Benjamin Mateus
This week, a new multinational study was released in preprint form investigating the burden of COVID-19 in developing countries. As the authors noted, the lack of appreciable detailed systematic data at national and subnational levels in low-income countries has made estimating the impact of COVID-19 in these regions complex.
The generally low reported deaths from COVID-19 in low-income countries has given the appearance that these regions, because of the population’s overall younger age, as some have observed, have skirted the pandemic’s impact compared to high-income countries. However, the true toll may be hidden due to underreporting. It remains a pressing issue, as a global response to the pandemic requires an accurate assessment of the devastation wrought by the pandemic in every part of the world.
The World Health Organization has assessed that the deaths from COVID-19 at the end of 2020 were at least three million instead of the officially reported 1.8 million. They wrote, “COVID-19 deaths are a key indicator to track the evolution of the pandemic. However, many countries still lack functioning civil registration and vital statistics systems with the capacity to provide accurate, complete, and timely data on births, deaths, and causes of deaths.”
The Economist’s analysis of excess deaths recently placed the burden of the pandemic at over 15 million deaths, even though reported COVID deaths were less than five million at that time. Many low-income nations had excess deaths many times as high as their official figures for COVID deaths, though they also acknowledged the uncertainty of these estimates due to inadequate data.
Even the model of the Institute for Health Metrics and Evaluation, one of the more conservative, places the current “excess COVID-19 deaths” at 12.35 million globally. In contrast, their current projections for reported COVID-19 deaths stand at 5.2 million, a vast undercounting indeed.
The latest study also acknowledges that substantial undercounts in developing countries may be contributing to these discrepancies. A study from Zambia noted that only ten percent of those who died from COVID with a documented positive PCR test had their deaths appropriately registered. The epidemiological investigation found that COVID may have caused up to 87 percent of all deaths in the country in mid-2021.
Similarly, the cumulative COVID deaths as of September 2021 in India are reported at 450,000. However, a study posted in preprint form in July 2021, estimating excess deaths through a review of civil registration system data, facility-based death reporting systems, and national-level surveys, found that more than three million lives had been lost to COVID or seven to eight times higher than reported.
Accordingly, the authors sought to determine the overall prevalence of COVID-19 infection in developing nations, establish the relationship between seroprevalence in relation to age, and then establish Infection Fatality Rates (the proportion of deaths among all those infected, including both detected and undetected cases) by age for these countries. Finally, they attempted to compare the IFR to those from high-income countries.
The rationale for using IFR is that many infected people are asymptomatic or have only mild symptoms and remain undetected. While proportion of deaths to diagnosed cases, or Case Fatality Rate, is easier to determine, IFR provides a more accurate assessment of the burden of the disease in the population.
As previously mentioned, the relationship between age and COVID-19 mortality is a critical factor to investigate. In many developing countries, the population’s median age is much lower than in high-income regions, leading many to conjecture that these countries are indubitably protected. The authors wrote, “Several recent studies have assessed the severity of COVID-19 in high-income countries with advanced healthcare systems, and several have documented a strong relationship between IFR and age. Indeed, one study found that differences in the age composition of the population and the age-specific prevalence of COVID-19 accounted for nearly 90 percent of the variation in population IFR across locations.”
Their findings have refuted previously held views that such regions were spared the pandemic’s devastation and provide the necessary context for the discrepancies between reported COVID deaths and excess deaths as documented in the cited sources.
The IFR was estimated on the basis of seroprevalence , the presence of antibodies to coronavirus in the blood serum of those tested . This measure of the level of infection in the population was considerably higher across developing countries after a single wave of infections compared to high-income countries. The authors write, “Where the majority of high-income locations have seroprevalence below 20 percent…a large number of developing countries have seroprevalence far exceeding this rate.” This means that in the course of a surge of infections, a large swath of the population became infected.
A significant finding of theirs noted that seroprevalence across age groups in developing countries was essentially the same, which meant that young people were as likely to become infected as the elderly.
