Incalculable Tragedy: We May Never Know the Truth about India’s Covid-19 Numbers

On May 11, the World Health Organization (WHO) designated as a “variant of concern” the double-mutant strain of the novel coronavirus first identified in India last year and believed to be responsible for the rapid spread of the disease across the country since at least February. For months before this, epidemiologists had worried that unbridled spread in the world’s second most populous country – home to 1.37 billion people or 18 percent of the world’s population – could give rise to new mutations, thwarting global efforts to control the pandemic as multiplying variants would forever move the target for vaccine development efforts. Now, as much commentary has since concluded: India’s problem is the world’s problem.

It is now clear that by undercounting the numbers, India consistently played down the course of infection and its dangers to society and the economy. This lulled the population – and those in charge of crucial healthcare systems – into a false belief in an Indian exceptionalism that purportedly kept people safe while developed countries went through surges that left millions in hospital and hundreds of thousands dead.

At IndiaSpend, we have tracked the metrics provided by the government since India’s first case was reported on January 23, 2020, and have repeatedly questioned India’s Covid-19 fatality numbers, and hence its overall infections. We have also shone the light on other vital data gaps: inadequate testing, which is essential for assessing the spread of infection; negligence in collecting data on crucial issues such as breakthrough infections when people already vaccinated go on to develop Covid-19; and failure to conduct genomic sequencing despite a first-rate biotechnology infrastructure.

Inadequate testing

Early in the pandemic, while India was working to ramp up its testing capacity like most countries, we reported how inadequate testing belied the true nature of contagion and the extent of its spread. By March 2020, signs of community transmission were everywhere and the WHO was exhorting countries to “test, test, test”. Yet, India continued to conduct fewer tests than needed, even on healthcare workers. Some regions, such as the northeastern states, continued to report lower case numbers than states with comparable populations, prompting warnings of inadequate testing and forecasts of a potential onslaught, we reported. It was more than six months after the first signs of the pandemic’s wide spread that India’s health minister, Harsh Vardhan, admitted in October 2020 that the country was indeed witnessing community transmission.

By May this year, India had significantly scaled up its testing capacity, but testing centers are mostly in urban areas while SARS-CoV-2 is making inroads into villages and remote regions. (Even cities continue to report delays and difficulty in testing because capacity has not kept up with the rising demand.) The government is not providing a rural-urban breakdown of new cases, deaths or tests conducted, but the local media are reporting vast undercounting, such as a report from Gandhinagar, the capital of Gujarat: While the government claimed 182 people had died of Covid-19 in the entire district, 690 people were reported to have died in just four of the district’s 200-plus villages. Nearly 66 percent of Indians live in villages, and unless innovative ways are found to scale up testing – for instance, door-to-door screening, as has been done with tuberculosis before, or mobile testing vans – the case and death count will always remain underestimated.

Omissions – inadvertent or deliberate

Estimating the death rate during a pandemic is a fraught exercise: At any given time, the total number of Covid-19 cases includes the number of active cases, the number of those who have recovered, and the number of those who have died. But it takes between two and six weeks (or more) for a case to be decided – for the patient to recover, or to die – so including active cases when calculating the death rate is incorrect, and keeps the number artificially low.

With India’s inadequate testing already keeping its Covid-19 case numbers low, its death rate is bound to be an underestimate when combined with the above problem, as IndiaSpend reported in June 2020. At a press conference on May 11, for instance, the central government claimed the death rate from Covid-19 was 1.09 percent, whereas using the more accurate formula (dividing the number of deaths by the number of decided cases) would yield a higher 1.3 percent. This might seem like a difference of a small fraction but translates into a significant number when deaths have exceeded a quarter of a million (again, by the underestimated official count).

Further, our reporting has shown that in official Indian data, only a person who has tested positive prior to death is recorded as having died of Covid-19, which leaves out not only those who were not tested or those who died at home but also those whose test may have returned a false negative (the antigen test, used widely in India, is known to return false negatives up to half the time). It also does not account for those who may have had “long Covid-19” and died of related complications. This is against the WHO’s guidelines for the certification and recording of Covid-19 deaths which specify that “Covid-19 should be recorded on the medical certificate of cause of death for all decedents where the disease caused, or is assumed to have caused, or contributed to death”.

For all these reasons, medical practitioners and epidemiologists, as well as journalists, have raised red flags and repeatedly asked questions, most pressingly on India’s Covid-19 case and death numbers, which are key to planning and implementing a response to the pandemic. Rukmini, for instance, has approached the audit committees that many states have formed to correctly estimate Covid-19 deaths, but has not been given any data on how many applications for death certificates they have received.

Local reporters in various cities have also tried to match officially declared numbers with the number of bodies cremated or buried with Covid-19 protocols, but these efforts are sporadic and inefficient at best. Many experts believe the only way to get a closer approximation of India’s Covid-19 deaths would be to calculate excess fatalities – the number who died during a Covid-19 year that exceed the average number of deaths in preceding years.

Overall mortality, however, can be accurately calculated only if all deaths are recorded. In India, only 79.6 percent were registered in 2017, and of these, only just over one in five (22 percent) were medically certified, with the underlying cause of death incorrectly recorded in many cases. In the middle of a raging pandemic, even states such as Kerala that normally register all deaths, were recording fewer numbers, officials told us for a story in March. They attributed this to reduced mobility during lockdowns and curfews, reluctance to visit government offices, and an increase in the number of deaths at home due to reluctance to visit hospitals.

In the end, this is an incalculable tragedy: The world may never know the true picture of India’s Covid-19 spread. And many who lost their lives in the pandemic may never be recorded in official statistics – uncounted witnesses to the Indian government’s gross mishandling of the crisis.