Arab Times

Coro­n­avirus Ques­tions raised on In­dia’s death toll

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NEW DELHI, Sept 17, (AP): When Narayan Mi­tra died on July 16, a day after be­ing ad­mit­ted to the hos­pi­tal for fever and breath­ing dif­fi­cul­ties, his name never ap­peared on any of the of­fi­cial lists put out daily of those killed by the coro­n­avirus.

Test re­sults later re­vealed that Mi­tra had in­deed been in­fected with COVID19, as had his son, Ab­hi­jit, and four other fam­ily mem­bers in Silchar, in north­east­ern As­sam state, on In­dia’s bor­der with Bangladesh.

But Narayan Mi­tra still isn’t counted as a coro­n­avirus vic­tim. The virus was deemed an “in­ci­den­tal” fac­tor, and a panel of doc­tors de­cided his death was due to a pre­vi­ously di­ag­nosed neu­ro­log­i­cal dis­or­der that causes mus­cle weak­ness.

“He died be­cause of the virus, and there is no point ly­ing about it,” Ab­hi­jit Mi­tra said of the find­ing, which came de­spite na­tional guide­lines that ask states to not at­tribute deaths to un­der­ly­ing con­di­tions in cases where COVID19 has been con­firmed by tests.

Such ex­clu­sions could ex­plain why In­dia, which has recorded more than 5.1 mil­lion in­fec­tions - sec­ond only to the United States - has a death toll of about 83,000 in a coun­try of 1.3 bil­lion peo­ple.

In­dia’s Health Min­istry has cited this as ev­i­dence of its suc­cess in fight­ing the pan­demic and a ba­sis for re­lax­ing re­stric­tions and re­open­ing the econ­omy after Prime Minister Naren­dra Modi or­dered a strict lock­down of the en­tire pop­u­la­tion ear­lier this year.

But ex­perts say the num­bers are mislead­ing and that In­dia is not count­ing many deaths.

“We are un­der­count­ing deaths by an un­known fac­tor,” said Dr. T. Ja­cob John, a re­tired vi­rol­o­gist.

The Health Min­istry has bris­tled at past al­le­ga­tions of an un­der­count in fa­tal­i­ties, but it re­fused to com­ment this week on whether states were re­port­ing all sus­pected and con­firmed virus deaths.

De­ter­min­ing ex­act num­bers dur­ing the pan­demic is dif­fi­cult: Coun­tries count cases and deaths dif­fer­ently, and test­ing for the virus is un­even, mak­ing di­rect com­par­isons mislead­ing.

In In­dia, record­ing mor­tal­ity data was poor even be­fore the pan­demic struck. Of the 10 mil­lion es­ti­mated deaths each year, fewer than a quar­ter are fully doc­u­mented, and only one­fifth of these are med­i­cally cer­ti­fied, ac­cord­ing to na­tional figures.

Most In­di­ans die at home, not in a hos­pi­tal, and doc­tors usu­ally aren’t present to record the cause of death. This is more preva­lent in ru­ral ar­eas, where the virus is now spread­ing.

Dr. Prab­hat Jha, an epi­demi­ol­o­gist at the Univer­sity of Toronto who has stud­ied deaths in In­dia, said coun­tries should err on the side of over­es­ti­mat­ing deaths if they want to make progress in fight­ing the virus.

“It is bet­ter to have no es­ti­mate than an un­der­es­ti­mate,” Jha said.

Record

The Health Min­istry guide­lines echo this con­cern, ask­ing states to record all sus­pected virus deaths, in­clud­ing “pre­sump­tive deaths” - those who likely died of COVID-19 but weren’t tested for it.

But those guide­lines are ad­vi­sory, and many states don’t com­ply. In Mahrash­tra, In­dia’s worst af­fected state with more than 1 mil­lion cases, sus­pected deaths aren’t recorded in the tally, said Dr. Ar­chana Patil, the state’s health di­rec­tor.

Other states, like As­sam, have cre­ated pan­els of doc­tors who dif­fer­en­ti­ate between “real virus deaths” and those from un­der­ly­ing ill­nesses. In some cities like New Delhi or Mum­bai, these pan­els oc­ca­sion­ally have added missed deaths to the tally.

But Dr. Anup Ku­mar Bar­man, who heads the panel in As­sam, said the state is not in­clud­ing many fa­tal­i­ties where the virus was “in­ci­den­tal” and not the cause of death. In Narayan Mi­tra’s case, he had more symp­toms of his un­der­ly­ing neu­ro­log­i­cal dis­or­der, Bar­man said.

As­sam state was fol­low­ing the fed­eral guide­lines and was cit­ing the virus only in those deaths due to res­pi­ra­tory fail­ure, pneu­mo­nia or blood clots, Bar­man added. But the guide­lines list these fac­tors as in­stances of how the virus can kill and are not a re­stric­tive check­list. Bar­man re­fused to an­swer any fol­low-up ques­tions from The As­so­ci­ated Press.

As­sam state has recorded over 147,000 in­fec­tions but fewer than 500 deaths as of Wed­nes­day.

In West Ben­gal state, a sim­i­lar panel was shelved in May and the state said it would sub­se­quently fol­low fed­eral guide­lines. Of the 105 deaths of those test­ing pos­i­tive for COVID-19 in April, the panel found that 72, or nearly 70%, weren’t caused by the virus.

P.V. Ramesh, who un­til July 8 headed COVID-19 man­age­ment for Andhra Pradesh state in south­ern In­dia, said coro­n­avirus deaths “at home, in tran­sit or while ar­riv­ing at hos­pi­tals don’t get counted.”

The gaps in data also mean that In­dia’s abil­ity to iden­tify spikes in deaths from nat­u­ral causes from pre­vi­ous years is spotty. Prob­lems in death counts have raised con­cerns in coun­tries like South Africa.

Mean­while, the courts have crit­i­cized some states, like Te­lan­gana, over trans­parency in shar­ing data about fa­tal­i­ties.

In ad­di­tion, fed­eral Health Min­istry guide­lines in May ad­vised hos­pi­tals against con­duct­ing au­top­sies in sus­pected COVID-19 cases to pre­vent ex­po­sure to the virus. Although the guide­lines say the cer­ti­fi­ca­tion can be done by doc­tors, ex­perts said this also was lead­ing to un­der­count­ing deaths.

The gov­ern­ment’s em­pha­sis on the low death toll de­spite the ris­ing num­ber of re­ported in­fec­tions has re­sulted in peo­ple think­ing the virus wasn’t nec­es­sar­ily fa­tal, lead­ing to a “false sense of pro­tec­tion,” said Dr. Anant Bhan, who re­searches pub­lic health and ethics in the city of Bhopal. That has led to peo­ple let­ting their guard down by not tak­ing pre­cau­tions such as wear­ing masks or main­tain­ing so­cial dis­tance, Bhan said.

Re­gional of­fi­cials also felt pres­sure to play down deaths to show the health cri­sis was un­der con­trol, said Dr. S.P. Kalantri, di­rec­tor of a hos­pi­tal in Ma­ha­rash­tra’s ru­ral Wardha dis­trict. Ini­tially there were “sub­tle hints” from dis­trict of­fi­cials to “play down the num­bers” by list­ing some deaths as be­ing caused by un­der­ly­ing diseases, he said.

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