World hits 1M COVID-19 deaths. How did we get here, and will it get worse?

MANILA/CANBERRA — Deaths from the novel coronavirus have reached 1 million globally, and the Institute for Health Metrics and Evaluation projects this to double by January 2021. At worst, deaths could climb to more than 3 million by that date.

COVID-19 deaths reached over 1 million on Sept. 28, according to Agence France-Presse. Data from Johns Hopkins University’s Coronavirus Resource Center, however, put the figures at 998,074 as of this writing, likely due to weekend lag in data processing.

“The worst case scenario for the northern hemisphere is the month of December and January. We are going to have a very difficult time when mortality will increase on a daily basis. We have to be ready for it mentally, and unfortunately hospitals need to be prepared for it and have to have the resources they need to address this virus,” Ali Mokdad, professor of health metrics sciences at IHME, told Devex.

The latest COVID-19 milestone serves as a grim reminder of its devastating human toll, and a renewed wake-up call to governments and populations of the seriousness of the disease. While some governments have maintained a low number of cases, others have struggled to control transmission.

Misinformation and disinformation — at times coming from government leaders — have also contributed to the challenges in tackling the pandemic. Dangerous conspiracy theories have kept people from following basic safety protocols, such as wearing masks and maintaining social distancing in public places.

“This is a serious and devastating disease to our health and economy all over the globe — and you still hear some voices that say it is a hoax and there is no COVID-19. That’s frustrating,” Mokdad said.

He expressed dismay over narratives that herd immunity can be achieved at 10% to 20% infection rates.

“People tell you of this. We haven’t seen it in our data.” He pointed to some places in Brazil, where as much as two-thirds of the population is believed to have been infected “and still there is no herd immunity. Whoever is spreading this rumour that we are going to have herd immunity at a lower rate [is spreading a false rumour], and we need to be very careful and make sure we don’t let down our guard until we have a vaccine,” he said.

What’s driving the death toll in the Americas?

China had been the epicenter of the pandemic until mid-March, when reported daily deaths in Italy started to increase, reaching at one point over 900 deaths reported in a single day. This overwhelmed doctors and health facilities, prompting the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care to publish triage recommendations for patients who would need priority access to intensive care.

But not long after, the high number of cases and deaths in the United States and Brazil made the Americas the new epicenter of the pandemic.

The first COVID-19 cases were officially confirmed in the United States on Jan. 20, and the country reported its first official deaths on March 3 — despite reports that people were dying as early as February. In less than a month, more than one thousand deaths were reached. By April 12, the U.S. had overtaken Italy’s death count.

At its worst in April, the U.S. was reporting an average of 3,000 new deaths daily. This has since dropped to less than 800 people, but there are fears of deaths rising again as COVID-19 cases continue and with the approaching winter season.

The latest data shows that the United States continues to account for most of the deaths globally, reaching 200,000 reported deaths as of last week. A weak federal response and wildly varying state-level interventions, coupled with a dangerous politicization of the pandemic response, have all contributed to a continued spread. IHME didn’t expect deaths to reach 200,000 until the second week of October, Mokdad said.

“It gives you an idea of what is unfortunately happening,” he said.

Brazil meanwhile recorded its first death on March 18, but in less than three months it became one of the countries with the highest death toll globally. By August, Brazil was averaging 44,000 new cases daily and over 1,300 new deaths, lowered now to an average of 700 daily deaths. As of Sept. 27, COVID-19 deaths in the country account for 14% of the global total.

COVID-19 deaths have been recorded in a total of 30 countries in the region, with lives lost in Mexico, Peru, Colombia, Argentina, Chile, and Ecuador in excess of 10,000.

Driving these numbers are a combination of several factors, including overwhelmed health systems, and demographic and socio-economic realities in a number of Latin American countries, said Marcos Espinal, director of the Department of Communicable Diseases and Health Analysis at the Pan American Health Organization.

In some cities in Latin America, there are poor communities living in highly urbanized areas “where it is very hard to practice social distancing,” he said.

The pandemic is particularly lethal for the elderly and people with other medical conditions, such as diabetes, cancer, and cardiovascular disease.

“It's a combination of factors. And this once again shows us how unpredictable this virus is, because we continue to see deaths. The curves are kind of flattening little by little, but that doesn't mean that we need to relax the measures because we also see new spikes in Europe,” Espinal said.

“Unless and until the vaccine is available, [as well as] more medicine and treatment, we need to continue implementing these non-pharmaceutical measures and find a balance in reopening in order to minimize the number of deaths,” he said.

Has Africa been spared by the pandemic?

The African region, excluding Egypt, has recorded over 25,000 deaths, the lowest in comparison to other geographical regions. The highest number of cases and deaths have largely been confined to South Africa, where more than 660,000 cases and over 16,000 deaths have been confirmed to date.

