Social Infrastructure and the Care Crises

An Evaluation of China’s Covid-19 Experience

BY Ying Chen, Zhongjin Li, and Yang Zhan | July/August 2021

This article is from Dollars & Sense: Real World Economics, available at http://www.dollarsandsense.org

This article is from the
July/August 2021 issue.

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All over the world, tthe Covid-19 pandemic has stretched caregivers past the breaking point. Cooking and cleaning, childcare, and eldercare are fundamental to society’s survival. Practically overnight, the lockdowns and distancing required to contain the coronavirus forced major changes in how these basic survival tasks could be done. Many of the changes exacerbated preexisting problems, but other changes carry positive lessons. China, for instance, was able to reinvigorate an almost dormant social infrastructure and engage community organizations in providing essential services.

Like women almost everywhere, women in China do more care work than men do (2.5 times more time spent in China’s case) and were straining under the burden even before the pandemic. When the pandemic hit, it hit women of different classes differently. Urban women who had been relying on hired domestic work or extended family found themselves with more unpaid household work to do. The internal migrant women who had been (poorly) paid domestic workers found themselves without income—but still with unpaid responsibilities to their own families. The many women working in the health care profession provided direct care to increasing numbers of ill patients while carrying the fear of bringing the virus home.

The burden was clearly too great for so many individual households to shoulder. Fortunately, communities acting collectively could do much that households acting in isolation could not. China has an institutional structure for participation in local communities, from residential urban neighborhoods to rural villages, and this allowed the larger community to be an effective complement to each of the households that needed a helping hand. In the context of China, community organizations assemble resources from various levels of government and local civic organizations. They are largely staffed with publicly employed community workers. At present, there are 650,000 rural and urban neighborhood councils in China, which employ about four million community workers, among which 1.5 million are women.

Among all types of community organizations, the neighborhood councils, which are funded and supported by the government, have the longest history in China, and have existed since the 1950s. They work closely with neighborhood residents and deliver social services directly to households. In normal times, neighborhood councils focus on routine tasks like gathering household registration information and organizing neighborhood entertainment activities. But when pandemics hit, such as the SARS outbreak in 2003 or Covid-19, they are tasked with providing vital services such as delivering medicines and public health advice.

Before a wave of privatization in the 1980s, state-owned enterprises coordinated a great deal of social support alongside industrial production. Childcare, schooling, and health care services were frequently available on site. During this period, community organizations mostly consisted of neighborhood councils in urban areas and communes in rural areas. With privatization, most urban state-owned enterprises and all rural communes have collapsed, so care responsibilities were shoveled back onto families all at once, provoking a crisis. In response, the government launched a community-building project to ease the strains of economic transformation—community health clinics and community service centers were gradually established to provide some minimal level of social services to partially compensate for the increasingly unaffordable social services following privatization. These organizations complement the work that is carried out by the neighborhood councils: clinics provide basic health care services, and the community service centers provide access to recreational and educational services like access to board games, books, and fitness classes.

It is important to emphasize that although these different types of community organizations exist, their capacity to provide social services has not always been fully utilized. They are very much like the underutilized physical infrastructure—such as railroads and highways—which is only viewed as being useful when it’s urgently needed. These community organizations create what we can regard as a social infrastructure that is crucial for the delivery of services during public crises such as the Covid-19 pandemic. China’s use of these organizations gives us a chance to examine how this collaboration between the state and community organizations can chart the course for constructing a new normal in which privatized and marketized care can be at least partially re-socialized as a public service.

China’s Community Organizations in the Pandemic

Against this backdrop, with decades of experience working alongside local community members, neighborhood councils were able to swiftly adjust to the new demands arising from communities throughout China during the pandemic. As a result, in both urban and rural areas, these neighborhood councils not only ensured the provision of basic necessities but also helped carry out public health measures, such as supervising in-house quarantines and coordinating quarantines in hotels, in a way that largely relieved family members from assuming extra care responsibilities.

