Empty Shelves and Packed Clinics: Rural China in Crisis
From herbal medicine to ginger and garlic water to nothing at all, villagers in China are bracing themselves for an uphill battle against COVID.
Editor’s Note: After launching on Dec. 14 in response to China’s abrupt end of zero-COVID, the volunteer group “The Rural Fever-Relief Initiative” received more than 100 requests for aid in its first week from medicine-deprived rural areas across the country. As of Dec. 29, the group had delivered the much needed medicine to around 13,000 elders in rural areas.
“I’m the only doctor in our village clinic. I can’t see fever patients and I don’t have anything for them anyway,” said Dr. Shi from Wangzongdian, a village on the outskirts of the city of Xingyang in Henan province. On Dec. 20, he told Sixth Tone’s sister publication The Paper that his village had completely run out of cold and flu medicine for nearly two weeks.
“I asked the wholesale department of the county pharmacy for medicine. For a 100-tablet bottle of ibuprofen, the wholesale price has risen to more than 20 yuan ($3) from 3.5 yuan. Regardless, the drug is still out of stock,” he said.
On Dec. 16, the National Health Commission (NHC) issued a notice, requiring village committees and clinics to facilitate timely access to medication and COVID-19 antigen kits for people returning home for the Spring Festival. Township and village clinics must stock up sufficiently to ensure supply to serve 15 to 20% of the local population at any time. They are also required to get enough medical devices such as pulse oximeters and infrared thermometers.
Dr. Shi’s clinic has never had antigen kits or pulse oximeters for monitoring symptoms. “Now flu symptoms are particularly rampant, affecting at least 30 to 40% of villagers, but I have no way of knowing for sure if it’s due to COVID-19. If they don’t have medicine at home, all we can do is advise them to drink water boiled with ginger and garlic,” he said. He advises patients with obvious symptoms to go to the township clinic. At the time of publishing, he wasn’t aware of any severely ill patients in the village.
As many places approach the peak of their first wave of cases, some cities have ramped up efforts to allocate fever medicine. One way is to “break bulk” — breaking up the packages of drugs and selling them in smaller batches — or offer medicine free of charge at designated times. However, in rural areas, health care resources have always been strained.
“Now, many cities have issued a large number of ‘treatment packages,’ but they are mostly meant for the central districts, not even the suburbs yet,” said Zheng Hongbin, founder of The Rural Fever-Relief Initiative. “This reflects the structure of our society, where resources are highly concentrated in urban areas, and the countryside is stripped bare. Many rural seniors still don’t have access to timely information about the pandemic.” He worries that with Spring Festival approaching, villages across the country will be hit hard.
“Both in terms of purchasing power and human resources, the difference we volunteers can make is very limited. Our consensus right now is to do as much as we can while appealing to authorities to step up efforts for the rural elderly population,” Zheng said.
Breaking bulk
In Jinan, the capital of the eastern province of Shandong, primary care clinics and pharmacies received 1.1 million tablets of ibuprofen over Dec. 16 and 17. Meanwhile, in the city of Wuhan in Hubei province, 3 million tablets of ibuprofen were distributed daily for a week beginning on Dec. 17, with 80% going to healthcare facilities and 20% to retail pharmacies.
Wang Houting, Deputy Director of the Beijing Medical Products Administration, said at a Dec. 19 press conference that pharmacies are strictly required to break up the packages of fever drugs into smaller batches before selling them to consumers. More cities are adopting the practice.
On the same day, the city of Zhuhai in the southern Guangdong province put a cap on how much medicine an individual can buy, limiting it to no more than six ibuprofen, diclofenac or loxoprofen capsules, and no more than one bottle of ibuprofen suspension in one week.
High fevers resulting from COVID-19 infections typically last three days at most, so breaking bulk is effective in getting medication to those in most dire need. In rural hospitals and clinics, doling out “mixed bags” of small-dose drugs has been common practice.
On the morning of Dec. 20, in Huichang, another village in Xingyang, 53-year-old Dajun had to line up for more than an hour at a private clinic before finally getting his medication. The prescription consisted of tablets in nine unlabeled paper pouches. It was a three-day supply: each package, carrying 12 tablets of five types of medicine, represented a single dose. Dajun was unsure just what exactly they were. “The doctor only mentioned that there is cephalosporin, so I shouldn’t drink alcohol while taking them,” he said.
Cephalosporin is an antibiotic, only used to treat bacterial infections following a cold. It’s not supposed to be a COVID-19 treatment. But Dajun had no way to know if he actually had contracted COVID-19 to begin with. There were no antigen tests at the clinic — the doctor simply asked him if he had symptoms such as a fever or sore throat before prescribing the medication.
The day before he saw the doctor, he had chills but was unable to buy medicine. Early the next morning, he went to the township to try his luck. There are about 70 to 80 small clinics, and many already had long queues at the door. “I didn’t even bother with the hospital. There must have been even more people there,” he said.
There have been recent reports of patients suffering liver damage, or even ending up in the intensive care unit, all because of mixing up cold medicine. When asked if he felt it was risky to take so many drugs at once, Dajun brushed the question aside. He explained that the private clinic is licensed, has operated for decades, and has given good treatment to elderly patients with complex conditions.
Alternatives
Dajun isn’t alone in taking whatever is available. Fan, another villager from Wangzongdian, has a family of six. Since Dec. 19, his son, daughter-in-law, and grandson all had a headache and fever. “Village cadres have been infected for more than a week and they are now recovering. In the last couple of days, the village committee has effectively stopped working.” Fan said. He added that they usually keep some Traditional Chinese Medicine (TCM) for fever at home, but this time it is not particularly effective.
