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The World Health Organization has released a report that says that there were 4.7 million COVID-19 deaths in India during 2020-21. This is almost 10 times the official death count as maintained by the Government of India. The WHO estimate places India topmost among countries in terms of excess deaths during this period. The numbers come just two days after India released its annual data for registration of births and deaths for the year 2020, recorded in its civil registration system (CRS). The CRS data showed about 4.75 lakh more deaths than in previous years. This has triggered a debate regarding the veracity of the report as well as official government data regarding COVID-19 Deaths.
What are the findings of the WHO?
Global: An estimated 1.5 crore people are likely to have succumbed to the direct or indirect impact of the disease globally during the first two years of the pandemic. This is much more than 54 lakh that have been recorded officially by countries separately. Nearly 84% of the total number of excess deaths happened in South East Asia, Europe, and the Americas.
The high-income countries account for 15% of these deaths, upper middle income countries 28%, lower middle income countries 53%, and low income countries 4%.
India Specific: The WHO’s data suggests that over 90% of deaths in India have gone unreported. About 8.3 lakh COVID-19 deaths are estimated to have happened in 2020, while Government’s official figure is 1.49 lakhs for 2020. Further, it has pegged India’s excess mortality for 2020 and 2021 at 47.4 lakh, caused either directly due to infection or through its indirect impact.
The Civil Registration System (CRS) and the Sample Registration Survey (SRS) are annual exercises that complement each other. The SRS uses a door-to-door survey in a few thousand sample towns and villages to produce an estimate of the total number of births and deaths in the country every year. This exercise is repeated after a few months to avoid duplication.
The CRS is a database of all births and deaths that get registered. The CRS database is therefore a subset of the SRS. Over the last few years, as more and more people are registering their births and deaths, the CRS numbers are converging closer to the SRS estimates. The Registrar General of India maintains the CRS and conducts the SRS.
CRS only has death registration data, and not every death in the country is registered. The actual death data is revealed by the Sample Registration Survey (SRS) whose report for 2020 has not yet been released. According to the Government, the registration of deaths with CRS has improved from ~70% in 2013 to ~99.9% in 2020.
Source: Indian Express
Why are the reasons for difference between WHO estimates and India’s official Data?
First, India has not yet stopped counting its COVID-19 deaths. The 5.24 lakh deaths counted until now is not the final official toll. The number is under constant revision, and is likely to remain so for several months, if not years. For instance, Kerala is updating its death toll almost every day, and many other states have been doing it periodically. Last week, Assam added 1,300 deaths on a single day.
Second, a physical count, and verification, of the dead in a country as vast as India during such chaotic times is bound to take a little more time.
Third, the WHO report does not get into calculating the scale of the undercount, for India or any other country. It has done a more straightforward exercise of calculating excess mortality. It has estimated the total number of people who likely died in India in 2020 due to all causes. From that, it has subtracted the expected number of all-cause deaths if there was no COVID-19. These ‘excess’ deaths are considered to be a direct or indirect result of COVID-19.
Fourth, India has consistently questioned WHO’s own admission that data in respect of 17 Indian states was obtained from some websites and media reports and was used in their mathematical model. This reflects a statistically unsound and scientifically questionable methodology of data collection for making excess mortality projections in case of India. WHO chose to ignore the available data submitted by India and published the excess mortality estimates for which the methodology, source of data, and the outcomes has been consistently questioned by India.
Some analysts have pointed out flaws that are directly apparent in WHO’s estimates. WHO has put the India’s COVID-19 deaths at 8.41 lakhs for 2020. There were 81.2 Lakh deaths in India in 2020 (CRS). Thus non-COVID-19 deaths were ~73 Lakhs. India’s total death toll for a year has never been below 80 lakh since 2007 till when data is available. Thus the number of 8.41 lakh deaths in 2020 is questionable. Kerala is said to have the best healthcare system in India. Kerala’s COVID-19 death rate is ~1900/million population. If this rate is extrapolated to pan-India level, the death-toll would be ~25 Lakhs which is nearly half of WHO estimates.
What is the need for accurate information on COVID-19 deaths?
First, it is crucial to address the shortcomings of public health facilities and framing responses to future medical emergencies.
Second, it will help in the adequate distribution of compensation to deceased and their family members. It is essential to support the families in pandemic times and reduce the financial burden on the.
Third, it will help in assessing India’s performance in tackling Covid 19 with respect to other countries.
Fourth, it is also a barometer to compare the performance of different Indian states with each other. It will help the poor performing states to learn from the healthcare model of top performers.
Fifth, the data will help in comparing the credibility of different studies that estimated India’s death toll at the onset of pandemic. For instance, In March 2020, a computer modeling study had predicted 1 to 3 million Covid-related deaths in India by the middle of April 2020. When nothing like that happened, the authors of the study acknowledged that the risk of dying from COVID was actually a lot lower than he had originally assumed. Prediction models are susceptible to deviate from actual outcomes due to flaws in underlying assumptions.
What lies ahead?
First, the Covid compensation exercise, under the watchful gaze of the Supreme Court, will, hopefully, encourage families to report their loss. This will help in giving a clearer picture of the COVID-19 deaths.
Second, the WHO’s Covid death estimates underline the need for India to further strengthen its death recording system, fine tune its accuracy and transparency. In this regard, the rapid digitalisation of social systems should translate to the strengthening of the Civil Registration System and Sample Registration System as well, the two main tools for recording births and deaths.
Third, the actual death data is revealed by the Sample Registration Survey (SRS) whose report for 2020 has not yet been released. The government should duly compile and release the same in order to give a clearer picture.
Fourth, the countries should also understand that there is no guarantee that WHO report models have an unquestionable capability to accurately mimic the dynamics of the current pandemic, whose nature and behavior is far from fully understood.
Fifth, the Government should make efforts to enhance healthcare surveillance and the data capture in the healthcare system. Both the quantity and quality of data capture need to improved. The data will not only be useful in better understanding of health pattern across India, but can be prove to be extremely beneficial in picking-up earliest signals of a possible outbreak. This will also enhance policy on healthcare interventions.
Counting the COVID-19 deaths is not a mere academic exercise. This effort is crucial to address the shortcomings of public health facilities, frame responses to future medical emergencies and find out how well or poorly a country managed the pandemic.