The End Game of China’s Zero-Covid Policy Nightmare
Originally published at WIRED on Feb. 18 2022. Photo: Cao Yiming
On December 22, 2021, the entire western Chinese city of Xi’an was put into lockdown. “It was all of a sudden,” says Fan, a Xi’An native and university student in his early twenties who didn’t give his full name, due to privacy concerns. “The university wouldn’t let us go outside of the dorms. Our freedom was restricted, and they stopped all our classes. I couldn’t leave and I couldn’t go home. We were stuck.” Xi’an, a city of 13 million people, spent the end of December 2021 and much of January 2022 in one of China’s most severe lockdowns. The trigger? A handful of cases of Covid-19.
Since the start of the pandemic, China has clung to a zero-Covid strategy consisting of strict containment measures that have served the nation remarkably well. China’s official death toll has remained under 5,000, and its total reported caseload of 124,900 is significantly lower than the 78 million cases in the United States or the 18.4 million in the United Kingdom. Aside from travel disruptions, life has been largely normal—and China’s success at containing the virus has become a source of national pride.
Yet the emergence of more infectious variants, like Omicron, is changing the calculus. While other countries are responding to Covid’s evolution by moving toward a strategy of living with the virus, China continues to rely on some of its harshest restrictions since the outbreak began. Surrounding the Lunar New Year and Winter Olympics, small but regular outbreaks of the Omicron and Delta variants have left Chinese authorities scrambling. After Beijing failed to trace its first local Omicron infection in January, its Center for Disease Control and Prevention pointed the finger at a mail delivery from Canada, prompting various cities to frantically disinfect international mail and test package recipients.
After two years of being a global Covid success story, China now appears to be struggling. In the Xi’an lockdown, national outrage has followed grocery shortages and the case of a woman losing her unborn baby in her eighth month of pregnancy after being denied medical attention for hours.
In China and abroad, people have started to question the validity of the government’s zero-tolerance approach. “I understand many are still afraid of the virus and willing to bear the burden [of zero-Covid], but I feel we’ve reached a certain point,” says Fan, whose parents had to quarantine for two weeks at their own expense after meeting a friend who visited a grocery store linked to a single Covid case. “It has a huge impact on us.” So why is the government insisting on pursuing a zero-tolerance strategy? The official line is that abandoning it would lead to a devastating outbreak that would overwhelm the health care system and disrupt social stability. And experts say this is valid—to a certain degree. But the situation is far from straightforward.
One key challenge is that Chinese vaccines are proving to be less effective. While approximately 87 percent of China’s total population is vaccinated, the majority received doses of the country’s homegrown Sinovac and Sinopharm inactivated-virus vaccines, which use a dead version of the virus to expose the body’s immune system to it. About one-third of the population has also received inactivated-virus booster shots.
In December, researchers from Hong Kong found that two doses of Sinovac failed to produce enough antibodies to fight Omicron. Pfizer and Moderna’s vaccines, while less effective against Omicron than previous strains, still provide substantial protection—especially after three doses. And even before the variants arrived, China’s vaccines were still some way behind the West’s mRNA jabs. The numbers are stark: Sinovac is 51 percent effective in preventing symptomatic Covid infection. Pfizer is 95 percent effective. China has yet to approve Pfizer and Moderna’s shots for use on the mainland, although Shanghai-based Fosun Pharmaceuticals was given the right to distribute Pfizer’s vaccine to Hong Kong, Macau, and Taiwan.
That issue of vaccine effectiveness is compounded by the uneven spread of coverage throughout China. Much of the country’s elderly population also remains unvaccinated and vulnerable—due to the government's decision to delay vaccinating seniors in order to prioritize those in high-risk jobs and to ensure the vaccine was safe for older people. (Chinese vaccine makers reportedly included fewer elderly people in final-stage trials than did those in the West.) Although China opened up vaccinations for seniors aged 60 and above in March, health authorities proceeded cautiously and vaccine hesitancy remains high—nearly nine months after China started offering Covid-19 vaccines to people aged 60 and above, about 50 million in this age group remain unvaccinated. For those aged 80 or older, vaccination rates range from slightly above 40 percent to below 30 percent in some areas, a National Health Commission official told state broadcaster CCTV in December.
