On the evening of July 13, Narayan Mitra, a 70-year-old businessman from Assam’s Silchar city, came down with a high temperature. Soon, he began to feel breathless. A chronic asthma patient, Mitra reached out for his inhaler, but found little relief.
In the morning, his son Abhijit Mitra phoned their family physician who suggested getting a Covid-19 test done. Abhijit Mitra accompanied his father to the government-run Silchar Medical College and Hospital on July 15. They travelled in an auto rickshaw. Narayan Mitra, his son said, was in fairly good spirits all the while. “He was a little weak and had some breathing troubles, but he was quite normal, conversing with the auto-driver the entire way,” said Abhijit Mitra.
At the hospital, the Mitras were told that they would need a clearance from a doctor to get a Covid-19 test. As they waited for a doctor, the on-duty health workers checked Narayan Mitra’s vitals and temperature. They also measured his blood oxygen levels using a pulse oximeter. It was dangerously low. He had to be administered oxygen immediately, the health workers reportedly told Abhijit Mitra – the Covid-19 test could wait. Narayan Mitra was whisked away to the emergency ward.
Soon, things took a turn for the worse, Abhijit Mitra recalled, with the hospital authorities informing him that Narayan Mitra had to be put on a ventilator.
In the evening, a molecular Covid-19 test was finally administered on Narayan Mitra.
The next morning, he died.
According to a media bulletin released by the Cachar district administration later that evening, Narayan Mitra had tested positive for the virus.
Yet, his name does not feature in the list of 370 people who, according to the Assam government, have died of the Covid-19, as of September 7.
What explains this?
Shadow over Assam’s rosy numbers
Assam is officially the state with the lowest mortality rate in India.With only 370 reported deaths out of nearly 1,30,000 cases as of September 7, the state has a stunningly low case fatality rate of around 0.28 %.
But cases like Narayan Mitra’s cast a shadow on this claim.
A spokesperson for the district health department told Scroll.in that the state death audit board had concluded that Narayan Mitra had died of myasthenia gravis, a chronic neuromuscular condition – not of Covid-19.
Narayan Mitra had been diagnosed with myasthenia gravis in 2017 and he was undergoing intermittent treatment for it at Vellore’s Christian Medical College, said his son. But he insisted it was unfair to attribute his father’s death to myasthenia gravis. “Okay, he died because he had myasthenia gravis, but would he have died had he not been Covid positive?” he asked. “It was triggered by the virus.”
Death audit boards
On July 11, days before Mitra’s death, Assam’s health minister Himanta Biswa Sarma announced the formation of a four-member death audit board for Covid-19. This, Sarma said in a tweet, was in accordance with the Indian Council of Medical Research’s guidelines. “Officially a death will be attributed to Covid-19 only after the board has ascertained it,” he wrote.
In truth, though, the ICMR, which is overseeing India’s response to the pandemic, has never recommended states to establish death audit panels.
Yet, several states have set them up, claiming they were helping ensure that Covid-19 deaths were accurately reported. Indeed, in states like Delhi, Tamil Nadu, and Maharashtra, data reconciliation exercises carried out by these committees have helped capture deaths that had gone unreported earlier.
In Assam, though, the death audit board seems to be doing the opposite – discounting deaths that should have been considered Covid-19 fatalities according to the ICMR’s protocol.
The scale of undercounting is massive: according to data provided by the state’s death audit board to Scroll.in, 550 people who died after testing positive for Covid-19 have been termed non-Covid deaths.
To make matters worse, cases of people who have posthumously tested positive for Covid-19 in Assam have not even been taken up by the death audit board.
The Assam model of undercounting deaths
In India, undercounting of Covid-19 deaths come in two variants, as this investigation in The Wire points out. First are the suspected Covid-19 deaths – people who had displayed clinical symptoms of the disease but there was no laboratory confirmation. These deaths have been ignored almost across the board in India.
The second is the failure to count deaths of laboratory-confirmed Covid-19 cases. This is what Assam has done in 550 cases.
Anup Kumar Barman, who heads Assam’s death audit board, said: “The cause of death in those cases was not Covid-19, but other comorbidities. For example, if a patient suffering from chronic kidney disease dies of end stage renal failure and incidentally he was Covid positive, that is not a Covid death.”
