***Editor’s Note: Please see the introduction to the Pandemic in Paradise series here.***
The islands of the Caribbean are similar in their turquoise beaches that captivate tourists, but their handling of the pandemic has been full of contrasts. When the Cayman Islands had 81% of its population fully vaccinated against COVID-19 at the end of October 2021, Haiti, with 0.3%, was one of the three countries in the world with the least number of people vaccinated. And in Guadeloupe, despite having doses to spare, most of the population does not want to be immunized.
When Grenada had a rate of 1,752 deaths per million inhabitants, in Haiti it was 58. This does not mean that Haitians are faring better, it’s that they are far from counting all their deaths.
A cross-border investigation done by the Center for Investigative Journalism (CPI, in Spanish), and journalists from partner media outlets in Haiti, Guadeloupe and the Dominican Republic shows the scope of deaths from COVID-19 in the Caribbean. The work, which included the analysis of documents and data available in different jurisdictions, as well as interviews with health professionals who have been working on the ground, provides a picture of great contrasts.
The figures collected by ourworld data.org, which offer indicators for the region, are a reflection of the fact that the response from governments and the Caribbean population to vaccination, and the measures to avoid contagion, have depended on the policy of each jurisdiction, its economy, and culture. In the Guadeloupe archipelago (with just over 375,000 inhabitants), these variables have led to a 227% increase in the mortality rate in the aftermath of the pandemic only in August, even with full access to the vaccine.
A massive vaccination campaign against COVID-19 began on January 7, 2021, in Martinique and the next day in Guadeloupe. However, although these French islands, located in the Lesser Antilles, have vaccines available, the demand has not been as expected. Among the causes is the strong distrust of the population toward colonial health authorities, linked to an environmental and health scandal due to chlordecone contamination in the French Antilles in the 70s and 90s.
Contamination by this pesticide, banned in France, was authorized for use in banana plantations in the West Indies, affecting the environment and wildlife. This contamination affected more than 90% of the population that has one of the highest incidences of prostate cancer in the world. Furthermore, there has been a rise of a new form of nationalism, which has sparked violent protests in recent weeks. Both Caribbean jurisdictions, colonized by France since the 16th century, have been territories of that European country since 1946.
Although vaccination has been available to the public since January 2021, most of the population has not been vaccinated. The authorities of both islands had to airlift medical evacuations to France to free up the hospitals, and there were logistical problems to organize burials.
It is still difficult to determine the number of deaths from COVID-19 outside of hospitals in Guadeloupe.
Lack of resources and skepticism in Haiti
In Haiti, the issue with the lag in the count is much worse: the lack of economic resources and the complete incapability of its institutions are coupled with alternative beliefs of a large part of the population regarding the disease. Many don’t believe in the existence or severity of the virus because the expected mortality has not been seen, and they believe in traditional medicine and herbal-based remedies, as is the country’s tradition, rather than in science, medicine, and vaccines. In the country of 11.4 million people, besieged by gangs and experiencing a governance crisis following the assassination of its president, Jovenel Moïse, last July, they have virtually no idea of how many people have died from the virus.
Initially, only two health centers opened their doors to those infected in Haiti. But due to the projection of millions of infected and hundreds of thousands of deaths in the poorest country in the Western Hemisphere, the Ministry of Public Health and Population (MSPP) set up more care centers, most of which lacked equipment for medical interventions.
However, many of those infected refused to be hospitalized. The centers were empty until they closed operations in September 2020.
Along the way, members of the population with symptoms of the disease did not have diagnostic tests, stayed at home, and preferred to rely on herbal teas. Hence the inability of the MSPP to share a true estimate of infected people in Haiti. In addition, the State has had a very limited capacity to carry out large-scale screening due to lack of materials.
The Haitian population rejected preventive measures and the advice from health authorities. Some of the people believe that there has never been COVID-19 in Haiti, and others say they have not seen the wave of deaths that was predicted. Hence their refusal to be vaccinated against the virus. Now, few people accept to be inoculated and the government itself has rejected donations of AstraZeneca vaccines offered to them by the World Health Organization and neighboring Dominican Republic. One of its reasons is the cases of blood clots detected in Europe in people vaccinated with this brand.
