1. A significant proportion of deaths are not being attributed to COVID-19
The clue to this comes from analysing all-cause mortality – basically the sum total of all deaths in a country. Although there can be steady rises or falls in deaths because of disease trends, most countries have similar numbers of deaths year on year. COVID-19 has meant that almost all countries have had a significant number of excess deaths over the usual all-cause mortality numbers, yet in many cases these exceeded the number of recorded COVID-19 deaths. A study of 22 countries around the world indicated that COVID-19 deaths may have been underestimated by around 35%. Another study in PLOS Medicine estimates that as US deaths from COVID-19 could have been underestimated by as much as 20%. There are several reasons for this, including misdiagnosis of COVID-19 as another respiratory condition.
2. A lack of capacity to count deaths accurately
Robust data collection has been a challenge for many low- and middle-income countries for decades. COVID-19 made this even harder because it was new disease that was difficult to diagnose in the beginning both because the symptoms were so wide and varied and because many countries lacked testing kits. The inability to accurately collect data on infections and deaths was one of the reasons given for why in most of 2020, COVID-19 seemed to affect countries in South Asia and Africa far less than Europe and the US, that were badly affected.
3. People are dying at home instead of in hospital
Official death numbers for COVID-19 in India are 307,000. The real number is believed to be 1.6 million, and in the worst case scenario it could be 4.2 million. The crisis in India has been unlike anything any country has experienced so far. With acute shortages of hospital beds and oxygen, people have no choice but to die at home. Labs that could diagnose COVID-19 are overwhelmed. Even before COVID-19, India had struggled to keep robust medical records. The re-calculation was done on the basis of antibody levels in the population that indicated the real number of infections was much higher than official counts, which also suggests the number of deaths is much higher.
4. Social inequity is worsening access to healthcare
Newer strains of COVID-19 could be affecting children and adolescents more than at the start of the pandemic. But in countries like Brazil, inadequate access to healthcare is a major risk factor for children who are often being diagnosed too late. In remote parts of the country, it can take days to reach a hospital; by this time, the illness may have worsened to require critical care that is in short supply. As often, it is the poorest, most vulnerable children who are worst affected.
5. COVID-19’s collateral damage
The fallout from the pandemic is almost as catastrophic as the disease and loss of life from infection. Income losses, economies going into freefall and lockdowns that have disrupted trade and aid are all taking their toll, especially on the most marginalised and vulnerable people. Now, middle income countries like India, Brazil and South Africa are seeing cases of hunger and malnutrition soar. In Africa, over 100 million people are facing “catastrophic levels of food insecurity” as COVID-19 has come on top of conflict, climate change and population displacement. Malnutrition and undernutrition put people at even higher risk of infections such as COVID-19, and potentially reduce the efficacy of the vaccine as they do with other vaccines. On the plus side, last year’s flu season was considerably lighter than in previous years, however the world is likely to be suffering the after-effects of the pandemic for many years to come.