COVID-19: Two Million Deaths and Not Over Yet

Here are several reasons why this pandemic is not over yet

This table presented in the picture can be found and accessed by anyone who has Internet access. It’s available at:

https://www.worldometers.info/coronavirus/?

When looking at this table, you can see that since the beginning of the COVID-19 pandemic, more than two million people have died. The order of countries in this table in the picture is determined by the number of deaths per million inhabitants of each respective country. This is the “Deaths / 1 M pop” column. At the top are the countries which have had the most deaths per million inhabitants to date.

This table is fairly credible, but the number of deaths from COVID-19 across the world is probably higher by at least 20–40 percent, because many countries have not yet managed to include deaths which occurred at people’s own homes, deaths in retirement homes and deaths outside of the reach of health systems — the latter represents a particular problem in poorer countries.

What conclusions can we derive from looking at this table?

1. As I wrote in one of my earliest columns in the Croatian newspaper “Večernji list”, epidemics are most dangerous for very small countries. Namely, when the virus is just starting to spread somewhere, it has a similar dynamics when it comes to its spread and it does not matter to the virus whether the country in question has 60 thousand people or 60 million people living there. It will still infect, and quite suddenly so, a much larger proportion of the population in smaller countries at the same time than it will in larger countries. That is why San Marino (1st), Gibraltar (4th), Lichtenstein (9th) and Andorra (15th) are at the top and close to the top of this table. We can ignore them in this table, these countries were unlucky because they were small in terms of their respective populations at the time of the pandemic, so their parameters expressed per million inhabitants are naturally very unfavourable.

2. If we ignore these four small countries, the worst affected in the world so far are Belgium, then Slovenia, then Bosnia and Herzegovina. In seventh place we notice North Macedonia, Montenegro takes eleventh place, and the fourteenth most severely affected in the world is, quite unfortunately, my homeland Croatia — although after the first wave it was among the best in the world.

3. Let’s now look at that column “Deaths / 1 M pop”. That column shows us that in all eighteen countries shown in the table, between 0.14 percent and 0.19 percent of the TOTAL population have already died. So, as many as 1 in 500 to 1 in 1,000 people have died from COVID-19 in those countries, although none of these countries is even remotely close to reaching any sort of “collective immunity” whatsoever. All countries across the world have been trying for a year to stop this virus’ potential to kill as many people as I predicted it could kill without the introduction of epidemiological measures back on March the 1st, 2020, on the Croatian TV show “Sunday at 2” — so, from 0.5–1.0%. This containment was achieved through deployment of proper anti-epidemic measures that are able to keep the parameter R0 below the value of 1.

4. Although the pandemic was still spreading throughout China at the time, back on March the 1st, 2020, I was well aware of how the Chinese healthcare system functions and how seriously the Chinese would apply all of their anti-epidemic measures. I was also aware of this for the United States and indeed for many other countries. I predicted that there would be no more than 5,000 deaths in China. That was a very bold estimate to publicly make almost eleven months ago, as was the one on the death rate of 0.5–1.0%, but both actually proved to be completely accurate.

Today, China has recorded 4,635 deaths from COVID-19, which is less than Croatia’s count which stands at 4,684. However, the important question here is how could I have been so sure of the outcome in China? Because, thanks to my knowledge of epidemiology, I knew that this infection could be stopped by the consistent deployment of anti-epidemic measures, and that the Chinese would do just that. What I didn’t know at the time was that many Western countries wouldn’t implement them.

5. I predicted back then, in another announcement at the very beginning of the pandemic, knowing the United States healthcare system, that COVID-19 would hit the United States very hard. Put quite simply, health system in the U.S. doesn’t have the comprehensive and universal nature which is required to control epidemics. In the United States, it is simply not possible to even expect a certain level of discipline from all citizens, whereas this is quite normal in Asia. Furthermore, there is no strong feeling of a “social contract” between the state and its citizens, which the great J. J. Rousseau instigated among the Europeans. In most countries of contemporary Europe, citizens expect the state to provide health treatment to them, should it be required. This is because they had been paying the state for healthcare costs until that point. As a result, there have now been more than 400,000 deaths in the United States, and the CDC estimates that there may have been at least 130,000 more which haven’t been attributed to COVID-19 yet.

6. And finally, let us look into how absurd the idea of allowing the virus to infect large numbers of people actually was. By the end of June 2020, the largest numbers of daily cases of new infections worldwide climbed to 150,000, and then by the end of October, that number had risen to 300,000. Nowadays, we are already reaching the numbers in excess of 700,000 newly infected people across the world. This happens every single day. So many infected people provide the virus with incomparably more opportunities to mutate and create new strains. Although the scientists discovered at the beginning of the pandemic that this virus mutates relatively slowly, the word “relatively” becomes important here. Because, when there are so many infected people, then the number of mutations also climbs very rapidly.

