Two worlds: In China's cities, everyday life is returning, such as at this New Year's party in Nanjing (left). In the countryside (right), by contrast, such as here in the province of Hebei, an unusual number of people are dying from "fever."

Two worlds: In China's cities, everyday life is returning, such as at this New Year's party in Nanjing (left). In the countryside (right), by contrast, such as here in the province of Hebei, an unusual number of people are dying from "fever."

Foto:

AFP; DER SPIEGEL

China's Battle against COVID The Omicron Wave Hits the Countryside

Instead of using the time gained through its zero-COVID policy to strengthen rural healthcare, services have actually decayed in recent years. Now, the Omicron wave is wreaking havoc in the countryside.
By Georg Fahrion und Christoph Giesen in Hebei and Tianjin, China

Sitting in his peach orchard, farmer Shang Ruitai looks out on the rural highway to Zanhuang, which runs by just on the other side of a thick row of poplar trees. The road connects the villages scattered throughout the southwestern corner of China’s Hebei province, a vital lifeline for the region. In recent weeks, though, it has become an alleyway of death.

Almost every day, there is a burial at some point along the road, with men wielding picks and shovels digging graves out of the frozen ground. If possible, Chinese farmers bury the urns containing family members' ashes on their own property. And fresh graves can be seen everywhere in the fields along the highway. Small mounds of earth decorated with brightly colored plastic flowers – green, orange and violet.

DER SPIEGEL 2/2023

The article you are reading originally appeared in German in issue 2/2023 (January 7th, 2023) of DER SPIEGEL.

SPIEGEL International

Parallel Worlds

Many of them died of fever. Starting in the middle of December, they suddenly fell ill, with the coronavirus spreading at lightning pace through the surrounding villages. "At least 95 percent of the people in our village were infected,” says Shang in his peach orchard, as he prunes back branches and shoots that bore fruit last year. "Around 1,800 or 1,900 people live in the village," he says. "I know four people from our village who died of COVID last month. In the neighboring village, where about the same number of people live, there were more than a dozen deaths."

One month after the government in Beijing abruptly jettisoned its zero-COVID policy, China finds itself existing in two parallel worlds. In many of the country’s largest cities, which were struck first by the vast Omicron wave, the infection wave is likely receding from its peak.

In places like Beijing, Shanghai and Guanghzou, normalcy is returning, and subways, restaurants and shopping centers are full once again. New Year’s was celebrated in the Beijing nightlife quarter of Sanlitun to a degree not seen since 2019.

In Qinhuangdao, on the northeast coast of China, a woman lights a firework on New Year's Day.

In Qinhuangdao, on the northeast coast of China, a woman lights a firework on New Year's Day.

Foto: WU HAO / EPA

The situation in intensive care units in the large cities remains desperate, but life has returned to the streets. If you don’t leave the cities, you can get the superficial impression that the worst has passed. "Everyone is holding on with great fortitude, and the light of hope is right in front of us," President Xi Jinping said in his New Year’s address.

But in rural areas of China, the catastrophe is only just now beginning to unfold, with Omicron striking a remarkably unprepared population. The vaccination rate in the Chinese countryside is lower than in in the cities and the healthcare system is far worse. On Monday, the National Health Commission warned on state television that the virus could be spread to all areas of the country due to travel stemming from the Chinese New Year on January 22.

An elderly COVID patient is treated in a hospital in Tianjin.

An elderly COVID patient is treated in a hospital in Tianjin.

Foto: NOEL CELIS / AFP

The British company Airfinity, which analyzes health data, believes that China is currently suffering 16,000 COVID deaths per day. By January 23, the death rate could peak at 25,000 per day, which would mean that 1.7 million people in China will have lost their lives as a consequence of the coronavirus by the end of April. Official Chinese statistics, of course, reveal nothing of the sort. From December 1 to January 4, those statistics documented just 25 COVID deaths. For the entire country.

Even WHO Doesn't Trust Chinese Statistics

Even the World Health Organization (WHO), despite its habitual reticence when it comes to China, announced on Wednesday that it doesn’t believe the official numbers provided by Beijing reflect reality. Because of the uncontrolled outbreak in the People’s Republic, numerous countries have introduced a testing requirement for travelers arriving from China, with German Health Minister Karl Lauterbach announcing on Thursday that Germany was following suit. WHO Director General Tedros Adhanom Ghebreyesus has referred to the measures as "understandable."

