Rural China faces crisis in the coming wave of Covid
Thanks to decades of official neglect, health systems in the countryside lack facilities and professionals to handle a surge of infections.
Millions in China are preparing to trek home to celebrate the Chinese New Year in late January. Many will travel from cities where large swaths of the population have been infected with Covid since the loosening of the country's notorious Covid Zero policy to small cities and the countryside where — so far — few significant outbreaks have been reported.
This Covid rebalancing promises to be brutal. Rural Chinese communities are older and thus more vulnerable to Covid than their urban counterparts. Yet thanks to decades of official neglect, their health systems lack facilities and professionals to handle a surge of infections.
For the already stressed Chinese authorities, there are no easy or inexpensive answers. In the new year, the pandemic is coming for the countryside.
As far back as the 1950s, China's authorities prioritised improvements in health-care access, especially in rural China, where most of the population lived.
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For example, 'barefoot doctors' — peasants with a few months of basic medical training — played a critical role in helping China manage diseases of poverty, like dysentery, and boost life expectancy from 44 to 63 years between 1960 and 1970.
In the 1980s, government support for the training of actual doctors and nurses increased, as did subsidies for clinics and hospitals across the country.
However, more of the support flowed to urban areas, which the government prioritised for development, than rural ones. Inevitably, private investments in health care, and independent doctors and nurses, followed the population flows.
The resulting imbalances, built over decades, are wide. In 2021, the Chinese government reported that there were 8.81 hospital beds for every 1,000 people in urban China, compared with 4.95 in rural areas.
Finding people to staff those rural beds has been difficult. As of 2018, there were four doctors for every 1,000 people in China's cities; in rural areas, there were 1.8. Of those doctors in rural communities, only 1 in 10 had at least five years of medical education.
The consequences are systemic. The rural health-care system is designed to address basic health issues at local clinics and refer patients to urban centers for more serious issues. In practice, urban hospitals are overburdened by patients seeking higher quality primary care services than they can find in rural China.
The bottlenecks are a heath burden on rural Chinese and the elderly. Though life expectancy continues to improve in China, rural Chinese lag their urban counterparts' life expectancies by roughly 2.7 years as they age with more health problems.
These troubling outcomes are poised to multiply: Chinese citizens older than 60 are a rapidly growing demographic, especially in the countryside, where they make up 23.8% of the rural population, compared with 15.8% in the cities.
From the earliest days of the Covid pandemic, Chinese policymakers and health-care workers feared outbreaks in rural regions that lacked adequate health-care infrastructure.
Low vaccination rates among seniors — only 65.8% of Chinese older than 80 are fully vaccinated — have only heightened those fears. When outbreaks occur (and are reported), those fears are quickly justified.
In late 2021, for example, health-care facilities in a remote part of Inner Mongolia were quickly overwhelmed by an outbreak that grew to 140 patients, Bloomberg News reported. Those patients were ultimately transferred to a designated Covid hospital in the provincial capital, which was also overwhelmed and requested help from other facilities.
In the two weeks since China decisively reversed its strict Covid Zero lockdowns, the biggest reported outbreak has been in and around Beijing. But that should be little solace.
Crowded hospitals and clinics, staffing shortages, drug shortages, school closings and a stalling economy have infected Shanghai and other Chinese cities. Meanwhile, reports of outbreaks in smaller communities are beginning to circulate.
Late last week, state media reported on a town of 50,000 in Hunan Province that had to make do with eight doctors and 15 nurses before Covid.
As the virus surges, this limited staff is stretched thin, incapable of meeting growing needs. "There is no way," the head of the local health service says.
The authorities are well aware of the danger. Last Friday, they issued national guidelines that, among other orders, direct local governments to increase staffing levels at clinics and hospitals, accelerate vaccinations of vulnerable groups and expand Covid information campaigns targeted at people returning to the countryside for Chinese New Year.
These are all excellent ideas, but — in the case of staffing levels, at least — the government is unlikely to accomplish in weeks what it has failed to enact over decades.
For now, rural and urban China are probably best served by efforts to rush medicine into Covid hotspots and use China's still-considerable propaganda abilities to increase vaccinations, boosters and awareness among Chinese New Year travelers.
Of course, China is far from the only country to have deficiencies in its health-care system exposed by Covid. But thanks to the size of its population and the uniquely vulnerable state of its rural communities, few countries are likely to suffer more this winter. Come spring, that fear and suffering should finally lead to a more equitable health-care system for China's countryside.
Adam Minter is a Bloomberg Opinion columnist.
Disclaimer: This opinion first appeared on Bloomberg, and is published by special syndication arrangement.
