- There are no long term disease death predictions
available, making it difficult to assess if the numbers of death from Covid-19
are correct. - Annual deaths have been declining since 2006, but
in 2020 Covid will increase our death toll this year by 10% or more. - Covid-19 has been the worst short-duration pandemic
since 1919.
Eight months into the Covid-19 pandemic, how well
has South Africa done at limiting infections, and how big a deal is the
pandemic anyway?
To answer that, we need to think about how the data
actually works and doesn’t work, GroundUp reported.
We are not 5th worst
Dashboards like Bing and Worldometer report that South Africa has the
fifth highest number of infections globally. By the measure of deaths per
million people, which more directly expresses how dangerous it is to live
somewhere, we are ranked 31st – so nowhere near the podium. Both of these
rankings, though, require a pinch of salt. There are many countries that almost
certainly have more infections (see the grey box below).
South Africa has performed more tests than most
(16th place, as far as we can tell) and we track births and deaths about as
well as some developed countries. These two factors, of which we can be proud,
unfortunately also make us look worse than many countries that have little
capacity to test for Covid, or to count deaths.
How many Covid deaths?
Officially, we have had about 12 000
“confirmed” Covid-19 deaths. However, the South African Medical
Research Council (SAMRC) reports that there were
27 500 more deaths (from all causes) between 6 May and 4 August than we have
seen in that time window in recent years. That number is probably a
conservative estimate of the true Covid-19 death toll. Here’s why:
Firstly: The number of confirmed Covid deaths only
started increasing dramatically in June, and is now on the decline. This aligns
impressively with the SAMRC mortality trends. “Collateral” deaths – non-Covid
deaths brought on by generally reduced access to healthcare – would be expected
to follow the severity of the lockdown, which has been slowly tapering off due
to the relaxation of rules and fatigue.
Secondly: Because of the lockdown, deaths from
“unnatural” causes (particularly homicides and accidents) have
dropped dramatically, even as the total has gone up.
Thirdly: Deaths from other infectious diseases
which we usually see at this time of the year have also dropped dramatically.
There has been no significant flu season. In children, there have been very few
Respiratory Syncytial Virus (RSV) infections and other respiratory tract
infections that usually cause deaths during winter, and less TB than usual.
Fourthly: Taking into account the previous two
points, the SAMRC produced a best estimate of excess “natural” deaths
over the same period – and that estimate runs to 33 500.
Fifthly: The death count gap, comparing the
officially confirmed Covid deaths and the total excess deaths, displays a sharp
provincial pattern. In the Western Cape, the official Covid death toll is about
70% of the SAMRC’s excess death estimate. Next is Gauteng, where official Covid
deaths are a mere 24% of the estimate’s excess deaths. In four provinces, the
official Covid-19 death toll is just one tenth of the excess deaths. This is
what we would expect if the excess deaths are mainly direct Covid deaths, but
provincial data collection systems are not equally effective at picking them
up. To believe that a Covid death in all provinces is roughly equally likely to
be recorded as such, would leave us with a strange and unexplained distribution
of “collateral” deaths.
Some of the excess deaths are presumably not Covid
disease, but the result of difficulties accessing healthcare, owing to lockdown
restrictions, fear of going to a clinic, or overburdened health systems. Given
the preceding points, these are likely to be a relatively small part of the
excess deaths.
How many Covid deaths will there be?
Reliable long-term disease death predictions are simply not available. Nevertheless, it now seems safe to say that by the end of September there will be over 40 000 actual Covid-19 deaths, though these will not be reflected in the official count.
The epidemic is in decline, but it is far from over
and it could surge again if lockdown relaxes and if we collectively drop our
guard with physical distancing, face masks and hand hygiene – that is what is
currently happening in many countries.
How bad is it?
In South Africa, annual deaths have been declining
since 2006, mainly thanks to antiretroviral treatment for HIV, and progress
against TB. There are also about 50 000 unnatural deaths annually, but barring
an outbreak of extreme violence, there will be far fewer this year.
There were about 450 000 recorded deaths in 2017,
the latest year for which official numbers are available. Covid will increase our
death toll this year by 10% or more. That’s huge.
How do Covid deaths compare to AIDS and TB?
TB is the most frequently recorded cause of death
in South Africa, and there were under 30 000 such deaths
in 2017 – fewer than any serious estimate of Covid deaths in 2020. Even though
the real TB number is likely to be significantly higher due to how death
certificates get filled in, we can reasonably expect more Covid deaths this
year than TB deaths.
South Africa’s most informative AIDS model (Thembisa)
estimated that there will be 63 000 AIDS deaths this year. That was before we
had social distancing and all the anti-Covid measures, which have reduced
transmission of respiratory infections – a major immediate cause of death for
people living with HIV.
But taking a longer term view, Covid in South
Africa doesn’t even come close to the HIV epidemic. In 2006, about 300 000
people died of AIDS here, almost 6 000 people per week, sustained throughout
the year. At the height of the just-passed Covid peak, it was about as bad – more
than 6 000 excess natural deaths in the week of 15 July. Because many people
get very sick from Covid and recover with oxygen support, some hospitals were
for a few weeks hit harder by it than they were ever hit by HIV.
