India’s official COVID death count is an underestimation and nobody believes this number to be true … the underestimation will progressively get worse as the disease spreads in rural India … however, it’s impossible to put a figure on the underestimation and I will not do so … the excess death method is a better way of counting COVID deaths … meanwhile, it’s wrong for the government to draw comfort from India’s low COVID mortality”: Anand Krishnan, Professor of Community Medicine at the All India Institute of Medical Sciences.
Giving this information in a statement about an interview with Dr. Anand Krishnan by noted journalist Karan Thapar, the interviewer’s office gave further details and said :
“One of India’s authorities on community medicine and a professor in the subject at the All India Institute of Medical Sciences has said that the official COVID death count is an underestimation and adds “nobody believes this number to be true”. Prof. Anand Krishnan says the COVID death count is presently based upon the spread of Covid-19 mainly in urban India but the underestimation will get progressively worse as the incidence of the disease increasingly moves into rural India. However, he added that it’s close to impossible to put a figure to the underestimation of COVID deaths and, despite repeated questioning, refused to do so. As he put it “I will not fall into that trap”.
In a 30-minute interview to Karan Thapar for The Wire, Prof. Krishnan said that it was wrong of the government to try and draw comfort form India’s low mortality. First, as he pointed out, it’s not as low as the government claims. Second, all our neighboring countries have lower mortality rates as do others further afield like Thailand, Philippines, Malaysia, and Indonesia and, of course, practically the whole of sub-Saharan Africa with the possible exception of South Africa.
Prof. Krishnan told The Wire there are several reasons why India’s official COVID death toll is an underestimation. First, the country’s mortality surveillance system is weak. Only 86% of deaths are registered but in some very populous states, the percentage is even lower. For instance, in UP its 61%, in Jharkhand 55%, in Bihar 35%. Second, only 22% of deaths are certified by a doctor and, again, in several states, the percentage is a lot lower. In Madhya Pradesh, it’s 7.4%, UP 5%, Jharkhand 2.6%, and in Bihar 2.4%. So in these states over 90% of deaths do not have a doctor certifying the cause of death.
Prof. Krishnan pointed out that specific issues to do with COVID have exacerbated the existing weakness of the mortality surveillance system. “COVID has adversely impacted death registration due to lockdowns, travel restrictions as well as the social stigma resulting in people hiding these deaths.”
Prof. Krishnan said there are two COVID-specific issues that also make it difficult to accurately calculate COVID deaths. First, there are suspected COVID deaths which are not always attributed to COVID because the death happened without a test. In these cases identifying the cause of death depends on the clinician’s judgment and there are bound to be many instances where COVID deaths have not been identified as COVID deaths.
A second COVID-specific issue that adversely affects the COVID death toll is COVID-related deaths. Because COVID exacerbates comorbidities like TB, diabetes, and heart trouble, many people die of these comorbidities and, again, in that case, their deaths are not always counted as COVID deaths. It depends on the clinician’s judgment and often these deaths are assigned to the comorbidity rather than to COVID. Yet these are clearly COVID deaths because COVID exacerbated existing comorbidity causing death much earlier than would otherwise have been the case.
Finally, Prof. Krishnan told The Wire that as the incidence of COVID moves from metropolitan India into small towns and then into rural India, where hospitals are few and far between and doctors perhaps often absent, the underestimation of COVID deaths will progressively increase. Many people could die of COVID without the cause of death being identified.
However, despite repeated questioning, Prof. Krishnan refused to put a figure to the extent of the underestimation of COVID deaths. As he said, “I do not want to fall into that trap”.
Prof. Krishnan said a better way of assessing COVID deaths was by the excess death formula. He said one needs to estimate the average annual number of deaths on the basis of the last 3 or 4 years and then compare it to the deaths this year to work out the excess deaths.
However, Prof. Krishnan was extremely skeptical of the Brihanmumbai Municipal Corporation figures of excess deaths versus official COVID deaths between March 1 and July 31. These figures suggest that the excess deaths (13,058) are over 100% more than the official COVID deaths (6,395). Prof. Krishnan refused to comment on these figures because he doesn’t know the basis on which BMC has calculated excess deaths. As he put it, if I refuse to believe one set of government figures i.e. the official COVID death count, how can I readily accept another set of government figures i.e. BMCs excess death count?
Prof. Krishnan made a point of stressing that even the excess death formula for assessing COVID deaths is not simple and straightforward. First of all, you have to take into account that during a lockdown deaths due to road accidents or pollution will have gone down. Second, not all excess deaths will be COVID deaths. Some or several could be because patients needing immediate and necessary medical attention were unable to get it, such as patients requiring dialysis or heart surgery, etc.
Finally, Prof. Krishnan was sharply critical of an article published in The Hindu on the 10th of August by Hemant Shewade and Giridara Gopal claiming that India is undercounting COVID deaths by a factor of 5.29. He said this was an oversimplification. He said he did not agree with the methodology the article used. He said he had pointed this out to one of the authors, Giridara Gopal, on the day the article was printed. Prof. Krishnan is mentoring Mr. Gopal’s Ph.D. thesis.
Video link: India’s official COVID death count is an underestimation that will get progressively worse as the disease spreads in rural India. The government cannot claim comfort from India’s COVID mortality: AIIMS Professor Anand Krishnan to Karan Thapar for The Wire. Here is the link: https://youtu.be/OHMEHMjT0oU
India’s Underestimated COVID Death Toll Will Get Worse As Disease Spreads in Rural Areas
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