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Poorer communities saw far more excess deaths during the pandemic than richer neighbourhoods, evidence from a new Chennai-based study shows. Taken with data from other parts of the country, the findings suggest that India’s poor, particularly the elderly, may have disproportionately borne the burden of the pandemic’s fatal impact.

In a study published in The Lancet’s Infectious Diseases Journal early Thursday, researchers led by Ramanan Laxminarayan of Princeton University looked at mortality data from the government’s Civil Registration System (CRS) alongside Census-based measures of affluence. Researchers from the Universities of Berkeley and Chicago and top bureaucrats in Tamil Nadu were part of the study.

Chennai recorded nearly 26,000 excess deaths between March 2020 and June 2021, or a 40% increase over deaths otherwise expected based on the pre-pandemic trend, the study said. This implies more than five excess deaths per 1,000 people, and this was particularly higher for older age groups.

“Excess deaths" refer to the surplus deaths registered during the pandemic as compared to the normal pre-pandemic number. All excess deaths need not be covid-19 deaths, but possibility of undercount in official data makes this the best measure to assess the pandemic’s impact.

The researchers mapped PIN codes on death certificates with socio-economic variables of affluence and deprivation to classify areas by socio-economic status. Neighbourhoods with lower socioeconomic status had substantially higher excess mortality. Living in dense households, lacking access to clean water and sanitation, and not having bank accounts and assets were all associated with higher excess mortality. Belonging to a scheduled caste or a scheduled tribe was also a predictor of higher risk of mortality.

First vs second wave

Neighbourhoods with lower socioeconomic status had 0.7-2.8% higher excess mortality possibly linked to the pandemic for each standard deviation increase in measures of community disadvantage, the study found. However, the paper also found this excess mortality was much more due to the second wave.

Mortality during the first lockdown period was lower than normal, driven by a substantial decline in deaths among men in their 20s. This excess mortality increased a little in the first wave, but reached its highest in the second wave.

Poorer neighbourhoods did not consistently report higher excess mortality than richer neighbourhoods in the first wave, indicating lesser impact in 2020. But this relationship was clearly established in the second wave.

B. Chandra Mohan, principal secretary to the government of Tamil Nadu, who is also a doctor, and one of the co-authors of the paper, said this was one of the first studies to look at demographic and other details rather than excess deaths alone.

Gross undercount

Chennai’s excess mortality ratio is unlikely to be representative of the country. Rather, it may even be a much more benign version of the national picture. The CRS-based estimates of excess deaths collected so far show that states such as Madhya Pradesh and Andhra Pradesh are likely to have missed far more covid-related deaths than Tamil Nadu or Kerala did.

“It would appear to be the case that states like Kerala and Tamil Nadu with better state capacity, whether in terms of reporting data and/or in terms of health management, had lower undercount ratios than states like Madhya Pradesh and Andhra Pradesh," Prabhat Jha, founding director of the Toronto-based Centre for Global Health Research, said.

Jha and his colleagues have collated estimates of excess mortality from the CRS and from the National Health Mission’s Health Management Information System to suggest in a pre-print paper that India’s covid mortality may be seven to eight times the official estimates.

Parallels from Mumbai

The trend showing higher burden of the pandemic on the poor has parallels from studies in Mumbai. Murad Banaji, a mathematician at the University of Middlesex, looked at the city’s official covid-19 fatality and seroprevalence data, and all-cause mortality data, and found a substantially higher spread of covid-19 infection in Mumbai’s slums than in non-slum areas in 2020.

While excess mortality was not substantially different in the two cases, Banaji found that officially-recorded covid deaths were disproportionately low in slums, implying far greater undercounting of deaths there.

The Chennai study shows correlation between deaths and affluence, but much more work needs to be done to establish the causal factors, Mohan said. “Wards are not homogenous and an area usually has both rich and poor households," he said. “It will take more granular work to conclusively establish why we are seeing this pattern."

Rukmini S. is a Chennai-based journalist.

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