How accurate is Nepal’s Covid-19 death toll?

Ganesh Shrestha was a healthy man. In his 68 years, he had never had any serious health issues nor had he ever been hospitalized.

But in May 2020, during the second wave of the pandemic, he contracted Covid-19 and was hospitalized due to breathing difficulties. After 20 days in the hospital, Shrestha died. The Nepal Army disposed of his body and he was among the nearly 11,928 Nepalis who have died because of Covid-19 over the past two years.

The immediate cause of Shrestha’s death was refractory bradycardia, which in layman's terms means a decrease in the heart rate that occurs to prevent abnormal increases in blood pressure. Bilateral Covid pneumonia was a contributing cause to his death, according to Karishma Shrestha, his daughter.

“My father’s CT value was already 35 [a CT value of above 35 may be considered as negative for Covid-19] and we were preparing to actually take him home when he suddenly died,” said his 28-year-old daughter, whose first name along with her father's has been changed for privacy reasons. “Because he was admitted in the Covid ward, he was automatically counted as a Covid death.”

Ever since the pandemic began, questions regarding what exactly constitutes a Covid-19 death have been asked time and again. Ganesh Shrestha’s case can be seen as emblematic of the confusion surrounding what ascribes Covid-19 as the primary cause of death. Although Ganesh Shrestha would’ve technically tested negative for the coronavirus, doctors attribute his death to complications developed from Covid-19, which makes it a Covid death. 

But things get more complicated when it comes to patients with comorbidities and long-term afflictions. There’s confusion over whether reported death statistics reflect those who’ve died from Covid-19 or those who’ve died with the virus, because the Covid-19 death toll published daily by governments around the world — including Nepal — does not differentiate between the two. Lumping these two statistics together does not provide a true picture of the pandemic’s death toll and can hinder targeted public health measures to prevent future deaths. 

According to the WHO’s international guideline for certification and classification (coding) of Covid-19 as the cause of death, a Covid-19 death is one “resulting from a clinically compatible illness, in a probable or confirmed Covid-19 case, unless there is a clear alternative cause of death that cannot be related to Covid disease (e.g. trauma).” 

In line with the WHO’s guideline, the Nepali Health Ministry’s Epidemiology and Disease Control Division (EDCD) only came up with its own guideline for recording Covid-19 deaths in January 2021. Before that, it was standard practice to record as a Covid death anyone who was positive for the coronavirus at the time of death. 

“Following WHO recommendations, we define Covid-19 deaths as all deaths where the individuals had the virus in their body at the time of death,” said Dr Amrit Pokhrel, chief of the Emergency and Outbreak Management Section at the EDCD. A unit at the EDCD is responsible for tallying confirmed Covid-19 cases, along with fatalities, reported by hospitals from across the country. The daily tally is then published every evening on the Health Ministry website. 

“Except for deaths like road accidents, suicide, and those caused by crime, anyone who tests positive for Covid at the time of death is counted as a Covid death,” said Dr Pokhrel.

But such a blanket rule does not provide an accurate picture of Covid deaths. It is important to distinguish between those who died with Covid and those who died from Covid to understand which section of the population remains susceptible to the virus and at this point in time, to assess the efficacy of the various vaccines that have been deployed. 

“At the time the guidelines were made, we were all scared of the virus and how fast it would spread. So the WHO and the EDCD established these guidelines in the hope that people would take the disease seriously and that would help to lessen the risk of spread,” said Dr Pokhrel. 

However, doctors have the authority to assess and decide on what is a Covid death on their own too. A doctor, alongside a committee of three other health professionals, can decide on the cause of death, whether a patient died with Covid or because of it, said Dr Pokhrel.

But given the manner in which Nepal’s data is collected, there is no indication of how many Covid deaths were decided upon by doctors and how many were simply chalked up to Covid-19 due to the presence of the virus. 

To better assess the actual mortality from Covid-19, many countries are calculating ‘excess mortality' during the pandemic. Excess mortality is measured as the difference between the reported number of deaths in a given period of time and an estimate of the expected number of deaths for that period had the Covid-19 pandemic not occurred. It is, in other words, all deaths arising from the pandemic but not just directly from a medical infection. Excess mortality provides a clearer picture of the actual effects of the pandemic as it doesn’t just take into account the deaths directly from Covid-19 but also the associated consequences of the pandemic like loss of employment, mental and physical stress, and increased poverty. 

For example, according to The Economist, in India, estimates suggest that perhaps 2.3 million people had died from Covid-19 by the start of May 2021, compared with about 200,000 official deaths, suggesting the country’s death toll is severely underreported. 

