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The Hidden Costs of Covid-19

From the series The struggle against coronavirus

Around 227 million people have been infected by the novel coronavirus SARSCoV-2 worldwide, causing 4.7 million deaths [Johns Hopkins University, September 17th, 2021]. If tracked over time, both figures can be seen as indicators of the pandemic’s evolution. However, they do not give the full picture of the humanitarian disaster — not only because the coldness of the statistics hardly expresses the violence with which this health crisis has disrupted the lives of millions, but also because the official figures are believed to greatly underestimate the real situation.

Missed diagnoses

The number of Covid-19 cases indentified and registered in the statistics depends in fact on the number of diagnostic tests performed. It also varies greatly from country to country and in the different phases of the pandemic curve, as well as being correlated with the capacity of health systems to provide care for symptomatic cases (many patients did not even have access to medical assistance either at home or in the hospital), to test suspected cases, to isolate positive cases and to trace their contacts. The test and trace strategy has been decisively and effectively adopted in some countries from the beginning, while it has failed in most of the European states and in the United States, where the spread of infections has overwhelmed an insufficient number of health workers dedicated to tracing. In Italy, which is currently experiencing a slowdown in infections, the Istituto Superiore di Sanità (ISS) reports difficulties with contact tracing. Contact tracing indeed contributes only 28.7% to the total number of diagnosed infections in the period from August 30th to September 12th [ISS, National update, September 15th, 2021].

In autumn last year, Mike Ryan, director of the World Health Organization’s Health Emergencies Program, reported that their best estimates suggested that 10% of the world’s population had been infected with the novel coronavirus. This would translate to about 760 million infections, compared to the 35 million officially confirmed at the time [Forbes, October 5th, 2020].

A large proportion of both symptomatic and asymptomatic infections are still undetected. This happens in the least developed countries with the most precarious health systems, but not only there. The University of Texas has studied the 50 countries that have been most affected by the pandemic. In 25 of them the actual number of infected people as at September 2020 was estimated to have been between 5 and 20 times more than the official figures [PLOS One, February 8th, 2021].

Recently, the Centers for Disease Control and Prevention (CDC) assessed the total number of infections in the United States from the start of the pandemic to May 2021 at 122.2 million, versus 33 million officially reported cases [July 27th].

Covid-19 deaths by country 2,157 Italy 2,020 USA 1,984 UK 1,835 Spain 1,726 France 1,708 EU 1,324 Russia 1,108 Germany 170 Vietnam 136 Japan 47 South Korea 35 Taiwan Number of deaths from Covid-19 per million people.
Covid-19 cases by country 126,140 USA 108,581 UK 105,456 Spain 104,049 France 83,443 EU 76,659 Italy 49,309 Germany 48,867 Russia 13,249 Japan 6,801 Vietnam 5,535 South Korea 676 Taiwan Number of Covid-19 cases per million people. Data as of September 17th Source: Our World in Data.

Secondary Impacts

The official death toll from Covid-19 gives an equally incomplete picture. To the deaths directly attributable to the disease one must add those due to the consequences of the pandemic. Even where the pandemic did not overwhelm the best-equipped health systems in Europe and in America, it did nevertheless put them to the test and forced them to postpone millions of health services, delaying appointments for diagnosis and treatment.

In Italy, a survey conducted by the Italian National Agency for Regional Healthcare Services (AGENAS) in collaboration with Sant’Anna School of Advanced Studies in Pisa calculated that between January and September 2020, compared to the same perod in 2019, emergency hospital admissions dropped by 28%, ordinary in-patient admissions by 50%, specialist visits and diagnostic services by 30%, with a similar drop in diagnostic screening for various cancers. In the UK, The Economist has reported that the waiting list for operations in all specialisms has reached a record 5.1 million and 4.6 million fewer people received elective treatment in 2020 than the previous year [July 10th, 2021].

Among the secondary impacts of epidemics — similar to previous ones, from Spanish Flu to HIV/AIDS and Ebola — the British medical journal The Lancet highlights the hidden pandemic made up of Covid-19 orphans. According to a 21-country study conducted by British and American research institutions, including Imperial College London and the National Institutes of Health, from March 1st, 2020 to April 30th, 2021, more than 1.5 million children and teenagers were orphaned by a parent or grandparent who looked after them, and often faced serious consequences as a result [July 31st, 2021].

Social disparities

Understandably, great emphasis is placed on the economic damage that Covid-19 has brought about; less emphasis is placed on the effects on basic standards of living in large areas of the globe. Various studies document the great disparity in the effects of the pandemic on the lives of people in poorer countries compared to the more developed economies. A recent study by the Bill & Melinda Gates Foundation estimated that the pandemic crisis has pushed 31 million people back into extreme poverty. One of the key indicators is food access.

