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Mortality rates need careful evaluation

His recent books include Planet in Peril and Man Over Machine.

BHARAT DOGRA | New Delhi |

Some of the most distressing images of recent times have related to dozens of dead bodies floating down the Ganges or excessive activity at cremation places. These images disturb all of us a lot, but at the same time we should avoid jumping to any hasty conclusions.

If we draw hasty but flawed conclusions, then we will not be able to have an evidence-based Covid response which is really needed.

This much is clear that there is significant excess mortality, but regarding the composition of this excessive mortality we are not yet sure.

Careful analysis and collection of data is needed to get a better idea. To give an example of the factors at work, we may look at the Ebola outbreak in West Africa in 2014-15. As Ebola is recognized as a high fatality disease and the talk of this pandemic had dominated the region at that time, most of the deaths were invariably attributed to Ebola.

However subsequent analysis, also accepted and quoted by the WHO in its recent documents, revealed that the mortality caused by a mix of preexisting diseases mainly measles, malaria, HIV and tuberculosis was even higher.

What had happened was that as the weak and inadequate health system had got centered mainly on Ebola, those suffering from other important killer diseases had not received normal treatment and care. Ultimately this proved so costly that the mortality caused by four preexisting diseases turned out to be higher than the mortality caused by Ebola.

What is more, some of the patients suffering from these other diseases got sent initially to the special facilities, exposing them to a delay and harassment and mistreatment, before they could be diagnosed properly sent to the proper treatment place, if at all. Now suppose that this reality, instead of being brought to light at a post-pandemic stage by careful researchers, had been realized by the health authorities much earlier. In that case they would have changed their policy to take into account this reality and by taking corrective measures many precious lives could have been saved.

Hence it is clear that understanding causes and composition of excess mortality at an early stage is very important for a proper policy aimed at reducing overall mortality and distress. More detailed data of excess mortality at a national scale is likely to emerge much later, so we must rely on whatever information we have to get as reliable an understanding as possible, while undue haste, rumour-mongering and sensationalism must be avoided.

A careful reading of the evolving situation in India during 2020-21 provides adequate basis for the fact that excess mortality exists and it has increased in more recent times.

This excess mortality is likely to be composed of a mix of factors. Covid mortality is likely to contribute to only a part of this. Another important part of this is likely to consist of other serious diseases and medical conditions (such as those relating to complicated pregnancies and childbirths as well as injuries) which could not receive normal attention during the last 14 months or so.

Another factor is that uncertainty, panic and mental tensions have increased during these times and this can also contribute to excess mortality directly and indirectly. Non-rational medical interventions and self-medications increase in times of uncertainty and profiteering and these too contribute to excess mortality. Livelihoods have been badly disrupted for a very large number of vulnerable people who were not exactly in good health before the pandemic struck. Initially, it is likely they had some reserves on which they could draw, but as the livelihood crisis lingered and then struck again with more ferocity in recent weeks, people faced new difficulties with depleted or zero reserves.

It is likely that higher levels of hunger, malnutrition and deprivation of other basic needs have all contributed to excess mortality. In fact, the excess mortality caused by non-Covid factors may even be higher than that relating to Covid-19 factors, particularly if we remember that in numerous cases of co-morbidity, a death with Covid virus is not necessarily a death caused by Covid virus, and the other aspects of co-morbidity may well be the more dominant factor. Hence policy interventions should seek to control and reduce all these aspects of mortality instead of being concentrated only on Covid-19 aspects.

This approach is likely to lead to a much higher contribution to overall reduction of mortality. Here it may be interesting to look at some recent aspects of this debate in the USA. The Centers of Disease Control and Prevention (CDC), USA, have put the total number of Covid-19 deaths in the USA in 2020 at 376,504. However, for another recent year, 2017, which was called a bad flu year, the same CDC data put the excess mortality numbers at 401,000. In the absence of other exceptional factors, this excess mortality is likely to be attributed mainly to the bad flu. Hence questions have been asked as to why there was so much panic and extended lockdowns in 2020 with 376,504 Covid19 deaths, while there were no lockdowns at all and no big panic with 401,100 bad flu deaths.

But the situation is actually even more peculiar than what is suggested by this data, as the higher mortality in 2017 affected the younger generation much more. To capture this aspect, medical statisticians calculate YLL or years of life lost. In the USA, as mentioned also in calculations presented in the Proceedings of the National Academy of Sciences, 13.3 million YLL were lost in excess mortality of bad flu year 2017, three times more than the loss of 4.41 million YLL attributed to Covid-19 in 2020.

This only re-emphasizes the importance of not rushing to hasty conclusions in pandemic times and looking at a more balanced view in a proper, wider perspective. This will ensure that distorted responses to the pandemic, which can accentuate difficulties, are avoided. The writer is a journalist and author.

His recent books include Planet in Peril and Man Over Machine.