Shanghai’s Low COVID Death Toll Revives Questions About China’s Numbers

Funeral home staff members load a body into a vehicle next to people being treated at a makeshift area outside Caritas Medical Center in Hong Kong on March 2, 2022. (Billy HC Kwok / The New York Times)

By the numbers, Shanghai has been an exemplar of how to save lives during a pandemic. Despite the city’s more than 400,000 COVID-19 infections, just 17 people have died, according to officials, statistics they have touted as proof that their strategy of strict lockdowns and mass quarantines works.

But those numbers may not give a complete picture of the outbreak’s toll. China typically classifies COVID-related deaths more narrowly than many other countries, labeling some chronically ill patients who die while infected as victims of those other conditions.

In addition, a nearly three-week lockdown of China’s largest city has limited access to medicine and care for other illnesses. A nurse who suffered an asthma attack died after being denied care because of virus controls. A 90-year-old man died of complications from diabetes after being turned away from an overwhelmed hospital.

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“If, at the time, he had been able to get treatment, he probably would have been killed,” said the man’s granddaughter, Tracy Tang, a 32-year-old marketing manager.

Residents and front-line workers have also been pushed to their limits by the policies. A hospital worker started bleeding internally after long hours conducting mass testing; she, too, died.

It may never become clear how many similar stories there are. China does not release information on excess deaths, defined as the number of deaths – from COVID as well as other causes – exceeding the expected total in a given period. Public health scholars say that figure more accurately captures losses during the pandemic, as countries define COVID-related deaths differently.

But as an example of the hidden effects, a prominent Chinese physician recently estimated that nearly 1,000 more diabetes patients could die than expected during Shanghai’s lockdown, urging authorities to take a more measured response.

The outbreak there has revived questions about the true toll of COVID in China, which has officially reported fewer than 5,000 deaths from the coronavirus in two years.

Beijing is unlikely to waver from its stringent approach. China’s leader, Xi Jinping, has made the country’s low death and infection rates central to his administration’s legitimacy. Officials have been fired after even a few cases were detected in their jurisdictions. Last week, Xi said “prevention and control work cannot be relaxed.”

The focus on minimizing COVID deaths risks incentivizing officials to neglect other causes of death, said Xi Chen, a professor of public health at Yale.

“People pay overwhelmingly large attention to those more visible deaths,” he said. “But every death counts. They count equally. ”

A Unique Accounting

When the omicron variant started coursing through Shanghai in March, some looked, with trepidation, at the example of Hong Kong. The curve of Shanghai’s infections was closely tracking that of Hong Kong’s own huge outbreak. Both cities have large older populations, many not fully vaccinated. Hong Kong’s COVID death rate had soon become the world’s highest, with around 9,000 fatalities.

But a month later, Shanghai – more than three times as populous as Hong Kong – has recorded only 17 COVID deaths.

Hong Kong never fully locked down. Deaths often lag infections, so the reported tally in Shanghai could rise. Experts, however, say there is another reason for the disparity: the way China counts COVID deaths.

Many places, including the United States, Britain and Hong Kong, do not differentiate between people who die with COVID or die from COVID, as long as the coronavirus was a contributing factor. But mainland China generally counts only those who die directly from COVID-related pneumonia, said Zhengming Chen, a professor of epidemiology at the University of Oxford. (It has long done the same for other illnesses.)

That may be why, even as COVID has swept through hospitals for older residents, none of the patients who died appear to have been registered as COVID fatalities. (Workers said they did not know the exact causes of death.) A Shanghai businessman said his 77-year-old father, who had diabetes, died two days after testing positive. He was not logged as a COVID death either.

“If you apply international criteria,” Chen said, “the number of deaths would be somewhat high.”

Chen co-authored one of the few studies to examine nonpublic mortality data in Wuhan, where the pandemic began, working with Chinese government researchers. They found that COVID deaths there during the first three months of 2020 were most likely at least 16% higher than reported.

