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Still, in a rare attempt to investigate Africa’s death toll with clinical data, the BU team’s work has had a significant impact, according to outside experts. Watson, who has worked on several studies of covid-19 in low-income settings, says prior to her first paper, that there is a “fairly even balance” within academia between those who “believe that something fundamentally different has happened in Africa, there hasn’t been too many deaths” and those highlighting the lack of data.

He says his Zambian research has played an important role in “shifting the narrative to second opinion.” Kirenga of Uganda says the study probably resonates with the undercount observations out there. But Roma Chilengi, special covid-19 adviser to Zambian president Hakainde Hichilema, who is also head of the organization that compiles Zambia’s official surveillance data, says he still believes the pandemic is not as deadly in his country as expected: initial fears are “sweep up like wildfire,” he told me, it hasn’t come yet. Still, Chilengi generally agrees with the BU team’s conclusions, “As an exploratory observation, there is no doubt that we have many people who have died from covid but have not been diagnosed,” he says.

Survivors and algorithms agree

Beyond UTH cadavers, a growing number of non-clinical studies have added weight to the claim that most deaths in Africa are being overlooked. Paper Published in The Lancet Following around 6,800 confirmed or suspected covid-19 patients referred to critical care facilities in 10 African countries last May, it found less than half were admitted and 48% of those who died within a month died. According to the paper’s authors, this represents an extreme in-hospital death rate of 11 to 23 deaths per 100 patients compared to the global average – a figure linked to inadequate staffing and the frequent absence of life-saving interventions such as oxygenation and dialysis.

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Although Zambia was not included in the study, locals told me the treatment gaps were acute as well. Sky Banda, 58, who lives in Kaunda Square, named after Zambia’s first president, says many community members who fell ill during the peak of the pandemic saw admission to hospital as “a direct ticket to the morgue.” Many opted for home-based herbal treatments instead.

Filmmaker Onechi Lwenje, 36, who spent a week in the covid-19 ward at UTH during Zambia’s second wave in early 2021, says staff are so overwhelmed that some patients will die and go undiscovered for hours. “Most people who went into that ward never came out,” he says.

Although death records from Africa remain patchy, attempts to approximate excess mortality through statistical workarounds also significantly support the undercount theory. A machine learning model developed by The Economist, based on more than 100 indicators associated with excess deaths in countries for which this data is available, shows that Africa has seen between 1.1 million and 3 million more deaths since the start of the pandemic. A model from the University of Washington Institute for Health Metrics and Evaluation was included in an article Published by The Lancet In March, a central estimate of 81,000 for Zambia puts the figure at 2.1 million for Sub-Saharan Africa alone as of December 2021 – 20 times the official toll of 3,967.