Comment

There is no getting past the pandemic till we credibly count COVID-19 deaths

In this file photograph taken on May 11, 2021, health workers wearing Personal Protective Equipment prepare the funeral pyre for those who died due to the Covid-19 coronavirus at a cremation ground in New Delhi.

In this file photograph taken on May 11, 2021, health workers wearing Personal Protective Equipment prepare the funeral pyre for those who died due to the Covid-19 coronavirus at a cremation ground in New Delhi. | Photo Credit: AFP

The World Health Organization (WHO) recently released a report that estimated global deaths from COVID-19 across 2020-2021. It suggested that about 14.9 million deaths could be attributed to the pandemic worldwide during that period, further estimating that about 4.7 million of these deaths were in India alone. For comparison, the official Indian COVID-19 toll for that period is 0.48 million, a number smaller than the WHO number by a factor of about 10. 

A number of independent news reports have suggested that there was pressure from the Indian government on the WHO to suppress their estimates. Indeed, once the report appeared, it was immediately criticised by a number of prominent government representatives. A government press release called the report “statistically unsound and scientifically questionable”. 

India’s rejection of the report makes it the only country to do so, out of the 194 member states of the WHO. However, the estimates for India are broadly consistent with estimates from a number of independent groups, all falling in the broad range of 2.2 million to 6 million deaths.

Understanding ‘excess mortality’

At the core of all such estimates, especially in situations where official numbers might not align with reality, is a quantity called “excess mortality”. This compares estimates of the actual death toll with the number of deaths expected in the same year but without the mortality caused by the pandemic, an obvious counterfactual. There are thus two estimates here — an estimate of the actual number of deaths, and the “counterfactual” estimate. The difference between these is the number of excess deaths that we should attribute to the pandemic.

For the counterfactual estimate, one should extrapolate from the number of deaths in previous pre-pandemic years, but with additional statistical corrections that represent how the population changes from year to year. Somewhat subtly, one must account for the indirect impacts of the disease as well. These should include the fact that fewer deaths from road accidents occur during periods of a lockdown, for example. Accounting for those who died simply because medical treatment was hard to access in the pandemic period, even if from non-COVID-19 causes, is also important.

For the actual death toll, one must rely on official data, if it is believed to be accurate, or estimate the number by other means, as the WHO did for India.

The government’s issue with the WHO report involves both these separate estimates. It argues that the model used by the WHO to estimate deaths in the counterfactual scenario is flawed. Further, it suggests that the way in which the actual deaths are calculated — from a combination of official reports, numbers from external non-government websites and news reports — is questionable. 

Response short on specifics

The official response from the government is short on specifics. It provides no alternative routes to these estimations, apart from insisting that the official record should be trusted. 

In its response to the WHO, the Indian government has argued that its own Civil Registration System, or CRS, is of sufficiently high quality that the numbers it provides can be used in place of model estimates. Data from the CRS for 2020 are now available, but were released just two days before the WHO released its own report and could not therefore be incorporated in its estimates. The CRS numbers point to an increase of 470,000 deaths in 2020 over 2019, although these are very unlikely to all be COVID-19 deaths. The WHO’s estimates for deaths from the pandemic in 2020 yield numbers that are larger by a factor of about 2.

The available CRS data do not estimate how many deaths actually took place in India in 2020, but only those that were registered, a number known to have a distinct urban-rural divide. Because the CRS only counts registered deaths, the quality of its numbers can only be understood by comparison to other methods. India’s Sample Registration System tracks a set of representative households to estimate deaths in a given year. This could have been a useful point of comparison. However, in 2020, the SRS did not take place. 

The CRS has been argued to undercount deaths in some of India’s most populous States, especially deaths of women and children. Low levels of death registration are believed to occur in the highly populous states of Uttar Pradesh and Bihar and are likely to have slipped further during the pandemic. Given these, it is possible that the discrepancy between the official and the WHO estimates may simply reflect inadequacies in our mechanisms for counting deaths.

There is universal agreement that the bulk of the deaths from COVID-19 across the span of the pandemic can be associated with the Delta wave, which struck India between February and June of 2021. Even in the WHO calculation, the year 2021 contributes more than 80% to the overall estimate of pandemic mortality. On this, government representatives have so far been silent. The CRS data for 2021 will only be available next year.

Responsibility to the dead and to those they left behind

Why is it important to count the dead? One reason is, of course, closure. It is hard to find an Indian who has not experienced a direct COVID-19 death of a family member, or an untimely death as an indirect consequence of an infection. To insist on the sanctity of an official record that potentially undercounts them, without providing an adequate reason for believing that record, would ignore our responsibilities to the dead and to those they left behind. 

We could ask whether any possible undercounting of deaths indicates deliberate mismanagement or whether it simply points to the difficulty of maintaining accurate records in a country of India’s size and complexity. We could ask how the Indian public health system fared in the defining public health event, so far at least, of this century, in comparison to other countries.

But here’s the larger question: How should the Indian government respond to independent, external measures of its performance on any issue where these measures diverge from the official narrative? In recent years, the Indian government has demonstrated some prickliness in such matters. In this particular case, it has been largely bolstered by a relatively unquestioning media that has supported the government’s refusal to acknowledge the potential toll of the pandemic as an act of “patriotic defiance”, in the words of the mathematician and COVID-19 modeller Murad Banaji. 

As he says, “It is an absurd version of patriotism that discards data and evidence, and disrespects the millions of families for whom COVID-19 brought tragedy”.

It is, however, possible to do a better job. Indian statisticians and modellers are equal to any in the world. The methodology adopted by the WHO is transparent and publicly available. The government could easily set up an independent panel of experts to evaluate and improve the WHO’s projections.

The numbers that such a panel comes up with might not coincide with the official record. Such an exercise would, however, establish the government’s commitment to an accurate and transparent reckoning of the impact of COVID-19 on India.

Gautam I. Menon is a Professor of Physics and Biology at Ashoka University, Sonepat. The views expressed here are personal.


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Printable version | May 13, 2022 9:22:35 am | https://www.thehindu.com/opinion/op-ed/there-is-no-getting-past-the-pandemic-till-we-credibly-count-covid-19-deaths/article65406519.ece