How Gujarat is undercounting its COVID-19 deaths

Khan Trust workers bringing bodies to the Ashwini Kumar crematorium in Surat. Shahid Tantray for The Caravan
Chahat Rana Photographs by Shahid Tantray
29 April, 2021

By late evening on 15 April, 140 bodies of COVID-19 patients had been cremated at the Ashwini Kumar Smashan, the biggest crematorium in Gujarat’s Surat city. The same day, the Gujarat government reported that 41 people had died due to COVID-19 across the state, including Surat’s official toll of 25 deaths. “On an average, every day we are getting around 150 deaths,” the man managing the cremation registry, told me. He asked not to be identified.  

As the second wave of COVID-19 ravages India, the overwhelming surge of bodies at crematoriums and mortuaries has cast doubts on the official mortality data collected and published by several state governments. While reporting on the crisis from Gujarat, The Caravan found large discrepancies in COVID-19 deaths reported by the state government compared to the numbers of bodies cremated according to COVID-19 protocols at cremation grounds in the worst affected cities. Three factors lie behind the mismatch in death data—recording numbers from only hospitals and not crematoriums, counting only people who have died after testing positive for COVID-19, and doctors recording comorbidities and not COVID-19 as causes of death.

The Surat crematorium employee pointed to a pattern of official under-reporting of deaths that had been going on for days. “On 11 April, we had 190 deaths and these are just the COVID-19 deaths,” he said. Officially, Gujarat maintained that 18 COVID-19 deaths occurred in Surat and 54 across the state, on that day. Similarly, for 14 April, the Ashwini Kumar crematorium register showed cremations of 160 bodies of COVID-19 patients, while the entire city’s tally of cremations following COVID-19 protocols was 275. In contrast, official data showed only 74 COVID-19 deaths in the whole of Gujarat. 

In Surat, we tracked the number of COVID-19 bodies cremated at two major crematoriums apart from the Ashwini Kumar Smashan. Jayesh Bhai Umrigar, who maintains records at the Ramnath Ghela crematorium in Umra, told me that they were handling between forty and fifty bodies of COVID-19 casualties every day. “We cremated 42 on 14 April and around 28 until now, today,” Umrigar told me, on the afternoon of 15 April. The Kurukshetra Smashan Bhumi, another crematorium in the Jahangir Pura area, recorded an average of seventy to eighty cremations of COVID-19 casualties every day, from 1 April to 15 April. “At least 70 COVID-19 bodies are being cremated every day in the past week,” Kamlesh Sailor, a trustee of the Kurukshetra crematorium, told me. Sailor said that 73 bodies were cremated as per COVID-19 protocols on 14 April. On 15 April, as The Caravan’s team stood outside the crematorium, at least eight ambulances were parked there, and most of them were carrying two or three bodies each. The ambulance first in line outside the crematorium was carrying six bodies. Within the span of an hour, we saw at least 20 bodies of COVID-19 patients brought to the crematorium.

Smoke coming out from a chimney at the Kurukshetra crematorium in Jahangirpura, Surat. Shahid Tantray for The Caravan

“At least 150 to 200 deaths are occurring every day and they are telling us there are only ten to 15 per day,” Vipul Suhagiya, a councillor from the Aam Aadmi Party in Surat, said. “These are confirmed COVID-19 cases I am talking about. There are many more who die before they are tested, or others who are suspected of having COVID-19 but test negative.” He added, “It is a joke. Government data is not to be believed.”

Krishnakant Chauhan, an activist with the Gujarat chapter of the People’s Union for Civil Liberties, a human-rights organisation, said that data on COVID-19 had been suppressed from the beginning of the pandemic last year. He had analysed official data provided by the Surat Municipal Corporation between March and May 2020. “We found that their data did not account for around 1,100 COVID-19 patients during this period.”  

Chauhan explained that during the first wave, the Surat Municipal Corporation provided a detailed database that included the number of tests conducted, the number of people who tested positive, the number of people who had been discharged and those who had died. The SMC provided daily and cumulative data across these categories. It also released personal details of people who had tested positive, had been discharged and died. These three categories had the most obvious discrepancies, he said. “We found there were some names missing.” He added, “There were some people whose name was in the list of positive patients, but not in the list of those who had been discharged or passed away. There were also names of people who had been discharged but had never featured on the list of those who tested positive.” He also said that the SMC had undercounted at least one hundred COVID-19 deaths.

Chauhan published a detailed report on these discrepancies at the end of June 2020, which was circulated and published by local media. “The chief minister had made a visit to the city, just after we published this report,” he told me. “Local media questioned him as to why there was a discrepancy in mortality data, but he just said they should ask the local bureaucracy these questions and refused to answer himself.” 

Chauhan told me that now, “the same undercounting is happening at an even more massive scale, but no one is going to admit it, of course.” He said that the quality of data from the SMC now is much worse than what it released until June 2020. For instance, in the early months of 2020, when India was witnessing the first wave of the pandemic, the SMC provided detailed break-ups of the number of positive cases in each ward or locality under its jurisdiction, along with details on the number of tests conducted in each area and mortality rates. In April 2021, it only provided data on daily positive cases and the number of people under quarantine. Surat’s mortality data was only reported in the daily bulletins shared by the Gujarat health department, as part of the state’s total mortality rates.

We found a similar situation in Ahmedabad, too. Narsimha, an employee of the Ahmedabad Municipal Corporation who works at the city’s Ellisbridge crematorium, told me that about 40 bodies were cremated at Ellisbridge every day, since the beginning of April. Ahmedabad has five other major crematoriums which are handling COVID-19 casualties. However, according to government data, the highest number of COVID-19 deaths in the city occurred on 25 April, when 29 people died.