Zhang Wenhong, an infectious disease expert who has become the country’s most trusted source on the pandemic, claimed earlier this month that the mortality rate among the elderly has remained high even after three doses. China has an estimated 4.37 ICU beds per 100,000 people, much lower than that of developed countries like the US and Germany, which have 34.7 and 29.2 ICU beds per 100,000 people, respectively.
“The initial rationale of having a zero-Covid strategy was to buy time so that a sufficient percentage of the population is vaccinated to reach herd immunity,” says Yanzhong Huang, senior global health fellow at Council on Foreign Relations, a US-based think tank. “But Chinese vaccines are not that effective in preventing infections. They cannot tolerate even a small number of infections.”
What has for so long been a point of national pride is now something of a trap. With ineffective vaccines and low protection from previous infections, a large-scale Covid outbreak could threaten vulnerable communities and overwhelm China’s health care system. To address this threat, China is adapting. Responding to the Delta variant in August, the government moved from its initial “zero-Covid” policy of literally pursuing zero cases to its current “dynamic zero-Covid” strategy, which seeks to instead swiftly crack down on outbreaks when they inevitably occur.
That shift in strategy doesn’t necessarily mean a loosening of restrictions. In the short run, the state will continue enforcing strict measures, like snap lockdowns, because unlike many countries—where lockdowns have become politically and economically unfeasible—China is both able to do so and prepared to pay the cost, according to Ben Cowling, chair of epidemiology at the University of Hong Kong. And in purely economic terms, the policy isn’t too much of a drag on China. A recent report by the Australia and New Zealand Banking Group found that the dynamic zero-Covid approach had shaved just 2.6 percent off the Chinese economy in terms of gross domestic product. “China’s been really good at cracking down and getting to zero,” says Cowling. “It’s very disruptive and involves lockdowns, mass testing, and isolation of cases, but that’s affecting a minority of people. If they can limit the spread, I’d say it’s an optimal strategy.”
As with the rest of the world, China is seeking to buy time so it can use science to beat back the virus—but on its own terms. In the coming months, officials are pinning their hopes on developing better, homegrown mRNA vaccines to target Omicron and other variants. The current mRNA frontrunner, ARCoV, completed its first-stage clinical trials (on 120 people between the ages of 18 and 59) and was found to have an efficacy rate of 80 to 95 percent, which is on par with Pfizer and Moderna’s vaccines.
And ARCoV might even have a logistical advantage. Unlike Pfizer and Moderna, which are challenging to distribute and store, this mRNA vaccine can be kept for six months at a normal refrigerator temperature of between 2 and 8 degrees Celsius. Pfizer and Moderna, by comparison, have to be kept at minus 70 degrees Celsius and minus 20 degrees Celsius, respectively. Experts predict that at least one Chinese mRNA vaccine could be launched for public use by the end of the year and an Omicron-targeting vaccine may be ready in two to six months’ time.
Yet scientists like Dongyan Jin, a biomedical professor at the University of Hong Kong, argue that it is “completely unwise” to wait for the development of homegrown vaccines instead of simply approving Pfizer or Moderna. Not only will waiting stall the process of building higher immunity in the population, but there’s also no guarantee that homegrown vaccines will be effective. Currently being tested in a global Phase 3 clinical trial, ARCoV recently exhibited a sharp drop in neutralizing antibodies against Omicron—although a third booster shot did trigger antibody activity in animal tests.
“There is no scientific reason for not approving them,” says Jin of the Pfizer and Moderna vaccines, adding that the Chinese government has made similar mistakes in the past. Jin cites the delayed approval of the human papillomavirus (HPV) vaccines against cervical cancer, which is the third most common cancer among women in China aged 15 to 44 and the sixth most frequent among women overall, as one such example. Although the first HPV vaccine was licensed by the US in 2006 and then by 80 more countries a year later, foreign HPV vaccines were only approved in China from 2016 to 2018, due to regulatory delays (China’s food and drug administration required repeated clinical trials to ensure safety and effectiveness prior to approval). China still suffers from a supply shortage of HPV vaccines, even after the country launched its first locally produced HPV vaccine in 2020.
