Why Reasons Given For Gujarat’s High COVID Death Rate Don’t Stand
Several propositions have been given to explain the high fatality rate due to COVID19 in Gujarat.
Several propositions have been given to explain the high fatality rate due to COVID-19 in Gujarat. These include ‘low testing rate’ claimed by the Union Health Minister of India, and the prevalence of stigma related to the virus by the director of AIIMS. The other reasons to explain the high death rate in any particular region include more international movement of passengers and cargo; high level of urbanisation; a high proportion of old age population and people with co-morbidities in the region; and of course, the healthcare infrastructure.
Here, I will try to explain where Gujarat stands in terms of these commonly cited explanations, and if any of them, except the state’s poor healthcare system, stand or not.
1. Low Testing Rate
In complete contrast to the claim of the Union Health Minister of India, about the relation between low testing rates and high fatality rate, Indian-American physician and oncologist Siddhartha Mukherjee explained that relatively low fatality rate in India in comparison to major western countries, is largely because of low testing rate in India. While our Health Minister blames low testing rate for high fatality rate, the physician and oncologist blames low testing rate for low fatality rate. This opposite interpretation of the same condition is mysterious.
Testing rate in Gujarat is much higher than the national average. There are states like Kerala, Telangana, Karnataka & Punjab whose testing rate is much lower than Gujarat and still, their fatality rate is lower than Gujarat. The testing rate in Gujarat is 2,367 per million population while it's only 1,382 for Kerala, 1,468 for MP, 1,934 for Punjab, and 628 for Telangana.
The fatality rate of Gujarat is 5.97 %, while its only 0.60 % for Kerala, 1.89 % for Punjab, 2.29 % for Telangana, and 4.65% for MP. Thus the relation between high fatality rate and low testing rate does not seem self-explanatory. The only state which has a higher fatality rate than Gujarat is West Bengal. While counting fatality rate, Bengal is the only state which includes deaths due to co-morbidity as part of total death due to COVID-19 and this may have increased the fatality rate substantially in the state.
2. Old Age Population
According to the World Health Organisation (WHO), 95% of total deaths due to COVID-19 are among those who are above the age of 60, while more than half of the deaths are above the age group of 80.
In case of the age distribution of population, again Gujarat, seems younger than many other states which have lower fatality rates. According to the 2011 census, only 7.93 % population in Gujarat are above 60 years, while the numbers are 12.55 % & 11.41 % respectively for Kerala and Tamil Nadu. The proportion of population above the age of 80 in Kerala is almost double than Gujarat. Similarly, Maharashtra and Punjab also have a higher proportion of the elderly but lower fatality rates due to COVID-19, in comparison to Gujarat.
3. Co-Morbidity & COVID-19
Several studies reveal that people with pre-existing chronic conditions such as diabetes, cardiovascular disease, lung disease, hypertension, and cancer are at increased risk of mortality due to COVID-19. WHO cited that 8 out of 10 deaths due to COVID-19 occur in individuals with at least one underlying co-morbidity, in particular those with cardiovascular diseases/hypertension and diabetes.
The National Health Profile 2019 reveals that in comparison to Gujarat, Kerala, Maharashtra and Rajasthan have almost double the number of patients with cardiovascular diseases while Uttar Pradesh and West Bengal have triple the number of cardiovascular patients. In terms of the number of people who attended NCB clinics for co-morbidity diseases, Gujarat stands far below many states including Kerala, Rajasthan, and Maharashtra.
Despite a low level of co-morbidity disease in Gujarat, the fatality rate in Gujarat is much ahead of the above-mentioned states and the national average. Thus, the logic of co-morbidity can also not explain the high fatality rate in Gujarat.
4. International Movement:
COVID-19 is believed to come to India from outside the national boundary. The states which receive more international passengers and cargos are logically supposed to get more number of infected cases of COVID-19.
