Even as coronavirus cases in India surged past the one-million mark, another key metric is showing a surprising downward trend. On Monday, India’s case fatality ratio – the proportion of deaths to Covid-19 cases – dipped below 2.5%. At 2.49%, India’s CFR is significantly below the global average of 4.2%. It is also lower than the corresponding figure for the United States (3.88%) and Brazil (3.81%), the only two other countries in the world to have a higher coronavirus caseload than India.
Taken at face value, this might point to some conditions that, luckily, favour India. Speaking toThe Hindu, virologist Dr Shahid Jameel points to India’s young population as well as the possibility that South Asians have higher innate immunity than Western populations due to possible factors such as exposure to other infections.
A history of bad data
However, at the moment, these are only theories: experts caution that we are still to know the exact medical reason for this low CFR is (if there is one at all). And, as a result, India’s policies cannot be based on it.
To add to this, before simply accepting these fatality numbers in the first place, a number of factors engender caution. For one, even in normal times, data collection on mortality is abysmal in India: only about 77% of deaths are registered and only 22% of those are medically certified, data from the Registrar General of India shows. As Covid-19 overwhelms health systems in India, and lockdowns disrupt public services and transport, there are fears that many deaths are not being counted.
Then, there are specific concerns about Covid-19 deaths. Several cities have seen funerals with Covid-19 protocols outstrip the number of confirmed coronavirus deaths, raising concerns that suspected Covid-19 cases not being counted in the official data.
Many public health experts fear local governments may have intentionally suppressed numbers of Covid-19 cases to protect their images. The BMJ reported that the city of Vadodara had attributed the deaths of nearly three-fourths of people who had the coronavirus to co-morbidities – or other underlying health conditions – ignoring World Health Organisation guidelines on the matter.
To make things worse, India’s local governments are not publishing the overall mortality data they collect. This is bad at all times – but especially given that there are strong indicators that coronavirus-specific mortality is not being captured well. With poor recording of coronavirus-specific mortality, even developed countries are tracking trends in overall mortality to watch for excess deaths, which might lead them to detect coronavirus outbreaks.
The Washington Post reported official data for Mumbai that shows a worrying rise in overall mortality during the month of May. Troublingly, three other metro cities that the paper contacted did not have updated mortality data. By extrapolation, data collection in towns and rural districts would at least be equally abysmal as in India’s big cities.
This dearth of critical mortality data is not only a major handicap while battling the coronavirus: it also hampers India’s attempt to gauge the impact fighting the pandemic has left on other health conditions. Speaking to Scroll.in, Prabhat Jha, one of the world’s leading experts on mortality in India explained that in Sierra Leone, the Ebola outbreak probably killed more children from lack of treatment for malaria than it did directly from the disease.
There are indications that point to a similar dynamic within India at the moment. Research has shown that there was an increase in deaths due to preventable causes as a result of the highly restricted access to healthcare during India’s harsh lockdown. For example, the shutdown of public transport prevented patients from accessing dialysis and chemotherapy treatment. Similarly, tuberculosis and HIV patients have been badly hurt by the lockdown restrictions.
As many parts of India lock down again, policy planners need to take into account both the coronavirus as well the healthcare damage inadvertently caused by efforts to contain the pandemic.
For all of this, mortality data is critical. All levels of the Indian state need to make sure it is collected, collated and published. Policy and public discussions without it stand severely impaired at the moment.