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Over a Third of China’s Babies Are Delivered via C-Section – The National Health Commission Wants to Change That

Fear of pain is a major reason for nonmedical cesarian deliveries on maternal request.

Manya Koetse

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Image by Sohu News

China’s National Health Commission wants to lower the nation’s high C-section rates. On Chinese social media, many women argue it should be up to the mother to decide how she wants to give birth.

In 2018 the percentage of deliveries by cesarean was 36.7% in mainland China, according to the latest Report on Women’s & Children’s Health (中国妇幼健康事业发展报告) that was launched by the National Health Commission on May 27.

This means that together with Hong Kong, Taiwan, Brazil, Egypt, and Turkey, the People’s Republic of China (PRC) now has the highest C-section rates in the world.

A World Health Organization report from 2010 estimated that 46% of Chinese babies were delivered via C-section. In 2017, another study found that this percentage was incorrect, although some urban and wealthier regions in China, such as Shanghai, did see C-section (CS) rates as a high as 68% (Black & Bhattacharya 2018, 1; McNeil 2017).

China’s CS rates have recently become a hot topic in Chinese newspapers and on social media. On May 27, the National Health Commission of the People’s Republic of China held a Beijing news conference in which Qin Geng (秦耕), the director, announced that more actions will be taken to encourage natural childbirth among Chinese women.

Qin Geng during the press conference on May 27.

These actions will, among others, include stricter regulation of cesarian section operations and the provision of more support and pain relief for laboring women, as well as a higher hospital income for natural births. The National Health Comission hopes to significantly reduce the number of unneccesssary C-sections without medical indication in this way (Beijing News 2019; Caijing 2019).

Since 1985, the international healthcare community has considered 10-15% to be “the ideal rate” for C-sections, of which the highest percentage are those CS deliveries with medical indications that can actually save the lives of mothers and babies.

Although the worldwide rates for CS deliveries have increased throughout the years, there is no evidence for the benefits of nonmedically indicated C-sections for women or children, according to the World Health Organization.

This is not the first time Chinese authorities try to combat the country’s high CS rates. After reports by the World Health Organization from 2010 and 2015 pointing out the potential hazards of unnecessary C-sections, there have been various state efforts to reduce the number of nonmedical cesarian surgeries.

Besides the introduction of free prenatal education classes, these efforts included monitoring public hospital CS rates and removing bonuses or cutting portions of a hospital’s income once their CS rates reached a certain threshold (e.g. 40%) (Wang 2017, 3). These government initiatives seem to have had effect: the country’s C-section growth rates have slowed down, but were not decreasing yet.

Since the Chinese government announced an end to its one-child policy in 2015, lowering cesarean sections rates has become a more urgent matter, as Chinese couples are now allowed to have a second child.

Although various studies from mainland China and beyond challenge the idea that nonmedical C-sections are less ‘safe’ than vaginal births for single deliveries, this risk changes when a woman who previously had a CS section plans another pregnancy: multiple cesarean sections are associated with additional risks including CS scar rupture and abnormal placental invasion (Biler et al 2017, 1074; Black & Bhattacharya 2018, 2; Liu et al 2015, 817).

 

Why So Many C-sections in China?

 

But why does China have such a high cesarian delivery rate at all? Since the early 1990s, mainland China saw a more dramatic rise in CS rates than, for example, the USA; from less than 10% (with only 3.4% in 1988), China went to one of the highest in the world (Hellerstein 2011; Wolf 2018, 13).

The answer to why this is, is not so straightforward and relates to socio-economic changes as well as cultural factors that come into play.

One reason is that there is a general belief in the ‘safety’ of cesarian births that influence women’s choices for a (nonmedical and planned) C-section (Black & Bhattacharya 2017, 2).

An insightful study into this matter is that of researcher Eileen Wang (2017), who found that anxiety about giving birth and fear of pain is also a major reason for nonmedical cesarian deliveries on maternal request, especially considering that only a minority of Chinese women are given any form of pain relief during labor. Besides traditional concepts, this is also because China faces a shortage of anesthetists and because obstetricians are not always well-informed to prescribe other forms of pain medication (2017, 5).

As noted by Wang, epidurals are denied to laboring women not just because anesthesiologists are too busy, but also because of various other factors: different from a scheduled C-section on their agenda, they are not always available during nighttimes and in weekends to administer anesthesia to women in labor, do not have the time to monitor a patient for hours during labor (whereas a cesarean could be done in an hour), or were not even trained to administer epidurals (2017, 5).

“Giving labor without pain: removing mom’s fear for giving birth” – image by Chinese website http://www.8bb.com/huaiyun/1381.html.

