   Even odder is that the paper suggests major undercounting of COVID deaths in Denmark and Japan – advanced countries with good reporting. This looks implausible, especially for Denmark, which tested even more hugely than the UK.

Even so, despite different methods and disagreements, the Lancet authors and the Economist both estimate c. 18 million excess deaths over 2 years. That concordance adds confidence, so let us accept it.  Evidently, it’s a huge and mournful tally – exceeding the population of the Netherlands. Moreover, it’s the sum of individual sorrow and bereavements for the families affected. In what I say next, I do not mean to belittle their loss.  But, especially in grim times, it is necessary to remember context.  

Remember, first, that around 120 million people die over 2 years.  An extra 18 million is three and a half months’ mortality, and a little under 0.25% of the 7.8 billion world population.  The Spanish flu of 1918-19 was an order of magnitude worse, killing 1 to 2.7% (18-50 million) of the world’s then population of 1.8 billion.  The Black Death reduced the European population by between one third and two thirds and so was over 100-fold more lethal. Smallpox and measles, imported by the conquistadores, had even greater impacts on the Incas and Aztecs.  

COVID is not among the great plagues of history.

Remember, second, that in the UK the median age of COVID deaths was 83 years, and so a little longer than average life expectancy.  In 2020, care homes accounted for around one third of deaths in developed countries, whilst deaths were rare among the young.  This is in stark contrast to the Spanish flu, which substantially killed the young.  We like to imagine care home residents enjoying long sunset years, but the reality is median life expectancy on entry is 462 days, and mean survival a little over two years.  What COVID did was to bring many deaths forwards by a year or two.  One would expect the pandemic to be followed by a balancing period of ‘negative excess mortality’, with fewer deaths than normal, though this may be delayed by the demise of folks whose incipient cancers were neglected during the pandemic.

Remember, third, that in our modern world we arrogantly delude ourselves into thinking we have escaped nature and history. Clean water, hospital hygiene, vaccines and antibiotics have banished or diminished many old infectious foes.  But not viral respiratory pandemics, which strike us every few of generations, just as throughout history.  

For much of the period the Lancet authors review, the pandemic was fought with the blunt instrument of lockdowns.  Vaccines – useful but imperfect – only playing a role from 2021 onwards.  And here, as in a recent analysis by the Johns Hopkins University, their data show little obvious correlation between excess deaths and lockdown stringency. Sweden had no lockdown and low excess deaths, little different from Denmark and Finland which had more restrictions. Florida, with few restrictions and a large elderly population, had lower excess mortality than 11 other States, all with more restrictions.  

Many billions of us have been more restricted than were the citizens of Sweden and Florida.  For what benefit? We have lost, say, half a quality-adjusted life year apiece, unable to see family and friends, to travel or to socialise. Some have lost far more. Consider the educations wrecked by school and university closures, the pre-school children who haven’t been socialised any more than the lockdown puppy that bit my leg last month on a Norfolk beach. Consider the care home ‘survivor’ deprived of family contact for two years and now unable to recognise her own children. Consider those whose businesses, nurtured over a lifetime, will never reopen.  Consider the savers whose pending retirements will be impoverished by the coming inflation. Not all of them know it yet, but their quality of life and health will be impacted, not by the pandemic, but by the aftermath of the response to the pandemic; by the debt and societal damage carried forward on the ledger.    

Can I gently suggest that this loss of 2 billion QALYs (0.5 year x 7.8 bn world population) is the biggest price, not the 18 million? It has been paid by us and our families without saving the 18 million and without evidence that their tally would have been higher had we followed the milder courses of Sweden, Florida, or the Great Barrington Declaration. There is an Inquiry pending and it is vital that it concludes that what was done in 2020-22 must never be repeated. 

If you appreciated this article please subscribe to our daily newsletter here, share and follow us on Twitter here – and like and comment on facebook here. Time for Recovery is a ‘not for profit’ campaign (we make a loss!) and need your financial support to survive – if you can spare some of your hard-earned pounds you can donate here.

David Livermore is professor of medical microbiology at the University of East Anglia. After working at the London Hospital Medical College from 1980 to 1997, he joined the Public Health Laboratory Service, and became director of its Antibiotic Resistance Monitoring and Reference Laboratory.

Photo by lusia599 from Adobe Stock