In mid-March, a Chinese healthcare worker wearing a full-body hazmat suit tromped into the potato fields of Peijiazhuang village in northwest China to test an 82-year-old farmer for covid. The white-suited workers were riding motorcycles all over the neighboring villages, climbing high into the hills to make sure they tested every member of every household.
The scenes in Peijiazhuang, as reported by Xinhua News Agency, are a testament to the extraordinary lengths the Chinese government has gone to keep its biggest covid surge under control. So far, most of China’s cases have occurred in cities; in the current outbreak, as of Thursday, more than 85 percent of cases have been diagnosed in Shanghai. But there’s a reason the octogenarian potato farmer and his neighbors received such attention: Their chances of surviving covid, if it were to penetrate the village’s defenses, are almost certainly lower simply because of where they live.
As the latest covid wave hits China, experts, officials and ordinary citizens have expressed concerns about the weakness of the country’s rural healthcare system. Many worry that the system could be overrun if covid breaks out of urban areas.
Even as anger has risen about lockdowns in Shanghai and other major cities, the government has doubled down on its zero-covid strategy, in part with rural areas like Peijiazhuang in mind. “There’s a worry given outbreaks in urban areas, that if those spread to rural areas, then that would be a concern given the health infrastructure there,” said Sean Sylvia, an assistant professor of health policy at the University of North Carolina. “So I think that’s probably one thing that’s contributing to their decision-making regarding the strict covid policies.”
Although China’s top cities have world-class medical services, healthcare in rural areas is utterly different. “China truly entails ‘multiple countries within one,’” Karen Eggleston, director of the Asia Health Policy Program at Stanford University, wrote in a 2020 paper.
Of course, China isn’t alone in this, but in China, the rural-urban gap runs counter to the government’s core messages about equality and major political platforms articulated by President Xi Jinping. Poverty alleviation has been a key Communist Party campaign for decades. In 2021, Xi declared a “complete victory” in eradicating extreme poverty. And over the last year, Xi has championed the reduction of inequality as a cornerstone of his agenda under the slogan “common prosperity.”
Bill Bikales, a former U.N. development economist based in China, says Xi’s criteria for poverty eradication overlooks the importance of social programs like healthcare. In a 2021 Sinica podcast interview, Bikales said poverty alleviation wasn’t just a matter of income growth: “There are people who think they’re doing fine who encounter some shock — can be death, illness, loss of employment, a natural disaster — and suddenly they’re thrown into poverty.”
Such shocks may be coming for the Chinese countryside, in the form of the omicron variant. Indeed, the virus may soon present one of the pillars of China’s development — the rural healthcare system — with its greatest test yet. How will the deep and persistent inequities in Chinese healthcare impact rural China’s ability to withstand a surge?
The rural-urban disparity: like ‘Iceland and North Korea’
China has made some progress in its rural healthcare system in recent years. In the early 2000s, the government extended health insurance to the countryside; by 2010, nearly all rural residents were covered under the New Cooperative Medical Scheme, according to a 2012 study. The government also increased funding for the primary care system, including in rural areas, by a factor of 10 and rolled out programs to recruit more highly trained doctors to work in remote areas.
More recently, Chinese leaders have taken a shortcut of sorts: relocating rural residents — sometimes by force — to new developments on the urban edge. “The theory is that if someone is living in a poor, remote village then their access to basic welfare and services was limited, and it’s also really expensive for the state to provide those services,” said Kristen Looney, an assistant professor of Asian Studies at Georgetown University. “So it was more efficient for public goods delivery to move people closer to urban areas.”
These reforms notwithstanding, data underscores the fact that China’s rural residents remain second-class citizens when it comes to health. For the top three causes of death in China — heart disease, brain disease and cancer — the rural rate is higher, often considerably so. In a 2020 paper, Eggleston wrote that the difference in healthcare access and quality between China’s regions was like “the difference between Iceland (the highest in the world) and North Korea.”
What’s behind China’s healthcare gap
Experts Grid spoke with cited several reasons for the wide gap between rural and urban health outcomes.
One involves the sheer number of healthcare resources available to rural residents. Urban areas have nearly twice as many beds in medical institutions per capita than rural areas, according to China’s 2021 national statistics. The lack of doctors is more profound. For every 1,000 people, there are only two licensed doctors in rural areas compared to 4.25 in urban areas; Beijing has seven.
It’s not just the number of doctors that matters; it’s also their training. In rural areas, village and township clinics are the front-line care centers for residents, but healthcare workers in those clinics rarely have full medical training. As of 2017, only 1 in 10 doctors at the township level had at least five years of training, according to Eggleston.
These deficiencies often translate to poor care. Researchers from Stanford University and other U.S. and Chinese universities have conducted studies to measure the level of care in rural clinics. In a 2015 study of clinics in Shaanxi, one of China’s poorest provinces, researchers found that village clinicians only made a correct diagnosis for angina and dysentery — two common illnesses — one-quarter of the time. In a separate study, researchers tested township doctors’ ability to diagnose tuberculosis — a “good litmus test,” they wrote, for pandemic preparedness. When treating patients with the classic symptoms of tuberculosis, the doctors made the correct recommendation in only 41 percent of cases.
