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    Counting Deaths and Feeling Bad: COVID19 as Spectator Sport

    For long, Western commentariat has treated poverty in the global South as a spectator sport, where improvements didn’t usually bring about the same enthusiasm that a perceived worsening of the situation would. For the same reason, India lifting a mammoth 271 million people out of poverty between 2006 and 2016 led to only some muted celebration in Western media over the last couple of years.

    In the same vein, following India’s early lockdown and the subsequent weeks and months of a relatively low COVID-19 mortality burden despite the initial doomsday scenarios, there have been a range of stories in the international media expressing doubt whether India numbers should be believed, and endorsing similar stories from within India. This is despite it being well accepted among experts that the COVID-19 death rates in India at present are nowhere near those in the Western countries, or the world average for that matter.

    Yet, the latest in this series appeared in the Washington Post this weekend, mischievously titled “As India skyrockets past 1 million coronavirus cases, a mystery surrounds death toll”. The story follows the by now familiar method and template: establish that COVID-19 reported cases in India are high, the surveillance system is weak, reported deaths (alone) are low, speculation in local media about data fudging is ripe, and thus, the actual death rates are much higher than what is being reported by the government. The authors conclude that the death rates are largely unreliable because COVID-19 deaths are being “missed or misreported”.

    Such reporting, despite the range of expert opinion sprinkled across the narrative; is at best oblivious to many facts obvious to anyone familiar to the India situation, or at worst, disingenuous in presenting a warped reality.

    To validate the assertion that a large majority of COVID-19 deaths may be missed by the government data collection since people in India routinely die in rural areas without any medical attention, the authors bring in Prof Prabhat Jha, who has been working closely with the Government of India in the past two decades to improve health data systems. In fact, part of what Prof Jha says is unexceptionable; that the only way to walk out of COVID-19 pandemic will be better data.

    However, in saying that it’s not being done, he seems to ignore the wealth of data being collected through seroprevalence surveys from across the country, and through a range of other ways. In fact, the first serosurvey conducted by ICMR showed that the death rates in India were possibly hugely exaggerated: the difference between Case Fatality Rate (CFR) and Infection Fatality Rate (IFR) in May was much higher than previously thought, as the survey results estimated the infection numbers in May itself to be ten million, a time when official case numbers were just around a hundred thousand. While complete survey results are not released to the public yet, it is clear that Indian government’s COVID-19 response is being supported by an information base more robust than many make it out to be. More seroprevalence surveys are underway.

    The first serosurvey conducted by ICMR showed that the death rates in India were possibly hugely exaggerated: the difference between Case Fatality Rate (CFR) and Infection Fatality Rate (IFR) in May was much higher than previously thought

    Many reports have been written about the obvious weaknesses of India’s health surveillance and data systems. In 2013, a government committee found that the actual number of malaria deaths in the country would be at least 20-30 times higher than earlier estimates. In 2015, the number of estimated deaths by tuberculosis (TB) in India needed to be doubled(480,000) compared to the estimated number in 2014 (220,000). Many of these weaknesses- particularly in rural areas- still remain despite rapid improvement, as the ministry of health has been struggling to enhance health information systems, given the low investments in health.

    The Washington Post authors inform correctly that on the average, 20 percent of deaths in India aren’t registered at all.   A pet companion statistic that is often cited to prove that government data on COVID-19 deaths is certain to be grossly incomplete is that on the average, only 22% of registered deaths in India are medically certified. However, to use the critique of the weaknesses of Indian health information infrastructure by experts like Prof Jha to directly deduce a gross underreporting of COVID-19 deaths seems erroneous for a range of reasons.

    Firstly, despite the authors’ mentioning rural deaths without medical attention, the COVID-19 pandemic in India currently is highly concentrated in a few states, and is urban in character, rendering India averages about death registration largely useless as a basis to arrive at conclusions . As of end June, four highly urbanized states/territories accounted for two-thirds of India’s COVID-19 cases and four-fifths of the total deaths from the pandemic. Within these hotspots, more than 80% of cases as well as deaths have been concentrated in a handful of cities. Over the last two weeks, new hotspots have emerged, but COVID-19 still remains an urban pandemic in India, mostly thanks to the early lockdown, expanding testing and aggressive contact tracing, isolation and quarantinine.

    The top three hotspots in India currently– Maharashtra, Tamil Nadu, and Delhi– are known to have very high levels of death registration. Maharashtra has 93% deaths registered and both Tamil Nadu and Delhi have 100% deaths registered against the national average of 80%. Also, the percentage of medically certified deaths to total registered deaths is way higher than the national average of 22% in the urban areas of these states: Maharashtra has 67%, Delhi has 69%, and Tamil Nadu has a high 85%. Ironically, COVID-19 largely affecting men with two-thirds of overall infections may also improve its death reporting as research has shown that undercounting of deaths for men is only one-third of that of women.

    In addition, it needs to be kept in mind that the whole Indian health system is repurposed to capture the spread, contain the infections, and treat cases often at the cost of ignoring non-COVID-19 conditions. It makes the system more efficient vis-à-vis COVID-19 than normal, and deaths at home less frequent than normal; particularly in better performing states and urban areas. While deaths can still be missed, it won’t be certainly to the extent that is being alluded to. In addition, when one considers the fact that just like every other country, COVID-19 cases are being missed in India at a greater scale than COVID-19 deaths, it is clear that any worry about death rates being way higher than what official numbers show, is entirely misplaced.

