India’s Uncounted COVID-19 Deaths

More than a year after the coronavirus began circulating around the world, India is facing a devastating second wave of infections and deaths. Hospitals in cities such as New Delhi and Mumbai are filled to capacity and facing oxygen shortages, with crowds of sick people forming lines outside. According to official statistics, the country currently has more than three hundred and fifty thousand cases and twenty-eight hundred deaths per day, with numbers continuing to rise. But unofficial statistics collected by journalists suggest that the true numbers are likely far greater, with one Financial Times analysis showing a death toll more than eight times the official count. The country’s Hindu-nationalist Prime Minister, Narendra Modi, has downplayed the scale of the crisis, holding large election rallies, and failing to deter people from attending a religious festival that attracts millions of people. (This past weekend, after a demand from the Indian government, Twitter blocked access to tweets critical of the Administration’s response.)

On Sunday, I spoke by phone with Rukmini S, a data journalist in Chennai who has been covering the pandemic for the Guardian and other publications. During our conversation, which has been edited for length and clarity, we discussed what crematorium data can tell us about the scale of the problem, the government’s mistakes in the past month, and why Modi remains popular amid the worsening crisis.

How have you and other people in your field been able to get a sense of the scale of the problem in India right now, given that we know official statistics are dramatically understating what is going on?

The most useful thing was being able to come into the pandemic with some prior understanding of how statistics function in India, and to know what the existing issues were. So, for example, we came in knowing that official statistics massively underreport all infectious diseases, such as malaria, and we got used to turning to other data sets that give us a better sense of underreporting. For infectious diseases, we know official statistics only capture reported data from public health facilities, which means that the whole world of private health [facility] data is left out. We have gotten used to turning to other sources that come up with estimates, such as the Institute for Health Metrics and Evaluation (I.H.M.E.).

And we had some sense of how deaths are reported in India. The lack of state capacity means that a lot of things the state wants to deliver cannot be delivered, so we know both births and deaths are underregistered in India. We have a sense of how much trouble there is to correctly assess the cause of death. And we know that this is a bigger problem for marginalized groups and women, who are more likely to be underrepresented in death statistics. So we came in knowing that even in the best of times, the statistical architecture, and the administrative architecture, struggles to register everyone properly. But I think that has helped us direct and focus our energies on models and estimates. And it has helped us focus on groups that might struggle more than others to have their deaths reported, and has caused us to come in with a strong and skeptical outlook, which means we know we might need other, outside sources, like newspapers or crematoria data. And we know data here has a long lag, so expecting immediate data is a problem.

We have official statistics about cases and deaths, and then other reports with unofficial estimates. What are you actually able to say about what we know?

Although there are official guidelines about what should be counted as a COVID-19 death, we know on record from officials in multiple states that those guidelines are not being followed. A very stringent definition of what is a COVID-19 death—a person testing positive prior to death—is being used, which leaves out the world of people who couldn’t get a test in time, or couldn’t make it to the hospital. So we know this is happening, but estimating the extent of that would be very useful. I have tried to make requests to state audit committees to ask about how many death certificates came to them, and how many were COVID-19 deaths. But that is not known and it’s a big problem, and there should be public pressure for it.

So I personally have come to the point where what I am concerned about is all-cause mortality. I don’t think that we are in a good position to understand COVID mortality, and I don’t think we will for a while. But what we see is a lot of people are dying, whether from COVID or not, and there are ambulances lined up, and they are dying out of lack of access to an I.C.U. bed or oxygen shortages or are simply unable to manage their chronic conditions because of a huge shortage of regular medical services in the past year. So I do think we have a huge rise in all-cause mortality, but I am tired of trying to figure out if they are COVID deaths or not. It’s just a partisan exercise right now.

So just to be clear: there is an enormous uptick in deaths at crematoria, but we don’t know to what degree those are directly caused by COVID, and to what degree they are caused by things such as oxygen shortages and other health crises caused by the chaos of the past year?

Yes. Again, it does appear there is a mass increase in deaths, but the administrative sectors are so tied up that I wouldn’t even be confident, in a country of this size, in claiming that we know what we are seeing. But it would make complete sense given the collapse of regular health care right now.

So when you see analysis, like the one in the Financial Times looking at crematoria data, it seems fair to say that COVID is causing a vast surge in deaths in India, but we don’t know exactly how many of them were caused by the coronavirus infecting the person, correct?

Yes. And, again, it is likely that COVID infections are causing a massive uptick in death. I think the one indicator that says a lot is hospitalizations. The fact that those are up across every big city and in every part of the country where we have information indicates that, even if you are not able to quantify the extent of underreporting, health systems are overwhelmed. All of the small factors that, added up, tell us about underreporting are clear. For example, in Delhi, there are five-day delays to even get a test. There is a thirty-three-per-cent positivity rate estimated in Delhi, but a huge number of people can’t get a test. We know from surveys in Bombay, for example, that people from non-slum areas are four to six times more likely to get a test. So that gives you a clue about the possible extent of underreporting in slum areas. We know historically that women and marginalized groups fall sick more, because they have less access to health care. So all this gives you some indication of what we are missing. The scale is undeniable.