In their joint report on the food situation, five United Nations agencies estimated that at the end of 2020 undernourished people in the world had increased by 1.5% and accounted for 10% of the world’s population: between 118 and 161 million more people suffered from hunger, bringing the total to about 800 million undernourished people [FAO, UNICEF, IFAD, WFP, WHO, The State of Food Security and Nutrition in the World 2021, July 2021].

Food insecurity has risen by nearly 4% in one year, affecting more than 30% of the Earth’s population: 2.7 billion people whose access to sufficient food is at risk. A large part of these worsened conditions reversed a ten-year positive trend, and is due to pandemic-related disruption of economic life, with effects that could last a decade.

Dramatic imbalances in the burden of the pandemic among different social groups are not exclusive to less developed countries. As our newspaper has documented, in the United States the health crisis has hit the lower income strata much harder, and resulted in worse housing and living conditions, more precarious employment, and greater difficulty accessing medical care for these classes [The Class Factor in the Health Crisis, Internationalism, July 2020]. This is a class disparity that only partially overlaps with the disparity between ethnic groups. A recent survey published by the Washington Post reported that the death rate from Covid-19 in adults aged 18 to 64 averaged three times as high among blacks and Hispanics as among whites [August 15th, 2021].

15 million deaths?

The official death toll is tainted by many factors: differences in the classification of causes of death, failure to diagnose, failure to indicate the cause of death on certificates, and failures of statistical services.

The weekly magazine The Economist published the results of elaborate calculations for 156 countries: it estimates the real human cost of Covid-19 by comparing the number of deaths due to any cause since the beginning of the pandemic with expected deaths based on the average for previous years [The Pandemic’s True Death Toll, September 17th, 2021]. The excess deaths are thus also inclusive of indirect deaths, e.g., those caused by lack of treatment for other diseases.

The extremely rough estimate, with all the limitations noted by the authors of this study, increases the actual deaths caused by the Covid-19 pandemic to 15.5 million from the official 4.7 million as of September 17th. The gap between excess deaths and recorded deaths varies considerably between countries: it is much smaller — in some cases negligible or zero — in richer parts of the world than in countries where demographic and health data registration services are seriously deficient and where previous mortality statistics are inaccurate. In the latter countries, the gap between the minimum and maximum estimate is indeed wider.

In Asia, The Economist’s model calculates between 3.4 and 11 million excess deaths, while little more than a million are officially reported: in India alone they are estimated at 4.3 million against 444,000 reported Covid-19 deaths; in Latin America 2 million deaths against the official figure of 1.1 million; and in Africa between 800,000 and 2.2 million deaths against the official figure of 205,000.

For the United States, The Economist estimates 850,000 actual deaths compared with 670,000 recorded deaths. This is in line with the calculations of America’s CDC, which last July updated its tally — for the same period from February 2020 to May 2021 — to 767,000 from the previous estimated figure of 594,000 [CDC, July 27th]. In the European Union, the number of deaths from Covid-19 would rise from the official figure of 763,000 to 830,000, and in Russia from 192,000 to 700,000 respectively. Italy, according to these calculations, would have between 20,000 and 30,000 unrecorded Covid-19 deaths to add to the official tally of 130,000. In some countries — France and Germany in the case of Europe — The Economist reports a negative gap instead, which it believes is due to the lower spread of other infectious diseases, such as influenza.

A provisional assessment

If the whole world was taken by surprise by the outbreak of the pandemic, different countries faced it with different levels of health system capacity (from the availability of hospital beds to the development of local medical care) and, ultimately, with different degrees of competence and fitness of political leadership. The battle against the virus has so far seen alternating winners and losers. Countries that effectively contained the pandemic at the outset have had to face new peaks or have been slow to vaccinate. Other countries, whose initial management was particularly inefficient — such as the United Kingdom and the United States and which were accused of incompetence in their response, have since found redemption in their vaccination campaigns. The assessment is still provisional.

Mortality is affected by a number of factors, from the demographic structure (such as the percentage of the elderly population) to the living and health conditions of the population, as well as the quality and accessibility of medical care. Comparison is problematic. Nonetheless, the number of Covid-19 cases and deaths in relation to the population sometimes presents considerable differences when the most industrialised countries are compared against each other — even taking into account the officially reported figures — despite having comparable health care systems, statistical reporting standards, and the smallest gaps between official deaths and estimates of excess deaths. Their crisis management has been different, and this resulted in different outcomes to be assessed.

Boschetti, Marco. Covid-19: i costi sommersi Lotta Comunista, , p. 9