UNIFI trainees.
Over 17 million dead. This is the staggering toll of the pandemic. Too many governments have failed to meet basic standards of institutional rationality and transparency, too many people have failed to comply with basic public health precautions, and major world powers have failed to work together to control the pandemic. But the death toll is not the same in the different regions of the world.
Globally, the COVID-19 pandemic has resulted in a cumulative number of 6.9 million deaths recorded by theInstitute for Health Metrics and Evaluation as at 31 May 2022, with an estimated number much higher and equal to 17.2 million (Figure 1). “This staggering number of deaths – reads the The Lancet Commission on lessons for the future from the COVID-19 pandemic (1) – is both a profound tragedy and a huge multi-layered global failure. Too many governments have failed to meet basic norms of institutional rationality and transparency, too many people – often influenced by disinformation – have failed to comply with and protest against basic public health precautions, and major world powers have failed to work together to control the pandemic. .
However, it has produced very different effects in terms of mortality in the various WHO Regions (Figures 1 and 2), . In fact, each region has adopted different strategies for managing the pandemic which have led to regional differences in mortality rates. It is important not only to distinguish the different strategies adopted (such as suppression and mitigation), but also to identify the underlying reasons (political, structural, organisational) which have led to such sensational differences in mortality. It is also important to distinguish between different countries within WHO regions.
Figure 1. COVID-19. Cumulative number of deaths – notified (red bars) and estimated (light blue bars) – per million inhabitants globally and at the WHO Region level, as of 31 May 2022 (Institute for Health Metrics and Evaluatione – IHME).
Figure 2. WHO Regions
The Western Pacific Region had on average 10 times lower cumulative mortality than the European and American regions. As can be seen from the Figure 3 the countries belonging to this region have in fact survived the first phase of the pandemic almost unscathed, while they have begun to record significant levels of mortality (but still much lower than those of the other regions) with the impact of the Delta and Omicron variants (Taiwan also resisted the Delta variant, but not the Omicron). Countries in this region have successfully adopted suppression strategies, made possible by well-equipped public health systems in terms of organisation, personnel and technologies. Until the arrival of the variants, they managed to cope optimally with the epidemic waves through tools for early and timely detection of cases, contact tracing, isolations, quarantines and targeted lockdowns. Only in 2022 was the suppression strategy interrupted and a mitigation strategy consequently adopted, following the appearance of the omicron variant characterized by high transmissibility. East Asian countries had learned the lesson from the previous coronavirus (SARS) epidemic of 2002-03. Among the Western Pacific countries, China is a special case; in fact, it maintained a suppressive line (zero COVID policy) until December 2022, when the government reacted to the protests of the population by ending most of the restrictions. This sudden turnaround caused the infection to spread rapidly to many millions of Chinese. The health system went into crisis resulting in high levels of mortality among the elderly. The decision to ease restrictions has been exacerbated by the insufficient vaccination rate among the elderly, the impending Chinese Lunar New Year and the resulting surge in travel across the country.
Figure 3. COVID-19. Cumulative number of reported deaths per million population as of January 14, 2023. Selected Western Pacific Region countries
The European Region – like the Region of the Americas – has the highest level of cumulative mortality per million inhabitants (Figure 4). The catastrophic effects of the pandemic are attributable to a mix of factors. The most important is the process of weakening public health services and progressive privatization as occurred in the two major Beveridge model healthcare systems, namely the British and the Italian one. These systems arrived exhausted at their rendezvous with the pandemic, both lacking a pandemic plan. It should also be noted that in England, in the first wave, the excess mortality can also be attributed to the choice, later revised, to let the virus circulate freely to achieve herd immunity. It should be noted that this strategy has been pursued with determination by Sweden which has paid the consequences with decidedly higher mortality levels than in other Scandinavian countries (Figure 5). However, all European countries have paid a high price for not having public health services ready to deal with a coronavirus pandemic (for example, the Germania contained the mortality rates in the first wave, which however increased significantly with the arrival of the variants). Several Eastern European countries have recorded high levels of mortality resulting from poor vaccination of the population (see Bulgaria).
Figure 4. COVID-19. Cumulative number of reported deaths per million population as of 11 January 2023. Selected countries in the European Region
Figure 5. COVID-19. Cumulative number of notified deaths per million population as of 15 January 2023. Scandinavian countries in the European Region.
