More evidence of excess deaths in India during pandemic

A recent paper in Science concluded India’s cumulative COVID-19 deaths were six to seven times higher than reported official mortality

January 22, 2022 09:54 pm | Updated January 25, 2022 11:25 am IST

In the State-wise data compiled by the Union Government, represented by the Additional Solicitor General Aishwarya Bhati in the Supreme Court, it was shown based on media reports that 6,14,211 claims of compensation for deaths due to COVID-19 were filed in 20 States against the reported death toll of 4,29,872 in those States. The numbers were stark for some States. Telangana reported only 3,993 deaths but received 28,969 compensation claims and sanctioned compensation for 15,720 deaths (nearly four times the reported death toll). Gujarat reported only 10,094 deaths but there were 89,633 compensation claims, and 68,370 of them were sanctioned – a multiple of nearly seven times the reported death toll. In contrast, Kerala which reported 49,300 deaths has received 27,274 compensation claims and has processed 23,652 of them.

Reflect undercounting

Now, compensation claims are not a reliable measure of what the actual death toll due to COVID-19 could have been – in States, where there is greater State responsiveness and general public awareness, claims of compensation could be more, and this could be lower in States with limited capacities. Yet, the fact that some States have gone to process a high number of compensation claims, several multiples over and above their reported death tolls suggest that their governments have acknowledged that these tolls reflect an undercounting of the actual death tally.

Excess deaths

This is not surprising. Excess deaths analyses based on deaths registered in the Civil Registration System (CRS) have shown that they have been as high as six times the official death toll for just 11 States and Union Territories (Maharashtra, Punjab, West Bengal, Tamil Nadu, Kerala, Karnataka, Himachal Pradesh, Haryana, Delhi, Madhya Pradesh and Andhra Pradesh) for which such data was available. Studies have found the CRS method to analyse death tolls to be a robust way to measure mortality across States. The more complete the CRS registration in States, “the better the opportunities to understand population health and its determinants,” a paper by Aashish Gupta and others recently found.

A recent peer-reviewed paper in Science by Prabhat Jha and others used a national survey of 1.4 lakh adults and estimated that COVID-19 constituted 29% of deaths from June 2020 to July 2021. This corresponds to 32 lakh deaths, of which 27 lakh occurred in April–July 2021. This number was corroborated with two government data sources – one of which was the CRS and which showed all-cause mortality increased by 27% and 26% respectively, leading them to conclude that “India’s cumulative COVID-19 deaths were six-seven times higher than reported official mortality with COVID and non-COVID deaths peaking similarly”.

There could have been a possible overreporting of deaths in the national survey conducted by CVOTER. The authors went on to address this by reaching out to approximately 57,000 people in 13,500 households, and this showed “similar temporal increases in mortality with COVID and non-COVID deaths peaking similarly”.

Worldwide phenomenon

Is this an Indian phenomenon alone? A recent news feature published in Nature journal based on the World Mortality Dataset maintained by researcher Ariel Karlinsky, besides other models, found that across countries the pandemic's true death toll was millions more than the official tolls. For example, the WMD dataset revealed that excess deaths in Russia numbered more than one million by the end of 2021, while only 3,00,000 COVID-19 deaths were recorded in the same period. The WMD dataset does not contain figures for India as excess deaths are available only for “subnational” units (States) and not for the whole country or for countries such as China. But extrapolating from subnational data, it could be shown, as the Science paper did for India, that excess deaths were several multiples over the official death toll and revealed undercounting.

A data story in The Hindu published in September 2021 compared excess deaths for the countries with the highest reported death toll and found that the estimated multiple over the reported toll (using the same method) for India was the highest (5.8 times) and only Chile (5.7 times) came close.

Varied reasons

What explains this substantive undercounting of deaths? In the case of India, the reasons are varied. In States like Kerala which have tallied a high number of deaths after reviewing its COVID-19 mortality reporting over time, initially, some deaths of infected people who died after testing negative or left hospitals and then died were not tallied under COVID-19 deaths. This has since been corrected, and Kerala’s case fatality rate has risen to 0.9 (closer to the national average).

But in others such as Gujarat, Madhya Pradesh and Telangana, where excess deaths multiples were quite high, the reasons for the undercounting have also got to do with the States seeking to report less of the mortality as COVID-related. There are States such as Uttar Pradesh, for example, where public health systems remain weak and were overwhelmed by the sudden increase in the spurt of infections and mortality during the second wave, in particular. This also contributed to the significant underreporting of COVID-19 deaths. Many cases were not detected through adequate testing in several States. Also, the absence of proper health care institutions resulted in several deaths occurring outside institutional care and were undocumented.

States with a robust CRS (Tamil Nadu, Karnataka and Kerala for example) in which deaths are quickly registered after occurrence have tended to show lower excess deaths multiples or have addressed these deaths as COVID-19 related after audits – Maharashtra, for example.

But as the Gujarat example shows, even if undercounting of deaths was done for political expediency, such States have had to acknowledge compensation claims even if they are much higher than the reported COVID-19 tolls for the same reason.

Estimating the actual death toll due to COVID-19 is an important step in acknowledging the challenges faced by public health institutions and the state in India. This should help epidemiologists and public health specialists devise clear steps to take when faced with a pandemic-like situation and also to prepare institutions to respond to it.

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