Even within China, classification practices can vary. Shanghai officials have said that the 17 people who died had underlying conditions that were the direct causes of death, suggesting that the criteria they are using now is more in line with international practices. China’s National Health Commission did not reply to a faxed request for comment on its method of counting COVID deaths.

An incomplete accounting of the pandemic’s death rate could actually erode the Chinese public’s support for strict containment measures, Chen said.

If the number was truly so low, he said, residents might ask, “Why bother?”

“But if the true number of deaths due to COVID, depending on how you calculate,” was much higher, he said, “then that probably needs careful thought.”

Delays Turn Deadly

Before the outbreak, Tang, the marketing manager, and her family were already worried about her 90-year-old grandfather, whose feet had become infected because of his severe diabetes.

But before they could schedule surgery, Shanghai locked down. His feet soon started to smell rotten, Tang said. The family rushed him to the hospital, but doctors said they did not have enough staff to accept him. He was eventually admitted at another hospital days later, but died three days afterward.

“It was torture for him, and they also missed the window of opportunity for saving him,” Tang said.

Stories of similar delays have flooded social media.

In March, a nurse with asthma, Zhou Shengni, died after being turned away from her own hospital’s emergency room, which was closed for disinfection. Last week, Larry Hsien Ping Lang, a well-known economist, wrote on social media that his 98-year-old mother had died while waiting for COVID test results, without which she could not get kidney treatment.

Around the world, the pandemic has led to missed medical screenings and other interruptions to care. Research has also shown that death rates fell in parts of China during lockdowns, in part because of reduced traffic accidents.

Still, even officials have at times acknowledged the cost of China’s strict lockdowns: After the nurse died, the director of Shanghai’s health commission said medical facilities should ensure timely care.

But the authorities continue to insist that a looser approach would be disastrous. And they have silenced voices suggesting otherwise.

This month, a prominent Shanghai physician, Dr. Miao Xiaohui, estimated that the number of excess diabetes deaths could reach nearly 1,000 by the end of his city lockdown. His estimate was based on the Wuhan excess mortality study, which, in addition to tracking COVID deaths, also showed that deaths from noncommunicable diseases, including heart disease and diabetes, were 21% higher than expected during that city lockdown.

“Why can’t we consider a middle road” between zero COVID and living with the virus, Miao wrote in a blog post.

The post was censored.

The Burden of Enforcement

As the epidemic escalated in early March, staff members at Shanghai Putuo People’s Hospital were sent to conduct multiple rounds of community testing. They worked long hours, with few breaks, according to two people with knowledge of the conditions, who requested anonymity for fear of retaliation.

A nurse in the general surgery department, surnamed Ma, began feeling unwell, developing purple patches on her skin, according to the two people, who asked for her not to be identified by her full name. Ma, 40, was eventually diagnosed with acute aplastic anemia, which causes the body to stop producing enough blood cells. While it is not clear exactly what caused the condition, doctors linked her sickness to exhaustion, the people said. On April 6, she died.

Asked about Ma’s death, a staff member who answered the phone at the hospital said she had no information.

Neighborhood officials, responsible for overseeing locked-down streets, have also staggered under their workloads. Recordings said to be of phone calls between residents and officials, in which the officials express frustration or helplessness, have circulated widely online.

On Thursday, authorities confirmed the death of Qian Wenxiong, an official with Shanghai’s health commission. They did not give a cause, but Hu Xijin, the former editor of a state-run tabloid, wrote on social media that Qian killed himself.

“This tragedy has of course intensified the impression that Shanghai’s epidemic prevention has become an unbearably heavy burden for some grassroots workers,” he wrote.

The need to weigh the costs of such strenuous containment will only grow as omicron continues to spread, along with any future variants that are similarly more contagious but seem to cause less severe illness.

“This is not the final one,” Chen, from Oxford, said of Shanghai’s lockdown. “I think this needs to be properly evaluated, to try to find a way to mitigate the hazards.”

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