Why COVID-19 numbers matter

The World Health Organization (WHO) has estimated the number of deaths due to COVID-19 directly or indirectly at 4.74 million in India. This is the highest for any country and nine times the country’s official number of 5,24,000 as of May 2022. The WHO figures are obtained through robust statistical methods that consider “excess” deaths during the pandemic period. The WHO has models to which India has objected.

The WHO figures come as an embarrassment to the government, as Prime Minister Narendra Modi claimed in Parliament on February 8, 2022 that “India’s efforts (in tackling the pandemic) are being appreciated worldwide “. The Ministry of Health and Family Welfare has questioned the use of mathematical models when “authentic data” is available from India. According to this data, the total number of all-cause deaths in India in 2020 was 4,75,000 more than the previous year. Surprisingly, according to official figures, the year-on-year increase was higher than in the years just before the pandemic – around 6,95,000 in 2019 in 2018 and 4,87,000 in 2018.

The Indian numbers are highly skeptical given the irreconcilable and alarming discrepancy between India’s count and the WHO’s estimates. The government has received a lot of criticism for the way it handled the pandemic – from a sudden and complete lockdown to a lack of oxygen, the way many people struggled to be admitted to hospitals and died waiting for beds at a slow pace . who was vaccinated.

Inability to report accurately

But this should not blind us to flaws in our ability to count deaths and determine the causes of deaths. This process requires systems, money and commitment. For more than 75 years after becoming independent, India has not had a public health department that can systematically collect and analyze data on diseases. Such a government branch would mandate doctors to report infectious diseases, pick up on early signs of an outbreak in any part of the country, and count the number of cause-specific deaths. No one in power has publicly acknowledged this missing link or considered it fit to build such a system. The WHO, sometimes sacrosanct in its advice and sometimes emphatic in its prescriptions, has for the past several years simply brushed off any support or guidance on that important front.

It may be easy, even reasonable, to argue that the government is hiding the actual number of deaths, or that image management is taking precedence over the truth, even though the official count is widely believed to be lower than the actual number of deaths. goes. The only difference now is that the magnitude of the discrepancy is staggering, and it comes with the official seal of the WHO.

Still, the government needs to do little to hide the real numbers that are yet to be documented. India’s system lived up to its time-tested tendency to under-report. The data’s internal drivers are under-reported for a number of reasons, the government image being but one of them. In the absence of a robust reporting system and standard, hospitals, bureaucrats, civic bodies and even clerks report less.

What needs to be emphasized is that India’s health management machinery has taken no other way than to report the numbers. The reporting of deaths worked this way when no one was watching, and it worked when everyone else was watching. In this case also it suits the government.

The counting problems are similar in cases of death from malaria, typhoid, cholera, rabies, leptospirosis, scrub typhus or snakebite. The reporting numbers only with respect to tuberculosis (TB) warrant some degree of caution. This is due to the heavy disease burden and an elaborate system of surveillance that includes a TB division in the Union Health Ministry, and state, district and local TB units, which go to the last mile with a holistic design supported by WHO. Still, reliable, locale-specific, real-time numbers are absent. Eventually the data gets compiled, but no one scrutinizes the methods.

So, we must hold the government accountable, but we must also look beyond immediate blame and see this as an opportunity for India to build a system that can fix this long-standing problem. We urgently need to invest in a strong public health infrastructure that will have to be built from the ground up.

Health management has two parts: public health (with monitoring and prevention) and health care (for diagnosis, treatment). If someone dies of typhoid fever, it hardly matters to the doctor (health care), because it does not change anything for the next patient to diagnose and treat another disease. But for a public health professional, the accuracy of typhoid fever to trace the transmission channel and source of the microbe is important, to prevent more cases. Therefore, public health is required to report each death with an accurate/verifiable cause of death, if it exists. The demand for accuracy comes from public health, not healthcare.

TB cannot be controlled by the healthcare protocols given by WHO. TB control requires both public health and universal, primary and secondary health care.

public health surveillance

Health care professionals must report all health events necessary to public health in a process called public health surveillance. It should act as an early warning radar system that works round the clock in all parts of India. It’s not that challenging to build as an online platform or app with the available bandwidth. This is necessary to address and act on emerging threats and to audit the results of the budget spent on disease control. We need diseases diagnosed according to protocol, information collected in real time and acted upon immediately, and statistics can be verified. Such a surveillance system was piloted by one of us (Dr. John) in the 1980s in North Arcot district, lasted for a decade and was repeated in the 1990s in Kerala’s Kottayam district, before the Ministry of Health did not destroy it. Understand the importance of monitoring as information for action.

Births and deaths are demographic events and counting them has been an age-old tool for managing state wealth. It did not develop in our culture but was necessary for the colonial rulers to manage the wealth. Therefore the calculation must be objective, and statistics must emerge as a by-product of that calculation. Administrators may assume that counting is only for post-facto data. In this, the importance of monitoring and numbers is lost and any inaccuracy is considered insignificant.

In Europe, health managers found that microbial diseases have social and environmental determinants that allow governments to intervene and prevent infectious diseases; Thus the concept and infrastructure called public health was born. We should take advantage of this opportunity to design our own health management plan in our best interest. The WHO can give advice, but is not accountable for the consequences. If the government takes this step, it will be a signal achievement towards making India a developed nation.

Jagdish Ratnani is a journalist and a faculty member at the building’s SPJIMR; T. Jacob John is a retired Professor of Clinical Virology, Christian Medical College, Vellore and former President of the Indian Academy of Pediatrics (Through the Billion Press).