This story first appeared in China Report, MIT Technology Review’s newsletter about technology developments in China. Sign up to receive it in your inbox every Tuesday.
Almost exactly a year after the World Health Organization declared mpox (formerly known as monkeypox) a public health emergency, the hot spot for the outbreak has quietly moved from the US and Europe to Asia. China in particular is experiencing a concerning increase in mpox cases right now.
This morning, I published a story on the developing mpox situation there and the government’s response so far. While Beijing did recently issue a guidance on mpox prevention, the country hasn’t taken a very proactive approach to containing the outbreak—a stark contrast from its strict covid policies (which I wrote about extensively last year).
It’s particularly worrying that the government hasn’t talked at all about using mpox vaccines, though there are three options available globally and they have proved to be effective at containing the mpox spread in countries including the United States.
Beijing’s omission may be a result of “technology nationalism,” says Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. But delaying the approval of effective foreign vaccines could stymie prevention and result in more dangerous outcomes, Huang warns—the same thing that happened with covid.
You can read more about the difficulties in containing the mpox spread in China in the story today.But in this newsletter, I want to highlight a different challenge: because of the way Beijing has so far reported mpox data and the way the WHO publishes it, it’s quite difficult to understand the exact scale of mpox in the country.
When I started reporting this story, I found that the only available mpox case count China has published is a one-time report tallying cases from June 2 to June 30. No information on weekly developments or cases from before or after June has been made public, even though other Asian countries, including Japan, started to see cases rise back in March.
But when I looked up the WHO dashboard on the global mpox outbreak, with data starting in January 2022, I was surprised to find a consistent stream of new cases being reported by China several times a week, as recently as July 20.
For some time I thought this meant Chinese health authorities or researchers had been quietly reporting more timely data to the WHO while keeping the information inaccessible to the public. After all, something similar has happened before with covid data.
Honestly, I found this data surprising and alarming. News about mpox in China has been mostly under the radar, but as the WHO overview explains: “In the most recent week of full reporting, 7 countries reported an increase in the weekly number of cases, with the highest increase reported in China.” The WHO data shows that from May to July, China reported 315 mpox cases, the most around the world in this time frame.
Sounds quite bad, right?
It turns out the reality is a tad more complicated. On the WHO website, the recent mpox data listed under China is the sum of cases reported in China, Taiwan, and Hong Kong.
The lack of data separation is significant here for a few reasons. First, while case counts have indeed risen in China, we don’t know by how much and over what time frame. China reported 106 cases in June alone, and it’s safe to assume there were additional cases in May and July. But there’s no information there to help us understand the exact urgency and severity of the outbreak, which can lead to panic and uninformed interventions. What’s more, as its handling of covid shows, the Chinese government may be holding onto data to serve its own interests.
Beyond that, this combined data reporting obscures the fact that Taiwan and China, with their different governing bodies, have responded to public health emergencies in very different ways.
While China has not signaled any interest in using mpox vaccines, Taiwan, which has its own CDC, has already administered over 72,000 shots so far. While China has only issued a one-month report of case counts, Taiwan has a public database showing how many new cases are reported each week, making it easy to see that the outbreak is on the decline there, six months after local transmission started.
So aggregating very different sources of data creates a confusing landscape and makes it hard to follow the impact of public health measures.
This means that when the WHO data shows a 550% increase in weekly new cases in China between July 10 and July 17, the jump means little. It doesn’t reveal the direction of the mpox outbreak; it only emphasizes the broken, irregular pattern of case reporting from China.
This is not to say the outbreak in China is insignificant, but that the data on the WHO website can easily mislead observers.
It’s important to realize that despite how authoritative they may sound, international organizations like the WHO don’t have a magic source of data that overcomes the limited public health information coming out of China. It can only rely on individual countries to voluntarily report such data. (The WHO didn’t immediately respond to questions about its data aggregation practices; today is a public holiday in Switzerland, where it’s headquartered.)
Unfortunately, as the status of Taiwan remains one of the most sensitive security topics to Beijing, even the act of singling out the island’s public health data can be seen as a political move. That is larger than any technical obstacle. At a crucial time like this, transparent and timely case counting is one of the most important public health tools against infectious diseases. It’s too bad that politics is getting in the way of that.
Do you think WHO should disaggregate the mpox data of China and Taiwan? What are your reasons? Tell me at zeyi@technologyreview.com.