But according to the Airport Authority of India, Delhi is the busiest state of India for international movements. Chatrapati Shivaji Maharaj International Airport in Mumbai receives the second-highest number of international passengers and cargos yearly. The only international airport in Gujarat which is in the list of 20 busiest international airports (Sardar Vallabbhai Patel International Airport) has been fighting for 7th position with Kerala (Cochin International Airport) for decades. While Kerala secured three of its international airports in the list of 20 busiest airports with international passengers and cargos, Gujarat continues to have only one airport in that list.
The more ghettoised settlements in urban setups make urban populations more venerable to any infectious diseases. Here, again, Kerala is more urbanised than Gujarat. 42.58% of the population of Gujarat is living in urban areas, as compared to Kerala’s 47.72%. Even Maharashtra and Tamil Nadu are also more urbanised than Gujarat. Urbanisation in West Bengal is far below than Gujarat while the fatality rate in Bengal is more than Gujarat.
6. Stigma & COVID-19
Adding more mystery to the issue, is the claim of Randeep Guleria, Director of All India Institute of Medical Sciences (AIIMS), that stigma is at the root of high fatality rates in Gujarat. But the data related to the claim above does not seem to agree with him.
It is difficult to measure which state has more COVID-19-related stigmas than others. The closest possible measure could be people’s resistance to getting screened, quarantined, or hospitalised. Such resistance often leads to a clash between health workers, police and the people. "Because of the fear of getting bad name or getting quarantined, some patients are scared of visiting hospital or getting tested. When they are positive and come late, it raises chances of mortality," Dr Guleria said.
In comparison to many other states, Gujarat saw less number of clashes between people and health workers or police while they were in the process of giving treatment for COVID-19. Till today, there is not a single case of violence upon the health workers in Gujarat.
Two reports of attack on police personal were reported in Gujarat. In one case, a group of four people attacked police personnel, which may have been a personal issue between them. The second case of Vallabh-Vidyanagar town (Anand district) looks like a clear case of stigma where the local residents tried to not allow the police to cremate a dead body in their locality. Abdul Malabari from Surat emerged exemplary in giving the service of cremation or burial to the people who died due to COVID-19 infection.
Even states like Kerala, which have done tremendously well in handing the crisis, witnessed several cases of abuse and discrimination of health workers by patients and locals. A recently returned man from the Gulf, entered into the house of an Asha worker, slapped and attacked her for informing the health authorities about him. Even a former Member of Parliament (MP) from CPI(M) allegedly misbehaved with health workers in Kozhhikkode.
In comparison to Gujarat, many other states including Madhya Pradesh, Bihar, Uttar Pradesh, Telangana, Karnataka, also saw more number of attacks on health workers and police, but have a lower fatality rate. Bihar witnessed a number of cases where people fled the quarantine centers. Not a single attack on health workers is reported in states like Punjab and Maharashtra, but they have a substantially higher rate of fatality due to COVID-19.
Thus the co-relation drawn between stigma related to COVID-19 and high fatality rate seems unrealistic.
Public Trust in Healthcare
All attacks on healths workers or police personals cannot be linked to the stigma related to COVID-19. For instance, an attack in case of negligence of health services in hospitals or quarantine centers cannot be linked to stigma. Similarly, attacks on police personals against lockdown rules by migrant workers cannot be linked to stigma. Such attacks happened in Gujarat and West Bengal as discussed above, and speak more about the fragile public health facilities in the state and less about the stigma attached to COVID-19.
Putting disproportionate blame on stigma for high fatality rate ignores the role of poor health facilities and services to the patients and people quarantined. In an interview with The Independent, Dr Sumit Ray, head of an ICU department at a hospital claimed that the only proper solution is to rebuild public trust. “In the long run we have to gain the confidence of the people and improve the public health system,” he said. “Wherever there is good quality, accountable healthcare – and I use the NHS as an example – the fact is that the trust is there.”
(Sanjeev Kumar is working with TISS as Program Manager. He can be reached at firstname.lastname@example.org. This is an opinion piece and the views expressed are the author’s own. The Quint neither endorses nor is responsible for them.)
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