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

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 to death certificates.

Instead, if the deceased had an underlying condition, it should be listed as the primary cause of death, according to the notice, a copy of which was seen by Reuters.

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

Six doctors at public hospitals across China told Reuters they had either received similar oral instructions discouraging them from attributing deaths to COVID, or they knew their hospitals had such policies.

Some relatives of people who died with COVID say the disease was not listed on their death certificates, and some patients said they were not tested for coronavirus despite arriving with respiratory symptoms.

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

Such guidelines have led to criticism from global health experts and the World Health Organization that China has significantly underreported COVID deaths as the coronavirus plagues the country, which ditched its strict “zero-COVID” diet in December.

On Saturday, officials said 60,000 people with COVID-19 had died in hospitals since China’s policy reversal, a roughly tenfold increase from previously reported figures but still below expert expectations. internationals, who said China could see more than a million COVID-related deaths this year.

The Chinese Center for Disease Control (CDC) and 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 not authorized to speak to the media.

Several said they were told the advice came from “the government”, although none were sure which department, a common situation in China when politically sensitive instructions are issued.

Three other doctors from public hospitals in different cities said they were unaware of such guidelines.

One, a senior emergency doctor in Shandong province, said doctors issue death certificates based on the actual cause of death, but “how to categorize” these deaths depends on the 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 – a charge it has denied to many times.

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

Michael Baker, a public health specialist 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 find that most COVID deaths are caused directly by infection rather than a combination of COVID and other illnesses,” he said. “In contrast, deaths reported in China are mostly (90%) a combination of COVID and other infections, which also suggests that deaths directly due to COVID infection are underreported in China.”

Yanzhong Huang, senior global health researcher at the Council on Foreign Relations in New York, said it was unclear whether the new data accurately reflected actual deaths, in part because the numbers only included deaths in the hospital.

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

We speak of excess mortality when the number of deaths for a given period is higher than it should be compared to historical averages.


Seven people told Reuters that COVID was not mentioned on the death certificates of their recently deceased relatives, despite the relatives having tested positive for the virus or exhibiting 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 respiratory problems, doctors did not ask her if she had the virus and did not didn’t mention COVID, Yao said.

“The hospital was full of patients, all in their 80s or 90s, and the doctors had no time to talk to anyone,” Yao said, adding that everyone seemed to have symptoms similar to COVID. .

The patients, including her aunt, were rigorously tested, but not for COVID, before being told they had pneumonia. But the hospital told him there was no more medicine, so they could only go home.

Ten days later, she recovered.

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

Not focusing on 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: “Since antivirals are very rare, I don’t think laboratory tests will make a big difference in case management”.


A chief medical officer in the eastern city of Ningbo said doctors should be “careful” about saying someone had died of COVID, but if they wanted to, they should get an approval.

No other disease required the same level of “caution” to be listed on a death certificate, he said.

The doctor at a major public hospital in Shanghai said weekly death rates since the recent COVID surge were three or four times higher than normal for this time of year. Most had more than one illness, but COVID made them worse, she said.

“On the death certificate, we fill in one primary cause of death and two to three sub-causes of death, so we’re basically omitting COVID,” she said.

“There is no other way for us but to follow the orders given by the hospital, which come from the government. I am too insignificant to make a decision,” she said.

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

Our standards: The Thomson Reuters Trust Principles.

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