There could be two reasons behind the attempt of the Mamata Banerjee led West Bengal (WB) government to make a distinction between deaths directly impacted by Covid-19 and those where the virus is only “incidental” to the cause of death.

A charitable view would be that the government does not want to spread panic by reporting higher numbers, as it goes through its task of putting the processes and infrastructure in place in the state. A fallout of this approach would also be the political brownie points that it can score by touting itself as an “efficient” administration in containing the pandemic. The more hostile view, arguably with a higher subscriber base, is that the government wants to hide its administrative failure in reining in the disease – and thereby fosters a false sense of security in the state through gross underreporting of casualties and violating the basic tenet of transparency.

Had there been a third view, nonexistent or at best minimally advocated now (even by the government itself), that the WB government only played with a perfectly straight bat in implementing the medical guidelines of the World Health Organization (WHO) – and that its “Audit of Deaths” by a panel of eminent doctors was merely a part of that process – there was a good chance that it could have stood the scrutiny of reason. Let’s look at the International Guidelines for Certification and Classification (CODING) of Covid-19 as Cause of Death – issued by WHO fairly recently.

The crisp guidelines define death due to Covid-19 in no uncertain terms: “A death due to Covid-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed Covid-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease…” The guidelines further state clearly – “A death due to Covid-19 may not be attributed to another disease (e.g. cancer) and should be counted independently of pre-existing conditions that are suspected of triggering a severe course of Covid-19.” In Section 3. D of the said guidelines. WHO brings in the “Comorbidity” factor as below: “There is increasing evidence that people with existing chronic conditions or compromised immune systems due to disability are at higher risk of death due to Covid-19. Chronic conditions may be non-communicable diseases such as coronary artery disease, chronic obstructive pulmonary disease (COPD), and diabetes or disabilities…” Thereafter, WHO goes on to define the structure of the “International Form of Medical Certificate of Cause of Death”.

It divides this Death Certificate into two parts – viz Medical Data : Parts 1 and 2. Part 1 would specify the causal sequence (called Chain of Events) leading to death, which may be more than one factor, including the “Time interval from their onset till death”. Part 2 would indicate “Co-morbidity” which contributed to the death. Most importantly in the above, Part 1 would include the trigger that was the “underlying cause of death” (the exact terminology used by WHO in its guideline) – as the last item in its sequence of events. Example – If a person had Covid-19 that led to Pneumonia and that resulted in Acute Respiratory distress causing death, and the person also had a long history of Cerebral Palsy, the Death Certificate would reflect as Part 1 a) – Acute Respiratory Stress 1 b) Pneumonia 1 c) Covid-19, and would identify Covid as the “underlying cause of death”. In Part 2 it would list Cerebral Palsy as “Co Morbidity.” It is here that WHO also clearly brings in another example to demonstrate the opposite case – i.e where a person may be having Covid19 but that is only in Part 2 as an incidental consequence of death and NOT the underlying cause. In this example, the WHO guideline takes the case of a person who had Myocardial Infarction (5 days) leading to Heart failure. Here the immediate reason for death in Part 1 (a) is Heart failure while the underlying cause of death in Part 1 (b) is Myocardial Infarction. This person was also infected with Covid 19 – but reported only in Part 2 as a Comorbidity.

The guideline mentions – “Persons with Covid-19 may die due to other conditions such as myocardial infarction. Such cases are not deaths due to Covid19 and should not be certified as such.” The West Bengal government may argue that the objective of creating a 24 point checklist and authorising a committee of five eminent medical practitioners to “Audit” the death – by analysing the chain of events, medical history, laboratory reports etc. to make the distinction between “underlying cause of death” and Comorbidity is only an attempt to strengthen the WHO-mandated guidelines. It may even argue that this is a pioneering process among all the States in India to uphold the said guidelines. While questions may always be raised on the authenticity of the figures and the conclusions reached by the Audit Committee, and whether they were unfairly “influenced” by political considerations, the process of “Audit of deaths” itself cannot be challenged. It may even be construed as an instrument of transparency and fair reporting, going by the aforesaid WHO parameters.

(The writer is a Chartered Accountant and freelance writer)