To get an impression of what might lie in store for the country at large in the coming weeks, a trip to Beijing’s neighboring province of Hebei can be instructive, or to the countryside surrounding the metropolis of Tianjin. Both are rural areas that are bound closely enough to large cities to have been struck early on in the Omicron wave, yet which also have inadequate healthcare infrastructure.

The farmers in the village New Delight in the province of Hebei grow wheat in the winter and soy in the summer. Liang Huibing, a nurse, operates a small village medical practice here with his wife, and together, they do their best to tackle colds, flu infections and smaller injuries. They send more serious cases to the city.

That’s how things were until November 12, when they had to lock up their practice. The country’s zero-COVID policy, which was still in force at the time, was to blame for the closure. Because the village had been declared a "high-risk area" after a few infections had been discovered, the authorities shut everything down – stores, schools, butcher shops and the only medical practice far and wide. Liang was only allowed to open his doors again on December 7, the day on which the government in Beijing suspended all corona-related restrictions.

Liang Huibing and his wife operate a village medical practice in the Hebei province.

Liang Huibing and his wife operate a village medical practice in the Hebei province.

Foto: DER SPIEGEL

"I used to be required to measure the temperature of all of my patients and immediately report positive cases so that they could be brought to a quarantine facility," he says. "Now, we treat them." Or rather, they try to. Four elderly people are sitting in the tiny practice crammed together on a metal bench of the kind you might see in a train station or airport – all of them receiving saline solution infusions.

Liang can remember his first COVID patient well. "It began on the morning of December 10. A woman over the age of 50, she had a fever, felt nauseous and had diarrhea. I tested her, and she was positive. We gave her a shot to lower her temperature. In the ensuing days, her husband and two children also showed up. They had all been infected.” And before long, it was the entire village. "More than 90 percent of the people in our village have now been infected," Liang estimates. He was still able to test the first patients and give them a bit of ibuprofen. But he now no longer has any supplies at all, unable to do much of anything except administer Chinese herbs and saline infusions.

"On December 17, I had a sore throat myself, so I took a test and found that I was positive. We immediately closed to avoid infecting anybody." They reopened again after a few days. When asked how many people in the village had died in recent weeks, he says: "We don’t have a number. But there have certainly been a higher number of deaths this year than average."

One hour’s drive southeast of the center of Tianjin, population 13 million, with its skyscrapers and shopping centers, lies a village in a flat, winter landscape surrounded by wind turbines and oil wells. The village is part of the city’s administrative region, but it feels like a completely different world. It is here that Zhang Baoli has her rural medical practice. Her name has been changed for this story.

Just as they have in hundreds of thousands of Chinese villages, the authorities have razed some of the old farmhouses to make way for apartment buildings. In this particular village, that makeover looks to have taken place several decades ago. The four-story residential buildings are run down, as are the shops surrounding them.

Zhang Baoli’s practice is located in a garage. It includes a sofa, a leather recliner and plastic stools, where patients and their family members sit. Here, too, four women are receiving infusions, the oldest of whom is 91. At her wooden table in the corner, Zhang is stirring together a brownish powder and a liquid in a small bowl, before smearing it on a bandage and sticking it to a young woman’s exposed hip.

A Weakened Rural Healthcare System

"Strictly speaking, this place is illegal," she says. The official permit only applied to her former clinic, which she operated for around 20 years at the same site, but which was shut down last year. For as long as the zero-COVID policy was in force, Zhang wasn’t even allowed to give patients aspirin or cough syrup, since they could have been used to cover up COVID symptoms. The authorities also mandated that only a single patient could be in the building at one time. Which meant that keeping the clinic up and running no longer made sense. "I closed the clinic because they were so strict," Zhang says. Instead, she found a job in the city administering PCR tests. She opened her current, provisional clinic after the zero-COVID policy was lifted.

"In my old clinic, I could also give patients oxygen, but that’s not possible in this garage," she says. She says she still has access to the clinic building, "but it has neither electricity nor heating. I can’t treat any elderly patients there."

An assistant pushes a COVID patient in a wheelchair through a hospital in Tianjin.

An assistant pushes a COVID patient in a wheelchair through a hospital in Tianjin.

Foto: Noel Celis / AFP

It’s absurd: Instead of using the time won through the zero-COVID policy to strengthen underdeveloped healthcare infrastructure in rural areas, the government managed to weaken it further with its rigid policy. Zhang Baoli’s experience during the pandemic, after all, is far from unique. Many village doctors had similar experiences. And they are the first place rural residents go with health complaints, and in remote areas, they can be the only option.

