COVID and deaths in post zero-COVID Tibet

Note: As of Jan. 24, 2023, this report has been edited to clarify that the estimates provided reflect a potential worst-case scenario of elderly Tibetans dying from COVID-19 following China’s abrupt abandonment of its “zero-COVID” policy on Dec. 7, 2022.

Given the lack of reliable and pertinent data from the Chinese government, this report uses a Brazilian vaccine study—as well as China’s census data, other research studies and firsthand accounts by Tibetans—to warn about the possible number of deaths of Tibetan elders that could occur if the Chinese government does not improve its COVID management in Tibet. If necessary, additional updates will be made.

After resuming its reporting of COVID-19 data on Jan. 14, China’s National Health Commission (NHC) reported close to 60,000 deaths between Dec. 8 and Jan. 12, a period following the abrupt end of China’s “zero-COVID” policy on Dec. 7, 2022. The NHC attributed 5,503 deaths to respiratory failure caused by COVID and 54,435 deaths to a combination of COVID and other diseases. However, it is important to note that the data only account for deaths in hospitals and do not consider deaths in homes or other facilities. The data also do not account for the death toll in China’s “ethnic minority” regions like Tibet.

It is difficult to determine the overall COVID death toll in Tibet, but according to China’s 2020 census, 692,911 Tibetan elders (60 years and older) are at risk, with 82,672 of them (80 years and older) being the most vulnerable. A study in Japan and acknowledgement by China’s NHC show that the fatality risk is highest for those 80 years and older during COVID surges. Additionally, a study in Brazil shows that the effectiveness of two doses of Chinese vaccines is very low for those 80 years and older. According to sources, elderly Tibetans have been left out of a third-dose vaccination campaign that began last year.

Therefore, it is estimated that over 45,000 Tibetans who are 80 years and older may die following the end of the zero-COVID policy, and if the Brazil vaccine study is used as a benchmark for all Tibetans 60 years and older, more than 220,000 Tibetan elders may die.

While the estimates provided for the number of deaths among Tibetan elders reflect a potential worst-case scenario based on current levels of vaccination and immunity, a true COVID death toll in Tibet cannot be determined without genuine transparency from the Chinese government. Additionally, it should be noted that these estimates assume that Tibetan elders have received only two doses of the CoronaVac vaccine, as the International Campaign for Tibet has been informed that elders, along with pregnant individuals, those with high blood pressure or heart diseases, and those who have had major surgery in the past, have been excluded from the third-dose vaccination campaign that started around March 2022. The extent of the policy is not known as Tibetans live in the officially designated Tibet Autonomous Region and in Qinghai, Sichuan, Gansu and Yunnan provinces. ICT has also been informed that by and large, most Tibetans have received three doses of Chinese vaccines as publicized by Chinese state media, but the data shared are not broken down by age group.

COVID fatality models

Multiple analytical models have projected the number of COVID infections and deaths in China since it abandoned the “zero-COVID” strategy on Dec. 7. A notable study by Airfinity, a London-based health analytics firm, released on Nov. 28, 2022, estimated that there would be 167 to 279 million COVID cases and 1.3 to 2.1 million COVID deaths in three months after the lifting of the zero-COVID strategy. Another notable study by researchers at China’s Fudan University, published in May 2022, projected 112 million symptomatic cases and 1.6 million deaths in six months based on the vaccination rate if zero-COVID was lifted at that point of the pandemic in China. Chinese national health officials estimated that 250 million had been infected in the first 20 days of December, according to news reports and data cited on Chinese social media.

Non-transparency of the Chinese party-state and COVID death projections

The Chinese party-state has a history of being opaque and non-transparent. This is evident in its handling of the COVID-19 pandemic. The lack of transparency surrounding the emergence of COVID-19 in Wuhan more than three years ago helped lead to the current state of the pandemic. When the party-state finally decided to share information about the emergence of COVID-19 in Wuhan, it was too late to stop the virus from spreading globally.

With the sudden reversal of the zero-COVID strategy on Dec. 7, 2022 and the significant increase in COVID-19 cases in China, the Chinese party-state had decided to be non-transparent about infection and death data. China’s National Health Commission stopped sharing COVID-19 infection data on Dec. 25, 2021. Before that, only 5,273 people were reported to have died due to COVID-19 in China, which has been heavily criticized by experts around the world and the World Health Organization. Under pressure from the international community, the Chinese government resumed sharing COVID data on Jan. 14. But the lack of genuine transparency in the handling of COVID-19 in China raises concerns about the accuracy of the reported data and the Chinese party-state’s ability to effectively manage the pandemic.