Catch up with China
1. Chinese feminists are rushing out to support the Barbie movie. (But you can’t do a “Barbenheimer” double feature yet, since Oppenheimer isn’t arriving in China until August 30.) (Financial Times $)
2. The US government believes Chinese hackers have inserted malware into the communications, logistics, and supply networks of US military bases. (New York Times $)
3. A former party official in the city of Hangzhou, who oversaw the rise of tech giant Alibaba, was imprisoned for life for taking $25 million in bribes. (Bloomberg $)
4. Volkswagen bought a 5% stake in the Chinese electric vehicle company Xpeng, and the companies will jointly develop two EV models under the Volkswagen brand. (Wall Street Journal $)
5. TikTok’s newly launched ad library in Europe shows that Chinese major state media have run over 1,000 ads on the platform, even though TikTok’s policy forbids political ads. (Forbes)
6. Shein spent $600,000 on lobbying activities between April 1 and June 30, nearly three times its lobbying spending in the first quarter. (Business of Fashion)
7. China will restrict the export of long-range civilian drones, citing concerns that they might be converted to military use. (Associated Press)
8. A Taiwanese businessman accused of espionage and stealing state secrets was freed after two years in a Chinese jail. (BBC)
Lost in translation
A new AI photo generator app called 妙鸭相机 (Miaoya Camera), developed with support from a Alibaba-owned company, is all the rage in China right now. Users can upload 21 photos with their faces to create personalized portraits that look as if they were created by a professional. It’s priced at just 9.9 RMB ($1.38), a tiny fraction of what chain photography studios often charge. (These studios have become a popular business in recent years.)
Experts told Chinese publication Southern Metropolis Daily that the technology Miaoya Camera uses—mostly the open-source model Stable Diffusion and a technique called “low-rank adaptation of large language models” to improve the result—is nothing groundbreaking but just well packaged for the user experience. Expectedly, a controversy then arose about the broad data use permissions in the app’s user agreement; the app apologized and promised it will use personal data only to generate profile photos.
These Barbies and Kens are from Dongbei, the northeastern region of China, where food portions are gigantic and people are often stereotyped as being straightforward and tough. (Sort of like the Texas of China, you know.) But really, these are created by an AI artist, Kim Wang, through Midjourney. I talked to Wang in a story earlier this year about using Midjourney to reimagine Chinese history.
Hazmat suits, PCR tests, quarantines, and contact tracing—it was hard not to feel déjà vu last week when China’s Center for Disease Control and Prevention published new guidance on how to contain a disease outbreak.
But what was happening was not another covid wave. Rather, the Chinese government was addressing a potentially significant new public health concern: mpox. The World Health Organization reports China is currently experiencing the world’s fastest increase in cases of mpox (formerly known as monkeypox), and the country needs to act fast to contain the spread.
While the Americas and Europe have mostly contained the mpox outbreak that started in mid-2022, Asia has emerged as the disease’s new hot spot. Japan, South Korea, and Thailand, which all saw sporadic imported cases last year, have reported weekly new case numbers in the double digits in 2023, meaning the virus has been spreading in the domestic population. But according to the latest data reported to the WHO, China has surpassed all other countries in the world, with 315 confirmed cases in just the past three months—though irregular case reporting from Beijing means it’s impossible to know the true scale of the disease at this point.
Mpox is less contagious than covid, but since 2022, more than 88,000 people have contracted the disease, which can be painful and even debilitating for some. More than 150 people have died. Some countries have been more successful than others at containing domestic mpox outbreaks—and much of their success is arguably a result of proactive measures like vaccination campaigns.
But the Chinese government has barely started to take action.
“Compared with the response to covid-19 … the [Chinese] response is certainly dramatically different,” says Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. “Even though [mpox] is less likely to develop into a large outbreak in the country, the Pollyanna attitude may encourage the spread of the disease among the at-risk population—unless they take a more active campaign against the disease.”
How it’s spreading now
In May, the WHO declared that mpox was no longer a public health emergency of international concern (PHEIC) because cases had gone down significantly in countries that had seen large outbreaks last year, mostly in the Americas and Europe. (Mpox has been endemic in West and Central Africa for decades and remains so.)
“Overall, compared to where we were last year, we’re definitely in a different place,” says Krutika Kuppalli, an infectious-disease physician and chair of the Infectious Disease Society of America’s Global Health Committee. “We have much fewer cases, but we are seeing sporadic outbreaks in different parts of the world.”
Indeed, by the time the WHO rescinded the PHEIC declaration, many Asian countries were already starting to see an uptick. Japan was the first Asian country to report a significant increase in mpox cases, in March. In May, a report by researchers in the country warned that the disease could surge across Asia, owing to the connectedness between Japan and other Asian countries and the low mpox vaccination rate in the region. If the outbreak grows to the level that it did in the West, the researchers noted, over 10,000 cases might be expected in Japan alone before mpox is successfully contained.
It’s less clear what exactly is happening in China. According to data collected by the WHO, China reported 315 new mpox cases from May to July. A case count this high suggests that not all cases were travel related.
But—in another situation reminiscent of its covid response—China isn’t as forthcoming as other countries with its disease data; it doesn’t publish weekly reports of new cases. Rather, it has released a one-time report of the number of mpox cases recorded in June: 106. The Chinese government didn’t release data from May, and hasn’t released any data about July cases yet.
The WHO, though, lumps together the case counts from Taiwan, which has its own government and CDC, and Hong Kong under the name of China. And there’s no way for the public to separate the data. So the 315 number includes the 106 cases Beijing says it identified in July, plus the number of infections in Taiwan and Hong Kong over May, June, and July.
This all further obscures the true toll of mpox in China—even though it’s critical during an infectious-disease outbreak to be on top of things as soon as possible.
