The official global death toll from COVID-19 eclipsed six million on Monday — underscoring that the pandemic, which officially enters its third year at the end of this week, is far from over.
The milestone, recorded by Johns Hopkins University, is the latest tragic reminder of the unrelenting nature of the pandemic even as people are shedding masks, travel is resuming and businesses are reopening around the globe.
As death rates remain high in Poland, Hungary, Romania and other eastern European countries, the region has seen more than 1.5 million refugees arrive from war-torn Ukraine, a country with poor vaccination coverage and high rates of cases and deaths.
Meanwhile, despite its wealth and vaccine availability, the United States will hit one million reported deaths sometime this spring.
Both the U.S. and Canada are removing many COVID-19 restrictions as the Omicron coronavirus variant wave subsides. Canada, which will likely surpass 37,000 coronavirus deaths in two years on Monday, had 5,136 people in hospitals with COVID-19 at the end of February, less than half the total of the hospitalization peak of the Omicron wave, which occurred on Jan. 22.
Real total could be much higher
Globally, the six millionth death likely occurred some time ago. Poor record-keeping and testing in many parts of the world has led to an undercount in coronavirus deaths, in addition to excess deaths related to the pandemic but not from actual COVID-19 infections, like people who died from preventable causes but could not receive treatment because hospitals were full.
Edouard Mathieu, head of data for the Our World in Data portal, said that, when countries' excess mortality figures are studied, as many as nearly four times the reported death toll have likely died because of the pandemic.
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An analysis of excess deaths by a team at The Economist estimates that the number of COVID-19 deaths is between 14.1 million and 23.8 million.
"Confirmed deaths represent a fraction of the true number of deaths due to COVID, mostly because of limited testing, and challenges in the attribution of the cause of death," Mathieu told The Associated Press. "In some, mostly rich, countries that fraction is high and the official tally can be considered to be fairly accurate, but in others it is highly underestimated."
Mexico has reported 300,000 deaths, but with little testing, a government analysis of death certificates puts the real number closer to 500,000.
In India, where the world was shocked by images of open-air pyres of bodies burned as crematoria were overwhelmed, the scars are fading as the number of new cases and deaths has slowed. India has recorded more than 500,000 deaths, but experts believe its true toll is in the millions, primarily from the Delta variant.
With about 250,000 reported deaths, the African continent's smaller death toll is thought to stem from underreporting, as well as a generally younger and less-mobile population.
"Africa is a big question mark for me, because it has been relatively spared from the worst so far, but it could just be a time bomb," Pang said, noting its low vaccination rates.
The Africa Centers for Disease Control and Prevention is still pressing for more vaccines, though it has been a challenge. Some shipments arrive with little warning for countries' health systems and others near the expiration date — forcing doses to be destroyed.
In a good sign, at the end of last month Africa surpassed Europe in the number of doses administered daily, but only about 12.5 per cent of its population has received two shots.
Global vaccine disparity continues, with only 6.95 per cent of people in low-income countries fully vaccinated, compared to more than 73 per cent in high-income nations, according to Our World in Data.
Pacific islands see Omicron wave
Death rates worldwide are still highest among people unvaccinated against the virus, said Tikki Pang, a visiting professor at the National University of Singapore's medical school and co-chair of the Asia Pacific Immunization Coalition.
"This is a disease of the unvaccinated — look what is happening in Hong Kong right now, the health system is being overwhelmed," said Pang, the former director of research policy and co-operation with the World Health Organization. "The large majority of the deaths and the severe cases are in the unvaccinated, vulnerable segment of the population."
The world has seen more than 445 million confirmed COVID-19 cases, and new weekly cases have been declining recently in all regions except for the Western Pacific, which includes China, Japan and South Korea, among others. Hong Kong, which is seeing deaths soar, is testing its entire population of 7.5 million three times this month as it clings to mainland China's "zero-COVID" strategy.
Remote Pacific islands, whose isolation had protected them for more than two years, are just now grappling with their first outbreaks and deaths.
"Given what we know about COVID ... it's likely to hit them for the next year or so at least," said Katie Greenwood, head of the Red Cross Pacific delegation.
Tonga reported its first outbreak after the virus arrived with international aid vessels following the Jan. 15 eruption of a massive volcano. The Solomon Islands also saw the first outbreak in January and now has thousands of cases and more than 100 deaths.
It took the world seven months to record its first million deaths from the virus after the pandemic began in early 2020. Four months later another million people had died, and one million have died every three months since, until the death toll hit five million at the end of October.
