The Ministry of Health and Family Welfare has yet again issued a statement questioning studies that have found that India's COVID death burden is at least four times than currently reported.
This time around India is raising doubts about the World Health Organisation's methodology of counting COVID-19 deaths after a New York Times, and Devex article revealed that a report by the organisation has found that there were close to four million COVID-19 deaths in India. The country has so far reported only 522006 COVID deaths.
The New York Times article titled India Is Stalling the W.H.O.'s Efforts to Make Global Covid Death Toll Public states that, in the yet to be released Excessive COVID Mortality Report, the WHO has found that the total death toll till the end of 2021 stands at over 15 million. Along with India, the report points out several other countries such as China, Russia, Egypt, Indonesia for underreporting or not counting the exact COVID death toll. The New York Times, however, does not have an exact estimate of the number of deaths reported in this new report.
However, the WHO has not set a release date for the report, yet. A spokesperson from the WHO media team told BOOM that the WHO intends to release the report in the near future but did not share any tentative date. He also stated that the media will be intimated when the date is finalised. BOOM asked the spokesperson about India's reaction to the estimates but he did not answer the other questions.
This is not the first time that the Indian government has criticised and questioned studies that found that India missed counting several COVID deaths. One such study was published in Science in January 2022 by Dr. Prabhat Jha, an epidemiologist at the University of Toronto. BOOM spoke to Dr. Jha who is a member of the Technical Advisory Group formulated by the WHO but he was commenting independently on the current topic.
"Each study can have errors and can be wrong, but assembly of many studies- using registration data (WHO, us, others), modellling (less reliable) etc show a consistency as do our 3 studies noted above," Dr. Jha said also adding that of India's 10 million deaths estimated by the United Nations Population Division (UNPD) in 2020, over 3 million were not registered and over 8 million did not undergo medical certification.
What Is The Methodology Used By WHO?
First reported by Devex, India was not happy with the WHO's estimates and even requested the apex health body to squash these estimates for a period of 10 years.
The WHO has used various methods to calculate the excess death estimates. They have combined national data on reported deaths from the respective countries along with new information from localities and household surveys, and statistical modelling to account for deaths that were missed. The difference in the new global estimates mostly represents deaths that were previously uncounted both from COVID as well as indirect deaths such as people who lost their lives because they were unable to access care for other diseases due to the ongoing pandemic.
The calculations also take into account expected deaths that did not occur because of Covid restrictions, such as those from traffic accidents. Excess mortality here suggests the difference between all deaths that occurred and those that would have been expected to occur under normal circumstances.
To ensure that the WHO was accounting for the real measure of the impact of the pandemic, the WHO constituted a 33- member Technical Advisory Group comprising of demographers, public health experts, statisticians, and data scientists. These experts used statistical models and made predictions based on country-specific information such as containment measures, historical rates of disease, temperature and demographics to assemble national figures and, from there, regional and global estimates along with the already provided data.
In case of India, the country has not submitted its mortality data to the health organisation for the past two years. The experts thus gathered data from 12 states which showed at least five to six times as many deaths as a result of Covid-19.
Why Is India Opposing It?
Even though India has not submitted annual data, the country in a press release stated that they find the methodology flawed as he research does not take into account India's diverse topography and demography.
"India feels that the process was neither collaborative nor adequately representative," the government said in a statement to the United Nations Statistical Commission in February. It also argued that the process did not "hold scientific rigor and rational scrutiny as expected from an organization of the stature of the World Health Organization."
In the recently released statement, the government is against the fact that 'the analysis uses mortality figures directly obtained from Tier –I set of countries, but uses a mathematical modelling process for Tier II countries (which includes India).'
The statement also says that India has presented its apprehensions about the data on several occasions and has been accompanied by China, Ethiopia, Indonesia, Egypt in questioning WHO's us of unofficial data sets. India has asked that the models used on the 18 Indian states also be applied to Tier 1 countries to validate and authenticate the model. They also said that the WHO is yet to respond to questions on demographic indicators, test positivity, and containment measures as they were subjective to India for every state has different measures and indicators.
When asked to react to India questioning the methodology, Dr. Jha asked India to share official data sets or bring about a change in counting deaths or increase medical registration and certification of deaths.
How Is India Counting COVID Deaths?
After the Supreme Court asked the Centre to issue standard guidelines for counting COVID-19 deaths, the Indian Council of Medical Research prepared an eleven-page document describing the methodology to note deaths. Only if an individual tested positive for the disease and presented symptoms along with suffering from other co-morbidities, then the underlying cause of death both institutionally and non-institutionally would be considered as COVID-19.
What Should India Do For Proper Counting Of Deaths?
BOOM asked Dr. Jha how India could improve its reporting of missed deaths and increase registration and certification.
"Add a simple question on 2022 Census to be run in September. Since Jan 1, 2020 has there been a death in this house (FROM ANY cause) and if so, age in years, sex and DATE (exact or at least the week). This would allow DIRECT measurement of all the possible COVID deaths including the major delta wave of April-June 2021. Also, re-start the Sample Registration System which surveys about 1% of houses randomly in the country and which would include verbal autopsy to get at causes of death. The Million Death Study works within the SRS but the last SRS report released is for 2017."
The epidemiologist concluded by saying that if this collected data suggested that the death toll was at par with what India is reporting, all the studies would revise their estimates.