The Chinese name for mpox—猴痘, or houdou—has also been thrown around casually as a slur against gay men.
“We also need to understand more about the people that have been infected,” Kuppalli says, “such as … the demographics, the clinical presentation, their immune status, and about how they’ve been presenting to care. I think that type of information is important.”
A muddled response that makes LGBTQ communities a target
The lack of clarity on how the disease has spread has caused some Chinese people to panic. The news that mpox cases have started to appear in the country has been circulating for weeks. But not until July 26 did China’s CDC and health ministry co-publish a new guidance on how to prevent its spread, and even that left unanswered questions.
The directive asked that all confirmed mpox patients transfer to a medical facility for quarantine unless they have only mild symptoms. It said contact tracing going back three weeks would be conducted for every patient, and their close contacts would be asked to self-quarantine for three weeks. It also recommended that local authorities monitor the mpox virus level in wastewater around certain areas.
What makes monitoring the outbreak more difficult in China is that, as in the West, the current mpox spread has been seen mostly among communities of men who have sex with men (MSM). And similar to what happened in the US and Europe, that association is consistently misinterpreted in China to suggest that mpox is only an STD spread by gay men through sexual activities—a particularly dangerous connection, as the LGBTQ community is increasingly targeted in the country.
Many Chinese social media users who have spotted men withskin lesions in public have been posting their photos to ask whether it’s an mpox symptom. And the Chinese name for mpox—猴痘, or houdou—has also been thrown around casually as a slur against gay men.
To efficiently stop the spread of mpox, public health officials need to strike a delicate balance between destigmatizing the disease by dispelling the idea that it affects only gay men and prioritizing the MSM communities that are most vulnerable to it.
“Working with the people that are affected, helping to have non-stigmatizing language and communication, has been hugely effective in helping to curb the outbreak” in the West, Kuppalli says.
So far, some local LGBTQ communities in China feel they’re on their own.
M, who works for a queer rights organization in Guangzhou and asked to be identified only by his first initial given the sensitivity of his work, points out that the CDC recommended wastewater monitoring specifically near venues that MSM communities frequent, including bars, clubs, and saunas. He says this has become controversial within the Chinese LGBTQ community, and that some organizers feel this puts a target on their backs.
“It will take a long time. I have some friends who have already traveled to Hong Kong or Macau to get vaccinated for mpox.”
Another LGBTQ organizer, Suihou, who works in the central province of Hubei and asked to be identified by a pseudonym, tells MIT Technology Review that even though contact tracing information is supposed to be strictly confidential, he has seen one example in which an mpox patient’s private information, including phone number, national ID, address, and HIV status, was leaked and passed around on social media.
Organizers like M and Suihou are doing their own work to mobilize a disease response. To spread information about mpox prevention, M has recently sent text messages to 700 people and hosted in-person lectures that reached over 900 people.
And Suihou has worked with one mpox patient closely, helping him get testing and treatment. Not all the medical workers they’ve encountered have been trained on how to handle the sensitivity of these cases, he says; during the contact tracing process, the doctor told the patient that this disease is a problem for “your kind of people.”
Suihou warns that some people may avoid seeking medical help altogether, particularly given the lack of state support for mandatory quarantine and contact tracing.
“From the individual cases that I have heard of, everyone who has a confirmed case is being asked to go to a quarantine facility,” Suihou says. But, he explains, since the government has not provided a budget to help cover the quarantine, as it did with covid, patients have no choice but to pay for the hospital stay and all medical tests out of their own pockets. Many marginalized individuals, who are also more vulnerable in an infectious-disease outbreak, may not be able to afford that.
“With the slowdown of the [Chinese] economy, local governments don’t have the physical capacity or even the willingness to invest more in public health,” Huang explains. Even the WHO doesn’t have funding specifically earmarked for mpox prevention; it has been using its emergency fund to cover mpox-related work.
A lot of the financial burden will again fall on local organizers. M tells me that his organization is using funds intended for HIV prevention to conduct mpox outreach work.
All of this could further disincentivize people who get infected from seeking medical tests and treatment. This in turn would make the community spread of mpox even harder to track—and could undermine prevention efforts taken so far.
A lack of available vaccines
Much as with covid, vaccination is one of the best ways to get mpox under control. Worldwide, three vaccines are currently being used for mpox prevention: ACAM2000, MVA-BN (also known as JYNNEOS in the US), and Lc16m8. All these vaccines were originally designed for protection against smallpox but have been found effective against mpox.
The US has administered more than 1.2 million JYNNEOS and ACAM2000 shots. And in Asia, South Korea imported 10,000 JYNNEOS shots last year and is planning to procure another 20,000 this year, while Taiwan, despite its small size, has procured and administered over 72,000 JYNNEOS shots so far. Japan, meanwhile, has relied on a Japanese company to produce its own Lc16m8, while also donating doses of the vaccine to countries including Colombia.
But none of these vaccines have been approved for use in China. The situation recalls how China refused to import any mRNA covid vaccines, instead relying on a few homegrown vaccines that were shown to be less effective. In this case, though, the country doesn’t currently produce any of its own smallpox vaccines; production was terminated after smallpox was eradicated globally in 1980.