According to Wang, the concerns about labor pain result in more requests for C-sections, both before and during labor. With relatively low awareness and availability of labor pain relief methods many Chinese women simply opt for a C-section as a way to control their pain.

But there are also other factors that contribute to the relatively high rate of women requesting C-sections for nonmedical reasons. One of them is the importance placed in the astrological calendar: having a baby on that one ‘lucky day’ or within that ‘lucky year’ is considered enough reason to plan a cesarian birth for many Chinese families.

In early 2015, ahead of the Chinese New Year, many women rushed to the hospital to make sure their baby was born in the Year of the Horse (2014) as the Year of the Goat (2015) was coming up. There is an old Chinese saying that nine out of ten people born in the Year of the Goat are incomplete and will suffer from great misfortune throughout their life (“十羊九不全”).

Another factor that leads to more cesareans on maternal request relates to the existing concerns among women that vaginal delivery will affect their figure or sex life (Wang 2017, 2).

 

Responses on Chinese Social Media

 

Since the Beijing news conference of May 27, the hashtag “Reducing Unnecessary Cesarean Section Surgery” (#减少非必需剖宫产手术#) has taken off on Chinese social media.

On Weibo, the hashtag page received 340 million views at time of writing. One thread about this topic even received over 28400 comments.

“What do you call ‘unnecessary cesarian’?” one of the most popular comments said: “Isn’t it that so many women in labor choose to have a C-section because natural childbirth is too painful?”

Other commenters also called for a normalization of pain relief in labor, saying that the high percentage of C-sections lies in the fact that Chinese women lack access to “wútòng fēnmiǎn” (无痛分娩) or “painless birth,” meaning vaginal delivery with pain relief.

Some Weibo users also stress that women should have the freedom of choice on how they wish to give birth, saying: “C-section or natural should be my own choice” and “If you leave me no choice I might as well not give birth at all.”

Multiple commenters write: “The lower the C-section rate, the higher the suicides,” referring to an incident that occurred in Shaanxi in 2017 when a pregnant woman committed suicide by jumping from the fifth floor of the hospital after she was allegedly denied a CS delivery.

Other Chinese netizens also complain about the fact that it seems to be men who are promoting the new policies to combat the high C-section rates, writing: “Isn’t there a way to have them suffer the pain of labor instead?”

In her study, scholar Eileen Wang also argues that the lack of pain relief is one of the major issues that should be addressed by policymakers who are hoping to reduce the number of C-sections in China. Further improving the childbirth experience by, for example, integrating a midwifery model, is also essential in making natural childbirth more attractive for Chinese women, Wang argues.

For now, many hospitals in China are still offering C-section “packages”: some prices start at RMB 5800 ($840) for a C-section, other hospitals have packages that start from RMB 88,000 ($12,741) including a three-day hospital stay in a private room.

“It’s a pregnant’s woman body, so she should decide how she wants to deliver her baby,” one commenter on Weibo writes: “It should be a woman’s right to decide.”

By Manya Koetse

References

Biler, A., Ekin, A., Ozcan, A., Inan, A. H., Vural, T., & Toz, E. 2017. “Is It Safe to Have Multiple Repeat Cesarean Sections? A High Volume Tertiary Care Center Experience.” Pakistan Journal of Medical Sciences 33(5): 1074–1079.

Black, Mairead & Sohinee Bhattacharya. 2018. “Cesarean Section in China, Taiwan, and Hong Kong— A Safe Choice for Women and Clinicians?” PLOS Medicine 15(10): 1-3.

Caijing. 2019. “卫健委:全国剖宫产率为36.7% 积极推广分娩镇痛.” Caijing , May 27 http://economy.caijing.com.cn/20190527/4591594.shtml [5.31.19].

Hellerstein, Susan Celia. 2011. “Cesarean Delivery in China Analysis of Cesarean Deliveries Without Indication.” The American College of Obstetricians and Gynecologists: 20s.

McNeil, Donald. 2017. “Study Finds Lower, but Still High, Rate of C-Sections in China.” New York Times, Jan 9 https://www.nytimes.com/2017/01/09/health/c-section-births-china.html [6.2.19].

Wang, Eileen. 2017. “Requests for Cesarean Deliveries: The Politics of Labor Pain and Pain Relief in Shanghai, China.” Social Science and Medicine (173): 1–8.

WHO. 2015. “WHO statement on caesarean section rates.” World Health Organization, April https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/ [6.2.19].

Wolf, Jacqueline H. 2018. Cesarean Section – An American History of Risk, Technology, and Consequence. Baltimore, Maryland: Johns Hopkins University Press.

