China’s zero-covid policy won’t work forever. But there’s no easy way out of it.

Dan Vergano

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Chinese President Xi Jinping is facing mounting political pressure to end the country’s strict and increasingly unpopular “zero-covid” policy. But experts say there’s no easy way to end zero-covid without significant illness, suffering and death.

China’s frequent, large-scale lockdowns have halted outbreaks and saved lives — but they’ve also prevented widescale infections that would help build immunity in China’s population. Compounding the problem, Xi has relied on mediocre homegrown covid vaccines. And the virus has grown more infectious over time, raising doubts about how long the current approach will hold.

“China’s ‘Dynamic Zero-Covid’ strategy is unsustainable and will almost certainly fail over time,” said Lawrence Gostin, faculty director of the O’Neill Institute for National and Global Health Law at Georgetown University. “SARS-CoV-2 is too infectious to be contained, especially with a population that has very little natural or vaccine-induced immunity. If China abruptly ends its zero-covid strategy, it would see an explosion of hospitalizations and deaths.”

Amid a rash of protests against China’s pandemic policies, the country’s National Health Commission on Tuesday announced a new “Work Plan” aimed at getting more booster shots among those 80 and older, the most vulnerable, claiming that two-thirds of them now had boosters (a marked jump from a lower estimate released earlier in November) and decrying a “one size fits all” approach to restrictions from local governments.

The move followed earlier announcements in November of relaxed contact tracing and other quarantines, promises whose reversal is seen as a spark to protests. A leading Chinese official on Thursday suggested to public health experts that further loosening of mass testing and mass quarantine rules may come within a week, according to Reuters, citing a lower rate of severe disease after vaccination.

But whatever loosening is coming may be too little, too late to hold off either more protests or the eventual overtaking of the pandemic throughout China, fear public health experts, with implications both for the Chinese economy and geopolitics.

“China is, frankly, between a rock and a hard place,” said Victoria Fan, a senior fellow in global health at the Center for Global Development. The country “is in a situation not too different from 2020. It’s almost like a pre-vaccine moment for China,” she said. Former zero-covid nations like Taiwan, Singapore and New Zealand have confronted difficult questions about how, whether and when to relax restrictions in the past year and a half, managing the transition with timely responses to outbreaks, backed up by hospital capacity lacking in China. “It’s hard to imagine they will vaccinate their way out now,” she added.

The risky option

Since January of 2020, China has pursued its aggressive zero-covid strategy of strict home confinement, centralized quarantines, contact tracing, mass testing, border restrictions and police surveillance in response to outbreaks of SARS-CoV-2 — keeping reported deaths there to around 16,000 people. As many as 300 million people were under these lockdowns as recently as September, at a time when the country averaged around 3,000 cases a day.

China has regarded the policy as a great success in protecting lives, in contrast to the 1.6 million covid deaths in the U.S. or the 530,000 reported in India, a fraction of the real number there. (China’s actual number of deaths is also suspected to be under-reported.) However, the policy has staggered the economy and led to public remonstrations after an October Communist Party congress vow to “unswervingly adhere” to zero-covid — protests that flared after 10 people died in an apartment thought to have been locked down by the policy, despite official denials.

What makes China’s position precarious is that the pandemic didn’t end in 2020. Instead, it spawned variants that have led to today’s omicron varieties, which have evolved to evade both natural immunity and vaccines in the human population. China lacks strong protection from either factor right now, notwithstanding its high initial vaccination rate, over 90 percent, and just over half of the population receiving a booster shot. That’s because China relied on its own domestic vaccines, ones with a relatively low effectiveness, to get to those numbers. And keeping all those people locked down prevented them from getting infected and acquiring natural immunity. That means the hundreds of millions who haven’t received a booster are left with SARS-CoV-2 antibodies that have faded, and are reliant on later-acting immune memory cells from long-ago vaccine shots to protect them from severe disease.

The catch is that the virus spreads early in a person’s illness, before severe disease develops, which would give it a vast playing field in which to spread and evolve further in China’s huge population if the zero-covid approach ended today. Another catch is that even if far fewer people get severe disease, a surge might still kill great numbers of them, simply by sheer numbers infected in a vast country. A taste of such an outbreak came in Hong Kong’s winter surge, which overwhelmed isolation wards, killed more than 2,000 people and struck the unvaccinated elderly hard. Likewise, the U.S., which has committed its own dreadful blunders throughout the pandemic, is still seeing 300 to 400 covid deaths a day, even with better vaccines.

For most countries, even ones that once pursued zero-covid policies, the development of vaccines and their distribution last year was the moment to loosen restrictions. That often led to more infections and filled hospitals, straining medical services, said Fan, and forced a kind of thermostat effect on responses, where restrictions were tightened or loosened in response to case numbers. “Covid works fast, but it is not immediate, and there is a kind of two-week window to see trends, and nations that responded well acted accordingly,” she said. Among those, she listed Taiwan, Singapore and South Korea, which have an even lower rate of covid deaths than China.