2020 Census of Tibetan demography

Reasoning and extrapolating COVID deaths in Tibet

While many models projecting COVID deaths in China emerged since the abandonment of the zero-COVID strategy on Dec. 7 last year, there is no estimate of COVID deaths in Tibet.

Using the 2020 China census data on Tibetan demography as the baseline and basing estimates on reasoning, logical deduction and extrapolations from available analytical studies, the International Campaign for Tibet estimates over 220,000 Tibetan elders who are 60 years old and above may die following the end of the zero-COVID strategy in Tibet. Although COVID deaths of Tibetans of all age-ranges are emerging, it is hard to estimate an overall death toll due to the limitation of non-disaggregation of publicly available vaccine data in Tibet. It is widely known that the elderly are the most vulnerable in the current COVID surge in China, and Tibet is no different. Anecdotal and visual evidence emerging from Tibet also support the fact that the majority of COVID deaths in Tibet are of elderly people.

It is a fact that vaccines are critical in preventing COVID deaths. It is also a fact that the Chinese party-state did not consider vaccination of the elderly a priority throughout the years when the zero-COVID strategy was in place. Elsewhere in the world, in countries like New Zealand where a zero-COVID strategy was also implemented in the initial stages of the pandemic, vaccination was the top priority during the time before those countries reopened. It is only after lifting the zero-COVID strategy that China’s National Health Commission made vaccinating elders a priority within a six-month timeframe. That does not help elders amid the COVID surge. Many would have caught the infection and died before receiving their third dose. In “ethnic minority” areas like Tibet, deaths due to COVID would be worse because of the poor healthcare infrastructure and the population’s status as second-class citizens.

Chinese vaccine effectiveness and the cruciality of boosters

Compounding toward the worst-case scenario is the fact that the protection offered by the two predominant Chinese vaccines—CoronaVac and Sinopharm—is not as effective as the Western vaccines, especially for elders, and the vaccines’ effectiveness wanes with time. Chinese vaccines can be as effective as Western vaccines like Pfizer and Moderna for those under 60 years, as demonstrated by a study by researchers in Hong Kong. But the study also showed that CoronaVac loses its effectiveness significantly for elders by giving only 64-75% protection after two doses compared to Pfizer’s 95-97% protection. Similarly, a very large sample size (75,919,840 Brazilian vaccine recipients who received either Vaxzevria or CoronaVac) study carried out in Brazil showed that CoronaVac is 67.2% effective against death for the 80 to 89 age range and 33.6% effective for the elders 90 years and above. Another vaccine efficiency statistical analysis conducted in Brazil on a cohort of 66 million vaccine recipients estimated that CoronaVac is 71.2% effective against death in the 60-79 year age group and 45% effective against death in the 80 and above age group, showing that “preventing deaths diminished with age, most significantly in the group of 80+ old.”

A massive analysis of some 1 million people who were hospitalized with COVID-19 in Brazil found that CoronaVac offered up to 60% protection against severe disease up to the age of 79—not far off the 76% protection offered by the Oxford–AstraZeneca vaccine, according to Smriti Mallapaty in Nature. But the picture changes drastically in people over 80, says co-author Daniel Villela, an epidemiologist at the Oswaldo Cruz Foundation at Rio de Janeiro. In that group, CoronaVac was only 30% effective at preventing severe disease and 45% effective against death, compared with 67% and 85%, respectively, for the Oxford–AstraZeneca jab.

Both the CoronaVac studies conducted in Brazil are remarkable for their sample size and clarity of analysis, especially in quantifying vaccine effectiveness among the elderly. Both the studies concluded that CoronaVac effectiveness diminishes by age, with 80 years and above elders most vulnerable to death if they are infected with COVID. Although both the Chinese and Western vaccines’ effectiveness diminishes with age, the evidence shows that Western vaccines are significantly more effective than Chinese vaccines, especially in the elders even in a diminishing effectiveness curve.

The Chinese authorities and state media have given vaccine data for the “Tibet Autonomous Region.” But most of the data date to January 2022, with a few data from April 2022. Complicating analysis of the authorized data is non-disaggregation of data, which is crucial for estimating deaths. In post zero-COVID China, Chinese officials have provided various vaccine data for public consumption that are deliberately vague and incomplete.