The low levels of transmission and deaths in the continent have become both a source of celebration and tension. Earlier projections painted a grim picture of the impact of COVID-19 in Africa. In May, the World Health Organization estimated that between 29 million and 44 million could become infected with COVID-19 there, and between 83,000 and 190,000 people could die from the disease in 2020 "if containment measures fail.” At that time, almost 1,000 African health workers had been infected with COVID-19.

But the situation in the continent is now proving those earlier predictions wrong, with some arguing that these previous models were a product of biases against Africa.

During an online press briefing on Sept. 24, Dr. Sam Agatre Okuonzi, chairman of the Hospital Management Board at Arua Regional Referral Hospital in Uganda, spoke about how Africa has often been seen as a “natural home of disease” and “a place where this kind of disease [COVID-19] would flare-up most.”

“In Uganda there was panic. It was predicted by the beginning of September there would be 600,000 cases of COVID, and 30,000 deaths. But the reality is starkly different,” he said.

There are 7,364 COVID-19 cases and 71 deaths in Uganda as of Sept. 27, according to WHO. Okuonzi said that similar observations have been made in other African countries, shattering biases about the disease, but also about Africa.

Some question the accuracy of reported cases and deaths in the region, although IHME’s Mokdad argued there is underreporting and underestimation in a lot of countries, including in high-income economies like the U.S.

“There could have been some underreporting [of cases in Africa], I agree ... but you cannot suppress deaths. The deaths that occur in society are so loud and so visible that you can only conclude that they must be accurate, and they’re very few,” Okuonzi said.

Dr. Matshidiso Moeti, regional director for WHO in Africa, said in a press briefing early preparations and restrictions on movement created a window of opportunity for many countries in the continent to strengthen their response while keeping cases low.

“Are we missing very many people who are infected and not detected? Some early results suggest a higher number of infections than those that are reported in places like Kenya, Malawi, and Zambia. But to extrapolate these findings to the national level, we think that further research is needed, going beyond urban areas including in rural areas where transmission seems to be lower,” she said.

She noted that over 80% of cases in the continent are asymptomatic, and is evident in health facilities not being overwhelmed. And while there are death registration problems in most countries in Africa, she said previous outbreaks have shown how communities, when they see a pattern of deaths among people, will start reporting them.

Demographic profiles in African countries could have also played a factor, with most having a younger population. The elderly also mostly stay at home instead of living in specialized living quarters found in many Western countries, where high transmission and deaths were recorded.

But she and other experts expressed caution amid the continent’s early successes.

“We're very pleased that in places like South Africa [they] are bringing the disease under control and that we haven't seen this awful impact in people living with HIV. Again, governments and humanitarian agencies deserve great credit. A lot of work has gone into protecting vulnerable refugee and displaced populations,” said Dr. Michael Ryan, WHO director for health emergencies.

“But Africa hasn't escaped unscathed. There are still many, many deaths, and South Africa had a very severe impact of disease,” he pointed out during a WHO press briefing on Sept. 25. Countries in the continent also need to accelerate their testing capacities, he added.

“I think maybe Africa is teaching us a trick or two. But again, don't get me wrong. Africa is not out of the woods. Vigilance is absolutely required,” he said.

Could the world avoid the 2 million death projections?

There’s been a plateauing in weekly cases and deaths reported to WHO, but this is “not a promising situation” according to the United Nations aid agency, noting that 1.8 million to 1.9 million cases and 40,000 deaths a week remain “far too high.”

In addition, seroepidemiological studies demonstrate that only a small proportion of people have developed antibodies against COVID-19, which means “the virus still has a large leeway and will continue to spread if we do not suppress it,” WHO wrote in an emailed response to Devex.

WHO said it is particularly concerned about the northern hemisphere. As the colder season approaches, there will be less room for outdoor activities. The cold months also bring with it other respiratory diseases, complicating diagnoses and adding to the disease burden.

When cases increase, IHME’s Mokdad noted, people start behaving — wearing masks and staying at home. But the reverse is also true. Once cases start to decline or it’s no longer a focus of media coverage, people start letting down their guard.

IHME also adjusts its projections based on government actions, although he acknowledges that the decision is never easy as governments try to balance protecting lives and protecting livelihoods.

“It’s hard work, and it has been very difficult because we keep reminding ourselves these are not numbers or metrics — these are human beings and loved ones. On a personal note, every time I put in a number I look at everybody and I hope and pray that whoever has the lowest projection that they are right and we are wrong,” he said.

WHO’s Ryan meanwhile said during Friday’s press conference: “1 million is a terrible number. And I think we need to reflect on that, before we start considering the second million. There is a lot that can be done to save lives, both in terms of disease control, existing lifesaving measures, and the innovations that are coming down the pipe. The real question is, are we prepared collectively to do what it takes to avoid that number?”