How many people have died of COVID-19 since the pandemic began?
The official global total as of this week: 4.1 million.
But everyone agrees the true toll is far greater. A study released on Tuesday looks at how much of a disparity there may be in India, one of the epicenters of the pandemic.
The analysis, from the Center for Global Development, a think tank in Washington, D.C., looks at the number of "excess deaths" that occurred in India between January 2020 and June 2021 — in other words, how many more people died during that period than during a similar period of time in 2019 or other recent years.
Drawing death data from civil registries and other sources, the report came up with three estimates for undercounts. The conclusion is that between 3.4 and 4.7 million more people died in that pandemic period than would have been predicted. That's up to 10 times higher than the Indian government's official death toll of 414,482.
The researchers looked at India in particular because, says study co-author Justin Sandefur, the country has been hit so hard by COVID-19. "The second wave in particular led to heart-wrenching stories from friends and colleagues — and a sense that official numbers are not capturing the true scale of that toll."
But COVID death undercounts are happening almost everywhere. In the United States, the official toll is 500,000 but the real number is closer to 700,000, says Ali Mokdad of the Institute for Health Metrics and Evaluation (IHME). The group's website has a global rundown that estimates "excess mortality" in many countries during the pandemic.
When counting "excess deaths," the cause of death is not part of the data set. But during a health crisis like the pandemic, the assumption is that these additional deaths are part of the COVID-19 toll, says Mokdad. They reflect not only those who died of the virus but those who might have died, say, of heart disease or diabetes because they were afraid to seek treatment during lockdowns, and those who killed themselves due to pandemic stresses, he adds.
How the India undercount happened
There are various reasons for the death toll discrepancies in India, as NPR's Lauren Frayer and Sushmita Pathak reported earlier this year. Dr. Aniket Sirohi, a municipal health official in south Delhi, told NPR he counted 702 deaths on a day in mid-April and passed those numbers up the chain of command. But the death figures the government has published for his region have been at least 20% lower than what he's seeing on the ground, he said.
He attributed this disparity to administrative chaos. People from neighboring states flock to Delhi for medical treatment. Some die in Delhi and are cremated there but remain registered as residents somewhere else. They don't get counted anywhere, he said.
"Somehow the numbers are not getting recorded or not shown or getting missed," Sirohi said. "India always had a poor record of maintaining these things. We have a lot of population. So there's a bit of a problem with coordination — especially in times like this [pandemic second wave], when 50% of my staff is sick."
In the western state of Gujarat, local media tracked 689 bodies that were cremated or buried under COVID-19 protocols in one day in mid-April. But just over a 10th of those deaths made it to the government's tally: The official death toll that day was 78. Such discrepancies were being reported in several states.
There have also been allegations that some politicians tried to suppress inconvenient news about rising case numbers, as NPR reported in April.
In the not-too-distant future, the estimates in India and around the world will likely be confirmed by the collection of additional data, says Mokdad. India, for example, conducts household surveys asking about family deaths, which will fill in some of the death tally gaps. In addition, census numbers will reflect the people who "disappeared" during the pandemic, he says.
What do 'excess deaths' show us?
More accurate death counts will help the world "understand what went wrong from a public health and policy perspective" during the pandemic, says Sandefur. To determine what could have "been done to limit the death toll, we have to understand the scale and scope of the tragedy," he says.
Mokdad agrees with Sandefur's assessment. For example, he says, a realistic COVID death count will shed light on the impact of vaccine inequality — the lack of doses provided in a timely fashion to low-resource countries.
Knowing the death counts will also bring new insights into the "ripple effects [of mortality rates] that we are only beginning to understand — such as erosion of confidence in the health system and state," says Liana Rosenkrantz Woskie of the Harvard Global Health Institute.
There's also a very human reason for finding the truth. "Accurate accounting of death is also one of the simplest dignities," says Woskie. "Knowing how and why your family member died is fundamental to grieving but also to knowing that they were valued by society — and their loss might help mitigate future harm."