More than a year after the coronavirus began circulating around the world, India is facing a devastating second wave of infections and deaths. Hospitals in cities such as New Delhi and Mumbai are filled to capacity and facing oxygen shortages, with crowds of sick people forming lines outside. According to official statistics, the country currently has more than three hundred and fifty thousand cases and twenty-eight hundred deaths per day, with numbers continuing to rise. But unofficial statistics collected by journalists suggest that the true numbers are likely far greater, with one Financial Times analysis showing a death toll more than eight times the official count. The country’s Hindu-nationalist Prime Minister, Narendra Modi, has downplayed the scale of the crisis, holding large election rallies, and failing to deter people from attending a religious festival that attracts millions of people. (This past weekend, after a demand from the Indian government, Twitter blocked access to tweets critical of the Administration’s response.)
On Sunday, I spoke by phone with Rukmini Shrinivasan, a data journalist in Chennai who has been covering the pandemic for the Guardian and other publications. During our conversation, which has been edited for length and clarity, we discussed what crematorium data can tell us about the scale of the problem, the government’s mistakes in the past month, and why Modi remains popular amid the worsening crisis.
How have you and other people in your field been able to get a sense of the scale of the problem in India right now, given that we know official statistics are dramatically understating what is going on?
The most useful thing was being able to come into the pandemic with some prior understanding of how statistics function in India, and to know what the existing issues were. So, for example, we came in knowing that official statistics massively underreport all infectious diseases, such as malaria, and we got used to turning to other data sets that give us a better sense of underreporting. For infectious diseases, we know official statistics only capture reported data from public health facilities, which means that the whole world of private health [facility] data is left out. We have gotten used to turning to other sources that come up with estimates, such as the Institute for Health Metrics and Evaluation (I.H.M.E.).
And we had some sense of how deaths are reported in India. The lack of state capacity means that a lot of things the state wants to deliver cannot be delivered, so we know both births and deaths are underregistered in India. We have a sense of how much trouble there is to correctly assess the cause of death. And we know that this is a bigger problem for marginalized groups and women, who are more likely to be underrepresented in death statistics. So we came in knowing that even in the best of times, the statistical architecture, and the administrative architecture, struggles to register everyone properly. But I think that has helped us direct and focus our energies on models and estimates. And it has helped us focus on groups that might struggle more than others to have their deaths reported, and has caused us to come in with a strong and skeptical outlook, which means we know we might need other, outside sources, like newspapers or crematoria data. And we know data here has a long lag, so expecting immediate data is a problem.
We have official statistics about cases and deaths, and then other reports with unofficial estimates. What are you actually able to say about what we know?
Although there are official guidelines about what should be counted as a COVID-19 death, we know on record from officials in multiple states that those guidelines are not being followed. A very stringent definition of what is a COVID-19 death—a person testing positive prior to death—is being used, which leaves out the world of people who couldn’t get a test in time, or couldn’t make it to the hospital. So we know this is happening, but estimating the extent of that would be very useful. I have tried to make requests to state audit committees to ask about how many death certificates came to them, and how many were COVID-19 deaths. But that is not known and it’s a big problem, and there should be public pressure for it.
So I personally have come to the point where what I am concerned about is all-cause mortality. I don’t think that we are in a good position to understand COVID mortality, and I don’t think we will for a while. But what we see is a lot of people are dying, whether from COVID or not, and there are ambulances lined up, and they are dying out of lack of access to an I.C.U. bed or oxygen shortages or are simply unable to manage their chronic conditions because of a huge shortage of regular medical services in the past year. So I do think we have a huge rise in all-cause mortality, but I am tired of trying to figure out if they are COVID deaths or not. It’s just a partisan exercise right now.
So just to be clear: there is an enormous uptick in deaths at crematoria, but we don’t know to what degree those are directly caused by COVID, and to what degree they are caused by things such as oxygen shortages and other health crises caused by the chaos of the past year?
Yes. Again, it does appear there is a mass increase in deaths, but the administrative sectors are so tied up that I wouldn’t even be confident, in a country of this size, in claiming that we know what we are seeing. But it would make complete sense given the collapse of regular health care right now.
So when you see analysis, like the one in the Financial Times looking at crematoria data, it seems fair to say that COVID is causing a vast surge in deaths in India, but we don’t know exactly how many of them were caused by the coronavirus infecting the person, correct?
Yes. And, again, it is likely that COVID infections are causing a massive uptick in death. I think the one indicator that says a lot is hospitalizations. The fact that those are up across every big city and in every part of the country where we have information indicates that, even if you are not able to quantify the extent of underreporting, health systems are overwhelmed. All of the small factors that, added up, tell us about underreporting are clear. For example, in Delhi, there are five-day delays to even get a test. There is a thirty-three-per-cent positivity rate estimated in Delhi, but a huge number of people can’t get a test. We know from surveys in Bombay, for example, that people from non-slum areas are four to six times more likely to get a test. So that gives you a clue about the possible extent of underreporting in slum areas. We know historically that women and marginalized groups fall sick more, because they have less access to health care. So all this gives you some indication of what we are missing. The scale is undeniable.
What should the government be doing now that it is not currently doing?
It should not be minimizing the scale of what is happening. It did that for most of this year, right up until now. In his address to the nation a couple of days ago, Modi did say that the second wave hit like a storm. But we have also seen a lot of simultaneous attempts to clamp down on people who are talking about deaths on social media, and people having a bit of a go at journalists, saying they are spreading fear and panic. So that is something that needs to stop immediately.
The government also needs to get moving really fast on oxygen. A lot of the big public-health scale-up measures that the government is doing are not going to help now. They should have been done in January, and some of them will only help five years from now. So, for example, if we allow colleges to educate more doctors, they will open in a year, and then five years from now we will have more doctors. With oxygen, the government announced it was going to set up these oxygen plants, and a whole lot of money poured into PM CARES, the fund Modi created for charitable donations. He set up this fund, which is not transparent, and we cannot get information on it under the law. And we know that for eight months no bids [for oxygen plants] were even invited. Thirty-three [plants] are functioning now out of a hundred and sixty that were sanctioned.