Bavarian Nordic, the Danish company that produces the JYNNEOS vaccine, tells MIT Technology Review that it can’t disclose client information unless requested by the government and can’t confirm whether China has procured any JYNNEOS shots. But it says the company is not in the process of applying to register the vaccine in China.
The WHO also has a sharing mechanism in place that allows member states to receive vaccines if needed. But it’s unclear whether China has applied for mpox vaccines. The organization did not immediately respond to an inquiry about whether there are plans to send vaccines to China.
The new Chinese CDC guidance on mpox made no mention of any vaccine as part of its outbreak response. “It’s quite unlikely that China will focus on procuring vaccines at this moment, since there’s no precedent and [no] emergency approval of the vaccines. Rather, there seems to be a focus on surveillance, monitoring, quarantine, contact tracing, etc.,” says Zoe Leung, a senior associate at Bridge Consulting, a Beijing-based communication consultancy specializing in public health.
It may not be this way forever: Sinopharm, a Chinese state-owned pharmaceutical company, announced last November that it had developed the world’s first mRNA vaccine against mpox, and it has been found effective in preclinical studies. On July 13, Sinopharm officially applied for clinical trial approval for a “replication-defective mpox vaccine,” though it’s unclear whether these are the same products. Sinopharm did not immediately reply to questions about its mpox vaccine development.
“There is domestic research [on a mpox vaccine], but we don’t know when it can be commercially available. It will take a long time,” says M, the organizer in Guangzhou. “I have some friends who have already traveled to Hong Kong or Macau to get vaccinated for mpox.”
But for Chinese people to get vaccinations outside mainland China, there is often a high cost, a long wait time, and layers of bureaucracy to wade through. It’s again similar to trends seen earlier in the pandemic, when Chinese people with means traveled to Hong Kong to get mRNA covid vaccines.
“It doesn’t necessarily mean [Beijing is] not interested in vaccines,” says Huang, “but there’s this technology nationalism that discouraged them from rapid approval of the use of foreign vaccines.” And that, he warns, “certainly contributed to the rapid increase in covid-related mortalities.”
Hirabai Koli’s medical reports were normal—but she wasn’t happy.
She had been monitoring her weight over the first two months of her pregnancy, and she surprised community health-care worker Suraiyya Terdale when she asked why she wasn’t gaining more. (To protect her safety and private health information, Koli is being identified by a pseudonym.)
“It was an odd question—something I heard for the first time,” says Terdale. She then remembers Koli saying, “Someone told me that if the pregnant mother’s weight isn’t increasing fast, then it’s a girl child.”
Over 13 years of helping hundreds of women with childbirth in the Ganeshwadi village of Maharashtra, India’s second-most populous state, Terdale had heard a lot of medical misinformation, but never this particular myth. Terdale is an accredited social health activist, or ASHA—part of an all-women cadre of 1 million community health-care workers. Across India’s villages, one ASHA is appointed for every 1,000 people; they are responsible for over 70 health-care tasks and make public health care accessible to people from remote areas and marginalized communities.
Countering false information has become an increasingly important, if unofficial, part of the job for each ASHA. Medical misinformation is rampant in the country, especially in remote villages like Ganeshwadi, which has a population of just a few thousand.
Experience told Terdale that countering Koli’s beliefs without context could backfire. “If you tell someone they are wrong, then people don’t listen,” she says.
Indeed, when Terdale told Koli that her understanding was unscientific, Koli wasn’t convinced. Instead, Koli asked if she knew of any doctor who could confirm if it was a male fetus, even though the Indian government banned prenatal sex-determination tests in 1994 in response to the high rate of abortions of female fetuses.
So Terdale began doing the tricky work of probing why Koli believed this. After several rounds of trust-building conversations, Terdale learned that Koli was a victim of domestic violence and sexual abuse because her first child had been female. “My in-laws taunt me every day for giving birth to a girl,” Koli told her. “It has been so traumatic that I won’t be able to survive if it’s another girl child.”
After, Koli’s requests to get a prenatal sex determination became more frequent, and Terdale decided to turn to the most accessible and discreet way to help her: WhatsApp. She sent Koli “scientific videos of what decides the biological sex of a child,” but “none of it made sense to her,” says Terdale. “The videos were in English, but I am sure the animation helped to a certain extent.” After further digital and in-person interventions, Terdale was finally able to convince Koli she wasn’t responsible for the sex of the child.
Terdale is one of many ASHAs across the country who are turning to WhatsApp as a means to combat medical misinformation and navigate sensitive medical situations, particularly regarding pregnancy. Even though ASHAs weren’t trained to do this, are paid very little, and are at the mercy of India’s poor health-care infrastructure, the approach has had surprisingly good results. In 2006, India’s maternal mortality rate was 254 deaths per 100,000 live births, one of the highest in the world. By 2020, ASHAs had helped slash the maternal mortality rate by over 60%, to 96 per 100,000 live births. This is particularly significant, because for a rural population of 833 million, India only has 763 functioning district hospitals, with just under 27,000 doctors.
