4 min readMay 7, 2022 09:38 AM IST
First published on: May 6, 2022 at 07:30 PM IST
There is a raging debate on the underreporting of Covid deaths. This so-called underreporting is gauged through approximations of excess deaths, either from past trends or by modelling enhanced mortality risks due to the pandemic. In either case, it is difficult to provide an accurate count of Covid-related deaths in an environment where death registration varies and the cause-specific description remains fluid. Hence, an estimate of excess deaths requires checks for robustness.
This draws attention to death registration and its cause-specific details. While there is apprehension regarding the Covid death count, it is not at all realistic to associate all the deaths during the pandemic with Covid alone. There are three major concerns related to Covid mortality – the enhanced risk of Covid mortality with base clinical conditions, the age-specific differential vulnerability to the severity of the disease, and pinpointing the cause of death to the virus and not other related complications.
Apart from these issues, the pandemic resulted in constrained and inadequate access to critical health care, giving rise to avoidable mortality. While keeping these complexities in mind, there is every reason to be conservative in subscribing to the magnitude of Covid deaths suggested by the international community – these estimations harp on our insufficient health infrastructure and the vulnerabilities to widespread infections owing to compromised living conditions. In fact, the undercounting of Covid deaths should only be corrected in recognition of the heightened risk of mortality during the pandemic.
The challenge of arriving at a near accurate number for Covid mortality rests on having a reasonably accurate death count due to all diseases during the pandemic. Clearly, a large number of people were treated for Covid during the past two years but the fatalities among them need not necessarily be due to the virus but from other complications as well. Therefore, the criteria for associating the cause of death to Covid needs proper clarity. Attributing all the excess deaths during the pandemic to Covid will be an overestimation. Similarly, obtaining a real count of deaths associated with Covid requires an adjustment for underreporting of deaths by institutions on the one hand and the non-recognition of deaths from Covid that occurred without being treated for the disease.
On the whole, the excess-deaths approach is merely an approximation of additional deaths that occurred during the pandemic based on a secular extrapolation of mortality trends under normal circumstances. A meticulous effort is needed to estimate the real magnitude of Covid deaths. It calls for the characterisation of excess deaths with their age-sex attributes and carving out a subset of such deaths that can be ascribed to Covid. Undoubtedly, such an exercise will list Covid deaths as a subset of the derived excess deaths. A robustness check of the same can be carried out in relation to other information available like enumerating households that experienced deaths during the pandemic or number of orphans across regions.
It is not unusual to undercount deaths during a pandemic. But the international community’s current obsession with the accuracy of the Covid mortality count raises questions. It seems akin to attempts in the past to reaffirm the superiority of the health system of the developed world over the developing one through an exhibition of the “mortality advantage”. The Covid death count may well be revised, but certainly not in terms of adopting an excess death approach.
The estimates of the death count offered by epidemiological modelling as well as the calculations made based on counting funerals at crematoriums are not a replacement for the demographic extrapolation of excess deaths and a subset of such deaths being adjudged as due to Covid.
This column first appeared in the print edition on May 7, 2022, under the title ‘The right Covid count’. The writer is professor, Department of Epidemiology and Biostatistics, International Institute for Population Sciences. Views are personal
The challenge of arriving at a near accurate number for Covid mortality rests on having a reasonably accurate death count due to all diseases during the pandemic. 
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