Who Dies of COVID-19? Explaining the US’s and India’s Divergent Estimates

Relatives mourn a man who died due to COVID-19, at a crematorium in New Delhi, June 2020. Photo: Reuters/Adnan Abidi.

Two recent studies on deaths among patients COVID-19 and comorbidities in the US and India indicate contrasting trends. The US’s Centre for Disease Control and Prevention (CDC) released its findings in mid-June based on the data of 17 lakh+ coronavirus cases and 1 lakh+ deaths. It concluded that COVID-19 patients with underlying conditions were 12-times more likely than healthy patients to die of the virus. Conversely, an analysis of the data reported in India until July 2 by the Integrated Disease Surveillance Programme (IDSP) revealed no known comorbidities in 43% of deaths due to COVID-19. The 43% of deaths also occurred in the age group of 30-60 years.

The CDC finding is in line with global patterns among older people and those with comorbidities – and these groups often overlap in a major way – being at a higher risk of severe illness and death due COVID-19. The Indian government has staked the same claim, linking old-age with higher risks. What then explains the clearly contradictory findings of the IDSP? There are  two interrelated explanations.

For a few decades now, India has been among the most malnourished and undernourished countries in the world, both by percentage and absolute numbers. This means Indians – whether young, middle-aged or old – without comorbidities could still have compromised immune systems. Considering how India is a young nation, with a median age of 29 years, it is inevitable that there are as many deaths in the younger cohort. Add to this the fact that barely 8% of India’s current population is older than 60 years. So we don’t see as many deaths in the older age group as is evident across the world.

Experts have long observed that, owing to the high costs of healthcare, people in India don’t visit hospitals until the illness becomes serious. With the aim of universalising preventive and primary healthcare, the 2017-2018 Union budget announced the building of 1.5 lakh health and wellness centres (HWCs) across India. Approximately 41,000 HWCs have become functional thus far – but they were allocated meagre resources in the 2020-2021 Union budget, and have found no mention in the Rs-20-lakh-crore Atma Nirbhar economic stimulus either.

As such, our healthcare system is not geared towards preventing illnesses but towards subsidising cures for them. Leave alone villages and towns – studies have shown that far fewer people visit doctors in urban areas than in the developed world. And though people frequent informal doctors, these are not recognised by the state machinery. State-funded health insurance programs in India are also not applicable to pre-medical healthcare.

Medical costs and out-of-pocket expenditure are the two most important reasons that push families into poverty in India. People don’t approach hospitals until they are really hurting with an illness. Thus, the explanation of a compromised immunity must be tempered with the lived reality of expensive and dysfunctional healthcare, in private and public hospitals respectively.

So the other more plausible way to explain the contradictory findings of CDC and IDSP is that there are too many patients in India with unidentified comorbidities. When they are treated as out-patients or admitted to the hospital, they are treated as ‘normal’ coronavirus patients. The lack of digital medical records and patients’ ignorance of their underlying medical conditions result in doctors treating them as patients who have been healthy until being diagnosed with COVID-19.

We already have the technological mechanisms, infrastructure (albeit with meagre funds) and informal healthcare providers to make universal preventive healthcare a reality. On the flip side, what we lack are political will and enough certified doctors in rural areas. It is a clichéd complaint today that India spends too small a fraction of its GDP on healthcare. Byzantine bureaucratic procedures delay the flow of health funds from Delhi or a state capital to panchayat or sub-centres for months after the appropriation bills are passed.

As such, harping on a vaunted Indian immunity seems only to hide the very real dangers of disease, malnourishment and apathetic healthcare faced by an individual growing up in India. The COVID-19 pandemic is a reckoning for our health system. Whatever India’s frailties, it has always attempted major reforms during crises. We must not let the current upheaval go unchallenged either.

V. Vamsi Viraj is an economics graduate with prior work as a research assistant in studying Rayalaseema factionism, and as a research associate for the Member of Parliament of Srikakulam. A. Mohan Dutt is an engineer by education from IIT Madras. He previously worked under the MP of Karimnagar, and is currently working for a regional political party.  Both authors are affiliated with CovidWire, a nonprofit initiative bringing a wide range of information on COVID-19.

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