Completely Unprepared for the Omicron Wave

The municipalities usually provide the buildings in which the clinics are housed free of charge, but in many places, the state doesn’t pay doctors a salary. They also aren’t allowed to bill much for examinations and diagnostics. Instead, village doctors generally charge a 15 to 30 percent surcharge on medical drugs, which they buy wholesale and then sell to their patients. It results in a payment of around 30 yuan per patient, the equivalent of around 4 euros.

The term "doctor" is, in many cases, a bit generous. Around 42 percent of practicing medical professionals in China don't have a university degree. Many of those who provide healthcare in rural areas have completed a nurse training program at best, or served as an assistant to an older village doctor. Most of them were completely unprepared for the Omicron wave.

"We village doctors are made of steel."

Zhang Baoli, healthcare professional

The garage door flies open and a man with a white beard under his mask rushes into the room. "Examine me!" he demands, without introducing himself. "I can barely breathe!" Zhang Baoli points him to a stool and his breathing slows down after a time.

In the new pandemic situation she finds herself, Zhang has quickly established a routine. When her garage practice opened in December, people began lining up in front of it as early as 7 a.m. Often, she says, she worked until 11 p.m., treating up to 200 patients a day – in a village of just 2,000 people. All of her assistants also fell ill. "We village doctors are made of steel," Zhang says, adding that she continued working even when she became infected as well.

She says that people are still showing up every day with fevers, but the wave in Tianjin is beginning to flatten. She doesn’t have any precise numbers about the number of people who fell ill or died. But here, too, it is clear: "More older people died this year than in past years."

A Wake for Grandfather

In the yard next to the practice, there are two, coal-fired cast iron stoves and a woman wearing a headscarf is preparing food in woks. Men in skullcaps come and go, taking along portions in plastic bags. Is it the kitchen of a restaurant? Actually, it is part of a wake. The men are wearing white sashes on their hips, the traditional mourning dress for the Muslim Hui minority.

Plates are stacked on the table full of bread baked in oil, shrimp with celery and cashews and a lamb stew, freshly slaughtered today. One week has passed since they cremated their 93-year-old grandfather. On the seventh day, as is tradition, the family has gathered in mourning.

How did he die? "COVID," says his 62-year-old nephew immediately. "He was healthy, but then he got a fever, and 20 days later, he was dead." The woman in the headscarf contradicts him: His age was to blame, she says. They will never find out for sure, since he was never tested for COVID. They only know that they all contracted a fever in December as well.

A patient receives oxygen in the hallway of a hospital in Beijing.

A patient receives oxygen in the hallway of a hospital in Beijing.

Foto: Andy Wong / AP

People who die in China are cremated in state crematoria, which have been set up across the country in recent years. China is densely populated, officials say unsentimentally, and there is simply no room for expansive cemeteries. Exceptions are only made for Muslims, if they expressly request it, or in areas where crematoria have not yet been established.

Services take place in the attached rooms, where speeches are held and mourning music is played. A cannon in the courtyard is fired to ward off evil spirits. Together, guests bow three times before the dead person and then burn paper money for the afterworld. Such ceremonies in the People’s Republic tend to last around 45 minutes. In Hong Kong, where ancient Chinese traditions are still upheld, people tend to think that the practices in China are overly hasty.

But the coronavirus has has further accelerated the process. Instead of 45 minutes, many crematoria only allow family members five minutes before the coffin is slid into the incinerator. There is no more cannon fire and there are no more speeches. In some facilities, family members of the deceased must take a number.

"Quick and Convenient"

There are around 100 cars parked in the crematorium where the deceased from the village of New Delight in Hebei province are incinerated. Hot exhaust air is rising out of the chimney. A man in a flattop is standing at the entrance. "No photos," he growls. He is holding a spreadsheet and a walkie-talkie.

He is the doorman, and it is up to him when which family is allowed into the crematorium. Dozens of people in white mourning gowns are waiting outside in minus 5 degrees Celsius (23 degrees Fahrenheit) to finally be allowed into the facility.

Somebody – likely before the corona outbreak – stuck a marketing slogan on one of the doors, reading in big, blue letters: "Quick and Convenient." It likely refers to the service provided at the facility, but nobody has apparently felt the need to remove this bit of impiety.

A propaganda poster from bygone days also hangs on the walls of the crematorium. "The epidemic is our mandate. Prevention and control are our responsibility." Control and prevention? They were abandoned not all that long ago – but it feels like an eternity.

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