Featured image by Sohu News.

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©2019 Whatsonweibo. All rights reserved. Do not reproduce our content without permission – you can contact us at info@whatsonweibo.com

Manya Koetse is the founder and editor-in-chief of whatsonweibo.com. She is a writer, public speaker, and researcher (Sinologist, MPhil) on social trends, digital developments, and new media in an ever-changing China, with a focus on Chinese society, pop culture, and gender issues. She shares her love for hotpot on hotpotambassador.com. Contact at manya@whatsonweibo.com, or follow on Twitter.

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Explainer: Ten Key Terms and Concepts of the 20th CPC National Congress

Take a look at the essential keywords and concepts surrounding the 20th Party Congress.

Manya Koetse

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What are the key terms and concepts mentioned in Xi Jinping’s speech that are propagated all over Chinese social media this week? Here, we explain ten important concepts and keywords that you are probably going to see much more of in the coming five years.

It is the week of the 20th CPC National Congress, China’s quinquennial major political event that is all about discussing and deciding on important Party issues, appointing Party leadership and officially announcing new governance concepts, thoughts and strategies proposed by the CPC Central Committee.

The Party Congress opened on Sunday, October 16, when Chinese leader Xi Jinping delivered his nearly two-hour-long speech reflecting on the recent past and the future of the Communist Party and the country at large, signalling the direction China will be heading.

In our earlier article covering Xi Jinping’s speech, we focused on how Chinese official channels turned parts of the work report into hashtags that were promoted on social media and then became trending topics.

Here, we will go over some of the terms and words that were used in the political report delivered by Xi and were propagated on Chinese social media as ‘key terms’ through general hashtags such as “Understanding These Key Terms from the 20th Party Congress Report,” “Studying the Essence of the 20th Party Congress” or “The New Era and Journey of the 20th Party Congress” (#看懂二十大报告中这些关键词#, #学习二十大精神#, #党的二十大新时代新征程#).

During the 19th CPC National Congress in 2017, Party newspaper People’s Daily published a vocabulary list containing 100 relevant words and terms. That list included terms such as “5G Era” (5G时代), “Sharing Economy” (分享经济), “The 20th anniversary of Hong-Kong’s return to China” (香港回归祖国20周年), “Made in China 2025” (中国制造2025), and other key terms that were deemed relevant in 2017 for China’s nearing future.

This Congress, there has not been a comparable official vocabulary list, but there have been various shorter lists and hashtags encouraging netizens to study key terms that are important to this year’s Congress and the Party goals. Many of these terms are visualized in infographics or explained in online posts and articles.

We’ve gathered some of these key terms from Xi’s speech here that are important to understand, not just for the fact that they are mentioned in Xi’s speech but also because they are specifically highlighted by various official channels.

 

1. Modernizing the Chinese Way 中国式现代化

This concept was mentioned at least five times throughout Xi Jinping’s address and it is one of most important themes of this Party Congress: “Chinese modernization” or “Chinese-style modernization” (中国式现代化 Zhōngguóshì xiàndàihuà).

While the 19th Party Congress was all about China’s ‘new era’ (新时代), this 20th Party Congress term grasps the idea of further modernizing the country in a ‘Chinese way,’ meaning a type of modernization in which typically Chinese features and characteristics (“中国特色”) are maintained.

This is a relatively new term. A tool that shows searches on the Chinese search engine Baidu indicates that it did not receive any significant amount of searches before spiking during the week 20th Party Congress.

Baidu trend search shows that the term “Chinese-style modernizarion” “中国式现代化” did not receive any significant searches before October 2022.

The concept, however, did pop up in Chinese official media discourse since late 2021, such as in one article published by Xinhua News on September 27 in 2021 titled “Grasping the Main Features of the New Path of Chinese-Style Modernization” (把握中国式现代化新道路的主要特征)

The idea of Chinese-style modernization is closely related to other key concepts such as “common prosperity for all” (全体人民共同富裕 quántǐ rénmín gòngtóng fùyù) and “harmony between humanity and nature” (人与自然和谐共生 rén yǔ zìrán héxié gòngshēng).

 

2. The Central Mission 中心任务

The term “central mission” (中心任务 zhōngxīn rènwù) was mentioned at least once in Xi Jinping’s address to convey how the central task of the CPC is to “unite and lead the people of all nationalities to build a strong socialist modern country,” and to “promote the great rejuvenation of the Chinese nation with Chinese-style modernization.”

Although the term “central mission” itself is not particularly tied to the 20th Party Congress at all, it is now because of how it is being used in the new context of the Party’s ‘main goal’ in China’s ‘new era.’ People’s Daily also promoted a hashtag including this term: “The Communist Party of China’s Central Task from Now On” (#从现在起中国共产党的中心任务#”).