Chinese state media in January 2022 reported that in the TAR, “3.52 million people had received their first shots, while 3.33 million people had gotten second shots, the region’s health commission told Xinhua. The region is also following the rest of the country closely in administering booster shots, and has already completed 1.22 million third jabs, said the commission.” Another state media outlet reported that, “As of April 2, the total number of vaccinations in the region exceeded 9.26 million doses, of which 83.59% of the first dose, 70.55% of the second dose and 40.68% of the third dose were administered to people aged 60 years and above.” By the end of 2022 when zero-COVID was lifted, the majority of Tibetans in the TAR seems to have received the booster. Similarly, most Tibetans in the Tibetan areas outside the TAR also seem to have received booster jabs. Sources on the ground in Lhasa, Qinghai and Sichuan corroborated to ICT that most of the Tibetans had received three vaccine shots, with a caveat for the elderly, many of whom have not been vaccinated or have avoided vaccination due to fear of complications. The vaccination rate also depends on the efficiency of the local leaders at various places and the willingness of the people to get vaccinated, the sources said. However, a Tibetan said, “in Nagchu [Chinese: Naqu] county, the administration of the third Sinovac [or CoronaVac] vaccine began March 2022 onwards. However, those who are pregnant, has high blood pressure or heart disease, had a major surgery in the past and the elders were excluded from vaccination. The Sinovac vaccine recipients fall very sick when they become sick. Western vaccines like Pfizer and Janssen were available in some Chinese cities, but it was Sinovac that was administered in our county.”

COVID crisis with three jabs

All of the vaccine effectiveness findings point toward the criticality of third and fourth doses for continued protection against COVID. Ben Cowling of the Hong Kong study, speaking to news media, also pointed out that Chinese vaccines are as effective as Western vaccines if there is “an extra booster – or third dose – of CoronaVac,” which “lifts the protection to about 98%, the same protection observed with three doses of Pfizer.” The World Health Organization also recommended three doses as crucial with Chinese vaccines built on the inactivated virus.

But experts have also argued that all effectiveness of vaccines wane with time, and they become ineffective with the emergence of new COVID variants. This argument seemingly holds true for the current COVID crisis and deaths in Tibet despite most people having three jabs in the arm, and some even four.

Severe shortage of treatment could also explain the current death rate in Tibet, as sources on the ground have reported that there is severe lack of medical treatment for the ill. Chinese scientists, after studying 314 COVID hospitalization cases in Nyingtri (Chinese: Nyingchi) city, concluded that Nirmatrelvir-ritonavir is effective in COVID treatment, as all the patients under study recovered and none died. But the current anecdotal and visual death evidence point toward severe shortage of medicine. The same study also states that although Tibet’s high altitude acts as a barrier against COVID spread, once infected, Tibetans in Tibet “may suffer more severe respiratory stress due to the compounding effect of hypobaric hypoxia and SARS-CoV2-induced hypoxemia.” Compounding the severity of COVID in the elders could be preexisting conditions, as China’s 5-year plan on elderly care published in early 2022 reported that “78% of the senior population has at least one chronic disease.” During the revelation on Jan. 4 of the COVID death data in hospitals, the head of the medical administration of the NHC reported that the average age of those who died was 80.3 years, and over 90% of them had underlying conditions. Another reason is the possible prevalence of a mutant virus in Tibet, as speculated by Chinese scientists explaining the sub-variant BA.2.76 outbreak after July 2022.

COVID deaths in Tibet estimate

China’s State Council Information Office in a news conference on Jan. 9 said that the omicron subvariants BA. 5.2 and BF. 7 are most prevalent in the current COVID outbreak in China, with a fatality rate of 0.1%.

However, the anecdotal and visual evidence of the current COVID crisis and deaths in Tibet, despite most Tibetans having three doses of Chinese vaccines, do not entirely support the claims of protection or reassurance of low fatality rate. Unlike societies across the world, prior to the lifting of the zero-COVID strategy, China did not have herd immunity either through effective vaccination or infection.

A study by the Institute for Health Metrics and Evaluation, based at the University of Washington School of Medicine, shows that CoronaVac’s efficacy is 37% against severe disease and 24% against infection for BA. 5. with waning immunity.