Similarly, if a Covid-19 positive hypertensive or diabetic patient died of a heart attack, the board was not adding them to the official toll, said Barman, who is also Assam’s director of medical education.
In the past, health minister Sarma has also taken a similar line. On August 15, he told reporters that in addition to the official death toll, 300-350 more Covid-19 patients had died in the state. Their deaths were not counted by the death audit board as Covid-19 casualties as they had other comorbidities.
In other words, almost 60% of the deaths of lab-confirmed positive cases have not been counted as Covid-19 deaths.
Barman insisted this was in line with the ICMR’s guidelines for appropriate recording ofCovid-19 related deaths. “As per ICMR guidelines, Covid deaths are those where people die of ARDS [Acute Respiratory Distress Syndrome], pneumonia, and DIC [Disseminated Intravascular Coagulation],” he said.
What the ICMR guidelines actually say
However, Prashant Mathur, director of ICMR’s National Centre for Disease Informatics and Research, who drafted the guidelines, took objection to Barman’s claims. “The ICMR guidelines give a much wider range of options,” he said. “A person could have other conditions than these three.”
Indeed, the guidelines note: “COVID-19 is reported to cause pneumonia/acute respiratory distress syndrome/cardiac injury/disseminated intravascular coagulation and so on.”
Also, contrary to Barman’s claims, the guidelines caution against recording existing comorbidities as the underlying cause of death in patients who have been found to be Covid-19 infected in laboratory tests:
“Patients may present with other pre-existing co-morbid conditions… These conditions increase the risk of developing respiratory infections, and may lead to complications and severe disease in a COVID-19 positive individual. These conditions are not considered as UCOD [underlying cause of death] as they have directly not caused death due to COVID-19,” the guidelines state.
Mathur explained, “If the sequence of events leading to death started because of Covid-19, then Covid-19 should be recorded as the underlying cause of death, otherwise it should be a contributing cause of death.”
Either way, Mathur said Covid-19 should be recorded as a cause of death in all cases where Covid-19 was confirmed by laboratory test. “What needs to be understood is if a patient [with comorbidities] would not have contracted Covid-19, his condition may not have deteriorated that fast,” Mathur said, when asked about Barman’s example of a Covid-19 positive patient with chronic kidney disease dying of end stage renal failure. “What happens is Covid accelerates the underlying chronic disease, the kidney damage in this case.”
To be sure, Assam is not the only state to be discounting deaths of Covid-19 positive people with comorbidities from the official, but the scale of it may be particularly profound in Assam, considering the state machinery’s brazenness about it. West Bengal, for example, shelved its death audit committee and started including all deaths of laboratory-confirmed cases in its official tally after coming under criticism.
Another peculiar Assam ‘protocol’
Besides, in Assam, a peculiar “protocol” has meant that cases of people brought dead to hospitals who subsequently test positive for the virus are not referred to the death audit board. Since Assam does not report deaths unless approved by the death audit board, these have gone totally unreported.
Take for instance, the case of 28-year-old Sayan Das who authorities in Silchar Medical College and Hospital claim was already dead when his family brought him to the facility on the evening of July 30. (His family contests that – his mother Supta Das claimed her son was alive when they reached the hospital but the authorities refused to treat him till the result of his rapid Covid-19 test was out). The previous day, Sayan Das had developed a fever and breathlessness.
Sayan tested positive – the test was conducted posthumously, according to the Silchar Medical College and Hospital’s vice-principal Bhaskar Gupta.
Das’s case was not sent to the death audit board at all, said Gupta. “We have a Covid protocol here – when a patient is brought dead we cannot consider,” he said.
This supposed protocol has left Sayan Das’s family and friends perplexed. “If he tested positive, why is the government saying he did not die of Covid?” asked one of his friends. “If he did not die of Covid-19, then what did he die of?”
In the same city, Narayan Mitra’s son Abhijit Mitra is at a loss too. “Why can’t the state government accept that my father died because of Covid-19?” he asked. “It matters to me because was it not because he was Covid positive that they did not even let me see his face one last time?”
This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.