    The whole Indian health system is repurposed to capture the spread, contain the infections, and treat cases often at the cost of ignoring non-COVID-19 conditions. It makes the system more efficient vis-à-vis COVID-19 than normal, and deaths at home less frequent than normal

    A story in the British Medical Journal discussing difficulties in accurately recording COVID-19 deaths in India brings forth the contrast between perception and reality. In the case study discussed, while the allegation by the victim’s family is that the death is not recorded by design, it becomes clear later in the narrative that the particular patient – a suspected COVID-19 case in Madhya Pradesh- was indeed tested and the test had turned negative.  While it is true that tests can occasionally return false negatives (a universal problem), it will be a relatively small number, not certainly to the extent that can cause gross under-reporting.

    In fact, anyone familiar with India’s healthcare delivery system will be surprised that samples from “suspected patients” are being collected post-mortem in states like Madhya Pradesh, pointing to a much more alert system than normal times. It is reported that government hospitals are handling most of the critical load of COVID-19 patients across the country. This also may have improved the death reporting tremendously; as private sector has often been the missing link in India’s health information ecosystem.

    A cautious COVID-19 response by the Indian public health system has had some unintended consequences too. For example, mysterious datasets emerging from graveyards and crematoriums across Indian cities have triggered an epidemic of speculative stories in the media, many of which simply counted burials/cremations conducted under the COVID-19 protocols, and compared those numbers with official death counts. The clarification that crematoriums and graveyards are asked to follow COVID-19 burial/cremation protocols for even the suspected COVID-19 deaths, has not reduced the enthusiasm of such investigations, and Washington Post cites two of these.

    To keep things in perspective about ‘suspected cases’, in 2017, the latest year for which an estimate is available, India had 3200 deaths per day due to respiratory illnesses alone. In addition, hospitals in many Indian cities cater to patients from not just neighbouring districts but neighbouring states as well. Since dead bodies of COVID-19 victims and even suspected victims are to be taken care of following protocols by health authorities rather than families, the cremations/burials happen within the city itself.

    What we often forget is that India is by no means an outlier in terms of low mortality or morbidity rates, which merits story after story about a “mystery”, “enigma” or “paradox”. One only needs to look at India’s neighbours. While the Washington Post accurately states that India is not the only country with a high number of reported cases and relatively low official fatalities, it chose to compare India with Russia, perhaps only to refer to “suspicion over counting methods”. A customary glance at data from India’s neighbours and other large Asian countries show that there is a pattern.

    India has 19 deaths per million population; Bangladesh and Philippines have 16, Indonesia 15, Pakistan 25, and Afghanistan 30 ,against a world average of 77. Thailand has 0.8 and Sri Lanka has 0.5. Coronavirus may indeed mutate further to become even more dangerous or reach the rural areas or indeed reach the around 5% elderly and cause severe damage in India and the other countries listed above despite the governments’ and people’s best efforts, but what is unfortunately happening in the media now mostly in the name of investigating missing deaths is a sort of wailing in anticipation, rather than analysis.

    Across the op-ed landscape, a deep disappointment hangs in the air like fog- that despite Kiplings all around, India’s streets aren’t yet strewn with bodies of beggars, monkeys, street magicians, mahouts and snake-charmers dying of COVID-19 in hordes. India has a weak health surveillance system, vibrant democracy, sloppy dissemination of official data, an often hyperactive media, and very few health editors. This heady cocktail often makes journalists slip easily from a healthy skepticism to speculative conspiracy theory-building, which unfortunately certain international media platforms are only too happy to amplify.

    It is a fact that COVID-19 cases as well as deaths are undercounted in India as they are across the world. However, cases are undercounted more than deaths, and Indian hotspots like Delhi and Maharashtra are reconciling death data as quickly as the system allows. Administrative backlog till mid-June was cleared by the respective governments by adding a massive 1700 deaths to the tally at one go on 16th June. This is exactly what the rest of the world is doing during a pandemic: they have excess deaths, and they reconcile data and revise the tally as they go along.

    COVID-19 cases as well as deaths are undercounted in India as they are across the world. However, cases are undercounted more than deaths, and Indian hotspots like Delhi and Maharashtra are reconciling death data as quickly as the system allows.

    Many Western media houses have yet to cope with the fact that their fancy health systems couldn’t prevent the COVID-19 bloodbath, while certain poorer countries seem to have done much, much better. According to the Global Health Security Index 2019, prepared by the Johns Hopkins Center for Health Security (JHU) and The Economist Intelligence Unit (EIU), USA and UK were the two best prepared nations to tackle a pandemic -on paper-  ranked one and two respectively. The rest is history.

    There may be a need for Western media to look within and ask some hard questions rather than vainly try to distract their audience by suggesting they take a telescopic view of the nostalgic spectacle of largely imagined deaths elsewhere.  “Nobody is trying to hide deaths intentionally. You can’t hide mass deaths,” one of the experts cited in the Washington Post piece had  told BBC way back in April about the situation in India. It is time Western media came to terms with that fact.

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