After reporting fewer than fifty coronavirus deaths since the end of the zero-COVID policy, Chinese health officials revised the death toll to 59,938 virus-related deaths in hospitals between December 8 and January 12. Experts believe even the new count may vastly underestimate the true number of deaths over the past month. Anecdotal accounts of overtaxed funeral parlors and exorbitant cremation fees paint a grim picture of a health system struggling to cope with the unmitigated spread of COVID. Bloomberg News reported on expert analysis of China’s COVID numbers and what they reveal about the extent of China’s outbreak:

“This reported number of Covid-19 deaths might be the tip of the iceberg,” said Zuo-Feng Zhang, chair of the department of epidemiology at the Fielding School of Public Health at University of California, Los Angeles.

While the figure is roughly in line with what Zhang estimated might be coming from the country’s hospitals, he said it’s only a fraction of the total Covid deaths across the country.

Using a report from the National School of Development at Peking University that found 64% of the population was infected by mid-January, he estimated 900,000 people would have died in the previous five weeks based on a conservative 0.1% case fatality rate. That means the official hospital death count is less than 7% of the total mortality seen during the outbreak.

The official toll translates to 1.17 deaths daily for every million people in the country over the course of five weeks, according to a Bloomberg analysis. That’s well below the average daily mortality rate seen in other countries that initially pursued Covid Zero or managed to contain the virus after relaxing their pandemic rules. [Source]

The World Health Organization “welcomed” Beijing’s new data release but asked for further details on the progression of outbreaks and more information about virus sequencing which could help detect new variants. “It’s really sad to see the number of hospital-related deaths of 60,000 in the last month, but that should be considered the minimum,” said one WHO leader. China’s relatively low death number is in part of a product of its incredibly restrictive definition of what constitutes a COVID death. Leaked minutes from a meeting from the National Health Commission reveal that officials urged hospitals to only label deaths as COVID-related if patients had no underlying conditions. Doctors across China have confirmed that they have been pressured not to write COVID on death certificates. Top leaders at the WHO had earlier warned China that: “Limiting your diagnosis of ‘death from covid’ to someone with a covid-positive test and respiratory failure will very much underestimate the true death toll associated with covid.”

Experts and political leaders are especially concerned about outbreaks in rural China over the coming holiday period. In his Lunar New Year address, Xi Jinping said: “I am most worried about the rural areas and farmers. Medical facilities are relatively weak in rural areas, thus prevention is difficult and the task is arduous.” Roughly 40% of China’s elderly live in rural areas without access to large hospitals equipped to deal with mass COVID outbreaks, and only 66% of China’s over-80 population had been vaccinated by the end of November. Grassroots medical workers have little medical training—less than one percent hold college degrees, and only slightly over half have graduated from vocational technical high schools. What’s more, the number of village clinics actually dropped from 616,000 to 599,000 and rural health care workers dropped from 1.45 million to 1.36 million over the three years of the zero-COVID policy because they were prevented from treating fever patients locally. Bloomberg News reported on steps the State Council has instructed rural governments to take to mitigate outbreaks: 

Local authorities must check in with vulnerable people during the festival that kicks off this weekend, including the elderly, pregnant, and those with underlying diseases, according to a notice issued by the State Council on Wednesday. Residents have also been asked to check in on their elderly neighbors, and group gatherings including dining and the traditional practice of coming together at village entrances must be limited, it said.

The central government is also set to provide more staff and medical supplies to rural communities. It’s working to equip every village clinic across the country with one oxygen concentrator — a device that delivers concentrated oxygen to patients with respiratory illness — and two pulse oximeters for free, an agriculture ministry official said at a briefing Wednesday.

[…] The State Council’s list of instructions also urged local authorities to promote vaccination among the elderly living alone, and to provide vulnerable people with special care. Nursing homes in the countryside must have ample medical supplies and could be locked down if a severe outbreak occurs.

Organizers of funerals and weddings must separate and sanitize garbage from the event. People attending any fairs or shows must wear masks at all times. Bathrooms and corridors at venues like restaurants and internet cafes must also be regularly disinfected. [Source]

Some reporters found little concern for the virus in rural China. In a small village in Henan where village doctors estimate 90% of people caught the virus in a wave that started on December 4, a migrant worker told the Economists’ David Rennie that COVID was “a wind that has blown through” and “we’ve all had it.” Video journalist Fu Beimeng reported on COVID outbreaks in rural Sichuan for Sixth Tone, and also found that the virus has already penetrated the countryside—but documented doctors struggling to deal with severely ill patients:

In early December, China dismantled its “zero-COVID” policy. Within a month, the virus was everywhere. Sixth Tone’s @BeimengFu traveled to remote villages in the southwestern province of Sichuan, where she witnessed firsthand how the virus surge has inundated local hospitals. pic.twitter.com/kO1cq3cMmx

— Sixth Tone (@SixthTone) January 18, 2023

The true number of deaths is highly politically sensitive. The revised death total was released just before China announced that its population decreased in 2022, the first annual population decrease since the Great Leap Forward. The decrease was not directly related to COVID; long term demographic trends rather than virus-related deaths were the primary factor pushing total deaths above new births. Nonetheless, censors deleted a WeChat essay dispelling the perception that the pandemic was the main driver, an indication of just how politically sensitive the new death numbers are. Censors also targeted essays that implied a high COVID-related death toll, even if the pandemic was not their main focus. Censors struck down a report on the rural Shandong funerary custom of burning paper horses, likely because it noted that demand for the horses had outstripped local artists’ capacity to produce them, even at prices five times higher than usual. They also targeted a graphic essay published to WeChat titled, “They’re Really Gone,” that seemed to intimate the death of a loved one upon the end of the zero-COVID policy. Another WeChat essay (itself not censored as of the time of publication) compiled screenshots of other essays that had been, one of which was titled, “The silent deaths of those who aren’t famous, don’t warrant obituaries, and who aren’t included in official statistics.”