With 11 million residents mandated to stay home during the Wuhan lockdown, neighborhood councils were responsible for disseminating medical advice about how to control the virus as well as delivering food and medicine to every household. By doing so, community workers and volunteers took up a large portion of household chores (such as shopping for groceries and medicine) and helped reduce stress imposed upon individual households. In contrast, in the early days of the pandemic in the United States and many other countries, we saw photos of people waiting outside of grocery stores for hours, a practice that is both risky and inefficient.

The neighborhood councils in Wuhan, along with the community health clinics, also helped with coordinating health screenings and contact-tracing, which played a crucial role in containing the virus. Community workers from the neighborhood councils, who are employed in the public sector, as well as medical staff from community clinics and local volunteers, were able to build on their relationships with neighborhood residents to stay in close contact with families throughout the pandemic. As part of these efforts, community workers and volunteers screened community members for fevers, and then helped transfer them to quarantine sites for medical observation or to fever clinics for diagnosis. In Wuhan, community health clinics also provided care to affected patients with severe symptoms, relieving the pressure from large hospitals early in the lockdown when resources were extremely scarce. Additionally, many community clinics and neighborhood councils hired professional psychologists or relied on volunteers to provide counseling services to local residents, especially those who had been infected with Covid-19, or were under quarantine, as well as their family members, following a recommendation from the state to do so.

In Shanghai, which is the country’s biggest city with more than twice as many residents as Wuhan, both community clinics and neighborhood councils played crucial roles in preventing the spread of the virus. The local government ensured that all 246 community clinics remained open during the lockdown, which meant that all residents continued to have access to basic health care services. For people coming back to China via international flights, the neighborhood councils also took the lead in ensuring community safety through implementing protocols such as airport pick-ups and quarantine procedures to ensure proper safety measures were taken. This was particularly helpful for family members who were immunocompromised or suffered from pre-existing conditions, since they would have been at an increased risk of contracting the virus from people who had recently traveled.

International Experience

China is not the only country utilizing the involvement of community workers and local volunteers to enforce and coordinate isolation and quarantine operations, which have proven to be two of the most crucial steps in stopping the spread of the virus. At the community level in Venezuela and India, local efforts have offered a bright spot against the stark backdrop of significant government failures to protect citizens from the pandemic in these countries.

In Venezuela, for instance, the Altos de Lídice Commune in western Caracas, which was founded two years before the pandemic, has played a crucial role in imparting knowledge about Covid-19 prevention and coordinating quarantines. Commune doctors had gathered information on individual households prior to the pandemic, which helped them to quickly identify the most vulnerable members of the community with extra physical and psychological needs. Before the pandemic even hit Venezuela, doctors had already started to make house-to-house visits to inform residents about the nature of the virus and how to avoid catching it. Such preventative methods are labor- and time-intensive, yet in the context of a pandemic, it has proven to be an extremely prescient method that helps to limit the spread of Covid-19 and lessen the burden on major hospitals.

The case of the state of Kerala in India is also exemplary. The state’s combination of a robust health care system with local political leaders who took the pandemic’s threat seriously led Kerala to have the lowest Covid-19 death rate in the country (just 0.4%). As a result of its progressive political history, Kerala currently has more than 11,000 cooperatives across agricultural, industrial, and service sectors. The state government is also deeply committed to poverty alleviation, and in the late 1990s formed a government agency, Kudumbashree, to help with these efforts. The organization, which has fostered a network of 4.5 million female members, played a crucial role in providing pandemic relief. With years of catering experience, they became “the government’s natural choice to run a number of kitchens,” as a World Bank article describes. Some even took on essential production functions such as aiding in the output of face masks and hand sanitizer to prevent virus spread.

