It was a reminder of just how much things have changed in China in the last month alone: Shanghai’s main train station, jammed with travelers on Friday, headed off to destinations across the country for the Lunar Year holiday. No PCR tests or checks required — certainly no social distancing. Many of them were heading to their hometowns for the first time since the covid-19 pandemic began, leaving the city that last spring suffered through a two-month-long lockdown — a defining moment in China’s “zero-covid” era.
Now, zero-covid is over, lockdowns are a thing of the past and those Shanghai crowds are just a small fraction of the hundreds of millions of people traveling to celebrate the holiday. But as people embark on their New Year’s journeys, along with the traditional red envelopes of cash, cases of fruit and bottles of baijiu, they are bringing an unwelcome guest: covid.
The official holiday begins on Jan. 21, but people have been heading home for weeks, carrying the virus to all corners of China. The Chinese government is no longer tracking total covid cases, so it’s impossible to know just how far the virus has spread, but there has been an explosion of infections in rural areas since the restrictions were lifted in December.
Over the past few weeks, Chinese social media platforms have been filled with stories about people in rural areas getting sick and dying from covid. Grid surveyed the situation in rural parts of Shaanxi, Guizhou, Qinghai, and Sichuan provinces, through people who have returned for the holiday or have family in these places. All said that most of their relatives have already gotten sick.
“I have a really big extended family, maybe around 50 people,” said Amy, whose family lives in a rural area of Tongren, in western Qinghai province. “There are only I think two or three of my cousins that didn’t get it. Other than them, everybody got it. Everybody.”
While National Health Commission officials said that nationwide caseloads and hospitalizations have fallen since early January, the covid battle isn’t over. The wave has landed slightly later in rural areas, and as China’s New Year travel spikes this week, remote areas that have managed to dodge the virus so far are likely to take a further hit — straining beleaguered rural clinics and hospitals and underlining the gap between the affluent cities and the under-resourced countryside.
Apprehension has reached the very top. In a Lunar New Year’s address aired on CCTV, President Xi Jinping said, “I am most concerned about the rural areas and rural residents.” He continued, “Medical facilities in these areas are already relatively weak, therefore prevention will be difficult, and the task [to contain the virus] will be tough.”
The healthcare gap that left rural areas vulnerable
The abrupt end of zero-covid has wreaked havoc across China’s medical system over the past month, but a sick patient is far better off in Shanghai than in Tongren or any number of other remote parts of China.
Even before the pandemic, the gap between rural and urban healthcare quality was stark — as wide as the gulf between Iceland and North Korea, Karen Eggleston, director of the Asia Health Policy Program at Stanford University, wrote in a 2020 paper. As she put it then, “China truly entails ‘multiple countries within one.’”
A quick glance at the numbers is telling. First, demographics alone mean that the population is more vulnerable to complications from covid. While most young people have left small towns and villages for jobs in China’s cities, elderly people and children are typically left behind; as a result, about a quarter of the rural population is now over 60 years old. Yet the rural healthcare system is actually less well-equipped to treat the elderly; if you go to an urban hospital, you’ll find, on average, almost twice as many beds per capita compared to a rural one. The gap is about the same for doctors. In cities, the average number of licensed doctors per thousand people is four; there are two doctors for every thousand residents of rural areas.
It’s not just a matter of quantity but quality as well, Sean Sylvia told Grid. An assistant professor of health policy at the University of North Carolina, Sylvia has conducted extensive research on health outcomes in the small village clinics that are at the frontlines of China’s rural healthcare system. He has found that rural clinics often struggle to diagnose common diseases correctly. Well-trained doctors end up working in the big cities, whereas doctors staffing the rural clinics are typically far less qualified; only one in 10 doctors at the township level had at least five years of training as of 2017, according to Eggleston.
Ideally, the years of relative calm during the zero-covid period, when urban lockdowns largely kept covid from the countryside, would have allowed rural areas to prepare for the inevitable wave. But experts say that time wasn’t well utilized. As of November, vaccine rates among the elderly remained lower than the rest of China, and it didn’t help matters that the few covid cases that came to rural clinics had been regularly directed to higher-level hospitals. “As a result, they haven’t gotten much experience dealing with the virus,” Sylvia said.
In December, as China dismantled its zero-covid defenses, the State Council issued hasty plans to try to address the coming rural surge. On Dec. 15, the officials called for a renewed effort to vaccinate the rural elderly; no data has been released on the effectiveness of that push, but it was likely hampered amid the strain on the healthcare system as cases surged nationwide. The government also called for local officials to strengthen the reserve of fever and cough medicines, train rural doctors to handle covid and help set up channels to transfer patients from rural clinics to bigger hospitals.
