 Hello and welcome to NewsClick. Today we have with us on our usual COVID Roundup, Professor Satish Dhrath. And we're going to discuss two issues. What is a COVID death? Why we are going to discuss it is partly because the argument is excess death increased the number of COVID deaths unnecessarily that's according to government media and WHO's claims that excess in some sense are related to uncounted COVID deaths. So that is why it's important to also argue well do you know what's really a COVID death and how well have we counted in India the number of COVID deaths which otherwise have been recorded as deaths but not maybe as COVID deaths. So to do that we're going to ask Satish in this question. Satish what is a COVID death because as we know from the controversies that had taken place earlier both in the time of Delta as well as the earlier wave that a lot of the reports which would be given which the death certificates which have been given to the civil registry system actually did not follow even the ICMR guidelines which said COVID death if you are having COVID and you die within a certain time frame then it should be registered as COVID death as the immediate cause of death and other causes should come later but we know from both Delhi as well as Gujarat where lots of examples came in the newspapers as well as evidence which have been talked about by journalists looking at COVID protocols being followed during cremation and burial as well as looking at what the numbers were. Now question to you and that's really a technical question what is a COVID death because people really die according to some of the death reports death certificate reports due to heart stopping or the breathing stopping now what does it really mean? So before we get into the technicalities of what is a COVID death let's first get our intentions clear what is our interest in counting these deaths and there are three separate categories of deaths that I would like all of us in these conversations to keep in mind because counting these three separate categories of deaths has different consequences for public health policies so the first category the straightforward category is what everybody is calling a COVID death meaning that somebody is infected somebody becomes virus test positive somebody develops that person develops difficulty in breathing oxygen tension goes down they're admitted to hospital they go into cytokine storm multi-system failure get put on ventilator in that that is a straightforward no ambiguity COVID death and it should be recorded as such whether it has always been recorded as such even in India's wanted civil registration system or not is a separate question we will come to but at least technically it should be counted as a COVID death. A second category of deaths is the kind of deaths where people are sick people are people have chronic kidney disease chronic lung disease chronic heart disease and are teetering on the edge of being well ill for quite some time and then they develop COVID and the COVID in one way or another interacts with their basic chronic illness and together they are pushed into such a severe stage that they are this is not necessarily the COVID illness being in and of itself so medically severe that it killed the individual as much as this is a situation where any illness of this kind would have been the last straw on the camel's back that would have led to a pushing of the balance towards death this is let's call it a COVID associated death this is important because for people who are severely ill already with other chronic ailments during the pandemic COVID became an additional risk and therefore this category of deaths also needed to be identified carefully recorded and counted. The third category of deaths is what brings us into the excess death estimate territory where what we are really looking at is statistical estimates of what is the normal pattern year by year of how many deaths in a particular area in a particular community per million individuals carefully segregated demographically tend to occur and how many actually occurred during the pandemic and the difference between those becomes then the count of excess deaths and these excess deaths include our first category that is the straightforward COVID severe illness killing people include our second category of people who were quite chronically sick but COVID became an additional last straw risk that took them all the way into death and a whole large and poorly understood number of additional deaths which took place because of a variety of reasons ranging from people not getting enough food because livelihood damages people dying because they were trying to walk back home and of course people not getting medical care that they routinely needed this includes preventive medical care such as babies not getting vaccinated because routine vaccination campaigns are suspended with the result that avoidable childhood illnesses such as measles and so on and so forth begin to spread in these communities of babies cohorts of babies made vulnerable by the pandemic and some of them dying all sorts of epidemic associated deaths as you can imagine all three categories of deaths need to be counted separately need to be recognized separately and need to be thought over separately as we begin to reformulate our public health policies not simply as a short-term epidemic response but over the long term so that sense all these are COVID related whether they are COVID deaths by the definition of ICMR or registered the death certificate is really not the issue and of course as you have stated they are COVID deaths which can be the indirectly also related to COVID other infectious deaths but also there would be a set of people who didn't go to hospitals as you said and they also died as a consequence of course there are excess deaths because of this but there could also be less deaths because a certain set of things did not happen for example I think we gave it last time deaths due to road accidents may have come down because of lockdowns infectious diseases like for instance influenza seems to have come down in lots of countries because again masking and social distancing as well as lockdowns all of that might have contributed to coming down so you look at excess deaths for epidemiological reasons what you're really talking about the net excess deaths so some which are more some which are less and the consequence of this is really the public health system because it has to cater what is the