COVID-19: Three States Had 3.5L Excess Deaths, and the Ex Gratia May Elude Many
Government, Health
Tapasya, Harshitha Manwani and Mayank Aggarwal
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Family members in PPE kits perform the last rites of a COVID-19 victim, Jammu, January 22, 2022. Photo: PTI
Excess deaths in Rajasthan, Jharkhand and Andhra Pradesh were over 12-times the corresponding official COVID-19 death toll until early January 2022.
Data from across the country suggests governments are undercounting COVID-19 deaths by the lakhs, possibly to avoid the charge of epidemic mismanagement.
As a result, facilitated by disparate protocols, poor record-keeping and red-tape, thousands of families haven't received the compensation they are due.
Last year, just as the novel coronavirus shifted shape into a more virulent variant and helped set off India's ferocious second COVID-19 wave, Sharvan Singh rushed to the safety of home. Singh believed he had better chances of survival in his village in Rajasthan's Sikar than Tamil Nadu, where he worked.
On May 14, a month and half after he arrived in his village in Dhod, he developed symptoms of COVID-19. His family admitted him to a government hospital in Sikar as he struggled to breathe. He tested positive for the infection on May 16 and died the next day. "It was all very sudden," his brother Jeetu Singh told The Reporters' Collective.
But Sharvan Singh isn't counted among the official COVID deaths even though he died of the infection in the hospital. "The death certificate of my brother does not mention the cause of death. We were not provided any document by the hospital suggesting my brother died of COVID," said Jeetu.
Because his death was not attributed to COVID-19 despite a positive test report, his wife Reena Rathod didn't qualify for the state government's one-time assistance of Rs 1 lakh for widows of COVID-19 victims, launched in June 2021. The village panchayat, which processes the application for chief minister's 'Corona Sahayata Yojana' scheme, told the family that the primary health centre didn't have a record of Sharvan being a COVID-19 case.
Rathod might have a chance with the Rs 50,000 compensation the Union government promised the Supreme Court it will give relatives of all those who died of COVID-19, including those who died within 30 days of testing positive or after being clinically diagnosed with a novel coronavirus infection.
Though the state government has to set up grievance redressal committees in each district to provide certificates that could eventually help with payouts, Singh's family is not aware of the process.
Death registration data collected by The Reporters' Collective from districts across the country shows Singh is among the lakhs of people whose deaths weren't counted in the official COVID toll, possibly to under-report deaths to avoid the charge of pandemic mismanagement. Though that may change with the government redefining what a COVID death is, under pressure from the apex court, experts say there are thousands whose compensation claims may fall through due to unavailability of official records on COVID-19 deaths, the requisite papers or bureaucratic rigmarole.
The Collective picked Rajasthan, Jharkhand and Andhra Pradesh to calculate excess deaths – a metric that estimates the number of deaths that may have gone unreported by comparing deaths due to all causes during the pandemic with that in a normal year. While all excess deaths may not be because of COVID-19, experts believe it can be a contributing factor in many.
The three states together are estimated to have had 3,59,496 excess deaths between March 2020 and June 2021 over those in the corresponding months in 2019. The numbers mean the excess deaths in 13% of India's population were roughly equal to the population of Iceland – even as the Union government has said (only) 4,82,017 have died of COVID-19 in India until January 4.
The official death count for the three states together was 28,609 till early January. Our calculation indicates that the total compensation their families alone stand to receive could go over 140 crore rupees. The amount could burgeon further if we assume most of the excess deaths are COVID deaths.
Excess deaths
Representative image of a cremation in progress at Ahmedabad, amidst a surge in COVID-19 cases. Photo: PTI
In August 2021, The Reporters' Collective analysed death registers in 68 municipalities in Gujarat under the 'Wall of Grief' project, which aims to gather and disseminate information on pandemic mortality. With insights from public health experts, the Collective estimated Gujarat's excess death toll to be 2.81 lakh for the period of the pandemic until the first week of May 2021.
A study by researchers at Harvard University based on this data estimated 16,000 excess deaths in 54 municipalities, which together house 5% of Gujarat's population. In contrast, the government had recorded only 10,075 COVID-19 deaths in the state at the time.
Subsequently, the Collective and 101 Reporters filed applications under the Right to Information (RTI) Act with 576 district authorities across India, seeking the month-wise number of deaths in the districts, municipalities and municipal corporations. After six months, only 71 districts had replied, and much of their replies were apples and oranges – annual instead of month-wise death count, and data that wasn't clear if it was for the entire district or the urban/rural areas of the district – leaving them incomparable. Only 42 districts provided the records in a manner fit for analysis.
