Variability in excess deaths across countries with different vulnerability during 2020-2023

"Abstract

Excess deaths provide total impact estimates of major crises, such as the COVID-19 pandemic. We evaluated excess death trajectories across countries with accurate death registration and population age structure data and assessed relationships with vulnerability indicators. Using the Human Mortality Database on 34 countries, excess deaths were calculated for 2020–2023 (to week 29, 2023) using 2017–2019 as reference, with adjustment for 5 age strata. Countries were divided into less and more vulnerable; the latter had per capita nominal GDP < $30,000, Gini > 0.35 for income inequality and/or at least ≥2.5% of their population living in poverty. Excess deaths (as proportion of expected deaths, p%) were inversely correlated with per capita GDP (r = −0.60), correlated with proportion living in poverty (r = 0.66), and modestly correlated with income inequality (r = 0.45)...

Results

Cumulative Excess Deaths and Vulnerability Indicators: Table 1 shows the estimated cumulative excess deaths (p%, absolute number, and per million) during the entire pandemic period and the 3 vulnerability indicators for each of the 34 countries...

Across the 34 countries there were 2,097,101 excess deaths, 58% were accounted by the United States of America alone (1,220,295). There were only 176,439 excess deaths in the 17 countries of the less vulnerable group (500 per million in the 2021 total population of 352,667,986, people) versus 1,920,662 in the 17 countries of the more vulnerable group (3,046 per million in the total population of 630,541,384 people).

The United States of America would have had 1.60 million fewer deaths if it had the performance of Sweden, 1.07 million fewer deaths if it had the performance of Finland, and 0.91 million fewer deaths if it had the performance of France.

Discussion

... COVID-19 was a crisis of inequalities and many measures taken may even have fostered worsening inequalities.

The United States of America is a striking case, with extremely high cumulative excess death rates despite high per capita GDP. USA income inequality is high, many people live in poverty, and many lack health insurance coverage... [M]any excess deaths apparently are due to sharply increasing deaths due to overdose and deaths due to suboptimal healthcare access during 2020–2023. Such noninfectious causes may largely explain the exceptionally high excess death p% estimate among USA nonelderly people."