What is excess death and what is Covid-19's true toll on the world?
Singapore saw 2,490 excess deaths due to Covid-19 between January 2020 and June 2022. The Straits Times explains what all this means and how the figure compares with other countries.
Q: What are excess deaths?
A: Excess deaths refer to the difference between actual deaths from all causes since the pandemic began and expected deaths if there had not been Covid-19.
Measuring excess deaths, including those of people who died due to delayed or inadequate healthcare access, helps people understand Covid-19's impact.
Q: How does Singapore classify deaths due to Covid-19?
A: There are a few broad categories, said Associate Professor Alex Cook, the vice-dean of research at the National University of Singapore's Saw Swee Hock School of Public Health.
First, people who have died because of Covid-19 will be in the official death toll.
Second, for some people, a Sars-CoV-2 infection contributed to their death, but it was not the main cause. Their death could have been due to a heart attack or some other underlying medical condition, and Covid-19 contributed to their poorer health.
Third, people could have died of Covid-19 but this was misdiagnosed as something else. This number is probably more important in other countries.
Finally, there is also a group who may have died due to other reasons indirectly influenced by Covid-19. An example is the inability to access timely care for other medical conditions because of a lack of hospital resources or beds as they have been used up for Covid-19 patients.
Q: What is Singapore's death toll to date?
A: There were 2,490 excess deaths in Singapore's population between January 2020 and June 2022, the Ministry of Health (MOH) has reported.
In comparison, the official death toll from Covid-19 is 1,403 as at the end of June.
MOH said the World Health Organisation (WHO) estimates the excess mortality for Singapore to be 26 per 100,000 for 2021, among the lowest of the countries that chose to live with Covid-19 in 2021.
Q: How did vaccinations influence Singapore's figure?
A: It is clear that the unvaccinated were disproportionately affected by Covid-19.
Among the excess deaths in the first half of 2022, 28 per cent were people who had not been fully vaccinated, even though only about 5 per cent of the eligible population were not fully vaccinated by mid-March.
Q: How does Singapore's excess death figure compare with other countries?
A: To compare countries, one cannot just look at the total number of deaths, because bigger countries will naturally have more deaths than smaller countries, even if their Covid-19 response was better.
Rather, there needs to be some standardisation, such as by looking at the number of deaths per million residents.
For example, the estimated excess deaths per million is in the range of 600 to 700 per million in Singapore, Malaysia, Japan and Australia, but four to five times higher in the United States or Britain, Prof Cook said.
"Interestingly, although China's confirmed Covid-19 deaths are minuscule, the excess deaths are not that much lower than in Singapore: 470 per million in China versus 640 per million," he added.
This could be the result of actual Covid-19 deaths not being reported to the central government, or side effects of China's zero-Covid-19 strategy, leading to deaths due the country's strict control policy rather than the virus.
One example is the unfortunate bus accident that killed 27 people en route to a Covid-19 quarantine facility on Sunday in rural Guizhou province, Prof Cook said.
Other causes of big discrepancies between official Covid-19 deaths and excess mortality rates would be if treatment of chronic diseases are postponed because hospitals are working at full capacity, and higher suicide rates during the dark days of lockdown.
"That's why it's not necessarily the case that countries with strict lockdown policies will incur fewer overall deaths, and why the public health response should not blindly focus on reducing the numbers of confirmed deaths," Prof Cook noted.