Of these 42, the Collective studied death data from 20 districts in Andhra Pradesh, Rajasthan and Jharkhand to arrive at the state-wise numbers of excess deaths. The states were analysed separately because their death data was substantial, ranging from around 6% to 40 % of each state's population.
What do the numbers show?
A health worker prepares an 'oxygen triage facility' for COVID-19 patients, at Omandurar Government Hospital, Chennai, January 23, 2022. Photo: PTI/R. Senthil Kumar
The total excess deaths in areas of the 20 districts between March 2020 and June 2021, compared with the corresponding months in 2019, were 55,042. This is over six-times the official total COVID-19 death toll in these districts until January 4, as the respective state governments have admitted.
In cases where data was available for only parts of a district, we still compared excess deaths in those areas with the number of COVID-19 deaths in the entire district until January 4. We also used Census 2011 figures to extrapolate.
Let's zoom in.
In Rajasthan, there were 10,438 excess deaths in less than 7% of the population – while the government has recorded only 8,964 COVID deaths in the whole state. An extrapolation of the excess deaths in 6.4% of the population – in four districts and one municipality – to the entire state shows there were 1,62,039 excess deaths in Rajasthan. This is around 18-times the state's official COVID death toll.
At Rs 50,000 for each family, the governments already have to foot a bill of Rs 44.82 crore as compensation to the relatives of those included in the official death toll until early January.
"Constitution of grievance redressal committees at the district level is a step in the right direction. But such a high number of excess deaths means there will be a high number of applications for COVID-19 death certificates before these committees," said Shreya Shrivastava, a health-law and policy researcher and a fellow at the Vidhi Centre for Legal Policy. "For a fair redressal of their grievances, these committees need to be accessible and function transparently."
Additionally, according to the Union government's guidelines, for COVID-19 death certification, a victim's family has to submit a test report or some medical record of clinical determination of COVID-19 that shows that the person died within 30 days of the test/check-up.
"But during the peak of the pandemic, many victims in rural areas and small towns did not have access to testing facilities or hospitalisation and many hospitals also haven't maintained proper records," Shrivastava added. "It is not clear how families of such victims can claim compensation."
And then there were pandemic deaths not directly caused by the virus. For example, as the number of COVID-19 cases rose rapidly in March and May last year, hospitals swamped with patients had to turn away many with other serious illnesses, some of whom died at home. The governments don't have a specific mechanism to record these deaths.
"One way is to have a category in a medical certificate that records deaths where even if COVID-19 infection is not the cause, the death can be attributed to the pandemic," said Dr Satchit Balsari, an assistant professor in emergency medicine at the Harvard Medical School. "All the pandemic deaths should be counted, but giving compensation is a financial question for every government, which policymakers need to think about. We, as a society, need to come to a consensus on how to count indirect deaths and to what purpose."
In Andhra Pradesh, death registration data reveals 33,099 excess deaths in around 19% of the population during the pandemic period, until June 2021. This is higher than the state's official COVID-19 death toll of 14,498 until early January – entailing a payout of Rs 72.49 crore.
The data corresponds to the urban population in four districts: Kurnool, Nellore, Srikakulam and Visakhapatnam, plus the entire population of Kadapa and Vizianagaram. A simple extrapolation suggested that Andhra Pradesh's excess death toll to be 1,68,408 – which is 11-times the state's official COVID-19 toll.
A similar exercise vis-à-vis deaths in eight districts and the urban population of one district in Jharkhand, making up 39% of the population, placed the state's excess death toll at 29,049, which is over five-times the state's official COVID-19 toll of 5,147 until January 4. This in turn would entail a compensation of Rs 25.73 crore.
Compensation conundrum
There are two reasons why governments might be suppressing or obfuscating their official COVID death tolls: to save face, as is known, and the burden of compensation.
The Indian government didn't accept the responsibility to pay compensation at first, citing financial constraints. After a Supreme Court judgement in June 2021, the National Disaster Management Authority (NDMA), which the prime minister chairs, had to issue guidelines for governments to pay ex gratia.
According to the NDMA guidelines, issued in September 2021, each COVID-19 victim's family is to receive Rs 50,000 from the State Disaster Response Fund, which receives at least 75% of its money from the Centre. The payout, small though it may be relative to the family's medical expenses and the loss of a member itself, amounts to an outgo of at least Rs 2,410.08 crore for officially recorded COVID-19 deaths until January 4, 2022 – and much more if excess deaths are included.