 

3. Top Priority 第一要务

The key term ‘top priority’ (第一要务 dì yī yàowù) refers to the Party pursuing the kind of “high-quality development” (“高质量发展”) that will lead to the further modernization of the country.

“High-quality development” was also mentioned in the 19th Party Congress report in 2017 to indicate a shift and a new phase in China’s economic development from a focus on high-speed growth to a focus on more high-quality development, which is also outlined in the 14th Five-Year Plan (2021-2025).

This means, among others, that there will be more focus on innovation-driven industries and technological advancement.

 

4. The “Two-Steps” Strategy “两步走”战略安排

In the segment of Xi’s speech where he addresses China-style modernization in the new era, he also mentions the “two steps” strategy (“两步走”战略安排 “liǎng bù zǒu” zhànlüè ānpái). This is not a new term and it has been previously introduced as part of China’s journey to becoming a strong, rejuvenated country – making China great again.

The two steps of this strategy are to realize ‘socialist modernization’ by 2035 and then to enter the next phase from 2035-2050 to build China into a “strong, democratic, civilized, harmonious and beautiful socialist modernization country.” The year 2049 will mark the 100th anniversary of the People’s Republic of China, and this is the moment when China’s “great rejuvenation” should be completed.

 

5. The Road to Follow 必由之路

At the end of Xi Jinping’s speech, he mentioned “the road to follow” (必由之路, bìyóuzhīlù) five times. On social media, the “road to follow” has been reiterated multiple times as well by official channels, including in a propaganda video published by CCTV.

The five ‘roads to follow’ mentioned in the Party Congress and in the state media videos are the following that are together presented as “the only road” the country and the Party must take. They are all linked together and are actually somewhat circular, namely:

– to develop socialism with Chinese characteristics, they must adhere to the overall leadership of the Party
– to achieve the “great rejuvenation” of China they must stick to socialism with Chinese characterics
– to reach this historic undertaking, they must be united in struggle
– to allow China to grow and develop in the ‘new era,’ they must implement the new concepts for development
– to be able to take this new road together & keep the Party full of vitality, they must follow the way of comprehensive and strict Party governance

 

6. Building Beautiful China 建设美丽中国

In the 20th CPC National Congress report, the idea of “building beautiful China” (建设美丽中国, jiànshè měilì Zhōngguó) was mentioned in the segment dedicated to the “green development” of China as part of its overall modernization. This includes environmental protection, pollution control, carbon reduction, and climate change awareness.

‘Beautiful China’ as a concept was first introduced during the 18th Party Congress in November of 2012 as part of China’s long-term environmental protection plan within the context of people’s welfare and the future of China.

 

7. Whole-process People’s Democracy 全过程人民民主

This concept of ‘whole-process people’s democracy’ (全过程人民民主, quán guòchéng rénmín mínzhǔ) is mentioned at least five times in Xi Jinping’s 20th Party Congress speech and it is one of the political concepts and terms proposed by Xi himself as part of Xi Jinping’s Socialist Thought with Chinese Characteristics for a New Era. It was mentioned in the speech Xi gave during the celebration of the Party’s 100-year anniversary in 2021.

This so-called ‘whole-process people’s democracy’ is officially presented as a ‘process-oriented’ democracy that, despite being different from Western democracy, supposedly “covers all aspects of the democratic process and all sectors of society” through a combination of elections, consultations, decision-making, management and oversight.

This idea of China having its own particular kind of democracy – or perhaps having invented a Chinese version of what ‘democracy’ actually means – also suits the idea of Chinese-style modernization, in which China’s path to the future will not be like the route Western countries are taking, but instead combining modernization with Chinese features.

 

8. Socialist Culture 社会主义文化

‘Socialist Culture’ (社会主义文化, shèhuì zhǔyì wénhuà) comes up at least four times in the 20th Party Congress report. The term represents a cultural side of China’s modernization, and emphasizes that, in order to build a strong socialist country, there must also be a strong socialist culture.

Although not explicitly stated, official media propaganda inescapably plays an important part in the cultivation of a strong ‘socialist culture’ that is all about cultural self-confidence, cultural innovation, creativity, and ‘spiritual energy.’

At time of writing, the Baidu Trends tool did not have enough information to show any relevant data on the search engine interest in this particular term, but the idea of ‘socialist culture’ is by no means a new one. “Socialist culture with Chinese characteristics” was already proposed by Jiang Zemin (江泽民) at the 15th CPC National Congress in 1997.

