Bitter controversy over India’s epidemic mortality rate

How many people died in India as a result of the COVID-19 pandemic? This question has since become the subject of a heated debate. The World Health Organization (WHO) has estimated that the pandemic has caused about 4.7 million more deaths in India., Government of India issued a strong answerAnd the media houses and editors surrounded. It is almost as if life and death themselves are now matters of opinion.

background

Here are some basic observations. Firstly, we will never know exactly how many deaths occurred in India during the Novel Coronavirus pandemic. second, all mortality studies, including the WHO’s latest, include choices about what data to include, how to fill in the gaps, and how to deal with uncertainty; There is always room for debate and disagreement about these options. Third, uncertainty doesn’t necessarily mean outright ignorance: even the most optimistic reading of the data gives six or seven times more deaths than official COVID-19 deaths.

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The current controversy has been more noisy than usual, but it is not new. Several studies, most of which put India’s pandemic excess deaths at between three and five million, have been met with a strong “denial” from the government. These denials have highlighted uncertainties (which is valid), and then jumped – without justification – to claim that there are no additional deaths beyond the recorded COVID-19 deaths. The rebuttals are also littered with irrelevant, confusing and absurd points.

The latest response is well summarized in its headline: “India strongly objectes to the use of mathematical models to project higher mortality estimates in view of the availability of authentic data”. The “authentic data” in question is mortality data from the Civil Registration System (CRS), and has two implications: CRS data has been ignored by researchers; that the CRS data do not support estimates of high epidemic mortality.

Both are false. Estimates of epidemic mortality rates, including those of the WHO, are largely data-driven, and the main data-source is – you guessed it – the CRS. This data strongly supports estimates of high epidemic mortality. The “modelling” that the government objected to is largely simple data analysis and techniques to fill in the gaps in the data, which if we were to use CRS data to estimate excess mortality would be entirely is inevitable.

citizen registration data

To understand all this, we have to consider what data is available and what it shows. In 2021, journalists managed to obtain monthly death registrations at the state or city level; These significant efforts provided the first hard evidence that official COVID-19 deaths were only the tip of the iceberg. Although valuable, the data is unclear: not all states and territories are covered; This often comes from online systems that do not capture all registrations; And it often misses the later part of India’s disastrous second wave. Nevertheless, a clear picture emerges: there was a gradual increase in deaths during the second half of 2020, which subsided and was followed by a tsunami of deaths during April-June 2021.

Although the data comes from local government records, the health ministry says it is “non-official”. However, there is no official CRS report for 2021, and only recently (on May 3, 2022) the 2020 CRS report was made available. This report does not provide monthly registrations, so it is difficult to cross-check with earlier data. In the annual totals, there are some discrepancies; But, nevertheless, we found that 2020 gross estimates were roughly aligned with the states whose data we used in our own projections.

With everyone agreeing on the value of CRS data, how does the government propose to address the pandemic surge in deaths? We find the answer in a strange claim: during 2020, the government claims that 99.9% of all deaths in India were recorded. The message is this: what appears to be an increase in the death rate in 2020 actually reflects a sharp improvement in registrations. Note that this can never explain the large number of excess deaths that occurred during 2021. But is the claim of full death registration in 2020 plausible?

On the contrary, it is absurd. Consider the statistics of Uttar Pradesh. The government sample registration system tells us to expect about 1.5 million deaths in Uttar Pradesh every year. But only 0.87 million deaths were recorded during 2020, which is about 60% of the estimated toll. If registration is complete, 2020 saw a massive, unexplained, drop in deaths in the state!

Consider also Andhra Pradesh, where freely available CRS data tells a startling story: during the 15 months from April 2020 to June 2021, 50% more deaths than expected were recorded. Could this reflect an improvement in registration? No. As per the 2019 CRS report, there was no scope for improvement as death registration in the state was already completed before the pandemic. This is probably an exaggeration; But however we see it, the huge increase in Andhra Pradesh’s mortality rate cannot be explained through increased registration coverage.

It is possible that registration coverage has improved during the pandemic in some states. But, overall, registrations probably dropped during 2020. Data from the government’s latest National Family Health Survey shows that deaths in 2020 were less likely to be recorded than deaths in 2019. Birth registration data from the CRS points in the same direction: after an increase of 5% during 2017-18 and 7% during 2018-19, birth registrations declined by 2.5% in 2020.

Disruptions in registration can be particularly severe in marginalized communities and in states where registration is weak anyway. In Uttar Pradesh, for example, both birth and death registrations declined sharply during 2020. Assuming that registration remained stable during the pandemic, as we and many others have done, underestimated the increase in mortality.

some conclusions

India was badly affected. A year ago, sad stories of hospitals overflow and oxygen shortages filled the news as the virus spread through the country. There is now a lot of evidence – not only from CRS, but also from surveys – which are telling us that many millions died. Data is still emerging, and estimating pandemic mortality will be an ongoing effort; But that effort is undermined by the government’s scathing, inconsistent response after each study.

All estimates come with uncertainty and depend on alternatives. For example, the WHO estimate drops from 4.7 million to 4.4 million if we consider the period April 2020-July 2021 instead of January 2020-December 2021. It is natural to accept uncertainties and debate alternatives, but it is very different from being rejected. Estimate.

strengthen CRS

The tragedy has been great; But in the global context, India is no outsider. Equally high epidemic mortality rates were observed in developing countries and parts of Eastern Europe. Historical vulnerabilities and deliberate dishonesty, well documented by journalists, have meant that India recorded only 10%-15% of its pandemic deaths. India is not alone in this too. India’s all-cause mortality data is incomplete – but in many Asian and African countries, the data is even less. The current situation highlights both the value of India’s CRS data and the need to strengthen CRS.

What is most troubling – and what makes India stand out – is the government’s relentless hostility to every effort to understand the pandemic. If the objections were made in good faith, the government can expedite the release of data, for example from the CRS for 2021 or from the sample registration system. Ultimately, the crackdown isn’t about science, data, or methodology; The basic question is whether we want to discover the truth or not.

Ashish Gupta is a David E. Bell Fellow at Harvard University. Murad Banji is a UK-based mathematician who has closely tracked India’s pandemic data