Why India’s Covid death numbers are lower than US, Brazil while cases rise at a higher pace

As of Monday, India was among the top three nations for Covid fatalities. While US has recorded 2.02 lakh deaths, the toll was 1.41 lakh for Brazil. India, meanwhile, had 94,503 deaths.

An employee of the Central Delhi district authorities patrols the roads dressed as Yamraj as part of Covid awareness campaign

New Delhi: The global toll from the coronavirus pandemic crossed 10 lakh or one million Tuesday, even as thousands continue to get infected everyday. However, while the number of cases in India is growing at a higher pace than any other country, its fatalities remain relatively lower than countries with comparable case burdens.

As of Monday, India was among the top three nations for Covid fatalities, after the US and Brazil. While the US has recorded 2.02 lakh deaths, the toll was 1.41 lakh for Brazil. India, meanwhile, had 94,503 deaths, even though it had recorded 13 lakh more cases than Brazil by Monday.

The trend appears puzzling. India’s high population density makes it ideal for viral outbreaks. Implementing measures of social distancing is difficult when 1.3 billion people live in close quarters — large families, especially in India’s dense slums, are often known to live in small rooms where distancing is well-nigh impossible, and peak-hour public transport is a relentless crush.  

Furthermore, lack of access to basic sanitation needs like clean water means frequent handwashing is not as easy to implement for many sections of the population.

It is difficult to pinpoint any one reason why India appears to be witnessing fewer fatalities. Its young demographics are a possible reason since Covid-19 has proved to be more lethal among older patients. 

It could also be the fact that the pandemic had a relatively late advent in India, thus giving it a chance to learn from the experience of others. 

At the same time, there are those who refuse to take India’s numbers at face value, pointing to concerns that they may not present an accurate picture.

Covid numbers

By caseload, only the US has a higher number of Covid-19 cases than India, 69.6 lakh against 59.9 lakh. 

Over the past two weeks alone, India has added 11,14,466 new infections, the highest in the world. The US, meanwhile, added 5,61,356 new cases, or just about half of India’s, in the same period.

India’s total deaths-per-million stood at about 70 as of Tuesday, against 633 in the US and 668 in Brazil. The country’s case fatality rate — the share of Covid-19 patients who die — is 1.56 per cent, while the US’ is 2.85 per cent and Brazil’s 2.99 per cent.  

India, however, is not an outlier as far as low fatality rates are concerned. Countries in South Asia have overall fared far better in terms of death rates. Bangladesh and Pakistan, for example, have reported 31 and 29 deaths per million, respectively. 

A similar trend has been recorded in Africa. With its crowded slums and overburdened public healthcare infrastructure, Africa had drawn predictions of up to 3 lakh Covid-19 deaths within the year. However, its toll stands at around 35,000, or 12 per cent of the predicted fatalities, with only three months to go in 2020. The number of infections in Africa was pegged at 14 lakh as of Monday.

Why are mortality rates low in countries like India?

Several sociological factors are thought to be contributing to the low rate of death from Covid in India. One is India’s demographics. Compared to countries in the West, South Asian nations have a younger population.

The average age of the Indian population is 26.8 years, while that of the US and Brazil is 38.5 years and 33.2 years, respectively. Among other South Asian nations, Pakistan has an average age of 22 years and Bangladesh, 27.9 years.

Research has shown that younger Covid-19 patients are less likely to die from the infection. 

In Italy, where the average age is 45.5 years, the country’s older population was believed to be among the primary factors for the hard knock it took from Covid-19 earlier this year.

“This (demographics) is certainly a contributor to low death rates, as seen for the South Asian region in general, including Pakistan and Bangladesh. Whether there might be some additional biological component to this is currently unclear,” Gautam Menon, an infectious disease expert and a professor at the Sonepat-based Ashoka University, told ThePrint.

There has also been speculation since the early days of the pandemic that countries where children are required to get the tuberculosis vaccine — Bacillus Calmette–Guérin vaccine — have a lower Covid-19 burden, by number of cases as well as deaths. 

Clinical trials on BCG vaccines with respect to Covid-19 are ongoing, but many experts are sceptical of its role.

“To my knowledge, there is no conclusive data to support this idea till now and, indeed, some data which would argue against such a correlation,” Menon said.

For example, Brazil has universal BCG vaccination, but its case fatality rate is about twice that of India, which mandates BCG vaccination.

The flood of research surrounding Covid-19 has also thrown up suggestions that antibodies against the dengue virus, endemic to at least 100 countries including India, can confer some level of protection against SARS-CoV-2. 

One recent study, conducted by researchers from the US and Brazil but yet to be peer-reviewed, used mathematical models to suggest that Brazilian “states in which a large fraction of the population had contracted dengue fever in 2019-2020 reported lower Covid-19 cases and deaths”. However, this theory has yet to be conclusively proven.

One explanation for India’s low fatality rates is the fact that the country’s healthcare authorities got time to learn about treatment strategies since the virus wrought havoc here later.

Cases of coronavirus were first reported from Wuhan in China in late 2019.

The first three Covid-19 cases in India were reported between 30 January and 3 February in Kerala, but the infection did not spread to other areas during those months. It was only in March that  India began to see a rise in Covid-19 cases. 

By the time India had reported 4 deaths on 27 March, Italy had already reported over 80,000 cases and more than 8,000 deaths, while the US had seen some 991 deaths from over 68,000 Covid-19 infections. 

“I think there is merit to the suggestion that we were better placed to learn from the experience of others, since the Indian epidemic did take off slower than in other countries, such as Italy and the UK, which were hit hard in the first wave,” Menon said.

The early lockdown — which kicked in 25 March and brought the entire country to a near halt — is also believed to have helped slow the spread, giving India time to expand testing centres and quarantine facilities 

India’s Covid-19 figures have also been hit by allegations of under-reporting, with some experts saying that India’s death recording framework has been patchy since before pandemic days.

Even so, India trails behind Brazil and the US by a huge margin of deaths. Even if the alleged undercounted deaths were added to the official toll, it is likely that India’s death rate would still be lower than some of the worst expert predictions. 

For example, a study by the Institute for Health Metrics and Evaluation, a health research centre at the University of Washington, had predicted over 4 lakh Covid deaths in India by 1 December if people don’t follow social-distancing guidelines. 

As things stand, India is reporting hundreds of new deaths daily. Although it’s fatality rate is lower, India has been recording more deaths than the US and Brazil in recent days. Over the last two weeks, Covid-19 has killed over 14,766 people in India, while the toll for the US and Brazil stands at 10,263 and 9,735, respectively.