Written by Nandita Saikia and Krishna Kumar
Undercounting of India’s Covid-19 related deaths is a matter of serious debate. Reports in the media have highlighted how cremation grounds have run out of space and the shortage of resources they face. Depending on their political inclination, social media users are either exaggerating Covid deaths or arguing that India’s reported death rate is much lower than that of Western countries. While under-reporting of deaths is most likely due to several lacunae in the death reporting system, it is unscientific to amplify the true burden of deaths to as high as 10 times. Understanding the current outbreak is crucial for governments and citizens — for effective intervention, precautionary measures, and preparing for future outbreaks.
There are many reasons for the true burden of Covid-19 deaths in India being underestimated. Before this pandemic, deaths in India were usually undercounted due to the lack of an efficient registration system at the local level. The underreporting might have increased since many Covid patients succumbed to the disease at home. The high stigma associated with Covid-19 and lack of testing or healthcare facilities could have contributed to underreporting. In the case of institutional deaths, Covid-19 positive patients without a valid laboratory report may be recorded as non-Covid deaths. In certain places, Covid-19 deaths are being ignored in official records if the deceased had comorbidities and did not show Covid-19 symptoms. We also know that a person could recover from Covid-19 but succumb to post-Covid complications. There is also the possibility of declaring non-Covid deaths as deaths due to the disease in extraordinary cases. The WHO guidelines direct that the death of a Covid positive person should be ascribed to the disease, even if the person dies without showing Covid symptoms. Most reports show the death count of urban areas, reports on Covid deaths in rural areas are, by and large, missing.
Interestingly, it has been more than a year since the virus outbreak, yet there has been no effort by the government to clear the air on Covid deaths. Death estimates based on statistical assumptions are creating confusion. For example, a consumer pyramid household survey based on 2,34,000 households, conducted in May-August 2020 by the Centre for Monitoring Indian Economy showed the Covid toll could be more than twice the officially reported figure. The Institute of Health Metrics and Evaluation, USA shows that estimated Covid deaths in India are around nine lakhs, three times higher than the current reported figure. However, such estimates depend greatly on the sample representativeness, statistical models, and other assumptions, all of which could produce a biased conclusion.
The reasons mentioned come in the way of accurately estimating Covid-19 deaths in India. However, it is possible to estimate the total excess deaths indirectly (deaths because of Covid-19 together with non-Covid deaths due to lockdown, over-burden health facilities, shortage of oxygen and medicines) using historical and current monthly mortality rate. India already has two major data systems, Civil Registration System (CRS) and Sample Registration System (SRS), which collects monthly death data for all population and sample population, respectively. Monthly mortality rates are available in many urban municipal offices where death data is covered through civil registration. The Sample Registration System of India collects monthly mortality data for urban and rural areas. Unfortunately, however, both systems do not publish this monthly data. Moreover, annual reports are published only after two or three years of collection. The need of the hour is to publish this data either weekly or monthly so that scientific estimates are available for intervention. This will also end the speculation on Covid deaths and lead to an informed discourse on the pandemic.
It is equally necessary to release the data on Covid-19 patients collected by the Indian Council for Medical Research (ICMR). Since the outbreak of the disease in 2020, ICMR has continuously been collecting hospital-based data. The release of this high-quality hospital-based data will allow researchers to investigate the Covid-19 pattern clinically as well as study it from a social science perspective.
Loss of human resources is a matter of big concern for everyone. Premature deaths because of the pandemic will have long-term economic and psychological effects at an individual and social level. We know that the second wave has been more lethal and infections have spread to rural areas where testing and health facilities are limited. Precise knowledge on premature deaths due to Covid or other causes will facilitate proper intervention at the local level. This could prevent avoidable deaths. The information could be a crucial input for budget allocation, implementation of health services, and creating behavioural changes among people.
It is disappointing that India lacks a comprehensive and accurate death registration system. A robust data system is one of the pillars of democracy and one of the essential requirements of a welfare system. While the Sample Registration System can give death accounts at the state level, the sample is not sufficient to assess district-level mortality. The pandemic has highlighted the need for a comprehensive Civil Registration System at the village or municipality level. Technology should be used to strengthen the system and obtain real-time dynamic data. Since interstate and international migration is linked to death statistics, it is equally important to update the National Population Register continuously at the local level. The government must show interest in transparent and quality death statistics and its timely dissemination.
Saikia is Assistant Professor in Population Studies, JNU and Kumar a PhD candidate in Population Studies, JNU