Count the dead

The relatively low number of Covid-19 deaths reported in South Asia continue to puzzle analysts. While the low numbers might be true for reasons yet to be fully confirmed, there are now serious charges of undercounting.

Reports of undercounting have been circulating in India for a while but now an investigative piece in the London Telegraph has leveled charges of deliberate malfeasance. It claims to have seen written orders to a West Bengal hospital that in case of Covid-positive determinations, the cause is not to be recorded on death certificates. A doctor at a government hospital in Cooch Behar is reported as saying: "We were ordered to strictly refrain from using the word 'Corona' in the death certificates until it gets a nod from the state government's opaque committee.” In Pakistan, doctors told the newspaper that “deaths were being undercounted because of stigma around the disease and public resentment at strict burial regulations.”

Such charges need investigation without delay. If proven false, it would validate the low mortality rate and enable the countries to confidently move towards resumption of normal life with necessary precautions. If true, the danger of a looming unmanageable and damaging crisis becomes very real. Undercounting, by promoting a sense of complacency, does not do anyone any good. Truth will out in the end simply because the dead do not disappear.

This suggests a very simple, inexpensive, and transparent check – COUNT THE DEAD.

This is the check that is signalling trouble in India. Staff at a crematorium near Kolkata say “we used to cremate 15 to 20 bodies usually in a week, prior to the arrival of Covid. But now we receive that number of dead bodies in a single day.” The municipal corporations of Delhi have reported 426 corona positive cremations or burials while the Delhi government’s official bulletin has reported 194 Covid deaths during the same period. In Ahmedabad, a graveyard reported 376 burials in the first 25 days of May compared to just 61 in the same period last year.

Similar trends have been noticed in other places. Moscow has reported 20 percent higher fatalities in April 2020 compared to its average April mortality total over the past decade. In New York City, between March 11 and May 2, “there have been 23,000 more deaths than would normally be expected, while only 18,706 deaths have been reported from Covid-19, suggesting that up to 4,300 additional people may have died from the virus.” In Paris, March-April deaths were 89 percent in excess of the same period in 2019 but in early May the excess had fallen to just six percent as the epidemic was controlled.

A very simple first check would be to count the total number of burials in Lahore and Karachi starting from the date the first case was reported and compare them with the same-period averages over the past few years. Any significant deviation from the norm should trigger an alert for further investigations. The burial counts would also be tallied against the numbers reported by the city authorities to address the concerns about undercounting.

Needless to say, the number of burials would need to be adjusted for inadvertent impacts of the lockdown – fewer deaths because of reduced environmental pollution and vehicular traffic and increased deaths because of lack of access to medical care for non-Covid diseases. These adjustments are not difficult to make but may not be needed initially. Any significant deviation from comparable periods in previous years would alert authorities to some abnormality. On the other hand, the absence of an upswing could suggest that even if the infection was spreading (something that cannot be confirmed without large-scale testing), it was not resulting in an above-average number of deaths or hospitalizations. This would provide a platform for further analysis.

My attempts at pursuing this inquiry have been stymied because most graveyards in Lahore and Karachi either do not retain this information or are unwilling to release it. This is quite in keeping with the tradition where either data is not valued or every minor piece of it is treated like a state secret whose key is tucked away in the waistband of someone with no respect for research.

This harmless data should be in the public domain and readily accessible as it has been in other countries for hundreds of years. Daniel Defoe’s account of the 1665-1666 plague in London (‘A Journal of the Plague Year’) begins with a listing of the weekly bills of death posted by the infected parishes in the city. The contemporaneous diary of Samuel Pepys of the same plague mentions the “bills of mortality,” the weekly tallies of burials printed by the Company of Parish Clerks in London.

My request to those who are forever blabbering about transforming Pakistan into the cutting edge of global research is to start by paying attention to the little things. City authorities should mandate graveyards to release what information they have and to immediately begin recording burials if they are not doing so already. Count the dead because in this case the dead may have tales to tell.

The writer is a former dean of the School of Humanities and Social Sciences at LUMS.