When the second phase of lockdown was relaxed early this month the number of infections spiked and on the 10th of May the number of new infections exceeded 4000. Now that the 3rd phase of lockdown is over and 4th begins from the 18th of May the infection rates in India have now exceeded that of China. While our eyes are glued to the Covid 19 related statistics and dashboards, we probably need a little more clarity about Covid and how to live with it otherwise we may be paralysed with uncertainty and fear a situation death like in Italy or Spain or UK where the death rates were very high not so long ago.
Has Covid 19 Virus Contributed to Excess Mortality in India?
The fear of death is a primal fear and Covid 19 has been compared to the deadly scourges like Black Death in the middle ages and the Spanish Flu in the early twentieth century. The Black Death or bubonic plague laid waste to Europe, killing a large proportion of the population in middle of the 14th Century. The Great Plague of London is said to have killed about one fourth of the population of London in 1665. Smallpox is said to have decimated the Native American population between the 16th and 19th Centuries. The Spanish Flu is said to have infected about a third of the world’s population killed and about 50 million people succumbed to it across the world. 18 million people are said to have died in India alone. These diseases are part of the legacy of a pandemic, but is it the same with Covid19 especially here in India?
On the 16th of May 2020 there were more than four and a half million confirmed infections and over 300 thousand deaths across the world. There were over 80 thousand deaths in the US alone and over 30 thousand each in UK, Italy. However, it is difficult to interpret these numbers without reference to the overall population of these countries and the infection rates in each of these countries. Table 1 compares the number of deaths in these countries in the context of the overall population and death rates of these countries with that of India. India has the highest population among these four countries, but also the lowest crude death rate, or the number of people who die in any population of 1000 people in a particular geography during the year This may sound contradictory because the people in these three other countries live longer and could be considered healthier. However, the population in India, even though they are poorer and have more diseases, consists of much larger proportion of younger people and so the crude death rate is lower.
The Case Fatality Rate or the number of people who die among those who contract the infection is also among the lowest in India. However, there is lack of clarity about what these numbers mean, because the number of tests done in each country are vastly different. The last column in Table 1 indicates one data that could be considered more comparable because it relates to the overall population of the country and refers to the rate of death per I lakh population (100,000) in the four countries due to Covid 19 on the 16th of May. This figure is extremely low in India compared to the three other countries.
There are some concerns in India that the number of deaths due to Covid 19 are extremely low not only because of inadequate testing and because the classification of deaths may be faulty. The issue of inaccurate recording has been raised in Delhi as well as in Kolkata. In Delhi it has been reported that cremations and burial procedures following Covid 19 related protocols were done in four times as many deaths as reported. In Kolkata the Central team which had gone there for an investigation, made adverse observations on the way Covid deaths were recorded and the records were subsequently revised. Considering these uncertainties around the actual number of Covid 19 related deaths another approach would be to understand where there has been an excess in overall mortality in India during this period.
Common Causes of Mortality in India
The total number of deaths from Covid 19 from 8th March when the first Covid 19 death was reported in India to May 16th was a little more than 2500. Even if this is an underreported figure it is worthwhile comparing it with the total deaths that take place in India from other reasons. With a population of over 1.3 billion and a crude death rate of about 7 per 1000 population over 9 million people die in India every year and this means more than 25000 people die daily from routine causes. This means that in the 53-day period between March 25 and May 16 over 1.3 million people would have died from some reason or the other. Table 3 provides an overview of the reasons for death in India. Nearly a fourth or more than 6000 daily deaths are due to cardiovascular reasons. Cancers, diarrhoeal diseases, stomach ailments and accidents and injuries account for roughly 5% or between 1000 to 1500 deaths every day. TB accounts for nearly 1000 deaths every day and a similar number of babies die during or around the time of birth. Respiratory diseases and respiratory infections are also important causes of death and together are responsible for another 3000 deaths every day.
The various health related conditions noted in Table 2 and many more are those which exist among our people. These conditions need care daily and this care may have been compromised by the overall fear and panic that has been generated by Covid. It is possible that many people who may have needed care for the regular illnesses during the lockdown were deprived of care. This may have added to some excess mortality as well. Since Covid 19 has been primarily an urban phenomenon it is comparatively easy to calculate the impact of Covid 19 and its management strategies on overall mortality in urban India from the municipal records. Considering all available data, Covid 19 cannot be considered a reason for excess mortality in India, at least till now.
Find ways of living together with dignity and respect
We still do not know much about the disease and the search for treatment and vaccines is underway. The scientific community has been stumped by this virus and with all the advanced technology at our command we are still grappling for answers. About two years ago there was news that humans will only die of accidents and all illnesses and aging would be conquered by 2045. Covid 19, a tiny virus has pricked the balloon of this scientific overconfidence and medical hubris. Our plans have to be made with imperfect knowledge and without the certainty of technology-driven solutions.
While there is much that we do not know about Covid 19, there is much that we do know. While Covid 19 is a rapidly spreading disease, research shows that not all infected persons become diseased. Similarly, many who do show symptoms do not need hospitalisation. And a large proportion of those who do require hospitalisation recover and return home. The chances of survival even with infection, far outweigh, that of death. Our plans for recovery have to be built upon this knowledge. The way the disease has been managed by the authorities in India has caused widespread fear and panic. It has led to new ways of stimatisation and discrimination. Our plans need to take this into consideration as well.
Lockdown, quarantine, containment, surveillance and use of force and coercion have underpinned the management efforts till now. The nature of the infection is changing. In cities the infection has now travelled into the more densely populated neighbourhoods where the poor stay. As migrants are travelling back home, the infection too will spread to rural India. There is a high probability that stigma and discrimination will travel into the rural areas. The least that migrants deserve as they return home after immense struggle is to be welcomed with respect and not be shunned in fear. While the need to keep a distance, wear masks, wash one’s hands regularly and not touch the mouth, nose or eyes are important, there has been little in the way of reassurance and better ways of coping and survival have not been provided. With protection and caution the chances for infection too can be reduced. Ultimately, we need to survive with Covid 19. The continuous message of fear from infection, disease and death that is emanating from the authorities and the media must change immediately as we develop mechanisms for coping and revitalising our lives. While economic recovery is of utmost importance we cannot do so without dignity and respect. We need to develop those strategies immediately.
Abhijit Das
