How many people have died of COVID-19 since the pandemic began?

The official global total as of this week: 4.1 million.

But everyone agrees the true toll is far greater. A study released on Tuesday looks at how much of a disparity there may be in India, one of the epicenters of the pandemic.

The analysis, from the Center for Global Development, a think tank in Washington, D.C., looks at the number of “excess deaths” that occurred in India between January 2020 and June 2021 – in other words, how many more people died during that period than during a similar period of time in 2019 or other recent years.

Drawing death data from civil registries and other sources, the report came up with three estimates for undercounts. The conclusion is that between 3.4 and 4.7 million more people died in that pandemic period than would have been predicted. That’s up to 10 times higher than the Indian government’s official death toll of 414,482.

The researchers looked at India in particular because, says study co-author Justin Sandefur, the country has been hit so hard by COVID-19. “The second wave in particular led to heart-wrenching stories from friends and colleagues – and a sense that official numbers are not capturing the true scale of that toll.”

But COVID death undercounts are happening almost everywhere. In the United States, the official toll is 500,000 but the real number is closer to 700,000, says Ali Mokdad of the Institute for Health Metrics and Evaluation (IHME). The group’s website has a global rundown that estimates “excess mortality” in many countries during the pandemic.

When counting “excess deaths,” the cause of death is not part of the data set. But during a health crisis like the pandemic, the assumption is that these additional deaths are part of the COVID-19 toll, says Mokdad. They reflect not only those who died of the virus but those who might have died, say, of heart disease or diabetes because they were afraid to seek treatment during lockdowns, and those who killed themselves due to pandemic stresses, he adds.

How The India Undercount Happened

There are various reasons for the death toll discrepancies in India, as NPR’s Lauren Frayer and Sushmita Pathak reported earlier this year. Dr. Aniket Sirohi, a municipal health official in south Delhi, told NPR he counted 702 deaths on a day in mid-April and passed those numbers up the chain of command. But the death figures the government has published for his region have been at least 20% lower than what he’s seeing on the ground, he said.

He attributed this disparity to administrative chaos. People from neighboring states flock to Delhi for medical treatment. Some die in Delhi and are cremated there but remain registered as residents somewhere else. They don’t get counted anywhere, he said.

“Somehow the numbers are not getting recorded or not shown or getting missed,” Sirohi said. “India always had a poor record of maintaining these things. We have a lot of population. So there’s a bit of a problem with coordination – especially in times like this [pandemic second wave], when 50% of my staff is sick.”

In the western state of Gujarat, local media tracked 689 bodies that were cremated or buried under COVID-19 protocols in one day in mid-April. But just over a 10th of those deaths made it to the government’s tally: The official death toll that day was 78. Such discrepancies were being reported in several states.

There have also been allegations that some politicians tried to suppress inconvenient news about rising case numbers, as NPR reported in April.

In the not-too-distant future, the estimates in India and around the world will likely be confirmed by the collection of additional data, says Mokdad. India, for example, conducts household surveys asking about family deaths, which will fill in some of the death tally gaps. In addition, census numbers will reflect the people who “disappeared” during the pandemic, he says.

What Do ‘Excess Deaths’ Show Us?

More accurate death counts will help the world “understand what went wrong from a public health and policy perspective” during the pandemic, says Sandefur. To determine what could have “been done to limit the death toll, we have to understand the scale and scope of the tragedy,” he says.

Mokdad agrees with Sandefur’s assessment. For example, he says, a realistic COVID death count will shed light on the impact of vaccine inequality — the lack of doses provided in a timely fashion to low-resource countries.

Knowing the death counts will also bring new insights into the “ripple effects [of mortality rates] that we are only beginning to understand – such as erosion of confidence in the health system and state,” says Liana Rosenkrantz Woskie of the Harvard Global Health Institute.

There’s also a very human reason for finding the truth. “Accurate accounting of death is also one of the simplest dignities,” says Woskie. “Knowing how and why your family member died is fundamental to grieving but also to knowing that they were valued by society — and their loss might help mitigate future harm.”

Sean Jin is 31 and says he’d not washed a dish until he was in his sophomore year of college.

“Literally my mom and my grandma would … tell me to stop doing dishes because I’m a man and I shouldn’t be doing dishes.” It was a long time, he says, before he realized their advice and that sensibility were “not OK.”

Now, as part of the Masculinity Action Project, a group of men in Philadelphia who regularly meet to discuss and promote what they see as a healthier masculinity, Jin has been thinking a lot about what men are “supposed to” do and not do.

He joined the peer-led group, he says, because men face real issues like higher rates of suicide than women and much higher rates of incarceration.

“It’s important to have an understanding of these problems as rooted in an economic crisis and a cultural crisis in which there can be a progressive solution,” Jin says.

In supporting each other emotionally, Jin says, men need alternative solutions to those offered by the misogynist incel — “involuntary celibate” — community or other men’s rights activists who believe men are oppressed.

“Incels or the right wing provide a solution that’s really based on more control of women and more violence toward minorities,” Jin says.

Instead, he says, he and his friends seek the sort of answers “in which liberation for minorities and more freedom for women is actually empowering for men.”

Once a month, the Philadelphia men’s group meets to learn about the history of the feminist movement and share experiences — how they learned what “being a man” means and how some of those ideas can harm other people and even themselves. They talk about how best to support each other.

