India’s Official COVID-19 Death Toll Is Still an Undercount

Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization (WHO), visited India last month to launch the new Global Centre for Traditional Medicine in Gujarat. The trip came amid controversy over the country’s COVID-19 death toll as the WHO seeks to revise global mortality figures from the pandemic. India’s official count numbers 520,000 deaths, but the WHO and several previous studies have estimated that as many as 4 million Indians have died from COVID-19.

New Delhi has reportedly attempted to delay the release of the WHO’s revised figures, in which India would have the highest death toll of any country in the world. Indian officials have bristled at any estimate that exceeds the official count, questioning researchers’ methodology. Despite Tedros’s visit, the disagreement over the statistics is unlikely to be settled anytime soon, which does not bode well for India’s working relationship with the WHO.

The discrepancy between New Delhi’s official count and the WHO estimate begins with the chronically underfunded Indian public health system, which lacked the capacity to handle rising COVID-19 cases, and particularly during the massive second wave of infections that came in April 2021. Furthermore, only around one-fifth of deaths in India are medically certified under normal circumstances; during the surge, many Indians died at home, leaving their cause of death unreported. The WHO figures largely conform to estimates from independent scientific and medical professionals. But Indian officials continue to obscure an accurate assessment of the pandemic’s human impact—with long-lasting effects for public health.

The Indian government’s response to the pandemic faltered from the start, with political concerns often outweighing technical expertise. New Delhi announced a nationwide lockdown in March 2020 without consulting key ministries, stranding millions of migrant laborers across the country. In October 2020, the first case of the delta variant emerged but went undetected—or at least unannounced—in India, resulting in record deaths across the country in April 2021. Officials struggled with supply chain issues, creating oxygen distribution problems during the height of the surge and a constant sourcing challenge for raw vaccine materials.

Throughout the pandemic, independent observers have questioned India’s official case numbers and death toll. Many analysts have suggested that the Indian government suppressed numbers for political purposes. But it is just as likely that officials undermined the data collection process so that no one—including those in the government—had an accurate picture of what was unfolding amid the surge. More than one year later, it is clear that this failed data collection process was not just a capacity issue but a political failing.

For decades, the WHO worked with the World Bank and the U.S. Centers for Disease Control and Prevention (CDC) to train public health agencies on disease monitoring and surveillance. One of the hallmarks of this cooperation in India was the Integrated Disease Surveillance Programme (IDSP), which was housed in the National Centre for Disease Control (NCDC). The IDSP set protocols for hospitals and laboratories to identify and report infectious diseases, which would allow information to be quickly aggregated into intelligence for government officials. Authorities could then trace outbreaks, contain disease spread through targeted lockdowns, and rapidly deploy personnel and equipment to overwhelmed areas.

However, shortly after India identified its first COVID-19 cases in January 2020, it temporarily shut down the existing IDSP system. The government was seemingly concerned that the NCDC and its apolitical public health officials could not be trusted to report such sensitive data. India’s Ministry of Health and Family Welfare eventually developed its own IDSP for tracking COVID-19, ensuring that political appointees had direct control of data collection.

The health ministry struggled to build a new infectious disease monitoring system on the fly. Health care facilities and state governments were left in the dark about how to report cases and fatalities. Even when state-level public health systems adopted new protocols, the reporting procedures were inconsistent at the national level, impeding cross-state coordination efforts. And once the health ministry set up its own rudimentary system, whistleblower accounts suggest that it refused to disclose COVID-19 data with other government scientists and epidemiologists.

Given that Indian officials were unwilling to share data with their own experts, it should come as no surprise that they are now resisting calls to share their data with the WHO. A close study of India’s experience with COVID-19 could significantly strengthen the country’s response to other infectious diseases, and perhaps to the next global pandemic. Having reliable data would enable the government to deploy suitable resources to cope with a future health crisis. But as long as the issue remains a political one, health experts are unlikely to access this much-needed information.

There is one certainty public health officials can take from India’s response to the pandemic: Capacity-building, whether through a system like the IDSP or through the placement of foreign-trained experts within state health agencies, is pointless if these investments are sidelined for political reasons. Organizations such as the WHO and the U.S. CDC must also lend political support to their technocratic agencies in other countries. Meanwhile, public health experts should be prepared to engage in their countries’ political processes. Of course, such trainings would require suitable government cooperation.

Data collection problems in China are already holding up researchers’ investigations into the origins of the coronavirus pandemic. The WHO is working to arrive at an accurate estimate of COVID-19 mortality figures as quickly as possible. India is one of the countries that has suffered the most; the WHO should not let quibbles about measurement errors stand in the way of revealing the human costs of the pandemic.