Following a visit from Tedros Adhanom Ghebreyesus, the Director-General of the World Health Organization (WHO), the WHO and the Indian Government have been at odds over the official death toll of COVID-19.
India’s official death toll places the figure at 520,000, however, the WHO has cited studies that suggest the figure could be as high as four million. Such a discrepancy is considerable, and would place India’s death toll as the highest in the world.
Reports have cited the fact that even under normal circumstances, pre-COVID-19, India’s record for official medical certification of deaths is lacking. It has been more than fifty years since it was written into law that births and deaths must be officially registered, and while roughly 86 percent of estimated total deaths are registered, medical certification covers less than one in five deaths.
Some states performed better than others, according to the Times of India, “deaths with medical certification of the cause were a mere 25 percent of estimated deaths in Jharkhand, 3.1 percent in Uttar Pradesh and 4.7 percent in Bihar.” Among the best performing states were Delhi, with 62.3 percent of all deaths medically certified, and Tamil Nadu, at 45 percent.
The difference, as with many aspects of the Indian medical system, lies in the urban-rural divide. With the medical system being chronically under equipped in rural areas, surveillance of disease, treatment, infrastructure, knowledge and staff are all insufficient, leading to many instances of illness simply falling through the gaps.
It is therefore speculated by many studies that the bulk of COVID-19 deaths in India have gone unreported. Given the fact that the healthcare system was caught unprepared for such a major outbreak, this may be the case.
During the initial lockdown – which came at a moment’s notice and left many migrant workers and day labourers without work and unable to pay for accommodation – there was a mass exodus of workers from the cities back to their villages and towns of origin. This resulted in COVID-19 being spread across the country to rural areas.
While official figures stated that hotspots were typically within the cities, the speculation that rural deaths were simply not recorded would add credibility to the four million figure. Establishing an official count for the figures after the fact is likely to be an elongated and arduous process, with Indian officials disputing the methodology used by the researchers that arrived at the higher figure.