China instead chose to focus heavily on containment, even as the virus evolved into those more infectious variants, said Texas A&M University disaster preparedness expert Michael Lindell, the senior author on a study in the journal Vaccine looking at acceptance of shots in rural China. “It looks like the Chinese government took the risky option,” he said. “Perhaps they overestimated their ability to enforce containment or the length of time that containment would be needed.”

Where China fell down in the time it bought with zero-covid is building out hospital facilities that gave other countries the breathing room to adjust to changing case rates. A lack of intensive care beds, where a full reopening might put 5.8 million people into ICUs — orders of magnitude above current capacity — is seen as a key limit on ending zero-covid. Without them, the ability to dial up or dial down restrictions in response to caseloads can’t work. “What has been missing is a build-out of the Chinese hospital sector,” said William Kirby, the T.M. Chang professor of China Studies at Harvard University. “Zero-covid is a mammothly unpopular policy, and this shows the weakness of an authoritarian system to respond to that signal.”

All the same, it’s a mistake to think of China’s only choices as keeping zero-covid or a full-scale opening, said Fan. “It’s not an either-or — there are a lot of loosening measures they could pursue instead.” Strong masking policies, contact tracing, social distancing and border restrictions, and business closures, for example, are already the rule of the day in China and are not the subject of contention like lockdowns. “They need to get their elderly vaccinated first, though, before they do anything else,” she said.

Off-ramp

A kind of “vaccine nationalism” has left China out of the mRNA vaccine revolution that occurred in the pandemic, said Kirby. China only approved a first mRNA vaccine in November, and only for foreign residents, despite years of study and their use worldwide. “If you allowed the introduction of those vaccines, within six to nine months, I think you would see quite a different picture in China,” he said.

China’s Sinovac and Sinopharm vaccines rely on inactivated viruses that inject killed viral particles into the arm to trigger an immune response to SARS-CoV-2. This is a more traditional approach to vaccine-making, one that takes more time than mRNA vaccines to produce shots. Those more directly instruct the immune system what kind of antibodies to ready against an infection. Initially, the Chinese shots were thought around 65 percent effective against infection, about as good as a flu shot in a good year. Their effectiveness has since waned against newer variants.

Worth noting, China’s covid vaccination campaign had to overcome public distrust owing a series of vaccine-related scandals in China dating back to 2013, when people died after taking a bad hepatitis B vaccine. That was followed by illegal sales of rabies vaccines in 2016 and a biomedical company bribing officials to give shoddy diphtheria, pertussis and acellular tetanus vaccines to infants in 2018. Those incidents undermined Chinese residents’ confidence in their pharmaceutical industry and may partly explain a reluctance among more of the elderly to get booster shots. Just as in the U.S., some concern over the vaccines also springs from being fast-tracked and authorized under emergency use rules.

Regardless, mRNA vaccines look like the best options for shots that can most quickly change to address new covid variants in the future. “There is only one effective off-ramp for President Xi, which is to import more effective Western mRNA vaccines and to vastly increase vaccine uptake among its most vulnerable population, such as the elderly,” said Gostin. “The problem is that President Xi needs a face-saving way to end its zero-covid strategy. The current protests in China show that the population is deeply unhappy with the policy. It needs to change but change in a way that does not see massive loss of life.”

Protests and politics

The protests and zero-covid’s association with Xi led to a politicization of the strategy that necessitates that face-saving. Rather than becoming solely a medical question, the protests have elevated zero-covid’s continuation to a question of the strength and legitimacy of the national government, said Kirby.

In a June letter to the journal Science, Jianan Huang of Nanyang Technological University noted that the disagreement over keeping or loosening zero-covid has become seen as “divergences between China’s senior leadership teams,” within the country, and therefore politically fraught ahead of the recent October party congress. Going by this explanation, Xi’s cementing of his rulership at that meeting bodes ill for loosening zero-covid and for protesters. Against this, Thursday’s suggestion of ending mass quarantines from Vice Premier Sun Chunlan — and recent moves by a few cities to relax polices — might point to a thaw following the week’s turbulence.

And despite the demonstrations, not everyone in China wants to end zero-covid restrictions, said Carl Mitcham, a science and technology policy scholar at the Colorado School of Mines and Renmin University of China. From conversations with Chinese colleague, his sense is that some want more time to come to a consensus on ending the policy and that for others the protests are seen as more isolated to cities such as Beijing or Shanghai, rather than reflecting sentiment everywhere.

A cultural reluctance to force shots on the elderly may also have played a role in China not getting boosters out more widely to the aged, said Kirby: “It is a good value, to respect the elderly, but it is a problem now, and it is hard to understand how a government which can force severe conditions on the population, just consider the history of China, hasn’t acted more strongly until now.”

“The virus escaped from Wuhan [in 2020] because of the political system, which refused to acknowledge its existence until it was too late,” he added. Next, the zero-covid policy was erected, which undoubtedly saved hundreds of thousands of lives. “But it didn’t prepare them for a post-covid zero world. At the end of the day, that has to be a political decision, not a medical or scientific one.”