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As the coronavirus contagion hits the Indian capital, the country has good reason to fear that it could be missing many novel coronavirus cases. Given the glaring gaps in how health and mortality data are recorded in the country, the official figure of zero death so far could be an underestimate.

While the true picture on coronavirus will take some time to appear, past studies show that few deaths are certified and among those that are certified, doctors routinely misdiagnose the cause of death.

Since 1969, the registration of a death is legally mandatory in the country. However, only 77% of deaths are officially registered, and just 22% of these registered deaths are medically certified, according to data from the Registrar General of India (RGI).


Medical certification takes place mainly in urban areas and for deaths that make it to hospitals. Hospitals record more sudden deaths while more deaths from chronic illness and infectious disease take place at home, and never make it to hospital death records.


Even in that minority of deaths which are medically certified, there are major problems with the way doctors arrive at the cause of death. One consistent problem, which has implications for estimates of coronavirus deaths, is that doctors record the mode of death (for example, “heart attack") rather than the underlying causes (“chronic heart disease" or “hypertension"). Multiple reviews of death certificates filled in at individual hospitals have shown that underlying and contributory causes of death are incomplete or incorrect.

Even household surveys which ask family members about the cause of death in a household may not work in developing countries. In 2011-12, the District Level Household Survey in India marked 39% of neonatal and 50% of post-neonatal deaths as those whose cause was unknown or could not be ascertained.

Smaller studies have shown that “verbal autopsies" can produce more accurate results for causes of death than death certificates. In 2004, a team of college students in Tamil Nadu was trained to interview the families of the deceased and to write a verbal autopsy report in Tamil on the “complaints, symptoms, signs, duration and treatment details of illness prior to death". Each report was reviewed by two physicians independently who concluded what the medical cause of death was. The study found that this reduced the proportion of deaths attributed to unspecified and unknown causes from 54% to 23% in Chennai and from 41% to 26% in rural Villupuram. It highly improved the accuracy of identifying cancer.

In 2001, the Toronto-based Centre for Global Health Research began the “Million Death Study" with the RGI at the all-India level. The MDS is a study of the causes of death in a nationally representative sample of 1.3 million deaths. Field enumerators conduct “verbal autopsies", and two doctors then review these details and arrive at the underlying cause of death. If they disagree, a third doctor weighs in.

India vastly underestimated deaths from smoking, snakebites and malaria among other causes, the MDS found. The MDS documented 50,000 snakebite deaths in 2005, which was the World Health Organisation's global estimate at the time. (The WHO has subsequently revised global snakebite death totals to 100,000 and declared snakebites a neglected tropical disease priority.)

The MDS also found a higher suicide rate than was earlier known especially among younger people, and in south India, particularly from ingesting pesticides.

It found that road traffic accident deaths were under-counted, estimating 68,000 pedestrian deaths in 2005 as compared to the 9,000 registered in police records.

Could India be underestimating the number of coronavirus cases and possible deaths, given this background of low level of death certification and high levels of errors?

It’s hard to say “as death registration and certification is too slow", says Prabhat Jha, director of the CGHR, who leads the MDS. The RGI’s office has not released any new data on causes of death since 2013.

Rukmini S. is a Chennai-based journalist.

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