Opinion: In China’s countryside, a Covid-19 tsunami is brewing

Editor’s Note: Yanzhong Huang is a senior fellow for global health at the Council on Foreign Relations and a professor at Seton Hall University School of Diplomacy and International Relations, specializing in Asia. He is the author of “Toxic Politics: China’s Environmental Health Crisis and Its Challenge to the Chinese State.” The views expressed here are his own. Read more opinion on CNN.



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When I was a little boy in rural China, one of my happiest moments was seeing my dad getting off the ship from Shanghai, carrying the load of goods he had purchased for the Lunar New Year – also known as the Spring Festival.

At that time, my father worked for a tailor factory in suburban Shanghai, and only returned home when the Lunar New Year was around the corner.

This, after all, is the most important festival in China, with roughly 4,000 years of history.

For hundreds of millions of migrant workers across China, the 2023 Lunar New Year – happening on January 22 – will be a particularly special celebration.

Many have been separated from their children and parents in the countryside for three years, due to the government’s strict Covid-19 controls.

Now that the country has abandoned its zero-Covid policy and lifted domestic travel restrictions, the government estimates the number of passenger trips during the Lunar New Year rush (from January 7 to February 15) will be double that of the same period last year – reaching close to 2.1 billion.

And the world’s largest annual human migration is expected to fuel the spread of Covid-19.

As early as mid-December, many rural areas were already seeing a deluge of cases. In a village of central Henan province, one health worker saw more fever patients during the period of December 17 to 24, than in the entire previous year.

A study conducted by Chinese scientists forecasts that rural areas will be hit by the viral wave in mid-to-late January 2023. But the study apparently underestimates the speed and scale of the spread. Henan, a major supplier of migrant labor, reported that as of January 7, almost 90% of the population, or 88 million people, had been infected.

Is China’s rural healthcare system able to withstand skyrocketing Covid-19 cases? Until recently, the government’s answer was clear: no.

In fact, it justified its zero-Covid policy by pointing to China’s large elderly population and limited healthcare resources. Both problems are pronounced in the vast countryside.

The population there is aging faster than in urban areas. More than 120 million people aged 60 and over live in the countryside – accounting for 23.8% of the rural population, compared with 15.8% in urban areas, according to the 2020 census.

When it comes to Covid-19, age matters. Population aging is highly correlated with the incidence of noncommunicable diseases – including diabetes, cancer and cardiovascular diseases. As much as 83.4% of the rural elderly had underlying conditions, according to a 2015 study, making them highly vulnerable to Covid-19.

Unfortunately, the government healthcare reform, launched in 2009, has failed to significantly beef up the ability of the rural health system in addressing major disease outbreaks. There are 4.95 hospital beds and 5.18 health professionals per 1,000 population in the countryside. That’s compared with 8.81 hospital beds and 11.46 health professionals in the cities.

Most of the grassroots health workers in rural areas receive little medical training: no more than 1% of them hold college degrees. Worse, the reform has not altered healthcare providers’ profit-seeking behavior. Wasteful overservicing, including excessive use of high-tech checkups and performance of unwarranted operations remain common in the countryside.

Concerns about the quality and cost of healthcare may explain why rural patients often bypass the community health clinics, to seek care directly at county hospitals or urban health centers.

To add insult to injury, the implementation of zero-Covid over the past three years widened the rural health system capacity gap. The government restrictions on purchasing fever and cough medicines resulted in the shortage of their supply. (One likely reason is that because of the government ban, manufacturers curtailed their manufacturing capacity.)

Rural clinics were prohibited from admitting patients with fever, forcing some of the village health workers to close their clinics and change careers. Between 2019 and 2021, the number of village clinics dropped from 616,000 to 599,000. And the number of village health workers fell from 1.45 million to 1.36 million.

The obsession with implementing zero-Covid also provided little space for preparation for an outbreak in the countryside. Until early January 2023, few village clinics were equipped with oxygen tanks or even oximeters to detect patient oxygen levels. State media reported that some doctors in county hospitals in northeastern China did not know how to operate ventilators.

Zero-Covid did not create strong incentives to promote booster shots among the elderly population either. For three months, between August and November 2022, there was little progress in increasing the vaccination rate among the elderly. As a result, antibodies triggered by inactivated vaccines dropped to a very low level before China moved away from zero-Covid.

On December 1, the government launched a campaign to vaccinate the elderly. But the campaign soon lost its momentum with the explosive growth of Covid-19 cases and the infection of health care workers and the elderly (which reduced the interest in receiving a vaccine).

Not surprisingly, when the government lifted restrictions and effectively opened the floodgates for Covid-19, village clinics immediately ran out of their stockpile of fever medication. There was also a shortage of antigen test kits and effective antiviral drugs, which might explain why in most village clinics and township health centers, the preferred treatment regimen was antibiotics, vitamins, hormones and glucose.

While residents in large cities like Beijing and Shanghai had access to antivirals like Paxlovid, their counterparts in the countryside had to rely on traditional Chinese medicine. Patients with more severe symptoms were referred to county hospitals, where ICUs are not equipped with the required facilities to treat them.

On Saturday, a senior health official announced that fever clinical visits and Covid-19 hospitalizations have already peaked even in the countryside. According to the government data, as of January 12, over 5,000 county-level hospitals received 15,800 severe patients – accounting for only 15.1% of the national total.

All of which seems to suggest that only a very small percentage of the nearly 60,000 officially reported Covid-19 deaths between December 8 and January 12 occurred in the rural areas.

Given that each county-level hospital treated no more than four severe cases during that period, the official statistics might be a gross undercount of the actual severe cases and deaths in the countryside. In the coming weeks, as families and friends gather to celebrate the lunar New Year, there might be another peak in the number of severe cases and deaths in the rural areas.

That said, the onslaught of Covid-19 is unlikely to cause the collapse of the rural health system or pose a major threat to social stability in rural China. Because of the stigmatization of Covid-19, there appears to be little discussion about the disease among the villagers.

Covid-19 is still referred to as “that disease” by the villagers in some localities or just treated as a severe cold for people to suffer from silently. Even those who developed severe symptoms did not actively seek care in urban hospitals for fear that spending on treatment was going to use up their children’s savings.

Because of the lack of access to test kits or the reluctance to be tested, those rural patients who died at home would not be included in the official data.

Sadly and paradoxically, it is such a fatalist approach that makes the health system “resilient” in coping with the Covid-19 tsunami in rural China.

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