Forgetting Covid: Kosovo Sleepwalks Towards the Next Pandemic
Illustration: Sanja Pantic/BIRN
Governments fighting Covid often compared it to war but Arbnora Fazliu, who experienced both, believes Covid was worse. “In the war, we had the enemy,” she said. “But in the hospital, we were among our kin. It is terrible to lack mercy for your compatriots.” The Fazliu family is originally from Mitrovica, a flashpoint city in northern Kosovo whose population is divided along ethnic lines – part Albanian, part Serb. During the war in the late 1990s that delivered Kosovo’s Albanian-majority population from Serb control, the family fled its home.
Most of its members ended up in neighbouring Albania, among the hundreds of thousands Kosovars who sought refuge there. Eleven years old at the time, Arbnora was constantly worried about her two brothers, who had been left behind to an unknown fate in Kosovo. As it turned out, one brother was in prison while the other was sheltering with relatives, and the siblings would be happily reunited when the family returned to Kosovo in 1999.
In July 2020, roughly four months after Italy recorded Europe’s first wave of Covid-19 deaths, Arbnora’s father, Xhafer, was admitted to hospital in Kosovo’s capital, Pristina. Xhafer had contracted the virus but the family were not overly worried. The 70-year-old mainly needed oxygen therapy and was expected to be discharged after a short stay. Most European countries at the time were trying to check the spread of the virus by barring all visitors from hospitals, but Kosovo had gone the other way. The infectious diseases ward at Pristina’s University Clinical Centre had enlisted patients’ relatives to help its overwhelmed doctors and nurses.
Arbnora joined her brother and sister in looking after their father, in squalid conditions reminiscent of a war zone. “The food was covered with flies because of the heat, we had to buy our own disinfectant,” Arbnora said. “My father’s room had no toilet, we had to go to other rooms. I saw a lot of people who had to do everything in their beds.” Arbnora said her sister was tasked with administering sedatives to her father and monitoring his oxygen supply.
Xhafer died in hospital at three a.m. on July 5, three days after being admitted. Arbnora’s brother, who was with him at the time, said the oxygen equipment had abruptly stopped working during the night, and it had taken half an hour to find a member of hospital staff to fix it. The autopsy report would conclude that Xhafer died of natural causes. But the Fazliu family suspected that the disruption to the oxygen supply had contributed to his death. Xhafer was one of six Covid patients to die that night on the hospital’s infectious diseases ward. “Our hearts still ache because of what happened to him,” Arbnora said. “We still have no explanation from the state.”
An ambulance brings a Covid patient to a hospital in Skopje, North Macedonia. The worldwide pandemic hit the elderly and infirm hardest. Photo: EPA-EFE/GEORGI LICOVSKI
Just over a year has passed since the World Health Organisation, WHO, declared that Covid was no longer a global health emergency. In many of the wealthier democracies of Europe, public inquiries are now poring over the flaws in Covid responses that brought healthcare systems to the brink. However, the governments in the poorest Balkan countries that were worst hit by the pandemic have avoided a reckoning. Data on deaths have been obscured or cherry-picked, calls for inquiries have been sidestepped, and the true picture of what happened in hospitals has been whitewashed.
Kosovo fared better than its neighbours according to some metrics: its relatively youthful population meant fewer people became seriously ill. But thanks to a broken healthcare system, the sick were significantly less likely to survive. “The situation just went out of control,” said a doctor in Pristina, speaking on condition of anonymity because, he said, he was loyal to his colleagues. “It was impossible to manage, we were all lost. Something was always missing, sometimes the oxygen, sometimes the medicines. People were forced to buy essential, expensive medicines by themselves. Those who didn’t have money didn’t get proper treatment.”
Kosovo had the highest excess mortality rate in Europe during the height of the pandemic between 2020-21, according to data compiled from national statistical agencies and the EU’s statistical agency, Eurostat. For the purposes of this story, “Europe” includes the EU member states, Turkey and the Balkan countries that have applied to join the bloc, and excludes those countries that were formerly part of the Soviet Union.
The excess mortality rate describes the percentage rise in the number of deaths from all causes during a specific crisis period, compared to what might be expected under “normal” conditions. The measure, while far from perfect, has been used by epidemiologists as a reasonably reliable means of gauging the impact of the pandemic. It gives a rough indication of the rise in the number of deaths as a result of Covid by expressing it as a proportion of the projected deaths – or the number of deaths that would have been expected anyway if the pandemic had not happened, estimated using an average for the preceding four years.
