India, from the earliest days of the pandemic, has reported far fewer COVID-19 deaths than expected given the toll elsewhere—an apparent death “paradox” that some believed was real and others thought would prove illusory. Now, a prominent epidemiologist who contended the country really had been spared the worst of COVID-19 has led a rigorous new analysis of available mortality data and concluded he “got it wrong.” India has “substantially greater” COVID-19 deaths than official reports suggest, says Prabhat Jha of the University of Toronto— close to 3 million, which is more than six times higher than the government has acknowledged and the largest number of any country.
If true, the finding could prompt scrutiny of other countries with anomalously low death rates and push up the current worldwide pandemic total, estimated by the World Health Organization (WHO) at some 5.45 million people. “I think it does call for a recalibration of the global numbers plus saying, ‘What the heck is going on in India?’” says Jha, whose team published the new India analysis today in Science. And India’s suffering could be far from over—the Omicron variant of the coronavirus has begun to surge there.
At the end of 2021, India reported about 480,000 deaths from SARS-CoV-2 infections. That’s 340 COVID-19 deaths per million—about one-seventh the per capita COVID-19 mortality tallied in the United States. Jha’s own early analysis supported the assertion that India had an unusually low mortality rate from COVID-19, but he and his colleagues have now probed more deeply. They tapped data from an independent polling agency that surveyed nearly 140,000 people across the vast country by telephone, asking whether anyone in each household had died from COVID-19. They also analyzed government reports from hospitals and similar facilities and looked at officially registered deaths. The result: a much higher estimate—between 2300 and 2500 deaths per million by September 2021, comparable to the rate in the United States, which has one-third as many people.
Jha says his early, low estimate was based on the first wave of infections in the fall of 2020, which may have been less deadly than the Delta variant that drove India’s massive surge in spring of 2021. He also focused on the large cities, where death rates may have been lower than in the countryside. And death registration in the country had been spotty even before the pandemic. But those factors can’t be the whole story, he says. “There must be other things that we still don’t understand.”
One, he says, is politics: He thinks the administration of Indian Prime Minister Narendra Modi has clouded the true picture of the pandemic. “The Indian government very much is trying to suppress the numbers in the way that they coded the COVID deaths,” Jha says. He and others also fault the government for not releasing data from what’s known as the Sample Registration System (SRS), which routinely surveys 1% of India’s population to track births and deaths. “I think the political pressures were such that they said, ‘Anything that’s going to come out is going to be embarrassing.’”
Ramanan Laxminarayan, a Princeton University epidemiologist and economist, doesn’t see the undercount as entirely deliberate. He notes SRS data haven’t been released since 2018, before the pandemic, so that suspension may just reflect a disorganized system. He adds that almost every country undercounts COVID-19 mortality. “I think all governments want to downplay the degree of deaths,” he adds. (Three Indian government sources that Science contacted did not immediately reply to requests for comments on the new study.)
The new estimates for India come as little surprise to Laxminarayan. “My starting point is that unless you can tell me why India is different, I’m going to assume that India is the same as any other country,” he says. “I don’t believe in exceptionalism of any kind unless it’s well justified.” His team last month published a study in The Lancet that focused on the Indian district of Chennai and concluded that reported deaths “greatly underestimated pandemic-associated mortality.”
Virologist Shahid Jameel of Ashoka University says the countrywide estimates by Jha’s team are also “in broad agreement” with two other independent studies that examined a similar time frame. “India paid a heavy price for not having good real-time data on deaths, especially during the first wave. That led to complacency and a terrible toll in the second wave,” Jameel says.
The work nicely triangulates data from different sources, each of which has its own limitations, says Samira Asma, a WHO assistant director general who works on data and analysis. “The study design is robust,” Asma says. “Countries can learn from this approach to … produce country-specific estimates.” WHO is now updating its estimates of excess deaths caused by COVID-19 and plans to release them soon, she says.
A worldwide comparison of all-cause mortality before and during the pandemic, posted in eLife 6 months ago, suggests undercounting is widespread. Russia had 4.5 times more deaths than normal, far beyond its official COVID-19 tally, and the trend has continued, the researchers recently tweeted. Tajikistan, Nicaragua, Uzbekistan, Belarus, and Egypt also had profound disconnects.
Omicron has begun to run riot in India, and Jha warns the country should not count on it causing milder disease than earlier variants, as data from other countries suggest it might. “I would be really careful about those assumptions because they’re based on selected populations that you can’t take from South Africa or the U.K. or Canada to India,” he says. And he’s wary of “wishful thinking” that the prior high levels of infections in India and wide-scale vaccination will create population level immunity against the variant causing severe disease. “We just don’t know enough about how these different variants behave in immunized populations,” he says.
Spoken like a researcher who doesn’t want to get it wrong again.