India has no data to challenge WHO excess Covid deaths

India has strongly objected to the World Health Organisation (WHO) estimates of 4.74 million excess death in India due to the pandemic in 2020 (0.83 million) and 2021 (3.91 million). This is over and above India’s official death count of 0.48 million (0.149 million for 2020 and 0.332 million for 2021).

India’s objections to the WHO are mainly four: (i) it used mathematical model for estimates (ii) it ignored India’s “authentic data” available in its Civil Registration System (CRS) (iii) India was put in tier II countries (where mathematical modelling is used because of lack of direct data) even though it has “effective and robust system” of data collection and (iv) it used media reports for estimation.

India’s claim of “authentic”, “effective” and “robust” data is highly questionable.

Civil Registration System (CRS) data of 2020

Firstly, the CRS data is only about registration of births and deaths. It is not about Covid-19 deaths at all.

The CRS 2020 report is useful in knowing “excess” deaths in 2020 over 2019. It does talk about the pandemic but only to explain the difficulties it posed to data collection. There are other reasons for poor data collection too, more about which later.

Second, the CRS 2020 data gives “registered” deaths in 2020 alone, not for 2021 – so, there is no way of knowing “excess” deaths in 2021 over 2019 or 2020 – while the WHO estimate is for excess Covid-19 deaths in both 2020 and 2021.

The CRS 2020 says there were 0.48 million excess deaths “registered” in 2020 over 2019. These deaths could have been caused by Covid-19 and non-Covid-19 illness as most private healthcare facilities shut and public healthcare was overwhelmed by the pandemic care, depriving healthcare for non-Covid diseases.

Third, the CRS 2020 report doesn’t tell the “level of registration” of deaths.

Unless “level of registration” is known, there is no way of knowing how many were left out of the registered deaths.

Here is how. The CRS report of 2019 had given “level of registration” of deaths for 2019 to be 92%. That is, the rest 8% deaths were “not” registered.

Level of registration was “arrived at using the Mid-Year Projected Population of respective States/UTs of from 2011-2019 based on 2011 census (Report of the Technical Group on Population Projections, July. 2020, National Commission on Population, Ministry of Health & Family Welfare)”.

How many deaths were not registered at all-India level in 2020? The CRS 2020 report doesn’t say.

Instead, it gives state-wise “death registration completed within prescribed time limit of 21 days”.

As per this, 11 states/UTs had more than 90% registered deaths and the rest 23 states/UTs lower. Of these 23, 7 state/UTs fall in 80-90% level, 7 others in 50-80% level and 8, including the most populous Uttar Pradesh in less than or equal to 50% level.

Here are some examples: Uttar Pradesh 50%, Bihar 75.5%, Madhya Pradesh 81%; Uttarakhand 44.2%; Assam 20%; Jharkhand 50.7% etc. Since these six states account for 37% of India’s population (as per Census 2011), imagine how many deaths were not registered within 21 days.

But the Centre’s rebuttal to the WHO says the “level of death registration” in 2020 was 99.9% and attributed this to “Vital Statistics of India based on the CRS 2020, office of RGI”.

The state-wise information provided by the CRS 2020 doesn’t add up to 99.9% – as it specifically says “11 States/UTs, namely Punjab, Chandigarh, Mizoram, Haryana, West Bengal, A& N Islands, Puducherry, Himachal Pradesh, Tamil Nadu, Andhra Pradesh, and Gujarat have achieved more than 90% registration of deaths” and the rest 23 states/UTs had less.

Where did 99.9% level of registration come from? And if indeed that was the case, what prevented the CRS 2020 from saying so?

Fourth, the Indian government doesn’t tell you how many excess Covid-19 deaths happened in 2020. It doesn’t even say anything about excess deaths in 2021. So, why the claim it has authentic, robust and effective data and squabble with the WHO?

Fifth, the CRS 2020 comes with a disclaimer: “The Office of Registrar General, India (ORGI) has only compiled and collated the data and presented it in the form of this report. As data is being furnished by States/UTs, ORGI is not responsible for authenticity of the information.”

So much for the robustness of its data.

Pandemic and other difficulties to collect data

As for the impact of Covid-19 scourge and other issues that impacted data collection for 2020, the CRS 2020 has devoted a segment to this.

Here are some examples of the difficulties other than the pandemic: In Uttar Pradesh “due to lack of manpower, publicity, remote rural areas” etc.; in Gujarat “most of the posts of Taluk/District Statistical Assistants are vacant”, “Registrars are not utilising the powers vested…regarding corrections and cancellation of entries”; in Assam “lack of awareness”, “not availability of CRS fund”; in Madhya Pradesh “vacant posts of Assistant Statistical Officer, Statistical Clerks and Clerks in various Municipal Corporations and Municipalities”; in Odisha “shortage of staff/manpower in the State”; in Punjab “shortage of Staff at every level” etc.

If you think the CRS 2020 can tell you anything about the Covid-19 deaths, let alone excess Covid-19 deaths in 2020, you are being naïve.

