 Hello and welcome to NewsClick. Today we have with us Professor Gautam Menon. And we are going to discuss what has been hotly debated, at least in the government, in their circles, and among mathematical modelers and those who look at COVID-19 pandemic, particularly on the question of deaths due to the pandemic. Gautam, we had a lot of discussions regarding excess deaths this time. And this seems to be not something that we have earlier associated with pandemics. I don't think that you talked about influenza deaths. We had a concept of excess deaths, because the deaths itself are estimated. So the difference between excess deaths and real deaths are not even a question then. So do you think that this part of this examining excess deaths is because we are supposed to have civil registry systems in different places, so a better number of actual deaths being monitored, registered, and therefore the concept of excess deaths as an indication, how good the system has been? I think there's many things. One is just, of course, the scale of mortality of COVID-19, which is certainly in excess of what one might expect of flu. Our other mechanisms for monitoring, for example, TB, malaria, et cetera, are in place. They're separate mechanisms to monitor those. But for COVID-19, we didn't have anything that specifically looked at deaths that were registered as COVID-19 deaths. And as it is, our certification of the medical causes of death is incomplete. In India, prior to what the government says is true for this year, we've typically, although we register between 70% to 80% of our deaths, only about 20% of those registered deaths have an accompanying medically confirmed cause of death. So it's always been unclear as to the extent to which we're able to label deaths correctly. And that's really come out during this pandemic. In the latest set of data that the government has released, they claim that registrations are around 98%, 99%. And although that is true, that you're registering a large number of deaths, and certainly probably more than you did earlier, questions still remain regarding the completeness of those registration. You're only able to register those deaths that are registered. But you have no way of comparing it to something else that says that this is how much you're off by. This is the discrepancy. And for that, you need additional methods those aren't in place yet. But there are some statistical methods and sample data that we do in order to estimate the actual deaths. This is also done by the government of India, right? Yes, there is. There's something called the SRS or the sample registration system, which sort of looks at a group of people and tracks them across a representative population and tracks mortality in that representation, representative population, among other things. The problem is that we don't have data for 2020 from the SRS. So we have nothing to compare with. That would have been a good point of comparison, even though people have raised issues about the quality of SRS data, as indeed they have about the quality of the civil registration system of the CRS data as well. But you do need multiple ways of comparison. You need to be able to compare what the civil registration system provides you in terms of numbers against other independent measures to see are you getting it right? How much are you actually counting? And of course, it's known that there are discrepancies with the CRS data. For example, the state of Bihar records fewer deaths than a bunch of other states with lower populations. These are surprising. These are suggestions that maybe all data regarding deaths are not being calculated correctly. Also, we have this issue, what is the COVID death itself? Because a lot of co-morbidity cases that the doctors, at least we know in Delhi and many others major cities, they have been reluctant to write in the death certificate instead they have given heart attack, which of course happens, pneumonia, et cetera, et cetera. But that we are not going to discuss today because I think that's a larger question of what is a COVID death. But in this case, assuming there is a unanimity on that, that itself is open to question. The other issue is what is registered, what is accounted and what is not. And what you're telling me, if it is 2020, then the major cause of deaths being COVID-19 was really the delta wave. And that then is not covered at all in this, where the death seems to have been even higher from all accounts. So coming back to the issue, is Governor of India's objection that it should not look at any modeling at all in looking at excess deaths and only look at CRS data? Or is it that the modeling has not been done correctly? In essence, what the government seems to be saying is that look, we do have complete data. We believe that we're registering 98%, 99% of deaths in India. And therefore just look at our numbers for 2020 and use that as your basis. Now you could say that, look, we have no numbers for 2021. The delta wave was really between the 15th of February and the 15th of June of 2021. And even in the WHO's analysis plus any other independent analysis, that really contributes a bulk of the deaths. So the bulk of the WHO estimate was about 4.8 million people. Those deaths, most of those deaths, 80% of those deaths came in the delta wave. So what we're arguing about is really what came before that for which there is some CRS data, there is no SRS data currently for 2020. And you have a WHO estimate that is somewhat larger than the number that we have from the government. What the government is essentially saying is, trust our numbers and don't ask us more questions and don't do any modeling on top of those numbers, even if you believe or even if people believe that these numbers may not capture the true reality on the ground. It's an interesting issue because government of India has been willing to talk about modeling to see how the pandemic will disappear from India, as you know it didn't. And you