But the work of ASHAs can be arduous and sometimes dangerous. Even after she changed Koli’s mind, Terdale still had to convince her husband.
“Even I was scared. He abused whoever questioned him,” Terdale recalls. His repeated pressure to get a prenatal sex-determination test was causing Koli tremendous stress; Terdale worried about what he would do next. “To birth a male child, people reach out to babas [faith healers] and quacks,” she says.
So she used the same approach, attempting to connect directly with Koli’s husband and debunk sex-related misinformation via WhatsApp messages. He didn’t respond. Finally, a few days later, she mustered the courage to confront him in person. “He verbally abused me and even declared that no matter what happened, he wouldn’t bear any medical expenses if it were a girl,” she says.
Suraiyya Terdale, an ASHA since 2009, has saved the lives of hundreds of women by busting pregnancy-related misinformation through WhatsApp and her fieldwork.
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Over the next month, Terdale persisted—sending the husband videos about the impact of mental health on the overall well-being of an expectant mother and fetus. She also messaged him relevant news reports. After a few weeks, she increased the frequency of her messages.
He eventually changed his mind, and stopped bothering Koli with the demand for a male child. However, the damage was already done; she reported symptoms of depression.
Terdale continued to use WhatsApp to counsel Koli every few days: “When I wasn’t allowed to enter their house, WhatsApp helped me save her.”
When it comes to pregnancy, most people in India rely on the experiences of their friends or relatives for information, though “this experience-sharing becomes another potent way of sharing misinformation, especially when it’s not backed by science,” says Hemraj Patil, who has over a decade of experience in public health and previously worked with India’s National Health Mission.
When younger women are coerced by family into following superstitions—about what foods they can and can’t eat, or that they can’t buy new clothes, leave the house, or wear bangles in the first two trimesters—ASHAs counsel the pregnant women and ensure they receive proper science-backed health care. If conservative parents stop ASHAs from entering their houses, the ASHAs can use WhatsApp to remotely support pregnant women and then ask senior doctors or other community members to visit their homes. Notably, ASHAs are also using WhatsApp to create safer spaces for women through targeted group channels, where women share their personal experiences and speak candidly in ways they can’t anywhere else.
ASHA Maya Patil notes the health conditions of a community woman and her newborn.
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“Ever since ASHAs started using WhatsApp to bust misinformation, I’ve seen a positive change,” notes Patil. Last year, the World Health Organization honored ASHAs with the Global Health Leader award for their work on covid and in slashing India’s maternal mortality rate.
Koli is just one success story. After months of patiently counseling her, Terdale took her to the hospital to give birth in early 2022. “It was a male child,” says Terdale. “The case was no doubt challenging and risky, but I am proud I could change someone’s mind and make people think.”
Crucially, the effects of changing one mind are not restricted to a single family. “Whenever you enter someone’s house in a village, you are not just talking to that particular member, but also the neighbors, sometimes the entire community,” Terdale says with a laugh that implies the concepts of privacy and personal space remain a significant challenge in India’s villages.
Today, Terdale proudly says she is in touch via WhatsApp with over 60% of the women in the villages she oversees.
“We are health-care workers and hope for so many people. How can we fear and let them down?” Terdale asks. In many Indian languages, ASHA means hope.
“I started noting down the WhatsApp number of everyone in the community”
When she became an ASHA in 2009, Netradipa Patil, from Maharashtra’s Shirol region in western India, was immediately forced to grapple with pregnancy-related misinformation and superstitions.
During her field visits back then, Patil saw a few young women using WhatsApp. “I started noting down the WhatsApp number of everyone in the community,” she says. “Every day, many people would send ‘good morning’ wishes to me.” By sometime in 2014, she started to think: if they were already connecting on the messaging app, why not tackle misinformation there, too?
Such work would go above and beyond Patil’s job requirements. In 2005, the Indian government launched the National Rural Health Mission to improve maternal and infant health. Under this program, ASHA workers were appointed in 18 states; by 2009, the program had expanded to all 28 states. ASHAs, though, are technically volunteers and are not paid a fixed salary but rather receive “performance-based incentives” for completing tasks. In Maharashtra, for instance, they are paid just 1,500 Indian rupees ($18.50) for maintaining detailed records of every community member and 250 rupees ($3.70) for nine months of prenatal care for one patient and for facilitating hospital delivery. Payment is often delayed.
“We aren’t paid well,” Patil notes, “but that has never stopped us from saving lives.”
Despite the increased workload and the inadequate (or sometimes nonexistent) compensation for internet charges, Patil decided to try using WhatsApp in her work. “Before directly busting any misinformation, I started posting general bits of advice from doctors regarding pregnancy,” she says. To her surprise, many younger women replied to her personal messages and even thanked her.
Along with WhatsApp, ASHA workers also rely on books and articles to reach the most vulnerable and marginalized people in the community. Here, Maya Patil talks to a group of migrant sugarcane cutters.
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She then experimented by tackling the superstition that if a woman reveals her pregnancy to any health-care worker in the first trimester, she will face complications and be at risk of miscarriage. A few women challenged this—though many supported her.
