Updated: May 25, 2021 4:50:40 pm
Death registers in villages; kickstarting the sample survey system to find out how many died in rural areas; getting municipalities to put out daily or weekly death numbers; and mapping hotspots.
These are among the proposals that Prabhat Jha, epidemiologist and Director of the Centre for Global Health Research in Toronto, has put on the table for the Government to consider amid the second Covid wave that has spread to rural areas raising questions over India’s official death toll of over 3 lakh so far.
Jha, whose Million Death Study with the Registrar General of India and the ICMR is one of the most authoritative studies on mortality, spoke to The Indian Express. Excerpts:
One characteristic of the second surge has been a clear gap between the official Covid death toll and those laid to rest as per Covid protocol. We found this in Delhi in April. How do you then count the dead?
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India has about 10 million deaths occurring a year, of which 7 million occur in the rural areas. So you have to look at counting the dead separately for urban and rural India. If you want to know what was the contribution of Covid to deaths, the best way is to actually look at how many excess deaths occurred in a city versus deaths over the same period in previous years. Unfortunately, these data are available but not released. Municipal corporations have weekly or daily data of how many people died; not whether they died of Covid or not because that’s very uncertain…
Relying on Covid as a diagnosis is not as reliable as relying on overall deaths…
The situation is different in rural India because most deaths aren’t registered or recorded. It’s very easy to cremate or bury in the fields or in the villages. That’s of particular concern because the first wave appeared to have been focused on some of the big cities with urban populations (while) the second wave seems to have spread all over India.
In parts of Bihar and UP, bodies were found in the river, some buried in the sand, more in number than in previous years. People don’t test in villages out of fear or stigma, so how do you evolve a system to count the rural Covid dead?
The only way to fill the gap in rural areas is for the Registrar General of India to conduct the Sample Registration System (SRS). What that does is take a random sample of villages all over the country from the Census and send teams every six months to ask who was born, who died. And if anyone has died, they complete a simple two-page form in the local language on what happened. That gives you information on whether there are increases in overall mortality or whether they are Covid-related… But unfortunately, no data has been released since 2014 and the system is sitting idle when it is absolutely necessary.
So if the SRS study were back up and running, we would find that we have some people who say, yes, we have someone who died, and we think of Covid…The SRS has been extraordinarily effective in recording child and maternal mortality and other things. So it absolutely needs to be restarted because it will be helpful for Covid.
The other thing that could help is we have made a call to political pollsters… they have their sampling frames. If they were to call… and simply ask: who was alive in your home on January 1, 2019, and their age and sex, and then, since that time period, who has been hospitalised and who has died. And then simply record the month of hospitalisation and the month of death. Really simple. It could be a 5-6 minute interview. That would give some very simple information because you can compare in May of 2021 how many people report someone hospitalised or dying versus, let’s say, May 2019.
Why is death data so crucial?
They actually offer a roadmap out of the pandemic. When vaccine supply is limited in India, prioritising hotspots would be the best way to reduce the infection. Which is what we had to do in Canada, we didn’t have enough vaccines so had to adopt the hotspot approach. To enable that, you need data. You can’t simply guess as to what are the hotspots.
If all data on deaths in India and the municipal corporation data were released and if the ICMR releases all testing data and vaccine data… your Aadhaar card is needed to get a vaccine, so if they were to release this data… by age, sex, education level and pincode of anyone tested and anyone vaccinated, you could put together a map of the whole of India and see where are the infections and where are the vaccines, and that would be a credible way that the public would trust. (Lack of data) hampers the attention and information you need to tackle the pandemic. You can’t walk out of the pandemic without good data — who has died, who has tested, who is vaccinated.
What are the consequences of missed deaths?
In the absence of data, people outside of India are making guesses…and they might be quite wrong. So the ‘Economist’ has said perhaps a million deaths have already happened in India, the WHO said the death toll might be a lot higher than the official 300,000. When we looked at it, for the first part of the wave, in the big cities, there was underreporting but it wasn’t that huge — maybe 40 per cent. It wasn’t 60 per cent or 100 per cent or 200 per cent, that’s now being estimated. So if the Indian government wants to know how to curtail the epidemic, how to prioritise vaccinations, data will help. The absence of data simply prolongs the pandemic, prolongs suffering.
What would your prescription be?
First, all municipal corporations release their total death counts every week starting from January 2019. How many deaths by ages, sex… right up to the current. And keep reporting them. Put them up on a website.
The second is for the Registrar General to restart the survey and find out the rural deaths through the Sample Registration System. The third is to make all of the individual-level data on who gets vaccinated, and who gets tested, up on a website so that it can be used for prioritising vaccines and understanding hotspots.
I wrote to Honourable Ministers (Home) Amit Shah and (Health) Dr Harsh Vardhan around three months ago, arguing these points should be implemented. And I can understand the reluctance because you think, well, it’s going to scare people or embarrass the government. But the truth is, this data will strengthen your hands…They just need political will to make them happen.
Is that will lacking?
Every pandemic has humbled every government, no matter how competent they think they are. So I don’t blame the Indian government for being underprepared for what was just a historic catastrophe but what you should do is, once you know it’s there, then you know what’s the right thing to do…Without data, there’s just no way to walk out of the pandemic.
There’s been speculation about the ‘actual’ Covid toll. Would you hazard a guess?
No, because what we don’t want at this stage is to be precisely incorrect. Just bring out the data, and you will get the real picture.
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