Known only to God and statisticians

 5 October 2020 –  Mukesh Kapila

Image by Anna Shvets

Someone died somewhere recently,  and the Johns Hopkins University’s COVID-19 dashboard passed 1,000,000.   We are not sure when exactly this happened as death reporting is not timely, complete, or accurate. Nevertheless, a grisly shiver went down the global spine as the roundness and hugeness of a million number always has symbolic resonance.

We don’t know this person but the odds are that he was a man and perhaps an American, Brazilian, or Indian. He may have had diabetes and was over-weight. We don’t know the colour of his eyes but the colour of his hair would have been grey-white, as he was probably older.  Of course, we may be completely wrong: there is a chance that she was a healthy young woman in Sweden or South Africa – or anybody, anywhere. As such our unknown millionth casualty is akin to the un-identified soldier memorialised in war monuments – known only to God and statisticians. But vested in his or her anonymity are the collective memories and sorrows of everyone who has been directly or indirectly touched by the coronavirus.

Since the first confirmed COVID-19 death in Wuhan, China in early January 2020, this is undoubtedly a tragic milestone, the significance of which should not be under-played.  At the same time, perspective is important along any journey with milestones to pass. So, it is worth asking: who else perished during the intervening nine months?

The Global Burden of Disease database logs death and illness around the world (population 7.8 billion). Applying its latest available statistics for 2017 to the current year, we can estimate that 37 million people died worldwide over the same period that COVID-19 mortality reached 1 million  i.e. COVID-19 constituted about 3% all deaths.  What did the remaining 97% die from?

The commonest cause was cardiovascular disease:  12 million perished from high blood pressure, heart attack, stroke, heart failure, and related afflictions.  Next was cancer with 6.4 million deaths, with lung, trachea, and bronchus leading the way, followed by colon and rectum, stomach and liver, and then breast. Lung and lower respiratory conditions followed with 4.3 million  deaths including from bronchitis, asthma, and pneumonias.   

Various forms of trauma and violence extinguished over 2 million lives – mostly from road injuries and suicide, and also homicide, armed conflicts, and accidents.  The triple scourges of tuberculosis, HIV/AIDS, and malaria took away another 1.8 million.

The rising tide of dementia killed 1.7 million – the most common form of which was Alzheimer’s disease in which there is deterioration, beyond normal ageing, in memory, thinking, and the ability to perform everyday activities. Close behind were a variety of digestive disorders that cost 1.6  million lives.

Maternal and neonatal disorders claimed 1.3 million – mothers’ lives tragically cut short due to pregnancy-related complications and babies lost within 28 days of birth.  Diarrhoeas, caused mainly by viruses and bacteria, are still very common and led to 1.1 million deaths.

COVID-19 enters next with 1 million fatalities followed by diabetes at 0.9 million and subsequently a long tail of other conditions.

Such a table of human mortality during 2020 is not quite accurate as there is a considerable lag before all data are recorded and validated. Also, it significantly under-estimates the non-COVID death toll. This is because COVID-related lockdowns everywhere reduced employment, incomes and coping capacities, and increased destitution, malnutrition and hunger. Poverty kills directly and indirectly. Health systems also closed down or re-oriented massively towards the management of COVID-19. That delayed attention to other life-threatening conditions such as cancers and heart disease, further costing many tens or hundreds of thousands of lives on a global scale.  Perhaps there were some lockdown wins such as fewer deaths from road accidents and lower air pollution, but they may have been countered by increased suicides and mental illnesses.

Of course, a global scan does not do justice to individual communities and nations which vary so much in their disease burdens that are influenced by their own population demographics, and social and economic conditions. Take India (population 1.35 billion) where recorded COVID-19 deaths till September 2020 were approaching (and have now exceeded) 100,000 but other deaths totalled at least 17 million. Both numbers are considerable under-estimates but the main causes of non-COVID deaths in India are much the same as globally except for diarrhoeas which are more fatal in India – killing almost 5 times more individuals than COVID-19. As further example, take Kenya (population 51 million) that recorded around 700 COVID-19 deaths over the same period while other deaths totalled around 200,000 with HIV/AIDS at the top. This killed a staggering 46 times more people than the coronavirus.

As with  past pandemics, COVID-19 will also pass with the science of behaviour change, diagnostics, therapeutics, and vaccinology trying to reduce its sojourn and giving us time to learn to live with the coronavirus. But the other scourges will remain to set grimmer milestones, even as we await new organisms to emerge and challenge us.

Such reflections on mortality raise disturbing questions on the ethics of public health policies that decide on the lives to be saved from certain conditions, at the cost of lives to be sacrificed by de-prioritising others.  How these trade-offs are made are not usually debated by the public. They also illustrate the competition between diseases and which ones win favour and resources . This is driven, perhaps, by the dominant narrative constructed in the popular mind alongside the realpolitik of which grouping suffers from which condition and is loudest in drawing attention. 

There are also no easy answers in multipolar and unequal  societies where real-world policies don’t automatically follow the logic of dispassionate statistics. But investing in universal health coverage for all populations and conditions offers  hope. Perhaps COVID-19 is the shock needed to push this further.

Published by Mukesh Kapila


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