Of course, not every country or region is equipped with pre-existing social infrastructures like China, sections of Venezuela, or Kerala. But that doesn’t mean that other countries have ignored the importance of community-level organizations as the pandemic unfolds. Taiwan, for instance, has struggled to mobilize limited public resources to provide ad hoc support at the community level. In addition to applying technology (i.e., big data and cell phone signals) for contact-tracing and quarantine monitoring, borough chiefs (the lowest-level elected officials) were required to check on people daily who were in quarantine. Borough chiefs were also tasked with assisting people with grocery shopping and occasionally providing psychological comfort. With a small population and a comparatively low case count, Taiwan’s ad hoc community-level services proved to be extremely effective in enforcing quarantine, especially in the initial stage, although borough chiefs and other temporarily mobilized staffers were overwhelmed with all the additional tasks induced by the pandemic. Taiwan is reported to have a recent surge in confirmed cases beginning on May 21st, and by mid-June, the country reported 13,106 confirmed cases and 452 deaths. Further research is needed, but this pattern could suggest the ultimate limits of Taiwan’s ad-hoc community approach.

Building Community as Part of the Social Infrastructure

All of these cases suggest that it is necessary to fully incorporate community-level organizations in the social infrastructure in order to guarantee the delivery of essential care services. Just as public transportation needs physical infrastructure (e.g., railroads and subways) as its platform to carry out its services, care services, along with other social services (e.g., education and medical services), also need social infrastructure to facilitate their delivery to recipients.

This means that the community should serve as a platform to mobilize state as well as local resources, and at the same time, we should also develop its potential to provide decent jobs and promote long-term human well-being. This implication is especially relevant for our current pandemic-ridden world, and particularly for the Global South.

Countries in the Global South have abundant labor resources, which are conducive to the labor-intensive nature of care work. In countries with limited public financial resources, it is crucial to determine where and how to invest existing resources to bring about the best possible health outcomes. In this sense, employing these relatively abundant (and hence less costly, compared to their Global North counterparts) labor resources to build a universally accessible, community-centered social infrastructure for the provision of care is feasible cost-wise, at least in the short run. When care services become universally accessible, it will also foster a healthy cycle of social reproduction, which could improve labor productivity and contribute to economic and social development in the long run.

One challenge to implementing an adequate care-work infrastructure throughout the Global South is the different levels of community development in different countries and regions. Some communities are still largely agrarian, so solutions that work in urban settings will not be applicable. This makes specific local knowledge extremely important in the effective provision of care services in neighborhoods across different regions. Thus, community-based organizations with trained local leaders will be in the best position to provide locally targeted support, as compared with top-down state policies or nongovernment organizations funded through foreign sources.

Although it is important that local communities have a say in deciding priorities and allocating resources, it is also crucial that they receive funding and staffing support from outside of the community, especially from the state. Countries in the Global South are afflicted with the uneven distribution of human and material resources across regions, and even more so in local neighborhoods. This means that leaving local neighborhoods alone to mobilize resources to create long-standing community organizations for the provision of health care will only lead to higher levels of inequality, with the best services only available to communities that already have significant human and financial resources. Only the consistent and non-exclusive institutional and financial support of the government can alleviate these existing inequalities.

The Covid-19-induced care crisis and its gendered impact show that privatized and family-based care provision are not up to the task of fighting against a global pandemic. Like China, most Global South countries that have adopted neoliberal market reforms have experienced the privatization of public service sectors in the past few decades, which have contributed to the current care crisis. The difference lies in the fact that in China both the institutional memory and social infrastructure for the public provision of care services still remain, and so this social infrastructure can be utilized in times of crisis. China’s heavy reliance on community organizations during the current pandemic should provide an important lesson for other countries to contemplate as they develop long-term solutions for the care crises that will almost certainly outlive the current pandemic.

Ying Chen is an assistant professor of economics at The New School. Zhongjin Li is an assistant professor of economics at the University of Missouri-Kansas City. Yang Zhan is an assistant professor of anthropology at the Hong Kong Polytechnic University.

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