The guidelines include specifications from the Union health ministry and the Indian Council of Medical Research (ICMR)1 on the conditions that a 'COVID-19 death' need to meet. The person needs to have died within 30 days of having tested positive on a PCR test, a molecular test or a rapid antigen test. Alternatively, in the absence of a positive test result, a person who was clinically determined to have COVID-19 and died within 30 days can be considered a 'COVID-19 fatality'.
Persons who died in a hospital or an in-patient facility even after 30 days of testing positive can be considered 'COVID-19 deaths' if they were treated in the facility from the time of admission to the end.
Finally, COVID-19 cases in which the medical certificate of cause of death is available will be considered to be 'COVID-19 deaths'.
The guidelines also include a mandate to set up grievance redressal committees – technically 'COVID-19 Death Ascertaining Committees'. They are to deal with cases where claimants haven't been issued the cause of death certificates or aren't satisfied with the cause of death that has been mentioned.
Such a district-level committee is to comprise the additional collector, chief medical health officer and subject experts. They are to investigate test reports, hospital records and the death summary to verify each claim, and subsequently issue an official document for the death.
While many pandemic deaths will inevitably be left out of this process, experts say the real outcome – even for the eligible deaths – will depend on the efficiency of the mechanism at the state and the district levels.
A coronavirus-themed globe installed alongside a road to create awareness about staying at home in Hyderabad, April 2020. Photo: Reuters/Vinod Babu
Khush Vachharajani, the national resource person at the Social Accountability Forum for Action and Research, a collective, analysed the standard operating procedures state governments have issued to disburse compensation. He found that authorities haven't widely publicised the guidelines and that the application processes, both offline and online, aren't clear.
This encourages unawareness of and illiteracy about the procedure to claim compensation.
"The state guidelines don't clearly lay down the procedure for those who do not have COVID-19 death certificates," Vachharajani said. "States should approach families where COVID-19 deaths are officially recorded. The process of applying should only be for people who do not have COVID-19 death certificates. Additionally, give people more ways to submit applications. It would make the scheme more accessible to people."
His findings reflect the ground situation.
Palivela Srinivas Rao, the district medical and health officer of Andhra Pradesh's East Godavari district, told the Collective in January that his district had received around 6,000 applications for compensation under the Disaster Management Act. The district's official COVID-19 death toll was 1,290, which means there were four-times as many applications.
"Of these, around 1,000 people have received compensation," Rao said.
"People who get excluded are those who have died after 30 days of testing positive or have a positive rapid antigen test report from a private hospital or lab," he added.
(The health ministry and ICMR guidelines state that deaths with a positive rapid antigen test result should also be considered.)
On January 19, 2022, the Supreme Court reprimanded state governments over their low rates of compensation disbursal. According to one submission made to the court, only 3.42 lakh claimants had been compensated in 13 states against 5.67 lakh claims.
Last week, the Gujarat government submitted that it had approved 68,370 claims although it had recorded only 10,094 deaths due to COVID-19 at the time. Similarly, Andhra Pradesh had sanctioned 31,000 claims against an official toll of 14,471 until then.
Rajasthan had approved compensation for only 8,577 people and Jharkhand had compensated none, as of December 16. The Supreme Court had pulled up the Rajasthan government for not disclosing how many applications they had received for ex gratia, and said the state's official COVID-19 death toll wasn't reliable.
Lack of rigorous documentation of COVID-19 deaths and governments' disparate compensation practices have created a complicated mesh of procedures, according to health and policy experts. In this scenario, fair compensation for relatives of the dead takes the hit.
"India does not have a solid legal framework to tackle public health emergencies with uniformity," Shrivastava said. "The existent Epidemic Diseases Act is more about policing than the rights of people. The Disaster Management Act does not envision a pandemic of the nature of COVID-19".
Note on methods
On the method of extrapolating excess deaths in smaller populations to the entire state, Yogesh Jain, a public health physician and co-founder of the Jan Swasthya Sahyog, said:
"Extrapolation can lead to underestimation or overestimation but a 6-9 % population is a good sample, and extrapolating to the entire state would be fair in order to understand the scale of pandemic mortality."
In the states whose data the Collective analysed, many big municipal corporations and densely populated areas that had more COVID-19 deaths (e.g. Jaipur and Alwar) were not included, rendering our results an underestimate.
In Andhra Pradesh, the data didn't include rural populations that may have had more cases but lower death registration and death reporting.
Tapasya, Harshitha Manwani and Mayank Aggarwal are members of The Reporters' Collective.
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Tapasya, Harshitha Manwani and Mayank Aggarwal 28/01/2022