BEIJING (Reuters) – During a busy shift at the height of the coronavirus wave in Beijing, a doctor at a private hospital saw a notice printed in the emergency department: Doctors should “not attempt” to write coronavirus respiratory failure on death certificates.
Alternatively, if the deceased had an underlying disease, that must be specified as the primary cause of death, according to the notice, a copy of which was seen by Reuters.
If doctors believe the death was solely caused by COVID-19 pneumonia, they must inform their superiors, who will arrange two levels of “expert consultations” before confirming a COVID-death.
Six doctors at public hospitals across China told Reuters they either received similar verbal instructions discouraging them from attributing deaths to COVID or were aware that their hospitals had such policies.
Some relatives of people who died of COVID say the disease did not appear on death certificates, and some patients have reported not being tested for coronavirus despite arriving with respiratory symptoms.
“We have stopped categorizing COVID deaths since it reopened in December,” said a doctor at a large general hospital in Shanghai. “It is pointless to do this because almost everyone is positive.”
The directives led to criticism by global health experts and the World Health Organization that China had drastically underreported COVID deaths as the coronavirus spread 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 shift, a nearly tenfold increase from previously reported numbers but still short of expectations by international experts, who said China could You see over a million COVID-related deaths this year.
The Chinese 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 declined to be named because they are prohibited from speaking to the media.
Several of them said that such directives had come from “the government”, although none of them knew from which department, which is a common situation in China when politically sensitive instructions are published.
Three other doctors at public hospitals in different cities said they were not aware of any such directive.
One of them, a senior doctor at the emergency room in Shandong Province, said that doctors were issuing death certificates based on the actual cause of death, but that “how to classify” these deaths was up to hospitals or local officials.
Since the start of the epidemic, which first emerged three years ago in the central city of Wuhan, China has been under fire for not being transparent about the virus — an accusation it has repeatedly denied.
Before Saturday, China was reporting five or fewer COVID deaths per day. Of the nearly 60,000 COVID-related deaths since Dec. 8 that it has announced on Saturday since then, less than 10% have been due to respiratory failure due to COVID. The rest was caused by a combination of COVID and other diseases, said Jiao Yahui, head of the Medical Management Office under the National Health Commission.
Michael Baker, a public health researcher at New Zealand’s University of Otago, said the updated death toll still “appears low” compared to China’s high level of infection.
“Most countries are finding that most deaths from COVID are a direct result of infection rather than a combination of COVID and other diseases,” he said. “By contrast, the deaths reported in China are mainly (90%) a combination of COVID and other infections, which also indicates that deaths directly caused by COVID infection are underreported in China.”
It’s unclear whether the new data accurately reflects actual deaths, said Yanzhong Huang, a senior fellow on global health at the Council on Foreign Relations in New York, in part because the figures only include hospital deaths.
The World Health Organization (WHO) on Monday recommended that China monitor excess deaths to get a fuller picture of the impact of the surge in COVID.
Excess deaths occur when the number of deaths in a given period is higher than it should be relative to historical averages.
The test ends
Seven people told Reuters that the coronavirus was not mentioned on the death certificates of their recently deceased relatives, even though the relatives either tested positive for the virus or had COVID-like symptoms.
Social media was full of similar reports.
When a Beijing resident surnamed Yao brought his 87-year-old aunt, who had COVID, to a large public hospital late last month with breathing problems, Yao said, the doctors didn’t ask if she had the virus and didn’t mention COVID.
“The hospital was full of patients, all in their 80s and 90s, and the doctors didn’t have time to talk to anyone,” Yao said, adding that everyone seemed to have symptoms similar to the coronavirus.
The patients, including his aunt, were thoroughly tested, despite not having the COVID virus, before being told they had pneumonia. But the hospital told him they were out of medicine, so they could only go home.
She recovered ten days later.
Medical staff at public hospitals in several cities in China said PCR testing, which under “COVID zero” was an almost daily requirement for large parts of the population, is now almost abandoned.
De-focusing on testing may be the best way to maximize resources when hospitals are overwhelmed, two experts told Reuters.
Almost all patients with severe respiratory problems will have COVID, said Ben Cowling, an epidemiologist at the University of Hong Kong: “Because there is such a severe shortage of antivirals, I don’t think laboratory testing will make much difference in case management.”
Doctors there have been told to “be careful” about saying someone died of COVID, said a senior doctor in the eastern city of Ningbo, but if they wish, they will need to get approval.
No other disease, he said, required the same level of “caution” to be recorded on a death certificate.
The doctor at a large general hospital in Shanghai said weekly death rates since the last COVID wave have been three or four times higher than normal for this time of year. Most of them had more than one illness, she said, but the coronavirus worsened their condition.
“On the death certificate, we fill in one primary cause of death, and two to three sub-causes of death, so we basically ignore COVID,” she said.
“There is no other way but to follow the hospital orders issued by the government. I am not important to make any decision,” she said.
(Reporting by Martin Quinn Pollard in Beijing and Engin Tham in Shanghai). Additional reporting by Brenda Goh in Shanghai and the Hong Kong, Shanghai and Beijing newsrooms. Editing by Tony Monroe and Jerry Doyle
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