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In China, doctors say they are discouraged from citing COVID on death certificates

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BEIJING, Jan 17 (Reuters) – During a busy shift at the height of the COVID wave in Beijing, a doctor at a private hospital saw a notice printed in the emergency department: doctors should “try not to” write COVID-induced respiratory failure on the time of death certificates.

Instead, if the deceased had an underlying illness, that should be named as the main cause of death, according to the notice, a copy of which was seen by Reuters.

If doctors believe the death was caused by COVID-19 pneumonia alone, they should inform their superiors, who will arrange two levels of “expert consultations” before a COVID-19 death is confirmed, he said.

Six doctors at public hospitals across China told Reuters they had been given similar oral instructions discouraging them from attributing deaths to COVID or were aware that their hospitals had such policies.

Some relatives of people who have died from COVID say the disease did not appear on their death certificates, and some patients have reported not being tested for the coronavirus despite arriving with respiratory symptoms.

“We have stopped classifying COVID deaths since reopening in December,” said a doctor at a large public hospital in Shanghai. “It’s useless to do this because almost everyone is positive.”

Those guidelines have led to criticism from global health experts and the World Health Organization that China has dramatically underreported COVID deaths as the coronavirus spreads rampantly in the country, which abandoned its strict “zero-COVID” regime in December.

On Saturday, officials said 60,000 people with COVID-19 had died in hospitals since China’s policy turnaround, a roughly ten-fold increase from previously reported numbers but still short of expectations from international experts, who said the China could see over a million COVID-related deaths this year.

China’s Center for Disease Control (CDC) and the National Health Commission (NHC) did not immediately respond to Reuters requests for comment.

The doctors in this article did not want to be identified because they are not allowed to speak to the media.

Several said they were told such guidance came from “the government”, although none knew which department, a common situation in China when politically sensitive instructions are disseminated.

Another three doctors from public hospitals in different cities said they were unaware of such guidance.

One, a senior emergency physician in Shandong province, said doctors were issuing death certificates based on the actual cause of death, but “how to categorize” these deaths depends on hospitals or local authorities.


Since the start of the pandemic, which first emerged three years ago in its central city of Wuhan, China has drawn heavy criticism for not being transparent about the virus – an accusation it has repeatedly rejected.

Prior to Saturday, China was reporting five or fewer COVID deaths a day. Of the nearly 60,000 COVID-related deaths since Dec. 8 announced on Saturday since, less than 10% were due to respiratory failure because of COVID. The remainder resulted from a combination of COVID and other illnesses, Jiao Yahui, head of the National Health Commission’s (NHC) Bureau of Medical Administration, said Saturday.

Michael Baker, a public health scholar at the University of Otago in New Zealand, said the updated death toll still “looks low” compared to the high level of infection in China.

“Most countries are finding that the majority of deaths from COVID are directly caused by the infection rather than a combination of COVID and other illnesses,” he said. “By contrast, deaths reported in China are mostly (90%) a combination of COVID and other infections, which also suggests that deaths directly from COVID infection are underreported in China.”

Yanzhong Huang, senior fellow for global health at the Council on Foreign Relations in New York, said it was unclear whether the new data accurately reflected actual fatalities, in part because the numbers only include deaths in hospitals.

The World Health Organization (WHO) on Monday recommended that China monitor excess mortality to get a fuller picture of the impact of the COVID outbreak.

Overmortality occurs when the number of deaths in a given period is greater than it should be in relation to historical averages.


Seven people told Reuters that COVID was not mentioned on the death certificates of their recently deceased relatives, even though the relatives tested positive for the virus or had COVID-like symptoms.

Social media is full of similar reports.

When a Beijing resident surnamed Yao brought his 87-year-old COVID-positive aunt to a major public hospital late last month with breathing problems, the doctors didn’t ask if she had the virus and didn’t mention COVID, Yao said.

“The hospital was full of patients, all in their 80s or 90s, and the doctors didn’t have time to talk to anyone,” Yao said, adding that they all appeared to have COVID-like symptoms.

The patients, including her aunt, were rigorously tested, though not for COVID, before being told they had pneumonia. But the hospital told him they had run out of medicine, so they could only go home.

Ten days later, she recovered.

Medical staff at public hospitals in several cities across China said that PCR testing, which under “zero COVID” was an almost daily requirement for much of the population, has now been virtually abandoned.

Taking the focus off testing may be the best way to maximize resources when hospitals are overwhelmed, two experts told Reuters.

Ben Cowling, an epidemiologist at the University of Hong Kong, said that almost all patients with acute respiratory problems would have COVID: “As antivirals are in short supply, I don’t think laboratory tests will make much difference in case management.”


A senior doctor in the eastern city of Ningbo said doctors were told to be “cautious” when saying someone had died of COVID, but if they wanted to do so they would need to get approval.

No other disease required the same level of “caution” for entry on a death certificate, he said.

The doctor at a large public hospital in Shanghai said that weekly death rates since the recent wave of COVID have been three or four times higher than normal for this time of year. Most had more than one illness, but COVID had worsened their condition, she said.

“On the death certificate, we fill in a main cause of death and two to three sub-causes of death, so we basically leave out COVID,” she said.

“There is no other way but to follow the hospital’s orders, which come from the government. I am too insignificant to make any decisions,” she said.

Reporting by Martin Quin Pollard in Beijing and Engen Tham in Shanghai. Additional reporting by Brenda Goh in Shanghai and at the Hong Kong, Shanghai and Beijing newsrooms; Editing by Tony Munroe and Gerry Doyle

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