The idea that building a strong socialist culture is important for the further development of China has been further cultivated over the past few years under Xi’s leadership. Also read this article in English titled “How to build a strong socialist culture” in Qiushi, the CPC Central Committee bimonthly.

 

9. Improve the Distribution System 完善分配制度

This phrase comes up once in the part of the 20th Party System report that disusses a fairer economic system with more equal employment & income opportunities and regulated wealth accumulation, encouraging hard work to get rich.

Although it is the first time that a regulation of wealth accumulation has come up in this way (and it is not explained what this actually means), the idea behind these concepts of the distribution system and wealth accumulation standardization is that of ‘common prosperity,’ one of the most important concepts guiding China’s recent policymaking.

‘Improve the distribution system’ (完善分配制度, wánshàn fēnpèi zhìdù) was explicilty mentioned as one of the key concepts for this week’s meeting by various channels, but it mainly is ‘the regulation of wealth accumulation’ that is featured in social media hashtags (#中国将规范财富积累机制#).

 

10. Focus 着力点

Many of the words or phrases propagated as ‘key terms’ for this 20th Party Congress are insignificant by themselves but are merely used to represent a bigger body of thoughts. The aforementioned “Top Priority,” “Central Mission,” and “Road to Follow” are all just words that only mean something within the context of Xi Jinping’s speech.

Another example is “Major Principles” (“重大原则” zhòngdà yuánzé) which is also included by CCTV in this list of most important keywords, but which actually just goes back to the same ideas that are referred to in the other terms, namely strengthing the overall leadership of the Party, adhering to the road of socialism with Chinese characteristics, emphasizing people-centered ideology, etc. – which is similar to the idea behind the “Road to Follow” (必由之路) keyword.

Explanation of ‘Major Principle’ concept in English and Chinese by People’s Daily, posted on Weibo.

Then there is the keyword “focus,” 着力点 (zhuólìdiǎn), which is about the focus of China’s economic development.

In China’s coming years, the economic focus should be placed on the real economy (实体经济). This literally is also a hashtag promoted on Weibo by CCTV this week (“Put the Focus of Economic Development on the Real Economy” #把发展经济的着力点放在实体经济上#).

Different from the Financial Economy, the Real Economy is the realm of economy that is about businesses, production, and the direct exchange/purchase of goods or services.

Also part of this ‘focus’ is China’s new industrialization, manufacturing, product quality, aerospace, transportation, new technology, and digital China. Another related term that is proposed as one of the keywords of this Party Congress is ‘innovation’ (创新, chuàngxīn).

Please check in with us again this week as we will keep an eye on social media trends surrounding the CPC National Congress. Don’t forget to subscribe. For previous posts on the Party Congress, check here.

By Manya Koetse 

 

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“Guarding the Green Horse” – How China’s Health Code System Provided Solutions and Generated Problems

The Health Code system and the ‘Green Horse’ meme have become part of everyday life in a zero-Covid China.

Manya Koetse

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Since 2020, China’s Health Code apps have become utterly ingrained in everyday life as a pivotal tool in the country’s ongoing fight against Covid-19. What is the health code system, what are its implications, and why have so many Chinese netizens become obsessed with holding on to their ‘green horse’?

 

This is the “WE…WEI…WHAT?” column by Manya Koetse, forthcoming publication in German by Goethe Institut China, visit Yì Magazin here.

 

There is the Grass Mud Horse,1 the River Crab,2 and now another mythical animal is living in China’s social media jungle: the Green Horse. The Green Horse is a cute bright green horse-like animal, a treasured creature that will protect you during your travels and keep you safe from quarantines and lockdowns at a time of China’s zero-Covid policy. The Green Horse will watch over you, but in return, you have to do everything you can to defend it.

‘Green Horse’ in Chinese is 绿马 lǜmǎ, which sounds exactly the same as the word for ‘green code’ (绿码), referring to the green QR code in China’s Covid health apps, which have become a part of everyday life in China since 2020. In a social media environment where homophones and online puns are popular and ubiquitous, it did not take long for the ‘green code’ to turn into the ‘green horse.’

The Green Horse, image via Weibo.

China’s health code system was designed as a solution to resume work and daily life during the pandemic and is widely praised in the country as a pivotal tool in combating the spread of the virus. But it has also given rise to new problems and has triggered resistance against a new kind of digital governance.

 

A SHORT INTRODUCTION TO CHINA’S HEALTH CODE SYSTEM

 

In February of 2020, when China was in the midst of the fierce battle against the novel coronavirus, the country’s tech giants competed over who would be the first and the most efficient in providing digital solutions to aid the anti-epidemic fight.