7. Back at the very beginning of the pandemic, I underscored several times that epidemiologists are most afraid of is the situation in which the virus mutates significantly during its spread around the world. Therefore, the virus spreading to other animals, such as to minks or otters, attracted attention and showed that it was very dangerous to humans, too. Namely, in this way, the number of opportunities that the virus has to mutate increases if it spreads to other species. There, it can spread without our constant monitoring and supervision of the mutations it creates.

8. I already explained in my earlier texts that mutations can help a virus to spread more quickly, or slow down its spread. They can also make it more dangerous or indeed less dangerous to our health. However, a new and mutated strain of the virus that spreads more quickly will soon dominate all other strains and eventually replace them, through “selection advantage”. Unlike the faster-spreading strains, those strains that are more dangerous to health should not dominate over others, as they actually prevent themselves from spreading by adversely affecting its carriers. This is why the rate of spread is a significantly more important property for positive selection of any virus than the actual death rate attributable to the virus. That’s why a particular misfortune can occur when, on the basis of the RNA molecule which already mutated to allow the virus to spread faster, another mutation ‘’hitchhikes’’ and then proves to be associated with a higher health risk. If that were to happen, then we would really have a much bigger problem on our hands than we have at the moment.

9. Although reports initially spoke of a relatively slow mutation process in the case of SARS-CoV-2, the vast number of people now infected with it each day are apparently beginning to reach a critical mass at which mutations are no longer of a negligible effect. We now learn almost every week or two of a new strain of the virus that can spread more quickly. We now know of the Kent one (United Kingdom, called B.1.1.7), then those from South Africa, Brazil, and now the latest one from Denmark-California, called L452R.

10. Therefore, any neglect of proper epidemiological surveillance and epidemiological control over COVID-19, which marked the response of many countries in the western world, where the virus has so far led to the highest number of deaths, was a rather unwelcome idea, because:

(i) obviously, this should not have been the choice, had the epidemiologists been listened to; as an example, two billion people in Asia lived throughout 2020 without much concern about the pandemic. China will even manage to record economic growth in 2020 of about 2%, if not more;

(ii) neglecting and underestimating an epidemic of a communicable disease not only increases the number of deaths, but also harms the economy and the healthcare system of a country;

(iii) it has led to an unnecessarily large number of people infected with a previously unknown virus, and it appears that a significant proportion of those people will have long-term symptoms (“long COVID”), some with lasting consequences;

(iv) we can now see quite clearly how this large number of infected people actually helps the virus to mutate further, so we now have faster-spreading strains which pose a new problem;

(v) faster-spreading strains will pressurize hospitals and require even more rigorous measures to prevent the rapid spread in the community, thereby further harming society as a whole;

(vi) a very inconvenient consequence is that mutated, rapidly spreading strains of the virus increase the threshold for collective immunity to a very high percentage; the new variants will probably require the protection of 80%, or even more of the population by vaccination; one question that we should all ask ourselves in our countries is whether or not is this truly realistic ;

(vii) finally, it is still uncertain how long immunity acquired following the contraction of this virus actually lasts, even in the case of a virus which would not mutate, and we now know that it does indeed mutate.

Basically — trust needs to be placed in those who deal with epidemics. Epidemiologists convey the scientific truth about an epidemic, based on data they gather daily from around the world.

Not over yet

We have another uncertain chapter ahead of us and we are engulfed in a race against time — will we either manage to get vaccinated in time, or new strains will find a way to avoid the evoked immune response through vaccination; such a scenario may require the development of new vaccines.

Another conclusion of all of this is that with rapidly spreading strains, it will no longer be enough to take care of one’s own country if new strains are spread freely in neighbouring countries. This is because it only takes a few people who happen to introduce those strains to lead to fast-spreading strain dominance in a more cautious country. So, it would not surprise me if in the next phase of the pandemic both the European Union and wider geographical areas elsewhere in the world begin to coordinate a uniform response to these new strains, to reduce the number of infected people in their part of the world and vaccinate as many people as they can, and as quickly as possible.

In conclusion, unfortunately, although we now have the first vaccines available to us, it seems increasingly clear that this pandemic is not over yet.

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Declaration: Professor Igor Rudan, FRSE, is the President of the International Society of Global Health; co-Editor-in-Chief of the “Journal of Global Health”; Joint Director of the Centre for Global Health and the WHO Collaborating Centre at the University of Edinburgh, UK.

TWITTER: @ProfIgorRudan

FACEBOOK: Professor Igor Rudan

LINKEDIN: https://www.linkedin.com/in/igor-rudan-279a5352/

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Translation Assistant: Lauren Simmonds

Image credit: Worldometers.info

Director of the Centre for Global Health and the WHO Collaborating Centre at the University of Edinburgh, UK; Editor-in-Chief, Journal of Global Health