Where WHO got India’s Covid death toll wrong

Controversy over the under-reporting of Covid deaths in India has skyrocketed. A World Health Organization report projected, through mathematical modeling, that India had 4.7 million, or 47 lakh, excess Covid deaths in 2020-21. Surprisingly, none of the authors seem to have engaged with the Registrar General of India (RGI) who is responsible for the Civil Registration System (CRS). Responsibilities for reporting and registering births and deaths are set out in the Registration of Births and Deaths (RBD) Act 1969, which derives its strength from the concurrent list of the Constitution.

By law, each state’s chief registrar has one year to send compiled birth and death data to the RGI for collation and publication. CRS 2020 was released on May 3, and a two-year lag has been the norm even in pre-Covid years. Cause of death is recorded as part of the Medical Cause of Death Certification (MCCD) system – the scope of this data is limited as it only applies to urban areas and notified hospitals. The RGI has not yet published it. But for the WHO and other mathematical modellers, to assume that India has no system for counting the dead and delving into calculating mortality based on tiny samples collected through informal channels is absurd.

CRS death data shows an overall increase of more than 6% in Maharashtra, Bihar, Gujarat, West Bengal, Andhra Pradesh, Tamil Nadu, Karnataka, Madhya Pradesh, Rajasthan, India. ‘Assam, Andhra Pradesh and Haryana. The CRS data even provides a breakdown by age cohorts and the comparison of deaths among the elderly from 2018 to 2020 shows a reduction in deaths in the 70+ age group in Kerala and partially in Telangana. Of course, further analysis and commentary is needed, but no one can say the system is dysfunctional.

An even more reliable tool than the CRS is the Sample Registration System (SRS) – it is the largest demographic survey in the world and has been in operation since the sixties. Eight million home visits result in a body of data on fertility and mortality. These visits were, however, delayed during the pandemic, from 2020 to early 2022, when families, enumerators and examiners faced repeated Covid outbreaks and lockdowns. The SRS has been operational for decades, although the focus on timely data collection could certainly improve.

By law, the whistleblower and registrar must complete the registration process within 21 days. Registration after 21 days requires approval at the higher levels – these appear to be increasing incrementally – specified in the RBD Act. Surprisingly, Maharashtra and Delhi are not included in the relevant tables because “only partial information has been provided”. This shows that status responses are not accepted mechanically. The gaps and delays call for giving higher priority and monitoring to the collection of data on births and deaths.

The RGI has a legal obligation to declare births and deaths. For the calendar year 2020, the CRS figure is around 81 lakh deaths, which is 4.7 lakh more than the previous year. The SRS release is expected soon and will in all likelihood show a higher figure. But by no means will it come close to the 47 lakh deaths that WHO modellers have announced for 2020 and 2021 for India. The WHO Technical Advisory Group selected India for its modeling exercise without engaging with the RGI. Instead, modellers and academics have published a slew of papers using data such as deaths among Indian Railway MPs and staff or have based their studies on state websites or responses from RTI to questions from the media. None of these is sufficiently representative to warrant extrapolation to cover a country as large and diverse as India.

India’s population will soon be (if it hasn’t already) been the largest in the world. The population of Tamil Nadu is roughly that of France and Bihar is the size of Germany. The population of Uttar Pradesh, India’s most populous state, is roughly that of Brazil. In such a scenario, basing an international WHO report and academic research on various samples and extrapolating data to yield alarming results does a disservice to an age-old national system. But it also overturns a convention that UN systems only rely on national data sources. The report has unnecessarily alarmed Indian citizens and the global community.

That tens of thousands of people have lost their lives in tragic conditions for which no one was prepared is a fact. Currently, around seven lakh claimants have sought compensation related to Covid deaths – not millions. The publication of CRS reports has always taken two years, which undoubtedly requires a reduction. But that doesn’t justify the WHO’s search for new sources, almost implying that the state’s data is unreliable. If this were the case, data on female mortality, for example, would not show a registration rate of 40% compared to 60% for males – this is in line with the realities on the ground, as female deaths are not not considered important for issues such as inheritance and property rights.

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The good news is that awareness of the need for birth and death registration is growing. The RGI website says tighter reporting schedules and requiring medical facilities and practitioners to report the cause of death are on the cards through amendments to the RBD Act. Digitization at the primary level has reached 85% and this will reduce the time to publish data. The use of digital software is increasing in all states and reliance on manual reporting is decreasing. Future RGI reports need to be released quickly because only this data can alert the political system, policy makers and society to progress or lack thereof. That is what should drive the reform.

India faces several challenges, but collecting and publishing data is not one of them.

This column first appeared in the print edition of May 19, 2022 under the title “WHO turned bad”. The writer is a former secretary at the Ministry of Health. Views are personal

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