There has been a morbid fascination with the number of deaths associated with covid-19 and the extent to which countries are mishandling the crisis. But we are also facing a data crisis which distorts proper analysis of either. 

Scientists are tinkering with models on the expected number of deaths based on incomplete data as not all countries apply the same covid-19 testing rules and not all deaths are accurately recorded. At the same time countries are still deliberating about who they should test, be it asymptomatic cases, only those with symptoms, those presenting to healthcare systems or healthcare workers. 

Officials in the US have cast doubt on the numbers being reported by China, and not all countries have the resources to follow the WHO’s “test, test, test” advice. This is particularly true for economies with under-developed healthcare systems such as India, Africa and Latin America. 

So with that cautionary note, we have tried to work with the data at hand—incomplete as it is—to map the number of confirmed cases of covid-19 against deaths per 100,000 population over time. While the absolute numbers of deaths are important to note because each loss of life is painful to loved ones, we should also look at death rates across populations to better understand the virus and to keep abreast of potentially effective containment measures. In developing countries cause of death information is often hard to obtain, mostly because systems for recording these details are inadequate or non-existent.

The bubbles represent absolute deaths in an individual country. You can eliminate regions from the timeline to see, for example, how Europe is faring against North America, or zoom in on the trajectory for an individual country. As of April 20th, death rates appear to be highest in Europe with Belgium reaching around 50 deaths per 100,000 population.

While people are still focused on covid-19 deaths, be prepared for a new type of death associated with covid-19 over time. These are deaths and morbidity that will arise as healthcare systems direct more and more resources to covid-19 and less and less to common diseases such as stroke and cancer. For developing countries, the common diseases affected will be tuberculosis, malaria and AIDS. 

These “excess” deaths may also arise as people become more fearful of overloading healthcare systems or worried about catching the virus if they attend healthcare facilities including hospitals. There are also the deaths of older people living in residential care facilities or dying at home that are not being properly accounted for. If you have cancer and your treatment is delayed, that is a life and death situation for your overall prognosis. The same applies if treatment is delayed following the first signs of stroke. Patients living with chronic health conditions will see a significant change in the level of service and care received during this crisis, and the damage caused may take years to repair. 

So while scientists study the data around covid-19, expect new data to emerge on how other diseases have been affected by this pandemic. 

David Miliband is taking refuge in North-west Connecticut during the covid-19 lockdown, but his thoughts are very much global, and inevitably political. 

The former UK foreign secretary heads up the International Rescue Committee (IRC), a humanitarian non-governmental organisation (NGO) that works in war-ravaged countries and helps resettle refugees. Refugees, who make up nearly 30% of the world’s 71m “forcibly” displaced people, are especially vulnerable to disease: they have limited access to healthcare, live in poor sanitary conditions and often suffer from pre-existing illnesses. So what needs to be done? 

“It's very, very basic,” Mr Miliband says. Are they counted? Are they covered when it comes to testing or healthcare access? Are they assisted by income support schemes or other mechanisms? Do they have rights? 

“If the answer to those questions is ‘No’, we know that the consequence is not just a lot of poverty and security violence,” he explains. It also elicits a survivalist response born of desperation. “[People] go underground and they try to make ends meet in any way that they can. And that obviously carries its own dangers, especially in the context of a public health pandemic.”

IRC is working at Cox’s Bazar in Bangladesh. Host to over 1m displaced Rohingya Muslims from neighbouring Myanmar, it is one of the world’s largest and most crowded refugee camps. Social distancing to contain the spread of covid-19 in such camps is, of course, hard. 

“I think it would be beyond unfortunate if this [pandemic] was used to further buttress the trend that we've seen in the past 15 years which is what people call democratic recession. And that is the retreat of countries from democratic models.” 

“It's easier for the rich than the poor,” Mr Miliband says. “[But] we shouldn't somehow take refuge in the idea that social distancing can't be done so we just shrug our shoulders.” 

Where social distancing is more difficult, Mr Miliband explains, hygiene, effective isolation measures and testing become more important: fever testing, at a minimum, and eventually covid-19 testing.

