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(CNN) --
The Covid-19 pandemic may have been three times deadlier than the reported death toll suggests.
Globally, official reports through the end of 2021 show that 6 million people have died directly from covid-19.
But researchers estimate in a new study that from the beginning of 2020 to the end of 2021, there have been at least 18 million more deaths than researchers would normally expect over the course of two years.
Some of this excess mortality may have been missed in official counts due to a lack of diagnostic or reporting resources.
But some can be attributed to other indirect effects of the pandemic, such as lack of access to health care, behavioral changes during lockdowns, or the economic crisis.
There were not enough data to distinguish the cause of death.
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Excess mortality is "a much more accurate measure of the true impact of the pandemic" precisely because of the known problems of underreporting direct deaths from Covid-19 and due to the deadly indirect effects of the pandemic, said Haidong Wang, a demographer. specialist at the Institute for Health Metrics and Evaluation at the University of Washington.
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The researchers, led by Wang, looked at all-cause mortality in 187 countries, using weekly or monthly reported data when available and creating models to estimate for others.
Their study was published Thursday in the journal The Lancet.
They found that seven countries accounted for more than half of all excess deaths in the last two years: India, the United States, Russia, Mexico, Brazil, Indonesia and Pakistan.
There were more than 4 million excess deaths in India alone and more than 1.1 million in the United States.
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For every 1,000 people in the world, the pandemic caused more than one excess death over the course of two years, according to the study.
The World Health Organization has also argued for the importance of understanding broader COVID-related mortality.
In February 2021, an advisory group was formed in partnership with the United Nations Department of Economic and Social Affairs to explore the issue.
"Gaps in high-quality, timely and disaggregated data are a major challenge for global health," WHO Director-General Tedros Adhanom Ghebreyesus said at the group's opening meeting.
"Covid-19 has created an unprecedented demand for this data. While we are all familiar with the number of daily deaths, the total mortality figures are likely to be much higher."
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An information page for the advisory group promotes the importance of understanding this data as early as possible to build an equitable response.
"Deaths directly attributable to COVID-19 provide only a narrow perspective on the wide range of damage caused by the pandemic. The collateral damage from COVID-19 is much broader," says a statement on the group's website.
"It's important to quantify this now, as it can inform the choices governments need to make regarding prioritization between routine and emergency health systems."
Understanding excess mortality is also critically important for future global population estimates and pandemic preparedness.
But a recent WHO assessment of the capacity of health information systems found that in parts of Africa, only 10% of all deaths were recorded.
According to the new study, excess mortality rates in the last two years of the covid-19 pandemic have varied widely by country and region.
Bolivia, Bulgaria, and Eswatini had the highest estimated excess mortality rate, each with more than six excess deaths per 1,000 people.
Excess mortality rates were also particularly high in their respective regions: Andean Latin America, Central and Eastern Europe, and Southern Sub-Saharan Africa.
But five countries reported fewer deaths in 2020 and 2021 than previous trends would have predicted: Iceland, Australia, Singapore, New Zealand and Taiwan.
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The cause of death needs to be investigated further, but the hypothesis is that strict lockdown policies in these countries led to fewer deaths from external factors such as traffic accidents, Wang said. Wearing masks and social distancing have also led to a reduction in influenza mortality in many countries.
"That's the impact of mediation policies or intervention strategies on all-cause mortality," he said.
Excess mortality due to the Covid-19 pandemic varied widely within the United States, according to the study.
Per capita, it was estimated to be nearly twice as high in Mississippi as it was in the nation as a whole, for example, but only half as high in Washington state.
"Some excess deaths in Texas are the result of the blackout there last year. And there are always deaths due to natural disasters," said Bob Anderson, chief of mortality statistics for the Centers for Disease Control and Prevention in Texas. USA, who was not involved in the new study.
“To some extent, the quality of reporting will depend on the resources available to do things like post-mortem testing. Jurisdictions with medical examiner offices that have resources to investigate deaths will tend to do better than their local elected coroner.”
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