Undercounting of COVID Deaths: Two Million More People Died in 2021 Compared to 2020 Shows Govt Data

New Delhi: Four years after the deadly delta wave of COVID-19, the government has released a slew of reports that question the official numbers of deaths that it had put out earlier. These reports, which were withheld for a long time, show that not only did the wave wreak havoc but years of progress on reducing the death rate of the country got reversed in 2021.

One of the key reports, which the government has released is the Civil Registration System (CRS) 2021 report. The CRS gives the numbers for deaths that are actually registered. Not all deaths are registered officially. The CRS presents deaths caused due to all the causes in a given year or what is known as All Cause Mortality (ACM) data

The number of total deaths registered in 2021 were 10.2 million. This was also about 2 million more than 2020 – an increase of nearly 26%. 

From 2016 to 2020, the year-on-year rise in the number of registered deaths remained between 2-10% – as against the 26% increase from 2020 to 2021.

But what could explain the sharp rise from 2020 to 2021, when such an increase was not seen in the previous years? No  significant event happened in 2021 other than the deadly delta wave of COVID-19. And, therefore, does it explain undercounting of Covid-19 deaths by a big margin?

COVID-19 deaths that were actually registered

The fact that the Indian government had undercounted pandemic-related deaths was widely published by statisticians and academics. But the Indian government refuted all publications and maintained that the government's systems were robust enough not to miss any deaths. 

Now let us look at another crucial  report the  government has released: ‘Medically Certified Cause of Deaths-2021’ report. It must be noted here that out of all deaths registered in India, only a small proportion of them are ‘medically certified for a particular cause’. 

The 2021 MCCD report says only 23.4% of all deaths, which were registered, could be medically certified or put under a particular cause-related category. This proportion remains low for a variety of reasons, like healthcare institutions not being adequately equipped to certify the cause of death or deaths that occurred outside such institutions. 

Before 2020, India had 19 categories for causes of deaths. Five most prominent were cardiovascular diseases, respiratory diseases, infectious parasites diseases, endocrine and metabolic diseases, and injury and other external causes.

In 2020, another category was added for COVID-19. It was termed 'Deaths due to special purposes (COVID-19)'. 

The MCCD reports say nearly 160,000 and 410,000 died due to COVID-19 in India in 2020 and 2021, respectively – thus totalling to 570,000 deaths. However, there is an important rider here. The MCCD report itself accepts that overall, only 23.4% of registered deaths are medically certified for cause of deaths under one of its 20 categories. In other words, the cause/category of all deaths are not known.

Therefore, it is safe to assume that only a small fraction of COVID-19 deaths have been categorised as the deaths caused by the pandemic.

Now, according to the government, 470,000 died in 2020 and 2021 due to COVID-19, as per the data released back then. 

And, the MCCD data itself admits that 570,000 died due to COVID-19. In other words, the official estimates that the government had put out are nearly equal to what the  MCCD report – which registers only a fraction of deaths as certified or categorised.

This clearly reveals that only a small proportion of COVID-19 deaths got classified and recorded in the system and a large number of them could not be properly attributed. 

However, there is another important trend that the MCCD 2021 data reveals. One of the categories in an MCCD report is deaths caused due to respiratory infections. From 2017 to 2019, the increase in deaths caused due to respiratory illness ranged between 5 to 11%, when computed on a year-on-year basis. For example, the percentage increase in respiratory infection deaths between 2017 and 2018 was by 5.6%. Similarly between 2018 and 2019 it was about 11%

But the graph rises steeply between 2020 and 2021. The number of deaths caused due to respiratory infection in 2020 and 2021 was 180,000 and 300,000 respectively. Thus, the  year-on-year rise was around 68% between 2020 and 2021.

COVID-19 was mainly a respiratory disease and there are many symptoms that it shared with other respiratory infections. Such a sharp rise in deaths due respiratory infections between the two years of pandemic remains unexplained. It raises doubts whether some of the COVID-19 deaths were classified  under 'respiratory diseases’ category, instead of COVID-19.

Estimated deaths

The third important dataset the government has released is the Sample Registration Bulletin (SRS). The SRS provides estimates of death rates, as against the actual number of deaths which get registered in the official records which are reported in CRS. The SRS indicators are arrived at by a survey conducted by government officials.

The bulletin reveals India registered the highest death rate (number of deaths per 1000 population) in 2021 since 2012. The death rate in 2021 stood at 7.5. It was the same in 2012 and had been consistently declining since then, till 2021, except for a marginal increase in 2020. 

The death rate in 2020 was 6 per 1,000 thousand people. In 2021, it climbed to 7.5 per 1,000. This may seem like a small change, but in absolute numbers, it is a significant increase.

The last census in the country was held in 2011. Therefore, to make calculations about the absolute number of deaths in 2021, the projected population for 2020 and 2021, which has been provided by the National Commission for Population, has been used. 

The calculations reveal as many as 8.11 million people died in India in 2020. This figure rose to 10.43 million in 2021  – a 27% rise. In other words, nearly 2 million (20 lakh) more people died in 2021 as compared to 2020. 

Contrast this with the fact that between 2017-2019, the number of deaths had declined on a year-on-year basis. From 2019 to 2020 (the year in which the first wave of COVID-19), the deaths increased by 1.63%. 

To put things in perspective, these estimated deaths, as reflected in SRS bulletin, were due to all causes and not just COVID-19

From 2016 to 2020, the year-on-year rise in the number of registered deaths remained between 2-10% . This increased by 26% in 2021. 

But, again, what could explain the sharp rise from 2020 to 2021, when such an increase was not seen in the previous five years? No other significant event happened in 2021 other than the deadly delta wave of COVID-19. 

It is also interesting to note here that though the death registration rate, which is captured for all age groups, went up, the infant mortality rate registered a decline. 

In other words, while adults’ death rate increased, that of infants declined. This trend was not visible in previous years. 

It is widely understood that COVID-19 caused a higher mortality among adults as compared to children. The SRS 2021 trend is in line with this assertion.