China’s covid explosion: How the country went from ‘zero-covid’ to millions of cases a day

Lili Pike

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In the month since China cut covid loose, dropping its “zero-covid” restrictions, the virus has run rampant. But it’s impossible to know just how rampant. The official death toll has barely ticked up — from 5,233 at the beginning of December to 5,272 on Sunday, meaning that officially only 39 people have died of covid in that period. Local government reports and expert modeling suggest that the toll is far higher and that daily caseloads are in the millions.

The Chinese government ended mass testing on Dec. 7 and stopped recording total cases a week later. Since then, the data on the outbreak has been murky at best. The Chinese Center for Disease Control and Prevention is still publishing daily covid statistics, listing just confirmed cases, but these numbers also bear little resemblance to on-the-ground reports. Global health experts have called for China to share more comprehensive information on the outbreak, but for the moment, China’s covid explosion is being obscured by the lack of data in a country that was already known for uneven reporting during the pandemic.

“China has a long and notorious history of delaying the reporting, or not reporting at all, of important epidemic information of international importance,” said Victoria Fan, a senior fellow in global health at the Center for Global Development. “Unfortunately, China’s recent actions are consistent with its past history of actions.”

The current reality — whatever the government says — is that China is in the throes of a voracious covid wave that is taking a toll on hospitals and families across the country. How bad is it? Using social media accounts, interviews with people in China’s major cities, epidemiological models and local data, Grid has tried to piece together as clear a picture as possible of a nightmarish sequel to zero-covid.

From “zero-covid” to hundreds of millions of cases

Before China abandoned its zero-covid restrictions, the country was reporting only tens of thousands of cases a day — a far lower figure than other countries have experienced in the omicron era (by way of comparison, the U.S., with one-third the population, had an average daily caseload of 800,000 at the peak of omicron last January — and that was also likely an undercount). Since early December, the spike in infections across China has surprised even seasoned public health experts — including some inside the country.

In a closed-door meeting last month, Chinese public health officials estimated that a fifth of the country’s population — some 250 million people — were infected with covid in the first 20 days of December alone, according to Financial Times’ reporting. Italian officials got a small window into that covid tsunami when they tested airline passengers arriving from China in late December and found that 50 percent were positive on a single flight.

Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations, said, “I assume that now nationwide, very likely at least 50 percent of the population has been infected.”

Local data and on-the-ground accounts appear to bear out these frightening assessments. In December, several city government officials in China estimated that they were seeing hundreds of thousands of cases a day.

“Every person I knew in Beijing got covid — every one of them — even the ones who were the most fervent supporters of the government’s policies got covid within one week,” Yiming, a Beijing-based investment analyst who spoke on the condition of partial anonymity, using his first name only, told Grid. He said he was working remotely in Shanghai as his friends and colleagues in Beijing were getting infected; when he returned to Beijing in December, he immediately got covid too.

“People were joking that covid was in the air,” he said. “As long as you were breathing, you would get covid.”

For some, a quick recovery

Infections blew through so fast that the wave of cases may already have crested in some parts of the country. Sources in Beijing, Wuhan, Shanghai and Chengdu told Grid that infections appeared to have peaked in their cities. At the end of December, Zeng Guang, the former head epidemiologist of the CDC in China, estimated that more than 80 percent of the city’s population had already had covid. And starting in late December, subway traffic began returning to normal in 11 major cities, including Beijing, Tianjin, Shanghai and Guangzhou, after falling during the initial wave. Yiming reported that most of his colleagues had returned to work in person in his office in Beijing.

Local government officials are confirming these accounts — in Chongqing, Beijing, Guangzhou and Tianjin, they reported that cases had already tapered off in the last couple of weeks. The top health official in Henan province said last week that nearly 90 percent of the province had likely already been infected.

“They say that we have smoothly passed the viral peak,” said Huang, “so they make this sort of like an accomplishment.” He added that local governments may have an incentive to report that their covid surge is behind them so that they can focus on economic reopening, the party’s central task for the year ahead.

In any event, the price of China’s steep “viral peak” has likely been a death rate far higher than would have been the case had the transition from zero-covid been less sudden — as well as a punishing impact on the country’s hospitals.

A battered healthcare system

The torrent of cases in recent weeks has taken a heavy toll on China’s healthcare providers.

