One world, two pandemics?

How different types of mortality data support opposite views on pandemic severity across countries and why one of them is completely wrong

If there is one thing the pandemic should have taught us, it is that we live in one globally interconnected world. Yet, judging the discourse on the pandemic over the last few years, one could be forgiven for thinking that the world has suffered two different pandemics: an intense pandemic for the rich countries and a mild one for the poorer, developing countries. A view that is supported by the officially reported COVID-19 mortality rates

But nothing could be further from the truth once we correct for inequality in data quality and take the broader perspective of excess mortality, which is the gold standard for capturing the true and total impact of the pandemic. Two pandemics? No, it’s been one pandemic with also very severe — if not more severe — outcomes in the developing world. 

Setting the record straight

With data on excess mortality now more abundantly available, we are able to assess the impact of the pandemic more comprehensively. Let us consider in what follows the mid-point estimates of excess mortality derived from the excess death model by The Economist. These are broadly in line with those of other outlets, including the WHO (see here for a discussion). 

The chart plots on the horizontal axis the mortality rate and on the vertical one the mortality head count. It does so for the concept of estimated excess mortality as well as, for comparison purposes, reported COVID-19 mortality as per the officially published statistics. These quantities are shown for two aggregates: the group of high-income countries countries (HICs) – the rich countries of the world – and the developing world (DW) – the developing countries or simply all other countries but those who belong to the HIC category as per the World Bank’s income classification. The observations are scaled by population size. 

The different mortality concepts are compatible with two completely opposite views of how the pandemic has impacted on the world.  

  • The “one world, two pandemics” view supported by the officially published COVID-19 mortality data is illustrated by the blue bubbles. The cumulative mortality rate of the DW is just 0.27 times that of HICs (59 versus 216 fatalities per 100,000 people). Due to this huge difference in rates and despite the much larger population size of the developing world (6.6 versus 1.2 billion), the cumulative mortality head count in developing countries is “only” 1.5 times larger than that of the HICs (3.9 vs 2.7 million). The finding that absolute mortality counts are relatively similar is very surprising keeping in mind that the rich countries represent only 16% of the global population.
  • The red bubbles based on estimated excess mortality present a view that is diametrically opposite. Cumulative mortality rates in the DW are currently 1.12 times those of HICs (296 versus 264 fatalities per 100,000 people), which is a dramatic difference with the previous view. As to excess death counts, developing countries dominate the global excess death tally. Developing country excess deaths are 6.0 times larger than those in HICs (19.6 vs 3.3 million). 

The differences underneath the averages

What would these comparisons look like if we adopt a more granular perspective? The group of countries that encompass the developing world is both large and heterogenous, including countries as diverse as Chad and China or Suriname and Syria. The aggregate results for the developing world presented in the previous section may therefore mask considerable differences underneath. 

To explore this in more detail, we decompact the group of developing countries into the four income groups of the full World Bank’s income classification: the high income countries (or HICs as noted earlier) and the upper-middle, lower-middle and low income countries (UMICs, LMICs, and LICs), which together make up the developing world category discussed earlier. In other words, we split up the DW group into its constituent member groups of UMICs, LMICs and LICs. 

The chart below plots the results for these four groups again by mortality concept, with the blue bubbles representing officially reported mortality statistics and the red bubbles the estimates of excess deaths. The axes are the same: rates horizontally and counts vertically. 

Based on this more granular view, we get the following results:

  • The pandemic’s excess mortality toll is being driven by middle-income countries. That’s perhaps not surprising given that they make up 75% of the global population. But not only are these groups populous, their excess mortality rates have also been much higher than the official COVID-19 rates would suggest. Note the long horizontal distances in the lines that connect the observations for LMICs and UMICs.
  • Lower-middle income countries have been affected by far the most. LMICs stand out in terms of both rates and head counts. They are the largest group population-wise, but the high level of the estimated excess death rate over the course of the pandemic suggests has elevated the mortality impact well above the weight of its population. This is all the more severe given LMIC populations consist of predominantly younger age categories which, all else equal, would be less vulnerable to the severe manifestations of COVID-19.
  • Upper-middle income countries too have been more severely affected than HICs. Their excess death rates are estimated to be very similar to those of HICs. While we have seen considerable aging in UMICs over the last few decades, the elderly shares are still considerably smaller than those of HICs, which again suggests that the mortality impact has been disproportionately severe. The difference between COVID and excess death numbers is smaller than those seen in LMICs but remains nevertheless very considerable.
  • While low income countries are last in the ranking, their excess death rates suggest a much more severe impact than indicated by the official stats. LICs have some of the youngest populations in the world. Yet, their estimated excess death rates are roughly in line with those of HICs and UMICs. Of course, a large margin of uncertainty surrounds the estimates and particularly so in the more data-scarce LICs and there is also the possibility of upward bias (discussed in greater detail here). However, if these results hold true, they suggest a picture that could hardly be more different from the “one world, two pandemics” view. 

Parting thought

The pandemic has accentuated pre-existing trends in polarization through misinformation and disinformation that has sought to minimize the severity of pandemic outcomes within and across borders. 

Well into this third year of the pandemic, it remains necessary to drive home the point that we need to use the right concepts to assess the severity of impact. They need to cast the net broadly so as to capture the indirect effects of the pandemic. And to get a comprehensive global picture, we need to rely on estimates of excess mortality so that those countries where regular or reliable mortality updates are not available are included in our assessments. Excluding them would be to ignore the suffering in much of the developing world.  

As we have argued here, the world remains underprepared to deal with the adverse contingency of a possibly more dangerous variant going forward. The finding that the developing world has been dealt a very severe – if not, the most severe – blow is based on a review of backward-looking information. But it also holds forward-looking relevance as there is not only undiminished need to bolster our pandemic defenses but also a pressing need for more inclusive approaches in the future.

The call for cross-border equity is often presented as being in the “enlightened self-interest” of richer countries. Cross-border externalities in this globally interconnected world make it so and how many times have we heard it before: “the pandemic isn’t over until it’s over everywhere!”  

But in light of the results presented in this post, which have shown how understated the impact on the developing world has been, the clarion call for greater equity should not be mainly based on that it’s in everyone’s benefit. No, it should be primarily motivated by the fact that it is morally the right thing to do.  

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