Patil began spending several hours a day responding to all the doubts and apprehensions of community women. “It did take a lot of my time, but after two weeks, I saw a woman agreeing,” she says.
Patil, who is also a union leader of over 3,000 ASHAs, invited a few hundred workers from nearby villages to discuss how to use the technology. “I shared my experience of using WhatsApp and asked ASHAs to start experimenting in their communities,” she says. Many reported positive results, and their work picked up momentum in 2017 when WhatsApp introduced a feature to share photos and videos as a status.
The first time Patil posted a WhatsApp status—a motivational quote—she thought it was just another distraction in her long workday. An hour later, over 100 people had seen it. Just before the 24-hour mark, at which point the status gets archived, over 500 people had viewed it.
For a few days, she shared inspiring messages in Marathi and Hindi and remembers many people replying to say they found them helpful. That encouraged Patil to scale up her work from one-on-one texts, and it also gave her a feeling of recognition from her community.
She experimented more from there. One day, she shared an infographic of basic health-care precautions for pregnant women. “It got a tremendous response,” she says. “Many pregnant women wrote to me saying the health-care chart was beneficial, and they had even taken a screenshot.”
It has since become something of a best practice for ASHAs to share visually rich articles and posters via WhatsApp. “These drawings or photos stay in people’s minds,” says Patil. “Instead of sending a long message, we condense the information in a single flowchart or use infographics, and it does help.”
Netradipa Patil often takes photos of the informational posters in Shirol’s rural hospital to share with a WhatsApp group or as a status.
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Maya Patil explains information about malnourishment.
ASHAs often distribute iron and folic acid supplements and calcium tablets to women.
Another way ASHAs make their responses particularly effective and persuasive has been by sharing case studies of real patients who have followed their advice. “Give an example of someone who is either their friend or someone they trust,” says Terdale, the ASHA who worked with Koli. As a result, she says, the number of cases of people “blindly following superstitions and misinformation came down … Moreover, several people who benefited from our advice support us. So, there’s no fear of any backlash because we have a much stronger support system.”
Over the past five years, Patil has trained hundreds of ASHAs from different states to use WhatsApp to debunk false information.
Maya Patil, an ASHA from Maharashtra’s Kutwad village, says she’s noticed similar positive results after using WhatsApp. She’s been working in the field for 13 years, and in 2018 she met a woman in her ninth month of pregnancy with falling hemoglobin levels who had recently been diagnosed with anemia. She tried to connect the woman to the relevant public doctor, but the family wanted her to use natural methods to increase her hemoglobin levels.
Patil asked the pregnant woman to start drinking pomegranate juice, which has been proven to increase hemoglobin levels, but her mother said pomegranate juice causes kidney stones. Patil tried for several hours to explain the science, but the family wasn’t convinced, nor were they interested in anemia medications.
As a habit, Patil had been taking photos of hundreds of regional newspaper articles addressing common health misinformation that were written by doctors. In one, she found details about the benefits of pomegranate seeds and juice. She sent the pregnant woman the article in a WhatsApp message. Then she found more relevant YouTube videos recorded in Marathi, the woman’s language. After 10 such messages, she finally had an impact; the family allowed the woman to follow her advice, and within 12 days, her hemoglobin levels had increased.
They worked together for three weeks, and when the woman gave birth, it was a normal delivery with a healthy newborn weighing six-and-a-half pounds.
Creating a safer space for women
Though they had successfully addressed a great deal of misinformation over several years, many ASHAs were still seeing pregnant women who were too scared to talk about their pregnancies for fear of their in-laws and husbands. Even in big, ASHA-led group messages, many men in the community responded with “ill-informed comments,” says Netradipa Patil, the ASHA union leader.
Maya Patil similarly laments the persistence of dangerous medical information passed down by family. “The primary goal of any fake news related to pregnancy is to make women suffer,” she says. “Many older women say that they had suffered these rituals during their pregnancy, so why should the next generation not face this?”
Along with ensuring safer childbirth, ASHA workers are also responsible for providing proper postnatal health care to community women. Here, Maya Patil explains how to take care of a newborn.
SANKET JAIN
So, in 2018 and 2019, ASHAs started to form hyperlocal all-women WhatsApp groups. With a smaller group of just 15 to 20 pregnant women and their close femalerelatives, Netradipa Patil would focus on helping them understand the scientific aspects of care. “It was difficult, but easier than dealing with hundreds of people in one go.” After six months of test runs, women in the groups even reported talking about misinformation in their households.
Patil and several other ASHAs have created multiple groups; some are limited to a household and some include entire villages, others are meant only for pregnant women or only for ASHA workers and their supervisors.
The topics of conversation in these groups now go beyond health care; women share their dreams for the future, or ask ASHAs about how they can become financially independent or start small businesses. Many women also discuss workplace exploitation and ask ASHAs how to deal with it, or they ask about how to benefit from government welfare programs. These groups are particularly beneficial “when freedom is so restricted in many rural houses,” says Terdale.