The chart at left lists European countries by their excess mortality rate, using data from Eurostat and the statistical agencies of Kosovo and North Macedonia. The chart at right shows GDP per capita for 2020, using World Bank data. Illustration: Sanja Pantic/BIRN
Data from Kosovo’s statistical agency indicate that the excess mortality rate in Kosovo was 41 per cent during the 2020-21 period, the height of the pandemic, compared with the annual average over 2016-19. The average excess mortality rate across the EU over the same period was 14 per cent, according to the European Union’s statistical agency, Eurostat. The worst performers after Kosovo were neighbouring countries: North Macedonia, with an excess mortality rate of 35 per cent, and Albania, with an excess mortality rate of 33 per cent.
These three countries are the poorest in Europe in terms of GDP per capita. Meanwhile, the wealthiest countries in terms of GDP per capita fared significantly better. Germany had an excess mortality rate of 8 per cent, according to Eurostat data. The excess mortality rate in Italy, the country least prepared for Covid because it was hit first, was 14 per cent. In Sweden, which controversially refused to impose lockdowns, it was 5 per cent. Put simply, your chances of surviving a life-threatening bout of Covid were significantly worse if you happened to be in Kosovo, North Macedonia or Albania.
None of these countries have held public inquiries looking back at their Covid response. In Kosovo moreover, media and civil society institutions did not dig into the numbers that were being made public at the height of the pandemic, according to Albert Spahiu, economics editor at Pristina’s Telegrafi newspaper. “There was no scientific reporting of the data,” he said. “The reporting was simple, superficial, focused only on daily figures, while there was no research on the exact number of deaths and what caused them.”
More than four years have passed since an outbreak of the novel coronavirus, Covid-19, was reported in the eastern Chinese city of Wuhan. The first pandemic of the 21st century would go on to kill more than 7 million people worldwide, some 2 million of them in Europe. Rapidly developed vaccines gradually reduced the virus’ spread and virulence, and the memories of death and disruption have receded. Today, global health officials are discussing how best to prepare for the next pandemic. “Disease X”, as they call it, is believed to be an inevitable prospect – a matter of “when”, not “if”.
Meanwhile, on the nation-state level, countries such as the UK, France and Italy have launched public inquiries into their Covid response, in an effort to demonstrate accountability, strengthen healthcare systems, and offer some consolation to the bereaved. In the UK for instance, a Covid inquiry – launched in 2022 and expected to wrap up in 2026 – has yielded revelations of senior government officials holding office parties in defiance of their own guidelines. In Sweden, an inquiry delivered a mixed assessment of the country’s controversial “no lockdown” strategy. It criticised early failures to protect the elderly but vindicated the overall approach, noting that the excess mortality rate was lower than in many countries that had imposed strict lockdowns.
Lockdowns were introduced and eased throughout Europe over the course of 2020 and 2021 to limit the impact of the pandemic. Photo: EPA-EFE/VALDRIN XHEMAJ
Unsurprisingly, no such inquiries have been held in the places that recorded the highest excess mortality rates in Europe. Kosovo, Albania and North Macedonia are among the poorest countries in the western Balkans, and their healthcare systems have been weakened by decades of under-investment and a steady “brain drain” of qualified doctors and nurses. Their hospitals lacked the capacity to care for the most seriously ill Covid patients, leading to high excess mortality rates.
Today, similar constraints are thwarting an honest assessment of what went wrong. Good quality public healthcare, like trustworthy public inquiries, tends to be costly. Countries that cannot afford the former are unlikely to dedicate resources for the latter. However, the lack of resources is not the only hurdle. Experts say an honest evaluation of the pandemic response is being held back by a lack of transparency.
In October 2021, the Pristina prosecutors’ office completed an investigation into the case of the six patients that had died on the same night on the infectious diseases ward of the University Clinical Centre. The prosecutors backed the findings of the initial autopsy reports: they confirmed Covid as the cause of death and offered no indication that the disruption to oxygen supply had played a role. Arbnora’s family wanted to launch court proceedings over Xhafer’s death, but found no lawyers willing to take on the case. I contacted the daughter of another Covid patient who died on the same night as Xhafer on the infectious diseases ward. The woman, who did not wish to be identified by name, said she too had tried to pursue legal action over the death, but gave up because no lawyers were willing to take on the case.
Bujar Vitija, a healthcare journalist who runs the Shneta portal, said there was “complete chaos” in the first summer of Covid. Hospitals often ended up using oxygen cylinders because they could not rely on a modern, concentrated oxygen system, delivered via pipeline. “It was often hard to provide enough for the patients,” Vitija said.
People aged 65 and over queue for vaccines in Kosovo. Many Balkan countries lagged behind the EU in the rollout of vaccination programmes. Photo: EPA-EFE/VALDRIN XHEMAJ
I asked the University Clinical Centre to comment on claims that the patients’ deaths were linked to the disruption of the oxygen supply. The hospital responded by citing the prosecutors’ report, which did not indicate any such link. In response to other issues raised by this story, the University Clinical Centre said Covid patients’ relatives had assisted in their care at the height of the pandemic by administering tablets, as they might have done in their homes, and by making sure oxygen masks remained in place. The hospital emphasised that relatives had not administered any intravenous treatments to the patients. “The hospital environment was overcrowded and the doctors and nurses did humane and heroic work,” Arben Vishaj, the director of the University Clinical Centre, said.
