Twenty months ago, in July 2022, I wrote a long essay sketching what I called the “pretty brutal” endemic future for Covid: probably about 100,000 deaths annually, at least for the next few years. The number was just a ballpark estimate, drawn from modeling by the epidemiologist Trevor Bedford. But as it is turning out, it looks to have been almost exactly right. The official count is that about 170,000 Americans died of Covid over those 20 months, at a pace that suggests at the end of year two, the total may have been just past 200,000.
Two hundred thousand deaths still counts as “pretty brutal,” and one of the many things the pandemic has taught us again and again is our capacity for normalization. But the burden of Covid is also obviously subsiding, and the shadow of the first-year emergency retreating even further. And as the fourth anniversary of the pandemic brings a new flurry of retrospectives, I find myself marveling not just about the many narratives we’re still getting wrong, but also about how many seemingly contradictory stories can be justified by the facts.
You can see this phenomenon most clearly when examining what was at the start of the pandemic its most immediate and perhaps its most heated question: How many people was it killing, and where? We often used that data to advance arguments about mitigation policy, but it also represented a more fundamental kind of information, around which anxiety and perspective might be calibrated.
In 2020, we often assessed that toll pretty crudely, using raw death counts, which invariably made the United States look like the world’s biggest pandemic failure. This produced one of the dominant morality tales of the pandemic’s first years: that the countries that should have expected to do best were in fact faring worst and that the United States under Donald Trump was the world’s most conspicuous example of pandemic mismanagement.
Occasionally, we would adjust those figures for population size, which yielded per capita measures that showed the country doing only somewhat worse than most rich nations considered American peers. By this measure, Britain became the poster child for rich-world failure — “Plague Island” it was often called in the British press.
But these statistics, though valuable records of the sheer scale of suffering and tragedy within nations, were also biased in two big ways when it came to international comparisons. First, they depended on how much Covid testing was being done: Countries with better disease surveillance tended to register more official Covid deaths while less aggressive places registered far fewer deaths from it. Second, the death counts were driven in part by the age structure of a country’s population, because Covid was so much deadlier for the old and especially very old than for the young and middle-aged. (In an immunologically naïve population facing the original pandemic strains, the infection fatality rate for nonagenarians was perhaps a thousand times higher than for their grandchildren.)
And so as the pandemic wore on, we grew a bit more sophisticated, at least those of us with an undiminished or even morbid interest in the detailed course of the pandemic. We started to talk more about excess mortality models, which offer comparisons between the number of people dying in a given place over a given time with the number that would have been expected, in that place and time, given previous demographic and mortality trends. This approach adjusts for both of the biases and also captures deaths from pandemic disruptions rather than Covid infection, but it also requires a fair amount of modeling and is therefore sensitive to design choices and demographic assumptions.
The Economist maintains what is perhaps the gold-standard database, and according to its per capita excess mortality tables, the harshest pandemic impacts were not in the United States or in Britain but in Eastern Europe, a region that had what turned out to be a catastrophic mix of aging populations, weak health-care systems and often incapable or indifferent central governments. Of all the large nations of the world, this analysis suggests, Russia fared the worst.
And though the public began to tune out, as vaccination spread across the wealthy world, this phase of mortality analysis gave rise to a number of different claims about the global pandemic. For instance, it allowed you to see much more clearly the brutality of India’s 2021, when between the beginning of April and the middle of June perhaps two million Indians died of Covid, 10 times the official number. It gave a different picture of the U.S. experience, marking the country as only somewhat below average globally. And it raised big questions about Sweden, which had been initially derided as a reckless experiment in do-nothing public health and appeared, in this context, if not vindicated then at least unfairly maligned. (This revisionism was a bit overhyped but it’s still remarkable, given the hand-wringing, how average the country’s pandemic was.)
But there is also another way of analyzing death counts that has gotten considerably less public attention. Conventional excess mortality uses projections about expected deaths based on the age structure of a country and its recent mortality trends. But you can also adjust for age structure more fully, asking how many additional deaths among, say, 70-year-olds there were in a given country, then comparing it with another place as though the two countries had exactly the same number of septuagenarians. Then, you can do the same for every other age group.
The Economist now calculates this data as well, and the story it tells is entirely different. When you control for demographic differences, the pandemic was bleakest not in the “rich failed states” of the Anglosphere or indifferent middle-income ones in Eastern Europe but in the poorest countries of the world, particularly across sub-Saharan Africa, just as one might have predicted in early 2020.
The worst hit was Uganda, which registered a demography-adjusted mortality rate seven times higher than the United States’. The next hardest-hit country in the Economist table is Zambia, then Chad, Zimbabwe and Mozambique. Two more African countries follow — Ethiopia and Malawi — before the first non-African countries, Bahrain and Afghanistan.
Early in the pandemic, there was a lot of talk about the unusually light burden of Covid in the developing world, which was often attributed to some combination of the age structure of those societies (which are very young, overall) and what was taken to be the striking efficacy of low-cost public-health interventions. In retrospect, it seems to have been more age-driven, especially once a year or more of “vaccine apartheid” meant the poorest countries of the world suffered a much longer pandemic emergency than did the rich countries. As Philip Schellekens of the United Nations Development Program documented, throughout 2022 and 2023, vaccines greatly shifted the global burden of Covid toward low-income countries and away from rich ones, which had the luxury of behaving as though the pandemic risk had retreated a year or more before those places with much slower vaccine distribution.
In the United States, vaccination rates remained a source of frustration for years, but by global standards American uptake was a success, with more than 95 percent of seniors having gotten at least one shot by the end of 2021. That may help explain why, according to the Economist’s demography-adjusted excess mortality tables, the American pandemic experience now registers in the top third of pandemic outcomes. That is still bleaker and more brutal than the outcomes in nearly all of its wealthy-nation peers, who tended to do better with mitigation and better still with vaccination. But it’s nevertheless closer to the world’s “best” performers than its “worst” ones.
In the end, everyone got it, and probably the most important factor shaping national death totals was how many people were vaccinated before their first infection and how many weren’t. The United States could’ve done much better on that test, given that more Americans have died of Covid since the vaccines were made available to anyone who wanted them than had died to that point. But by some estimates, those vaccines also saved more than three million American lives.
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