Association between democratic governance and excess mortality during the COVID-19 pandemic: an observational study
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Abstract
Excess mortality has been used to assess the overall health impact of COVID-19 across countries. Democracies aim to build trust in government and enable checks and balances on decision making, which may be useful in a pandemic. But during the pandemic, they have been criticised as being hesitant to enforce restrictive public health measures.
Methods
Through linking open-access datasets we constructed univariable and multivariable linear regression models investigating the association between country V-Dem Liberal Democracy Indices (LDI), representing strength of democratic governance and excess mortality rates, from January 2020 to September 2021. We adjusted for several important confounders and conducted a range of sensitivity analyses to assess the robustness of our findings.
Results
Across 78 countries, 4.19 million deaths million excess deaths were recorded. On multivariable regression, a one-point increase in V-Dem LDI was associated with a decrease in excess mortality of 2.18 per 100 000 (p=0.004), after accounting for age, gender, wealth and universal health coverage. This association was only partially attenuated by COVID-19 vaccination rates and remained robust in all sensitivity analyses.
Conclusions
Democratic governance may have played an important role in mitigating the overall health impact of COVID-19 across countries. This study strengthens the case to broaden the scope of traditional pandemic risk assessment and discussions on preparedness.
Article activity feed
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SciScore for 10.1101/2021.08.25.21262614: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable For the proportion of the population who were female, two outliers were identified (Oman and Qatar, with 34.0% and 24.7% female, respectively), but retained for analysis. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Given limitations in testing, surveillance systems and death reporting, excess mortality estimates …
SciScore for 10.1101/2021.08.25.21262614: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable For the proportion of the population who were female, two outliers were identified (Oman and Qatar, with 34.0% and 24.7% female, respectively), but retained for analysis. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Given limitations in testing, surveillance systems and death reporting, excess mortality estimates are less reliable than for HICs. Nevertheless, it may also be the case that LMICs face additional challenges which are more important predictors of excess deaths than democratic governance, such as limited access to affordable healthcare [32], vulnerability due to high rates of undiagnosed and poorly controlled chronic conditions [33], and vast numbers pushed into poverty due to the pandemic [34]. With large informal sectors and many relying on daily wages, COVID-19 restrictions were also less extensive in many LMICs compared to HICs. Even severe restrictions appeared to have less of a dramatic impact on population mobility compared to HICs [35]. This means the impact of restrictions on individual behaviours and healthcare attendance may not have been as severely affected, making democratic governance less relevant in this context. Other factors explaining excess mortality: Older people and those with co-morbidities are at a greater risk of severe disease, ICU admission and death from COVID-19 [2,3]. We found that although the proportion of the population aged ≥65 was not significantly associated with increased excess mortality, the proportion who were female was, in both the overall and high-income country models. Given systematic differences between men and women in life expectancy, it is likely that the proportion of the population who were female acted as a proxy for very ol...
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
Results from scite Reference Check: We found no unreliable references.
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