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    Why COVID-19 Probably Killed More People Than We Realize
    Research & Ideas
    Why COVID-19 Probably Killed More People Than We Realize
    02 Nov 2021Research & Ideas

    Why COVID-19 Probably Killed More People Than We Realize

    by Michael Blanding
    02 Nov 2021| by Michael Blanding
    Millions of people around the world have died from COVID-19, according to government records, but research by Ethan Rouen, George Serafeim, and Botir Kobilov suggests that the actual number could be much higher.
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    As the number of casualties from COVID-19 ballooned at an alarming rate last year, some feared that government officials were failing to report several coronavirus-related losses and the actual death toll was much higher worldwide.

    While the official count shows more than 5 million people have died of the disease, a new study of underreported casualties in several countries indicates that COVID has actually killed hundreds of thousands more people than government records document.

    "We were shocked by the magnitude of what we were seeing."

    In 2020, 51 countries reported 3,140 more deaths on average than they typically see in a year, the research shows. COVID likely caused that lethal spike, but government officials didn’t link these unexplained deaths with the disease, according to a team of Harvard Business School researchers.

    In fact, the number of actual deaths in some countries, like Ecuador and Bolivia, was more than triple the number reported, representing tens of thousands of losses that were never attributed to the pandemic. And the United States saw the highest number of unexplained deaths in 2020: a total of 50,876, the research shows.

    “We were shocked by the magnitude of what we were seeing,” says Ethan Rouen, an assistant professor in the Accounting and Management Unit at Harvard Business School, who conducted the study with HBS Professor George Serafeim and HBS doctoral candidate Botir Kobilov. “This was something that was being covered heavily in the news media, but there was no real research focused on it.”

    Unexplained death figures vary widely

    The level of underreporting varied significantly from one country to the next, the research team outlined in a recent article in the Journal of Economics and Government called Predictable Country-Level Bias in the Reporting of COVID-19 Deaths.

    At the highest end, Ecuador and Bolivia had 2.5 times more unexplained deaths per month than they typically saw when the researchers compared 2020 figures to historic totals over the previous three to five years. This amounts to an excess of more than 300 deaths for every 100 they reported from COVID, the researchers say.

    Other countries with significantly high unexplained death totals: Peru, which had 160 percent excess deaths; and Kyrgyz Republic, Spain, Mexico, and Poland, each with between 50 and 100 percent excess deaths. On the low end, Japan and Bulgaria had few unexpected deaths.

    In percentage terms, the US ranked just below the middle of the pack, at 32 out of the 51 countries the researchers examined, with 9.5 percent excess deaths. “We’d expect it to be in the middle,” Rouen says, “since of all the countries, it has the most diffuse reporting system, with variation from a lot of different states.”

    However, the US had higher monthly COVID-19 death totals than other countries—with a high of 80,000 per month, compared to less than 40,000 for the next highest country, Brazil—turning even that low percentage of excess deaths into the high number of more than 50,000 people whose deaths were not officially counted among pandemic losses in 2020.

    Countries requiring masks shied away from reporting COVID deaths

    The HBS researchers gathered the reported monthly numbers of deaths during the pandemic in each of the 51 countries from a variety of sources, including reports in the New York Times and the European Commission’s database, Eurostat. They compared that data to figures from the same months for the past three to five years to calculate excess deaths. Subtracting the number of official COVID deaths for each country helped them gauge potential underreporting.

    “There’s been a lot of research on COVID in terms of health and mitigation efforts, but as accountants, we felt like we could bring a unique perspective,” Rouen says.

    To explain the wide variation in underreporting, the researchers speculated that countries with more stringent mitigation policies, such as those requiring masks and social distancing, would see higher rates of underreporting. “More stringent policies might put public pressure on politicians to underreport deaths, just to show that their policies are working,” says Kobilov.

    "If the numbers aren’t accurate, then we can’t accurately identify what mitigation efforts are best."

    In fact, countries with more stringent policies in place did, on average, have 59 percent higher unexplained excess deaths—that is, 159 deaths for every 100 reported for COVID.

    “When governments ask citizens to make sacrifices,” adds Rouen, “they’re inclined to overstate the positive effects of those sacrifices.”

    Along the same lines, countries with less stringent policies underreported at a lower rate, an average of 28 percent. “These are places that claim to value freedom—they say, people have their own agency,” Rouen says. “Therefore, it’s their responsibility if they get sick or not, so governments have less fear of being blamed.”

    Healthcare woes linked with higher underreporting

    The researchers also found that healthcare capacity impacted the degree of potential underreporting. Countries with a lower capacity to care for sick patients before the pandemic tended to underreport COVID deaths more; on average, these countries had 53 percent unexplained excess deaths, compared to an average of 23 percent for countries with higher pre-pandemic healthcare capacity. Again, the researchers speculated that underreporting was worse in these areas because policymakers feared that citizens would blame them, in this case, for not adequately preparing for the health crisis.

    While such fears may be understandable for governments caught unprepared to deal with the magnitude of a pandemic, they are ultimately counterproductive, the authors say. Especially in the early days of the pandemic, countries faced an incredible amount of uncertainty over how best to fight the disease. That said, government officials should have shared the true picture of the toll COVID was taking, rather than downplaying the number of lives lost, the researchers say.

    “We were in a huge guessing game over how best to stop the spread,” Rouen says. “If the numbers aren’t accurate, then we can’t accurately identify what mitigation efforts are best.”

    "In times of crisis, leaders need to be brave and not afraid of criticism."

    The research team didn’t study data in 2021, so it’s unclear whether government officials are continuing to underreport COVID deaths. But Rouen hopes leaders have learned by now that providing accurate death data could help prevent more casualties.

    “In times of crisis, leaders need to be brave and not afraid of criticism,” Rouen says. “The government is going to need to ask people to make sacrifices, and not all of them will pay off as expected. They have to have faith in their constituents, that they can forgive mistakes as long as they’re done in the genuine interest of the greater good.”

    About the Author

    Michael Blanding is a writer based in the Boston area.
    [Image: iStockphoto/domin_domin]

    What should governments do to prepare for the next pandemic?

    Share your thoughts in the comments below.

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    Botir Kobilov
    Botir Kobilov
    Doctoral Student in Accounting and Management
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    Ethan C. Rouen
    Ethan C. Rouen
    Assistant Professor of Business Administration
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    George Serafeim
    George Serafeim
    Charles M. Williams Professor of Business Administration
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