ASHAs say one of their most important tasks is ensuring women aren’t abused for confronting traditional beliefs. Particularly in cases of family conflicts, many ASHAs use very careful and specific language to communicate with women. “Sometimes during fieldwork, we use a code language [with patients], which often means that there’s some family or medical issue which needs to be discussed personally,” Patil says. “We have been working for over a decade and have built a bond with everyone. None of this could have been possible if the community members [didn’t] trust us.”
Patil recalls one particularly dangerous case. Saniya Makandar, a woman with a high-risk pregnancy, was in an interfaith marriage that wasn’t accepted by their families, and many ASHAs wouldn’t work with her because they “feared attacks from religious fanatics,” Patil says. (To protect her safety, Makandar is being identified by a pseudonym.)
Patil had to build trust with Makandar and ensure her safety during treatment, even as frequent family clashes and religious fights weighed on her. Soon, Makandar opened up about her precarious condition. She didn’t know if she’d received certain vaccines, and she reported swelling in her legs, high blood pressure, extreme weakness, and even suicidal thinking. Patil found that her hemoglobin level had dropped to seven during a time in which it should have been 12 to 16 grams per deciliter.
Terdale plays with Hirabai Koli’s son during a visit with Koli.
SANKET JAIN
Low hemoglobin during pregnancy remains a problem across India, but in Makandar’s case, misinformation made it more difficult to address. Patil discovered that she was eating only wheat flatbreads, due to a local superstition that the diet was healthy. While Patil prepared a proper diet chart for her, visiting her house daily wasn’t feasible because of the backlash Patil might face from her own Hindu community. So she decided, again, to turn to WhatsApp. “Every day, I started sending photos, videos, and articles on what food to eat.”
But just addressing the health myths wasn’t enough. So every day, Patil followed up with simple messages via WhatsApp, like, Are you feeling better today? Or, Is there something you want to share?
Such questions from ASHAs have had a tremendous impact on many women like Makandar, who had never opened up about their pregnancies, or their families and futures, before they began sharing their problems with the ASHAs and women in their WhatsApp groups.
After two months of intense work with Patil, Makandar’s health improved, and she gave birth to a healthy baby via cesarean section at the public district hospital.
“A message can save someone’s life,” says Terdale, “and we see it happening almost every day.”
Sanket Jain is an independent journalist and a documentary photographer based in India’s Maharashtra state. His work has appeared in more than 30 publications. He tweets at @snktjain.
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On December 1, 2019, the first known covid-19 patient started showing symptoms in Wuhan. Three years later, China is the last country in the world holding on to strict pandemic control restrictions. However, after days of intense protests that shocked the world, it looks as if things could finally change.
It’s a confusing time. Instead of a single top-down decision from Beijing to roll back zero-covid policies, there have been many independent decisions announced by local governments in the last week, mostly about canceling mandatory PCR tests and reopening businesses. Yet they sometimes contradict each other, and plenty of Chinese cities are keeping their tight controls.
Lots of people are celebrating the fact that China has finally started pursuing a covid response emphasizing vaccines and treatments instead of quarantines and lockdowns, as the latter strategies hit the Chinese economy hard. But doubts are starting to grow because of a lack of clear messaging from the top.
So in this newsletter I’ll try my best to summarize and explain the different policies.
The speculation started with a vaguely worded top-level speech. On November 30, Sun Chunlan, China’s vice premier, dubbed the “zero-covid czar,” said at a meeting in Beijing that China’s pandemic control is “facing new situations and new tasks” as the omicron variant takes center stage. She didn’t mention “dynamic zero,” China’s overarching policy to eliminate local outbreaks at any cost—thus signaling a change in the works.
In response, at least three provinces and 13 other cities, covering China’s most economically developed regions, have announced changes to their local covid control rules as of Monday, December 5.
Despite the confusingly different language, these changes mostly target one thing: mass PCR testing.
Ever since May 2020, when Wuhan managed to test its whole population of over 10 million in the span of 10 days, China has been conducting mass PCR testing campaigns. The frequency of these campaigns increased this year as omicron spread, and many cities instated mandatory tests for all citizens every two or three days. Without a recent negative test result, people are barred from activities like using public transport or even entering stores, which became a significant burden to their daily lives.
That is finally changing. Many local governments are now replacing mandatory PCR tests with a new regime called “愿检尽检,” or “Those who want to get tested can all get tested.” The requirement for a negative PCR test result is being lifted across China. Cities like Tianjin have removed it for public transport, while it’s been lifted in Shanghai for entering most public venues, and Beijing even waived it for buying drugs in pharmacies.
This has been welcomed by people like Eric, a Guangzhou resident who resisted mass PCR campaigns and suffered from the inconvenience it caused. His health QR code had been yellow for a long time, thus barring him from taking public transport, but it suddenly turned green last week as Guangzhou changed its covid rules.
In fact, his neighborhood committee, which carries out China’s covid policies at the grassroots level, sent him a refreshingly unusual note encouraging people to “take fewer PCR tests and more at-home antigen tests.” The reasoning was that a positive PCR result means the whole building will be locked down, while results from a self-conducted antigen test are not reported to the government.