On the morning of Dec. 20, Fan’s grandson ran a fever of over 39 degrees Celsius. Besides giving him some TCM, they also put a cooling gel patch on his forehead. But seeing how well his fellow villagers had recovered from COVID-19, he was not particularly worried about his grandson.
On Dec. 19, several rural pharmacies said fever medicine had sold out at least a week ago and that they didn’t know when supply would return again. One pharmacist in the northwestern Shaanxi province mentioned that all they had left were metamizole tablets for adults.
Metamizole, now a banned drug in more than 30 countries due to the risk of it causing a dangerously low white blood cell count, is a painkiller that used to be popular in rural areas due to its low price and fast-acting relief. A village doctor in the city of Xi’an recently stirred controversy by distributing metamizole to his fellow villagers.
That said, the drug is not completely banned in China. In March 2020, China’s drug regulator required drugmakers to revise their instructions for metamizole tablets to include more extensive explanations of side effects, cautions, and contraindications. The drug is prohibited for use in people under 18 years of age and in women in the late stages of pregnancy, and is contraindicated for women in early to mid-pregnancy as well as those who are breastfeeding.
According to Chinese law, metamizole should not be a first-line treatment and should only be used in cases of severe illness where no other effective medication is available. Including metamizole in a list of drugs recommended for treating COVID-19 by Beijing’s Health Commission reflects the desperation for fever medicine across the country.
Clinics
On Dec. 24, Qing Kong was set to take her postgraduate entrance exam for the second time. Two weeks ago, she experienced a fever shortly after returning to her rural home in Pucheng County, Shaanxi province, but has since recovered. What scared her the most was her grandmother, who lives with her, also ran a fever up to 38.5 degrees Celsius. She’s 75 years old with heart disease and tuberculosis. She has not been vaccinated and couldn’t find medicine anywhere.
The three pharmacies in a neighbouring town had already been picked clean. Drugs sold out within seconds on online shopping platforms such as Taobao and JD.com. “There’s not much point in getting a consultation. All you need is medicine, and we don’t have any,” a doctor in the village told her. On Dec. 15, her uncle went to the county hospital, only to return with just one box of TCM for cold and flu — the only thing patients were allowed to buy. The pharmacy at the hospital put up a notice saying “Lianhua Qingwen capsules are sold out. Drugs containing ibuprofen and acetaminophen have long been out of stock.” Lianhua Qingwen capsules, a type of TCM, have been recommended by the government as a treatment for COVID-19.
A doctor in Pucheng said over the past three years, local policies forbade township clinics to treat fever patients, an echo of the zero-COVID policy. Instead, they were referred to the county hospital. “Before, we had some ibuprofen in stock, but they expired because there was no use for them,” he added. Now, they can only prescribe TCM recommended by the government.
A receptionist at the fever clinic at Pucheng County Hospital said the hospital has received many patients with COVID-19. No drugs are to be prescribed to outpatients. To receive infusions, patients will need to be hospitalized. The hospital recommended people with mild symptoms stay at home.
The Dec. 16 notice issued by the NHC also called for more township clinics to serve rural populations. These clinics are indispensable in the treatment of COVID-19.
The same day, Pucheng reopened a fever clinic in one of its townships. According to a local doctor, two or three staffers are working in that clinic and offering antigen tests. No one knows when the test kits will run out. “At the moment, we only receive a couple of patients daily. Many people still go directly to the county hospital. We don’t know how bad things will get,” the doctor said.
The vaccination of elderly people has now become the focus of the fight against COVID-19 in rural areas. “Throughout the pandemic, we were constantly taking swabs but weren’t allowed to vaccinate the public. Now we’ve started to arrange booster shots at township clinics. For villagers with limited mobility, arrangements will be made to go to them,” the doctor explained.
Homebound
Chang’an, a college student, is worried about her grandparents back home in Zhaoqing, a city in Guangdong province. Although they have already received three doses of the vaccine, her grandfather has had stomach surgery and her grandmother has heart conditions. All they know about the coronavirus is that “it’s pretty strong” and they are anxious about getting it.
She is well aware that elderly people who are less internet-savvy don’t know how to go about stockpiling medication. As soon as she read news about people in her county snatching up drug supplies, she knew she had to move quickly for her grandparents. “I made the rounds of all the pharmacies, large and small. I couldn’t find a single box of ibuprofen or acetaminophen,” she said.
Other members of her family work in Foshan and Guangzhou, major cities in Guangdong province. Younger relatives had a fever, but they were unable to find any medicine and had to tough it out. Zhaoqing is said to have one of the lowest infection rates of Chinese cities, but Chang’an is apprehensive about the imminent wave of Spring Festival travelers.
As far as she’s heard, her hometown already recorded several cases two weeks ago that have been traced back to people returning home from Guangzhou. Neighboring towns fare similarly. “PCR testing booths have been closed and very few people use antigen tests, so everything is uncertain now,” she said. Her village committee has yet to record the number of infections and is unable to monitor the drug shortage situation.
She posted a request for help on the Weibo page of Rural Fever-Relief Initiative and received a batch of free medicine. Xiaohaotu, the first village in Shaanxi province to reach out to the group for help, received 3,000 tablets of fever drugs, including ibuprofen and acetaminophen, on Dec. 21. The group has delivered drugs for the rural elderly in the provinces of Guangdong, Guangxi, Chongqing, Hebei, Shandong, and Henan, expecting to help around 3,000 people.
Zheng, the group’s founder, said requests for help mostly come from people returning to their hometowns to visit their elderly parents, as well as non-governmental organizations. They can help his group collect data on the local outbreaks to facilitate relief measures.
He explains that the group mostly distributes ibuprofen and acetaminophen, the two drugs recommended by the WHO. Given the lack of medical knowledge among the rural population, the group has commissioned professionals to write up a guide to give out to villagers with the drugs.
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