It has been just over a month since China dropped its zero COVID approach to the pandemic. Since then the disease has spread rapidly in China’s cities and there is lots of evidence that many people have died (hospitals, funeral parlors and crematoriums in Beijing have been overwhelmed) but very few of those deaths get reported in the official COVID death toll.

Today the NY Times reports there’s reason to think the situation is going to get worse as the disease is now moving into rural areas where there are no real hospitals or treatment available for anyone who gets sick.

The infections in Dadi Village, a corn farming community tucked between verdant hills in China’s remote southwest, started in early December when a handful of young people returned from jobs in big cities.

The nearest hospital was an hour away, and few could afford the $7 bus fare there. The village clinic is not equipped with oxygen tanks or even an oximeter to detect if someone’s blood is dangerously deprived of oxygen. It quickly ran out of its stockpile of five boxes of fever medicine, so officials told sick residents to stay home and drink lots of water…

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.

Of course the omicron variant often results in no symptoms or mild symptoms but the rural health clinics can’t even keep up with demand for medicines to help with fever. The real problem will be for the, mostly older, people who get a serious enough infection that they need a bed or a ventilator. There are no ventilators in rural clinics and the ones in regional hospitals are limited.

The problem China has is threefold. First, because zero COVID was in place for years most people have no natural resistance at all. Second, Chinese vaccines were very much second rate and won’t be as effective as US vaccines at keeping susceptible people from becoming seriously ill. Third, because zero COVID was dropped all at once, everyone is essentially going to get sick at the same time. Given the population of China, a lot of people will get seriously ill (even if it’s a small percentage of the total) and there won’t be enough room in hospitals for all of them.

“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.

Some belated efforts are underway to prepare but the question is why none of this was done over the past two years. China has also received offers of help from the US, specifically offers of the much more effective US vaccines. Those won’t prevent people from catching omicron but they are effective at keeping people out of the hospital. But China has turned down those offers.

China has rebuffed repeated US offers to share advanced vaccines as Beijing battles a fast-spreading wave of Covid-19, a rejection that’s led to growing frustration among American officials concerned about a resurgence of the pandemic.

Worried about the rise of new variants and impact on China’s economy, the US has repeatedly offered mRNA vaccines and other assistance to President Xi Jinping’s government through private channels, according to US officials who asked not to be identified discussing the deliberations.

US officials have also proposed indirect ways to supply the vaccines in an effort to accommodate political sensitivities in China on accepting foreign aid, they said, without providing more details.

At this point it’s really too late to reverse course. The spread is going to happen fast over the next several weeks. Once again, there will be lots of overcrowded hospitals, lots of body bags and long lines a funeral parlors but I suspect the official numbers won’t change very much.

This report was published yesterday and focuses on the ongoing glut of patients in Beijing.