How bad could it have been?
It’s clear that the measures taken since 16 March
have saved lives. Lockdowns work. China, where measures were highly enforced,
and testing was pushed as hard as possible, had a tiny first peak compared with
European countries. We know it worked here because we see the reduction in
other infectious diseases. Perhaps the lack of international traffic helped
prevent the flu season, but it doesn’t explain the drop in other infections in
children which do not depend on international travellers.
The restrictions on inter-provincial travel,
coupled with mask wearing, physical distancing, hand hygiene, and a massive
reduction in public events and large gatherings have likely played their part.
Had we continued life more or less as normal after 16 March, what would have happened? It’s impossible to produce credible hard numbers, but our guess is that several times as many deaths have been prevented; we have probably avoided a devastating flood of deaths.
Yes, planning for the surge of cases, in some provinces,
was abysmal. The ban on cigarettes made no sense; nor did the restrictions on
exercise hours. Overzealous restrictions on workplace activity have left the
economy reeling, but a comparison of other countries (including Sweden) shows
that epidemics can easily stall economies even if one does not explicitly
decree a halt to most activities. Stealing protective equipment contracts and
other opportunistic corruption are indeed abominable. Despite all this, it
could easily have been so much worse. The government has not done too badly in
its stated main aim: to reduce Covid-19 deaths.
Further reading: MRC analysis of excess deaths
Explainer: Official death tolls globally fall short
Worldometer says 777 076
people have died of Covid-19 as of 17 August. Except for clerical errors and
some minor technical exceptions, every single one of those deaths links back to
a specific person, certified by a healthcare worker as having probably died of
the disease. (Bing and the WHO also tally the daily
deaths with slight differences.) This is an astonishing accomplishment, and a
first in history. Yes, there have been gimmicky daily counters of global AIDS
and other disease deaths on some websites, but these are at best rough
estimates, based on sparse direct data, spread thin by mathematical models.
Yet far more people have died of Covid-19 than are recorded on the global dashboards. There are several reasons why people who die of the disease don’t get counted in the official stats. Many people die at home or in care institutions, without being diagnosed. Even if they’ve been tested, their results often come back long after a doctor has filled in the death certificate, and PCR tests miss many positive cases.
The New York Times (among others) tracks “missing
deaths” in 28 locations. This is estimated by subtracting the excess
deaths in the location from the official Covid-19 death toll. As of 31 July,
there were 161 000 missing deaths in these locations. This means that in about
eight months, at least 919 000 people have died of Covid-19 (i.e. adding
specifically counted deaths from WHO, Worldometer, Bing, etc. to the missing
deaths). Some of these excess deaths may be due to health systems being overrun
or people being too scared to go near health facilities, but they are
nevertheless deaths due to the pandemic.
But in fact, the real death toll is much greater
than this. Those 28 locations being tracked by the Times don’t even account for
half the world’s population. Missing are China, India, Pakistan, Bangladesh,
Iran, most of Russia, most of Indonesia, all of Africa except South Africa, and
many other places. The places where excess deaths are being counted are
generally those with the best systems for keeping vital statistics, and
counting Covid deaths directly.
Although current data collection systems are far better than ever before, we really don’t know the total number of Covid deaths. It is definitely over a million; it could well be over two million already; and even three million is not implausible.
About 60 million people die globally annually. So
the Covid death toll, a brand new way of dying upon all the other ways we die,
is a significant extra few percent, even using the minimum possible estimate.
It’s also important to account for the ages at which people die, and while
Covid fatality is highest at older ages, that’s true of death generally, and
Covid is certainly striking down many otherwise healthy people who had
reasonable expectations of living out many more years.
This lack of certainty is not new; we should treat
all estimates of disease tolls with caution. Although it’s commonly said that
50 million people died in the Spanish flu pandemic of 1918-19, this is just
intelligent guessing; it could be wildly wrong.
But there are some things that we can say with
great confidence.
This is unequivocally the worst short-duration
pandemic since 1919. In bad years, standard seasonal flu kills no more than 650
000 people globally, but usually much fewer than that (about 400 000). The 1957
and 1968 flu pandemics were exceptional, killing about a million people
(estimates, not known for sure). What’s more, most countries in the world, and
most people, have taken exceptional measures to avoid contracting Covid-19.
Things would be much, much worse had we carried on as people did in 1957 and
1968; perhaps as bad as the Spanish flu, which is estimated to be the worst
pandemic in history in terms of total number of people killed – though far from
the worst in terms of the proportion of the total human population.
Compared to the slow-acting infectious pandemics,
like AIDS and TB, Covid-19 will kill more than both those diseases this year,
but cumulatively, HIV and TB have been far worse.
Geffen is GroundUp editor. He has a PhD in
algorithms for modelling infectious disease. Welte is Research Professor at,
and the former director of, the South African (National Government) Department
of Science and Innovation – National Research Foundation (DSI-NRF) Centre of
Excellence for Epidemiological Modelling and Analysis (aka SACEMA), at
Stellenbosch University.
Originally published on GroundUp.
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