actually wrote pieces on why this modeling has problems. So while predicting the future, you are quite happy to use models for looking at estimates of something you have not counted, modeling is somehow not supposed to be good. And this is something which is very strange. Is there any explanation they've given why they don't want modeling for this? I suspect that the reason is that any model approach will come up with larger numbers than the current set of numbers. As I said, even with the CRS data for 2020 that's available, it will just release 48 hours before the WHO report came out and could not be incorporated into the WHO report. Any reasonable modeling estimate on top of those numbers will come up with larger figures for mortality. We know this because multiple different ways of estimating mortality for COVID-19 in India all come up with numbers that are, the WHO estimate is pretty much in the middle to slightly above the middle of that range. You have numbers between 2.5 million deaths and about six to seven million deaths altogether in India across the whole of the two waves starting in 2020 and going on to the end of 21. So that would be that would encompass the original peak in September of 2020, as well as the Delta wave and going on towards the Omicron wave. Any estimate from multiple different methods and there's no reason to sort of say that all of them are in cahoots with each other to give you an exaggerated number of the actual figures. So while I myself personally might favor a somewhat smaller number closer to three million rather than the WHO 4.8 million, I certainly see that this range of numbers is completely consistent with what we might imagine to be the actual case. So if you take the lower bounds to the upper bounds you're talking about four to five times to about 10 to 12 times that would be the range. And since they are estimates, so of course the estimates are not hard numbers but bounded numbers. They have an upper bounded and lower bound. If you and I say, okay, we don't want to get into what exactly are the mathematical models used or what are the base data used? What we can say is it could be anything between four to five times to about maybe 10 times as WHO's claiming. So it's really a question of public and system that we are not going to get hard numbers for deciding what future course to take. So we need to take a model based approach to understand what the possible likelihood of the pandemic is. And that's exactly what the dead men they put out models to say, well, actually the pandemic is over I'm not getting into that. But the approach of modeling for the future is really also part of our public and system isn't it? I agree completely. And for this set of numbers, there really is no way of sort of extracting information from them without the use of models. For example, if we were to do a properly nuanced approach to this, we'd have to account for the fact that fewer people died from road accidents during the period of the lockdown. We'd have to find that more people died because they didn't access regular care. For example, patients who needed dialysis or patients who need other types of follow-up on a regular basis, most of these patients, certainly anecdotally and probably on the record, were unable to access regular medical services during the fairly stringent lockdowns that we had in the early part of 2020. A good model accounts for all of this, the difference between male and female mortality, the variations, for example, more people die in warmer months and cooler months, for example, heat strokes, et cetera. Although some of those people were indoors during periods of lockdown, these nuances are really going to determine what is the background level of deaths that you would have in the absence of the pandemic. And from there, you can try and estimate how many more deaths or what is the excess deaths that happened because of the pandemic. These are nuanced and difficult issues. The excess deaths, of course, must come from a variety of government, non-government sources. And we've seen examples in which intrepid journalists had challenged government narratives, looking at the difference between actual numbers of cremation, barriers, et cetera, versus official records in a bunch of different states of how many deaths there actually were. We're now seeing in terms of the number of insurance claims which states have been quietly playing out, that there is again a discrepancy between the state's own record of their mortality, as well as the numbers of people who are claiming to have been affected by COVID-19, people associated with them in their families who have died of COVID. So it's certainly true that the bare numbers as they are are probably incorrect. The real question is what is, as you said, what is that multiplier? And as we can see, any reasonable estimate of that multiplier gives you anywhere between three to four to up to about 10. And the WHO figure is close to the 10, it's 9.8. Although that, as I said, errors on that number can be large, but there is no doubt, at least in my mind, that at least a factor of three should be applied to the numbers that we have currently. And it's interesting because by denying the validity of all modeling exercise to say that only our figures, which we don't have for 2021, where the maximum number of deaths took place, that should be the basis. What effectively you're saying is that we can't give you the numbers just to wait. And that doesn't seem to satisfy, at least even if you leave out our curiosity and the need to know, even at least the public health requirements that we might think of for the future. And the other part that, you know, it's interesting that India after all is expected to have a large number of deaths because your population is so large. So since you don't have a zero COVID policy like China, so you can expect the deaths to be lower. But I'm going to think that, yes, of course, the Indian number of deaths would be higher. And