Stronger health system could have averted 500,000 non-Covid deaths in India in early lockdown period

As India is focused largely on responding to the threat from Covid-19, it has been forced to turn a blind eye to deaths due to other causes as a result of highly restricted access to healthcare during the lockdown. These deaths have been caused often from causes that are preventable. They reflect the weakness of the Indian health care system. This is also a huge challenge when fighting the coronavirus itself.

A crisis is not created only by the incriminating agent or event. As novelist Michael Crichton wrote in The Andromeda Strain, which inspired the film that has an uncanny resemblance to the events that are now unfolding, “A crisis is the sum of intuition and blind spots [of men], a blend of facts noted and facts ignored.”

The sad fact ignored in midst of the crisis is that lakhs of people are dying in India due to causes other than coronavirus, and many more will do so if we do not immediately take measures to redeem this.

Between January 30, when the first case of Covid-19 was reported in the country, and May 3, the last day of the second extension of the lockdown, we estimate that about 24 lakh people have died in India. We also review evidence that the prolonged nationwide lockdown and resultant huge decreases in healthcare utilisation across rural India will lead to lakhs of additional deaths due to causes such as tuberculosis, HIV and cancers.

Estimates of deaths so far

The civil registration system in the country is highly deficient in several states. The system cannot produce a simple count of births and deaths occurring in the country on a real-time basis. In any case, incomplete registration coverage in some of the bigger states does not allow any meaningful use of the counts for analysis.

In absence of any official population projections for the country, we used the estimates of populations and crude death rate provided by the United Nations Population Division to estimate the expected number of deaths for India in 2020, which when divided by 366 in this leap year provides an estimate for the average daily number of deaths in the country. We used this estimate to calculate the estimated number of deaths in the period between January 30 till May 3.

Assuming that during the period of lockdown, there would have been no deaths due to road traffic accidents, suicides and intentional injuries (though the deaths in Maharashtra of 16 migrant workers as they slept on a rail-track and at least 11 residents in an industrial accident in Vishakhapatnam belie this assumption), we subtracted the deaths due to these causes (as estimated from the Million Deaths study mentioned below) in the lockdown period from the total expected deaths.

We thus estimate that more than two million people died in India during this period.

India does not produce any data on causes of death for the country on a regular basis. The Registrar General’s office produces data on causes of death from a large number of hospitals under the Medical Certification of Causes of Death scheme. The data is deficient in terms of completeness, quality, and timeliness. To address this deficiency, the Registrar General’s office uses a verbal autopsy tool (an assessment of cause of death based on an interview with a close family member of the deceased) to record causes of all deaths recorded in the annually conducted household survey, known as the Sample Registration System.

We used the results from the last such exercise conducted between 2010-2014, covering a million reported deaths (or the Million Deaths Study), to estimate the contribution of these causes to total deaths in this duration. For neonatal deaths, we used UNICEF estimates for 2019. We used these proportions and applied them to estimate number of deaths due to select causes in the period under consideration.

During this period, more than 100,000 children would have died within the first month of life, and 6,000 mothers in the maternity period. More than 100,000 would have died due to cancer, and similar numbers due to diarrhoea. More than 90,000 died due to tuberculosis.

It is not less significant that out of the 23 lakh estimated deaths in the time period under consideration here, about five lakh could be prevented by stronger health systems. Based on comparison of chances of dying due to a disease (case-fatality) between India and comparing it to case-fatality of 24 countries with stronger health systems (Universal Health Coverage index score over 90), researchers at Harvard TH Chan School of Public Health estimated that roughly 2.4 million annually or about 25% of all deaths in India are preventable.

Using the same proportion, it can be safely estimated that of the two million deaths in India between January 30 till May 3, strong health systems could have averted about 500,000 deaths.

Restricted access

Restricted access and availability of services will lead to huge increase in deaths

In the rural areas of South Rajasthan served by AMRIT Clinics managed by the Basic Health Care Services not-for-profit organisation, we are witnessing diabetic patients present with ketoacidosis since they could not get their insulin, patients with tuberculosis deteriorate (and in one case died) because they could not receive treatment, and those with HIV living in fear since they have not been able to get their drugs last month.

This is the result of public transport being shut down, fear of the police and restrictions of services offered by most public and private hospitals. An analysis based on a review of National Health Mission data across the country for the month of March and April 2020 shows a disturbing picture in comparison to similar periods of 2019: it showed that about 100,000 fewer cancer patients reached hospitals, 450,000 fewer children received vaccinations and 30% fewer obstetric emergencies were presented to the hospitals.

A modelling based on rapid assessment last month showed that a two-month lockdown followed by two months of gradual resumption of TB services (defined as the “recovery phase”) would even in the best-case scenario lead to 150,000 additional deaths due to TB over the next five years. In the more plausible scenario of a three-month lockdown and a 10-month recovery phase, the number of additional deaths due to TB alone would be more than 500,000.

This estimate does not take into account the impact of economic slowdown on the disease – such as by reducing availability and intake of nutritious food – and hence is likely to be an underestimate.

While the numbers presented here may vary somewhat using different methods, the magnitude of deaths, and inference being drawn here will not alter significantly.

A very large number of people in India continue to die due to preventable causes. The extended lockdown with restricted access and scaled-down health services will lead to a huge increase in deaths due to many of these causes. Managing the Covid-19 epidemic does not mean that we need to restrict access to other services.

The Tata Memorial Cancer Hospital in Mumbai, for instance, has shown how the two objectives can be met simultaneously with understanding, courage and leadership. The hospital set up a core Covid-19 team to plan and coordinate the response, set up screening camps outside the hospital, instituted standard operating procedures for suspected and confirmed Covid-19 cases, and offered paid leave for high-risk staff members.

We need to redouble our efforts to strengthen health systems and to reduce all preventable deaths while managing the pandemic. As an immediate measure, we should help people to reach health facilities or health services to reach patients (such as carrying out home delivery of drugs for TB patients) and opening up all health facilities to provide full set of services, with due caution.

We should no longer ignore the uncomfortable fact of high levels of non-Covid-19 deaths now and in times to come.

Pavitra Mohan, a paediatrician and public health physician, is the co-founder of Basic Health Care Services. He leads health services at Aajeevika Bureau.

Raj Gautam Mitra is a statistician who earlier served as Inter-regional Advisor to the UN Statistics Division at New York.

Arpita Amin is Executive Research at Basic Health Care Services.