This spring, part of one of the group’s meetings involved standing in a public park and giving a one-minute speech about any topic they chose. One man spoke of being mocked and spit upon for liking ballet as a 9-year-old boy; another spoke of his feelings about getting a divorce; a third man shared with the others what it was like to tell his father “I love you” for the first time at the age of 38.

The idea of such mentoring and support groups isn’t new, though today’s movement is trying to broaden its base. Paul Kivel, an activist and co-founder of a similar group that was active from the 1970s to the 1990s in Oakland, Calif., says men’s groups in those days were mostly white and middle-class.

Today, the global nonprofit ManKind Project says it has close to 10,000 members in 21 nations, is ethnically and socioeconomically diverse and aims to draw men of all ages.

“We strive to be increasingly inclusive and affirming of cultural differences, especially with respect to color, class, sexual orientation, faith, age, ability, ethnicity, and nationality,” the group’s website says.

Toby Fraser, a co-leader of the Philadelphia group that Jin attends, says its members range in age from 20 to 40; it’s a mix of heterosexual, queer and gay men.

Simply having a broad group of people who identify as masculine — whatever their age, race or sexual orientation — can serve as a helpful sounding board, Fraser says.

“Rather than just saying, ‘Hey, we’re a group of dudes bonding over how great it is to be dudes,’ ” Fraser says, “it’s like, ‘Hey, we’re a group of people who have been taught similar things that don’t work for us and we see not working or we hear not working for the people around us. How can we support each other to make it different?’ “

Participants are also expected to take those ideas outside the group and make a difference in their communities.

For example, Jeremy Gillam coaches ice hockey and life skills at an after-school hockey program for children in Philadelphia. He says he and his fellow coaches teach the kids in their program that even though the National Hockey League still allows fighting, they should not respond to violence with violence. He says he tells them, “The referee always sees the last violent act, and that’s what’s going to be penalized.”

That advice surprises some boys, Gillam says.

“One of the first things that we heard,” he says, “is, ‘Dad told me to stick up for myself. Dad’s not going to be happy with me if I just let this happen, so I’m going to push back.’ “

Vashti Bledsoe is the program director at Lutheran Settlement House, the Philadelphia nonprofit that organizes the monthly men’s group. She says men in the group have already started talking about how the #MeToo movement pertains to them — and that’s huge.

“These conversations are happening [in the community], whether they’re happening in a healthy or unhealthy way … but people don’t know how to frame it and name it,” Bledsoe says. “What these guys have done is to be very intentional about teaching people how to name [the way ideas about masculinity affect their own actions] and say, ‘It’s OK. It doesn’t make you less of a man to recognize that.’ “

Meanwhile, the American Psychological Association published guidelines this year suggesting that therapists consider masculine social norms when working with male clients. Some traditional ideas of masculinity, the group says, “can have negative consequences for the health of boys and men.”

The guidelines quickly became controversial. New York magazine writer Andrew Sullivan wrote that they “pathologize half of humanity,” and National Review writer David French wrote that the American Psychological Association “declares war on ‘traditional masculinity.’ “

Christopher Liang, an associate professor of counseling psychology at Lehigh University and a co-author of the APA guidelines, says they actually grew out of decades of research and clinical experience.

For example, he says, many of the male clients he treats were taught to suppress their feelings, growing up — to engage in violence or to drink, rather than talk. And when they do open up, he says, their range of emotions can be limited.

“Instead of saying, ‘I’m really upset’, they may say, ‘I’m feeling really angry,’ because anger is one of those emotions that men have been allowed to express,” Liang says.

He says he and his colleagues were surprised by the controversy around the guidelines, which were intended for use by psychologists. The APA advisory group is now working on a shorter version for the general public that they hope could be useful to teachers and parents.

Criticism of the APA guidelines focused on the potentially harmful aspects of masculinity, but the APA points to other masculine norms — such as valuing courage and leadership — as positive.

Aylin Kaya, a doctoral candidate in counseling psychology at the University of Maryland, recently published research that gets at that wider range of masculine norms and stereotypes in a study of male college students.

Some norms, such as the need to be dominant in a relationship or the inability to express emotion, were associated with lower “psychological well-being,” she found. That’s a measure of whether students accepted themselves, had positive relationships with other people and felt “a sense of agency” in their lives, Kaya explains. But the traditional norm of “a drive to win and to succeed” contributed to higher well-being.

Kaya adds that even those findings should be teased apart. A drive to win or succeed could be good for society and for male or female identity if it emphasizes agency and mastery, but bad if people associate their self-worth with beating other people.

Kaya says one potential application of her research would be for psychologists — and men, in general — to separate helpful ideas of masculinity from harmful ones.

“As clinicians,” she says, “our job is to make the invisible visible … asking clients, ‘Where do you get these ideas of how you’re supposed to act? Where did you learn that?’ To help them kind of unpack — ‘I wasn’t born with this; it wasn’t my natural way of being. I was socialized into this; I learned it. And maybe I can start to unlearn it.’ “

For example, Kaya says, some male clients come to her looking for insight because they’ve been struggling with romantic relationships. It turns out, she says, the issue beneath the struggle is that they feel they cannot show emotion without being ridiculed or demeaned, which makes it hard for them to be intimate with their partners.

Given the findings from her study on perceptions of masculinity, Kaya says, she now might ask them to first think about why they feel like they can’t show emotion — whether that’s useful for them — and then work on ways to help them emotionally connect with people.