of course, there are systems which have calculated or monitored deaths more closely. They have stronger civil registration system than we have. So this shouldn't surprise us, is it? No, it shouldn't surprise us at all. In fact, it's completely natural. In fact, I should point out something that most discussions have missed, which is if you look at deaths on a per capita basis, the excess deaths potentially attributable to COVID on a per capita basis, India's 33rd on that list. Peru is first and the US is 40. So on that basis, again, we're not, you know, on that basis, you could argue that we are not top of the league, certainly, in terms of the number of deaths. It's just that exactly as you said, we're a large country, in a large country with some background level of mortality from COVID-19, we'll have large numbers for COVID-19 deaths. We should not concentrate on that number, but we should look at the more reasonable per capita number, the per 100,000 number for those deaths. And then we don't look too bad from that point of view. Nevertheless, it's important to come to a reckoning of why is it that there are these discrepancies? How do we improve our registration systems so that we capture deaths correctly? And this is more important exactly as you said, from broader issues of public health and recording of public health information. Of course, we have to also nuance the per capita per 100,000 number of deaths because we also have a younger population, like the countries which have had larger number of deaths per 100,000. And all these adjustments become therefore matters which people like you come into. And we have to therefore accept that there is a need for expertise to talk about number of deaths as well, because we really can't count them anyway. I agree. And you point out a very important point that the differential impact of COVID-19 on different countries is very, very much a function of how their population is structured in age. COVID-19 hits older people. In fact, that's probably the dominant sort of effect that you must take into account when you look at the impact on mortality of COVID-19. Older people are just at much, much more risk of dying of COVID-19 than younger people. And younger populations, for example, Bangladesh, Pakistan, many countries and in sub-Saharan Africa will do better simply because their populations are younger. So these adjustments are model adjustments. They have to be taken into account when you try to discuss these numbers. And this is the only reasonable way of doing it is through good models. So I certainly wouldn't diss models. I think they're extremely important in coming to the right understanding from a technical point of view of how many deaths actually happened. Thank you, Autumn. Any last thoughts for us while we close? This is very interesting and currently a very hot topic for discussion. Not so much for scientific reasons or for public health reasons, but it appears so political reasons. I'm sort of, the general tone of the discussion is that they're all against us. Our systems are, we have very good system, the sort of nationalism surrounding the fact that our Indian numbers are being challenged by all of these Western agencies. There must be a vested interests. There must be pharmaceutical interests behind this. And why it's always good to maintain a certain healthy level of skepticism about why you're being criticized for something specific. It's also important to keep all of this, the background in your mind. We know that we don't record deaths accurately. We know that many of our registration systems have to be improved. We know that people have died for COVID-19 and certainly anecdotally, I don't think that there are many families in India who have not had one family member who has been known to die of COVID-19. So at least we know that the scale of deaths of COVID-19 certainly exceeds by far the number that is officially being put up by government. There are multiple ways of arriving at that final conclusion. So I think it would be in the interest of transparency, in the interest of closure, as I pointed out in an article two days ago. For an independent agency set up by government but allowed to be independent to come up with its own estimates. We don't have to rely on the WHO estimates. We can do our own. What matters is that our methodology is transparent so that people can criticize it, improve it, nuance it further. Whatever numbers we have at the end will then be Indian numbers. They will be obtained by Indian scientists working on this area using Indian data with access to different types of Indian data that the WHO may not have had access to. And that would allow us to come to a certain degree of closure on this issue, which I think is very important for the future. No, that's a very, very important point to make that if Indian independent body is set up, which has access to government records in a way that you and I don't have, then that would give much more credibility to the exercise. And secondly, I think the other thing that we perhaps should keep in mind in this that such an estimate would also point out when have the deaths happened, excess deaths happened, and you would find what we have been saying anecdotally or based on limited amount of data that the largest number of deaths takes place when the hospitals collapse and really your intensive care beds are in short supply. That is when actually deaths start multiplying in India. We also had the shortage of oxygen to contribute to that. And therefore this ratio, which we haven't really also discussed maybe some other day, is a very important issue, which could be highlighted if such an exercise is done. Thank you, Gautam, for being with us, sharing your expertise on this in an area which has become what was otherwise an esoteric area, esoteric area, modeling and so on, a hot, debated area of politics. This is all the time we have for NewsClick today. Do keep watching NewsClick and do visit our website.