Will We Ever Know How Many People Died of Covid-19 in India?

Excerpt from ‘The Making of a Catastrophe: The Disastrous Economic Fallout of the Covid-19 Pandemic in India’ by Jayati Ghosh (2022) 

By Jayati Ghosh

ONE of the major problems with describing the trajectory of the Covid-19 pandemic in India is the absence of reliable data on actual cases and deaths from the disease. It is true that even by the end of 2020, before the more devastating second wave, India’s official death rate from Covid-19 was actually higher than most other countries in the Asian region, even those with lower per capita income and less health infrastructure, such as Nepal, Bangladesh, Pakistan, and Afghanistan.” It is possible that there was under-reporting of such deaths in these countries, but this was also true of India, especially for some states. So even with the disputed official figures, while India’s Covid-19 death rate was lower than in other large countries that have shown rapid spread of the virus, it was still among the highest in Asia.

Indeed, under-reporting of Covid-19 deaths has been a problem across the world. Some of this results from the unwillingness of authorities to record deaths as Covid deaths or of relatives not reporting these due to fear of stigma. Some is simply because of lack of certainty as to the cause, especially with patients with comorbidities, whose deaths are often assigned to those, or because of false negatives of the Covid-19 tests, which are known to be quite high. Even deaths that are medically certified could be underestimating Covid-19 deaths, since it is often the case that such deaths are not recorded as such because of the required procedures and conditions to be met before such certification. Advisory guidelines from the Indian Council of Medical Research (ICMR) say that people with suspected or probably Covid-19 should be included in the related mortality data, but most state and local governments have not implemented this.

Sometimes-especially in the early months of the pandemic- it resulted from the shortage of testing kits, which were sought to be reserved for the living: a doctor in a Mumbai government hospital noted in mid-April 2020 that in a single day six patients with acute respiratory distress syndrome were brought to his hospital dead, and none were tested for Covid-19 because of a shortage of kits?

In other cases, operational difficulties combined with bureaucratic requirements to reduce the numbers recorded as dying from the virus. For example, twenty-seven-year-old Manish was admitted into a hospital in Bhopal with a ruptured liver abscess. When he developed fluid in his lungs and showed other respiratory symptoms of Covid-19, he had tubes inserted in his windpipe and nasal channel to help him breathe and eat.

But this meant that swabs could not be taken to test him for the disease. When he died, doctors were sure that the cause was Covid- 19 because of indirect evidence from the CT scans, but they could not record it as such because they were not allowed to record any deaths from Covid- 19 unless they were confirmed by the RT-PCR test.

Manish’s death was therefore recorded as due to other causes. There are other cases of those who died in hospital with Covid-19 symptoms, whose tests came back negative; even though doctors believe these are part of the false negatives’ that often require repeated testing, which is not possible for the dead, and they are not recorded as Covid deaths.

There was widespread incidence of deaths being recorded as due to the pre-existing conditions or comorbidities of the patients, rather than due to the virus. In extreme cases, as in Murshidabad in West Bengal, there was even evidence of orders to doctors at the local medical college hospital prohibiting such recording: ‘In case of Covid positive – No mention of Covid in death certificate’, was the official directive! There were many reports across the country of different state governments attempting to suppress the number of Covid-19 cases and deaths through various means, even if not so blatant. The problem was compounded by the spread of the disease to more rural and remote areas, where both health facilities and official registration of deaths is less developed, and where it is likely that more cases have gone undetected or unrecorded.

These limitations are widely recognized, which is why several countries have moved to considering the number of “excess deaths’, that is number of all deaths per population in the period, beyond what could be statistically expected in normal conditions. This has been used to suggest that actual deaths from the pandemic could be as much as 50-60 per cent higher than those reported.

In India, recent estimates of excess mortality during the period of the pandemic have come up with even more stark and startling numbers. As it happens, even the excess death figures are underestimates in India, because official mortality numbers are themselves suspect, with not all deaths registered, and less than half of the registered deaths being medically certified.

Around 86 per cent of deaths are estimated to be registered even in urban areas. In 2018, only 21 per cent of registered deaths were medically certified as to cause. Even in the national capital of Delhi, less than two-thirds of deaths get a medical cause of death’ certification. The problem is much more acute in rural and remote areas. Despite this, attempts to assess the extent excess mortality during the Covid-19 pandemic show death rates that would make India the worst affected country in the world.

• Excerpted with permission from ‘The Making of a Catastrophe: The Disastrous Economic Fallout of the Covid-19 Pandemic in India’ by Jayati Ghosh, published by Aleph Books 

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