bandwidth it needs then to handle pandemics and that is the crux of the reason why we are looking at what is a COVID death and what are excess deaths and now coming back to the therefore the the public health issue that you've raised we are not by all accounts we have not reached a stage when we can call it endemic though what is endemic or not is itself a major debate becoming endemic doesn't become doesn't mean that we are now okay everything is uncanny after all you had you have tuberculosis which is endemic it doesn't mean therefore it's not a killer and earlier also smallpox was endemic polio was endemic it still meant that public health systems had to gear up for that so endemic doesn't mean becoming safe so that is one question that we have already addressed but Satyajit we have professor Srinath Reddy who's written about that we now need to look at this particular COVID-19 disease as something which should be the way we look at floods that it doesn't mean that we sound alarm every time the rain start but we are prepared for the fact that floods may happen and therefore we have to take steps what does it mean when he talks about public health system therefore being to be treated like we gear up every rainy season for the floods so professor Reddy's piece in today's Indian Express is interesting instructive and appropriate and I must confess that for me it doesn't go far enough so and let me explain that he gives an interesting analogy which I must thank him for pointing out I had not thought of this with a flood control system at a variety of levels of preventive measures of floods and so on and so forth and of warning signs and calibrated responses and there is a great deal of substance in that comparison here is where I think professor Reddy's piece at least doesn't quite go far enough I won't venture to say professor Reddy doesn't go far enough and that is the one question that is not asked in his pieces how well do our flood control systems work how well do our public health systems in response to already endemic diseases of the kind that you pointed out the influenza tuberculosis until relatively recently polio how well did these systems actually work how well do they work how well as citizens of India are we accustomed to seeing them work and I would argue that that is the point where professor Reddy's piece stops where we all of us as citizen activists attempting to use the lessons of the pandemic to bring about durable change have to begin thinking forward we have to begin to ask how are all the components that go into such a multi-layered multi-faceted public healthcare system that plans for the environment that plans for disease surveillance that plans for good warning that plans for test and vaccine development pipelines and as and when necessary provides calibrated decisions to communities takes them into confidence if acute measures if if if crisis measures become necessary for all of this to be put together as a system what do we need what are all the components that will go into this is a far more fundamental question than simply thinking about the technological factors of can we diagnose a virus can we develop a vaccine can we get enough ventilators out is can we make enough oxygen and so on and so forth that I think is going to be where the bulk of productive energies in health activism will have to be focused over coming months years that actually raises three issues we're not going to discuss these three issues today but maybe next time we should that one is to make medicines and vaccines available widely and cheaply now that we have at least antivirals so how to make that available to the public at large because this is something which then people if this available over the counter then can do themselves or get a prescription from a doctor and go and get cheap antivirals if they're available so that is one the second is of course vaccines very important and how to bring the cost of vaccines down and make it available widely how to treat vaccines as an essential part of pandemic control of COVID-19 control for the future and third and I think the most critical element when you come to deaths is the bandwidth and you have talked about it time and again in our discussions that the real issue is when you have a flood well you need to go to flood shelters if we take people out to different heights from the low lying area similarly when people fall seriously ill you need to take them to the hospitals and the hospitals should have in fact intensive care beds available to handle that in fact one of their argument that China has been giving is that we have intensive care beds which are 110 that of the United States and we are about five times that population that is why you are forced to go for a no COVID policy because we just can't handle what would otherwise happen now whether that's a correct argument or not that's a separate topic for discussion but certainly what we saw in the delta wave the loss of lives was directly related to the availability of oxygen and intensive care beds so I think these are the three elements which according to you I think also Srinath professor Srinath Reddy may have put some indicative at least directions of what we need to do but they are the hard ones because that is money that is political will and there is also the need to develop the science and technology network that the country had which you seem to be handling go handing over to private capital or similar profit-minded institutions including multinationals any last thoughts on that before we close the discussion well at the risk of extending an already long conversation let me remind all of us of a parallel we have been talking about antibiotic resistance bacterial infections and we've been talking about development and deployment of antibiotics simultaneously we've been talking be mourning the fact that easy and free availability of antibiotics has actually led to antibiotic resistance as a problem or at least has contributed to the emergence of the seriousness of the problem and what that peculiar paradox points to is that simply the technological fix of making antibiotics which are antibacterials or antiviral drugs widely and cheaply available although a crucial component of the response cannot be the entirety of the response a multifaceted decentralized people centric healthcare system is fundamental so on that note a good people centric public health system I think we'll close this discussion do visit our website and do look at our shows