Within eight weeks after the start of the initial Wuhan Covid outbreak, Alibaba (on Alipay) and Tencent (on WeChat) developed and introduced the ‘Health Code’ (jiànkāngmǎ 健康码), a system that gives individuals colored QR codes based on their exposure risk to Covid-19 and serves as an electronic ticket to enter and exit public spaces, restaurants, offices buildings, etc., and to travel from one area to another.

Scanning a green code (image via Tech Sina, 2020).

Hangzhou, Alibaba’s hometown, and Shenzhen, Tencent’s home base, were the first cities in China to introduce the Health Code in early February of 2020, and other cities soon followed in collaboration with either Tencent or Alipay. By late February, a nationwide health code system was first embedded in WeChat (Chen et al 2022, 619).

Now, people can receive their Covid-19 QR codes via ‘mini programs’ in Alipay or WeChat, or via other provincial government service apps. Apart from the personal health code apps, there is also the ‘Telecommunications Big Data Travel Card’ (通信大数据行程卡), better known as the ‘green arrow code,’ which tracks users’ travel history and is also available inside WeChat or can be downloaded as a standalone app. Its goal is to track if you’ve been to any medium or high-risk areas over the past 14 days.

The Green Arrow Code is used to track people’s travel history of past 14 days (Image via 人民视觉).

The health code system is not as centralized as you might expect it to be. Instead, it is fragmented and sometimes complicated. There are basically two kinds of Health Codes in China. One is the ‘Health Information Code’ (防疫健康信息码) provided by China’s national government service platform (link) which can also be used by those without mainland ID cards (including people from Hong Kong, Macao, and Taiwan).

The other kind of Health Code, which is the one that is most used across China, is the local version of the health code system provided by each province/municipality. There are at least 31 different regional health code applications, from Beijing’s ‘Health Kit’ (北京健康宝) to Shanghai’s ‘Suishenma’ (随申码), from Jiangsu’s ‘Sukang Code’ (苏康码) to Anhui’s ‘Ankang Code’ (安康码). There are sometimes also separate health code apps being used within one province (e.g. in Shenzhen both the local Shen-i-nin 深i您 app as well as the Yuekang Code 粤康码 are being used).

These local Covid health apps are developed by different provinces and cities, and they are not always compatible with each other. This means that those traveling to different provinces or municipalities need to go through the inconvenient process of applying for different local health code apps depending on where they go. Although one single centralized system has been proposed ever since 2020, the process to unify the system is not easy since the various apps have varying functions and are managed by different local government departments (JKSB 2022; Lai 2022). In early September of 2022, China’s National Health Commission announced that it was working with relevant departments to improve the interoperability and mutual recognition of health apps across the country.

Do you get a Green, Yellow, or Red QR code? That all depends on personal information, self-reported health status, Covid-19 test results, travel history, and more – the health code system operates by accessing numerous databases. The Green color means you’re safe (low-risk) and have free movement, the Yellow code (mid-risk) requires self-isolation and the Red color code is the most feared one: it means you either tested positive or are at high risk of infection. With a red code, you won’t have access to any public places and will have to go into mandatory quarantine. Once the quarantine is finished and you’ve consecutively tested negative, the code will switch back to green again.

Three color codes in the Health Code (image via Tech Sina, 2020).

By the end of 2020, around 900 million Chinese citizens were using Health Code apps and although there are no official records of the latest numbers, virtually anyone visiting or traveling anywhere within China will now use the health code system. Besides keeping records of your latest nucleic acid test results, the Health Code app also includes Covid vaccination records since 2021.

 

LEAVING THE ELDERLY BEHIND

 

Despite the efficiency of China’s health code system, it has not been without controversy. One major issue is that it basically forces Chinese citizens to have a smartphone and to download and properly use these apps. This creates a problem for younger children, those without access to smartphones, or those with lower levels of digital skills, including senior citizens.

Although the use of smartphones, the internet, and QR codes are widespread in China, where mobile payments are far more common than cash, more than 60% of Chinese aged 60 years and over still did not use the internet in June of 2020. In China’s ‘Zero-Covid’ era, it is becoming almost impossible for China’s digital illiterate to live a ‘normal’ life.

Chinese authorities have attempted to simplify things for Chinese seniors by making platforms more user-friendly and introducing alternative ways to enter venues, such as offline codes. But at a time when systems differ per region and some venues do not have the tools to check offline (paper) codes, many elderly still struggle (see Gu & Fan 2022).