But these measures seem to have been a case of too little, too late. As Sylvia said, “The rural health system -- my impression is that it was just vastly unprepared for a covid wave.”
How the wave has hit
Reports from rural areas indicate that these regions have suffered significant losses under the crush of the covid wave.
When people come down with covid in rural China, their first stop is usually the local doctor. “They just go to small clinics, and everybody just sits in one room and then gets an injection,” said Amy, referring to the IV saline drip her sick family members sought out in Qinghai. “That is the only thing they’re doing.” (Amy is using a pseudonym due to the sensitivity of the topic in China).
Beyond such basic treatments, many clinics have been short on solutions for more serious symptoms. Wang, a doctor in Henan’s Luyi village, told Bloomberg that he was out of ibuprofen, antibiotics and antivirals and hadn’t received any help from the government. Many other firsthand accounts and media reports suggest a lack of Paxlovid and other medicine in rural areas, although the National Health Commission said in a Jan. 14 press conference that the situation was improving.
Many rural residents who have traveled the often considerable distance to their county hospitals to seek better care have found overcrowded conditions in recent weeks. “The wards of the rural hospitals are completely full, there are only beds in the hallway available,” one person wrote on Weibo on Jan. 15. “I hope my father’s safe and healthy.” In one instance, the New York Times reported that a county hospital serving rural patients in Anhui had run out of ICU beds and ventilators earlier this month.
In town after town, the picture looks bleak.
“My mom is saying there were so many funerals in the village in the past few weeks because it’s hitting so many older people,” Amy told Grid. “One of my aunts, she’s 92 or 93. She also passed away a few weeks ago.” She died at home, Amy added; the nearest well-equipped hospital is a two-hour drive away.
In a 300-household village in Shaanxi’s Pucheng county, a source told Grid that covid claimed the life of one middle-aged diabetic; the Economist reported that a crematorium in rural Henan was handling three times the usual number of cremations. These rural deaths may not be included in the overall covid toll because they are largely happening in homes rather than hospitals, wrote Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations.
Huang says that by not seeking care, elderly patients have likely eased the burden on hospitals.
“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,” he wrote.
In the coming days, all those hundreds of millions of people across China will gather to make dumplings, feast and visit distant relatives. The question lingers: How much worse will the rural wave get?
Estimates vary. Government health officials have said the worst of the surge is behind the country. And Shengjie Lai, an infectious disease expert at the University of Southampton, told Grid that because of the extent of the spread over the past two months, the current Lunar New Year migration will have only a limited impact on the wave.
However, modeling from U.K. health analytics group Airfinity suggests that nationwide cases will peak between Jan. 13 and Jan. 27, with further spread driven by the New Year’s travel. “Our forecast estimates a significant burden on China’s healthcare system for the next fortnight and it is likely that many treatable patients could die due to overcrowded hospitals and lack of care,” Analytics Director Matt Linley wrote on Jan. 16. At the worst of the outbreak, the firm projects deaths will reach 36,000 a day during the Lunar New Year period.
To put that figure in context — 36,000 would be roughly seven times the total number of deaths China reported in the first two years of the pandemic, for the entire country.
It will likely be some time before researchers know how many people in China really have died in the current wave. The government figures are widely considered an undercount, and the burden will almost certainly be disproportionately high in rural places. One indication lies in past data: Among the leading causes of death in China — heart disease, brain disease and cancer — the rural mortality rate is higher, often much higher.
Fears of fresh rural outbreaks have caused some people to alter their travel plans. One source who traveled to Zunyi, a city in Guizhou province, for the New Year told Grid he won’t venture out of the city. “Some relatives who live in a rural area invited me to have a New Year’s meal with them, but I decided not to go because I am afraid of infecting them,” he said. “Coming from Shanghai, I’m a lot more worried about covid than they are.”
Another woman Grid spoke with is taking the scenic route — a three-day drive from Beijing to Shaanxi province to avoid exposing her elderly in-laws in rural Shaanxi to new variants that might be picked up on a crowded train or plane.
Others deemed it unwise to travel at all. One person wrote on Weibo, “This year we’ve basically decided that I will not go home for the New Year … More than 20 elderly people in the village have passed away, and some relatives are in the hospital. I told my family members not to go back to their hometown in the countryside and not to visit for New Year’s.”
For some, the covid wave may forever break the New Year’s tradition of returning to a rural hometown. “This epidemic has taken away many people, including my 94-year-old grandfather,” one person wrote on Weibo recently. “Even though every time I went to the countryside to see him it was just to exchange a few pleasantries, now it seems like I won’t have any reason to go back to the countryside anymore.”
Cleo Li-Schwartz contributed reporting. Thanks to Brett Zach for copy editing this article.