Future Tense

What’s Happening in India Might Be Even Worse Than You Think

A man and a woman, both wearing masks, hold their hands in prayer to their mouths.
Relatives mourn as they arrive for the cremation of their loved one who died due to the COVID-19, in New Delhi. Arun Sankar/Getty Images

On the night of May 3, Nabeel, a resident of Delhi, was in an ambulance with his COVID-positive brother in search of an ICU ventilator bed. (Nabeel is not his real name.) The oxygen cylinder that was helping his brother breathe was almost out, but they couldn’t find the necessary bed in hospitals around them. Nabeel’s phone was constantly buzzing with leads on where to go, but none materialized. Soon, both time and oxygen ran out, and his 32-year-old brother breathed his last breath in the ambulance on the outskirts of Delhi.

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But this loss may not have been counted among the more than 4,000 COVID deaths a day the Indian government is officially reporting, with a total death toll of more than 250,000 as of Wednesday. Experts agree the real number is far higher—perhaps three times that or more. One reason for the discrepancy is that people who die outside hospitals or on their way to a medical center are often not included in the official coronavirus death count.

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“It’s in the gray area of where and if [his death] will get recorded,” says Jeevika Shiv, a lawyer and one of the many volunteers who was helping Nabeel with hospital options. “In the last three weeks, we have found that there are different kinds of deaths—institutional ones due to lack of oxygen, or people dying in isolation—how do you count them?” There are other reasons why deaths go uncounted, too. Sometimes patients who died of COVID had false negative tests. And the Indian government, per reports, only considers deaths caused by COVID when they are directly connected to the coronavirus—like if someone dies of viral pneumonia. Against World Health Organization guidelines, cases where the virus has contributed to the death of a person with an underlying condition are not being included.

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India is experiencing a devastating COVID surge with 3.7 million active cases and less than 3 percent of the 1.4 billion population fully vaccinated as of Monday. Both cities and rural areas have been hit and the already-weak health care infrastructure is crumbling. Crematoriums are full and in some cases, dead bodies are being dumped in the river Ganges. Meanwhile, the Indian government is busy spinning counternarratives and penalizing taking pictures at crematoriums. As a result, citizens such as Shiv are coming up with ways to track the real death count and ensure that those who are lost are not forgotten. Journalists and activists are interviewing undertakers at crematoriums and tracking paid obituaries in local newspapers. These citizen-led documentation initiatives could eventually become a proxy for the real number of deaths in what has become one of India’s biggest humanitarian crises.

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Shiv is part of a group of lawyers and researchers working on the launch of an online COVID-19 death tracker, starting with documenting COVID deaths caused by lack of oxygen supplies. Expected to be updated weekly, it will include details from media reports and isolated home deaths. The group is also receiving leads from individuals on such deaths and is working on verifying each of them before updating the online database. “We want [the families] to feel like there is a space for them to come forward,” said Shiv.

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Undercounting of deaths isn’t a new challenge during a pandemic. Chinmay Tumbe, an urban historian and author of the book Age of Pandemics, says that even during the 1918 influenza pandemic deaths were undercounted. At the time, he says, that the number of deaths was estimated at 6 million in India, but Tumbe’s research suggests the real number was 20 million. How does he do this? One way is to look at how many more people are dying than normal.

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To estimate the number of deaths during an 1817 cholera pandemic, Tumbe relied on the registry of deaths in burial grounds of South Park Street cemetery in Kolkata, which recorded a sudden spike in burial rates that sustained over the next 50 years. He believes the same process can be followed during the current pandemic.

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“Researchers can tell how many people have died during a pandemic by looking at the excess mortality spike even if the cause of death is registered as something else,” said Tumbe, an economics professor at Indian Institute of Management and a researcher who will be working on estimating COVID-19 deaths in India. This means researchers would assume that the sudden spike that has followed a flat line would be due to COVID, though for such an analysis it’s better to wait until all the data is available as opposed to working on it in real time.

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(That approach has also been used in the U.S. There, the official COVID-19 death count is said to be about 581,000, while a report from the University of Washington’s Institute for Health Metrics and Evaluations that examined excess mortality suggests the real number could be more than 900,000.)

The real problem, Tumbe says, comes in when the death is not registered at all. “In India, apart from willful underreporting [by the government], the other issue is that in many cases it’s almost impossible to register deaths, especially if the entire family has succumbed to the virus.”

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But, Tumbe says that every death leaves a trace—whether it is in the burial or the cremation ground, a lake where corpses are dumped, or obituaries. This is where some of the journalists in the western state of Gujarat come in. A bunch of local reporters—some traveling up to 100 miles—have been visiting cremation grounds, talking to workers, counting body bags, and more to calculate the real number of deaths, according to a BBC report. It said that one day in April, this team of reporters counted 200 dead bodies in Gujarat’s largest city, Ahmedabad.* That same day, the city reported just 25 deaths.

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One journalist among them, Deepak Patel, posts details on Twitter every few hours with their estimates versus the government’s data released, showing a major discrepancy between the two tallies. He also uploads images of paid obituaries in local language newspapers in his attempt to document the real extent of the disaster. There are others, too, estimating the real count to be five times of the official numbers, calculating based on India’s crematoriums running out of space and firewood.

That said, Tumbe says state-specific data cannot be used to zoom out and scale for the rest of the country as the intensity of the pandemic has varied by region.

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Amid all the conversations about numbers, it may be easy to forget that each figure represents a person who died—a person who leaves behind family and friends. So as these efforts to create better data continue, so do projects to memorialize those who have died as individuals. Some have already launched online memorial websites and Instagram pages for people as an outlet for their loved ones to grieve.

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Tarun Cherukuri, who founded a public policy organization, and a friend plan to launch an online memorial for families of COVID deceased. The idea, he says, is to “record every name, capture their story and undertake a collective healing process, following principles of restorative justice like it was done in truth and reconciliation processes in Germany, South Africa, New Zealand.”

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Similarly, entrepreneur Natasha Malpani Oswal is in the process of launching an online initiative titled In Loving Memory, where friends and family can submit a story related to the person who passed during this period as a way to honor their memory. “We want to preserve the memory of people who have been lost,” said Oswal. “Because it’s so easy to just become a statistic.” And if a death isn’t counted in the first place, it can’t even become that.

Correction, May 13, 2021: This article originally misidentified Ahmedabad as Gujarat’s capital city. It is Gujarat’s largest city.

Future Tense is a partnership of Slate, New America, and Arizona State University that examines emerging technologies, public policy, and society.

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