The estimated excess mortality for Nepal was 114,126 as of February 13, 2022. The reported mortality rate from Covid-19 is currently 392.6 per 1 million ( or about 39 per 100,000) which implies that there could be many more deaths due directly to the coronavirus, in addition to other related stressors. 

These, however, are estimates and Covid-19 has been a thoroughly unpredictable pandemic. This further hammers home the importance of accurate, reliable data, which is sorely lacking in Nepal. Unavailability of data remains a critical problem in Nepal, especially at a time when accurate data is necessary to gauge the extent of Covid-19 and its myriad effects. Even the data that is available is notoriously unreliable and unscientific. 

“Even if we wanted to look for discrepancies, we can’t because we don’t have any data to compare. All the Covid-19 numbers we have are coming directly from the Health Ministry,” said Yogendra Gurung, a professor of population studies at Tribhuvan University. 

Neither the health ministry nor the Central Bureau of Statistics has records of annual deaths. The only data that is available is Nepal’s annual death rate. If we look at the death rate of Nepal from 2020-2022, it ranges from 6.264 to 6.327 per thousand (6.327 in 2020, 6.295 in 2021, and 6.264 in 2022). If we compare just the death rate, then the last three years’ numbers are the lowest yet, declining each year even during the pandemic years. But these are just projections made by the UN and do not help us discern how accurate the national Covid-19 death toll is. 

“These projections are most probably based on the 2001 census and do not take into account the deaths caused by the pandemic,” said Gurung. “Maybe the 2021 census could help us look at the numbers but it is not complete yet.” 

Globally, there have been other discrepancies surrounding Covid-19 deaths. According to this data tracker, Peru has the highest number of deaths per million (6,216, as of February 22). Nepal, for comparison, had 416.83 deaths per million as of February 22. But if you take a look at the total number of cases, Peru is 25th, with 3,497,896 cases. This discrepancy raises questions as to whether testing is limited in Peru, if death cases are being over-reported because Covid-19 deaths are not defined properly, or if the data calculation is faulty.  

Dr Sher Bahadur Pun, chief of the Clinical Research Unit at the Sukraraj Tropical and Infectious Disease Hospital in Teku, acknowledges that determining the cause of death amidst Covid-19 is complex. 

“Covid-19 can cause an extraordinarily wide range of clinical complications. And at the core of the issue is the fact that Covid-19 kills in myriad ways, typically setting off a combination of potentially fatal afflictions. Thus it can become challenging for medical professionals themselves to distinguish Covid deaths,” said Dr Pun. 

While some reports suggest that Covid-19 deaths have been grossly exaggerated, there are others that suggest that cases are severely being underreported. 

Dr Pun and Dr Pokhrel, like many other health professionals, believe that Nepal’s death toll is severely underreported and that the total number of fatalities may be much higher. There are several reasons for this.

“First, there could be a lot of people who died because of coronavirus but did not get themselves tested or visited hospitals or health care centers due to a lack of financial resources, or even social stigma,” said Dr Pokhrel. 

Second, Nepal has limited testing capabilities and limited resources to keep track of everything, he said. 

There’s yet another issue with keeping track of Covid fatalities currently. 

“Earlier, the Nepal Army would dispose of all the bodies and it was easier to keep track of the number of casualties. But now that the fear of Covid has decreased among the public, people are disposing of the dead themselves and because of that, there could be cases that are slipping out from the national record,” said Dr Pokhrel. 

Data from the Health Ministry and the Nepal Army have conflicted at times. Last year, during the height of the second wave, the Nepal Army and the ministry released different numbers for Covid-19 fatalities. On May 11, 2021, the Health Ministry had placed the death toll at 4,084 while the Nepal Army said that it was 4,682. Public health experts had sided with the army’s data. 

Periodically, the Health Ministry omits deaths in its daily update while it tallies its data with that of the Nepal Army, leading to sudden jumps in the daily death rate. On May 12, 2021, the Health Ministry suddenly added 168 deaths to the day’s death count, without explicitly specifying that the deaths were cumulative over the past few days based on Nepal Army data. Again, on September 9 last year, 14 deaths were cumulatively reported.

Officially, nearly 12,000 people have died due to Covid-19 but the true death toll of the pandemic is certainly much higher, both in terms of direct deaths and those from related causes. Accurate, disaggregated data is part of the public’s right to information and in the midst of the pandemic, part of their right to life and an adequate standard of health. But doctors say that this is par the course for Nepal – things get done very late, if they ever get done at all. 

“I too have heard of family and friends who did not die directly from Covid but were declared dead due to the virus,” said Gurung, the Tribhuvan University professor. “But this is all subjective. There’s no way we can know the true death count unless we do a recount keeping in mind a more clear definition of a Covid-19 death.”