In the fight against Covid, delays could prove even more costly. Even if homegrown vaccines are successfully developed, China would still need to make and administer them—though it only took 10 months to jab 1 billion people against Covid back in 2021. That’s quick, but Huang argues it’s unlikely to be quick enough. “By the time China achieves a high vaccination rate, the Omicron-driven wave might already be in retreat,” he says. “We are likely going to see the emergence and dominance of new variants.”
So why doesn’t China approve Western vaccines? As well as citing the need to protect the domestic market, Calvin Ho, a bioethicist at the University of Hong Kong, says the move would also be costly and could trigger a global supply crisis. “Even if they approved Pfizer, it’s going to take some time to vaccinate everyone. Leaving aside the financial cost, there would be implications of global justice. If China approves it and is prepared to pay, what would be the implications for other countries that cannot afford it?” Ho says. “Realistically speaking, the way forward may be to hope there will be a more effective vaccine developed in the mainland or Hong Kong.”
China’s stance may be shifting. In a surprise move, the country this week conditionally approved Pfizer’s Paxlovid pill—even though the country is developing its own antiviral drugs and treatments. Earlier this month, an antiviral drug called Favilavir reportedly received approval to move forward with clinical trials investigating its possible use as a treatment against Covid, and the state’s drug authority granted emergency approval for a monoclonal antibody treatment in December. But the latter needs to be administered through injections, which Huang says would still put a burden on the health care system, since patients would need to go to the hospital.
And even if China can develop its own vaccines and treatments, that doesn’t mean it will abandon its dynamic Covid-zero strategy, officials have said. “As long as China has no new measures to prevent the imported strains of the coronavirus from triggering large-scale transmission and no effective way to contain the epidemic, the country will not adjust its dynamic zero-tolerance policy,” Wu Zunyou, chief epidemiologist of the Chinese Center for Disease Control and Prevention, told state media outfit Global Times in early February. “Relying on vaccines cannot contain Covid-19.”
Not everyone agrees a large-scale outbreak would be as disastrous as the state makes it out to be. In fact, there are many steps China can take to mitigate the damage done to vulnerable communities and the health care system as it eases out of a zero-tolerance strategy, experts argue. Such measures include introducing more effective vaccines from Pfizer and Moderna, making more accessible antivirals available for use, and educating the public on the health risks posed by the virus. “If you have these measures in place, you can significantly reduce the risk to make it manageable,” Huang says. The cost of maintaining zero-tolerance, he adds, will only increase over time. “You have to give up that strategy. You can’t expect the virus to disappear.”
But for all the science, it's impossible to untangle China’s Covid response from politics. In the mainland, discussions around China’s zero-tolerance strategy and homegrown vaccines have become highly politicized. Scientists advocating for a less strict approach have been attacked on social media, and in January one lawmaker in Hong Kong said that health experts who promote the idea of “living with Covid” should be seen as violating national security. “They see this [strategy] as a matter of national pride,” says Jin. “Many Chinese people are proud.” Chinese state media has played a significant role, too, he adds, by creating a partially false narrative around how the rest of the world is suffering.
Pandemic restrictions have also allowed the state to tighten its control over people in China, with security experts saying the virus has become a pretext for the government to accelerate mass surveillance and clamp down on freedom of speech. In February 2020, the government in Hangzhou introduced the mandatory Alipay Health Code app that tells people whether they should be quarantined or allowed into certain public spaces. The app, which appears to share information with the police, is now used across China and has become a normalized part of daily life.
For now, scientists say China will likely only shift away from a zero-tolerance strategy when the population is sufficiently vaccinated with an effective, homegrown, Omicron-targeted vaccine. Another scenario is that the virus evolves into a form mild enough to allow the country to open up without many casualties—a scenario that is unpredictable, to say the least.
In the short term, it is unlikely China would risk any such test before the Communist Party National Congress, which is set for this fall. The Congress, a major political event ushering in top-level leadership changes that is held every five years, will likely see president Xi Jinping announce his intention to seek an unprecedented third term in office. As with the rest of the world, the only way for China to end the pandemic is to rely on science. But there's a lot of politics involved too.