The healthcare divide often leads people to travel great distances for treatment. Wang Yingzhe, a middle-aged man who grew up in a family of doctors in Inner Mongolia and now lives in the bustling port city of Tianjin, told Grid, “When average Chinese people face severe illnesses, the bigger the city and the higher the standard of living, the stronger the medical care will be.” When his mother received a diagnosis of lung cancer, she traveled 450 miles from her home in Inner Mongolia to Tianjin for surgery in 2020. “Luckily I’m also in Tianjin, so I could take care of her,” Wang said.
The cost of care has also stymied improvement in rural health outcomes. While the Chinese government has been merging rural and urban health insurance, coverage in the remaining rural-only system, which still included 130 million people in 2018, leaves substantial costs for patients to bear. “The larger concern,” said Sylvia, “is that people will incur catastrophic expenditures that aren’t fully covered by the public health insurance scheme, and that still happens.”
These price tags for treatment can be devastating. A New York Times 2018 documentary followed several families from the countryside who had moved to Hefei, a city in China’s Anhui province, to seek care for children with cancer. “When we found out he had relapsed, they asked me to give a huge sum of money,” one mother, Ji Xilun, said about her son. The hospital asked for $75,000 to $90,000 upfront, and Ji made only $300 a month as a farmer. She said she had no choice but to give up seeking treatment. Her son died of leukemia a year later.
A ticking time bomb for covid?
How would China’s rural health system handle a huge wave of covid cases? Officials are hoping they don’t have to find out.
During the few documented covid flare-ups in rural China, officials have quickly implemented strict measures similar to those seen in cities. A 2020 study that surveyed more than 700 villagers in seven provinces found that all had experienced lockdowns. A rural resident from western Gansu province told the researchers: “There is a loudspeaker [that] repeats quarantine rules every morning and in the afternoon. Every household can hear it. If a villager has a fever, he/she will be taken to the designated hospital immediately,” the resident said.
As cases surged in several regions across China in March, the Ministry of Agriculture and Rural Affairs issued a notice to their departments across the nation to strengthen pandemic prevention during the spring plowing season, when migrants often return from cities to help on farms — the fear being that their return could be a gateway for covid to spread in villages. To keep the virus out, local officials have led rural testing drives, like those in the potato fields of Peijiazhuang, and city officials have visited villages to ensure that local leaders are prepared to stop the spread. Over the last month, Jilin, a province in northern China, has maintained a lockdown across the entire province of 24 million people, including its villages, as it has fought off an outbreak in its capital city. Most recently, ahead of China’s Tomb Sweeping holiday, when many people return to the countryside to pay respects to ancestors and clean their graves, provincial governments urged citizens to practice “virtual tomb sweeping,” to stop the spread.
On the one hand, these accounts showcase an important strength of the Chinese system: manpower. Despite bare-bones facilities in rural areas, Looney said, “The Chinese government has an impressive ability to mobilize human resources to enforce lockdowns and to do testing.” But experts warn that if rural areas were to face a large-scale covid onslaught, rural resources could still fall far short. Urban density and resources have allowed government officials in Shanghai and elsewhere to orchestrate lockdowns, quarantines and food deliveries on a scale that may not be possible in more sparsely populated and under-resourced rural areas.
There have already been a number of incidents that showed the vulnerability of the system. In January 2021, a rural outbreak hit Hebei province, forcing the government to build an emergency isolation center. Last October, an outbreak in a small city in Inner Mongolia overloaded local hospitals; patients had to be transported 600 miles by train for treatment in the provincial capital.
“The normal healthcare system is not as well equipped as urban areas, for sure, to deal with an outbreak,” Sylvia said.
A further concern is the rate of vaccination in rural areas. Many rural residents are elderly people who have stayed behind as their children and grandchildren have migrated to cities. Only 20 percent of China’s over-80 population has received three shots — the level a recent study showed is needed to protect against severe illness when using Sinovac, a Chinese vaccine. “When we talk about the unvaccinated elderly population,” said Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations, “we don’t have a distribution between rural and urban areas, but I suspect that many of them are in the countryside.”
If China’s latest covid wave causes significant infection beyond urban areas, Huang and other experts say it would bring a loud call for changes — in particular a push for more widespread vaccination. “This virus is spreading to a population that doesn’t have access to quality healthcare,” he said, imagining a rural surge. “That would be a clear sign that this approach is increasingly reaching its tipping point.”
And in a kind of boomerang effect, a tipping point in rural areas could lead to even further strain on those big cities already buckling under their own cases. “You can imagine if there was a rural outbreak,” Huang said. “People would flood the urban health centers and the county hospitals, and that could overload the hospitals.”
Thanks to Alicia Benjamin for copy editing this article.