Why WHO estimate of death in India is correct: Expert explains

T Sundararaman, former executive director of the National Health Systems Resource Centre, unpacks World Health Organisation’s estimate of the excess mortality caused by the pandemic in a conversation with TOI: What is the scope of WHO’s estimate? It’s about excess mortality, which means the difference between what would have been expected to be the mortality given the previous trend if there had been no pandemic as compared to the actual deaths that occurred after the pandemic. It includes Covid deaths, deaths due to the disruption of other essential health services and worsening of social determinants like poverty. You can’t measure all these separately. What you do measure is the net effect of a pandemic, that is, excess mortality. medium91522836 What it does not say is the break-up between the three. At no point does WHO comment on the number of deaths attributable to Covid. There are reasons why excess mortality is preferred. One reason is that direct and indirect effects, as long as they lead to mortality, are equally important. Mortality due to indirect causes is completely missed unless we look at excess mortality. India’s Sample Registration System (SRS) is the main source of mortality data. How is it connected to the Civil Registration System (CRS) of states? CRS across India is uniform and is organised by the Registrar General of India. States implement it and don’t have any flexibility. Knowing that death registration is weak and cause of death certification is as low as 21%, to get a better sense of mortality the RGI also does the SRS. They take a sample of villages across the country, send people to verify death registration, search for missing deaths and also explore causation. Problems of quality are overcome by taking a large enough sample and making a detailed estimate of death registration. SRS usually comes out after a two-year lag. By convention, it’s considered the gold standard. For 2020 and 2021, SRS data is not available. Now, what we have is only the death registration. The extent of death registration in India is inconsistent across databases. Why? Look at the 2019 reports of SRS and CRS. You would find in only 13 states and four UTs has there been 100% reporting. The large and populous states are not in this list. Now, to expect in a year when there was so much disruption that death reporting went up to 100% is not tenable. Look at the 2020 figures (of CRS) of UP and Bihar, we are getting an abnormally low death report. Instead, if we simply apply the 2019 mortality rate to the figures of UP and Bihar, deaths registered are almost 40-50% less. If you were to apply the 2019 mortality rates to the 2020 population and say there is no excess mortality, you would find we are missing 9.5 lakh deaths. Remember, most of WHO study’s excess deaths are for 2021. For the nation as a whole, the 13 states with 100% reporting show excess deaths as compared to their expected deaths. If you add the figures for India, the excess deaths of states with 100% reporting will be offset by states that are under-reporting. At the India level, you may claim a 90% plus death registration which is not valid. Also remember, the Covid deaths were collected through a parallel system, not through the civil registration and vital statistics system. They were collected directly from the district administrators reporting it from laboratories and from hospitals. Therefore, they had no cross-reference with the rest of the system. I think WHO’s methodology has been robust. If anything, it’s an underestimate. WHO’s study shows the bulk of the excess deaths were in 2021 for which data is not out. What WHO did was to take death reports from many sources. Many states have put it up in the public domain. The number has not been released but it’s available. They looked at the states where data is available and extrapolated for the whole country. Even an RTI should be able to uncover the number of deaths with the RGI because it’s reported on a regular basis. So, WHO used numbers available with states which have better systems of reporting to extrapolate. It stands to reason. Even in 2020 monthly reports, in March and April, there was a slight decline in mortality. The lockdown was there, but Covid-19 had not happened. Even disruption of essential services takes some time to manifest as deaths. Government must release its own estimate of excess mortality data and should not remain confined to its administrator-based Covid mortality reports. It’s not as if WHO is countering government reports, the government has not reported excess mortality. I don’t think we should shoot the messenger. Aren’t WHO’s numbers in sync with similar studies? Yes. There are at least five other studies and they have all come to similar conclusions. This is triangulation. We are not going by primary data, it’s an estimate. The best way to validate it is to triangulate it across different methods. That holds out the validity of WHO’s study.