The abject poverty across many of these developing regions, including Africa, Latin America, and Southeast Asia, is crippling. Many families are forced to live together in cramped dwellings. Those fortunate enough to find employment work in demanding manual labor in proximity to other workers, which gives the virus ample room to spread deep into communities. In such instances, the idea that the elderly populations can be insulated is preposterous.
Regarding estimates of regional IFR for a developing country’s population compared to high-income countries, these were more heterogeneous. Five regions were below the estimates for high-income countries, and four were equal. Broken down to smaller locations, sixteen were higher, of which eight areas had IFR double that of high-income estimates. Such differences may seem perplexing, but more on this later.
When the IFR between high and low-income countries was stratified by age, the real burden of the pandemic on developing countries became clearer. For instance, even though the virus rarely kills young people, the age-specific fatalities in developing countries compared to high-income countries for those under 25 were 2.3 times higher. In other words, someone of the same age in a developing country had more than double the risk of dying from COVID than his counterpart in a country with significantly more resources.
As the age groups rose, the differences in fatality ratios narrowed but never converged. For instance, those between 40 and 50 years had an IFR nearly twice those at the same age in high-income nations. Between 60 and 70, the IFR was 1.5 times higher in developing countries.
These discrepancies in fatality ratio underscore the significant impact socioeconomic factors have on any country. Early in the pandemic, it quickly became known that early medical intervention saved lives. Access to hospitals, high concentration oxygen, intensive care units, and variety of pharmaceuticals are indispensable to someone’s chances of surviving COVID-19.
The massive waves that struck diverse regions such as Brazil, Eastern Europe, Africa, and India demonstrated how quickly a developing country’s health sector became inundated. Scenes of families waiting in line with empty canisters of oxygen juxtaposed with mass graves and funeral pyres on fire were replete in the press. The graph of excess deaths from Poland and South Africa below captures the true hidden magnitude of devastation when these surges swept through the country.
Regarding the discrepancies in IFR by various regions, the authors compared these estimates with the percent of well-certified death registrations. As the figure below demonstrates, countries that more accurately documented the cause of death generally had a higher population IFR. In contrast, countries like India, Pakistan, Nepal, Kenya, and Ethiopia, with low population IFR, were deficient in certifying deaths properly.
The authors wrote, “In general, the most likely explanation for large differences in reported IFR appears to simply be the recording of deaths in each region. While other factors such as GDP are correlated with death rates, they are also highly correlated with death reporting, and a likely explanation appears to be that the majority of places with very low IFRs are simply those places that cannot capture COVID-19 deaths adequately.”
In other words, poor countries did not escape the impact of the pandemic, they simply lacked the reporting capacity to document this impact systematically.
The study underscores first and foremost the global character of the pandemic. No region has been spared the devastation caused by the capitalist policies that have allowed the virus to move freely so as not to impede the insatiable drive for profits. It also has glaringly exposed the tremendous inequity in access to resources that have produced such social misery.
Though global GDP fell by 3.3 percent in 2020, the collective wealth of the world’s billionaires increased by nearly $4 trillion in the same period.
The economic loss, in real terms, means the equivalent of 255 million jobs were erased across the globe, but particularly in Latin America, Southern Europe, and Southern Asia. The IMF predicts that 95 million more people have fallen into extreme poverty, with an additional 207 million by 2030 as a byproduct of the severe long-term impact of the pandemic.
Not only are more people becoming infected in the poorer countries than in high income countries, because of the inability to carry out social distancing, masking and other mitigation measures, the mortality rate associated with COVID infections is higher, for lack of health care infrastructure. Weak reporting systems mean that there is a vast burden of death hidden from the eyes of the world.
Only an international strategy based on a socialist revolutionary perspective can address these massive and harrowing disparities.
The ruling elites are not only refusing to use the resources needed to combat COVID-19 because it would lower their profits. They see the pandemic as a welcome “natural catastrophe” that will rid the planet of what they deem to be unproductive people who are only a drain on their ability to extract more surplus value. This is the other unspoken and criminal aspect of their policy towards the coronavirus.
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