The World Health Organization (WHO) has estimated the number of deaths in India directly or indirectly attributable to COVID-19 to be 4.74 million. This is the highest for any country and nine times the nation’s official count of 5,24,000 as of May 2022. The WHO numbers are derived through robust statistical methods that consider “excess” deaths during the pandemic period. The WHO has models that India has objected to.
The WHO numbers come as an embarrassment for the government, as Prime Minister Narendra Modi claimed in Parliament on February 8, 2022 that “India’s efforts (in tackling the pandemic) are being appreciated around the world”. The Ministry of Health and Family Welfare has questioned the use of mathematical models when “authentic data” is available from India. As per this data, India’s total reported deaths from all causes in 2020 were 4,75,000 more than the previous year. Surprisingly, the year-on-year increase in deaths was higher in the years immediately preceding the pandemic — about 6,95,000 in 2019 over 2018, and 4,87,000 in 2018 over 2017, according to official data.
There is a lot of scepticism over the Indian numbers given the irreconcilable and alarming discrepancy between India’s count and the WHO estimates. The government has received a lot of flak for the way it handled the pandemic — starting from the sudden and total lockdown to the shortage of oxygen to the way many had to struggle to get admitted in hospitals and died waiting for a bed to the slowness with which vaccination was rolled out.
Inability to report accurately
But this should not blind us to the flaws in our ability to count deaths and determine the causes of deaths. This process requires systems, money and commitment. More than 75 years since it became free, India does not have a public health division which can systematically collect and analyse data on diseases. Such a governmental arm would mandate doctors to report infectious diseases, pick up the earliest signals of outbreaks in any part of the country and keep count of the number of cause-specific deaths. No one in power has publicly acknowledged this missing link or thought it fit to build such a system. The WHO, sometimes sanctimonious in its advice and at other times coercive in its prescriptions, has conveniently side-stepped any support or guidance on that critical front for the last several years.
It may be easy, even fair, to argue that the government is hiding the real numbers of deaths, or that image management is taking precedence over the truth, even though the official count has been widely thought to be lower than actual deaths. The only difference now is that the magnitude of the discrepancy is staggering, and it comes with the official stamp of the WHO.
Yet, the government needed to do little to hide the real numbers that just do not get documented. India’s system simply stayed true to its time-tested tendency of reporting less. The internal drivers of data are geared to under-report for a host of reasons, governmental image being but one of them. In the absence of a robust reporting system and standard, hospitals, bureaucrats, civic bodies and even clerks under-report.
What needs to be stressed is that India’s health management machinery could not have taken any other route to report the numbers than it did. This is how reporting deaths worked when no one was looking, and this is how it worked when everyone was looking. It also suits the government in this case.
The problems of counting are the same with malaria, typhoid, cholera, rabies, leptospirosis, scrub typhus or death by snake bite. Only with regard to tuberculosis (TB) is there some degree of caution in reporting numbers. This is because of heavy disease burden and an elaborate system of monitoring that includes a TB division in the Central Health Ministry, and State, district and local TB units that go down to the last mile, with the entire design endorsed by the WHO. Yet, reliable, locality-specific, real-time numbers are absent. Eventually statistics get compiled, but no one scrutinises the methods.
We must, therefore, hold the government accountable, but we must also look beyond the immediate blame game and see this as an opportunity for India to build a system that can fix this long-term problem. We need to urgently invest in a robust public health infrastructure that will have to be built from the ground up.
Health management has two parts: public health (with surveillance and prevention) and healthcare (for diagnosis, treatment). It hardly matters to the doctor (healthcare) if somebody died of typhoid fever, since that does not change anything for the diagnosis and treatment of the next patient with some other disease. But for a public health professional, the accuracy of typhoid fever is important for detecting the transmission channel and source of the microbe, in order to prevent more cases. So, reporting every death with the accurate/verifiable cause of death is essential for public health, only if it exists. The demand for accuracy comes from public health, not from healthcare.
TB cannot be controlled by the healthcare protocols given by the WHO. TB control requires both public health and universal, primary and secondary healthcare.
Public health surveillance
Healthcare professionals must report all health events as required by public health in a process called public health surveillance. That must function as the early warning radar system that functions 24X7 in all parts of India. This is not challenging to build as an online platform or app with available bandwidth. This is essential for emerging threats to be noticed and acted upon and for auditing the outcome of budgets spent on disease control. We need diseases diagnosed according to protocols, information collected in real-time and acted upon immediately, and statistics that can be verified. Such a surveillance system was piloted by one of us (Dr. John) in the North Arcot district in the 1980s, sustained for a decade and replicated in the Kottayam district of Kerala in the 1990s, before it was dismantled as the Health Ministry did not grasp the significance of surveillance as information for action.
Births and deaths are demographic events and counting them has been an age-old tool for managing the wealth of the State. It did not evolve in our culture but was necessary for the colonial rulers for managing wealth. Counting must therefore be purposeful, and statistics should emerge as a by-product of that counting. The administrators may believe that counting is only for ex post facto statistics. In this, the significance of surveillance and numbers is lost, and any inaccuracy comes to be seen as unimportant.
In Europe, health managers figured out that microbial diseases had social and environmental determinants that allowed the governments to intervene and prevent infectious diseases; thus was born the concept and infrastructure called public health. We must seize the opportunity to create our own design of health management in our best interests. The WHO can advise, but is not accountable for outcomes. If the government takes that step, it will be a signal achievement towards making India a developed nation.
Jagdish Rattanani is a journalist and a faculty member at Bhavan's SPJIMR; T. Jacob John is retired Professor of Clinical Virology, Christian Medical College, Vellore, and Past President of the Indian Academy of Paediatrics (Through The Billion Press)