Gujarat’s official data has ignored suspected and probable cases that were not confirmed by testing at the time of death. The bodies at the crematoriums in Surat and Ahmedabad were in white plastic body-bags and marked with the words “COVID suspected” or “COVID positive.” Crematorium officials told us that only the COVID-19 positive bodies were counted for official records. Narsimha added that “Some of these are bodies are not considered COVID-19 related because the person had another illness as well.” He also told us that the corporation did not collect data from crematoriums. “The data from hospitals is taken into account, the Ahmedabad Municipal Corporation does not take any data from here,” he said. “Here, there is no difference between COVID-19 and non-COVID-19 anymore. All bodies are burnt under COVID-19 protocol now.” 

Officials from the Surat and Ahmedabad municipal corporations confirmed to us that they were collecting mortality data only from hospitals. “Our data is not collected from crematoriums. There is a team of experts that conduct audits on these death records from hospitals, and if they believe COVID-19 is the primary cause of death then that is what is taken into account,” an official with the Ahmedabad Municipal Corporation said, on condition of anonymity.

Bodies lying in an ambulance at the Kurukshetra crematorium in Jahangirpura, Surat. Shahid Tantray for The Caravan

Officials also told us that the deaths of people with comorbidities were not counted in the COVID-19 deaths tally. “Those who test negative but have symptoms indicative of COVID-19 are also not counted,” Dr Ashish Naik, deputy commissioner with the SMC, said. Moreover, in an interview with Sandesh News on 15 April, Vijay Rupani, the chief minister, said the state would not add cases where COVID-19 is considered a “secondary cause of death” to the official death toll. Rupani insisted that all deaths are being registered as per the Indian Council of Medical Research’s guidelines. 

The ICMR’s guidelines provide detailed instructions for doctors to fill death certificates, also known as the Medical Certification of Cause of Death or MCCDs, for COVID-19. An MCCD form asks for three significant details—an immediate cause of death, an antecedent cause of death and “other significant conditions contributing to the deaths.”

The ICMR’s COVID-19 guidelines say that for patients who test positive and die, COVID-19 should be recorded as an antecedent cause of death. The immediate cause of death is the injury or complication that led to the death in the moment, such as acute respiratory distress syndrome or an acute cardiac injury. The guidelines add that if a confirmed COVID-19 casualty has comorbidities, these should not be recorded as underlying causes of death. The reasoning is that while comorbidities might cause complications, they cannot cause death in these clinical scenarios. The guidelines allow for comorbid conditions to be added to the “other significant conditions” section, if there is evidence to suggest that the condition contributed to death. In case a patient has clinical symptoms of COVID-19 but has tested negative for the disease, “clinically diagnosed COVID-19” is added as an antecedent cause of death. If the patient died while the test results were pending, then the term “suspected COVID-19” is used in the certificate and if the patient’s test results are inconclusive then the term “probable COVID-19” is used on the death certificate.

Prashant Mathur, the director of the National Centre for Disease Informatics and Research, which is an ICMR-affiliated institution, drafted the ICMR guidelines. He responded to The Caravan’s questions about the guidelines by email and said “Official data is based on COVID -19 specified as the underlying cause of death in the Medical certificate of cause of death. The existing comorbidities may have worsened the COVID disease and are recorded as significant contributory conditions, but not as the underlying cause of death.” According to Mathur, if COVID-19 is deemed as the underlying or antecedent cause for death, then that should be counted in official records of COVID-19 deaths.

Mathur said there were no standing instructions for whether suspected, probable or clinically-diagnosed COVID-19 should be deemed as the underlying causes of death to be included in official death counts. “There is a specific code used in these certificates in case of a suspected or probable COVID-19 death, which differs from the code used for test confirmed COVID-19 deaths. It is this code which will be later computed for census data and death records,” he said, adding that these codes are useful for compiling official statistics under the census of India. “But what local and state governments put as data on the daily and how they come to the conclusion of what is a COVID-19 death or not, that is up to them. We can only give guidelines, we can’t police how data is recorded.”

Mathur noted that in instances when COVID-19 is present and some other condition or existing comorbidity like cancer or diabetes has led to the sequence of events that led to death, doctors record the comorbid condition as the underlying cause of death. In such cases, “then COVID-19 may not be counted as the underlying cause of death,” he said. A body lying on a stretcher at the Kurukshetra crematorium in Jahangirpura, Surat.

Health authorities are using this technicality to suppress COVID-19 death reporting, according to Jitendra Bhai Patel, former president of the Indian Medical Association. Patel, who runs a 28-bed COVID-19 hospital in Ahmedabad, told me that local health authorities had instructed hospitals to register significant comorbidities for COVID-19 casualties as antecedent causes of death on MCCDs. “It makes no sense because my argument is that even if the patient had hypertension or diabetes, he would have probably lived for 20 or 30 years with the help of their medicines,” Patel said. “It would have been controlled, like any other lifestyle disease. It is because they had COVID-19 that the patient died. Casualties suspected of having COVID-19, with clinical symptoms but without test confirmations, or with inconclusive tests were all not being counted as COVID-19 deaths.” 

Patel said that in usual circumstances, post-mortems would be conducted to determine which deaths were due to COVID-19 and which were not. “But under the current situation, no one has time for that. Plus family members usually do not wish to give up their relatives’ bodies for post-mortems.”

Chauhan, the activist, said that the outcome of Gujarat’s manipulation of data was that people were losing faith in the state. “If there is transparency in our data, then people will have more faith in the government,” he said. “They will listen to the government and behave accordingly. These are mechanisms to hide the truth, perhaps because they want to hide their inefficiency or because of political reasons.” He added, “They want BJP-ruled Gujarat to look good. The real situation is turning from bad to worse every day and the government is only working towards hiding the truth.”

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this reportage.