“I also think some social distancing is achieved through masks,” he explains. “It's important that we don't say that because masks are not the whole answer, that they're not any part of the answer. So, in other words, social distancing is more difficult but not impossible.” 

In many of the countries where IRC operates, however, Mr Miliband reports a “shocking” lack of covid-19 testing ability. He cites a recent video chat with the IRC team in Somalia who reported that “there have been 700 tests and 436 cases, so a very low number of tests but a very high hit rate”.  

Other resources, such as ventilators and intensive care beds, are also scarce. In South Sudan there are only four ventilators for its 11.7m population while Burkina Faso has only 11 for its 19.1m citizens. But the answer is not “trying to send 10,000 ventilators to South Sudan,” Mr Miliband explains.

“Not least because it'll be too late by the time they get there, but because it's a very skilled job to run a ventilator; it takes a whole set of health infrastructure to monitor and implement. So the truth is the prospects for someone who needs a ventilator in South Sudan are utterly grim.” 

Political response

Although he works for an international NGO, Mr Miliband remains a political animal. A request to grade the international political response to covid-19 hits a nerve. 

“If you are asking me to grade different actions, I have to be grading inactions.The G7 [group of the world's seven largest economies] couldn't agree on a statement because of a ridiculous argument about insistence on calling it a ‘Wuhan virus’. The G20 [which links governments and central banks from 19 countries and the EU] has had one virtual meeting [as of May 1st]. The UN Security Council has not yet been able to agree the resolution to back up the secretary-general’s call in respect of ceasefires. So, it's D-minus territory for the international political response.”  

Mr Miliband, whose ministerial tenure included the 2008 financial crisis, is slightly more positive about the economic response to covid-19. He believes there has been “some lesson-learning, but there obviously hasn't been something formally co-ordinated”. Regarding the scientific community, he comments that “there's been a lot of transparency from the scientists, including Chinese scientists, about presenting their data”.  

The World Health Organisation (WHO) has faced criticism for its handling of the crisis, but Mr Miliband is forgiving. “Every big organisation [...] will make mistakes, but the real lesson about the WHO is that it's got too little power and too little funding and too little independence—it needs to be able to rectify all three,” he says. 

“The lesson is that we need a stronger, better funded, more independent WHO that can speak truth to power.” He considers its year-by-year dependence on donor funding problematic, commenting that endowment with longer-term funding would allow for greater independence. 

Geopolitical rivals

The way in which countries have responded to covid-19 will be fuel for global rivalries, Mr Miliband predicts. “I think there’s undoubtedly going to be very significant geopolitical competition in trying to exploit and benefit from comparison coming out of this crisis.” 

China’s reputation could come under particular scrutiny, especially given the harsh criticism its handling of the outbreak has received from the US. “I think different parts of the world will trust [China] differently. And of course one question is, ‘How will the world trust China in absolute terms?’, and the second question is, ‘How will you trust China relative to other countries?’”  

Mr Miliband believes there was denialism in China at the outbreak of covid-19 and partly attributes this to its one party system. But there is continued denialism in the US, he adds. “Sadly, both democratic and autocratic countries have suffered from denialism.”

The US has reported a striking 79,000-plus deaths from covid-19 (as of May 11th), the highest death toll worldwide. Mr Miliband fears  the “continued chaos and [certain] aspects of the American response are going to be used by autocrats around the world to say the democratic systems can't work and can't cope”. 

By contrast, South Korea has reported only 256 covid-19 deaths out of a population of 51.3m. Germany, with its 83.7m population, has suffered 7,569 deaths (as of May 11th). Mr Miliband accredits this success to “the power of open societies” to build social trust and organise an effective national response.

“I think it would be beyond unfortunate if this [pandemic] was used to further buttress the trend that we've seen in the past 15 years which is what people call democratic recession. And that is the retreat of countries from democratic models.”

The UK response

So what about the covid-19 response in the UK, Mr Miliband’s home country and political proving ground? The country has the highest number of deaths in Europe at nearly 32,000 (as of May 11th).  

“It's really grieving to see the death toll in the UK,” he says. “I think I'm right in saying that around one-eighth of the global death toll is British, even though [less than 1%] of the global population is British. That’s a shocking mismatch.”