On a visit to the infectious diseases ward long after the pandemic, the medical staff I met in the corridors were reluctant to speak. Many disputed that Kosovo had a high excess mortality rate, even though the figures were drawn from official statistics. “North Macedonia had a high excess death rate during the pandemic,” one of the doctors said. “Not us.”
I asked the Ministry of Health in Pristina to comment on Kosovo’s high excess mortality rate. In an e-mailed response, the ministry appeared to acknowledge that the excess mortality rate had gone up between 2020-21. “Excess deaths in Kosovo during the pandemic indicate a change of this parameter,” the e-mail said. In November and December 2020, the ministry said, Kosovo recorded an excess mortality rate of 103 per cent and 88 per cent respectively – or roughly double what would be expected normally.
Students attend school in Pristina, wearing plastic shields to limit the spread of the Covid virus. Kosovo’s youthful population helped mask the failure of its healthcare system during the pandemic. Photo: EPA-EFE/VALDRIN XHEMAJ
However, the ministry also pointed to another measure – the number of excess deaths per 100,000 people – that appears to place Kosovo in a much more comfortable position. Citing data compiled by The Economist magazine up to November 2022, the health ministry said Kosovo’s record on excess deaths was “nowhere near the worst in Europe”.
The ministry’s e-mail said Kosovo had recorded 329 excess deaths per 100,000 people, outperforming Albania and North Macedonia, where the same figure was 584 and 823 respectively. It said Bulgaria had recorded 1,049 excess deaths per 100,000 people – the highest in the world. The ministry did not specify a time-frame for these numbers, and it was impossible to corroborate them with the link to The Economist data that it provided, which is updated regularly. The latest figures on The Economist website do indeed show that the number of excess deaths per 100,000 people has been significantly lower in Kosovo throughout the pandemic, compared to its neighbours and to EU member states.
To calculate the number of excess deaths per 100,000, we start by subtracting the number of projected deaths during “normal” times from the number reported during a crisis. Then we divide this figure by the country’s total population and multiply it by 100,000. The resulting measure allows for excess deaths to be compared across countries, according to a standardised unit of population.
Outside of wars and pandemics, a country with a relatively youthful population can be expected to have a low number of deaths compared to a country with an ageing population. During a pandemic such as Covid that disproportionately kills the elderly, both such countries will see an increase in the number of deaths per 100,000 people. However, this increase is still likely to be smaller in a country with a youthful population, compared to a country with an ageing population.
A man cycles past a mural celebrating pandemic healthcare workers in Skopje. Photo: EPA-EFE/GEORGI LICOVSKI
Kosovo is not only the newest country in Europe – it is also the youngest. Half its population of 1.87 million is under the age of 30, according to Eurostat data from 2021. In the EU, by comparison, the median age – or the age dividing the population in half – is 44. The fertility rate in Kosovo, traditionally high, is now declining as elsewhere in Europe but the country remains a youthful outlier in an ageing region.
Until recently, Kosovars tended to marry and start families at a relatively young age. The marriage rate is the highest in Europe: there are almost 10 marriages every year per 1,000 people in Kosovo, more than double the EU average of 4 per 1,000 people, according to Eurostat. Moreover, Kosovar families tend to be stable – the country has the lowest divorce rate in Europe. The EU also plays a part. Across much of eastern Europe, the young have been migrating westwards for work, pushing up the median age of the remaining population. Kosovars, however, have until recently been denied the right to visa-free travel in the EU. They still cannot easily migrate to the bloc, with the exception of qualified doctors and nurses, who are much sought after in the EU.
While Kosovo recorded a relatively low number of excess deaths per 100,000, these numbers do not vindicate its Covid response. Even before the pandemic, Kosovo had a strikingly low number of deaths per 100,000 inhabitants, compared to European countries. Data from the World Bank indicate that Kosovo recorded 560 deaths for every 100,000 people in 2019 – the second-lowest number in Europe after Turkey, and roughly half the average for the EU. Meanwhile, Bulgaria in 2019 already topped the world rankings, with 1550 deaths per 100,000 people. Demography offers an explanation: one in five Bulgarians are over the age of 65, the highest proportion in the EU after Italy and Portugal.
The percentage increase in the number of deaths offers a better indication of how Kosovo fared during the pandemic. According to World Bank data, Kosovo recorded 750 deaths per 100,000 inhabitants – an increase of 35 per cent – in 2020. This increase was not only the highest in Europe, but also among the highest in the world. Ecuador topped the chart with a 53 per cent increase in 2020. Bulgaria by comparison recorded 1800 deaths for every 100,000 inhabitants in 2020 – an increase of just 16 per cent.
