The world only knew about the reported number of cases, hospitalizations, and deaths due to the Covid-19 pandemic. The world needs to know the true devastation the pandemic has wrought on people over the last two years. People might have died due to Covid pneumonia itself. People might have died of other illnesses triggered by Covid. People might have died of other diseases even without Covid as they could not or did not access healthcare services. Some deaths like accidents might have been actually prevented due to lockdowns and travel restrictions. The reports on excess deaths from WHO and others have to be understood in the context of the above scenarios says Dr. Krishna Reddy Nallamalla, President, InOrder Regional Director, South Asia, ACCESS Health International.

Every country maintains the information on every birth and death in its Civil Registration System (CRS). Many developed countries maintain complete records with little lag time. Many developing countries capture nearly 90% of the actual data. Others may have inadequate data records. India has been witnessing a progressive improvement in the percentage of data collected every year and currently exceeds 90% across most of the states. While births and deaths are captured, the cause of death is available in less than 30% of the cases. Thus, verbal autopsies are used in national surveys to arrive at the cause of death indirectly.

Expected deaths in a year are calculated based on the trends observed in preceding years. Actual deaths published by civil registers will throw light on whether there were excess or fewer deaths than that predicted. Researchers arrive at excess deaths in a country in a year based on the information provided by the country’s civil death registers. In the absence of the information, researchers resort to advanced statistical modeling to arrive at likely excess deaths. While excess deaths reported by WHO and others for developed countries are actuals, the excess deaths reported for India and many other similar countries are as per modeling based on disclosed assumptions.

The disagreement in India’s case is on the assumptions used in modeling. Some of the assumptions were based on reports published in newspapers based on information they supposedly gathered through right to information (RTI) queries. A potential error in this approach is the assumption that the information provided through RTI is reliable and verifiable and the report published in newspapers is as per the information gathered. Actual figures released from CRS are definitely more reliable than the numbers arrived at through various assumptions unless the CRS figures are not trusted. It is very unlikely that the CRS figures are not true.

WHO and other researchers could have waited for actual figures from the civil registration system before publishing their reports. It takes time for any country like India to compile the data across the country after proper verification. Well-designed randomized surveys may be needed to validate the numbers and also to arrive at the percentage of data captured. While WHO and other researchers have clarified that their estimates do carry a potential for errors in their assumptions and statistical methods, the unintended harm the reports can result should have been thought out before making the reports public. Governments are at risk of losing public trust in their institutions. Trust in one’s government is one of the critical variables that had an impact on how people responded to rapidly changing guidelines. Vaccine hesitancy exhibited in many countries accounts for a lack of trust in governments and science.

Despite the debate, we should continue our efforts to arrive at true excess deaths and the cause of these deaths. There are well-established epidemiological methods to arrive at true excess deaths. It is also possible to arrive at possible causes of these excess deaths through well-designed verbal autopsy studies and structured questionnaires. Triangulation of data from compensation and insurance claims with data from surveys and civil registers will take us much closer to the truth. We should not lose the opportunity to learn from the pandemic. We should learn from what worked well and why and what did not work well and why.

The controversy should spur us to strengthen our civil registration system further. In addition, we need to strengthen our disease surveillance system and capacities in epidemiological studies. The national health information system envisaged in Ayushman Bharat Digital Mission (ABDM), when realized, will advance our ability to analyze real-time health data across the country. Let India not lose the opportunity to learn from the Covid pandemic to build back our health systems stronger and more resilient.

About the author- Dr. Krishna Reddy Nallamalla, President, InOrder, Regional Director, South Asia, ACCESS Health International