There are very serious questions to be answered, he says, about when the lockdown happened, how testing was organised, what happened with contact tracing and the alarm bell that should have been sounded regarding care homes. “Those are all questions which are going to need a very searching set of enquiries.” 

Is he confident that Keir Starmer, the new leader of the UK’s Labour party, will hold the government to account? “I think he'll be very good at that. He is a very accomplished lawyer. Britain has a proper opposition for the first time in five years.”

Does he miss politics? Yes, he says, with no hesitation. “In politics and government, you have more power than if you're an NGO—but you also have more obstacles.”

Solidarity in a crisis

Circling back to refugees, does he think attitudes towards them have improved or worsened over time?

“I think it is very mixed,” he says. “Two-thirds of the American public didn't want Jews to be allowed in from Europe in the late 1930s. So that's more or less some of the proportions on the before. But [...] crises [can] bring social solidarity”. 

While there are many stark obstacles ahead, Mr Miliband welcomes the fact that some countries are recognising how critical immigrants are to their healthcare systems and broader social structures.

“I think human nature is both fearful and intrigued by people who are different. And you've got to hope that those of us who think life is more interesting because we're not the same don't lose heart.

Vaccination is our best hope for stopping the coronavirus pandemic in its tracks. But producing safe, effective and globally accessible vaccines within the next 12 to 18 months is not only a scientific challenge: new levels of collaboration and investment across industry and government will be essential.

This pandemic is the biggest public health threat that humankind has faced in a century. It is wreaking havoc on societies and economies and it is an acid test for public-private partnerships. We need to move fast to unleash the funding required to develop vaccines.

Delivering covid-19 vaccines for the world—at record speed—will take a collective effort. We must combine the resources and expertise of academia and the private sector with the ability only governments have to mobilise the political will and amass the large sums of money that will be required.

No therapies to prevent or treat covid-19 are available, but research is advancing at a breakneck pace. The private and public sectors must now collaborate to ensure the best and fairest use of new products—wherever they come from—when they arrive.

In the case of vaccines, this means pursuing multiple approaches across both established and new technologies rather than trying to pick one or two “winners” prematurely since many candidate vaccines will inevitably fall by the wayside.

Given the threat posed by covid-19 we must regard vaccines as a global good: a shared resource that is deployed for the good of all irrespective of a country’s ability to pay. Given the global threat posed by covid-19 and the universal, simultaneous need for a vaccine, the world must devise a globally fair allocation system to ensure that healthcare workers and the most vulnerable segments of the world’s population get priority access.

Today, exceptional science is being done around the world. Researchers have been working around the clock to produce vaccine candidates ever since the genome of the new virus was sequenced in January 2020. The good news is this has yielded a flood of more than 90 promising candidates. Now this effort must be buttressed by large-scale public-sector assistance to optimise clinical trial procedures and scale-up manufacturing capacity—something that involves risky upfront investments before any product is approved.

The Oslo-based Coalition for Epidemic Preparedness Innovations (CEPI) provides a platform to deliver just this kind of private-public co-operation. The coalition was  initially set up in 2017 after West Africa’s deadly Ebola epidemic to accelerate work on vaccines against emerging infectious diseases. 

CEPI—a partnership of governments, industry and philanthropies—has a clear roadmap to accelerate covid-19 vaccine development at an estimated cost of US$2bn over the next 12-18 months. Financial support from the UK, Germany, Norway, Denmark and Finland has brought in around US$660m. Closing the remaining financing gap is imperative if we are to stay on track.

Vaccine development is complex and expensive. Rates of attrition are high. We need multiple candidates to ensure that we can produce safe and effective vaccines. My organisation estimates that a large part of the US$2bn will be needed by the middle of this year to develop eight vaccine candidates through initial phase 1 testing, prepare for phase 2/3 trials and to invest in manufacturing processes for up to six candidates.

Assuming one or more of these candidates succeeds, there will then be a huge global demand requiring unparalleled efforts to harness manufacturing capacity and distribution networks.

Last month, G20 leaders pledged to support the global effort against covid-19, including contributing to this vital vaccine work. The message could not be clearer: now is the time for governments and industry to join forces to fight back against this deadly disease.