NHFS-5 of 2019-21

India’s rebuttal to the WHO doesn’t mention the National Health and Family Health Survey-5 (2019-21). The latest part of it was released in March 2022. Among others, it tells you about the level of death registrations with the civil authorities (as disclosed during the household surveys) in three years of 2019, 2020 and 2021. Hence, it is another useful report to know about the level of death registrations in India.

It says: “Death registration: Seventy-one percent of deaths of usual household members were registered with the civil authorities (83% of urban households and 66% of rural households).”

Its table “percentage of deaths registered with civil authority” for 2019-21 shows the level of registration at all India level is 70.8%. About states, some of the populous ones fare poorly in registering deaths: Uttar Pradesh 47.7%, Bihar 36.4%, Madhya Pradesh 74.1%, Jharkhand 39.9% etc.

Whether one picks the 70.8% of registration from the NFHS-5 or the state-wise registration of deaths from the CRS of 2020 (all-India level is not given), none suggest anything close to 99.9% level of registered deaths that the Ministry of Health and Family Welfare claimed to rebut the WHO.

The CRS 2020 and NHFS-5 data are useful in estimating excess deaths, but not very specifically about excess Covid-19 deaths. It is known excess deaths happened from the disturbing images of unclaimed bodies floating in the Ganges and other rivers in Uttar Pradesh, Madhya Pradesh and Bihar, far more buried in the sands of Ganges across Uttar Pradesh and cremations on street sides.

Several states like Bihar and Madhya Pradesh revised death numbers upward after court raps and form part of the official tally. But all states didn’t do that and so a complete picture hasn’t emerged. Several states have sanctioned far higher number of ex gratia claims than the official tally. For example, by early February 2022, Gujarat had sanctioned 87,045 deaths against its official tally of 10,579; Telangana had sanctioned 22,873 against its official tally was 3,993, Andhra Pradesh had sanctioned 38,015 against the official tally of 14,527. These excess numbers are not part of the Government of India’s tally.

Many intrepid reporters visited mortuaries, collected data from panchayat and municipal levels to report gross under-reporting of deaths (several times more than the reported). Then there are multiple credible studies. One was published by the Lancet, estimating 4.7 million of excess deaths in 2020 and 2021 – the same as WHO’s. The Science published another estimating excess deaths of 3.1-3.4 million between June 1, 2020 and July 1, 2021.

The excess deaths captured by reporters and studies match with that of the WHO.

There is another critical aspect to the excess pandemic deaths.

How many deaths get medically certified? This is critical to avail ex gratia that the Supreme Court ordered.

There is one source to find it out.

Registration of medically certified deaths

The Registrar General of India releases yearly “Report on Medical Certification of Cause of Death (MCCD)”. The last one came in June 2021 and provides the “percentage of Medical Certification in States/UTs during 2017-2019”. The percentage of MCCD is of the “total registered deaths”.^[x]

This 2021 report says the percentage of MCCD at all-India level is extremely low and is falling. From 22% in 2017, medically certified deaths fell to 21.1% in 2018 and 20.7% in 2019.

Surely, the pandemic disruptions would have pushed MCCDs far below 20.7% of 2020 (which is likely in a few months). This could be the other reason for states to sanction higher number of ex gratia payments than the official death counts.

Here are two more disturbing revelations about deaths from the CRS of 2020 mentioned earlier.

It said (i) “no medical attention” was received in 45% of registered deaths in 2020 and (ii) “institutional” registered deaths accounted for only 28% – that is, 72% deaths occurred outside hospitals and nursing homes/clinics etc.

What is wrong with mathematical modelling?

One of India’s objections to the WHO estimate is that it used mathematical modelling instead of actual data, as is the case with all such tier-II countries. Given that India has no estimate of excess deaths due to the Covid-19 either for 2020 or 2021, the WHO is being wiser.

Besides, India has no reason to complain about mathematical models. Recall how, in April 2020, the NITI Aayog had presented a mathematical model to the media (with a graph too), to claim that the Covid-19 cases will touch zero on May 16, 2020? That day (May 16, 2020), the official count of daily cases was 4,864, total caseload was 90,648 and deaths 2,871. A few days later (May 23), the NITI Aayog denied having made such claim and apologised for “misconception”.

In the interim, the Aayog had also claimed that the lockdown had averted 14-29 lakh cases and saved 37,000-78,000 lives.

All these were based on mathematical models which were designed for non-COVID-19 diseases.

The past two-and-half years of the pandemic would have surely improved the mathematical models to be employed.

Why excess death count matters?

Death, rather excess death due to the Covid-19, is not just a matter of statistics.

It shows the number of people who actually perished. Many of them would have been sole income earners of the households and all those households would have incurred heavy Covid-care expenses – far more than the “catastrophic” healthcare expenditure that pushed 60 million into poverty every year in normal times – as the Ayushman Bharat programme) PM-JAY) of 2018 acknowledged.

All those households which saw Covid-19 deaths need to get ex gratia of Rs 50,000 announced under the National Disaster Management Act of 2005, alternate livelihoods need to be provided so that consumption demand could be revived.

Mapping excessive death accurately also enables policymakers to address shortcomings in public healthcare infrastructure and invest appropriately to prepare for future pandemic shocks. Therefore, India should put its data system in place now, rather than mount a no-win battle against the WHO.