China’s Covid surge threatens villagers as Lunar New Year approaches

China is bracing for an onslaught of infections in its fragile countryside as millions of migrant workers crowd onto trains and buses to leave factory towns, construction sites and cities to return to their rural homes for the Lunar New Year holiday. The travel period, which begins Saturday and lasts 40 days, is expected to overwhelm the rural health care system only weeks after hospitals in wealthy cities like Beijing and Shanghai were buckled by the outbreak.

“What we are most worried about is that after three years, everyone … can finally go home for the new year to visit relatives,” Jiao Yahui, an official with China’s National Health Commission, told state media. With the populous countryside’s limited medical resources, she said, “how to deal with the peak of infection in vast rural areas has become a huge challenge.”

Residents load a woman on the back of a motorcycle pickup after visiting a county health center in central China. (Qilai Shen/The New York Times)

In Dadi, the local clinic is little more than a converted cottage with four rooms and a closet. At best, it can offer intravenous drips, but for no more than five or six people at a time. No one from the county government told the village to prepare for an outbreak, Gao Hong, a village official, said by phone.

Because cases in Dadi have so far been mild, Gao said, villagers were most in need of fever-reducing and cough medicines, but even those have been hard to come by. “We are too remote to get any medicine purchased online delivered,” he said.

Despite the lack of reliable government data, there are signs that Covid is already being transmitted freely in the countryside, particularly in places with large numbers of returning migrants like central Henan province.

Long lines of people have been forming outside village clinics there, according to state media. Such clinics and local community health centers are meant to serve as the first line of defense in a triage system and prevent overcrowding at county hospitals, which are often the closest places rural residents can be treated for serious medical conditions.

Traditional paper horses flank a fresh burial site in a field near Maxiaoji Village. (Qilai Shen/The New York Times)

One such county hospital in Henan was so inundated with patients from the surrounding countryside that it had to ration fever-reducing medicine to patients registering a body temperature of 101.3 degrees or higher. Officials at another county hospital in central Anhui province said they had received so many patients that the facility would soon run out of critical care beds and ventilators.

China’s countryside is less densely populated than its cities, which could mean the virus will spread less quickly. But omicron variants have proved so infectious that population density may not make a difference, especially as friends and families gather to celebrate the Lunar New Year. Rural areas are also home to a disproportionate number of older adults, because so many younger people have left for the cities to seek better job opportunities.

The rate of vaccination in the rural areas is unclear. Nationwide, older adults have lower booster rates in general. The government tried in 2021 to ramp up inoculations but encountered resistance among residents skeptical of the safety of the vaccines, state media reported.

“When people move around, we are very likely going to see a surge of cases in the countryside, but the health care system does not have the capacity to withstand the rapid increase of demand,” said Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations.

Other countries such as India have already experienced the devastating consequences of a runaway outbreak in rural areas with underdeveloped health care. What later became known as the delta variant tore through the Indian countryside in early 2021, leaving bodies floating in the Ganges and villagers clamoring for what little supplies of oxygen were available.

In China, few things highlight the inequities between urban and rural life as starkly as medical care. Despite ongoing health reforms, access to everything from ventilators to fever medicine remains scant for the 500 million people who live in the countryside. Staffing in rural health facilities is also woefully low. There are 1.3 million physicians and 1.8 million nurses in rural China — roughly less than half as many per 1,000 people as there are in the cities, government statistics show.

Rural communities are largely served by grassroots health workers who have only minimal medical training; less than 1% hold university degrees, and just over half have graduated from vocational high schools. They’re often called upon only when needed.

“Village doctor is only a side job. The doctors need to farm as well,” said Hunter Ge, a migrant worker describing the level of care in Maxiaoji, his village of about 700 people in Henan that’s been hit with a massive virus outbreak.

Ge said village doctors couldn’t be relied upon for treating major illnesses but were often the only local source of medicine.

“They are quite nice,” said Ge, who works at a factory. “You can call a village doctor at midnight, if needed.”

Village health workers can provide basic services such as vaccinating babies and treating minor ailments. But experts say it’s unrealistic to expect them to know how to effectively treat Covid. Their lack of training makes them risk-averse, increasing the odds they’ll send people to a hospital and exacerbate overcrowding.

“What you ideally want is for people with less severe conditions to stay away from the higher-tier hospitals,” said Sean Sylvia, an assistant professor of health policy at the University of North Carolina who has studied rural China. “And if you’re relying on village doctors to appropriately triage patients, there’s a big question as to whether they can do that.”

The government is scrambling to address the looming crisis with social distancing restrictions, vaccination campaigns and pledges to improve the supply of drugs.

In southwestern Sichuan province, officials recently ordered villages to restrict gatherings at weddings, banquets and mahjong parlors. And southern Yunnan province is urging returning migrants to stay away from crowds and older people.

As recently as last month, the National Health Commission called on health workers in the countryside to expedite efforts to fully vaccinate rural residents, particularly older adults. In the southern island of Hainan, teams of Communist Party cadres, doctors and nurses are going door to door to vaccinate villagers.

The shortage of cough and fever medicines has been widespread, a result of the explosion of infections and stockpiling by residents. But those drugs only relieve symptoms. Antiviral treatments such as Pfizer’s Paxlovid, which can reduce the risk of hospitalization and death, are far more expensive and scarcer, even in cities where health care services are better, let alone the countryside.

The State Council, China’s Cabinet, issued a directive last week calling on local authorities and Communist Party cadres to marshal resources to blunt the outbreak by, among other things, ensuring medical supplies, bolstering critical care and prioritizing older adults. The Cabinet called for grassroots health workers to distribute health kits packed with fever and cough medicine, rapid antigen tests and masks to vulnerable groups.

Public health experts say the last-minute efforts underscore how ill-prepared the country was for the U-turn in Covid strategy.

“The bottom line is that these measures should have been rolled out prior to the policy pivot,” Huang of the Council on Foreign Relations said of the State Council’s directive.

“Many of the problems we are seeing in rural China are fundamentally problems in China’s health care reform, and you cannot expect to fix them in such a short period of time,” he said. “In short, they won’t be effective in significantly mitigating the harmful effects of the unbridled spread of Covid-19 in the countryside.”

Gao, the official in Dadi, said donors and nongovernmental groups recently delivered medicine to his village, offering relief for the community’s 760 residents. He estimates that 300 migrants will return to Dadi in the coming weeks and fuel infections, which currently stand at more than 150. Even if the medicine runs out, most will try to ride out the illness at home.

“This is not a rich village. It’s quite poor, actually,” Gao said. “It’s not realistic for villagers to spend 50 yuan to take a bus and buy medicine in the county. Even if they did take a bus, there’s no guarantee they’d get medicine because of the extreme scarcity.”