Excess deaths reveal unequal impact of COVID-19 in Ecuador


Leticia Cuéllar, Irene Torres, Ethan Romero-Severson, Riya Mahesh, Nathaniel Ortega, Sarah Pungitore, Ruian Ke, Nicolas Hengartner


Latin America has struggled to control the transmission of COVID-19. Comparison of excess death (ED) rates during the pandemic reveals that Ecuador is among the highest impacted countries. In this analysis, we update our previous findings with the most complete all-cause mortality records available for 2020, disaggregated by sex, age, ethnicity and geography. Our study shows that in 2020, Ecuador had a 64% ED rate (95% CI 63% to 65%) or 64% more deaths than expected. Men had a higher ED rate, 75% (95% CI 73% to 76%), than women’s 51% (95% CI 49% to 52%), and this pattern of higher EDs for men than women held for most age groups. The only exception was the 20–29 age group, where women had 19% more deaths, compared to 10% more deaths for men, but that difference is not statistically significant. The analysis provides striking evidence of the lack of COVID-19 diagnostic testing in Ecuador: the confirmed COVID-19 deaths in 2020 accounted for only 21% of total EDs. Our significant finding is that indigenous populations, who typically account for about 5% of the deaths, show almost four times the ED rate of the majority mestizo group. Indigenous women in each age group have higher ED rates than the general population and, in ages between 20 and 49 years, they have higher ED rates than indigenous men. Indigenous women in the age group 20–29 years had an ED rate of 141%, which is commensurate to the ED rate of indigenous women older than 40 years.

Summary box

  • The impact of COVID-19 in Latin America became a humanitarian crisis in 2020, amplifying the effects of structural socioeconomic inequalities.

  • Ecuador had 64% (95% CI 63% to 65%) more deaths than expected, one of the highest excess death (ED) rates in the world, with only 20% of those being officially attributable to COVID-19 due to limited SARSCoV-2 testing. The indigenous population had 125% more deaths than expected, and in the general population, men had higher or equal EDs than women in all age categories.

  • The patterns of EDs as a function of age and sex are different for the indigenous population: indigenous people aged from 60 to 69 years had 200% (95% CI 183% to 216%) more deaths than expected, and indigenous women aged from 20 to 29 years had an ED rate four times higher than that of same-aged men.

  • Increased disease surveillance programmes targeting the most affected subpopulations, including postmortem confirmatory testing of suspected cases, can improve situational awareness of public health to better allocate needed resources.