“They did nucleic acid testing in my grandma’s community compound today,” one woman from Shanxi writes on Weibo: “There are many elderly people in my grandma’s area, and I saw that so many of them had no smartphones, just senior mobile phones, but now they have to swipe a code to make an appointment for testing. One grandpa asked a staff member what to do without a smartphone, they just said it would be better to bring your son or daughter to do it for you. But all results also are processed digitally, so there’s no way for them to see it, and it’s really not easy for them to go to public places.”

On Chinese social media, there are many stories showing the difficult situations that some senior residents are caught up in because they do not have a smartphone or do not know how to get a Health Code.

In August of 2022, there was one viral story about an elderly man from Shandong walking ten kilometers every day because he could not take the bus without a health app. There was also another story about a visually impaired Hengyang resident who was unable to set up the code and was barred from using public transport. In May, a 70-year-old man got stuck inside the Wuxi train station for three days because he had no smartphone and had to scan a code in order to leave.

In another video that went viral, an old man got on a bus in Shanghai but had a hard time using his mobile phone to do the ‘venue check-in’ (场所码). When the bus driver got impatient, the man eventually got off the bus, saying he felt bad about delaying the other passengers.

“Heartlessness is scarier than the epidemic,” some Weibo commenters wrote in response.

 

RED CODE: CONTROVERSIAL DIGITAL GOVERNANCE

 

Another problem that concerns netizens in this Health Code era is that the code could pose an infringement of privacy and could be abused to limit citizens’ freedom of movement for reasons that are unrelated to Covid-19. There are still unclarities surrounding the app, such as what kind of information is exactly being collected, who is authorized to access the data, and how the data is processed and stored (Zhang 2022, 2).

Some people complain on social media that they do not understand why their Health Code is changing colors: “After I did a Covid test the other day, my Health Code was green. The day after, I woke up to a yellow code and after I had done my nucleic acid test again, it was still yellow. On the third day, it turned green. In the afternoon it turned yellow again. On day four, it was green again. Besides doing tests, I’ve been at home all this time. I’m stupefied.”

One incident where people who came to the city of Zhengzhou to protest suddenly saw their Health Codes turn red sparked major outrage on Chinese social media in June.

Earlier this year, thousands of Chinese depositors struggled to recover their savings in light of a major banking scandal in Henan Province. When dozens of affected depositors traveled to the provincial capital of Zhengzhou in June of 2022 to demand their money back, they suddenly saw their Health Codes turn red. The red code was unexpected and strange, considering that there were no new reported Covid cases in their vicinity. Accompanying family members who made the exact same journey reportedly did not see their Health Codes change, raising suspicions that the duped depositors were specifically targeted and that their Health Codes were being manipulated.

“Who is in charge of changing the Health Code colors?” became a much-asked question on social media platform Weibo, with many blaming local Henan authorities for abusing their power and trying to stop rural protesters from raising their voices in Zhengzhou. Although Henan authorities claimed they did “not understand” what had happened, five local officials were later punished for their involvement in assigning red codes to bank depositors without authorization (Wu 2022).

The incident sparked more discussions on the legal and privacy risks surrounding the health code system. Although many people in China support the use of Health Code apps (also see Chen et al), there is also a fear that a lack of transparency and management could allow the health code system to turn into a surveillance tool used by the wrong people for the wrong reasons.

The influential media commentator Hu Xijin also gave his view on the matter, saying that Health Codes across the country should only be used for “pure epidemic prevention purposes.”

“The fact that Henan can make the health codes turn red of people who come to the city to protest says a lot about the power of the IT,” one Weibo tech blogger wrote. Another Weibo user wrote: “As ordinary people, we have voluntarily given up too much of our personal privacy and rights in order to cooperate with the epidemic prevention. The current abuse and misuse of health codes have caused serious infringement on the legal rights of citizens (..) The state should quickly incorporate health codes into a unified system and place it under strict management, and once the epidemic is over, the health code system should stop running immediately.”

 

A GREEN HORSE FUTURE?

 

But will the Health Code and the ‘Green Horse’ ever disappear from daily life in China? And if so, how would the collected data be handled? Although the pandemic era is not over yet (and the question remains what would qualify as ‘the end’), local Chinese governments and tech firms are already looking to see how the health code system could be implemented and how its uses could be expanded in a post-pandemic future (Chen et al 2022, 619).

Back in 2020, the China Healthcare platform (健康界) already published an article exploring the post-pandemic use of the health code system as a digital health passport and information system that could continue to play a significant role in medical care, social security, public transportation, and tourism.

On social media, some people worry that the health code system – and everything that comes with it – is here to stay indefinitely. One Henan-based blogger wrote: “In the future, I hope my son will visit my grave and tell me, ‘dad, now we no longer need our Health Code, nucleic tests or masks when we go to the malls and take trains or airplanes.'”

