As Shanghai struggles to contain a record COVID-19 outbreak with disruptive lockdown measures, something of a miracle has happened.
Out of 400,000 cases found in the financial hub since the start of March, only 10 people have died of the virus, according to the city’s authorities. This translates to a death rate of 1 in 40,000 as of Tuesday, a fraction of that of most other countries.
The tally is largely in line with the staggeringly low national death toll reported by the Chinese government, which has attributed fewer than 5,000 deaths to COVID-19 since the virus emerged in the country of 1.4 billion people in late 2019.
But as authorities seek to use the low death count to justify harsh lockdown measures, medical experts warned that the figures might not reflect the actual scale of the human toll of the pathogen in China.
“There is no intervention that will reduce the severity rate to such an extent,” said Ben Cowling, an epidemiologist at the University of Hong Kong, referring to the BA.2 variant of COVID-19, previously known as stealth Omicron.
In Singapore, for instance, some 547 people out of 137,000 infected with COVID-19—or one out of 250—have died in the last 28 days. Shanghai has reported nearly three times as many cases since March and just 10 COVID-19 deaths and 21 severe cases as of Tuesday.
“I would imagine there are more severe cases than reported so far,” Cowling said of the outbreak in Shanghai.
Chinese health officials have credited the low fatality rate to the swift and tough enforcement of “zero-COVID” rules.
“Compared to overseas, our country’s COVID fatality rate is low because we implemented many measures to prevent or reduce deaths,” said Wu Zunyou, chief epidemiologist at the Chinese Center for Disease Control and Prevention, in a press briefing earlier this month.
But media reports suggest that the official statistics could have failed to account for at least dozens of COVID-19 deaths. The Wall Street Journal found earlier this month that at least 20 patients have died in recent weeks at Shanghai’s biggest elderly-care facility, where 100 patients have tested positive for coronavirus. Chinese domestic outlets including Sixth Tone and Caixin have reported further deaths in other elderly care facilities possibly linked to COVID-19, although the articles were swiftly removed.
Some experts say the discrepancy in data comes down to how China ascribes cause of death.
“The way they do the statistics on death from infectious diseases is very different from what we are doing in the rest of the world,” said Jin Dong-yan, a molecular virologist at the University of Hong Kong.
For example, in Hong Kong, the UK, and New Zealand, a death would be attributed to COVID-19 if the deceased tested positive for COVID-19 in the 28 days before they died regardless of the immediate cause, such as a traffic accident or suicide.
Chen Zhengming, an epidemiology professor at the University of Oxford, said China did not disclose exactly how it counts COVID-19 deaths but its internal guidelines tend to adopt a narrow definition. “It’s only classified as a COVID death if the person dies not with COVID, but directly from COVID.”
Jin, of Hong Kong University, said the different reporting standards are not a deliberate act of concealment but the product of a longstanding practice that has similarly led to the underreporting of deaths caused by other infectious diseases.
“Traditionally, China reported very few cases of flu deaths for the same reason. They aren’t recorded as flu, but corticobasal degeneration, diabetes or organ failure,” Jin said.
In 2018, China reported only 144 flu deaths, even though a study estimated that there could be up to 88,100 influenza-associated excess mortality during a typical year in the country. In comparison, 28,000 flu deaths were recorded in the U.S. in the 2018–2019 influenza season.
The rates of use of ventilators and occupancy of hospitals and intensive care facilities could be better indicators of the gravity of the situation, but China does not release these figures. It has also extensively censored articles and social media posts to control the flow of information about the pandemic.
“It’s difficult—given the way [the pandemic] is managed in China—to figure out exactly how the numbers are evolving over time,” Oxford’s Chen said.
As the number of deaths usually lags behind infections for several weeks, Chen said it was only a matter of time until it rose. “It definitely will go up. To what extent, it’s difficult to tell,” Chen told VICE World News last week.
Shanghai had not reported a single case of death since March until Monday, when it reported its first three deaths. City authorities announced seven more deaths the next day.
Health workers in the Jing'an district in Shanghai on April 18. Photo: Hector RETAMAL / AFP
Harder to measure still are the effects of the protracted lockdown and harsh pandemic control measures on the well-being of Shanghai’s 26 million residents.
Small-scale protests have erupted in several compounds across the metropolis as households ran out of food and supplies, and a citywide lockdown dragged on for weeks with no end in sight. Some non-COVID patients have been denied hospital treatment and died, potential victims of Shanghai’s pandemic response who won’t be counted in any official statistics.
Some cancer patients have reported being turned away by emergency wards as they could not provide evidence of negative COVID-19 test results. Some others have had trouble reaching the medical facilities in the first place, as public transport is suspended and cars are banned from the streets.
Despite these costs, some defenders of China’s absolutist approach to COVID-19 say the country is not ready to ease its harsh measures due to the low vaccine uptake among its seniors.
Some 52 million people above 60 in China were not fully vaccinated as of March, according to the Chinese National Health Commission. In Shanghai, only 38 percent of residents in the same age group have received three jabs.
The inactivated virus vaccines given to the Chinese population are also less protective compared to mRNA jabs if only two doses are administered, a recent study in Hong Kong found. China is developing its own mRNA vaccines, like those of Pfizer and Moderna, but they are not expected to be available until next year.
Based on the mortality rate of 37 deaths per million people in Hong Kong, where the elderly population is similarly undervaccinated, a projection by Bloomberg suggested China could see as many as 50,000 deaths a day if the virus goes out of control.
Sara Jane Ho, a businesswoman in Shanghai, believes the lockdown measures are necessary to prevent a catastrophic loss of lives.
“It’s very easy for the West to look at China and say, these measures are draconian,” said Ho, who runs an etiquette school for women. But, she said, “At the end of the day, the one thing we will remember in history is that we kept fatality low.”