They lead in vaccination, but face ups and downs
Handling of the pandemic has been different in the Dominican Republic and in Puerto Rico, where almost 11 million and 3.2 million people reside, respectively.
In Puerto Rico, the first months of the pandemic were known for the lack of diagnostic tests and response equipment such as ventilators, and by excess deaths from causes associated with the new virus, but not identified as such in the mortality registry. Also due to the corruption associated with the multi-million-dollar purchases of tests that never arrived, an incident for which criminal charges were filed. However, contagion and mortality were kept under control by the strict lockdown imposed early on all residents and businesses by then-Gov. Wanda Vázquez.
A massive vaccination campaign began in December 2020 when the use of the Pfizer and Moderna vaccines was approved and, although doses were scarce during the first two months and the government allowed many to skip the order established in the vaccination plan, the efforts have paid off, becoming the jurisdiction in the United States with the highest vaccination rate with more than 73% of residents vaccinated.
Strict protection measures, such as restrictions on people flow and the opening of businesses, and the mandatory use of masks, had an effect. However, in July, just as the Delta variant spread in the United States and began to reach Puerto Rico, Gov. Pedro Pierlusi canceled all measures, including the use of masks in crowded closed spaces.
The result was that August experienced the second highest peak in deaths from COVID-19 since the pandemic began, despite the high vaccination rate, according to data analyzed by the CPI. This rebound was close to the month with the highest number of deaths to date, which occurred in December 2020, but the profile of the victims was much younger.
The mandatory use of a mask indoors was restored and mortality from COVID-19 fell to the lowest levels recorded in October and early November.
Meanwhile, the Dominican government maintains a national vaccination campaign and — despite not having the support of all sectors — it has been one of the first countries to call for an optional third dose.
The Dominican Ministry of Health has released a daily bulletin including the pandemic’s official figures since March 18, 2020. However, it has also faced serious problems in managing its mortality statistics, presenting radically different figures through two of its public agencies: in July 2021 the Central Electoral Board (JCE), the institution that manages the Civil Registry, estimated that virus-related deaths exceeded 8,000, while the Ministry of Health pegged them at almost 4,000.
The Dominican government has also distinguished itself by maintaining strong control of information on the pandemic, delegating its handling to a health cabinet chaired by the Vice President of the Republic, Raquel Peña.
In its explanation to the Dominican media of the major mismatch in the figures, detected in an analysis by the CPI and disclosed by several media outlets in the country in September, the JCE indicated that its numbers of deaths from COVID-19 come from the documents issued by the entities authorized by law to issue death certificates and establish causes of death: the Ministry of Health and, in special cases, a small town mayor, an official from smaller communities who is elected by its residents.
The Ministry of Public Health argued that, although it uses the data from the JCE, it refines the causes of death established in the death certificates through a “social autopsy,” until validating the “real deaths from COVID-19.”
He pointed out that his Directorate of Epidemiology evaluates and classifies deaths according to the international criteria established for the new coronavirus. Such epidemiological surveillance implies further investigation of what has happened to each case to properly classify the deaths.
The CPI asked the agency on multiple occasions to explain how it carried out this process on a case-by-case basis, with what personnel and expertise, and how this was matched with international statistical standards that have agreed to count all suspected cases. The agency never released the information.
In September 2021, officials from the Ministry of Health and the JCE met to standardize the handling of the number of deaths from COVID-19. Up until the fourth week of July 2021, the Ministry officially counted 3,961 deaths from COVID-19, while the Dominican Civil Registry reported 8,263 deaths related to the disease.
In its report, the National Directorate of Civil Registry included about 2,000 deaths of individuals who died between March 2020 and July 2021, whose death certificates established that they were suspected or probably had the virus.
The CPI analyzed an extensive and detailed database provided by JCE’s National Directorate of Civil Registry, listing deaths in the Dominican Republic between 2015 and July 2021, which revealed at least 5,197 cases of people who had COVID-19 at the time of their death, according to their death certificate, and approximately 1,878 who were listed as suspected of having the disease.