These recent policy changes don’t affect aspects of China’s pandemic response like the expansive health QR code system and the gigantic central quarantine facilities. But people see them as a direct result of the protests and are welcoming even baby steps toward loosening the rules.
Still, a lot of chaos and unresolved problems remain.
First of all, different areas are doing different things. Beyond the cities that are dropping PCR testing requirements, the majority of China is either maintaining old restrictions or stuck in a confusing limbo. Hefei, a city of over 7 million people in eastern China, said on Sunday that it “can only increase and not decrease the number of PCR testing locations.” Jinzhou, a smaller city, doubled down on lockdowns on Thursday before immediately changing its stance and opening up public venues on Friday. Even among the cities that have relaxed their testing requirements, the rules differ. Some still require tests for entering indoor venues or getting medical services.
As a result of these discrepancies, people still need to take PCR tests if they are traveling between cities with different rules, even though they are told it’s technically not required anymore. Meanwhile, some cities have already started to shut down free PCR testing locations, so now there are longer wait lines and potentially higher costs to take the same tests.
To be honest, with no clear message from the central government, it seems to me that cities are just trying to guess what Beijing will decide later. And as usual, it’s ordinary people who have to accommodate the discrepancies and deal with the uncertainty.
While the protests have wound down, this is only the beginning of the pivot to looser covid restrictions, if China sticks to this path. Abandoning zero covid will not be easy, as the number of cases and deaths will rise, and China’s already weak health-care system will be severely squeezed. By November, only about 40% of Chinese people over 80 had received a booster shot, which studies show can significantly increase the defense against covid. Researchers also estimated that it could lead to 1 to 2 million deaths if China loosened its pandemic measures without also ramping up access to vaccination and treatments.
“At this moment, Xi’s China has become a time machine taking us backwards in time … to the dark days of 2020—first to the drama of Wuhan and then on from there to the horror of Bergamo and New York’s chaotic emergency rooms. Our problems then are China’s problems now, how to weigh up mass casualties against huge economic loss,” writes Adam Tooze, a history professor at Columbia University.
Whatever happens, there needs to be a lot more consistent government messaging and policymaking, and Chinese people will be desperately hoping to see that soon. Reuters reports that China may announce 10 more covid easing measures as early as Wednesday. I’ll update you in the next newsletter.
What do you think will be the biggest obstacle to getting rid of zero-covid policies? Let me know by emailing me at zeyi@technologyreview.com.
Catch up with China
1. Last week I talked to “Teacher Li,” a Chinese painter who had a meteoric rise on Twitter as he became the hub of protest information and footage. (MIT Technology Review)
Xi Jinping addressed the protests for the first time, according to European Union officials who met with him on Thursday. He reportedly blamed them on “frustrated students.” (South China Morning Post $)
2. Former Chinese president Jiang Zemin, who oversaw a decade when China’s economy opened up to the world, died on Wednesday at the age of 96. (BBC)
The government ordered a week of public mourning, during which livestreamers are explicitly instructed to wear formal attires, tone down the entertainment content, and not appear against brightly colored backdrops. (China Digital Times)
3. An Associated Press journalist was beaten and detained by Shanghai police during a protest, and his phone was confiscated. (AP)
4. After a violent protest at a Chinese Foxconn factory that makes iPhones, Apple is reportedly considering moving more manufacturing capacity out of the country and into India or Vietnam. (Wall Street Journal $)
5. The indictment against Meng Wanzhou, Huawei’s CFO and daughter of the company’s founder, has been officially dropped in the US, marking the end of a high-profile diplomatic saga. (Reuters $)
6. A teacher of Mongolian ethnicity protested against China’s cutback on primary school lessons in his mother tongue. Then the government tracked him down, even after he fled to Thailand. (The Economists $)
7. The Chinese surveillance camera company Hikvision is still advertising its ethnicity recognition features to European buyers. (The Guardian)
8. Three Chinese astronauts returned to Earth, while another three were sent up to finish building the country’s space station. (BBC)
Lost in translation
One community that suffered especially heavily from the three-month covid lockdown in China’s northwestern region Xinjiang is livestock farmers, reports Chinese magazine Sanlian Lifeweek. Farmers in Xinjiang have a tradition of seasonal migration, usually taking all their cattle to a different pasture to graze during the winter. But because the farmers were locked down at home, they missed the migration window, and many had to migrate amid snow storms. As a result, many cattle went missing or froze to death. Some counties are even requiring farmers to test negative for covid seven times consecutively in a week before they are allowed to transfer their stock in December.
Farmers who choose not to migrate have to buy a lot of animal feed, which has become significantly more expensive since lockdowns disrupted China’s economy. Having to deal with issues like getting a delivery truck certificate during lockdown and finding workers who are able to leave their homes has made animal feed 60% more expensive than last year.
One more thing
Ever wondered what Jack Ma, the Alibaba founder who paid a hefty price for criticizing China’s fintech regulators, is doing now? Turns out he’s been living in Tokyo the past six months, spending his time painting watercolors and collecting modern art. Before that, he was golfing in Spain and learning about agriculture in the Netherlands. What a nice retirement.
