As COVID-19 spreads largely unchecked from Beijing to Shanghai, China is bracing for a second surge, jumpstarted by millions of people who are planning holiday travel from cities back to their rural villages, where the health care system is far patchier.

"I really don't think the village doctors, or even the township or county hospital, can handle the increased number of severe cases," says Huan Wang, a researcher at the Stanford Center on China's Economy and Institutions. "I think the rural villagers are just left on their own in a dark COVID winter."

As the Lunar New Year approaches, health officials are concerned the celebrations could turn into superspreader events, catching rural systems off guard and driving up infections in a country where natural immunity is nearly non-existent and vaccine hesitancy has remained stubbornly high among the older population.

"In China the messaging has to be really careful right now, since we will have a new year coming up and people are going to travel to the rural communities, so it's going to be very important to inform the public that it's coming," says Ali Mokdad, an epidemiologist and chief strategy officer at the University of Washington's Institute of Health Metrics and Evaluation (IHME).

A million deaths by 2023

In its latest briefing, IHME forecasts up to 1 million deaths in 2023 if China does not maintain social distancing policies — a prediction echoed by another model released by researchers at University of Hong Kong last week.

Yet China's state media outlets have been emphasizing that the latest Omicron variant presents only light symptoms similar to the common cold — messaging intended to assuage the Chinese public, but which has contributed to vaccine hesitancy.

"As the experts say, just set off some fireworks, have a good party and scare away the virus," says Sun Caiyun, an ebullient restaurant owner in Beijing who says she is intent on heading back to her home village in the northern Shandong province – COVID or not. "Of course I am planning on returning home, because Beijing bans firecrackers!"

However, the strain China's on countryside is already evident as medicine shortages hit rural pharmacies. On Chinese social media, rural residents have been asking for donations, posting pictures of ransacked pharmacy shelves devoid of fever and pain medication. Some of the medication has been diverted to cities, which were initially hardest-hit by the surge and where supplies first ran out.

"People from the cities have been coming over and buying all of our medicines, or they'll order online and have our pharmacies mail it over to them," says Li Qian, a recent college graduate, who lives in a village in China's southern Jiangsu province. She worries most about her asthmatic grandparents; the nearest hospital, she says, is two hours away.

Rather than impose its usual combination of lockdowns and mass testing, China suddenly lifted nearly all of its quarantine and testing policies in early December as the more-infectious Omicron variant leapfrogged past its COVID controls.

The focus on containing the virus for nearly three years has now left China little prepared for treating the infected. "Other measures, especially vaccination of the elderly [and] stockpiling of antivirals, were all relegated to a back-burner issue," says Yanzhong Huang, a senior fellow following public health at the Council on Foreign Relations.

The exact number of those infected is not known, as the country has suspended most public testing and at-home tests are hard to come by. Officially, China says only two people in the entire country have died during December's surge.

"The Chinese have delayed reporting lately, and we don't have the breakdown at the hospital lately of people admitted for COVID, or with COVID," says Dr. Mokdad. The World Health Organization said this week that it, too, had not received new data from China on COVID-19 hospitalizations since early December.

The lack of data means public health officials have no accurate insight into exactly how far the virus has spread within cities or villages, sparking public confusion and anxiety within China.

"The number they [are] willing to show the number of deaths is almost bordering on ridiculous," says Ray Yip, an epidemiologist who founded the Center for Disease Control's office in China in 2003.

Airfinity, a British health data firm, estimates China may be seeing up to one million new infections up to 5,000 deaths daily based on regional data.

Hospitals that NPR visited in Beijing this week were busy but orderly, with a handful elderly patients in the lobby lying in gurneys hooked up to intravenous bags because beds had run out.

Last Thursday, China's national health commission said it was accelerating the expansion of fever treatment clinics – where patients can get quick medical consultations and supplies from a pharmacy — to cover 90% of rural areas to prepare them for the anticipated increase.

Urban hospitals are scraping by

So far, the health care system has held up in large cities – in part because many migrant workers have only rural health insurance that cannot be used in urban hospitals.

"You just have to suck it for a few days," says Zhang Xiaohu, a delivery worker who contracted COVID in early December. He says he worked through his symptoms, because he does not receive paid sick leave and could not afford to go to a Beijing hospital. "Being a delivery guy means you have to be the kind of person who dares to risk their lives."

Crematoriums and funeral homes in Beijing say they are already overwhelmed, despite the lack of officially reported COVID deaths. At Dongjiao crematorium, one of Beijing's biggest, a line of hearses and grieving families filled the intake lot earlier this week, and staff told NPR the waiting time for cremations was 10 days.

One man waiting in line said his grandfather started running a fever last week and tested positive for COVID, but they spent days looking for a hospital that could take him.

"Right now, no reputable hospital in Beijing has free beds," the grandson said. He didn't want to be named because of how sensitive the topic of COVID deaths is in China. His grandfather died Sunday, two hours after checking into the hospital, though China reported no deaths from COVID that weekend.

Chinese experts say worse is yet to come. Wang Guangfa, one of the country's best-known respiratory specialists, predicted that severe and deadly cases of COVID will peak at the end of this month. One Shanghai hospital warned residents that it was preparing for up to half of the city's population to be infected by next week.

Feng Zijian, former deputy director of the Chinese Center for Disease Control and Prevention, cautioned that up to 60% of China's 1.4 billion people could be sickened by COVID-19 at the peak.

"Eventually, 80 to 90% of our people will experience infection," he said in a speech at Beijing's Tsinghua University.

Aowen Cao contributed research from Beijing.

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