On Tuesday afternoon, more than 1,000 health workers returned to Hubei province after spending 59 days in Shanghai working as medical help, while another 134 stayed behind to attend to serious Covid-19 patients. “I am very happy to be able to finally return home. Not being wanted any more means Shanghai is back to normal,” Cheng Fang, head nurse at Wuhan Jinyintan Hospital, said on local TV. They are among about 50,000 health workers from across the country – including from the military – who came to attend to Shanghai’s medical needs in its battle against the worst Covid-19 surge the country has seen. During their stay, they carried out nucleic testing, treated patients with traditional Chinese medicine, managed mild cases in temporary hospitals and treated serious Covid-19 patients as well those who had mild Covid-19 but serious comorbidities. By June 1, when the city finally came out of lockdown , more than 620,000 people had been infected and 588 died in the wave that began in early March. The fact that Shanghai – the most developed city in mainland China, and with top medical resources – still needed large-scale medical help to overcome the surge showcases how fragile China’s health system is under zero-Covid when it is hit by the highly transmissible Omicron variant. The crushed health system could not function properly. Hospitals were closed, including accident and emergency departments, after being visited by Covid-19 infected patients. Chemotherapy for cancer patients and other non-emergency medical care was postponed. Ambulances could not respond promptly to calls, with hundreds of patients queuing at the height of infections. Shanghai finds 3 community cases, raising resurgence concerns It is a scenario Beijing aims to avoid. Health officials have repeatedly cited the limited and uneven distribution of medical care in the country as among the reasons China must stick with its zero-Covid response. But experts say that despite the legitimate concern, China should have capitalised on the time the response bought in the past two years to address the capacity shortfall. Instead, Beijing is increasingly allocating more resources for early identification and isolation of Covid-19 cases. “[China stresses] that limited resources, especially in rural areas, can mean a big disaster with many deaths if zero Covid is given up,” said Jin Dongyan, a virologist with the University of Hong Kong. “I agree this is a real and reasonable concern, but you need to have an action plan to rectify things so that it will not be a disaster in the future.” China lacks the resources that could effectively deal with the uncontrolled wave of Covid-19 cases. The country has fewer doctors and nurses as a proportion of the population than some advanced countries whose Covid-19 response focuses on preventing serious illness and death rather than eliminating virus transmission. The average number of practising doctors per 1,000 people in China was 2.41 in 2020, less than the 5.8 in Britain, 4.3 in Germany and 3.8 in Australia, according to National Health Commission and World Bank figures. The number of registered nurses per 1,000 people was 3.34 in 2020, compared to 18 in Norway, 13.95 in Germany and 11.79 in the United States. Within China, resources are unevenly distributed, with the highest tier hospitals in China’s health system located in cities, while rural areas, which are home to about 36 per cent of China’s 1.4 billion population, have only lower level hospitals and township clinics available for immediate care. For every 1,000 people, rural areas have access to 1.48 practising doctors and 2.1 nurses, compared with the 3.96 doctors and 5.4 nurses in urban areas. ‘Speechless’: health worker’s death amid Shanghai lockdown sparks online furore When Covid-19 hit lower level cities, this lack of resources meant patients could not get proper care and had to be transferred. Some provinces or municipalities under the central government are much more prepared for outbreaks while some provinces are under-resourced – even in non-pandemic times. Beijing tops the country with the highest number of doctors (4.62) and nurses (5.39) per 1,000 people but Hebei province, despite being near the capital, has only 2.48 doctors and 2.7 nurses for the same number of people. Shanghai is a recent lesson in how a wave of infections could drain healthcare resources. With its large population of 25 million, there are only 3.01 doctors and 3.91 nurses per 1,000 people. Nearby, Jiangxi province has just 1.92 doctors per 1,000 people, the lowest in the country. In Suifenhe, a county-level city in the northern Heilongjiang province with no tier-three hospital in town, all Covid-19 patients were transferred to upper-level city of Mudanjiang for treatment when the disease first hit in April 2020. Similarly, Ejin Banner in northern Inner Mongolia transported all Covid-19 patients to Hohhot 1,000km (620 miles) away for treatment after an outbreak of the Delta variant in October because the city was so poorly resourced and the 400km distance to the nearest metropolitan centre made supplies difficult to get. Jin, from the University of Hong Kong, said the shortfall in capacity could be helped with a high vaccination rate, especially among the elderly, to prevent severe illness and death, but more needed to be done to reach the high vaccination goal. “This is an urgent issue, but the low vaccination rate cannot be used as an excuse [to maintain the] zero-Covid response. With China’s mobilisation power, the authorities have not done sufficiently to vaccinate the elderly yet,” Jin said. China’s move to free up hospital resources welcomed by doctors About 82 per cent of the people over 60 years in mainland China have been fully vaccinated, with only 63 per cent boosted by May 26. The elderly were not considered at higher risk of exposure when the vaccination campaign was launched because of the zero-Covid strategy but infections became more frequent with the emergence of the Delta and Omicron variants. China is relying on domestically developed inactivated shots for its mass vaccination campaigns and it is delaying the approval of a very effective mRNA vaccine distributed worldwide by Pfizer. In a paper published in the journal Nature last month, researchers with Shanghai’s Fudan University projected that the level of immunity induced by vaccination by late March would not be enough to prevent an Omicron wave that would exceed critical care capacity and cause about 1.55 million deaths. But vaccinating vulnerable individuals and ensuring access to antiviral therapies could prevent overwhelming the health system. Otherwise, it must rely on non-pharmaceutical interventions – such as masks, social distancing and avoiding mass gatherings, including in schools – to reduce transmission to fewer than two people per infection. However, more resources are now being allocated to building permanent quarantine facilities and setting up dedicated teams to carry out testing. Provincial capitals and large cities have been directed to ensure a testing site is available within a 15-minute walk for residents, according to Health Minister Ma Xiaowei. “If resources are not put into prevention, it will result in mass infection and putting pressure on the treatment end, which will threaten the health of the vulnerable, including the elderly, pregnant, children and those with underlying diseases,” Ma wrote in the Communist Party journal Qiushi last month. In China, specialist intensive care doctors account for about 0.8 per cent of the total practising doctors. The number of intensive care beds per 100,000 people varies between provinces, although all have low levels of intensive care accommodation. Beijing has 4.76 beds while Shanghai has 3.27. The populous Henan and Shandong provinces have higher than the national average, with 7.6 and 5.53 beds per 100,000, respectively. Nationally, the ratio of intensive care beds in China – at 4.53 per 100,000 people in 2021 – lags compared with 33.9 in Germany, 28.9 in Australia, 25.8 in the United States and 7.3 in Chile. Covid-19 tests limits of Shanghai hospitals as very ill, elderly infected Yanzhong Huang, senior fellow for global health at the Council on Foreign Relations in the US, said most of China’s resources were put into testing and isolation but not towards long-term investments, such as building ICU capacity or training intensive care doctors and nurses “because it’s determined by the nature of zero-Covid response, which is [a] short-term solution”. “However, zero Covid is not only a self-fulfilling process but also a self-defeating one. It could bring collateral damage to the economy and society,” he said.