What should the government be doing now that it is not currently doing?

It should not be minimizing the scale of what is happening. It did that for most of this year, right up until now. In his address to the nation a couple of days ago, Modi did say that the second wave hit like a storm. But we have also seen a lot of simultaneous attempts to clamp down on people who are talking about deaths on social media, and people having a bit of a go at journalists, saying they are spreading fear and panic. So that is something that needs to stop immediately.

The government also needs to get moving really fast on oxygen. A lot of the big public-health scale-up measures that the government is doing are not going to help now. They should have been done in January, and some of them will only help five years from now. So, for example, if we allow colleges to educate more doctors, they will open in a year, and then five years from now we will have more doctors. With oxygen, the government announced it was going to set up these oxygen plants, and a whole lot of money poured into PM CARES, the fund Modi created for charitable donations. He set up this fund, which is not transparent, and we cannot get information on it under the law. And we know that for eight months no bids [for oxygen plants] were even invited. Thirty-three [plants] are functioning now out of a hundred and sixty that were sanctioned.

The government also needs to be making it easier to get information. Indian Twitter looks like one big help line right now. This points to the fact that the mechanisms around things like where to get home oxygen don’t exist in the country. And, lastly, what you would hope for is a culture of more transparency. I don’t know if there is any hope for that. Even around things like the vaccines, the country has two being deployed, and one has published efficacy data and one hasn’t. India has done a very poor job of tracking post-vaccination infections, but it does seem to be artificially inflating this data to try to drive up vaccine acceptance. The idea of basing strategies on faulty data is something they have done in the past that they should be trying to step away from right now. The reason these things are inexplicable is not because we haven’t tried to ask, but because we get very few answers.

What does India need to do to start vaccinating more people quickly?

The way India’s vaccination strategy worked was to start with health-care workers, and the expectation at the time was that there would be high uptake among health-care workers, because it was most important to vaccinate them, but also because it would lead to high confidence in vaccine uptake among the rest of the population. One vaccine, Covaxin, had a major issue. This is a vaccine on which the Indian government is one of the partners, and you could argue there was a conflict of interest there. That vaccine was rolled out before efficacy data was available, which is unusual. Even now, we don’t have published efficacy data for that one. Because health-care workers tend to be a relatively better informed group, I suspect that there was greater vaccine hesitancy in that group because of these issues around it, and I don’t know if it permeated to the groups that came after that.

How is the government doing in terms of administration of the vaccine?

India does have a lot of experience in mass-vaccination programs, so we do have the architecture for it. The first round of doses for people over forty-five ran out, and the communication was, again, extremely opaque. We had the Health Minister repeatedly say that there was not a shortage when we had the people on the ground reporting that there were no doses available. And what will happen on May 1st is that a vaccination program of the central government will now be opened up to state governments and private hospitals as well. There was an announcement that they were also free to strike their own deals with vaccine manufacturers, which raises its own questions about pricing and availability. The two vaccines that are currently available have already declared their open-market prices, which are quite high in India. Across the world and across India, public-health experts have said the way to do this is to make it free for everyone. So it is a bit shocking that the central government is passing on this price-and-procurement burden to states.

So, yes, there were some shortages and some hesitancy and some lack of tracking after vaccination. But I am a bit more worried about what is going to happen starting May 1st in terms of prices and how state governments are going to be able to strike these deals on their own, and the fact that the vast majority of the most vulnerable have not been covered yet. Someone like me who is under forty-five and well off can jump to the front of the queue while someone older won’t be able to. That is very worrying.

Modi is often grouped together with Trump and Erdogan and other right-wing populists who have risen to power in the past decade, but he is much more popular than Trump or Erdogan. [Morning Consult’s approval tracker currently has him at seventy percent approval.] Do you sense that is changing?

No. There is an immediate analogy that comes to me, which is the demonetization of high-value bank notes in 2016. It is, of course, not at the same scale at all, but it caused huge distress to working-class people, and the immediate response was to say this affected people’s lives and livelihoods and was going to affect him in the elections. To some extent that happened again after the lockdowns in 2020, when there was horrendous distress afflicted on migrants across the country. The assessment was again that people would go home and turn on Modi.

My theory about Indian politics has been that people vote on ideas, and not about the material things people assume they vote on—not on broad economic growth, or someone building a road. So, if there is a particular government in a particular state that manages to make this a clash of ideas, and manages to show that a good welfare state would have prevented this kind of distress, and [Modi’s party] isn’t able to deliver on one, that might affect Modi in that state. But, as a broad national story, I don’t think that is how elections are fought and won in India, and so I don’t see this as a referendum on his popularity.