“If I would wake up tomorrow in a world without health codes, travel codes, Covid tests, lockdowns, wouldn’t that be great,” another person wrote on Weibo, another netizen adding: “My health code is normal. My nucleic acid test is normal. It’s just my mental state that has become abnormal.”

The fears of receiving a ‘Red Code’ are also palpable. Earlier in summer, videos showed people in Shanghai fleeing out of a local mall once they heard that someone in the building had received notice of an abnormal test result.  The same happened at a local IKEA store. Afraid of Health Codes turning red and getting locked in, people rushed to get out as soon as possible. Some even compared the scenes to a ‘zombie apocalypse.’

People fleeing from a local IKEA store after someone in the building got an abnormal test result.

Although there are serious concerns regarding the health code system, social media users also make light of it through the ‘Green Horse’ meme. The phrase “Bàozhù lǜmǎ” (抱住绿码/马) is often used on Chinese social media, a wordplay meant to mean both “Keep your code green” as well as “Hold on to your Green Horse.”

Selection of ‘Holding on to the Green Horse’ memes.

Following the trend, Wuhan set up a giant green horse at a public square in the city, which soon became a popular place for people to take selfies. The meme is also a profitable one for businesses. On Chinese e-commerce sites, you’ll find there are ‘Green Horse’ keychains, stickers, toys, mooncakes, and coffee mugs.

Green Horse merchandise on Taobao.

As cases of Covid surged again in Chengdu, Shenzhen, and elsewhere in late August and September, worries over ‘keeping the green code’ grew again among those living in affected regions. One local Weibo blogger wrote: “I just couldn’t sleep the past few days, I kept checking my green code and latest Covid test results. It makes me anxious.”

“I feel safest at home,” others write: “This is where I can guard my Green Horse.”

“I hope this epidemic will go away soon,” one netizen wrote: “I hope we can all have our Green Horse and just keep it.”

 

By Manya Koetse
Follow @whatsonweibo

 

1 Grass Mud Horse or Cǎonímǎ (草泥馬) is one of China’s social media ‘mythical creatures’ and an online meme. It is a word play on the vulgar Mandarin term càonǐmā (肏你媽), which literally means “f*** your m*m.”

2 River Crab is another ‘mythical creature’: Héxiè (河蟹) is literally ‘river crab’ but sounds the same as héxié (和谐),”to harmonize,” referring to online censorship.

 

References (other sources linked to inside the text)

Chen, Wenhong. Gejun Hang, and An Hu. 2022. “Red, Yellow, Green, or Golden: The Post-Pandemic Future of China’s Health Code Apps.” Information, Communication & Society 25 (5): 618-633.

China Healthcare 健康界. 2020. “国家卫健委推行”一码通”健康码未来不止于”通行.”” CN Healthcare, 21 December https://www.cn-healthcare.com/article/20201221/content-547951.html [Accessed 22 Aug, 2022].

Gu, Peng and Yiying Fan. 2022. “In ‘Zero-COVID’ China, the Elderly Are Becoming Ever More Marginalized.” Sixth Tone, 9 Aug https://www.sixthtone.com/news/1010908/in-zero-covid-china-the-elderly-are-becoming-ever-more-marginalized [Accessed 22 Aug, 2022].

JKSB 健康时报网 [Health Times]. 2022. “国家健康码和地方健康码区别何在?专家:国家平台更接近理想状态.” JKSB, August 27 http://www.jksb.com.cn/html/redian/2022/0827/177853.html [Accessed 1 Sep, 2022].

Lai, Xianjin. 2022. “Unified Health Code Can Bring More Convenience, Efficiency.” China Daily, April 6 https://global.chinadaily.com.cn/a/202204/06/WS624ccc73a310fd2b29e55269.html [Accessed 31 August].

Liang, Fan. 2020. “COVID-19 and Health code: How Digital Platforms Tackle the Pandemic in China.” Social Media + Society (Jul-Sep): 1-4.

Wu, Peiyue. 2022. “Zhengzhou Officials Punished Over Red Health Code Saga.” Sixth Tone, 23 June https://www.sixthtone.com/news/1010627/zhengzhou-officials-punished-over-red-health-code-saga- [Accessed 22 Aug, 2022].

Zhang, Xiaohan. 2022. “Decoding China’s COVID-19 Health Code Apps: The Legal Challenges.” Healthcare 10 (1479): 1-14.

 

Featured image by Ama for Yi Magazin.

This text was written for Goethe-Institut China under a CC-BY-NC-ND-4.0-DE license (Creative Commons) as part of a monthly column in collaboration with What’s On Weibo.

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