With no data transparency, especially disaggregated third and fourth vaccine dose administration, it is hard to estimate the current COVID death rate in Tibet. What is known anecdotally and through visual evidence is that hundreds of bodies are continuously brought to various sky burial sites in Tibet. What is also known is that most of the dead are Tibetan elders. It can be inferred that 692,911 elder Tibetans who are 60 years and above are the most vulnerable. Until a current and very large sample size vaccine efficiency study of Chinese vaccines is conducted independently, the studies conducted in Brazil stand as the best proxy to estimate the number of deaths of Tibetan elders. More than 220,000 Tibetan elders who are 60 years and above may die from COVID following the end of the zero-COVID policy in Tibet. If case fatality rate during the current COVID surge is taken into consideration, over 45,000 Tibetans who are 80 years and above may die. Critical to understanding the true COVID death toll in Tibet and China is genuine transparency by the Chinese government.

Anecdotal and visual evidence of COVID deaths in Tibet

Sources in Lhasa informed the International Campaign for Tibet that a vast majority of the Lhasa population are infected with COVID, and the death toll is mounting each day. An unprecedented number of corpses are being brought to the five sky burial sites and one cremation ground in Lhasa and the suburbs. While the funeral of most Tibetans is carried out at the sky burial sites, cremation is required for Tibetans who are state employees.

According to the traditional Tibetan funeral practice known as “Jhator (giving alms to the birds),” a dead body is disposed of on a mountaintop for the birds of prey to consume to complete the natural cycle of life and death. The sky burial sites at Sera and Pabongka, which have alternate days of service (Monday, Wednesday, Friday at the Sera site and Tuesday, Thursday and Saturday at the Pabongka site); Drikung site in Meldrogongkar (Maizhokunggar); and two sky burial sites and a cremation ground in Toelung Dechen (Doilungdeqen) have been operating beyond capacity with the unprecedented number of bodies being brought for sky burial. A source told ICT that normally four or five bodies would be brought to the Drikung site but now around 100 are being brought for funeral. Another Tibetan says, “There’s shortage of vultures for the disposal of bodies.”

In a social media conversation heard by ICT, a Tibetan speaking to others in the community said “Don’t be lax. This cold [the Chinese authorities now call COVID infection a cold] is dangerous. These days a lot of corpses are being brought to the Drikung site. On January 2, there were around 100 corpses. This is unprecedented and not normal.” Sources also informed the US-based Radio Free Asia that 17 bodies were brought to the Sera site and 15 to the sky burial site in Toelung Dechen on the same day.

The stream of corpses arriving at the Drikung site is continuing, as a video clip (Warning: this video clip contains graphic images) of the Drikung sky burial site on Jan. 7 shows many people, possibly members of families, at the site as coroners ready the bodies for the vultures to consume.

Beyond the Tibetan capital Lhasa, a large number of deaths due to COVID were also reported in Tibetan areas outside the officially designated “Tibet Autonomous Region.” A Tibetan from Ngaba (Aba) now living in exile told ICT: “Around 90% of monks at Kirti Monastery are infected with COVID. Six monks that I know of had succumbed to the disease. From my count, around 200 Tibetans have already died due to COVID. Most of them are 50 to 70 years old. I know that 12 and 13 bodies were brought to Kirti Monastery for last rites. That was just for two days. I am told at least eight bodies are brought to the monastery daily. At the sky burial site in Ngaba, so many bodies are brought that the vultures have stopped consuming more than they could.” The person continued, “The government is not being responsible. There is a shortage of medicine, testing kits and the line at the local clinic is very long. Once they get an opportunity to speak to health staff, all they say is that it is cold. If someone falls sick, no one would confirm if it is COVID or an ill person’s death is due to COVID. Those who are better off either go to the provincial capital Chengdu or to the prefecture capital Barkham (Maerkang) to seek medical help. At least six monks that I know of are sick and hospitalized. No one is being responsible. It is very sad.”

A similar surge in COVID and death is taking place in neighboring counties, with the local sky burial sites functioning beyond normal operation. The well-regarded sky burial site at Larung Gar religious encampment in Serthar County receives 40 to 60 bodies daily, according to a source on Jan. 5. The bodies are brought to the site not only from Serthar county but also from the neighboring counties.

In video clips taken at another very important religious encampment known as Yachen Gar in Pelyul (Baiyu) County in Kardze (Ganzi) Tibetan Autonomous Prefecture in Sichuan, around 20 vehicles with bodies inside had arrived at the site for the monastics to provide last rites.

Another video clip taken at the same location on what appears to be a different date and obtained by RFA shows a similar number of vehicles with bodies waiting for last rites at Yachen Gar.

A Tibetan from Lithang (Litang) told RFA that a large number of bodies were brought to the sky burial site at Lithang on Jan. 2 and 3. A majority of the dead were elderly.