During a busy shift at the height of Beijing's COVID wave, a physician at a private hospital saw a printed notice in the emergency department: doctors should "try not to" write COVID-induced respiratory failure on death certificates.
Instead, if the deceased had an underlying disease, 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 that the death was caused solely by COVID-19 pneumonia, they must report to their superiors, who will arrange for two levels of "expert consultations" before a COVID death is confirmed, it said.
Six doctors at public hospitals across China told Reuters they had either received 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 with COVID say the disease did not appear on their death certificates, and some patients have reported not being tested for coronavirus despite arriving with respiratory symptoms.
"We have stopped classifying COVID deaths since the reopening in December," said a doctor at a large public hospital in Shanghai. "It is pointless to do that because almost everyone is positive."
Such directives have led to criticism by global health experts and the World Health Organization that China has drastically underreported COVID deaths as the coronavirus runs rampant 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 U-turn, a roughly ten-fold increase from previously reported figures, but still short of expectations of international experts, who have said China could see more than a million COVID-related deaths this year.
China's 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 permitted to speak to the media.
Several said they were told such guidance came from "the government", though none knew from which department, a common situation in China when politically sensitive instructions are disseminated.
Three other doctors at public hospitals in different cities said they were unaware of any such guidance.
One of them, a senior emergency room doctor in Shandong province, said doctors were issuing death certificates based on the actual cause of death, but "how to categorise" those deaths is up to the hospitals or local officials.
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 over the virus - an accusation it has repeatedly rejected.
Before Saturday, China was reporting five or fewer COVID deaths per day. Of the nearly 60,000 COVID-related fatalities since Dec. 8 it announced on Saturday since, fewer than 10% were caused by respiratory failure because of COVID. The rest resulted from a combination of COVID and other diseases, Jiao Yahui, head of the Bureau of Medical Administration under the National Health Commission (NHC), said on Saturday.
Michael Baker, a public health scholar at the University of Otago in New Zealand, said the updated death toll still "looks low" compared with the high level of infection in China.
"Most countries are finding that most deaths from COVID are caused directly by the infection rather than by a combination of COVID and other diseases," he said. "By contrast, reported deaths in China are mainly (90%) a combination of COVID and other infections, which also suggests that deaths directly from COVID infection are under-reported 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 include only deaths in hospitals.
The World Health Organization (WHO) on Monday recommended that China monitor excess mortality to gain a fuller picture of the impact of the surge in COVID.
Excess mortality is when the number of deaths for a given period is higher than it should be relative to historical averages.
Seven people told Reuters that COVID was not mentioned on the death certificates of their recently deceased relatives, although the relatives had either tested positive for the virus or displayed COVID-like symptoms.
Social media has been full of similar reports.
When a Beijing resident surnamed Yao brought his COVID-positive 87-year-old aunt to a large public hospital late last month with breathing problems, doctors did not ask whether she had the virus and did not mention COVID, Yao said.
"The hospital was full of patients, all in their 80s or 90s, and doctors had no time to talk to anyone," Yao said, adding that everyone seemed to have similar COVID-like symptoms.
Patients, including his aunt, were rigorously tested, although not for COVID, before being told they had pneumonia. But the hospital told him it had run out of medicine, so they could only go home.
Ten days later she recovered.
Medical staff at public hospitals in several cities in China said PCR testing, which under "zero COVID" was a near daily requirement for large parts of the population, has now been all but abandoned.
Taking the focus off testing may be the best way to maximise resources when hospitals have been overwhelmed, two experts told Reuters.
Ben Cowling, an epidemiologist at Hong Kong University, said almost all patients with acute respiratory problems would have COVID: "Since antivirals are in very short supply, I don't think laboratory testing will make much difference to case management."
A senior doctor in the eastern city of Ningbo said physicians there were told to be "cautious" about saying someone had died of COVID, but if they did wish 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 COVID wave were three or four times higher than normal for this time of year. Most had more than one illness, but COVID worsened their conditions, she said.
"On the death certificate we fill in one main cause of death, and two to three sub-causes of death, so we basically leave out COVID," she said.
"There’s no other way but for us to follow the orders given by the hospital, which come from the government. I am too unimportant to make any decision," she said.