But there were also cases of deaths in traffic accidents, by hanging or by epileptic events, that were counted as cases of COVID-19, because people had the disease at the time of death.
“Public Health is going to tell you that there are many unconfirmed cases, that they have no proof. They will also try to make their justification, but there’s no doubt that there’s underreporting, not in this epidemic, no, in all epidemics,” the president of the Dominican Medical College, Waldo Ariel Suero said.
Although the Ministry of Public Health acknowledges that there may be underreporting of deaths, it defends its official figure as valid, which it tries to keep under control with the requirement of showing the vaccination card to enter public and workspaces since last October 18. Record numbers of vaccination were recorded that day and the next, with 116,000 and 124,000 immunized, respectively, with the first, second and third doses of vaccine.
The Ministry of Public Health’s low figure — which is reported to international organizations — and having more than 50% of its territorial population fully vaccinated, are the justifications the country has used to confidently promote itself abroad to recover the tourism sector that was detained between April-June 2020 due to the pandemic. According to the Ministry of Tourism, in October 2021 more tourists arrived in the country than in that same month of 2019 and 2018, which were years when there was no pandemic.
In a report published this year entitled “Mortality from COVID-19: evidence and scenarios,” the Economic Commission for Latin America and the Caribbean (Eclac) stated that some countries have nearly complete national death records such as; Argentina, Chile, Cuba, and Uruguay. But, in others, such as the Dominican Republic, the estimated omission is greater than 25%.
The report explains that, in addition to variations in certifying deaths, the analysis by cause of death presents an additional level of complexity.
“The reason is that the region presents challenges regarding the codification of causes of death, since there are still significant percentages of causes classified with poorly defined or not very useful codes,” he adds.
The World Health Organization (WHO) itself warned in May of this year that the official number of deaths from the COVID-19 pandemic could present a significant underreporting and estimated that the true number of direct and indirect deaths related to the disease could be two to three times higher than the official one.
The absence of reliable systems to record deaths, and that in many cases deaths from COVID-19 happened before tests were done to detect the virus, are among the causes cited by the WHO for underreporting in many countries.
Excess deaths from all causes
According to an analysis of official statistics, in the Dominican Republic — where an average of 40,500 people have died each year since 2015 — significantly higher than average mortality was recorded in January, July and August 2020, and January, May and June 2021. At least four of those months coincided with spikes in COVID-19-related deaths.
Just over a month after the completely in-person school year officially started in September, a fourth wave of infections was declared in the Dominican Republic at a time when there is no curfew or confinement order. On October 31, 2021, the daily positivity rate stood at 14.72%.
Puerto Rico has experienced excess deaths, from all causes, during most of the pandemic.
The deaths, which began during the initial period of strict confinement implemented by the Government of Puerto Rico between March and April 2020, continued from July to April of this year, according to an analysis the CPI did of mortality data from the Puerto Rico Demographic Registry from.
The following months of 2021 could also reveal excess deaths, since the Government of Puerto Rico’s mortality data may currently include partial delays of up to six months because of the way the information is entered and refined. The Registry is currently changing its system so that funeral executives can input the information online, making the process more agile, agency Director Wanda Llovet told the CPI.
An investigation by the CPI, published in September, determined that the excess of deaths suggested that the real number of deaths linked to COVID-19 during the first six months of the pandemic could be up to three times higher than that reported. With the data available up to May 2021, the excess mortality was 3,222 deaths.
The US Centers for Disease Control and Prevention has been monitoring excess mortality from all causes of death in all states and jurisdictions practically since the start of the pandemic. This technique is used in public health and epidemiology during crises to detect trends in deaths above the norm.
It’s a comprehensive measure of the real impact of a public health emergency such as the COVID-19 pandemic that officially confirmed cases cannot provide alone due to a lack of evidence and ignorance about the novel virus, among other factors.
However, this alternate system for monitoring the real impact of the pandemic depends on the existence of an effective death registration system in each country and, just as the CPI team and its partner media found, that is not always the case.
This investigation was possible in part with the support of Para la Naturaleza, Open Society Foundations and Fondation Connaissance et Liberté (FOKAL).