Media workers check their phones outside a hospital in Tirana, Albania, in the first wave of the pandemic. Photo: EPA-EFE/Malton Dibra
Many experts prefer the excess mortality rate, rather than excess deaths per 100,000, to measure the impact of the pandemic. To calculate the excess mortality rate, we start by subtracting the number of deaths projected during “normal” times from the number of reported deaths during a crisis period. The result is then divided by the number of projected deaths and multiplied by 100 – showing, in effect, the percentage increase in the number of deaths. During a deadly pandemic, a country with a weak healthcare system will be expected to record a steep rise in its mortality rate, compared to a country with a strong healthcare system.
“Death population ratio does not show the reality, as many countries with elderly populations had a high number of deaths per unit of population, even before the pandemic,” said Artan Hoxha, the president of the Institute for Contemporary Studies, a Tirana-based think tank that has been tracking Covid fatalities. “The excess mortality rate is a better measure, because it shows how the country fared against its own historic performance.”
Healthcare systems across the Balkans are being weakened by the emigration of medical workers. According to WHO data for 2020, Albania had 18 physicians per 10,000 people, the lowest figure in Europe, while North Macedonia had 28 physicians per 10,000 people. Germany and Italy, both popular destinations for Albanian and Macedonian doctors and nurses, respectively had 45 and 40 physicians for every 10,000 people. Kosovo was ranked between Albania and North Macedonia, with 23 doctors per 10,000 people, according to 2019 data from the Chamber of Doctors, a Pristina-based professional body. Long before the pandemic, experts were warning that the exodus of doctors and nurses would create acute shortages in the domestic healthcare system.
As is often the case, there was no data for Kosovo from the WHO. The country is often left out of international charts, making it something of a statistical blind spot. Its contested sovereignty may play a part. Kosovo has yet to be admitted to the UN, EU and Nato, though most member states of the latter two organisations recognise its sovereignty.
Experts say Kosovo’s Covid response was characterised by the mismanagement of data. “The data about excess deaths were not transparent – there was a disconnect from the real problem,” said Safet Gerxhalliu, an economic analyst and former head of the Pristina-based Economic Chamber. “Studies are being conducted based on inaccurate figures. The country has suffered a great deal because of the lack of good data – it has lost the chance to seek help from international institutions.”
A child explores a deserted public square during a lockdown in Pristina in 2020. Future generation’s ability to withstand a pandemic will require an overhaul of the healthcare system. EPA-EFE/VALDRIN XHEMAJ
In neighbouring countries, the failure to review pandemic management has also been attributed to a lack of political will. In Albania, the government of Edi Rama trumpeted its response to Covid, despite the country recording Europe’s highest excess mortality rate in 2020, according to data from the International Monetary Fund. “If an investigation had been conducted, the government would have had to acknowledge the high death toll, and therefore its total failure to administer the pandemic,” said Artan Hoxha, the Tirana-based economic analyst.
Erion Dasho, a Germany-based physician and consultant of Albanian origin who has called for greater transparency over Tirana’s handling of the pandemic, echoed calls for an inquiry. “Most countries learnt lessons from what happened in the pandemic and are trying to strengthen their preventative capacities,” he said. “By claiming we did everything right, by not recognising mistakes, it is impossible to imagine that the government will correct those mistakes.”
In North Macedonia, the ministry of health has yet to answer calls to examine its Covid response. Shaban Memeti, the director of the Institute of Health, a state-funded research centre, said he had been urging the government to review its pandemic management. However, he said, his demands had gone unheard amid a rapid turnover of ministers. “We need to make a proper analysis of the death toll, of what did and did not work during the pandemic,” he said.
Memeti studied in Albania, and has analysed healthcare systems in Kosovo as well as North Macedonia. The region performed badly in the pandemic, he said, because many links in the chain were broken – from a weak network of family doctors to non-compliance with protocols, delays in testing, and a lack of communication between institutions. Being poor and dysfunctional, many Balkan countries were also slow to get mass vaccination drives off the ground – with Serbia a notable exception. Social attitudes also played a part. “People tried to hide the disease or were reluctant to get help until it was too late,” Memeti said.
Having exposed the cracks in these countries’ healthcare systems, Covid could offer some protection against the next pandemic, Memeti said. “It won’t be the same – they have the experience now, an institutional memory,” he said. Nonetheless, he warned, institutional memory would be no substitute for a long overdue overhaul of the healthcare infrastructure.
Ornela Liperi is a Tirana-based journalist specialising in data and economic analysis for Monitor magazine. This story was produced as part of the Fellowship for Journalistic Excellence, supported by the ERSTE Foundation, in cooperation with the Balkan Investigative Reporting Network. Editing by Neil Arun.