A medical professor at a hospital in Chengdu, who spoke on the condition of anonymity because of the sensitivity of the subject, told Grid, “It was a sudden reopening. There was a lack of preparation in many aspects.” Because it was focused on containment for three years, she said, “the medical system neglected research and treatment of the disease. After the reopening, there was no standard treatment plan in place.”

Jennifer Bouey, an epidemiologist and leader of China policy studies at the Rand Corporation, echoed the frustration over the government’s lack of foresight.

“I think the most disturbing fact is that the Chinese government didn’t do good preparation or any preparation at all before they changed the policy,” she told Grid. Officials didn’t lead a big vaccine push ahead of the change in rules, she added, and the government didn’t sufficiently stockpile antivirals and other medicines.

Yiming saw that firsthand in Shanghai and Beijing. “The first problem that we had when government reopened,” he said, “was that we didn’t really have easy access to those kinds of drugs because so many people are experiencing fever and coughing, but the shortage of available drugs made a lot of people suffer from the fever.”

Patients who have gone to the hospital for treatment have found a system crashing under the weight of the surge. In one series of videos published by the New York Times, patients lay on gurneys in the hallway of a Tianjin hospital after it reached capacity; such scenes have been shared in social media videos from hospitals in other major cities. More chronically ill and elderly patients have died because of these conditions, according to the Chengdu-based professor.

Grid spoke to a source who said his 87-year-old relative had been in the hospital in Chengdu for more than 10 days with pneumonia from covid, and her condition hadn’t improved.

Meanwhile, healthcare workers have been under duress. Bouey said many physicians she knew in China had come down with covid in early December, and media reports show that healthcare professionals have had to work even while covid-positive. Specialized departments have been converted into extra wards.

“The fever patients not only occupy the fever clinic, but also the internal medicine unit for the respiratory diseases,” said Bouey, “and then we see that the surgery, the OB-GYN wards, even the pediatric wards are all taken over by the covid patients.”

Counting the dead: obituaries and visits to crematoriums

Even though cases have peaked in many cities, international experience would suggest that China is still in for a rough stretch ahead, because severe cases and deaths typically continue to climb after overall cases peak.

So far, China’s official data shows only those 39 new deaths since the beginning of December. That’s due in part to China’s unique way of counting these deaths; if a patient had any other underlying condition, that condition — not covid — is recorded as the cause of death. That differs from the standard in other countries. The World Health Organization has criticized China for its definition, saying it muddies the view of the outbreak.

A more realistic view of covid’s recent toll can be found elsewhere. A slew of recent high-profile obituaries shared on Chinese social media, from the founder of a covid testing company to a famous opera singer, points to a much higher number of deaths. A woman’s recent post on Weibo detailed a spike in the cost of coffins — by hundreds of dollars — which her family encountered after her second uncle died of covid in Hebei province.

Chilling reports have also emerged from China’s crematoriums, where employees are working overtime, operating incinerators 24-7 with lines of hearses waiting outside. Using satellite imagery, the Washington Post showed an increase in vehicles at several funeral homes around the country. One funeral home outside of Beijing even built a new parking lot, seemingly to handle the overflow.

“The big cities have passed the viral wave,” Huang said, “but my understanding is that the rapid increase of the severe cases and deaths — that is still not over.” Huang and other experts are particularly concerned about a potential spread of cases to China’s rural areas during the upcoming Lunar New Year holiday, when hundreds of millions of people travel to visit their hometowns. China’s rural healthcare clinics are not equipped to handle the surge.

Airfinity, a U.K.-based health analytics firm, estimates that more than 269,000 people have died of covid in China since Dec. 1, 2022. Their projections show that by Jan. 23, deaths could reach a peak of 25,000 a day. After that, they predict China’s covid infections will fall before reaching a second peak in early March, after the Lunar New Year holiday.

The impact of these waves may have effects beyond China. Public health officials around the world are scanning what little genomic data they have from China to detect any new variants that may emerge. None have been reported to date.

Inside China, the sudden deluge of cases has been understandably shocking and dizzying, for a population that went almost overnight from “zero-covid” to covid afflicting millions.

“I would say that it was such a radical and abrupt shift from what [the government] had adhered to before that nobody really could get used to it,” said Yiming. “Unfortunately, what happened afterward was really kind of traumatic and tragic.”