Even in the Region of the Americas, the catastrophic effects of the pandemic can be attributed to a number of factors (Figure 6). Among all, the political situations of USA and Brazil where the presence of denialist presidents has certainly facilitated the spread of the pandemic and the achievement of high levels of mortality. In the USA, the situation has not overall improved much with the change of presidency because health policies (use of masks, closures, vaccinations) are decided by individual states. Quoting the Lancet document: “The United States, like many member countries of the Organization for Economic Co-operation and Development, chronically underinvested in public health before the pandemic, dedicating only 2.5-3% of the total health sector budget to public health to public health” (p. 19).” As in many other countries, the United States has invested little in community-based public health services. Within the health sector, the focus has been on secondary and tertiary health care rather than universal access to primary health care” (p. 31). The American region is full of weak and largely privatized health systems where the pandemic has run rampant, such as in Peru which records levels of cumulative mortality per million inhabitants double those of the USA and Brazil: “We are in the second wave, the vaccine doses are not arriving and we are hospitalizing more and more young people under 40 in intensive care, also due to the new variants of the virus” – said Francesco Segoni, MSF Project Manager. “It seems like a story that has already been heard: the second wave, the lack of oxygen, the full intensive care units and the exhausted health personnel. But here in Peru all this is still a dramatic reality and has already led to the deaths of over 180,760 people. The public health system is paid for, people avoid asking for assistance because they are unable to pay. In many cities there are very long queues to fill oxygen cylinders and hope to treat relatives sick with Covid-19 at home with disastrous consequences.” The lockdowns that were gradually adopted in the American region were not part of a suppressive integrated strategy, but only had the aim of flattening the curve of infections in order to avoid an excess of covid patients in hospitals. This has been associated with anti-vaccine propaganda and the marked vulnerability of the American population (due to advanced age, the high burden of chronic diseases and numerous social inequalities). All of this explains the high mortality rates.
In the American region, however, two exceptions stand out. The first is Canada, which managed to contain the pandemic also for having experienced the arrival of SARS in 2002-03 which produced a few dozen deaths. The second is Cuba, which thanks to its public health service survived the first wave without damage and contained the arrival of the delta variant with complete vaccination coverage guaranteed by an effective locally produced vaccine (Soberana) and the organization of an incisive and rapid vaccination campaign .
Figure 6. COVID-19. Cumulative number of reported deaths per million population as of January 11, 2023. Selected countries in the Region of the Americas
The Region with the highest number of deaths (in absolute, estimated numbers) is that of South-East Asia due to the presence of India which recorded a catastrophic spread of the coronavirus in the first half of 2021, from which the delta variant originated, with a dramatic peak of infections and deaths. Since this wave, cases have dropped steadily and efforts have been focused on increasing vaccination coverage (more than 70% of the population was fully vaccinated as of September 2022). For this reason, despite the Omicron wave in January 2022, the number of hospitalizations and deaths has remained low.
In the African regionDespite limited containment policies, the number of reported cases and deaths has been low. In reality it is probable that many cases have not been reported because, being a young population, there has been a high proportion of asymptomatic or paucisymptomatic subjects.
Finally in the Eastern Mediterranean region due to the conflicts present in various states, health systems have had a limited capacity to control the pandemic. Mortality rates were low, but possibly underreported. Vaccination coverage is highly heterogeneous, ranging from 90% in the United Arab Emirates to 2% in Yemen.
In conclusion, it was found that countries with well-equipped public health systems and in which health policies have invested a large number of resources, have been able to significantly affect mortality levels. In order to face the pandemic challenges, solid relationships with the resident populations, the creation of a sense of community and a strong community awareness are also necessary.
This post is the result of the collective work of a group of doctors in specialist training (from the first year of the specialization in Hygiene and Preventive Medicine at the University of Florence) on the Lancet Commission Report on lessons for the future from the COVID-19 pandemic
This work involved the analysis and re-elaboration of the Report, the presentation in the classroom with discussion and the production of 3 posts. The one published today will be followed by two other titles: An unequal pandemic and What we learned from the pandemic.
The group is made up of: Simone Baldacci, Manjola Bega, Andrea Benincampi, Raffaele Caldararo, Ludovica Costantini, Erika Del Prete, Debora Fontana, Veronica Gironi, Elena Morelli, Giulia Napoli, Neda Parsa, Concetta Francesca Rosania, Gianluca Pollasto, Francesco Toccafondi, Marcello Settembrini, Lediana Spaho, Elvis Vassallo.
Bibliography
- Sachs JD et Al. The Lancet Commission on lessons for the future from the COVID-19 pandemic. Lancet. 2022 Oct 8;400(10359):1224-1280.