The curious case of South Asia's 'low' coronavirus deaths

KONFRONTASI-Scientists and public health experts are continuing to conduct research into why some South Asian countries - despite their ramshackle health infrastructure and dense populations - have witnessed lower coronavirus mortality rates compared with many Western countries.

By early May, the world's richest countries accounted for more than 90 percent of all reported deaths from COVID-19, according to a paper published in The Lancet medical journal. Adding China, Brazil and Iran to that list takes the number up to 96 percent.

By contrast, many densely populated developing countries in South Asia and parts of Africa have fared far better when it comes to the mortality rate from COVID-19, data from Johns Hopkins University (JHU) shows.

In Europe, the observed case fatality ratio (CFR, or the percentage of deaths among confirmed coronavirus patients) has been high, with France reporting a rate of 15.2 percent, the United Kingdom 14.4 percent, Italy 14 percent and Spain 11.9 percent, according to JHU data. In the United States, the CFR is 6 percent, the data shows.

By contrast, in South Asian countries, those rates have been far lower. India has a CFR of 3.3 percent, Pakistan 2.2 percent, Bangladesh 1.5 percent and Sri Lanka 1 percent.

"The rest of the world - historically far more used to being depicted as the reservoir of pestilence and disease that wealthy countries sought to protect themselves from, and the recipient of generous amounts of advice and modest amounts of aid from rich governments and foundations - looks on warily as COVID-19 moves into these regions," write Richard Cash and Vikram Patel, public health experts at Harvard University, in The Lancet.

Doctors and scientists say there are a number of possible explanations for the discrepancy in how COVID-19 is affecting populations in different parts of the world, whether due to varying demographics, different levels of exposure to similar viruses or even incomplete data on mortality in some countries resulting in faulty conclusions.

In Pakistan, home to 220 million people and rickety health infrastructure that offers just six hospital beds per 10,000 people, the first case of the coronavirus was reported on February 26, a returning traveller from neighbouring Iran.

Since then, the virus has spread rapidly, with at least 42,125 cases reported countrywide as of May 18, making Pakistan the 20th in the world in terms of the total number of cases. It has reported 903 deaths, making it 26th worldwide on that list, with a CFR one-third that of the US, and up to 13 percent lower than some European countries.

Is the data accurate?

The first question researchers have asked when examining the data is whether the number of deaths being reported in Pakistan and other countries is, in fact, accurate.

In neighbouring India, for example, some have questioned whether deaths are being accurately documented, with as many as 78 percent of deaths not being medically certified under normal circumstances.

In Pakistan, too, this is a possibility - although medical experts working with the government in its fight against the pandemic suggest the error rate would be far lower.

"There is such a stigma around the whole business of COVID, that people do not want to bring their patients to the hospitals," said Dr Seemin Jamali, head of the largest government hospital in Karachi, the country's most populated city.

The bodies of those confirmed to have been infected with COVID-19 at the time of death are dealt with through strict measures at government hospitals, with officials in full protective kits bathing the body as part of traditional Islamic burial.

"The district [officials] come to receive the dead body, and we pack it in a body bag. There needs to be a better mechanism for transporting the dead, because this is something that people don't want to [happen]," says Jamali.

"Bathing [the dead body] is a very important ritual for Muslims in Pakistan, so it is not possible that you to completely sideline people and say you will bury [their family members] yourselves."

Nevertheless, Jamali and other experts agreed that this appeared to result in only a modest decrease in the reporting of deaths - whether COVID-19-related or not.

Dr Faisal Sultan, Pakistani Prime Minister Imran Khan's focal person on the coronavirus crisis, says the government has put systems in place to ensure that all deaths are being accounted for, including direct coordination with provincial health authorities and community outreach using Pakistan's extensive network for polio vaccination.

"The health system is so sensitised right now to COVID that in the present situation, the possibility of [large numbers of] underreported deaths is unlikely," he told Al Jazeera.

Dr Faisal Mahmood, head of infectious diseases at Karachi's Aga Khan University Hospital, the largest research hospital in the country, concurred, saying results from a preliminary survey at the city's graveyards had not suggested a rise in deaths as opposed to the previous year.

Al Jazeera also interviewed doctors and officials at major government hospitals in Karachi, the eastern city of Lahore, the capital Islamabad and the southwestern city of Quetta - where a number of coronavirus cases have been reported. None noted any marked increase in patients who were dead on arrival, whether from the coronavirus or other causes.

However, Dr Mahmood cautioned: "It may be that our death rate is not low, but that our epidemic is slow or that we are earlier in our epidemic, and that eventually, we will have the same death rate."