Getting a handle on the pandemic’s true toll

Published online 4 April 2022

An analysis reveals that COVID-19’s toll may have been greatly underestimated, including in the Middle East, where epidemiological monitoring efforts have generally fallen short.

Michael Eisenstein

Healthcare workers intubating a COVID-19 patient.
Healthcare workers intubating a COVID-19 patient.
Tempura/ E+/ Getty Images
The past two years have seen tremendous loss of life from the global COVID-19 pandemic. But new findings from researchers, led by the University of Washington’s Institute for Health Metrics Evaluation (IHME), reveal that the actual toll may have been far greater, including more than 1.4 million previously-uncounted deaths from the pandemic in the Middle East and North Africa (MENA) region.

By the end of 2021, the global public health community had tallied 5.94 million deaths worldwide that could be attributed to COVID-19. This number is inherently flawed for various reasons. For example, countries have different standards for assigning COVID-19 as the official cause of death, and the quality and extent of pandemic monitoring have varied wildly. Such reporting has been particularly unreliable in MENA countries, where the official count of 374,000 deaths is almost certainly a considerable underestimate.

To get a better sense of the pandemic’s true human cost, the IHME team set about calculating total excess mortality for every country in the world—in other words, systematically determining how many more people died annually in 2020 and 2021 than in prior pre-pandemic years. 

The IHME was able to leverage a battalion of international public health experts thanks to its role in coordinating the ongoing Global Burden of Disease study. Even so, this was no mean feat, according to lead author Haidong Wang. “We spent a considerable amount of time going through country statistics offices to make sure we have access to all publicly available data,” he says. “Most countries in the world either do not have a functioning vital registration system or simply were not reporting or releasing death data during the pandemic.”

To resolve this, the IHME team relied on countries for which robust data were available to develop a mathematical model that can accurately estimate excess deaths in countries and regions where these data are more limited. This model was informed by more than a dozen other variables, including measurements of regional SARS-CoV-2 prevalence and assessments of healthcare system quality and access. 

The results were staggering. The team estimated that as many as 18.2 million people worldwide may have died due to COVID-19, with 120 excess deaths per 100,000 people during the pandemic years. Importantly, the new estimates for COVID-19 mortality in MENA countries were nearly five-fold greater than prior counts. This differential also varied considerably at the national level, where the toll in countries like Afghanistan and Sudan was dramatically underestimated relative to places like Kuwait or Turkey. Overall, the disparity between excess mortality and reported COVID deaths in MENA countries was among the highest for any region assessed, with the exception of South Asia and sub-Saharan Africa. 

Wang says that these results highlight the inadequacy of officially reported COVID-19 death data in evaluating the pandemic’s true toll. But it is important to note that IHME’s findings are also just estimates of excess mortality from all causes. These measurements generally seem to map closely to COVID-19-specific mortality, but IHME’s future work will focus on teasing out specific causes of death from these numbers.


COVID-19 Excess Mortality Collaborators. Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21. The Lancet (2022).