By Polina Ivanova and Maria Tsvetkova
MOSCOW (Reuters) - Before she died in a Moscow hospital earlier this month, Liubov Kashaeva, 74, twice tested positive for the new coronavirus. Her death was not attributed to the virus, however. It was put down to the cancer she had been suffering from.
"The medical death certificate ... said she died of a malignant tumour," Kashaeva's daughter-in-law, Daria Kornilova, said. "Coronavirus was not mentioned anywhere."
Kashaeva is one of thousands of Russians infected with the novel coronavirus whose deaths have been put down to other causes.
Russia has registered the second highest number of infections globally, at 299,941 total cases, and 2,837 deaths. That produces a death rate of 1.88 per 100,000 Russians, according to Johns Hopkins University.
The equivalent U.S. figure is 27.61 per 100,000 Americans, and 52.45 in Britain.
Russia has defended the way it counts coronavirus deaths.
"We now know all the characteristics of COVID-19 sufficiently well," pathologist Oleg Zairatyants, author of the Moscow Health Department guidelines for coronavirus autopsies, told Reuters.
"The result (of the analysis) is objective and pronounced by the commission ... Unfortunately people are dying, but their cause of death is clear to us," he said, when asked about deaths not being attributed to COVID-19 even when someone had tested positive for the virus.
However, the relatives of several deceased patients dispute that their loved ones would have died when they did had it not been for the virus.
Kashaeva had been diagnosed with late-stage bowel cancer in January. But she was due to start chemotherapy and the family expected to have more time with her.
On May 3, Kashaeva was taken into hospital after feeling weak. Scans showed she'd developed pneumonia in both lungs, a common symptom of the coronavirus infection, and two tests were taken, coming back positive. On May 8, Kashaeva died.
"Coronavirus killed our grandmother of course and we're grieving," Kornilova said. "If it wasn't for coronavirus, with chemotherapy she would have held out for some time."
'NOT HIDING ANYTHING'
Moscow, the epicentre of Russia's coronavirus outbreak, has said that over 60% of deaths of people infected with the coronavirus in the capital city in April did not enter its death toll tally, and were put down instead to other causes.
Those cases occurred "as a result of an obvious alternative reason, such as vascular catastrophe (heart attacks and strokes), late-stage malignant diseases ... and other incurable diseases," it said.
The Moscow Health Department said the way Russia counted coronavirus deaths was more accurate than other countries and cited the benefits of a nationwide testing programme which has seen over 7 million tests done.
The jump in the death rate could be attributed to a seasonal increase in acute respiratory infections, including COVID-19, which had accelerated the progress of chronic diseases, it said.
Kornilova said she felt that the decision on how to classify her mother-in-law's death "depended on the party line.
"And as far as I know, right now, the party line says ... that Russia's death toll must be as low as possible."
The Kremlin said Russia's use of autopsies in determining cause of death sets it apart from many Western countries, where this is not done.
"We're not hiding anything. Cause of death is determined by an autopsy. It's specifically the autopsy that allows us to produce an accurate judgment, on the basis of which cause of death can differ," Kremlin spokesman Dmitry Peskov said in an emailed response to questions.
Unlike most countries, Russia relies on a postmortem analysis to decide whether the death of an infected person was caused by the virus.
Some doctors, however, say the distinction is arbitrary.
"Simply put, no one ever dies 'from' a virus. People die from complications resulting from a virus," Alexey Erlikh, head of the intensive cardiac care unit at Moscow's Hospital 29, which has been designated to treat coronavirus, said.
"But they also die from the complications of a chronic illness that are caused by the virus. Some people believe that such deaths shouldn't be counted in the coronavirus death toll. I believe they should," Erlikh said.
"On this point I am strongly at odds with some of my colleagues, those top doctors whose pictures are hanging up all over the city."
'FROM' OR 'WITH'?
In Britain, all deaths of people who tested positive for the coronavirus, and those with a negative test where coronavirus is suspected, enter the death toll, Carl Heneghan, a doctor and professor at Oxford University said.
"We're not in a position to distinguish dying 'from' or 'with' coronavirus," Heneghan said in an email.
Speaking anonymously, a Moscow-based pathologist said that making a clear distinction between the two was virtually impossible.
The World Health Organization (WHO) says it sees no problems with Russia's approach.
"There is no conscious undercounting," Melita Vujnovic, the WHO's chief representative in Russia, told Russian state TV last week. "It is possible that some recounts may be done or something else ... but right now I don't see anything serious."
Some Russians remain sceptical.
Leo Shlykov, a communications manager in Moscow whose father died on May 11 after a positive coronavirus test and 11 days on a ventilator, said that his family would have hospitalised his father earlier if they had thought so many people were dying of COVID-19.
The death certificate did not register coronavirus as his father's cause of death, Shlykov, writing on social media, said.
"Yes, he had a heart attack a few years ago, yes, he had renal failure and diabetes, but if it wasn't for coronavirus, he would still be alive."
(Additional reporting by Tom Balmforth, Polina Nikolskaya, Maria Vasilyeva, Gleb Stolyarov; Editing by Andrew Osborn and Mike Collett-White)