Beyond pandemic numbers
The figures of excess mortality during the pandemic, released by the WHO earlier this month, have generated much heat and controversy in India and elsewhere. It has estimated the number of lives lost due to the pandemic in the last two years is 14.9 million, which is almost 2.7 times more than what official agencies put together have reported across the world. For India, the estimate of excess mortality during 2020 and 2021 ranges between 3.3 million and 6.5 million. This is several times higher than about half a million deaths India has reported officially.
Inadequacy in reporting deaths is one of the several gaps exposed in the health system during the past two years.
Even before the WHO released the data, many experts had expressed fears about underreporting and some studies pointed to a higher death toll in India. For instance, a study published in March this year in The Lancet projected the global toll of the pandemic to be 18 million. Studies have also pointed to the lack of granular data (age, gender etc) in India. Anecdotally, every Indian has lost someone in the family, neighbourhood, close family circles, workplace and so on. The number of lives lost during the pandemic years appears certainly higher than normal times.
The operative phrase in the WHO report is ‘excess mortality’, meaning the additional number of deaths that occurred during the pandemic. Besides the deaths attributed directly to Covid-19, this includes deaths due to complications following infection, delay in treatment of cancers and other diseases, disruption in essential health services, postponement of surgeries, and lack of access to lifesaving medicines etc. All these are considered pandemic-related deaths and were anticipated as health systems got overburdened due to the pandemic. Many of them are not directly due to the infection, so death tolls reported by official agencies won’t reflect them. That should explain the huge margin of difference between WHO estimates and deaths reported by health ministries.
A simple way of estimating excess mortality is to calculate the difference between the number of deaths reported in pre-pandemic years and those during the pandemic year. This should give a clear picture but there were gaps or delays in data collection and reporting both during pre-pandemic and pandemic years. WHO experts, therefore, used mathematical models and statistical techniques to fill those gaps. Leading public health experts from India — fully conversant with ground realities here — were also part of this exercise in the WHO.
For any health system, it is critical not only to count the number of dead but also the underlying causes. An accurate number of deaths and their cause provide crucial information for decision-making in public health. There are systems and protocols for recording causes of death, like the International Classification of Diseases and Related Health Problems (ICD) so that data can be useful for comparative studies and policymaking. Doctors and people employed in death reporting and registration need to be trained in the classification system. A large study called Million Death Study (MDS) that tracked households across the country showed that we need to go beyond simple registration of death and its cause to get a clear picture of the health burden. Researchers in this study used a technique called ‘verbal autopsy’ to get to the cause of death. Trained health workers interviewed family members or others close to the dead, asking questions about medical history, symptoms and circumstances leading to the death. Health activists in Bhopal have used verbal autopsies to document mortality due to the lingering effects of the MIC gas leak.
Over the years, India has developed a mechanism for collecting vital statistics relating to birth and death. Data is collected through the Sample Registration System, Civil Registration System, National Family Health Surveys and the decennial census. All these datasets help the government arrive at fertility and mortality figures. However, the completeness and quality of data vary among states, which creates gaps in data and delays in finalising estimates. During the pandemic years, data collection was hampered in any case. The government also decided to postpone the work relating to the census scheduled for 2021. Even now, a new schedule for the national census has not been announced. The national census can very well settle the dispute with the WHO. Public health expert Prabhat Jha has suggested that all needs to be done is to add a couple of questions on Covid-related mortality when enumerators visit every household in India for the census. This can provide the most accurate data on pandemic-related deaths.
The inadequacy in reporting deaths is one of the several gaps exposed in the health system during the past two years. Some immediate measures like ensuring oxygen supply, creating additional bed capacity and strengthening diagnostic facilities were taken after the Delta wave in 2021, but hardly any systemic changes in the health system have been initiated. Barring the additional provisions made for vaccination, health budgets have remained stagnant. The health workforce has not seen any increase nor is there an improvement in working conditions or salaries of existing personnel. Health is a state subject in the federal structure, but there has been no dialogue between states and the Centre on improving the health system or technical capacity of states.
Everything connected with the pandemic got politicised, be it the lockdown, community transmission, migrant crisis, clinical trials of vaccines, shortage of oxygen, vaccine certificates, India’s one-year chairmanship of WHO Executive Board and so on. Now, it is the mortality data. Instead of targeting a multilateral technical body for estimating a supposedly higher number of deaths, the government should take urgent steps to set the health system to improve the accuracy, timeliness and quality of health data reporting at all levels. A proper response to the WHO data should be the promise of a robust, transparent and professional health data system, and not shrilled name-calling.
