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The healthcare system is so unprepared that any major shift away from Covid Zero — which in China has meant frequent mass testing, swift quarantines, lockdowns and sealed international borders — risks a public health crisis.
In Ejin, home to about 30,000 in the Chinese province that borders Mongolia, several dozen infections in mid-October quickly overwhelmed the two local hospitals. Authorities had to transfer more than 140 patients by train to the provincial capital of Hohhot, over 1,000 kilometers (621 miles) away, according to local media.
Before long, the Hohhot team, too, was asking for help. To handle the influx of Covid cases — including a one-year-old infant, an 82-year-old and a dozen seriously ill patients — Hohhot’s main hospital for Covid enlisted help from other facilities. The center wasn’t “capable of handling this many patients all of a sudden,” a doctor overseeing the response told state broadcasters in early November.
The experience shows how vulnerable China’s vast yet patchy hospital network — hobbled by lopsided distribution of resources and under-investment — is to the virus. Add to that the likelihood of unprecedented cases and deaths if China were to let the disease spread like it has in other parts of the world, in an environment where most people are vaccinated with less effective local shots, and it’s clear why the country is reluctant to embrace endemic Covid. Officials are said to plan on keeping the existing playbook through 2022, even as they signal a willingness to adjust policy marginally.
Cause for worry
China doesn’t have to look far to have cause for worry. The recent Omicron outbreak in Hong Kong, which has emulated the mainland in adopting strict border measures and sending all positive cases to public isolation facilities, has already led to overwhelmed hospitals. The city is now sending non-Covid and mild-Covid patients from government hospitals to private facilities. And this is one of Asia’s most-developed healthcare systems, on par with places like Singapore and Japan.
“If the country reopens, the healthcare system will be tremendously challenged for sure,” said Mia He, senior healthcare analyst at Bloomberg Intelligence. China’s “metrics on limited access to healthcare resources foretells a system that will come under significant strain,” and investment in infectious-disease response has historically lagged behind more urgent challenges like cancer, diabetes and hypertension, she said.
Even hospitals in developed nations like the US and Europe were overwhelmed during their worst Covid waves. While Hong Kong has been forced to forgo some of its mandatory isolation rules as hospitals buckled under record cases, China has stuck to its strict containment methods and kept control of increasing clusters across the country in recent months.
“Preventing the healthcare system from collapse is a complicated undertaking even in developed countries,” said Jin Dongyan, a virologist at the University of Hong Kong. China’s long-standing containment-at-all-cost Covid approach has reflected a lack of confidence among officials in putting the healthcare system to the test, he said.
Communist Party leaders have reason to be wary of the loss of social stability and legitimacy that could come if China’s hospitals were inundated. Official rhetoric often highlights the country’s success in avoiding the fatalities and chaos Covid has wrought in other countries.
“If you multiply Covid’s infectivity rate and a large population, you’ll get a big absolute number for severe disease and death in a country of 1.4 billion people,” Liang Wannian, a seasoned epidemiologist who has overseen China’s Covid response from the beginning of the pandemic, told the state-run CCTV in early December. “That means it’s a major public health, social as well as political problem and must be put under control.”
In the past two years, China has reported fewer than 5,000 Covid deaths, compared with more than 950,000 in the US, which has about one-quarter the population size.
The desire to protect that track record can be seen in the incremental easing steps said to be considered now — like creating bubbles similar to the one used in the Beijing Olympics to allow foreigners to visit without quarantine. There has been little mention publicly of how China will gird the healthcare system for the inevitable increase in cases and deaths that will come from opening up.
Uneven access
China’s healthcare system was already a source of public discontent before the pandemic. While the government has expanded rural healthcare and state medical insurance coverage, there were fewer than three doctors per 1,000 people in 2020, behind major developed nations but also lagging Brazil, another populous emerging market that suffered a devastating Covid hit.
A key challenge is the uneven distribution of medical resources. For the 500 million or so Chinese living in rural areas, access to doctors and hospital beds is far worse than for those in cities. For every 1,000 people in rural China, there are fewer than two doctors and nurses together. In Beijing and Shanghai there are more than five doctors alone for every 1,000 people.
That’s resulted in a sort-of medical migration, with 40% of the patients at top hospitals in Beijing and Shanghai in recent years coming from other parts of the country, according to local media reports citing official data.
Infectious Disease Model
When it comes to infectious diseases, most Chinese cities rely on designated hospitals to handle everything from tuberculosis and HIV infections to hepatitis — and since late 2019, Covid.
This model works well with the Covid-Zero strategy, in part because hospitals are able to shower abundant attention on the small number of patients. No one has died from the virus in China since early 2021, according to official data from the National Health Commission.
China’s cases have swelled in recent weeks, with daily infections topping 500, a level unseen since the initial deadly spread in Wuhan. If cases surge into the tens of thousands, there likely won’t be an abundance of care and vulnerable people could die quickly, as is being seen in Hong Kong now.
Risk of colossal outbreak
That seems guaranteed if China reopens. Statistical modeling by Peking University shows China could have a “colossal outbreak” with as many as 630,000 or so people infected in a single day if the country removes most of its restrictions as the US did.
The researchers said their projections were already optimistic because they assumed China’s domestic vaccines were as effective as the mRNA shots used widely in the US While more than 80% of Chinese have been fully vaccinated and over 554 million people have received boosters, studies have shown the local shots to be less potent, especially at stopping infections.
Even then, there would be more than 22,000 Covid patients needing hospitalization and expensive equipment like ventilators, according to the Peking University study.
China could quickly see an intensive-care crisis, with only 3.6 ICU beds for every 100,000 citizens, compared with 25.8 and 33.9 in the US and Germany, respectively.
Severe Covid preparedness
There’s also the challenge of weaning the public off the Covid-Zero mentality. Back when the virus first emerged in Wuhan, footage of people swarming hospitals and passing out while lining up for treatment went viral, feeding fear and panic. Since then, state media have focused on the pandemic’s apocalyptic impact in other countries as a way of validating Beijing’s isolationist response.
While China set up temporary hospitals and isolation facilities in record time in the early days of the pandemic, most of these have been dismantled or mothballed.
Big hospitals have been urged to improve their capabilities to discover infectious diseases early and to control them, while treatments for patients should still be centralized at designated hospitals rather than at the point of discovery and diagnosis, according to a person familiar with the national health strategy who asked not to be identified discussing information that’s not public. If the need arises, China can again build makeshift hospitals for mild cases, the person said.
“Ultimately it’s a matter of whether you want a soft landing or a hard landing for Covid Zero,” said Huang Yanzhong, a senior fellow for global health at the Council on Foreign Relations based in the US “Hong Kong to some extent is showing the mainland what a hard landing looks like and a soft landing is something you have to invest in.”
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